C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS › Subpart Q—Beneficiary Appeals

42 C.F.R. § 417.600

Basis and scope

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(a) Statutory basis. (1) Section 1869 of the Act provides the right to a redetermination, reconsideration, hearing, and judicial review for individuals dissatisfied with a determination regarding their Medicare benefits.

(2) Section 1876 of the Act provides for Medicare payments to HMOs and CMPs that contract with CMS to enroll Medicare beneficiaries and furnish Medicare-covered health care services to them.

(3) Section 234 of the MMA requires section 1876 contractors to operate under the same provisions as MA plans where two plans of the same type enter the cost plan contract's service area.

(b) Applicability. (1) The rights, procedures, and requirements relating to beneficiary appeals and grievances set forth in subpart M of part 422 of this chapter also apply to Medicare contracts with HMOs and CMPs under section 1876 of the Act.

(2) In applying those provisions, references to section 1852 of the Act must be read as references to section 1876 of the Act, and references to MA organizations as references to HMOs and CMPs.

[60 FR 46233, Sept. 6, 1995, as amended at 62 FR 23374, Apr. 30, 1997; 70 FR 4713, Jan. 28, 2005]
Notes of Decisions
Cited in 4 cases, 1996–2001 · leading case: McCall v. PacifiCare of California, Inc., 21 P.3d 1189 (Cal. 2001).
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McCall v. PacifiCare of California, Inc., 21 P.3d 1189 (Cal. 2001). · cites it 10× “460 (a) (1999)); and (J) the duty to provide grievance procedures for issues that do not involve organizational determinations and Medicare appeal rights ( 42 C.F.R. §§ 417.600 , 417.604, 417.606 (1999)).”
Grijalva v. Shalala, 946 F. Supp. 747 (D. Ariz. 1996). · cites it 4× “An HMO must establish grievance and appeals procedures, 42 C.F.R. § 417.600 (a)(2)(i), for Medicare enrollees dissatisfied because they do not receive health care services to which they believe they are entitled, at no greater cost than *754 they believe they are required to pay.”
Grijalva v. Shalala, 152 F.3d 1115 (9th Cir. 1998). “See 42 C.F.R. §§ 417.600 — 417.638. Under § 417.”
Redmond v. Secure Horizons, Pacificare, Inc., 97 Cal. Daily Op. Serv. 9516 (Cal. Ct. App. 1997). “; 42 C.F.R. §417.600 et seq.) Further, the face of the complaint reveals that plaintiff has failed to join the proper defendant, the Secretary of [Health and Human Services], actions against whom must be brought in federal court.”
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