Section 4: General Program Administration

32Revision: HCFA-PH-87-4 (BERC)

MARCH 1987OMB No. 0938-0193

Citation

SECTION 4 - GENERAL PROGRAM ADMINISTRATION

4.1 Methods of Administration42 CFR 431.15AT-79-29 The Medicaid agency employs methods of administration

found by the Secretary of Health and Human Servicesto be necessary for the proper and efficientoperation of the plan.

TN. No. 87-5

SupersedesTN No. 75-11

Approval Date 5-2-88 Effective Date 7-1-87HCFA ID:1010P/0012P

33Revision: HCFA-AT-80-38

MAY 22, 1980(BPP) OMB No.

State: District of Columbia

Citation42 CFR 431.202AT-79-29AT-80-34

4.2 Hearings for Applicants and Recipients

The Medicaid agency has a system of hearingsthat meets all the requirements of 42 CFR Part431, Subpart E.

TN. No. 75-11

SupersedesTN No.

Approval Date 6-7-76 Effective Date 10-1-75

34Revision: HCFA-AT-87-9 (BERC) OMB No. 0938-0193

August 1987

State/Territory: District of Columbia

Citation 4.3 Safeguarding Information on Applicants and Recipients42 CFR 431.301AT-79-29 Under State statute which imposes legal sanctions,

safeguards are provided that restrict the use ordisclosure of information concerning applicants andrecipients to purposes directly connected with theadministration of the plan.

52 FR 5967 All other requirements of 42 CFR Part 431, Subpart Fare met.

TN. No. 87-7 Approval Date 1988 Effective Date 2-19-88Supersedes HCFA ID:1010P/0012PTN No. 75-11

35Revision: HCFA-PM-87-4 (BERC)

MARCH 1987OMB No. 0938-0193

Citation

42 CFR 431.800(C)50 FR 21839§1903(u)(1)(D) ofthe Act,P.L. 99-509(Section 9407)


4.4 Medicaid Quality Control

(a) A system of quality control is implemented inaccordance with 42 CFR Part 431, Subpart P.

(b) The State operates a claims processing assessmentsystem that meets the requirements of 42 CFR431.800(e), (g), (h), (j) and (k).

Yes.

X Not applicable. The State has an approvedMedicaid Management Information system(MMIS).

TN. No. 87-5SupersedesTN No. 85-12

Approval Date 5-2-88 Effective Date 7-1-87HCFA ID:1010P/0012P

36Revision: HCFA-PM-88-10 (BERC) OMB No. 0938-0193

September 1988


Citation 4.5 Medicaid Agency Fraud Detection and Investigation42 CFR 455.12 ProgramAT-78-9048 FR 3742 The Medicaid agency has established and will maintain52 FR 48817 methods, criteria, and procedures that meet all

requirements of 42 CFR 455.13 through 455.21 and 42 CFR455.23 for prevention and control of program fraud andabuse.

TN. No. OX- Ota Approval D^IQV 2 "7 2002 Effective Dat-<=Supersedes" HCFA ID:1010P/0012PTN No. 84-13

37Revision: HCFA-AT-80-38 (BPP) OMB No.

MAY 22, 1980


Citation 4.6 Reports42 CFR 431.16AT-79-29 The Medicaid agency will submit all

reports in the form and with the contentrequired by the Secretary, and will complywith any provisions that the Secretaryfinds necessary to verify and assure thecorrectness of the reports. All requirements of 42CFR 431.16 are met.

TN. No. MA 78-4 Approval Date 4-28-78 Effective Date 10-1-77SupersedesTN No.


MAY 22, 1980


Citation 4.7 Maintenance of Records42 CFR 431.17AT-79-29 The Medicaid agency maintains or supervises

the maintenance of records necessary for theproper and efficient operation of the plan,including records regarding applications,determination of eligibility, the provision ofmedical assistance, emd administrative costsand statistical, fiscal and other recordsnecessary for reporting and accountability,and retains these records in accordance withFederal requirements. All requirements of 42CFR 431.17 are met.


39Revision: HCFA-AT-80-38 (BPP)

MAY 22, 1980OMB No.

Citation42 CFR 431.18(b)AT-79-29


4.8 Availability of Agency Program Manuals

Program manuals and other policy issuances that affect thepublic, including the Medicaid agency's rules andregulations governing eligibility, need and amount ofassistance, recipient rights and responsibilities, andservices offered by the agency are maintained in the Stateoffice and in each local and district office forexamination, upon request, by individuals for review,study, or reproduction. All requirements of 42 CFR 431.18are met.


TN. No. MA 75-6SupersedesTN No.

Approval Date 1-12-76 Effective Date 10-1-75


MAY 22, 1980

Citation 4.9 Reporting Provider Payments to Internal42 CFR 433.37 Revenue ServiceAT-78-90

There are procedures implemented inaccordance with 42 CFR 433.37 foridentification of providers of services bysocial security number or by employeridentification number and for reportingthe information required by the InternalRevenue Code (26 U.S.C. 6041) with respectto payment for service under the Plan.


41

New: HCFA-PM-99-3JUNE 1999


Citation

42CFR431.51AT 78-9046 FR 4852448 FR 232121902(a)(23)P.L. 100-93(section 8(f))P.L. 100-203(Section 4113)

Section 1902(a)(23)of the SocialSecurity ActP.L. 105-33

Section 1932(a)(l)Section 1905(t)

4.10 Free Choice of Providers

(a) Except as provided in paragraph (b), the Medicaid agencyassures that an individual eligible under the plan may obtainMedicaid services from any institution, agency, pharmacyperson, or organization that is qualified to perform the services,including an organization that provides these services orarranges for their availability on a prepayment basis.

(b) Paragraph (a) does not apply to services furnished to anindividual -

(1) Under an exception allowed under 42 CFR 431.54, subject tothe limitations in paragraph (c), or

(2) Under a waiver approved under 42 CFR 431.55, subject to thelimitations in paragraph (c), or

(3) By an individual or entity excluded from participation hiaccordance with section 1902(p) of the Act,

(4) By individuals or entities who have been convicted of a felonyunder Federal or State law and for which the State determines thatthe offense is inconsistent with the best interests of the individualeligible to obtain Medicaid services, or

(5) Under an exception allowed under 42 CFR 438.50 or42 CFR 440.168, subject to the limitations hi paragraph (c).

(c) Enrollment of an individual eligible for medical assistance in a primary carecase management system described hi section 1905(t), 1915(a), 1915(b)(l),or 1932(a); or managed care organization, prepaid inpatient health plan, aprepaid ambulatory health plan, or a similar entity shall not restrict thechoice of the qualified person from whom the individual may receiveemergency services or services under section 1905 (a)(4)(c).

TNNo. U~> ~(-SupersedesTN No. 02-06

Approval Date FFB 2 4 200! EffectiveA/uu


MAY 22, 1980


Citation 4.11 Relations with Standard-Setting and Survey42 CFR 431.610 AgenciesAT-78-90AT-80-34 (a) The State agency utilized by the Secretary

to determine qualifications of institutionsand suppliers of services to participate inMedicare is responsible for establishing andmaintaining health standards for private orpublic institutions (exclusive of ChristianScience sanatoria) that provide services toMedicaid recipients. This agency is:

THE DEPARTMENT OF HEALTH

(b) The State authority(ies) responsible forestablishing and maintaining standards, otherthan those relating to health, for public orprivate institutions that provide services toMedicaid recipients is (are):

THE DEPARTMENT OF HEALTH

(c) ATTACHMENT 4.11-A describes the standardsspecified in paragraphs (a) and (b) above, thatare kept on file and made available to the HealthCare Financing Administration on request.

TN. No.OA_-0\0 Approval Oft®, _ » nnfto Effective DateSupersedes NUV 6 I &JvLTN No. 87-1


MAY 22, 1980


Citation 4.11(d) The Department of Health42 CFR 431.610AT-78-90 (agency)AT-89-34 which is the State agency responsible

for licensing health institutions, determines ifinstitutions and agencies meet the requirementsfor participation in the Medicaid program. Therequirements in 42 CFR 431.610(e), (f), and (g)are met.

TN. No. OA-OVo Approval DdttAt/ n 7 Onno Effective Date .*|i ASupersedes '*uv & I 1UU£ J^i"TN No. 87-1

44Revision: HCFA-AT-80-38

MAY 22, 1980(BPP) OMB No.


Citation42 CFR 431.105(b)AT-78-90

4.12 Consultation to Medical Facilities

(a) Consultative services are providedby health and other appropriateState agencies to hospitals, nursingfacilities, health agencies, clinics andlaboratories in accordance with 42 CFR431.105(b).

(b) Similar services are provided toother type of facilities providingmedical care to individualsreceiving services under theprograms specified in 42 CFR 431.105(b).

Yes, as listed below:

Not applicable. Similarservices are not provided toother types of medicalfacilities.

TN. No. 74-3SupersedesTN No.

Approval Date 11-22-74 Effective Date 12-21-73HCFA ID: 7982E

45Revision: HCFA-PM-91-4

August 1991(BPD) OMB No. 0938

Citation

42 CFR 431.107


4.13 Required Provider Agreement

With respect to agreements between the Medicaid agencyand each provider furnishing services under the plan:

(a) For all providers, the requirements of 42 CFR431.107 and 42 CFR Part 442, Subparts A and B (ifapplicable) are met.

42 CFR Part 483§1919 of theAct

(b) For providers of NF services, the requirements of42 CFR Part 483, Subpart B, and section 1919of the Act are also met.

42 CFR Part 483,Subpart D

§1920 of the Act

(c) For providers of ICF/MR services, therequirements of participation in 42 CFR Part 483,Subpart D are also met.

(d) For each provider that is eligible under the planto furnish ambulatory prenatal care to pregnantwomen during a presumptive eligibility period,all the requirements of section 1920(b)(2) and(c) are met.

Not applicable. Ambulatory prenatal careis not provided to pregnant women during apresumptive eligibility period.

TN. No. 91-9SupersedesTN No. 87-5

Approval Date 11-30-93 Effective Date 10-31-91HCFA ID:7982E

Revision: HCFA-PM-91-9 (MB) OMB No.:October 1991

State/Territory: District of Columbia _

Citation1902(a)(58)1902(w) 4.13 (e) For each provider receiving funds under

the plan, all the requirements foradvance directives of section 1902(w) aremet:

(1) Hospitals, nursing facilities,providers of home health care orpersonal care services, hospiceprograms, managed care organizations, prepaid inpatienthealth plans, prepaid ambulatory health plans (unless thePAHP excludes providers in 42 CFR 489.102), and healthinsuring organizations are required to do thefollowing:

(a) Maintain written policies andprocedures with respect to alladult individuals receivingmedical care by or through theprovider or organization abouttheir rights under State law tomake decisions concerning medicalcare, including the right toaccept or refuse medical orsurgical treatment and the rightto formulate advance directives.

(b) • Provide written information to alladult individuals on theirpolicies concerning implementationof such rights;

(c) Document in the individual'smedical records whether or not theindividual has executed an advancedirective;

(d) Not condition the provision ofcare or otherwise discriminateagainst an individual based onwhether or not the individual hasexecuted an advance directive;

(e) Ensure compliance withrequirements of State Law (whether

TN No. 05- Ql Approval DatCh?J____F Effective Date".SupersedesTN No. New

45(b)

Revision: HCFA-PM-91-9 (MB) OMB No.:October 1991

State/Territory: District of Columbia _ __

statutory or recognized by thecourts) concerning advancedirectives; and

(f) Provide (individually or withothers) for education for staffand the community on issuesconcerning advance directives.

(2) Providers will furnish the writteninformation described in paragraph(l)(a) to all adult individuals atthe time specified below:

(a) Hospitals at the time anindividual is admitted as aninpatient.

(b) Nursing facilities when theindividual is admitted as aresident.

(c) Providers of home health care orpersonal care services before theindividual comes under the care ofthe provider;

(d) Hospice program at the time ofinitial receipt of hospice care bythe individual from the program;and

(e) Managed care organizations, health insuringorganizations, prepaid inpatient health plans, and prepaidambulatory health plans (as applicable) at the time ofenrollment of the individual with the organization.

(3) Attachment 4.34A describes law of theState (whether statutory or asRecognized by the courts of theState) concerning advance directives.

_ Not applicable. No State lawor court decision exists regardingadvance directives.

TNNo. f)Z~0\ Approval Dat Effective DateSupersedesTN No. New _

Revision: HCFA-PM-91-10 (MB)DECEMBER 1991


Citation42CFR431.6042 CFR 456.250 FR 153121902(a)(30)(C) and1902(d) of theAct, P.L. 99-509(Section 9431)

1932(c)(2)andl902(d)oftheACT, P.L. 99-509(section 9431)

4.14 Utilization/Quality Control

(a) A Statewide program of surveillance andutilization control has been implemented thatsafeguards against unnecessary or inappropriateuse of Medicaid services available under thisplan and against excess payments, and thatassesses the quality of services. Therequirements of 42 CFR Part 456 are met:

[X] Directly

[X] By undertaking medical and utilization reviewrequirements through a contract with a Utilization andQuality Control Peer Review Organization (PRO)designated under 42 CFR Part 462. The contract withthe PRO —

(1) Meets the requirements of §434.6(a):

(2) Includes a monitoring and evaluation plan toensure satisfactory performance;

(3) Identifies the services and providers subject toPRO review;

(4) Ensures that PRO review activities are notinconsistent with the PRO review of Medicareservices; and

(5) Includes a description of the extent to whichPRO determinations are considered conclusivefor payment purposes.

[X] A qualified External Quality Review Organizationperforms an annual External Quality Review that meetsthe requirements of 42 CFR 438 Subpart E eachmanaged care organization, prepaid inpatient healthplan, and health insuring organizations under contract,except where exempted by the regulation

TNNo.SupersedesTN No. 87-7

06-01 Approval Datej Effective Date


MAY 1985


Citation 4.14 (b) The Medicaid agency meets the requirements42 CFR 456.2 of 42 CFR Part 456, Subpart C, for50 FR 15312 control of the utilization of inpatient

hospital services.

X Utilization and medical review areperformed by a Utilization and QualityControl Peer Review organization designatedunder 42 CFR Part 462 that has a contractwith the agency to perform those reviews.

Utilization review is performed inaccordance with 42 CFR Part 456, Subpart H,that specifies the conditions of a waiverof the requirements of Subpart C for:

All hospitals (other than mentalhospitals).

Those specified in the waiver.

X No waivers have been granted.

TN. No. 85-5 Appr-oval n^t-*? 8-20-85 Effective Date 4 1 0 5SupersedesTN No. 82-11Supersedes HCFA ID: 0048P/0002P


JULY 1985


Citation 4.14 c. The Medicaid agency meets the requirements42 CFR 456.2 of 42 CFR Part 456, Subpart D, for control50 FR 15312 of utilization of inpatient services in mental

hospitals.

X Utilization and medical review areperformed by a Utilization and QualityControl Peer Review Organization designatedunder 42 CFR Part 462 that has a contractwith the agency to perform those reviews.

Utilization review is performed inaccordance with 42 CFR Part 456, Subpart H,that specifies the conditions of a waiverof the requirements of Subpart D for:

All mental hospitals.



Not applicable. Inpatient services in mentalhospitals are not provided under this plan.

TN. No » R -1 2 Approval Date Effective Liace 7-1-85

Supersedes HCFA ID:0048P/0002PTN No. 85-5


MAY 1985


Citation 4.14 (d) The Medicaid agency meets the requirements of42 CFR 456.2 42 CFR Part 456, Subpart E, for the control of50 FR 15312 utilization of skilled nursing facility

services.

X Utilization and medical review areperformed by a Utilization and QualityControl Peer Review Organization designatedunder 42 CFR Part 462 that has a contractwith the agency to perform those reviews.

Utilization review is performed inaccordance with 42 CFR Part 456, Subpart H,that specifies the conditions of a waiverof the requirements of Subpart E for:

All skilled nursing facilities.



TN. No. 85-5 Approval Date 8 20-05 Effective Date 4-1-85SupersedesTN No. 82-11Supersedes HCFA ID:0048P/0002P


MAY 1985


Citation 4.14 X (e) The Medicaid agency meets the requirements42 CFR 456.2 of 42 CFR Part 456, Subpart F, for control50 FR 15312 of the utilization of intermediate care

facility services. Utilization review infacilities is provided through:

Facility-based review.

Direct review by personnel of the medicalassistance unit of the State agency.

Personnel under contract to the medicalassistance unit of the State agency.

Utilization and Quality Control PeerReviewOrganizations.

Another method as described in ATTACHMENT4.14-A.

X Two or more of the above methods.ATTACHMENT 4.14-B describes thecircumstances under which each method isused.

Not applicable. Intermediate care facilityservices are not provided under this plan.

TN. NO. 85-5 Approval Date 8-20-85 Effective DdLe 4-1-85Supersedes HCFA ID:0048P/0002PTN No. 82-11

Revision: HCFA-PM-91-10 (MB)December 1991

Citation


4.14 Utilization/Quality Control (Continued)

42 CFR 438.356(e)

42 CFR 438.35442CFR438.356(b)and(d)

For each contract, the State must follow an open,competitive procurement process that is in accordance with State lawand regulations and consistent with 45 CFR part 74 as it applies toState procurement of Medicaid services.

The State must ensure that an External Quality Review Organizationand its subcontractors performing the External Quality Review orExternal Quality Review-related activities meets the competence andindependence requirements.

Not applicable.

TNNo.SupersedesTN No. 87-5..

Approval Date* Effectivefl

Documents

Section 4: General Program Administration