Early and periodic screening, diagnosis, and treatment (EPSDT) program--HCFA. Final rule

This final rule modifies present regulations to conform to legislative changes enacted by section 2181 of Pub. L. 97-35, the Omnibus Budget Reconciliation Act of 1981. That section eliminates the penalty which reduces by one percent Federal funds for a State's Title IV-A program, Aid to Families with Dependent Children (AFDC), for any quarter during which a State fails to: (1) Inform all AFDC families of the availability of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), services; (2) provide or arrange for requested screening services; and (3) arrange for corrective treatment of health problems found as a result of screening. In addition, even though the penalty has been eliminated, section 2181 mandates that States incorporate these three requirements into their Medicaid State plan with respect to all EPSDT eligibles. Further, this rule modifies current regulations to reflect Congressional intent that while States should continue to develop fully effective EPSDT programs, the Federal government should work to reduce current reporting requirements which entail a large volume of paperwork.     

Medicaid and Title IV-E programs; revision to the definition of an unemployed parent--Administration for Children and Families (ACF) and HCFA. Final rule with comment period

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) transformed the nation's welfare system into one that requires work in exchange for time-limited assistance. The law eliminated the Aid to Families with Dependent Children (AFDC) program and replaced it with the Temporary Assistance for Needy Families (TANF) program. The law provides States flexibility to design their TANF programs in ways that strengthen families and promote work, responsibility, and self-sufficiency while holding them accountable for results. Many States are using this flexibility to provide welfare to work assistance to two parent families, which was more difficult to do under the old welfare rules. However, pre-existing regulations regarding the definition of "unemployed parent" prevent some States from providing intact families with health insurance to help them stay employed. This rule will eliminate this vestige of the old welfare system in order to promote work, strengthen families, and simplify State program administration. In general under PRWORA, States must ensure that families who would have qualified for Medicaid health benefits under the prior welfare law are still eligible. While under the previous law receipt of AFDC qualified families for Medicaid, the new statute does not tie receipt of TANF to Medicaid. Instead, subject to some exceptions, Medicaid eligibility for families and children now depends upon whether a family would have qualified for AFDC under the rules in effect on July 16, 1996. Similarly, Federal foster care eligibility depends on whether the child would have qualified for AFDC under the rules in effect on July 16, 1996. In order for a family to qualify for assistance under the pre-PRWORA AFDC rules, its child had to be deprived of parental support or care due to the death, absence, incapacity, or unemployment of a parent. Two parent families generally qualified only under the "unemployment" criterion which was narrowly defined in the AFDC regulations. In this final rule with comment, we are amending these regulations to provide States with additional flexibility to provide Medicaid coverage to two parent families, facilitate coordination among the TANF, Medicaid and foster care programs, increase incentives for fulltime work, and allow States to eliminate inequitable rules that are a disincentive to family unity.     

Medicaid program; eligibility and coverage requirements--HCFA. Final rule with comment period

These regulations amend the requirements for coverage of certain groups of individuals under Medicaid and the requirements for determining Medicaid eligibility. The regulations relate to coverage of individuals in optional categorically needy groups; aged, blind and disabled individuals in States that use more restrictive requirements for Medicaid than those under the Supplemental Security Income (SSI) program; individuals receiving optional State supplementary payments; individuals under age 21 who are not receiving AFDC; individuals who are ineligible for cash assistance under the Social Security Act because of requirements that do not apply under Medicaid; and medically needy groups. In addition, the regulations revise the methodologies for determining income and resource eligibility under Medicaid, including financial responsibility of relatives, and for determining financial eligibility of medically needy groups, including determining medically needy income levels. These regulations interpret provisions of the Tax Equity and Fiscal Responsibility Act of 1982, as amended by several acts, including, most recently, the Omnibus Budget Reconciliation Act of 1987, the Medicare Catastrophic Coverage Act of 1988, the Family Support Act of 1988, the Omnibus Budget Reconciliation Act of 1989, and the Omnibus Budget Reconciliation Act of 1990. We are also making some administrative changes to achieve more efficient operation of the Medicaid Program.     

Cooperation in identifying and providing information to assist states in pursuing third party health coverage--Family Support Administration, HHS. Final rule

This final rule implements section 12304 of the Consolidated Budget Reconciliation Act (COBRA) of 1985 which requires each applicant or recipient to cooperate with the State in identifying and providing information to assist States in pursuing any third party who may be liable to pay for care and services available under State plans for medical assistance under title XIX, unless such individual has good cause for refusing to cooperate as determined by the State agency in accordance with standards prescribed by the Secretary. The regulations are applicable to the AFDC program in all jurisdictions.     

Supplemental security income for the aged, blind, and disabled; federal administration of State supplementary payments to individuals in Medicaid facilities--SSA. Final rule

These final regulations reflect section 12201(b) of Public Law 99-272 (the Consolidated Omnibus Budget Reconciliation Act of 1985, enacted April 7, 1986). Section 12201(b) permits Federal administration of optional State supplementary payments to individuals in medical facilities that receive little XIX (Medicaid) funds at a level exceeding 50 percent of the cost of their care (Medicaid facilities). Currently, the regulations prohibit Federal administration of optional State supplementary payments to a person who, throughout any month, is in a Medicaid facility. Under these regulations States will have the option of having the Social Security Administration (SSA) administer optional State supplementary payments to these individuals. States will be limited to one State supplementary payment level variation for residents of Medicaid facilities (Federal living arrangement "D").     

Medicaid program; Medicaid managed care--HCFA. Proposed rule

This proposed rule would amend the Medicaid regulations to allow the States greater flexibility by giving them the option to require Medicaid recipients to enroll in managed care entities without obtaining waivers. These revisions, which are authorized by the Balanced Budget Act of 1997, would establish new beneficiary protections in areas such as quality assurance, grievance rights, and coverage of emergency services. They would eliminate certain requirements viewed by State agencies as impediments to the growth of managed care programs, such as the enrollment composition requirement, the right to disenroll without cause at any time, and the prohibition against enrollee cost-sharing. They would also permit State agencies to amend their State plans to require enrollment in managed care organizations subject to certain conditions, including limits on whose enrollment can be mandated, and a requirement for beneficiary choice. In addition, this rule would extend most of these new requirements to prepaid health plans.     

Child support enforcement program; extension of services to Medicaid recipients and to former AFDC recipients--Office of Child Support Enforcement, HHS. Final rule

These final rules implement sections 9141 and 9142 of Public Law 100-203, the Omnibus Budget Reconciliation Act of 1987, which amended title IV-D of the Social Security Act (the Act). Section 9141, effective December 22, 1987, amended section 457(c) of the Act to require State child support enforcement (IV-D) agencies to provide appropriate notice and to continue to provide IV-D services to persons no longer eligible for Aid to Families with Dependent Children (AFDC) under title IV-A of the Act. The IV-D agency must continue to provide services and pay any amount of support collected to the family on the same basis and under the same conditions as pertain to other non-AFDC families, except that no application, other request to continue services or any application fee for services may be required. Section 9142, effective July 1, 1988, amended section 454 of the Act to require State IV-D agencies to provide IV-D services to families who receive Medicaid and have assigned to the State, under section 1912 of the Act, their rights to medical support and to payment of medical care from any third party, and to provide for distribution by the State of medical support collections under section 1912 of the Act.     

Medicaid program: outstation intake locations for certain low-income pregnant women, infants, and children under age 19--HCFA. Interim final rule with comment period

This interim final rule interprets the statutory requirement that State Medicaid agencies must provide for receiving and initially processing Medicaid applications by certain low-income pregnant women, infants, and children under age 19 at locations other than those used for the receipt and processing of applications for Aid to Families with Dependent Children (AFDC). The statutory requirement also provides that the application form for these individuals must be different from the application form used for AFDC. The basis for the rule is section 1902(a)(55) of the Social Security Act, as added by section 4602(a)(3) of the Omnibus Budget Reconciliation Act of 1990.     

Medicaid program; Medicaid managed care. Health Care Financing Administration (HCFA), HHS. Final rule with comment period

This final rule with comment period amends the Medicaid regulations to implement provisions of the Balanced Budget Act of 1997 (BBA) that allow the States greater flexibility by permitting them to amend their State plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without obtaining waivers if beneficiary choice is provided; establish new beneficiary protections in areas such as quality assurance, grievance rights, and coverage of emergency services; eliminate certain requirements viewed by State agencies as impediments to the growth of managed care programs, such as the enrollment composition requirement, the right to disenroll without cause at any time, and the prohibition against enrollee cost-sharing. In addition, this final rule expands on regulatory beneficiary protections provided to enrollees of prepaid health plans (PHPs) by requiring that PHPs comply with specified BBA requirements that would not otherwise apply to PHPs.     

Medicaid program; Medicaid Management Information System (MMIS) performance review; notification procedures for changes in requirements, performance standards, and reapproval conditions--HCFA. Final rule

This rule eliminates the requirement in the Medicaid regulations that HCFA meet certain Federal Register notification requirements for any changes in performance standards and other conditions for reapproval of State Medicaid Management Information Systems (MMISs), even if such Federal Register notice would not otherwise be required. An independent Federal Register publication requirement will remain in place with respect to changes in system requirements and other conditions for approval of MMISs. We believe that a revised process for notifying States and other concerned parties of changes in performance standards and other conditions of reapproval is appropriate and will facilitate the efficient issuance of revised MMIS review requirements and methodologies each year.     

Medicaid program; qualified family members--HCFA. Final rule

Under the Aid to Families with Dependent Children (AFDC) program, certain States may elect to limit the number of months of benefits provided to families who are eligible by reason of the unemployment of the principal wage earner. This final rule ensures that States that exercise this option continue to provide Medicaid to qualified family members beyond the time when AFDC ends solely because of the State's election of a time limit. This final rule conforms the regulations with sections 1902(a)(10)(A)(i)(V) and 1905(m) of the Social Security Act, as added by section 401(d) of the Family Support Act of 1988.     

Medicare, Medicaid, and Children's Health Insurance Programs; additional screening requirements, application fees, temporary enrollment moratoria, payment suspensions and compliance plans for providers and suppliers. Final rule with comment period

This final rule with comment period will implement provisions of the ACA that establish: Procedures under which screening is conducted for providers of medical or other services and suppliers in the Medicare program, providers in the Medicaid program, and providers in the Children's Health Insurance Program (CHIP); an application fee imposed on institutional providers and suppliers; temporary moratoria that may be imposed if necessary to prevent or combat fraud, waste, and abuse under the Medicare and Medicaid programs, and CHIP; guidance for States regarding termination of providers from Medicaid and CHIP if terminated by Medicare or another Medicaid State plan or CHIP; guidance regarding the termination of providers and suppliers from Medicare if terminated by a Medicaid State agency; and requirements for suspension of payments pending credible allegations of fraud in the Medicare and Medicaid programs. This final rule with comment period also discusses our earlier solicitation of comments regarding provisions of the ACA that require providers of medical or other items or services or suppliers within a particular industry sector or category to establish compliance programs. We have identified specific provisions surrounding our implementation of fingerprinting for certain providers and suppliers for which we may make changes if warranted by the public comments received. We expect to publish our response to those comments, including any possible changes to the rule made as a result of them, as soon as possible following the end of the comment period. Furthermore, we clarify that we are finalizing the adoption of fingerprinting pursuant to the terms and conditions set forth herein.     

Medicaid program; freedom of choice waiver; conforming changes--HCFA. Interim final rule with comment period

This interim final rule amends existing Medicaid regulations on freedom of choice waivers granted under section 1915(b) of the Social Security Act (the Act) to conform them to the amendments made to the Act by sections 4604 and 4742 of the Omnibus Budget Reconciliation Act of 1990. This rule: Specifies that the Secretary may not waive the requirement that the State plan provide for adjustments in payment for inpatient hospital services furnished to infants under one year of age, or to children under 6 years of age who receive these services in disproportionate share hospitals. Extends to any provider participating under a section 1915(b)(4) waiver the same prompt payment standards that apply to all other health care practitioners furnishing Medicaid services. This rule also makes technical changes in the regulations relating to a recipient's free choice of providers of family planning services and cost-sharing requirements under waivers.     

Medicaid program; Medicaid managed care: new provisions. Final rule

This final rule amends the Medicaid regulations to implement provisions of the Balanced Budget Act of 1997 (BBA) that allow the States greater flexibility by permitting them to amend their State plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without obtaining waivers if beneficiary choice is provided; establish new beneficiary protections in areas such as quality assurance, grievance rights, and coverage of emergency services; and eliminate certain requirements viewed by State agencies as impediments to the growth of managed care programs, such as, the enrollment composition requirement, the right to disenroll without cause at any time, and the prohibition against enrollee cost-sharing.     

Medicaid program; home and community-based services. Health Care Financing Administration (HCFA), HHS. Final rule with comment period

This final rule with comment period expands State flexibility in providing prevocational, educational, and supported employment services under the Medicaid home and community-based services waiver provisions currently found in section 1915(c) of the Social Security Act (the Act); and incorporates the self-implementing provisions of section 4743 of the Balanced Budget Act of 1997 that amends section 1915(c)(5) of the Act to delete the requirements that an individual have prior institutionalization in a nursing facility or intermediate care facility for the mentally retarded before becoming eligible for the expanded habilitation services. In addition, we are making a number of technical changes to update or correct the regulations.     

Medicaid Program; Medicaid eligibility quality control, progressive reductions in federal financial participation for FYs 1982-84, payment for physician billing for clinical laboratory services, and utilization control of skilled nursing facility services: removal of obsolete requirements--HCFA. Final rule

This final rule removes several obsolete sections of the Medicaid regulations that specify rules and procedures for disallowing Federal financial participation for erroneous medical assistance payments due to eligibility and beneficiary liability errors as detected through the Medicaid eligibility quality control program for assessment periods from 1980 through June 1990. The Medicaid regulations that contain the rules and procedures for the progressive reductions in Federal financial participation in medical assistance expenditures made to the States for fiscal years 1982 through 1984 are removed to reflect the repeal of the statutory bases for the reductions. The Medicaid regulations that provide for physician billing for clinical laboratory services that a physician bills or pays for but did not personally perform or supervise are removed to reflect the statutory repeal of this provision. In addition, the rule removes obsolete regulations that prescribe requirements concerning utilization control of Medicaid services furnished in skilled nursing facilities. This rule is part of the Department's initiate to reinvent health care regulations and eliminate obsolete requirements.     

Medicaid program; coverage of personal care services--HCFA. Final rule

This final rule specifies the revised requirements for Medicaid coverage of personal care services furnished in a home or other location as an optional benefit, effective for services furnished on or after October 1, 1994. In particular, this final rule specifies that personal care services may be furnished in a home or other location by any individual who is qualified to do so. This rule conforms the Medicaid regulations to the provisions of section 13601(a)(5) of the Omnibus Budget Reconciliation Act of 1993, which added section 1905(a)(24) to the Social Security Act. Additionally, we are making two minor changes to the Medicaid regulations concerning home health services.     

Aid to Families with Dependent Children; extension of Medicaid when support collection results in termination of eligibility--HHS. Final rule

These final rules interpret section 20 of the Child Support Enforcement Amendments of 1984, as amended by section 303(e) of the Family Support Act of 1988, and section 8003 of the Omnibus Budget Reconciliation Act of 1989. The 1984 law extended Medicaid coverage for a period of four months to certain dependent children and adult relatives who become ineligible for Aid to Families with Dependent Children (AFDC) as a result, wholly or partly, of the collection or increased collection of child or spousal support under title IV-D of the Social Security Act (the Act). The regulations are applicable to the AFDC and Medicaid programs in all jurisdictions.     

Waiver of certain membership requirements for certain health maintenance organizations (HMOs), and state option for disenrollment restrictions for certain HMOs under Medicaid--HCFA. Final rule

These regulations revise current Medicaid rules to bring them into conformity with statutory changes that (1) expanded the waiver authority of the Secretary to permit certain health maintenance organizations (HMOs) meeting specified requirements to exceed the composition of enrollment limit, (2) permitted certain organizations to contract on a risk basis, (3) permitted continuation of benefits to recipients enrolled in certain organizations after they have lost entitlement to Medicaid, and (4) granted States the option of restricting a Medicaid enrollee's right to disenroll from certain types of risk HMOs and other organizations. The statutory changes that are reflected in these regulations were enacted in section 2364 of the Deficit Reduction Act of 1984, as amended by section 9517 of the Consolidated Omnibus Budget Reconciliation Act of 1985 and section 4113 of the Omnibus Budget Reconciliation Act of 1987. We are also making a technical correction concerning HMO and PHP contracts.