42 C.F.R. § 447.304
Adherence to upper limits; FFP
(a) The Medicaid agency must not pay more than the upper limits described in this subpart.
(b) In the case of payments made under the plan for deductibles and coinsurance payable on an assigned Medicare claim for noninstitutional services, those payments may be made only up to the reasonable charge under Medicare.
(c) FFP is not available for a State's expenditures for services that are in excess of the amounts allowable under this subpart.
The Secretary may waive any limitation on reimbursement imposed by subpart F of this part for experiments conducted under section 402 of Pub. L. 90-428, Incentives for Economy Experimentation, as amended by section 222(b) of Pub. L. 92-603, and under section 222(a) of Pub. L. 92-603.
Notes of Decisions
Cited in 6
cases, 1982–2019 · leading case: State v. Campbell, 438 P.3d 448 (Or. Ct. App. 2019).
State v. Campbell, 438 P.3d 448 (Or. Ct. App. 2019). “42 CFR § 447.304 (2017). CMS also reviews and approves all of Oregon contracts with managed care organizations and requires that capitation rates-periodic payments to the contractors on behalf of health program beneficiaries-be actuarially sound.”
Pennsylvania Pharm. Ass'n v. Dep't of Pub. Welfare, 542 F. Supp. 1349 (W.D. Pa. 1982). “1982) does require that payments be consistent with quality care, but, as we indicate later, the pharmaceutical plaintiffs do not have standing to challenge the State’s reimbursement schedule on the basis that these payments have deprived medicaid recipients access to quality…”
In Re Pharm. Indus. Average Wholesale Price Litig., 457 F. Supp. 2d 65 (D. Mass. 2006). “See 42 C.F.R. §§ 447.304 ; 447.331-334. The state must also comprehensively describe its payment methodology for prescription drugs and assure CMS that it is in compliance with established FULs.”
Pharm. Soc'y of New York, Inc. v. Cuomo, 856 F.2d 497 (2d Cir. 1988). “28,648, 28,649 (1987); see 42 C.F.R. § 447.304 (a), (c) (1987). On November 18, 1987, Social Services published notice of proposed amendments to N.”
Still's Pharmacy, Inc. v. Cuomo, 981 F.2d 632 (2d Cir. 1992). “See 42 C.F.R. §§ 447.304 , 447.331-.332 (1991).”
Pharm. Soc'y of New York, Inc. v. New York State Dep't of Soc. Servs., 50 F.3d 1168 (2d Cir. 1995). “See 42 C.F.R. §§ 447.304 , 447.331-.332 (establishing limits).”
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