[Federal Register Volume 59, Number 51 (Wednesday, March 16, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-6008]
[[Page Unknown]]
[Federal Register: March 16, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Statement of Organization, Functions, and Delegations of
Authority
Reorganization of the Health Care Financing Administration
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) (49 FR 3547, September 6, 1984, as
amended most recently at 58 FR 42079, August 6, 1993) is amended to
reflect a major reorganization of HCFA. The Administration's
``reinventing government'' initiative has been considered in developing
this reorganization. In addition, the reorganization is also designed
to improve the efficiency of HCFA's total operation and to provide
increased responsiveness to the needs of the Administration,
beneficiaries, the States, and the health care industry.
The specific amendments to Part F are:
Section F.10., Health Care Financing Administration
(Organization) is amended to read as follows:
Section F.10., Health Care Financing Administration (Organization)
The Health Care Financing Administration (HCFA) is an Operating
Division of the Department. It is headed by an Administrator, HCFA, who
is appointed by the President and reports to the Secretary. It consists
of the following organizational elements:
A. Office of the Administrator (FA).
1. Provider Reimbursement Review Board (FA-1).
2. Equal Employment Opportunity Staff (FA-3).
3. Executive Secretariat (FA-4).
4. Office of Legislative and Inter-Governmental Affairs (FAA).
5. Medicaid Bureau (FAB).
6. Office of Managed Care (FAC).
B. Office of the Associate Administrator for Customer Relations and
Communications (FF).
1. Office of Beneficiary Services (FFA).
2. Office of Public Affairs (FFB).
3. Office of Public Liaison (FFC).
C. Office of the Associate Administrator for Policy (FK).
1. Special Analysis Staff (FK-1).
2. Bureau of Policy Development (FKA).
3. Office of Research and Demonstrations (FKB).
4. Office of the Actuary (FKC).
D. Office of the Associate Administrator for Operations and Resource
Management (FL).
1. Office of the Attorney Advisor (FL-1).
2. Office of Financial & Human Resources (FLA).
3. Bureau of Program Operations (FLB).
4. Bureau of Data Management and Strategy (FLC).
5. Office of the Regional Administrators (FLD(1-X)).
6. Health Standards and Quality Bureau (FLE).
Section F.20., Health Care Financing Administration
(Functions) is amended by deleting the statement in its entirety and
replacing it with the following statements. The statements that follow
provide the organizational structure of the Health Care Financing
Administration to the Bureau and Primary Office level. The remainder of
the organizational substructure will be published at a later date. The
new HCFA organizational structure is described as follows:
A. Office of the Administrator (FA)
The Administrator, Health Care Financing Administration, directs
the planning, coordination and implementation of the programs under
titles XI, VIII, and XIX of the Social Security Act, and related
statutes, as amended, and directs the development of effective
relationships between these programs and private and federally
supported health-related programs. The Administrator works with the
States, other Federal agencies and other concerned nongovernmental
organizations in administering health care financing programs.
1. Provider Reimbursement Review Board (FA-1)
The Provider Reimbursement Review Board (Board) is organizationally
assigned to the HCFA for administrative support. The Board, after
determining that it has jurisdiction, conducts hearings to resolve
disputes on cost and prospective payment submitted by Medicare
providers under Section 1878 of the Social Security Act. Upon the
completion of these hearings, the Board renders impartial decisions on
these appeals. This is the initial step in the judicial review process.
Provides staff support to the Medicare Geographic Classification Review
Board (MGCRB) and conducts Medicare and Medicaid hearings on behalf of
the Secretary or the Administrator that are not within the jurisdiction
of the Department Appeals Board, the Social Security Administrations'
Office of Hearings and Appeals, or the States.
2. Equal Employment Opportunity Staff (FA-3)
Provides principal advisory services to the Administrator
concerning equal employment opportunity (EEO) and civil rights policies
and programs. Develops EEO and voluntary civil rights compliance policy
for HCFA and assesses the Agency's compliance with applicable equal
opportunity statutes, executive orders, regulations and policies.
Identifies policy and operational issues and proposes solutions for
resolving these issues. Serves as the central liaison point with the
Department on EEO and civil rights issues. Coordinates the development
of HCFA affirmative EEO plans and evaluates their implementation by
HCFA components. Promotes EEO special emphasis programs and activities
affecting the concerns of minority groups, women and individuals with
disabilities. Provides for conciliation and adjudication of informal
and formal discrimination complaints by means of EEO counseling, formal
hearings, issuance of final decisions, etc. Manages, coordinates and
monitors HCFA's equal employment opportunity activities working
directly with bureau and office personnel.
3. Executive Secretariat (FA-4)
Assists the HCFA Administrator in the resolution of agency program
and administrative policy matters through memoranda, actions documents,
or correspondence. Monitors HCFA performance in developing necessary
documents for the Administrator's review. Manages the clearance system
and reviews documents for consistency with the Administrator's and
Secretary's assignments, previous decisions on related matters, and
editorial standards. Facilitates the resolution of issues connected
with matters forwarded to the Administrator. Operates the agency-wide
correspondence tracking and control system, and provides guidance and
technical assistance on standards for content of correspondence and
memoranda. Serves as a primary focal point for liaison with the
Executive Secretariat in the Office of the Secretary on HCFA
correspondence and special administrative matters.
4. Office of Legislative and Inter-Governmental Affairs (FAA)
The Office of Legislative and Inter-Governmental Affairs provides
leadership and executive direction within HCFA for legislative planning
and congressional and intergovernmental affairs. Develops and evaluates
recommendations concerning legislative proposals for changes in health
care financing. Develops the long-range HCFA legislative plans.
Coordinates activities with the Office of the Assistant Secretary for
Legislation (ASL) and serves as the ASL's principal contact point on
legislative and congressional relations, and intergovernmental affairs.
Manages HCFA involvement in congressional hearings. Provides technical,
analytical, and advisory services to HCFA components, to the
Department, to other elements of the Executive Branch, and other
government agencies interested in health care financing legislation,
congressional relations, and intergovernmental affairs. In conjunction
with the ASL, provides information services to congressional
committees, individual Congressmen, and private organizations on health
care financing legislation. Provides leadership for HCFA in the area of
intergovernmental affairs. Advises the Administrator on program matters
which affect other units and levels of government. In coordination with
the Department's Inter-Governmental Affairs office, the Regional
Directors, and other HCFA offices, meets with key State and local
officials in order to strengthen HCFA's relationships with other
governmental jurisdictions and to resolve sensitive intergovernmental
problems and issues. Reviews and consults with State and local
officials regarding proposed HCFA policy and operational issuances.
Assists States and localities in requesting and obtaining technical
materials, assistance, and support for appropriate HCFA components.
Upon State requests, coordinates the exchange of HCFA staff with State
and local agencies. Develops and provides briefings on
intergovernmental affairs issues for HCFA staff. Briefs State and local
agencies on HCFA's mission, organization, and functions.
5. Medicaid Bureau (FAB)
Directs the planning, coordination, and implementation of the
Medicaid program under title XIX of the Social Security Act and related
statutes, as amended, except for Medicaid managed health care.
Formulates, evaluates, and prepares policies, specifications for
regulations, instructions, preprints and procedures related to Medicaid
eligibility, coverage, and payment activities; makes recommendations
for legislative changes; and, reviews State plan amendments and make
recommendations on approvals/disapprovals. Oversees, coordinates,
processes and assesses the operation of State Medicaid Home and
Community-Based Services Waivers. Administers the State grants process
for administrative and program payments, including budget preparation
by States. Provides Medicaid payment policy for administrative costs,
availability of Federal Financial Participation (FFP) and designation
of appropriate FFP rates. Develops and monitors planning, development
and implementation of Medicaid program operations in regional offices
and State Medicaid agencies. Develops and promulgates policies and
procedures for the proper maintenance, review, and approval of State
plans and their amendments. Monitors State compliance with State plan
and oversees the compliance process. Develops requirements, standards,
procedures, guidelines, and methodologies pertaining to the review and
evaluation of State agencies' automated systems. Develops, operates,
and manages a program for the performance evaluation of Medicaid State
agencies and fiscal agents. Implements Medicaid maternal and infant
health initiative and the Early and Periodic Screening, Diagnostic, and
Treatment program through coordination of HCFA resources and activities
with those of the Public Health Service and other national
organizations, monitoring program performance, effective interagency
and interprogram liaison, guidance, and technical assistance. Provides
technical assistance to States, regional offices, and other interested
groups in all special Medicaid initiatives. Coordinates with HCFA's
Office of Legislative and Inter-Governmental Affairs on all issues that
affect States. Coordinates with the Office of Research and
Demonstrations HCFA review and management of State waiver requests and
projects.
6. Office of Managed Care (FAC)
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.
B. Office of the Associate Administrator for Customer Relations and
Communications (FF)
The Associate Administrator for Customer Relations and
Communications is responsible for the effective direction and
implementation of HCFA policies, rules, and procedures in the areas of:
advising the Administrator, HCFA, and HCFA components concerning the
services, requirements, and initiatives relating to HCFA beneficiaries;
liaison with external medical, dental, and allied health practitioners,
institutional providers of health services, and academic institutions
responsible for the education of health care professionals; and
directing the public affairs activities of HCFA.
1. Office of Beneficiary Services (FFA)
Provides advisory services to the Associate Administrator for
Customer Relations and Communications and HCFA components concerning
the services for, needs of, and initiatives relating to HCFA
beneficiaries. Promotes an awareness of the concerns of children, the
elderly, and needy among the HCFA components responsible for developing
program policies, regulations, and legislative proposals. Analyzes the
impact of proposed HCFA policies, regulations, and instructions on
beneficiaries. Maintains close working relationships with HCFA central
and regional components, the Social Security Administration District
Offices, the Public Health Service, other Federal agencies, State
agencies, and beneficiary consumer groups to identify and assess the
need for information, benefits and services; the impact of proposed
HCFA actions; and the effects that operating systems and programs have
on the health care system programs and current and future
beneficiaries. Presents the overall HCFA mission and promotes its
acceptance by beneficiaries and representatives of the constituent
organizations. Participates with other HCFA components in the
development and implementation of program objectives and strategies
pertaining to beneficiary services. Through direct contact with
children, the elderly, the needy and/or their representative groups
determines their understanding of HCFA's programs and services and
conveys this information to HCFA components. Responds to beneficiary
referrals concerning accessing and utilizing the Agency's health care
financing programs. Plans, directs, and coordinates the production of
radio, television, and film products, and the preparation of general-
purpose publications. Reviews and clears all print, audiovisual, and
exhibit plans and material intended for external dissemination and
serves as clearance liaison with the Office of the Secretary, Office of
the Assistant Secretary for Public Affairs.
2. Office of Public Affairs (FFB)
Plans, directs and coordinates the public affairs activities of
HCFA including: Speech writing, public appearances, Administrator's
meetings, special Associate Administrator for Customer Relations and
Communications (AACR&C) projects as well as conducting evaluations and
analyses. Provides advice and counsel from a public affairs perspective
to the AACR&C and all HCFA components. Administers the Freedom of
Information Act and Privacy Act responsibilities for HCFA.
3. Office of Public Liaison (FFC)
Directs and implements HCFA policies, rules, and procedures in the
areas of liaison with external medical, dental, and allied health
practitioners, institutional providers of health services, and business
and academic institutions responsible for the education of health care
professionals. Also, plans, directs and coordinates media relations.
C. Office of the Associate Administrator for Policy (FK)
The Associate Administrator for Policy is responsible for the
effective direction and implementation of the development and review of
policies and regulations pertaining to all HCFA programs including
HCFA's research and demonstrations activities. Conducts research and
develops legislative proposals designed to make improvements in the
health care delivery system and develops the technical specifications
for such legislation. Performs actuarial, economic and demographic
studies to predict HCFA program expenditures under current law and
under proposed modifications to current law.
1. Special Analysis Staff (FK-1)
Conducts legislative, economic and policy analyses related to the
private health insurance industry and the overall structure of health
care financing and reform. Analyzes and reviews current literature
regarding the state of the Nation's health policy in order to develop
national trend analyses for future HCFA program directions. Plans and
develops future HCFA program policy in order to assist in the
development of legislative strategies that will enhance the
Department's legislative program. Coordinates policy development and
research relating to legislative proposals designed to reform and make
improvements in the health care delivery system including the technical
specifications for such legislation.
2. Bureau of Policy Development (FKA)
Establishes national program policy on all issues of Medicare
payment including provider payment policy, provider accounting and
audit policy, and physician and medical services payment policy.
Develops, evaluates, and reviews national policies and standards
concerning the coverage and utilization effectiveness of items and
services under the Medicare program provided by hospitals, long-term
care facilities, hospices, End Stage Renal Disease facilities, home
health agencies, alternative health care organizations, comprehensive
outpatient rehabilitation facilities, physicians, health practitioners,
clinics, laboratories, and other health care providers and suppliers.
Serves as the principal organization within HCFA for evaluating the
medical aspects of Medicare coverage issues and for developing provider
conditions of participation. Develops, evaluates, and reviews national
Medicare and Medicaid coverage issues concerning reasonableness and
necessity for medical and related services. Develops, interprets, and
evaluates program policies pertaining to Medicare eligibility, Medicare
secondary payer policies and other technical issues. Develops
regulations for the Medicare and Medicaid programs. Manages the HCFA
system for developing regulations, setting regulations priorities, and
corresponding work agenda. In cooperation with the Office of the
General Counsel, coordinates litigation affecting the Medicare program.
3. Office of Research and Demonstrations (FKB)
Provides leadership and executive direction within HCFA for a wide
range of health care financing research and demonstration activities.
Develops, tests and evaluates new payment methods, coverage policies
and delivery mechanisms in Medicare, Medicaid and other health care
programs. Has primary responsibility for managing HCFA's Medicare and
Medicaid demonstration waiver authorities including the Federal review,
approval, and oversight of State health reform waivers. Develops new
and innovative ways to reform the quality, efficiency, and cost
effectiveness of Federal, State and private health care financing
programs. Works closely with the Associate Administrator for Policy,
other Bureau/Office Directors, and high level staff outside HCFA to
insure that the Agency's objectives and long range planning in these
areas are accomplished. Participates with departmental components in a
wide range of experimental health care delivery projects. Performs
claims adjudication, payment, and data collection for demonstration
projects. Undertakes research to facilitate informed program and policy
decisions designed to make improvements in the health care delivery
system.
4. Office of the Actuary (FKC)
Conducts and directs the actuarial program for HCFA and directs the
development of and methodologies for macroeconomic analysis of health
care financing issues. Performs actuarial, economic and demographic
studies to predict HCFA program expenditures under current law and
under proposed modifications to current law. Provides program estimates
for use in the President's budget and for reports required by Congress.
Studies questions concerned with financing present and future health
programs, evaluates operations of the Federal Hospital Insurance Trust
Fund and Supplementary Medical Insurance Trust Fund and performs
macroanalyses for the purpose of assessing the impact of various health
care financing factors upon the costs of Federal programs. Develops and
conducts studies to estimate and project national and area health
expenditures. Analyzes trend data sources such as the Consumer Price
Index to develop projections of health care costs. Analyzes data on
physicians' costs and charges to develop payment indices and monitors
expansion of service and inflation of costs in the health care sector.
Publishes cost projections and economic analyses, and provides
actuarial, technical advice and consultation to HCFA components,
governmental components, Congress and outside organizations.
D. Office of the Associate Administrator for Operations and Resource
Management (FL)
The Associate Administrator for Operations and Resource Management
(AAORM) is responsible for the effective direction, coordination and
implementation of all aspects of headquarters and regional program
operations and resource management activities. The program operational
functions include the Medicare financial management systems; the
development, negotiation, execution and management of contracts with
Medicare contractors; enforcement of health quality and safety
standards for providers and suppliers of health care services; the
administration of professional review and other medical review
programs; the evaluation of contractors and State agencies against
performance standards; and the statistically based quality control
programs which measure the financial integrity of Medicare. The 10
Regional Administrators report to the AAORM through the Deputy
Associate Administrator for Operations and Resource Management. The
resource management responsibilities include developing and
implementing HCFA's policies, rules and procedures in the areas of
financial, personnel and contracts management, project grant
administration, management evaluation and analysis and administrative
services; the nationwide operation of a centralized Automated Data
Processing (ADP) and telecommunications facility; establishing and
maintaining computerized records supporting HCFA programs; developing
and coordinating information and statistical plans and policies; and
maintaining a statistical data system which will provide program
accountability data to the Administrator, HCFA, Congress, and the
public.
1. Office of the Attorney Advisor (FL-1)
The Office of the Attorney Advisor is attached to AAORM for
administrative issues but continues to report to the Administrator,
HCFA, for substantive issues. The Supervisory Attorney Advisor
recommends initiation of ``own motion review'' of Provider
Reimbursement Review Board decisions and of Medicare Geographical
Classification Review Board (MGCRB) decisions. Evaluates cases under
``own motion review'' and recommends the disposition of such cases by
the Administrator. Evaluates and makes recommendations for disposition
of MGCRB decisions appealed to the Administrator.
2. Office of Financial and Human Resources (FLA)
Provides HCFA-wide policy direction, coordination and control in
the areas of budget, financial and accounting operations, personnel,
management evaluation and analysis, administrative services, project
grants, contracting and procurement, audit resolution, and
workplanning. Develops and promulgates HCFA policy in these areas and
executes these policies throughout HCFA; also assures consistency with
departmental policy. Designs systems support for personnel management,
financial management, procurement, and facilities management programs
within HCFA. The Director serves as the Chief Financial Officer and the
Deputy Ethics Counselor for the Agency.
3. Bureau of Program Operations (FLB)
Provides direction and technical guidance for the nationwide
administration of the Medicare health care financing programs.
Develops, negotiates, executes, and manages contracts with Medicare
contractors. Manages the Medicare financial management system and
national budgets for Medicare contractors. Establishes national
policies and procedures for the procurement of claims processing and
related services from the private sector. Defines the relative
responsibilities of all parties in the health care financing operations
and designs the operational systems which link these parties. Directs
the establishment of standards of performance for contractors. Compiles
operational and performance data for recurring and special reports to
reflect status and trends in program operations effectiveness. Prepares
recommendations regarding terminations, awards, penalties, non-
renewals, or other appropriate contract actions. Establishes national
policy and procedures for the recovery of overpayments. Directs the
processing of Part A beneficiary appeals and issues instructions and
guidance for resolving beneficiary overpayments. Following coordination
with pertinent HCFA components, notifies carriers and fiscal
intermediaries of findings resulting from quality control programs.
Makes recommendations to the Associate Administrator for Operations
and Resource Management regarding financial penalties authorized and
determined appropriate under regulations. Assists Medicare contractors
in improving the management of Federally required quality control
programs. Identifies significant trends and priority problems through
comprehensive analyses and program operations and performance and
evaluates findings surfaced through various assessment programs.
Develops and conducts comprehensive analyses and studies of selected
areas of policy and operations to evaluate the appropriateness, cost
effectiveness, or other impact resulting from the implementation of
law, regulations, policies or operational procedures and systems.
Develops recommendations for specific policy or operational
improvements based on assessment findings. Coordinates, monitors, and
evaluates all corrective action initiatives resulting from program
assessment findings. Develops programwide policies, regulations,
procedures, guidelines, and studies dealing with program oversight and
improvement. Coordinates the preparation of manuals and other policy
issuances required to meet the instructional and informational needs of
providers, contractors, State Agencies, Regional Offices, Peer Review
Organizations, the Social Security Administration, and other audiences
directly involved in the administration of HCFA programs.
4. Bureau of Data Management and Strategy (FLC)
Serves as the focal point for the management of HCFA's information
resources. Provides Agency-wide information management, decision
support, automated data processing (ADP), and data communication
services essential to the management and administration of HCFA
programs. Provides technical information planning and developmental
review of HCFA data collection initiatives. Collects, analyzes, and
disseminates data on beneficiary eligibility, enrollment entitlement,
and medical utilization. Collects and maintains data on Medicare
contractor claims processing workloads and maintains contractor quality
assurance and performance evaluation systems. Manages statistical data
systems on HCFA programs to support policy and program decisions.
Coordinates the development of special purpose statistical data bases
and tabulations required for assessing (1) the impact of proposals
which change health care financing programs, (2) the characteristics of
HCFA beneficiaries and (3) the utilization and cost of program
benefits. Provides applications software support to HCFA headquarters
and Regional Offices in administrative/program management systems.
The Director serves as HCFA's Principal Information and Resource
Management (IRM) Official and is responsible for overseeing the
Agency's IRM programs including those of the Medicare contractors, Peer
Review Organizations, and End Stage Renal Disease Networks. Directs the
HCFA ADP systems security program including its application to Medicare
contractors. Develops common coding standards and quality assurance
monitoring mechanisms. Negotiates and administers agreements and
provides ADP liaison between HCFA users and other external
organizations for the provisions of ADP capacity and support services.
Provides support and data handling capability to control/examine,
audit, investigate, and process/release a variety of provider billing,
query, enrollment, and premium billing correspondence and transactions.
5. Office of the Regional Administrators (FLD (I-X))
The Office of the Regional Administrator manages regional operation
in each of the Health Care Financing Administration's 10 regions. The
Regional Administrators provide executive leadership and guidance on
behalf of the Associate Administrator for Operations and Resource
Management to HCFA components at the regional level. Implements
national policy at the regional level. Assures the effective
administration of HCFA programs including Medicare, Medicaid, Peer
Review Organizations (PROs), HMOs/CMPs, quality control, and
certification of institutional providers in a major geographical area.
Participates in the formulation of new policy and recommends changes in
existing national policy for HCFA programs. Develops and implements a
professional relations program within the region for all HCFA programs
and serves as the principal HCFA contact for all professional
organizations such as hospital and medical associations. At the
regional level, takes action to implement HCFA national initiatives
undertaken to integrate HCFA program operations and is responsible for
coordination of HCFA programs with other departmental components and
Federal agencies. Coordinates with the Department's Regional Director
to assure effective relationships with State and local governments.
Manages all administrative activities for HCFA components and
coordinates such activities with the Regional Administrative Support
Center. Initiates and directs the implementation of special regional
and headquarters projects affecting HCFA programs. Directs regional
responsibilities relating to experimental and demonstration projects.
Oversees a beneficiary services program within the region for HCFA
programs. Provides regional perspective to the Administrator, Associate
Administrators, Bureau Directors, and Staff Office Directors in the
development of HCFA policies, programs and objectives.
6. Health Standards and Quality Bureau (FLE)
Provides leadership and overall programmatic direction for
implementation and enforcement of health quality and safety standards
for providers and suppliers of health care services and evaluates their
impact on the utilization, quality and cost of health care services.
Plans, develops and establishes procedures and guidelines for
administering and evaluating the nationwide Medicare and Medicaid
survey and certification program. Monitors and validates the process
for certifying that participating providers and suppliers are in
compliance with established conditions and standards. Responsible for
implementation and operation of professional review and other medical
review programs. Administers a comprehensive system for assessment of
individual professional and medical review organizations to determine
compliance with program requirements and to document the effectiveness
and impact of their activities. Establishes specifications for
information and data reporting, collection and systems requirements for
the survey and certification, professional review and other medical
review activities.
Dated: March 8, 1994.
Donna E. Shalala,
Secretary, Department of Health and Human Services.
[FR Doc. 94-6008 Filed 3-15-94; 8:45 am]
BILLING CODE 4120-01-M
