[Federal Register Volume 59, Number 60 (Tuesday, March 29, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-7346]
[[Page Unknown]]
[Federal Register: March 29, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Statement of Organization, Functions, and Delegations of
Authority; Substructure 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) is amended to reflect the
establishment of the subordinate organizational structure for HCFA
which was recently approved. Although the Bureaus/Offices have recently
been published, the entire set of HCFA's functional statements are
being republished to facilitate the amendment of Part F of the
Department statement. Included in this document are the new functional
statements for the subcomponents of HCFA.
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).
a. Division of Congressional Affairs (FAA1).
b. Division of Hearings & Policy Presentation (FAA2).
c. Division of Medicare Part A Analysis (FAA3).
d. Division of Medicare Part B Analysis (FAA4).
e. Division of Medicaid Analysis (FAA5).
f. Division of Intergovernmental Affairs (FAA6).
5. Medicaid Bureau (FAB).
a. Executive Operations Staff (FAB-1).
b. Medicaid Special Program Initiatives Staff (FAB-2).
c. Office of Medicaid Management (FAB1).
(1). Division of Financial Management (FAB11).
(2). Division of Program Performance (FAB12).
(3). Division of Payment Systems (FAB13).
d. Office of Medicaid Policy (FAB2).
(1). Division of Payment Policy (FAB21).
(2). Division of Coverage Policy (FAB22).
(3). Division of Eligibility Policy (FAB23).
6. Office of Managed Care (FAC).
a. Operational Analysis Staff (FAC-1).
b. Office of Managed Care Policy and Planning (FAC1).
(1). Division of Managed Care Policy and Evaluation (FAC11).
(2). Division of Planning and Promotion for Managed Care
(FAC12).
c. Medicaid Managed Care Office (FAC2).
d. Office of Managed Care Operations (FAC3).
(1). Division of Payment and Operations Support (FAC31).
(2). Division of Operations (FAC32).
(3). Division of Finance (FAC33).
B. Associate Administrator for Customer Relations and Communications
(FF).
1. Office of Beneficiary Services (FFA).
2. Office of Public Affairs (FFB).
a. Freedom of Information Division (FFB1).
b. Division of Public Appearances (FFB2).
3. Office of Public Liaison (FFC).
a. Division of Professional and Business Affairs (FFC1).
b. Division of Media Relations (FFC2).
C. Associate Administrator for Policy (FK).
1. Special Analysis Staff (FK-1).
2. Bureau of Policy Development (FKA).
a. Regulations Staff (FKA-1).
b. Office Of Regulations Management (FKA-2).
c. Office of Program Support (FKA-3).
(1) Executive Secretariat (FKA-31).
(2) Inquiries Staff (FKA-32).
(3) Program Liaison Staff (FKA-33).
d. Office of Payment Policy (FKA1).
(1) Division of Medical Services Payment (FKA11).
(2) Division of Hospital Payment Policy (FKA12).
(3) Division of Payment and Reporting Policy (FKA13).
(4) Division of Special Payment Programs (FKA14).
e. Office of Coverage and Eligibility Policy (FKA2).
(1) Division of Provider Services Coverage Policy (FKA21).
(2) Division of Medical Services Coverage Policy (FKA22).
(3) Division of Medicare Eligibility Policy (FKA23).
3. Office of Research and Demonstrations (FKB).
a. Office of Demonstrations and Evaluations (FKB1).
(1) Division of Long-Term Care Experimentation (FKB11).
(2) Division of Hospital Experimentation (FKB12).
(3) Division of Health Systems and Special Studies (FKB13).
b. Office of Research (FKB2).
(1) Division of Beneficiary Studies (FKB21).
(2) Division of Payment and Economic Studies (FKB22).
(3) Division of Program Studies (FKB23).
c. Office of Operations Support (FKB3).
(1) Division of Research and Demonstrations Systems Support
(FKB31).
(2) Division of Program Support (FKB32).
4. Office of the Actuary (FKC).
a. Office of Medicare and Medicaid Cost Estimates (FKC1).
(1) Division of Hospital Insurance (FKC11).
(2) Division of Supplementary Medical Insurance (FKC12).
(3) Division of Medicaid Cost Estimates (FKC13).
b. Office of National Health Statistics (FKC2).
(1) Division of Health Cost Analysis (FKC21).
(2) Division of Survey Analysis (FKC22).
D. Associate Administrator for Operations and Resource Management
(FL).
1. Office of the Attorney Advisor (FL-1).
2. Office of Planning and Support (FL-2).
3. Office of Financial and Human Resources (FLA).
a. Management Planning and Analysis Staff (FLA-1).
b. Office of Financial Management (FLA1).
(1) Division of Accounting (FLA11).
(2) Division of Budget (FLA12).
c. Office of Human Resources (FLA2).
(1) Division of Information and Organizational Management
(FLA21).
(2) Division of Performance Management and Development (FLA22).
(3) Division of Staffing and Employee Services (FLA23).
d. Office of Acquisitions and Grants (FLA3).
(1) Division of Health Standards Contracts (FLA31).
(2) Division of Contracts and Grants (FLA32).
e. Office of Administrative Services (FLA4).
(1) Division of Facilities Management (FLA41).
(2) Division of Safety and Property Management (FLA42).
(3) Division of Telecommunications and Graphics Services
(FLA43).
(4) Division of Printing and Distribution Services (FLA44).
4. Bureau of Program Operations (FLB).
a. Executive Secretariat (FLB-1).
b. Issuances Staff (FLB-3).
c. Office of Contracting and Financial Management (FLB1).
(1) Division of Acquisitions and Contracts (FLB11).
(2) Division of Financial Management (FLB12).
(3) Division of Contractor Planning and Management (FLB13).
(4) Division of Account Management and Collection (FLB14).
d. Office of Medicare Benefits Administration (FLB2).
(1) Division of Utilization Analysis (FLB21).
(2) Division of Entitlement and Benefit Coordination (FLB22).
(3) Division of Audit and Payment Management (FLB23).
(4) Division of Medigap Operations (FLB24).
e. Office of Program Operations Procedures (FLB3).
(1) Division of Claims Processing Procedures (FLB31).
(2) Division of Claims Processing Requirements (FLB32).
(3) Division of Appeals and Communications (FLB33).
(4) Division of Operational Systems Development (FLB34).
f. Office of Quality and Evaluation (FLB4).
(1) Division of Quality Programs (FLB41).
(2) Division of Standards (FLB42).
(3) Division of Program Evaluation (FLB43).
(4) Division of Reports and Information Management (FLB44).
5. Bureau of Data Management and Strategy (FLC).
a. Office of Information Resources Management (FLC1).
(1) Division of Information Systems Management (FLC11).
(2) Division of ADP Planning and Resources Management (FLC12).
b. Office of Statistics and Data Management (FLC2).
(1) Division of Payment Policy Support (FLC21).
(2) Decision Support Division (FLC22).
(3) Division of Special Programs (FLC23).
c. Office of Program Systems (FLC3).
(1) Division of Program Management Systems (FLC31).
(2) National Claims History Division (FLC32).
(3) Division of Medicaid Statistics (FLC33).
d. Office of Enrollment Systems (FLC4).
(1) Division of Enrollment Applications (FLC41).
(2) Division of Capitation and Collection Systems (FLC42).
(3) Division of Medicare Operations Support (FLC43).
e. Office of Information Technology (FLC5).
(1) Division of Administrative Systems (FLC51).
(2) Division of Office Automation Systems (FLC52).
f. Office of Computer Operations (FLC6).
(1) Division of Data Center Services (FLC61).
(2) Division of Data Communications and Distributed Services
(FLC62).
6. Office of the Regional Administrators (FLD(I-X)).
a. Division of Health Standards and Quality (FLD(I-X)A).
b. Division of Medicaid (FLD(I-X)B).
c. Division of Medicare (FLD(I-X)C).
7. Health Standards and Quality Bureau (FLE).
a. Management Resources Staff (FLE-1).
b. Office of Peer Review (FLE1).
(1) Division of Program Operations (FLE11).
(2) Division of Review Programs (FLE12).
(3) Division of Systems Management (FLE13).
(4) Division of Program Assessment and Information (FLE14).
c. Office of Survey and Certification (FLE2).
(1) Division of Long-Term Care Services (FLE21).
(2) Division of Systems Management and Data Analysis (FLE22).
(3) Division of Program Operations (FLE23).
(4) Division of Laboratory Standards and Performance (FLE24).
(5) Division of Hospitals, Home Health, and Ambulatory Services
(FLE25).
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 following statements
provide the overall organizational structure of the Health Care
Financing Administration. The new HCFA organizational structure is
described as follows:
A. Office of the Administrator (FA)
The Administrator directs the planning, coordination, and
implementation of the programs under Titles XI, XVIII, 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.
Within broad Department of Health and Human Services
policy and guidelines, the Administrator oversees the establishment of
program goals and objectives and the development of policies, standards
and guidelines; evaluates progress in the administration of HCFA
programs; and ensures that required actions are taken to direct or
redirect efforts to achieve program objectives.
The Administrator works with the States, other Federal
agencies and other concerned nongovernmental organizations in
administering health care financing programs.
The Administrator is assisted by a general deputy, who
functions with full authority during the Administrator's absence.
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 Administration's 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, action
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 from 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.
a. Division of Congressional Affairs (FAA1)
Serves as the HCFA focal point for all congressional
liaison activities. Coordinates HCFA's congressional liaison activities
with the Office of the Assistant Secretary for Legislation (ASL).
Responds to congressional inquiries and constituent
concerns related to Medicare, Medicaid, and other health care financing
issues. Organizes briefings for Congressmen, congressional staff and
the public on specific issues and prepares reports on these issues for
higher level management.
Notifies Congress of specific HCFA activities of interest
to Members.
Provides advice to the Director, Office of Legislative &
Inter-Governmental Affairs (OLIGA), the Administrator, and other HHS
policy officials on the resolution of sensitive congressional issues.
Prepares legislative histories and congressional profiles
used by HCFA senior staff in preparation for congressional hearings.
Prepares a variety of summary reports on congressional
legislative activities and inquiries for use by the Director, OLIGA,
the Administrator, and other HHS policy officials.
Maintains the HCFA legislative reference library. Provides
legislative reference and research services to HCFA, the Department,
and the general public.
b. Division of Hearings & Policy Presentation (FAA2)
In preparation for congressional hearings, drafts
testimony to be used by the Administrator, the Secretary, and other HHS
policy officials.
Serves as the principle HCFA contact point with the Office
of the Assistant Secretary for Legislation on congressional hearings
and coordinates the preparation for such hearings, working with other
Office of Legislative & Inter-Governmental Affairs and HCFA components.
Clears other departmental and Administration testimony
that has a bearing on Medicare, Medicaid, or other health care
financing programs.
Reviews other written products such as bill reports,
studies, policy statements, etc., for clarity, presentation, and
consistency with overall HCFA policy.
Develops policy presentations for the general media in
consultation with the Office of the Associate Administrator for
Customer Relations & Communications.
c. Division of Medicare Part A Analysis (FAA3)
Conducts legislative, economic, and policy analyses
related to Medicare Part A issues. Substantive areas include Medicare
Part A benefits, eligibility, payment, and financing, and other cross-
cutting parts of Medicare and the health delivery system that have an
effect on Medicare Part A.
Coordinates the development of Medicare Part A legislative
proposals and develops the technical specifications for such
legislation.
Plans, develops, and directs the strategy to enhance the
enactment of the Administration's Medicare Part A legislative program.
Analyzes and reviews Medicare Part A regulations, issue
papers, Office of the Inspector General reports, reports to Congress,
and other policy documents for the Director, Office of Legislative &
Inter-Governmental Affairs (OLIGA).
Designs and conducts long-range Medicare Part A policy
studies as well as other special projects, such as representing HCFA or
OLIGA on task forces, outside commissions or policy panels in assigned
areas.
Working with the Office of the Assistant Secretary for
Legislation (ASL), provides (or coordinates) technical consultative
services to congressional members, their staff and the public on
Medicare Part A legislation and related HCFA activities.
Recommends the HCFA and HHS position on Medicare Part A
legislation likely to be considered by Congress. Develops bill reports
and coordinates comments from other HCFA and HHS components. Clears
enrolled bill reports and recommends Presidential veto or signature.
Prepares legislative summaries of newly enacted legislation and
selected congressional bills.
Monitors all Medicare Part A congressional legislative
activity, with an emphasis on Budget Reconciliation and other major
legislation.
Assists in the preparation of Medicare Part A briefing
materials, background, and testimony for HCFA and HHS policy officials'
appearances at congressional hearings.
Provides assistance to other offices within OLIGA to
ensure consistent, coordinated analyses and responses. Provides input
to cross-cutting projects.
d. Division of Medicare Part B Analysis (FAA4)
Conducts legislative, economic, and policy analyses
related to Medicare Part B issues. Substantive areas include Medicare
Part B benefits, eligibility, payment, and financing, and other cross-
cutting parts of Medicare and the health delivery system that have an
effect on Medicare Part B.
Coordinates the development of Medicare Part B legislative
proposals and develops the technical specifications for such
legislation.
Plans, develops, and directs the strategy to enhance the
enactment of the Administration's Medicare Part B legislative program.
Analyzes and reviews Medicare Part B regulations, issue
papers, Office of the Inspector General reports, reports to Congress,
and other policy documents for the Director, Office of Legislative &
Inter-Governmental Affairs (OLIGA).
Designs and conducts long-range Medicare Part B policy
studies as well as other special projects, such as representing HCFA or
OLIGA on task forces, outside commissions or policy panels in assigned
areas.
Working with the Office of the Assistant Secretary for
Legislation, provides (or coordinates) technical consultative services
to congressional members, their staff and the public on Medicare Part B
legislation and related HCFA activities.
Recommends the HCFA and HHS position on Medicare Part B
legislation likely to be considered by Congress. Develops bill reports
and coordinates comments from other HCFA and HHS components. Clears
enrolled bill reports and recommends Presidential veto or signature.
Prepares legislative summaries of newly enacted legislation and
selected congressional bills.
Monitors all Medicare Part B congressional legislative
activity, with an emphasis on Budget Reconciliation and other major
legislation.
Assists in the preparation of Medicare Part B briefing
materials, background, and testimony for HCFA and HHS policy officials'
appearances at congressional hearings.
Provides assistance to other offices within OLIGA to
ensure consistent, coordinated analyses and responses. Provides input
to cross-cutting projects.
e. Division of Medicaid Analysis (FAA5)
Conducts legislative, economic, and policy analyses
related to the Medicaid program. Substantive areas include Medicaid
eligibility, payment, coverage, financing, the impact on Medicaid of
changes to Public Health Service, and welfare programs, and the health
care of low income individuals.
Coordinates the development of Medicaid legislative
proposals and develops the technical specifications for such
legislation. Plans, develops, and directs legislative strategy to
enhance the enactment of the Administration's legislative program for
the Medicaid program.
Analyzes and reviews Medicaid regulations, issue papers,
Office of the Inspector General reports, reports to Congress, and other
policy documents for the Director, Office of Legislative & Inter-
Governmental Affairs (OLIGA).
Designs and conducts long-range Medicaid policy studies as
well as special projects, such as representing HCFA or OLIGA on task
forces, outside commissions or policy panels in assigned areas.
Working with the Office of the Assistant Secretary for
Legislation, provides (or coordinates) technical consultative services
to congressional members, their staff and the public on Medicaid
legislation and related HCFA activities.
Recommends the HCFA and HHS position on Medicaid
legislation likely to be considered by Congress. Develops bill reports
and coordinates comments from other HCFA and HHS components. Clears
enrolled bill reports and recommends Presidential veto or signature.
Prepares legislative summaries of newly enacted legislation and
selected congressional bills.
Monitors all Medicaid congressional legislative
activities, with an emphasis on Budget Reconciliation and other major
legislation.
Prepares Medicaid briefing materials, background, and
testimony for HCFA and HHS policy officials' appearances at
congressional hearings.
Provides assistance to other offices within OLIGA to
ensure consistent, coordinated analyses and responses. Provides input
to cross-cutting projects.
f. Division of Intergovernmental Affairs (FAA6)
Provides leadership for HCFA in the area of
intergovernmental affairs.
Advises the Director, Office of Legislative & Inter-
Governmental Affairs, on all policy and program matters which affect
other units and levels of government.
In coordination with the Department's Intergovernmental
Affairs office, the Principal 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.
Assesses the impact on State and localities of HCFA
actions involving penalties, disallowances, compliance actions, or new
performance standards.
Assists States and localities in requesting and obtaining
technical materials, assistance, and support from appropriate HCFA
components.
Upon State requests, arranges for 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 makes 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.
a. Executive Operations Staff (FAB-1)
Advises the Medicaid Bureau (MB) managers on
organizational design and implementation; requests to establish
positions; and delegations of management and program administration
authorities.
Establishes and implements integrated and coordinated MB
work planning. Plans and monitors the execution of major Bureau program
initiatives through the administration of the Bureau's work planning to
ensure fairness and equity among components and to assure that
measurable and verifiable outputs are provided.
Interprets administrative budgetary policies and
limitations and develops and issues guidelines and instructions to MB
managers for budget formulation and execution. Executes the budget for
the bureau through the issuance of staff and dollar controls, budget
allowances for administrative expenditures, and employment ceilings to
bureau components.
Provides services and liaison with the Office of Financial
& Human Resources related to procurement; space acquisition,
utilization and management; telephone systems; records; publications;
forms printing; and reprographics.
Directs a bureau-wide tracking and control system for
legislation, regulations, instructions and correspondence; and provides
training and technical assistance on standards for content of written
documents.
Serves as the focal point for the General Accounting
Office and the Office of the Inspector General reports relating to MB;
and coordinates other operational reviews of, and within, MB (e.g.,
internal control reviews).
Provides bureau support and represents MB on issues
related to microcomputer systems.
b. Medicaid Special Program Initiatives Staff (FAB-2)
Implements Medicaid maternal and infant health initiative
and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
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.
Serves as HCFA liaison and manager of the Medicaid
Maternal and Child Health Technical Advisory Group.
Assists in developing Medicaid participation in
alternative service and delivery methods (e.g., collaboration and
pluralistic funding of health care for varied Human Immuno Virus/
Acquired Immune Deficiency Syndrome (AIDS)-infected Medicaid
Recipients) and conducts reconnaissance and analyses to identify
emerging and potential problem areas (e.g., financing community
substance abuse programs).
Provides technical assistance to States, regional offices,
and other interested groups in all special Medicaid initiatives.
Evaluates the effect of proposed legislation on sensitive
and special Medicaid issues (i.e., EPSDT and AIDS) and recommends new
or amended legislation in regard to these special areas.
c. Office of Medicaid Management (FAB1)
Provides oversight, coordinates, and formulates the
national Medicaid medical assistance and administrative costs budgets
and justifications. Develops and maintains budget preparation and
execution policies and procedures used by States and regional offices.
Administers the State grants process for administrative
and program payments including regional office disallowances.
Develops and monitors Medicaid automated systems
requirements, standards, procedures, guidelines, and methodologies.
Directs review, evaluation, and assessment of the operation,
development, and funding of Medicaid State agency automated systems,
including the claims processing and information retrieval and
integrated eligibility systems, and coordinates systems requirements
for Federal programs such as Child Health Assurance, Child Support
Enforcement, food stamps, and Aid to Families with Dependent Children.
Provides oversight and coordinates the Medicaid State plan
preprint process. Assists components in the development, publication,
timely issuance to States, and maintenance of the master copy of State
plan preprints.
Provides oversight of planning, development,
implementation, and monitors Medicaid program operations in regional
offices and State Medicaid agencies including drug rebate program,
Systematic Alien Verification for Entitlement System, national Medicaid
eligibility quality control program, Medicaid Drug Use Review program,
State claims processing and payment operations, and third party
liability activities.
(1) Division of Financial Management (FAB11)
Provides oversight and coordinates the national Medicaid
medical assistance and administrative costs budgets and justifications.
Develops and maintains budget preparation and execution policies and
procedures used by States and regional offices.
Establishes policies and procedures by which Medicaid
State agencies and regional offices submit quarterly budget estimates
and reports and administers the State grants process for administrative
and program payments.
Reviews all State claims for Federal payment under Title
XIX of the Social Security Act including regional office disallowances
of State claims.
Serves as the focal point for the defense of disallowance
decisions before the Department Appeals Board.
Provides oversight and manages the national State
Performance Evaluation and Comprehensive Test of Reimbursement Under
Medicaid review process.
Provides the definitive HCFA interpretation of Medicaid
payment policy for administrative costs. Responsible for operational
policies regarding availability of Federal Financial Participation
(FFP), designation of appropriate FFP rates, and for issuing
interpretations to regional offices regarding operational FFP issues.
Directs regional office financial reviews and audits of
State agencies and oversees the Medicaid claims processing review
activity.
Provides oversight, administration, and maintenance of the
Medicaid Budget and Expenditure System.
(2) Division of Program Performance (FAB12)
Develops, implements, and operates the national Medicaid
eligibility quality control program to determine the effectiveness of
Medicaid State agencies' performance in the area of eligibility
determinations.
Provides documentation and analysis necessary to initiate
and support actions on disallowances, penalties, and corrective action
requirements, and adjudication of appeals of disallowances and
penalties.
Develops, implements, and coordinates a system for
reviewing the States' performance of the Income Eligibility
Verification System (IEVS) requirements. Develops and interprets
regulations and policies for States to establish IEVS.
Develops, coordinates, and promulgates operational policy
for utilizing the Systematic Alien Verification for Entitlement system.
Provides expertise on sampling, precision, universe
identification, and other technical statistical issues in support of
the Medicaid quality control and assessment programs.
Develops and promulgates policies and procedures for the
proper maintenance, review, and approval of State plans and their
amendments. Monitors State compliance to State plan and oversees the
compliance process.
Ensures adherence to all Automated Data Processing (ADP)
security measures, policies, and procedures; assists with the
development, modification, and review of HCFA ADP policies as they
apply to Medicaid.
Directs the bureau's ADP activities relating to
development, implementation, and administration of mainframe ADP
systems programs.
Provides oversight and coordinates the Medicaid State plan
preprint process. Assists components in the development, publication,
timely issuance to States, and maintenance of the master copy of State
plan preprints.
Develops procedures with the Social Security
Administration concerning Medicaid eligibility operational issues such
as transfer of resources, deemed Supplemental Security Income
recipients and the State Data Exchange.
(3) Division of Payment Systems (FAB13)
Provides bureau support in the development and
implementation of new systems that interface with other HCFA components
or involve mainframe computers.
Develops the requirements, standards, procedures,
guidelines, methodologies, and test criteria pertaining to the review,
evaluation, and assessment of operations, development, and funding of
State agency automation, claims processing and information retrieval
and integrated eligibility systems to determine their compliance with
published Federal requirements.
Reviews State agency requests for Federal Financial
Participation (FFP) in the costs of operating Medicaid claims
processing, information retrieval systems, and development and
operations of the integrated eligibility systems.
Reviews State agency FFP requests for Medicaid Management
Information Systems and interdepartmental integrated eligibility
systems for approval.
Plans, develops, and monitors systems requirements for
Medicaid and coordinates systems requirements for related Federal
programs such as Child Health Assurance, Child Support Enforcement,
Food Stamps, and Aid to Families with Dependent Children.
Provides operational and systems support for
implementation of the Medicaid drug rebate program. Maintains liaison
with and provides technical assistance to drug manufacturers, Medicaid
State agencies, pharmaceutical associations, private sector vendors and
other parties regarding the drug rebate program. Prepares an annual
report to Congress regarding drug product and expenditure information.
Serves as the focal point for Medicaid third party
liability, qualified Medicare beneficiary, and Drug Use Review
operating instructions and policy guidance to Medicaid State agencies
and regional offices.
Coordinates with all State Medicaid agencies, in
conjunction with HCFA regional offices, implementation of system coding
and other changes related to the Medicare program's Physician Payment
Reform initiative and other data initiatives such as common coding,
uniform billing, and electronic media claims formats.
d. Office of Medicaid Policy (FAB2)
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 to improve
program policy and ease of administration.
Reviews State plan amendments and makes recommendations on
approvals/disapprovals.
Oversees, coordinates, processes, and assesses the
operation of State Medicaid Home and Community-Based Services Waivers.
(1) Division of Payment Policy (FAB21)
Formulates and evaluates policies, regulations,
instructions, and procedures related to Medicaid coverage activities.
Prepares regulations, manuals, program guidelines, State plan
preprints, and general instructions related to Medicaid institutional
and non-institutional payment policy.
Provides interpretations of Medicaid payment policies to
regional offices, congressional staffs, other Departments of the
Federal government, interest groups and State agencies.
Develops, evaluates, and reviews Medicaid policies,
regulations, guidelines, and instructions pertaining to provider and
other facility payment under the Medicaid program including, for
example, Medicaid institutional payment plans, Medicaid community
provider rates, Medicaid payment of such entities as rural health
clinics and federally qualified health centers and capitated rates for
Medicaid managed care organizations.
Formulates and evaluates policies and procedures related
to Medicaid payment for long-term care, physician services,
practitioner services, case management, obstetrical and pediatric
services, pharmaceuticals, supplies and equipment such as hearing aids,
eyeglasses, durable medical equipment, laboratory, and other medical
services.
Participates in the development and evaluation of proposed
legislation in the area of Medicaid payment.
Reviews State plan amendment requests under Medicaid.
Analyzes and recommends legislative or other remedies to
improve the effectiveness of Medicaid payment policies.
Reviews, with the Office of Research and Demonstrations,
research and demonstration agendas in the area of Medicaid payment.
(2) Division of Coverage Policy (FAB22)
Formulates and evaluates policies, regulations,
instructions, and procedures related to Medicaid coverage activities.
Prepares specifications for regulations, manuals, program guidelines,
State plan preprints, and general instructions related to these areas.
Provides interpretations of Medicaid coverage policies to
regional offices, congressional staffs, other departmental offices,
other Departments of the Federal government, interest groups and State
agencies.
Develops, evaluates, and reviews all Medicaid coverage
policies, regulations, and procedures.
Develops, evaluates, and reviews policies, regulations,
and procedures pertaining to States' requests for approval of waivers
of Medicaid requirements to provide home and community-based services
and makes recommendations whether the waivers should be approved or
disapproved.
Develops, evaluates, and reviews national coverage
policies concerning Medicaid medical service contracts, interagency
agreements, and prior authorizations.
Reviews coverage related Medicaid State plan amendment
requests.
Identifies, studies, and makes recommendations for
modifying Medicaid coverage policies to reflect changes in recipient
health care needs, program objectives, and the health care delivery
system.
(3) Division of Eligibility Policy (FAB23)
Develops, interprets, and evaluates policies pertaining to
all conditions under which recipients are eligible to have their health
care services covered under Medicaid, the rights and responsibilities
of recipients and applicants, and other special eligibility and
technical issues.
Evaluates the effect of proposed legislation on current
eligibility policies and recommends specifications for new or proposed
legislation on eligibility.
Provides consultation regarding State plan amendments and
waiver requests and prepares State plan disapproval actions.
Prepares specifications for regulations, preprints, and
manual instructions pertaining to Medicaid eligibility policy.
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.
a. Operational Analysis Staff (FAC-1)
Identifies and analyzes issues, problems, and trends
related to the Office of Managed Care (OMC) operations.
Develops OMC operational policy manuals, standard
operating procedures, and other instructions and issuances. Assists the
Office of Managed Care Policy & Planning (OMCPP) in the development of
policy and regulatory proposals.
Performs special studies and projects for OMC in the areas
of payment, operations, and finance.
Responds to operational policy questions generated by OMC
staff, regional offices, contractors, and other HCFA or departmental
components.
Establishes and maintains liaison with trade associations,
State regulatory agencies, OMCPP, and departmental components, such as
the Office of the General Counsel.
b. Office of Managed Care Policy and Planning (FAC1)
Develops national policies and objectives for the
development, qualification, and ongoing compliance of Health
Maintenance Organizations (HMOs) and Comprehensive Medical Plans
(CMPs). Plans, coordinates, and directs the development and preparation
of related legislative proposals, regulatory proposals, and policy
documents.
Acts as the focal point for all managed health care
research, demonstration, and evaluation study activity within and
external to the Department.
Develops and implements programs to encourage greater
access of Federal Medicare beneficiaries to HMOs and other prepaid
health plans.
Monitors and analyzes Federal activities and policies
regarding Federal beneficiaries in Medicare, CHAMPUS, and the Federal
Employees Health Benefits' programs. Coordinates the development and
implementation of health education and health promotion programs in
managed health care plans.
Coordinates the Department's efforts to move toward a
pluralistic health care delivery system.
Conducts special studies of managed health care plans
operations and operating data and identifies trends and develops
performance measures which can be used by the Office of Managed Care
Operations and by the industry to assess the development and operation
of managed health care plans.
Develops and issues technical guidance documents for use
by the industry in the development of managed health care plans and the
improvement of operations in existing managed health care plans.
Develops and maintains close relationships with national
organizations representing the managed health care plans industry to
enhance technical assistance capability and to establish appropriate
performance measures.
Plans, coordinates, and directs the development and
preparation of managed care legislative proposals, regulatory
proposals, and policy documents and performs strategic policy and
planning functions and other special tasks as required by the
Administrator.
Provides liaison staff for activities with other Federal
programs and agencies, health care professional associations, and trade
associations.
(1) Division of Managed Care Policy and Evaluation (FAC11)
Develops and coordinates legislative proposals, regulatory
specifications, and other policy documents to establish managed health
care national policies and to address the Agency objectives for the
development, qualification, contracting, and ongoing compliance of
health maintenance organizations (HMOs), comprehensive medical plans
(CMPs), preferred provider organizations (PPOs), and other managed
systems of health care.
Analyzes the manner in which the Agency objectives and
policies are tied into pending or existing managed health care
legislation and regulations. Evaluates national trends and their
possible effect on Agency-wide activities.
Reviews and analyzes policies regarding Federal
beneficiaries in Medicare, CHAMPUS, and the Federal Employees Health
Benefits' programs for coordination with managed health care programs.
Reviews and analyzes coordinated internal and external
health care research, demonstration, and evaluation study activities.
Develops presentation material for use with congressional
committees and with the Office of Management and Budget related to the
program and appropriation legislation affecting the managed health care
objectives of the Administration.
(2) Division of Planning and Promotion for Managed Care (FAC12)
Develops and implements activities to promote managed
health care programs to Health Maintenance Organizations (HMOs),
Comprehensive Medical Plans (CMPs), preferred provider organizations
(PPOs), employers, insurance companies, managed health care
associations/organizations, and other professional medical and private
groups, including Federal beneficiary and consumer groups.
Develops and coordinates managed health care education and
promotional programs within the Agency/Department to encourage greater
access of Federal Medicare beneficiaries to HMOs, CMPs, PPOs, and other
managed health care organizations. Supports the Agency/Department's
efforts to move toward a pluralistic health care delivery system.
Develops and supports the maintenance of close working
relationships with national organizations representing the managed
health care industry to enhance technical assistance options and to
promote appropriate managed health care performance measurement
standards.
Develops, coordinates, and supports strategic planning
activities for the managed health care program in the Agency and any
other specific managed health care planning initiatives.
Establishes and maintains a system to monitor the planning
schedule to assure appropriate coordination and completion of managed
health care activities within the Agency.
Supports the liaison activities for the Agency for managed
health care programs with other Federal/State programs and agencies,
health care professional organizations/associations, trade
associations, and consumer groups.
c. Medicaid Managed Care Office (FAC2)
Serves as the operational focal point for all Medicaid
managed care activities.
Formulates, evaluates, and prepares policies,
specifications for regulations, instructions, preprints, and procedures
related to Medicaid managed health care, including waivers.
Makes recommendations for legislative changes to improve
managed health care program policy.
Provides oversight of, and assistance to, State Medicaid
agencies on all managed health care issues, including Medicaid managed
health care contracting activities. Provides technical assistance to
State regulators.
Serves as the focal point and repository for State laws
and regulations dealing with Health Maintenance Organizations (HMOs),
group medical practice, insurance, licensing, foundations, service
corporations, certificate of need, and reserve requirement statutes.
Develops guidelines, policies, and procedures for use by
the regional offices when reviewing and approving/disapproving State
Medicaid agency contracts with managed health care plans.
Formulates and evaluates policies and procedures related
to HMOs and other managed health care contracts and freedom of choice
waiver programs including the preparation of recommendations for
waivers of freedom of choice and other State plan exception
requirements; monitoring of approved HMOs and other managed health care
contracts and freedom of choice waivers and recommendations for the
removal of waivers; State plan/waiver processing policy; and other
related issues.
Evaluates and assures the cost-effectiveness of approved
Medicaid freedom of choice waivers through review of State program and
cost reports, independent assessments, and regional compliance/
validation reviews.
d. Office of Managed Care Operations (FAC3)
Provides national direction and executive leadership for
managed health care operations, including health maintenance
organizations (HMOs), comprehensive medical plans (CMPs), and other
capitated health organizations.
Develops national operations objectives for the
qualification and ongoing compliance of managed health care plans.
Develops long- and short-range program operational goals
and objectives.
Serves as the departmental focal point in the areas of
managed health care plan qualification, ongoing regulation, employer
compliance efforts, and Medicare HMO and CMP risk contracting.
Administers Medicare managed care contracts, the
capitation formula, and payment policies.
Oversees the operation of the managed health care
information system.
Determines the amounts of payments to be made to managed
health care plans and the amounts, methods, and frequency of
retroactive adjustments.
Incorporates a prospective payment system for managed
health care through the implementation of the Tax Equity and Fiscal
Responsibility Act risk contracts.
Evaluates cost reporting methodologies and conducts a
continuing audit program to determine the final program liability for
cost contracts.
Administers beneficiary enrollment and disenrollment
including coordination with beneficiary groups and other HCFA and HHS
components.
(1) Division of Payment and Operations Support (FAC31)
Manages the national Medicare beneficiary enrollment and
disenrollment operations.
Ensures timely and accurate payment to managed health care
plans.
Plans, develops, operates, and evaluates the operational
and management information systems supporting the Medicare managed
health care program.
Conducts special analyses of specific managed health care
plans and management information systems to identify problems and
determine the need for new or enhanced systems design.
Establishes national operational policy, procedures, and
instructions for system specifications and data exchange methods which
define and automate the managed health care plans' enrollment,
disenrollment, and other systems operations.
Serves as liaison with the Bureau of Data Management and
Strategy and other HCFA Central Office and regional office components
in their implementation and evaluation of the management information
systems.
(2) Division of Operations (FAC32)
Directs the qualification applications process for Health
Maintenance Organizations (HMOs) under the requirements of section 1301
of the Public Health Service Act (PHS Act).
Coordinates with and provides technical assistance to the
regional offices on the monitoring of Medicare HMOs and Comprehensive
Medical Plans.
Manages and monitors the processing of Medicare managed
health care contract reconsiderations.
Investigates and evaluates applicants' conformance with
legal and financial requirements for qualification for Medicare
contracts under section 1301 of the PHS Act, section 1833 and section
1876 of the Social Security Act, and related regulations.
Coordinates Program Advisory Council activities, including
obtaining regional office reports and recommendations, incorporating
information from Central Office reviewers, and issuing approval of
initial applications and renewals. Coordinates and makes
recommendations on nonrenewals, terminations, and revocations based on
information and analysis provided by regional offices.
Implements new legislation and regulations regarding
managed health care operations.
Assures compliance with section 1310 of the PHS Act by
employers with the mandatory offering of a managed health care plan
alternative in employer health benefit plans.
In consultation with the regional offices, establishes
performance standards and evaluates the plans' performance.
Provides training for and guidance of regional offices in
activities related to managed health care. Also provides training and
workshops for HMOs.
Establishes and maintains liaison with appropriate State
and Federal regulatory agencies for coordination of qualification,
contract, and monitoring issues.
(3) Division of Finance (FAC33)
Establishes interim payment rates, retroactively adjusts
payments, and performs end-of-year settlements for all cost-based
contracting plans.
Reviews initial Adjusted Community Rate proposals.
Trains and guides the audit contractor who performs the
desk review of the Health Maintenance Organization (HMO) and
Comprehensive Medical Plan (CMP) cost reports.
Provides operational input for legislative and regulatory
proposals and standard operating procedures related to cost methodology
and fiscal responsibility.
Establishes national financial standards for federally
qualified HMOs and CMPs and assures that these entities comply with
these requirements.
Establishes national standards for the protection of
enrolles in the event of HMO or CMP insolvency. Assures that HMOs and
CMPs comply with these standards.
Develops procedures to improve or revise the payment
methodologies and processes of Medicare contractors and financial
reviews of HMOs and CMPs.
Manages the plan qualification fiscal soundness and
insolvency protection reviews process.
B. 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:
customer relations and program communication.
Advises 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 their 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.