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Code of Federal Regulations Title 42. Public Health § 42.422.352 Basic requirements

Current as of January 02, 2025 | Updated by Findlaw Staff

(a) General rule. An organization is considered a PSO for purposes of a MA contract if the organization—

(1) Has obtained a waiver of State licensure as provided for under § 422.370;

(2) Meets the definition of a PSO set forth in § 422.350 and other applicable requirements of this subpart;  and

(3) Is effectively controlled by the provider or, in the case of a group, by one or more of the affiliated providers that established and operate the PSO.

(b) Provision of services. A PSO must demonstrate to CMS's satisfaction that it is capable of delivering to Medicare enrollees the range of services required under a contract with CMS. Each PSO must deliver a substantial proportion of those services directly through the provider or the affiliated providers responsible for operating the PSO. Substantial proportion means—

(1) For a non-rural PSO, not less than 70% of Medicare services covered under the contract.

(2) For a rural PSO, not less than 60% of Medicare services covered under the contract.

(c) Rural PSO. To qualify as a rural PSO, a PSO must—

(1) Demonstrate to CMS that—

(i) It has available in the rural area, as defined in § 412.62(f) of this chapter, routine services including but not limited to primary care, routine specialty care, and emergency services;  and

(ii) The level of use of providers outside the rural area is consistent with general referral patterns for the area;  and

(2) Enroll Medicare beneficiaries, the majority of which reside in the rural area the PSO serves.

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.422.352 Basic requirements - last updated January 02, 2025 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-422-352/

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