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 J—Conditions for Federal Financial Participation (FFP)

42 C.F.R. § 438.806

Prior approval

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(a) Comprehensive risk contracts. FFP is available under a comprehensive risk contract only if all of the following apply:

(1) CMS has confirmed that the contractor meets the definition of an MCO or is one of the entities described in paragraphs (b)(2) through (5) of § 438.3.

(2) The contract meets all the requirements of section 1903(m)(2)(A) of the Act, the applicable requirements of section 1932 of the Act, and the provisions of this part.

(b) MCO contracts. Prior approval by CMS is a condition for FFP under any MCO contract that extends for less than one full year or that has a value equal to, or greater than, the following threshold amounts:

(1) For 1998, the threshold is $1,000,000.

(2) For subsequent years, the amount is increased by the percentage increase in the consumer price index for all urban consumers.

(c) FFP is not available in an MCO contract that does not have prior approval from CMS under paragraph (b) of this section.

Notes of Decisions
Cited in 2 cases, 2011–2016 · leading case: Medevac MidAtlantic, LLC v. Keystone Mercy Health Plan, 817 F. Supp. 2d 515 (E.D. Pa. 2011).
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Medevac MidAtlantic, LLC v. Keystone Mercy Health Plan, 817 F. Supp. 2d 515 (E.D. Pa. 2011). “§ 1396b(m)(2)(A)(iii)); see also 42 C.F.R. §§ 438.806 (b), 438.6. 10 . See Am.”
Appalachian Reg'l Healthcare, Inc. v. Coventry Health & Life Ins. Co., 214 F. Supp. 3d 606 (E.D. Ky. 2016). “§ 1396b(m); 42 C.F.R. § 438.806 . CMS approved each of the contracts, including the designated capitation rates, for the period of November 1, 2011 to June 30, 2014.”
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