Medicaid

Health Hippo: Medicaid

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER

That which is used – develops. That which is not used wastes away.

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U.S. Code

• Affordable Care Act: Role of Public Programs
  • Sec. 2001. Medicaid coverage for the lowest income populations.
  • Sec. 2002. Income eligibility for nonelderly determined using modified gross income.
  • Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance.
  • Sec. 2004. Medicaid coverage for former foster care children.
  • Sec. 2005. Payments to territories.
  • Sec. 2006. Special adjustment to FMAP determination for certain States recovering from a major disaster.
  • Sec. 2007. Medicaid Improvement Fund rescission.
  • Sec. 2201. Enrollment Simplification and coordination with State Health Insurance Exchanges.
  • Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.
  • Sec. 2301. Coverage for freestanding birth center services.
  • Sec. 2302. Concurrent care for children.
  • Sec. 2303. State eligibility option for family planning services.
  • Sec. 2304. Clarification of definition of medical assistance.
  • Sec. 2601. 5-year period for demonstration projects.
  • Sec. 2602. Providing Federal coverage and payment coordination for dual eligible beneficiaries.
  • Sec. 2701. Adult health quality measures.
  • Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
  • Sec. 2703. State option to provide health homes for enrollees with chronic conditions.
  • Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.
  • Sec. 2705. Medicaid Global Payment System Demonstration Project.
  • Sec. 2706. Pediatric Accountable Care Organization Demonstration Project.
  • Sec. 2707. Medicaid emergency psychiatric demonstration project.
  • Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.
  • Sec. 4106. Improving access to preventive services for eligible adults in Medicaid.
  • Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
• Balanced Budget Act Medicaid provisions.
  • Sec. 4701 State option of using managed care; change in terminology.
  • Sec. 4702 Primary care case management services as State option without
    need for waiver.

  • Sec. 4703 Elimination of 75:25 restriction on risk contracts.
  • Sec. 4704 Increased beneficiary protections.
  • Sec. 4705 Quality assurance standards.
  • Sec. 4706 Solvency standards.
  • Sec. 4707 Protections against fraud and abuse.
  • Sec. 4708 Improved administration.
  • Sec. 4709 6-month guaranteed eligibility for all individuals enrolled in
    managed care.

  • Sec. 4710 Effective dates.
  • Sec. 4711 Flexibility in payment methods for hospital, nursing facility,
    ICF/MR, and home health services.

  • Sec. 4712 Payment for center and clinic services.
  • Sec. 4713 Elimination of obstetrical and pediatric payment rate
    requirements.

  • Sec. 4714 Medicaid payment rates for certain medicare cost-sharing.
  • Sec. 4715 Treatment of veterans’ pensions under Medicaid.
  • Sec. 4721 Reforming disproportionate share payments under State medicaid
    programs.

  • Sec. 4722 Treatment of State taxes imposed on certain hospitals.
  • Sec. 4723 Additional funding for State emergency health services furnished
    to undocumented aliens.

  • Sec. 4724 Elimination of waste, fraud, and abuse.
  • Sec. 4725 Increased FMAPs.
  • Sec. 4726 Increase in payment limitation for territories.
  • Sec. 4731 State option of continuous eligibility for 12 months;
    clarification of State option to cover children.

  • Sec. 4732 Payment of part B premiums.
  • Sec. 4733 State option to permit workers with disabilities to buy into
    medicaid.

  • Sec. 4734 Penalty for fraudulent eligibility.
  • Sec. 4735 Treatment of certain settlement payments.
  • Sec. 4741 Elimination of requirement to pay for private insurance.
  • Sec. 4742 Physician qualification requirements.
  • Sec. 4743 Elimination of requirement of prior institutionalization with
    respect to habilitation services furnished under a waiver for home or community-based services.

  • Sec. 4744 Study and report on EPSDT benefit.
  • Sec. 4751 Elimination of duplicative inspection of care requirements for
    ICFS/MR and mental hospitals.

  • Sec. 4752 Alternative sanctions for noncompliant ICFS/MR.
  • Sec. 4753 Modification of MMIS requirements.
  • Sec. 4754 Facilitating imposition of State alternative remedies on
    noncompliant nursing facilities.

  • Sec. 4755 Removal of name from nurse aide registry.
  • Sec. 4756 Medically accepted indication.
  • Sec. 4757 Continuation of State-wide section 1115 medicaid waivers.
  • Sec. 4758 Extension of moratorium.
  • Sec. 4759 Extension of effective date for State law amendment.

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Code of Federal
Regulations

42 CFR CHAPTER IV, SUBCHAPTER C– MEDICAL ASSISTANCE PROGRAMS

• PART 430 GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS (430.0 – 430.104)
• PART 431 STATE ORGANIZATION AND GENERAL ADMINISTRATION (431.1 – 431.1002)
• PART 432 STATE PERSONNEL ADMINISTRATION (432.1 – 432.55)
• PART 433 STATE FISCAL ADMINISTRATION (433.1 – 433.322)
• PART 434 CONTRACTS (434.1 – 434.78)
• PART 435 ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA (435.2 – 435.1200)
• PART 436 ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS (436.1 – 436.1102)
• PART 438 MANAGED CARE (438.1 – 438.812)
  • SUBPART A General Provisions (438.1 – 438.12)
  • SUBPART B State Responsibilities (438.50 – 438.66)
  • SUBPART C Enrollee Rights and Protections (438.100 – 438.116)
  • SUBPART D Quality Assessment and Performance Improvement (438.200 – 438.242)
  • SUBPART E External Quality Review (438.310 – 438.370)
  • SUBPART F Grievance System (438.400 – 438.424)
  • SUBPART G [Reserved]
  • SUBPART H Certifications and Program Integrity (438.600 – 438.610)
  • SUBPART I Sanctions (438.700 – 438.730)
  • SUBPART J Conditions for Federal Financial Participation (438.802 – 438.812)
• PART 440 SERVICES: GENERAL PROVISIONS (440.1 – 440.390)
• PART 441 SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES (441.1 – 441.590)
• PART 442 STANDARDS FOR PAYMENT TO NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (442.1 – 442.119)
• PART 447 PAYMENTS FOR SERVICES (447.1 – 447.520)
• PART 455 PROGRAM INTEGRITY: MEDICAID (455.1 – 455.518)
  • Sec. 455.1 Basis and scope.
  • Sec. 455.2 Definitions.
  • Sec. 455.3 Other applicable regulations.
  • SUBPART A Medicaid Agency Fraud Detection and Investigation Program (455.12 – 455.23)
  • SUBPART B Disclosure of Information by Providers and Fiscal Agents (455.100 – 455.106)
  • SUBPART C Medicaid Integrity Program (455.200 – 455.240)
  • SUBPART D Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments (455.300 – 455.304)
  • SUBPART E Provider Screening and Enrollment (455.400 – 455.470)
  • SUBPART F Medicaid Recovery Audit Contractors Program (455.500 – 455.518)
• PART 456 UTILIZATION CONTROL (456.1 – 456.725)

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Cases

• Douglas v. Independent Living Center of Southern Cal. (US 2012) Since the Court granted certiorari, the federal agency in charge of administering Medicaid approved the state statutes as consistent with the federal law. In light of the changed circumstances, the Court believed that the question before it was whether, once the agency approved the state statutes, groups of Medicaid providers and beneficiaries could still maintain a Supremacy Clause action asserting that the state statutes were inconsistent with the federal Medicaid law.

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Reports

• Medicaid: Demographics and Service Usage of Certain High-Expenditure Beneficiaries (GAO 2014) In fiscal year 2009, states spent nearly a third (31.6 percent) of all Medicaid expenditures on the most expensive Medicaid-only beneficiaries, who were 4.3 percent of total Medicaid beneficiaries.
• Medicaid: Use of Claims Data for Analysis of Provider Payment Rates (GAO 2014) Medicaid fee-for-service claims data can be a useful source of information for analyzing provider payments. These data have the potential to provide a more complete representation of provider payment than do fee schedules, as claims data can capture both the distribution and frequency of actual payments to providers.
• State and CMS Oversight Of The Medicaid Managed Care Credentialing Process (OIG 2013) The Centers for Medicare & Medicaid Services (CMS) issued regulations that States must comply with to ensure the delivery of quality health care to Medicaid beneficiaries under managed care. To do so, States must establish uniform provider credentialing policies and include Federal credentialing provisions in contracts with Medicaid Managed Care Entities.
• Medicaid: CMS Should Ensure That States Clearly Report Overpayments
  (GAO 2013) States recovered $9.8 million in Medicaid overpayments, but they did not clearly report the overpayments and the return of the federal share to the Centers for Medicare & Medicaid Services.

• Medicaid: States’ Use of Managed Care (GAO 2012) Identified four groups of states that differed in their use of Medicaid managed care on the basis of the 12 indicators we included in our analysis. A handful of these indicators, namely Medicaid enrollment in MCOs and PCCM programs, HMO penetration rates, and the concentration of low-income individuals that lived in urban areas had significant influence on how states grouped.
• Medicaid: Providers in Three States with Unpaid Federal Taxes Received Over $6 Billion in Medicaid Reimbursements (GAO 2012) About 7,000 Medicaid providers in three selected states (Florida, New York, and Texas) had approximately $791 million in unpaid federal taxes from calendar year 2009 or earlier. This represents about 5.6 percent of the Medicaid providers reimbursed by the selected states during 2009. These 7,000 Medicaid providers with unpaid federal taxes received a total of about $6.6 billion in Medicaid reimbursements during 2009.
• CMS Oversight of Cost-Avoidance Waivers (OIG 2004) State Medicaid agencies can: (1) cost avoid, i.e., return the claim to the provider so that the provider can bill the liable third party, or (2) pay and chase, i.e., pay the provider’s claim and then seek recovery from the liable third party. States report cost- avoidance and pay-and-chase data to CMS as part of their CMS-64 report
• Medicaid: Oversight
  of Institutions for the Mentally Retarded Should Be Strengthened (Letter Report, 09/06/96, GAO/HEHS-96-131).
  Pursuant to a congressional request, GAO reviewed the role of the Health Care Financing Administration (HCFA),
  state agencies, and the Department of Justice (DOJ) in overseeing quality of care in intermediate care facilities
  for the mentally retarded (ICF/MR).

• Medicaid:
  Sustainability of Low 1996 Spending Growth Is Uncertain (GAO 1997) Pursuant to a congressional request, GAO reviewed Medicaid’s spending growth rate.

• Medicaid: Decline in Spending Growth Due to a Combination of Factors (GAO 1997) GAO discussed recent Medicaid spending trends and their potential implications for future outlays.
• Medicare and Medicaid:
  Meeting Needs of Dual Eligibles Raises Difficult Cost and Care Issues (GAO 1997) Pursuant to a congressional request, GAO discussed several issues that arise in financing health care for people known as dual eligibles, Medicare beneficiaries who are also eligible for some form of Medicaid support.

• Medicaid: Recent Spending Experience and the Administration’s Proposed Program Reform (GAO 1997) GAO discussed recent Medicaid spending trends and their potential implications for future outlays.
• Medicaid Managed Care: Serving the Disabled Challenges State Programs (GAO 1996) Pursuant to a congressional request, GAO examined state efforts to include disabled Medicaid beneficiaries in prepaid managed care programs.
• Medicaid: States’
  Efforts to Educate and Enroll Beneficiaries in Managed Care (GAO 1996). Pursuant to a congressional request, GAO provided information on state efforts to enroll Medicaid beneficiaries in managed care.

• Medicaid: States’
  Efforts to Educate and Enroll Beneficiaries in Managed Care (GAO 1996) Pursuant to a congressional request, GAO provided information on state efforts to enroll Medicaid beneficiaries in managed care.

• Medicaid: Waiver Program for Developmentally Disabled Is Promising But Poses Some Risks (GAO 1996) Pursuant to a congressional request, GAO reviewed states’ experiences in utilizing the Medicaid waiver program to provide care for developmentally disabled adults in alternative settings.
• Medicaid Managed Care: More Competition and Oversight Would Improve California’s Expansion Plan (GAO 1995) Pursuant to a congressional request, GAO reviewed California’s Medicaid managed care program, focusing on: (1) state oversight of managed care contractors; (2) state plans for expansion; and (3) key issues in implementing the expanded program.
• Medicaid:
  Statewide Section 1115 Demonstrations’ Impact on Eligibility, Service Delivery, and Program Cost (GAO 1995) The growth of Medicaid, which accounted for $142 billion in federal and state outlays in 1994, is outpacing even the growth of Medicare.

• Medicaid Section
  1115 Waivers: Flexible Approach to Approving Demonstrations Could Increase Federal Costs (GAO 1995) Pursuant to a congressional request, GAO examined the financing arrangements for four approved section 1115 Medicaid demonstration waivers.

• Medicaid:
  Restructuring Approaches Leave Many Questions (GAO 1995) Pursuant to a congressional request, GAO provided information on various proposals for restructuring the Medicaid Program, focusing on the: (1) different restructuring approaches and their implications for federal-state financing and program administration; and (2) need to establish a reserve fund to offset state tax losses and increased enrollments.

• Medicaid: Spending
  Pressures Drive States Toward Program Reinvention (GAO 1995) The $131 billion Medicaid program is at a crossroads. Between 1985 and 1993, Medicaid costs tripled and the number of beneficiaries rose by more than 50 percent. Medicaid costs are projected to rise to $260 billion, according to the Congressional Budget Office.

• Medicaid: State
  Flexibility in Implementing Managed Care Programs Requires Appropriate Oversight (GAO 1995) Requiring states to obtain waivers to broaden use of managed care may hamper their efforts to aggressively pursue cost-containment strategies.

• Medicaid:
  Tennessee’s Program Broadens Coverage But Faces Uncertain Future (GAO 1995) Pursuant to a congressional request, GAO reviewed Tennessee’s Medicaid capitated managed care program (TennCare).

• Medicaid Long-Term Care: Successful State Efforts to Expand Home Services While Limiting Costs (GAO 1994). Because nearly one-third of the nation’s Medicaid expenditures are now spent on long-term care ($42 billion in 1993), GAO was asked to review the experience of states in expanding government-funded home and community-based services.
• Medicaid: States
  Use Illusory Approaches to Shift Program Costs to Federal Government (GAO 1994) Medicaid, which provides health insurance for qualified low-income persons, is jointly funded by the federal government and the states.

• Medicare and
  Medicaid: Many Eligible People Not Enrolled in Qualified Medicare Beneficiary Program (GAO 1994) The Qualified Medicare Beneficiary Program pays many out-of-pocket expenses for Medicare recipients whose incomes are not quite low enough to qualify them for regular Medicare benefits.

• Medicaid:
  HealthPASS: An Evaluation of a Managed Care Program for Certain Philadelphia Recipients (GAO 1993) Federal and state policymakers believe that managed care programs are less expensive than traditional fee-for-service medical care, but critics express concern that cost-control measures may harm patient access to care and the quality of care.

Access to Care: Provider Availability in Medicaid Managed Care (OIG 2014) We found that slightly more than half of providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks.

Public Assistance Reporting Information System: State Participation in the Medicaid Interstate Match is Limited (OIG 2014) The Public Assistance Information Reporting System (PARIS) Medicaid Interstate Match is an important tool that has the potential to reduce improper Medicaid payments by identifying beneficiaries who are enrolled in multiple State Medicaid programs.

CMS and Its Contractors Have Adopted Few Program Integrity Practices To Address Vulnerabilities in EHRs (OEI-01-11-00571)

Some States Improperly Restrict Eligibility for Medicaid Mandatory Home Health Services (OEI-07-13-00060)

Part D Plans Generally Include Drugs Commonly Used by Dual Eligible: 2013 Report (OEI-05-13-00090)

Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)

ACF Strengthened its Oversight of Head Start Eligibility in Fiscal Year 2011 (OEI-05-11-00140)

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2012 (OEI-05-12-00060)

Part D Plans Generally Cover Drugs Commonly Used By Dual Eligibles (OEI-05-10-00390)

State Income and Eligibility Verification Systems: State Profiles (OEI-06-92-00081; 10/94)

State Income and Eligibility Verification Systems: Summary of Literature (OEI-06-92-00082; 10/94)

Reforms Are Needed In State Income and Eligibility Verification Systems (OEI-06-92-00080; 7/94)

Medicare Entitlement Age (OEI-07-91-01600; 8/93)

AFDC Pre-Eligibility Verification Measures (OEI-04-91-00100; 8/93)

AFDC Pre-Eligibility Fraud Investigative Units (OEI-04-91-00101; 3/95)

Catalogue of Automated Front-End Eligibility Verification Techniques (OAI-12-85-00051; 9/85)

Eligibility Errors Resulting in Misspent Funds in the Medicaid Program (OAI-04-87-00014; 5/88)

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