C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 438—MANAGED CARE › Subpart B—State Responsibilities

42 C.F.R. § 438.60

Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts

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The State agency must ensure that no payment is made to a network provider other than by the MCO, PIHP, or PAHP for services covered under the contract between the State and the MCO, PIHP, or PAHP, except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State plan.

Notes of Decisions
Cited in 4 cases, 2013–2017 · leading case: Armstrong Cnty. Mem'l Hosp. v. Dep't of Pub. Welfare of Pennsylvania, 67 A.3d 160 (Pa. Commw. Ct. 2013).
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Armstrong Cnty. Mem'l Hosp. v. Dep't of Pub. Welfare of Pennsylvania, 67 A.3d 160 (Pa. Commw. Ct. 2013). · cites it 2× “) CMS, however, would not allow DPW to direct the MCOs on how to distribute the enhanced capitation payments called for in Act 49, because CMS determined that such a scheme would violate 42 C.F.R. § 438.60 . 4 (Pet-¶ 24.) In *167 stead, CMS indicated that it would only approve a…”
Sw. Pharmacy Solutions, Inc. v. Texas Health & Human Servs. Comm'n, 408 S.W.3d 549 (Tex. App.—Austin 2013). “; 42 C.F.R. 438.60. Thus, the record shows that HHSC considered alternatives that were legal and potentially viable but that it concluded there were legal and practical barriers making them infeasible.”
Armstrong Cnty. Mem'l Hosp. & Monongahela Valley Hosp., Inc. v. DPW, No. 438 M.D. 2012 (Pa. Commw. Ct. Oct. 16, 2017). “8 42 C.F.R. § 438.60 provides: The State agency must ensure that no payment is made to a network provider other than by the MCO, [the prepaid inpatient health plan (PIHP)], or [the prepaid ambulatory health plan (PAHP)] for services covered under the contract between the State…”
Sw. Pharmacy Solutions, Inc. v. Texas Health & Human Servs. Comm'n & Thomas Suehs, Solely, No. 03-12-00293-CV (Tex. App.—Austin July 12, 2013). “; 42 C.F.R. 438.60. Thus, the record shows that HHSC considered alternatives that were legal and potentially viable but that it concluded there were legal and practical barriers making them infeasible.”
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