[Federal Register Volume 59, Number 197 (Thursday, October 13, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-25372]
[[Page Unknown]]
[Federal Register: October 13, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Statement of Organization, Functions, and Delegations of
Authority
Part F of the Statement of Organization, Functions, and Delegations
of Authority for the Department of Health and Human Services, Health
Care Financing Administration (HCFA), (Federal Register, Vol. 59, No.
60, pp. 14634-14637, dated Tuesday, March 29, 1994) is amended to
reflect changes in the structure of the Office of Managed Care (OMC).
The OMC-level functional statement has been republished because of a
change in administrative codes.
The specific amendments to Part F are as follows:
Section F.10.A.6. (Organization) is amended to read as
follows:
6. Office of Managed Care
a. Program Support Team
b. Medicaid Managed Care Team
c. Data Development and Support Team
d. Beneficiary Access and Education Team
e. Program Policy and Improvement Team
f. Medicare Payment and Audit Team
g. Operations and Oversight Team
(1) Operations A Team
(2) Operations B Team
(3) Operations C Team
Section F.20.A.6. (Functions) is amended by deleting the
statement and substructure in their entirety and replacing them with
the new functional statements. The new functional statements read as
follows:
6. Office of Managed Care (FAD)
Provides national direction and executive leadership for
managed health care operations, including Health Maintenance
Organizations (HMOs), Prepaid Health Plans (PHPs), Primary Care Case
Management programs, Competitive Medical Plans (CMPs), and other
Capitated Health organizations.
Serves as the departmental focal point in the areas of
managed health care plan qualification, including quality assurance,
ongoing regulation, State and employer compliance efforts, Medicare and
Medicaid HMO, Medicare CMP contracting and Medicaid freedom of choice
waivers.
Develops national managed care policies and objectives for
the development, qualification, and ongoing compliance of HMOs and
CMPs.
Plans, coordinates, and directs the development and
preparation of related legislative proposals, regulatory proposals, and
policy documents.
Formulates, evaluates, and prepares policies,
specifications for regulations, instructions, preprints, and procedures
related to managed health care.
Makes recommendations for legislative changes to improve
managed health care program policy.
a. Program Support Team (FAD-1)
Develops, coordinates, and implements the Office of
Managed Care (OMC) staff utilization programs including: employee
development and training, employee performance, personnel
administration, recruitment, selection, placement, and position
control.
Develops, coordinates, and implements OMC's internal
financial management program, including formulation, justification, and
execution of the OMC budget and coordination of OMC contracts and
cooperative agreement expenditures.
Processes and implements all OMC program and
administrative delegations of authority and serves as the focal point
for all delegations of authority issues concerning OMC.
Coordinates OMC involvement in outside audit activity
(e.g. Office of Inspector General, the General Accounting Office).
Coordinates and tracks the Freedom of Information Act
requests for OMC.
Coordinates the controlled correspondence, assignments,
congressional, and public inquires related to OMC; coordinates
preparation of replies for the signature of the Secretary of the
Department of Health and Human Services, the Health Care Administration
(HCFA) Administrator, OMC Director, and other senior officials.
Serves as liaison or provides OMC with support services
such as supply; property management; work space; equipment utilization;
purchase of computers, hardware, software, and supplies; and printing.
Orders manual issuances, forms and records.
Directs, coordinates and tracks strategic and work
planning efforts for OMC.
Serves as Project Officer for subject related contracts
(e.g. consultant, training, evaluation, and program monitoring).
Develops, modifies, and implements procedures for the
ongoing maintenance of official files for OMC including: serving as the
control point for the receipt and initial processing of HMOs
applications and financial, enforcement, and related documents for
appropriate dissemination. Maintains the OMC library which serves as
the primary focal point for distribution of information for the
industry, the public and OMC staff.
Provides support to OMC's Program Policy and Improvement
component (e.g. assistance with regulation and manual clearance).
b. Medicaid Managed Care Team (FAD1)
Federal focal point for all Medicaid managed care
activities including operations, policy, and technical assistance.
Provides oversight of, and assistance to, State Medicaid
agencies on all Medicaid managed care issues, including managed care
entity contracting activities. Provides technical assistance to State
regulators and enforces Federal requirements.
Evaluates and makes recommendations on the access,
quality, and cost effectiveness information on State freedom of choice
waiver requests (including selective provider contracting requests),
through review of state submittal, independent assessments, and
regional compliance/validation reviews.
Evaluates and makes recommendations on managed care
concerns specified in State health care reform proposals.
Provides concurrence on managed care issues involving
Section 1115 waivers.
Formulates, evaluates, and prepares: policies,
specifications for regulations, manual instructions, State plan
preprints, procedures, and legislative proposals related to Medicaid
managed care.
Develops guidelines, policies, and procedures for Regional
Offices (ROs) when reviewing and approving State Medicaid agency
contracts with managed care entities. Provides training to HCFA ROs for
contract and waiver reviews.
Coordinates and tracks Medicaid Freedom of Choice waivers
and state plan amendments.
Coordinates Medicaid managed care activities with the
Medicaid Bureau and other HCFA components.
Participates in joint projects with other Federal
agencies, States, and the managed care industry on program specific
managed care initiatives including: areas related to rate setting;
marketing; solvency; maternal and child health; Federally Qualified
Health Centers; and Early and Periodic Screening, Diagnosis, and
Treatment.
Supports and participates in Medicaid managed care
workgroups with state Medicaid agencies, the managed care industry, and
ROs.
Provides support to OMC's Program Policy and Improvement
(e.g. external coordination and communications).
c. Data Development and Support Team (FAD2)
Manages the HCFA national data systems for Medicare
beneficiary managed care enrollment and disenrollment. Provides
enrollment and disenrollment support to HMO which contract with
independent organizations.
Develops instructions on procedures for obtaining data on
Medicare managed care recipient enrollment and disenrollment.
Develops requirements/specifications for, and works with
the Bureau of Data Management and Strategy to then develop and maintain
operational information systems to support current programs (inventory
collection, analysis, reporting improvements such as: Plan Information
Control System (PICS), Beneficiary Information Tracking System (BITS),
Automated Plan Payment System (APPS), Medicaid reports, and monthly
Data Reporting Requirements (DRR) reports) for the use of HCFA staff.
Develops and maintains instructions in manuals on PICS, BITS, APPS, the
Reconsideration Tracking System, and the Group Health Plan System.
Provides technical assistance to Central Office (CO) and the ROs on
these systems.
Manages the Automated Plan Payment System and the National
Data Reporting Requirements System. Collects and disseminates Medicare
and Medicaid managed care data to the public (e.g., Medicaid enrollment
reports).
Provides special analyses of beneficiary enrollment and
disenrollment data to monitor managed care membership.
Provides training to plans and ROs on enrollment,
disenrollment, and other operational systems processes and
requirements.
Develops and implements a long-term strategy for data
systems improvements including: improved enrollment data, quality
performance standards tracking, and minimum data sets.
Develops a policy database information system. Evaluates
the effectiveness of existing and new managed care data systems and
implements improvements.
Works with Federal, State, and the managed care industry
on formats and methodologies for collecting and reporting encounter
data and other accountability measures.
Serves as the Project Officer for contracts to support
OMC's data needs.
Produces user-friendly reports of managed care statistics
and trends.
Identifies and utilizes software tools for program
improvement. Serves as trouble shooter and provides assistance to OMC
components on systems matters.
Conducts continual monitoring and evaluation of the
effectiveness of systems security for OMC to assure confidentiality.
Proposes policy changes in law, regulations, manual
instructions, and procedures related to Data Development and Support to
OMC's Program Policy and Improvement component.
d. Beneficiary Access and Education Team (FAD3)
Serves as the beneficiary advocate regarding access and
protection in Federal and State contracts with managed care plans and
the development of Federal and State policies affecting health plans.
Advises on health plan performance standards to assure beneficiary
protection.
Plans, directs, and implements educational efforts to
improve beneficiary information on health care plans. Develops consumer
information comparison charts and other educational tools to facilitate
beneficiary understanding of health care choices.
Conducts beneficiary focus groups to determine beneficiary
understanding of managed health care options including: respective
costs, benefits or quality, and improved consumers education.
Serves as liaison to the Social Security Administration
and States to distribute information on managed health plan options to
beneficiaries.
Serves as the Federal focal point for providing
information on beneficiary choice, including presentation of managed
care options to State Health Insurance Counselling Projects. Develops
an annual listing of managed care choices available to Medicare
beneficiaries.
Plans, conducts, and participates in joint educational
initiatives on health plan choices with other payers for retirees,
including Department of Defense, employers, and employer coalitions.
Develops and implements a strategy of promoting Medicare
and Medicaid managed care programs to the plan and employer industries,
in conjunction with the Office of the Associate Administrator for
Customer Relations and Communications. Develops Federal initiatives to
promote health education and prevention for beneficiaries in health
plans.
Serves as Project Officer for an external contract to
conduct reconsideration decisions for health plan appeals from
beneficiaries. Serves as the focal point for policy guidance to the
contractor. Disseminates data from reconsideration contract to OMC and
ROs.
Uses program data, including data from the reconsideration
contract and other sources, to conduct analyses of beneficiary access
and utilization of health care services. Identifies problems and
recommends solutions as appropriate.
Develops marketing standards for Medicare contracting
plans and reviews contractor strategies.
Responds to beneficiary concerns, including Congressional
and other inquiries. Develops model beneficiary satisfaction surveys
that can be used by plans to determine beneficiary satisfaction with
health plan services.
Proposes policy changes in law, regulations, manual
instructions, and procedures related to Beneficiary Access and
Education to OMC's Program Policy and Improvement component.
e. Program Policy and Improvement Team (FAD4)
Develops managed care policies reflecting OMC's vision,
Department of Health and Human Services and HCFA initiatives, and
Congressional mandates. Serves as the focal point for health care
reform issues within OMC.
Coordinates policy development within OMC, assuring input
and recommendations of the affected OMC components. Serves as a policy
development resource for OMC components. Coordinates policy development
between OMC and other HCFA, Office of General Counsel, and other policy
components.
Serves as the focal point for managed care policy. Plans,
develops and prepares policy documents including legislative proposals,
regulatory specifications, policy analysis, instructions, and
procedures. Develops legislative proposals to improve managed care
programs. Serves as legislative liaison for OMC components.
Develops OMC's research and evaluation agenda in
consultation with HCFA's Office of Research and Demonstrations (ORD).
Initiates and conducts managed care program policy
analyses and studies to assess program performance and prepares
reports.
Develops program improvement initiatives for OMC (e.g.,
payment reform, future delivery systems, and rural opportunity
initiatives). Develops initiatives to reach special populations,
including low income and vulnerable beneficiaries.
Develops new managed care products (e.g. new contracting
methods) and programs.
Coordinates policy issues with other payers.
Provide leadership and coordinate Medicare SELECT and dual
eligible issues.
Reviews HCFA policy documents to determine impact on
Managed Care components.
f. Medicare Payment and Audit Team (FAD5)
Establishes and disseminates interim payment rates,
retroactively adjusts payments, and performs end-of-year settlements
for all cost-based contracting plans. Ensures timeliness and accuracy
of all payments to participating plans and develops, reviews,
validates, and authorizes these payments.
Recommends payment to plans, checks payment accuracy, and
resolves payment disputes (including litigation support).
Develops and implements national payment procedures for
coordinated health care plans.
Develops and maintains national instructional manuals on
coordinated health care payment for coordinated health care plans.
Provides technical assistance to the plans, ROs, and CO relating to the
payment process.
Serves as Project Officer for the outside audit contractor
who performs the desk review of the HMO and CMP cost reports.
Reviews budgets and cost reports, manages the financial
audit process and settlement of final cost reports, ensures payment
integrity, and authorizes payments to cost-based contractors.
Determines and approves benefits and premiums on Adjusted
Community Rate (ACR) reviews for contract renewals. Trains and guides
OMC staff, contractors and plans in ACR reviews.
Develops procedures to improve or revise the payment
methodologies and processes of HMO and CMP Medicare contractors.
Manages and assures compliance with presumptive cost
limits for cost-based contractors.
Ensures that appropriate payment methodologies are
employed for HCFA Demonstration projects.
Coordinates OMC data input to the Adjusted Average Per
Capita Cost process.
Resolves payment disputes, including litigation support
for cost-based contractors.
Proposes changes in law, regulations, manual instructions,
and procedures related to Medicare Payment and Audit activities to
OMC's Program Policy and Improvement component.
g. Operations and Oversight Team (FAD6)
Investigates, evaluates, approves or denies approval of
applications for new Medicare contracts, Federal Qualification of HMOs,
and service area expansions of contracts and Federal qualification
under Section 1301 of the Public Health Service (PHS) Act, Section 1833
and Section 1876 of the Social Security Act, and related regulations.
Integrates RO review of elements of applicant operations into approval
or denial decision on Medicare contract applications.
Reviews and assures HMO and CMP fiscal soundness and
solvency during the application process. Monitors financial, fiscal
solvency provisions, and legal aspects of federally qualified HMO and
CMP operations. o Coordinates with and provides technical assistance to
the ROs, state regulators, and professional organizations on review of
health services delivery, legal, and financial sections of Medicare
contract and Title XIII applications, as well as other managed care
requirements.
Provides oversight of RO performance of monitoring and
other assigned regional functions. Provides training for RO staff about
procedures, program requirements and HMO operational issues.
In consultation with the ROs, establishes HMO/CMP
contractor performance measures and monitoring and evaluation
protocols.
Coordinates with and provides technical assistance to ROs
and ORD the monitoring of Medicare contracting HMOs and CMPs including
substantive review of demonstration projects.
Enforces employer compliance with Section 1310 of the PHS
Act (the mandatory offering of an HMO alternative to indemnity health
insurance plans).
Participates in Medicare contract post-approval activities
and coordinates all contract renewal/non-renewal, and terminations.
Evaluates RO recommendations regarding compliance or
enforcement actions. Implements intermediate sanctions and other
enforcement authorities and refers cases of Civil Money Penalties to
the Office of the Inspector General.
Analyzes Medicare contracting HMO/CMP physician incentives
and other economic arrangements to enforce appropriate compliance.
Reviews and approves or denies contracting HMO/CMP
requests for flexible benefits.
Serves as Federally Qualified HMOs' primary contact for
information on activities related to compliance.
Implements new legislation, regulations or policy
regarding Medicare contracting with managed care organizations or
Federal Qualification. Proposes changes in law, regulations,
instructions, and procedures related to Medicare HMO/CMP and Federally
Qualified HMO contracts to OMC's Program Policy and Improvement
component.
Reviews and approves HMO/CMP mergers, acquisitions,
changes of ownership, and novation agreements.
Directs Federal Qualification compliance activities
inclusive of investigation of complaints, conduct of for cause
activities, findings of non-compliance and revocation of Federal
Qualification.
Monitors loans made under the HMO Loan Program (Section
1310 of the PHS Act).
Reviews and approves initial ACR proposals from HMO/CMPs
applying for a Medicare contract.
(1) Operations A Team (FAD61)
Investigates, evaluates, approves or denies approval of
applications for new Medicare contracts, Federal Qualification of HMOs,
and service area expansions of contracts and Federal qualification
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the
Social Security Act, and related regulations. Integrates RO review of
elements of applicant operations into approval or denial decision on
Medicare contract applications.
Reviews and assures HMO and CMP fiscal soundness and
solvency during the application process. Monitors financial, fiscal
solvency provisions, and legal aspects of federally qualified HMO and
CMP operations.
Coordinates with and provides technical assistance to the
ROs, state regulators, and professional organizations on review of
health services delivery, legal, and financial sections of Medicare
contract and Title XIII applications, as well as other managed care
requirements.
Provides oversight of RO performance of monitoring and
other assigned regional functions. Provides training for RO staff about
procedures, program requirements and HMO operational issues.
In consultation with the ROs, establishes HMO/CMP
contractor performance measures and monitoring and evaluation
protocols.
Coordinates with and provides technical assistance to ROs
and ORD on the monitoring of Medicare contracting HMOs and CMPs
including substantive review of demonstration projects.
Enforces employer compliance with Section 1310 of the PHS
Act (the mandatory offering of an HMO alternative to indemnity health
insurance plans).
Participates in Medicare contract post-approval activities
and coordinates all contract renewal/non-renewal, and terminations.
Evaluates RO recommendations regarding compliance or
enforcement actions. Implements intermediate sanctions and other
enforcement authorities and refers cases of Civil Money Penalties to
the Office of the Inspector General.
Analyzes Medicare contracting HMO/CMP physician incentives
and other economic arrangements to enforce appropriate compliance.
Reviews and approves or denies contracting HMO/CMP
requests for flexible benefits.
Serves as Federally Qualified HOMs' primary contact for
information on activities related to compliance.
Implements new legislation, regulations or policy
regarding Medicare contracting with managed care organizations or
Federal Qualification. Proposes changes in law, regulations,
instructions, and procedures related to Medicare HMO/CMP and Federally
Qualified HMO contracts to OMC's Program Policy and Improvement
component.
Reviews and approves HMO/CMP mergers, acquisitions,
changes of ownership, and novation agreements.
Directs Federal Qualification compliance activities
inclusive of investigation of complaints, conduct of for cause
activities, findings of noncompliance and revocation of Federal
Qualification.
Monitors loans made under the HMO Loan Program (Section
1310 of the PHS Act).
Reviews and approves initial ACR proposals from HMO/CMPs
applying for a Medicare contract.
(2) Operations B Team (FAD62)
Investigates, evaluates, approves or denies approval of
applications for new Medicare contracts, Federal Qualification of HMOs,
and service area expansions of contracts and Federal qualification
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the
Social Security Act, and related regulations. Integrates RO review of
elements of applicant operations into approval or denial decision on
Medicare contract applications.
Reviews and assures HMO and CMP fiscal soundness and
solvency during the application process. Monitors financial, fiscal
solvency provisions, and legal aspects of federally qualified HMO and
CMP operations.
Coordinates with and provides technical assistance to the
ROs, state regulators, and professional organizations on review of
health services delivery, legal, and financial sections of Medicare
contract and Title XIII applications, as well as other managed care
requirements.
Provides oversight of RO performance of monitoring and
other assigned regional functions. Provides training for RO staff about
procedures, program requirements and HMO operational issues.
In consultation with the ROs, establishes HMO/CMP
contractor performance measures and monitoring and evaluation
protocols.
Coordinates with and provides technical assistance to ROs
and ORD on the monitoring of Medicare contracting HMOs and CMPs
including substantive review of demonstration projects.
Enforces employer compliance with Section 1310 of the PHS
Act (the mandatory offering of an HMO alternative to indemnity health
insurance plans).
Participates in Medicare contract post-approval activities
and coordinates all contract renewal/non-renewal, and terminations.
Evaluates RO recommendations regarding compliance or
enforcement actions. Implements intermediate sanctions and other
enforcement authorities and refers cases of Civil Money Penalties to
the Office of the Inspector General.
Analyzes Medicare contracting HMO/CMP physician incentives
and other economic arrangements to enforce appropriate compliance.
Reviews and approves or denies contracting HMO/CMP
requests for flexible benefits.
Serves as Federally Qualified HMOs' primary contact for
information on activities related to compliance.
Implements new legislation, regulations or policy
regarding Medicare contracting with managed care organizations or
Federal Qualification. Proposes changes in law, regulations,
instructions, and procedures related to Medicare HMO/CMP and Federally
Qualified HMO contracts to OMC's Program Policy and Improvement
component.
Reviews and approves HMO/CMP mergers, acquisitions,
changes of ownership, and novation agreements.
Directs Federal Qualification compliance activities
inclusive of investigation of complaints, conduct of for cause
activities, findings of non-compliance and revocation of Federal
Qualification.
Monitors loans made under the HMO Loan Program (Section
1310 of the PHS Act).
Reviews and approves initial ACR proposals from HMO/CMPs
applying for a Medicare contract.
(3) Operations C Team (FAD63)
Investigates, evaluates, approves or denies approval of
applications for new Medicare contracts, Federal Qualification of HMOs,
and service area expansions of contracts and Federal qualification
under Section 1301 of the PHS Act, Section 1833 and Section 1876 of the
Social Security Act, and related regulations. Integrates RO review of
elements of applicant operations into approval or denial decision on
Medicare contract applications.
Reviews and assures HMO and CMP fiscal soundness and
solvency during the application process. Monitors financial, fiscal
solvency provisions, and legal aspects of federally qualified HMO and
CMP operations.
Coordinates with and provides technical assistance to the
ROs, state regulators, and professional organizations on review of
health services delivery, legal, and financial sections of Medicare
contract and Title XIII applications, as well as other managed care
requirements.
Provides oversight of RO performance of monitoring and
other assigned regional functions. Provides training for RO staff about
procedures, program requirements and HMO operational issues.
In consultation with the ROs, establishes HMO/CMP
contractor performance measures and monitoring and evaluation
protocols.
Coordinates with and provides technical assistance to ROs
and ORD on the monitoring of Medicare contracting HMOs and CMPs
including substantive review of demonstration projects.
Enforces employer compliance with Section 1310 of the PHS
Act (the mandatory offering of an HMO alternative to indemnity health
insurance plans).
Participates in Medicare contract post-approval activities
and coordinates all contract renewal/non-renewal, and terminations.
Evaluates RO recommendations regarding compliance or
enforcement actions. Implements intermediate sanctions and other
enforcement authorities and refers cases of Civil Money Penalties to
the Office of the Inspector General.
Analyzes Medicare contracting HMO/CMP physician incentives
and other economic arrangements to enforce appropriate compliance.
Reviews and approves or denies contracting HMO/CMP
requests for flexible benefits.
Serves as Federally Qualified HMOs' primary contact for
information on activities related to compliance.
Implements new legislation, regulations or policy
regarding Medicare contracting with managed care organizations or
Federal Qualification. Proposes changes in law, regulations,
instructions, and procedures related to Medicare HMO/CMP and Federally
Qualified HMO contracts to OMC's Program Policy and Improvement
component.
Reviews and approves HMO/CMP mergers, acquisitions,
changes of ownership, and novation agreements.
Directs Federal Qualification compliance activities
inclusive of investigation of complaints, conduct of for cause
activities, findings of non-compliance and revocation of Federal
Qualification.
Monitors loans made under the HMO Loan Program (Section
1310 of the PHS Act).
Reviews and approves initial ACR proposals from HMO/CMPs
applying for a Medicare contract.
Dated: September 30, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-25372 Filed 10-12-94; 8:45 am]
BILLING CODE 4120-01-P
