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42 CFR Ch. IV (10–1–09 Edition)§438.58

(2) If the MCO, PIHP, PAHP, orPCCM or the State agency (whicheveris responsible) fails to make the deter-mination within the timeframes speci-fied in paragraph (e)(1) of this section,the disenrollment is considered ap-proved.(f)

Notice and appeals.

A State thatrestricts disenrollment under this sec-tion must take the following actions:(1) Provide that enrollees and theirrepresentatives are given written no-tice of disenrollment rights at least 60days before the start of each enroll-ment period.(2) Ensure access to State fair hear-ing for any enrollee dissatisfied with aState agency determination that thereis not good cause for disenrollment.(g)

Automatic reenrollment: Contract re-quirement.

If the State plan so specifies,the contract must provide for auto-matic reenrollment of a recipient whois disenrolled solely because he or sheloses Medicaid eligibility for a periodof 2 months or less.

§438.58Conflict of interest safeguards.

(a) As a condition for contractingwith MCOs, PIHPs, or PAHPs, a Statemust have in effect safeguards againstconflict of interest on the part of Stateand local officers and employees andagents of the State who have respon-sibilities relating to the MCO, PIHP, orPAHP contracts or the default enroll-ment process specified in §438.50(f).(b) These safeguards must be at leastas effective as the safeguards specifiedin section 27 of the Office of FederalProcurement Policy Act (41 U.S.C. 423).

§438.60Limit on payment to otherproviders.

The State agency must ensure thatno payment is made to a provider otherthan the MCO, PIHP, or PAHP for serv-ices available under the contract be-tween the State and the MCO, PIHP, orPAHP, except when these payments areprovided for in title XIX of the Act, in42 CFR, or when the State agency hasadjusted the capitation rates paidunder the contract, in accordance with§438.6(c)(5)(v), to make payments forgraduate medical education.

§438.62Continued services to recipi-ents.

The State agency must arrange forMedicaid services to be provided with-out delay to any Medicaid enrollee of an MCO, PIHP, PAHP, or PCCM whosecontract is terminated and for anyMedicaid enrollee who is disenrolledfrom an MCO, PIHP, PAHP, or PCCMfor any reason other than ineligibilityfor Medicaid.

§438.66Monitoring procedures.

The State agency must have in effectprocedures for monitoring the MCO’s,PIHP’s, or PAHP’s operations, includ-ing, at a minimum, operations relatedto the following:(a) Recipient enrollment anddisenrollment.(b) Processing of grievances and ap-peals.(c) Violations subject to inter-mediate sanctions, as set forth in sub-part I of this part.(d) Violations of the conditions forFFP, as set forth in subpart J of thispart.(e) All other provisions of the con-tract, as appropriate.

Subpart C—Enrollee Rights andProtections

§438.100Enrollee rights.

(a)

General rule.

The State must en-sure that—(1) Each MCO and PIHP has writtenpolicies regarding the enrollee rightsspecified in this section; and(2) Each MCO, PIHP, PAHP, andPCCM complies with any applicableFederal and State laws that pertain toenrollee rights, and ensures that itsstaff and affiliated providers takethose rights into account when fur-nishing services to enrollees.(b)

Specific rights

—(1)

Basic require-ment.

The State must ensure that eachmanaged care enrollee is guaranteedthe rights as specified in paragraphs(b)(2) and (b)(3) of this section.(2) An enrollee of an MCO, PIHP,PAHP, or PCCM has the followingrights: The right to—(i) Receive information in accordancewith §438.10.