The following payment practices shall not be treated as a criminal offense under section 1128B of the Act and shall not serve as the basis for an exclusion:
Contract health care provider means an individual or entity under contract with a health plan to furnish items or services to enrollees who are covered by the health plan, Medicare, or a State health care program.
Enrollee means an individual who has entered into a contractual relationship with a health plan (or on whose behalf an employer, or other private or governmental entity has entered into such a relationship) under which the individual is entitled to receive specified health care items and services, or insurance coverage for such items and services, in return for payment of a premium or a fee.
Health plan means an entity that furnishes or arranges under agreement with contract health care providers for the furnishing of items or services to enrollees, or furnishes insurance coverage for the provision of such items and services, in exchange for a premium or a fee, where such entity:
Note to paragraph (w): For purposes of this paragraph, the term "health center" means a Federally Qualified Health Center under section 1905(l)(2)(B)(i) or 1905(l)(2)(B)(ii) of the Act, and "medically underserved population" means a medically underserved population as defined in regulations at 42 CFR 51c.102(e) .
Note to paragraph (x): For purposes of paragraph (x) of this section, group practice shall have the meaning set forth at 42 CFR 411.352 ; member of the group practice shall mean all persons covered by the definition of "member of the group or member of a group practice" at 42 CFR 411.351 , as well as other prescribing health care professionals who are owners or employees of the group practice; prescribing health care professional shall mean a physician or other health care professional licensed to prescribe drugs in the State in which the drugs are dispensed; PDP sponsor or MA organization shall have the meanings set forth at 42 CFR 423.4 and 422.2 , respectively; prescription information shall mean information about prescriptions for drugs or for any other item or service normally accomplished through a written prescription; and electronic health record shall mean a repository of consumer health status information in computer processable form used for clinical diagnosis and treatment for a broad array of clinical conditions.
42 C.F.R. §1001.952
For FEDERAL REGISTER citations affecting § 1001.952 , see the List of CFR Sections Affected, which appears in the Finding Aids section of the printed volume and at www.govinfo.gov.
Effective Date Note: At 88 FR 90126, Dec. 29, 2023, § 1001.952(h)(5) (viii), (h)(6) through (9), (cc), and (dd) were stayed, effective Dec. 29, 2023, until Jan. 1, 2032.