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.     

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; 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.     

Medicaid program; model Medicaid application form--HCFA. Notice

This notice publishes a model Medicaid application form that States have the option of using in full, in part, with modification or not at all. It would be used for noninstitutionalized individuals applying for benefits under title XIX of the Social Security Act who are not receiving cash assistance under the Aid to Families with Dependent Children (AFDC) program, Part A of title IV of the Social Security Act. This notice is published in accordance with section 6506(b) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239), which requires the Secretary to develop a model Medicaid application form for publication in the Federal Register.     

Medicaid program; early and periodic screening, diagnosis, and treatment (EPSDT) program--HCFA. Proposed rule

This proposal would modify present regulations to conform to recent 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 States'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. In addition, section 2181 mandates that States incorporate these three requirements into their State Medicaid plan with respect to all EPSDT eligibles. Further, this proposed rule would modify current Medicaid EPSDT regulations to reflect Congressional intent that States should continue to develop fully effective EPSDT programs; however, current requirements which entail a large volume of paperwork should be significantly streamlined.     

Medicare and Medicaid programs; revaluation of assets--HCFA. Final rule

This final rule revises the Medicare and Medicaid regulations that are affected by section 2314 of the Deficit Reduction Act of 1984 and sections 9110 and 9509 of the Consolidation Omnibus Budget Reconciliation Act of 1985. Those provisions amended sections 1861(v)(1) and 1902(a)(13) of the Social Security Act. This rule describes new limitations on the valuation of assets acquired as the result of changes in ownership occurring on or after July 18, 1984. These changes affect hospitals and skilled nursing facilities under the Medicare program and hospitals, nursing facilities, and intermediate care facilities for the mentally retarded under the Medicaid program.     

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.     

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.     

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.     

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; deadline for submitting moratorium state plan amendments--HCFA. Notice

This notice announces the deadline for Medicaid State agencies to submit State plan amendments requesting moratorium protection under section 2373(c) of the Deficit Reduction Act of 1984, as amended by the Medicare and Medicaid Patient and Program Protection Act of 1987. Section 2373(c) initiated a moratorium period during which HCFA cannot take any compliance, disallowance, penalty or other regulatory action against a State agency whose State plan contains an income or resource methodology or standard for determining eligibility for medically needy and certain categorically needy groups that is less restrictive than the required standard or methodology. This notice provides formal notification to States that plan amendments requesting moratorium protection will not be accepted after the last day of the first full calendar quarter following publication of this notice in the Federal Register.     

Medicaid program; modification of certain requirements for health insuring organizations--HCFA. Final rule

This final rule implements statutory changes which expressly made certain Health Insuring Organizations (HIOs) subject to Medicaid Health Maintenance Organization (HMO) rules. The statute implemented in this rule requires that an HIO which became operational on or after January 1, 1986, and arranges for comprehensive health services for Medicaid recipients on a risk basis be subject to HMO requirements. The statute also provides that exemptions from certain HMO rules are permitted for HIOs which began operation on or after January 1, 1986, if the HIOs are operating under a section 1915(b) waiver obtained prior to that date, or if an HIO is otherwise identified in the law. The exemptions continue as long as the waiver under section 1915(b) of the Social Security Act remains in effect. The statutory provisions implemented in this rule were enacted in section 9517(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended by section 9435(e) of the Omnibus Budget Reconciliation Act of 1986, and section 1895(c)(4) of the Tax Reform Act of 1986.     

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.     

Medicare and Medicaid programs; OBRA '87 conforming amendments--HCFA. Final rule with comment period

These regulations amend certain sections of Medicare and Medicaid rules to reflect 15 self-executing provisions of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) and changes made by sections 102, 103, and 211(b) of the Medicare Catastrophic Coverage Act of 1988 (MCCA), section 608(d)(3)(G) of the Family Support Act of 1988 (Pub. L. 100-485), and sections 6113 and 6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). They also clarify related rules. The amendments are needed to make HCFA rules consistent with current provisions of law and to ensure that users of the regulations are not confused by outdated provisions or unclear language. This document also makes technical amendments, primarily to correct internal cross-references, make nomenclature changes, and revise an outdated definition.     

Medicaid program; required coverage of nurse practitioner services--HCFA. Final rule

This final rule stipulates the requirements for coverage of and payment for pediatric and family nurse practitioner services under the Medicaid program. The coverage of these additional services under the Medicaid program increases the availability and accessibility of medical care for specified Medicaid recipients. This final rule adds to the Medicaid regulations provisions of sections 1902(a)(10)(A) and 1905(a)(21) of the Social Security Act, as amended by section 6405 of the Omnibus Budget Reconciliation Act of 1989.     

The role of substitutes in policy analysis: acute care services in state Medicaid programs

Using four acute care equations (inpatient, physician, outpatient, and clinic) from a larger model of Medicaid, this research examines the "contents" of policy outcomes. This closer examination of outcomes brings to light the interactions between redistributive programs and services and the role of substitutes and complements in state-level policy analysis. (A substitute is a benefit or service that can be used instead of another to produce a similar outcome; a complement is a benefit or service that is likely to result in the use of another benefit or service.) Support is found for the inclusion of these theoretical constructs in policy analysis. Regarding Medicaid, the author concludes that physician, outpatient, and clinic services all complement hospital services; that physician and outpatient services substitute for one another; that state AFDC and SSI policy decisions have a greater impact on utilization than Medicaid-specific eligibility and service decisions do; and that the factors driving utilization (supply, demand, etc.) vary dramatically across acute care settings. The implications for Medicaid policymaking are also discussed.     

Medicaid program; state plan requirements and other provisions relating to state third party liability programs--HCFA. Final rule

This final rule implements certain Medicaid State plan requirements and other provisions relating to State third party liability (TPL) programs. Its provisions deal with: (1) The integration of a State's pursuit of third party claims with its Mechanized Claims Processing and Information Retrieval System; (2) exceptions to the cost avoidance method of claims payment in TPL situations; and (3) provider restrictions and penalties related to attempts at collection of cost sharing or portions of those amounts from Medicaid recipients when TPL has been established. These regulations implement portions of section 9503 of the Consolidated Omnibus Budget Reconciliation Act of 1985.     

Medicaid Integrity Program; eligible entity and contracting requirements for the Medicaid Integrity audit program. Final rule

Section 1936 of the Social Security Act (the Act) (as added by section 6034 of the Deficit Reduction Act of 2005 (DRA) established the Medicaid Integrity Program to promote the integrity of the Medicaid program by requiring CMS to enter into contracts with eligible entities to: (1) Review the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk, or other basis) for which payment may be made under an approved State plan and/or any waiver of such plan approved under section 1115 of the Act; (2) audit claims for payment of items or services furnished, or administrative services rendered, under a State plan; (3) identify overpayments to individuals or entities receiving Federal funds; and (4) educate providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care. This final rule will provide requirements for an eligible entity to enter into a contract under the Medicaid integrity audit program. The final rule will also establish the contracting requirements for eligible entities. The requirements will include procedures for identifying, evaluating, and resolving organizational conflicts of interest that are generally applicable to Federal acquisition and procurement; competitive procedures to be used; and procedures under which a contract may be renewed.     

Medicaid program; State share of financial participation--HCFA. Interim final rule with comment

Under certain circumstances, States are currently permitted to use voluntary contributions (donated funds) from providers and all revenues from State-imposed taxes, as the State share of the costs of the Medicaid program. There is now widespread use of State donations or other voluntary provider payment programs that unfairly affect the Federal share of Federal Financial Participation (FFP). This practice circumvents the States' statutory obligation to expend funds for medical assistance. Therefore, effective January 1, 1992, this interim final rule requires that the amount of funds donated from Medicaid providers be offset from Medicaid expenditures incurred on or after this date before calculating the amount of FFP in Medicaid expenditures. It also interprets section 4701(b)(2) of the Omnibus Budget Reconciliation Act of 1990, which added section 1903(i)(10) to the Social Security Act. Section 1903(i)(10), precludes Federal Financial Participation (FFP) in State payments to hospitals, nursing facilities, and intermediate care facilities for the mentally retarded for facility expenditures that are attributable to provider-specific State taxes.     

Medicare program; prospective payment system for long-term care hospitals: implementation and FY 2003 rates. Final rule

This final rule establishes a prospective payment system for Medicare payment of inpatient hospital services furnished by long-term care hospitals (LTCHs) described in section 1886(d)(1)(B)(iv) of the Social Security Act (the Act). This final rule implements section 123 of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA) and section 307(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 123 of the BBRA directs the Secretary to develop and implement a prospective payment system for LTCHs. The prospective payment system described in this final rule replaces the reasonable cost-based payment system under which LTCHs are currently paid.