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§ 438.58 42 CFR Ch.

IV (10–1–09 Edition)

(2) If the MCO, PIHP, PAHP, or § 438.62 Continued services to recipi-

PCCM or the State agency (whichever ents.
is responsible) fails to make the deter- The State agency must arrange for
mination within the timeframes speci- Medicaid services to be provided with-
fied in paragraph (e)(1) of this section, out delay to any Medicaid enrollee of
the disenrollment is considered ap- an MCO, PIHP, PAHP, or PCCM whose
proved. contract is terminated and for any
(f) Notice and appeals. A State that Medicaid enrollee who is disenrolled
restricts disenrollment under this sec- from an MCO, PIHP, PAHP, or PCCM
tion must take the following actions: for any reason other than ineligibility
(1) Provide that enrollees and their for Medicaid.
representatives are given written no-
tice of disenrollment rights at least 60 § 438.66 Monitoring procedures.
days before the start of each enroll- The State agency must have in effect
ment period. procedures for monitoring the MCO’s,
(2) Ensure access to State fair hear- PIHP’s, or PAHP’s operations, includ-
ing for any enrollee dissatisfied with a ing, at a minimum, operations related
State agency determination that there to the following:
is not good cause for disenrollment. (a) Recipient enrollment and
(g) Automatic reenrollment: Contract re- disenrollment.
quirement. If the State plan so specifies, (b) Processing of grievances and ap-
the contract must provide for auto- peals.
matic reenrollment of a recipient who (c) Violations subject to inter-
is disenrolled solely because he or she mediate sanctions, as set forth in sub-
loses Medicaid eligibility for a period part I of this part.
of 2 months or less. (d) Violations of the conditions for
FFP, as set forth in subpart J of this
§ 438.58 Conflict of interest safeguards. part.
(e) All other provisions of the con-
(a) As a condition for contracting tract, as appropriate.
with MCOs, PIHPs, or PAHPs, a State
must have in effect safeguards against
conflict of interest on the part of State Subpart C—Enrollee Rights and
and local officers and employees and Protections
agents of the State who have respon-
§ 438.100 Enrollee rights.
sibilities relating to the MCO, PIHP, or
PAHP contracts or the default enroll- (a) General rule. The State must en-
ment process specified in § 438.50(f). sure that—
(b) These safeguards must be at least (1) Each MCO and PIHP has written
as effective as the safeguards specified policies regarding the enrollee rights
in section 27 of the Office of Federal specified in this section; and
Procurement Policy Act (41 U.S.C. 423). (2) Each MCO, PIHP, PAHP, and
PCCM complies with any applicable
§ 438.60 Limit on payment to other Federal and State laws that pertain to
providers. enrollee rights, and ensures that its
staff and affiliated providers take
The State agency must ensure that those rights into account when fur-
no payment is made to a provider other nishing services to enrollees.
than the MCO, PIHP, or PAHP for serv- (b) Specific rights—(1) Basic require-
ices available under the contract be- ment. The State must ensure that each
tween the State and the MCO, PIHP, or managed care enrollee is guaranteed
PAHP, except when these payments are the rights as specified in paragraphs
provided for in title XIX of the Act, in (b)(2) and (b)(3) of this section.
42 CFR, or when the State agency has (2) An enrollee of an MCO, PIHP,
adjusted the capitation rates paid PAHP, or PCCM has the following
under the contract, in accordance with
dcolon on DSK2BSOYB1PROD with CFR

rights: The right to—

§ 438.6(c)(5)(v), to make payments for (i) Receive information in accordance
graduate medical education. with § 438.10.


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