42 C.F.R. § 438.106
Liability for payment
Each MCO, PIHP, and PAHP must provide that its Medicaid enrollees are not held liable for any of the following:
(a) The MCO's, PIHP's, or PAHP's debts, in the event of the entity's insolvency.
(b) Covered services provided to the enrollee, for which—
(1) The State does not pay the MCO, PIHP, or PAHP; or
(2) The State, or the MCO, PIHP, or PAHP does not pay the individual or health care provider that furnished the services under a contractual, referral, or other arrangement.
(c) Payments for covered services furnished under a contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the enrollee would owe if the MCO, PIHP, or PAHP covered the services directly.
Notes of Decisions
Cited in 5
cases, 2009–2019 · leading case: Robert F. Colwell, Jr. v. Iowa Dep't of Human Servs., 923 N.W.2d 225 (Iowa 2019).
Robert F. Colwell, Jr. v. Iowa Dep't of Human Servs., 923 N.W.2d 225 (Iowa 2019). “42 C.F.R. § 438.106 (b) (2016). Payments to providers may be less than providers would normally charge for a service rendered, and Medicaid enrollees are not responsible for unpaid services.”
MHA LLC v. HealthFirst, Inc., 629 F. App'x 409 (3rd Cir. 2015). “Accordingly, HFNJ is liable to Plaintiff as a Medicaid MCO for payment for emergency services under the Act, pursuant to SSA § 1923(b)(2); and enrollees must be protected against liability, even if the MCO is not paid by the State, and for any services furnished by “a provider…”
G. v. Hawaii, Dep't of Human Servs., 676 F. Supp. 2d 1006 (D. Haw. 2009). “§§ 1396b(m)(l)(A)(ii), (C)(i); see also 42 C.F.R. §§ 438.106 , 438.116. 1. The RFP To ensure that these solvency requirements were met, CMS carefully reviewed the terms of the RFP.”
G. v. Hawaii, Dep't of Human Servs., 676 F. Supp. 2d 1046 (D. Haw. 2009). “§§ 1396b(m)(l)(A)(ii), (C)(i); see also 42 C.F.R. §§ 438.106 , 438.116. In Counts I through IV of the State Second Amended Complaint, Plaintiffs contend that the QExA Contractors failed to meet these requirements and thus do not qualify as MCOs.”
A & E Auto Body, Inc. v. 21st Century Centennial Ins., 120 F. Supp. 3d 1352 (M.D. Fla. 2015). “See 907 KAR 17:005; 42 C.F.R. § 438.106 (c). ARH -has only Coventry to look to for reimbursement for healthcare services provided to Coventry members.”
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