[Federal Register Volume 60, Number 148 (Wednesday, August 2, 1995)]
[Notices]
[Pages 39404-39409]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-18977]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Statement of Organization, Functions, and Delegations of
Authority; Update of Regional Office Division Level Functional
Statements
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. 14658-14659, dated Tuesday, March 29, 1994) is being amended to
reflect changes to the functional statements to the Division level
components within the HCFA Regional Offices (ROs). Eight of the ROs
propose to streamline their organizational structure in accordance with
HCFA's Strategic Plan (SP) and the recommendations contained in the
National Performance Review. Seattle plans to streamline as a
demonstration project to last up to 18 months. Seattle will establish
seven organizations, called Clusters, that will report to the Office of
the Regional Administrator (ORA). The other ROs will retain the basic
three division structure, including the Division of Health Standards
and Quality (DHSQ), the Division of Medicaid, and the Division of
Medicare, in each of the ROs affected by this proposal. The changes to
the functional statements at the division level are minor and can best
be characterized as updates and clarifications of functional
responsibilities. The primary changes occur at the branch level where
the ROs propose to realign components to improve services to
beneficiaries, streamline their functions, to reduce the number of
supervisory positions, enhance employee empowerment and meet the goals
of the HCFA SP. The functional responsibilities of the Division of
Medicare and the Division of Medicaid are the same in all regions,
except Seattle, with minor variations indicated in the functional
statements.
The functional statements for DHSQ and the Divisions of Medicaid
and Medicare in Denver and San Francisco are being republished. The
functional statements for these two ROs will remain operational until
revised by a proposal later in the year. There are thus four distinct
functional statements for the DHSQ due to variations caused by the
concentration of primary responsibility for medical review activities
in three regions (Boston, Dallas, and Kansas City). The other ROs will
continue to have responsibility for some aspects of medical review but
will not have the primary responsibility for the function. The first
statement applies to those ROs (New York, Philadelphia, Atlanta, and
Chicago) that do not have primary responsibility for the medical review
function. The second statement applies to two of the ROs that have
primary medical review responsibility, Boston and Dallas. In both of
these regions, the medical review function will be assigned to DHSQ.
The third DHSQ statement applies to Kansas City, where the medical
review function will be assigned to the immediate ORA rather than DHSQ.
The fourth statement applies to the Denver and San Francisco which
retain the current DHSQ functional responsibility until revised by a
streamlining proposal later this year.
The functional statements for DHSQ and the Division of Medicaid and
the Division of Medicare in Denver and San Francisco are being
republished to avoid confusion.
The specific amendments to Part F. are as follows:
Section F.10.D.6 (Organization) is amended to read as
follows:
6. Office of the Regional Administrator
a1. Division of Health Standards and Quality (FLD(2-5)A)
a2. Division of Health Standards and Quality (FLD(1,6)A)
a3. Division of Health Standards and Quality (FLD(7)A)
a4. Division of Health Standards and Quality (FLD(8,9)A)
b1. Division of Medicaid (FLD(1-4, 6-7)B)
b2. Division of Medicaid and Managed Care (FLD(5)B)
b3. Division of Medicaid (FLD(8-9)B)
c1. Division of Medicare (FLD(1-7)C)
c2. Division of Medicare (FLD(8-9)C)
d1. Medicare Operations and Policy Cluster (FLDXD)
d2. Medicaid Operations and Policy Cluster (FLDXE)
d3. Program Fiscal Integrity Cluster (FLDXF)
d4. Consumer Services and Information Cluster (FLDXG)
d5. Managed Care Operations Cluster (FLDXH)
d6. Health Care Quality Improvement Cluster (FLSXJ)
d7. Certification Improvement Cluster (FLDXK)
Section F.20.D.6.a (Functions) is amended to read as follows:
a1. Division of Health Standards and Quality (FLD(2-5)A)
Assures that health care services provided under the
Medicare, Medicaid, and CLIA programs are furnished in the most
effective and efficient manner consistent with recognized professional
standards of care.
Interprets and implements health safety standards and
evaluates their impact on utilization and quality of health care
services.
Determines approval and denial of all provider and
supplier certification actions under the Medicare program.
Initiates and implements remedial actions, including
termination of agreements or alternative sanctions against health care
facilities not in compliance with Medicare requirements.
Makes final determination on all initial and supplemental
budget requests submitted by State survey agencies.
Monitors and evaluates State activities related to
Medicare and Medicaid survey and certification.
Oversees and monitors joint State survey agency/ESRD
Network activities.
Authorizes investigation of complaints received from the
public, the Congress, the media, and other sources which allege
deficiencies in the quality of care rendered by certified health care
providers.
Coordinates State survey agency activities related to
COBRA dumping, sanctions and civil money penalties.
Actively participates in and takes a lead role in
training, outreach and
[[Page 39405]]
collaborative activities involving providers, provider groups, and
State survey agencies, relating to quality of health care services.
Provides leadership in the development, implementation and
continuation of Continuous Quality Improvement activities for the State
survey agencies and providers.
Directs RO activities in support of HCFA's National
Managed Care Program.
a2. Division of Health Standards and Quality (FLD(1,6)A)
Oversees, monitors, coordinates, and evaluates the State
Survey agencies, Peer Review Organizations (PROs), and ESRD Networks.
Assures that health care provided under the Medicare,
Medicaid, and CLIA programs are appropriate, of high quality, and meet
recognized professional standards of care.
Improves the quality of care provided to Medicare
beneficiaries by administration of the PROs and ESRD Network programs,
hereafter referred to as Quality Improvement Programs (QIPs). Under the
Health Care Quality Improvement Program (HCQIP), QIPs collaborate with
providers to identify and act upon opportunities for the quality of
health care services.
Oversees the negotiation and award of contracts for QIPs.
Interprets and implements health and safety standards and
evaluates, through surveillance, and surveys, their impact on the
utilization and quality of health care services.
Evaluates services to ensure protection of beneficiaries
receiving health care services under the Medicare, Medicaid, and CLIA
programs.
Provides leadership and direction in beneficiary
information and outreach activities concerning health care services,
including information to enable beneficiaries to make informed health
care choices.
Determines program eligibility for all providers and
suppliers under the Medicare program, and executes required agreements.
Initiates, implements, and coordinates State related
adverse actions and alternative remedies, including civil money
penalties, and Federal activities against health care facilities not in
compliance with Medicare or CLIA requirements.
Makes final determination on all budget request submitted
by State survey agencies.
Establishes and maintains an extensive data and
information gathering system involving all aspects of the certification
program, CLIA, and QIPs.
Authorizes investigation of complaints received from
beneficiaries, the public, the Congress, the media, and other sources
which allege deficiencies in the quality of care rendered by certified
health care providers.
Actively participates in and takes a lead role in
training, outreach and collaborative activities involving providers,
provider groups, health care professionals, professional
reorganizations, consumer groups, and State survey agencies, relating
to quality of health care services.
Provides leadership in the development, implementation and
continuation of continuous Quality Improvement activities for the State
survey agencies and providers.
Provides leadership in the quality improvement aspects of
HCFA's National Managed Care Program.
Develops and conducts training programs for the State
survey agencies.
Provides clinical assistance and technical direction to
QIPs in the selection and evaluation of project, and develops, executes
and measures HCFA directed cooperative clinical projects.
a3. Division of Health Standards and Quality (FLD(7)A)
Oversees, monitors, and evaluates the State survey
agencies and Medicaid State agencies.
Assures that health care services provided under the
Medicare, Medicaid, and CLIA programs are furnished in the most
effective manner consistent with recognized professional standards of
care.
Interprets and implements health and safety standards and
evaluates, through surveillance, assessments and surveys, their impact
on the utilization and quality of health care services.
Determines approval, denial, or termination of all
provider and supplier certification actions under the Medicare program.
Implements and coordinates State, Contractor, and carrier
activities related to adverse sanctions and alternative remedies.
Makes final determination on all budget requests submitted
by State survey agencies.
Establishes and maintains an extensive data and
information gathering system involving all aspects of the
certification.
Authorizes investigation of complaints received from the
public, the Congress, the media, and other sources which allege
deficiencies in the quality of care rendered by certified health care
providers.
Actively participates in and takes a lead role in
training, outreach and collaborative activities involving providers,
provider groups, and State survey agencies, relating to quality of
health care services.
Provides leadership in the development, implementation and
continuation of continuous Quality Improvement activities for the State
survey agencies and providers.
a4. Division of Health Standards and Quality (FLD(8,9)A)
Assures that health care services provided under the
Medicare and Medicaid programs are furnished in the most effective and
efficient manner consistent with recognized professional standards of
care.
Interprets and implements health safety standards and
evaluates their impact on utilization and quality of health care
services.
Determines approval and denial of all provider and
supplier certification actions under the Medicare program.
Initiates and implements remedial actions, including
termination of agreements against health care facilities not in
compliance with Medicare requirements.
Makes final determination on all initial and supplemental
budget requests submitted by State survey agencies.
Monitors and evaluates State activities related to
Medicare and Medicaid survey and certification.
Oversees, monitors, and evaluates Peer Review
Organizations (PROs), including recommendations for contract renewal,
extension, and modification.
Recommends approval or withholding of monthly voucher
payments to PROs.
Authorizes investigation of complaints received from the
public, the Congress, the media, and other sources which allege
deficiencies in the quality of care rendered by certified health care
providers.
Coordinates State survey agency activities related to
sanctions and civil money penalties.
b1. Division of Medicaid (FLD(1-4,6-7)B)
Plans, manages and provides Federal leadership to State
agencies in program development, implementation, maintenance, and the
regulatory review of State Medicaid program management activities under
title XIX of the Social Security Act.
Plans, directs, coordinates, and approves Medicaid State
agency data processing systems (including MMIS)), proposals,
modifications, operations,
[[Page 39406]]
contracts, and reviews. Assists Medicaid State agencies in developing
innovative automated data processing health care systems. Assures the
propriety of Federal expenditures.
Reviews, evaluates, and determines acceptability of audit
findings and recommendations and takes necessary clearance and closure
actions.
Maintains day-to-day liaison with State agencies and
monitors their Medicaid program activities and practices by conducting
periodic program management and financial reviews to assure State
adherence to Federal law and regulations.
Reviews, approves, recommends disapproval, and maintains
official State plans and plan amendments for medical assistance.
Reviews, approves, and monitors State payment systems and
determines the allowablity of claims for Federal financial
participation. Takes action to disallow claims when expenditures are
not in accordance with Federal requirements and defends such action
before the Departmental Appeals Board and in court. Defers payment
action on questionable State claims for allowability.
Reviews States' Medicaid quarterly estimates and statement
of expenditures and recommends the amount to be estimated and allowed
in the quarterly grants.
Implements title XIX special initiatives and special or
experimental programs such as Maternal and Child Health, Acquired
Immune Deficiency Syndrome, statewide 1115 waivers, Freedom of Choice
Waivers (1915(b), Home and Community Based Services Waivers (1915c),
and operations of major management initiatives.
Provides consistent guidance, technical assistance, and
policy interpretation to States on Medicaid program and financial
issues.
Responds to beneficiary, Congressional, provider, and
public inquiries concerning Medicaid issues, including Freedom of
Information Act requests.
Conducts customer outreach and service initiatives.
Reviews and approves managed care contracts and prepaid
health plans.
b2. Division of Medicaid and Managed Care (FLD(5)B)
Provides Federal leadership to State agencies in program
implementation, maintenance, and regulatory review of State Medicaid
program management activities under Title XIX of the Social Security
Act.
Assures the propriety of Federal Medicaid expenditures
and, where appropriate, takes action to disallow claims.
Consults with and provides guidance to States on
appropriate matters including the interpretation of Federal
requirements, options available to States under these requirements, and
information on practices in other States.
Provides consistent policy guidance to States on Medicaid
program administration and the amount, duration, scope, and payment for
health services under the State program.
Monitors State agency Medicaid activities by conducting
periodic program management and financial reviews to assure State
adherence to Federal laws and regulations.
Reviews, approves, and maintains official State plans and
State plan amendments for medical assistance.
Directs activities in support of the Medicare managed care
program including technical support and oversight of these plans.
Reviews, approves or recommends for disapproval, and
monitors State institutional payment plans and systems (after CO
concurrence for hospitals and long term care facilities).
Reviews States' quarterly statements of expenditures and
recommends appropriate action on amounts claimed.
Defers payment action on questionable State claims for
allowability.
Issues orders suspending Federal financial participation
on unallowable State Title XIX payments and defends disallowance
actions at Departmental Appeals Board.
Plans, directs, and coordinates the review and approval of
Medicaid State agency data processing systems, proposals,
modifications, operations, and contracts.
Implements Title XIX special initiatives, such as maternal
and child health, Acquired Immune Deficiency Syndrome, managed care
plans, health maintenance organization contracts, and other special or
experimental programs and operations of major management initiatives.
Performs Medicaid eligibility quality control reviews over
State Medicaid eligibility and inspection of care practices to assure
their ongoing compliance with Medicaid laws and regulations.
b3. Division of Medicaid (FLD(8-9)B)
Provides Federal leadership to State agencies in program
implementation, maintenance, and regulatory review of State Medicaid
program management activities under Title XIX of the Social Security
Act.
Assures the propriety of Federal Medicaid expenditures
and, where appropriate, takes action to disallow claims.
Consults with and provides guidance to States on
appropriate matters including the interpretation of Federal
requirements, options available to States under these requirements, and
information on practices in other States.
Provides consistent policy guidance to States on Medicaid
program administration and the amount, duration, scope, and payment for
health services under the State program.
Monitors State agency Medicaid activities by conducting
periodic program management and financial reviews to assure State
adherence to Federal laws and regulations.
Reviews, approves, and maintains official State plans and
State plan amendments for medical assistance.
Reviews, approves or recommends for disapproval, and
monitors State institutional payment plans and systems (after CO
concurrence for hospitals and long term care facilities).
Reviews States' quarterly statements of expenditures and
recommends appropriate action on amounts claimed.
Defers payment action on questionable State claims for
allowability.
Issues orders suspending Federal financial participation
on unallowable State Title XIX payments and defends disallowance
actions at Departmental Appeals Board.
Plans, directs, and coordinates the review and approval of
Medicaid State agency data processing systems, proposals,
modifications, operations, and contracts.
Implements Title XIX special initiatives, such as Maternal
and Child Health, Acquired Immune Deficiency Syndrome, prepaid health
plans, health maintenance organization contracts, and other special or
experimental programs and operations of major management initiatives.
Performs Medicaid eligibility quality control reviews over
State Medicaid eligibility and inspection of care practices to assure
their ongoing compliance with Medicaid laws and regulations.
c1. Division of Medicare (FLD(1-7)C)
Directs Medicare program administration through working
relationship with contractors, providers, physicians, beneficiaries,
the Social Security Administration district offices, the Administration
on Aging, the Office of Inspector General, and other Federal agencies,
as well as local and national
[[Page 39407]]
organizations and individuals, as required.
Directs the review and revaluation of the effectiveness of
the Medicare program.
Directs activities in support of the Managed Care Program
including technical support and oversight of Health Maintenance
Organizations, and other prepaid contractors.
Monitor all aspects of contractor performance including
claims/bills processing; coverage decisions; Medical Review; the
detection of fraud, abuse, and waste in the Medicare Program;
overpayment identification and collection; Medicare Secondary Payer
(MSP); provider payment and audit; payment to physicians and suppliers;
and electronic media claims.
Coordinates on-going contractor fiscal management
activities, including subcontracting, cash management activities, and
compliance with the Chief Financial Officers Act.
Negotiates and approves Medicare contractor budget and
budget modifications.
Directs and coordinates Medicare contractor system and
workload transaction activities. Provides advice in the development of
the Medicare Transaction System (MTS).
Evaluates Medicare contractor performance and prepares
annual Report of Contractor Performance.
Manages beneficiary, provider, and public information
programs.
Recommends renewals, non-renewals, rescissions, and
terminations of Medicare contracts.
Coordinates the ESRD program.
c2. Division of Medicare (FLD(8, 9)C)
Directs Medicare program administration through working
relationship with contractors, providers, physicians, the Social
Security Administration regional offices, the Administration on Aging,
the Office of Inspector General, and other local and national
organizations and individuals, as required.
Directs the review and evaluation of the effectiveness of
the Medicare program.
Directs activities in support of the Managed Care Program
including technical support and oversight of health maintenance
organizations, and other prepaid contractors.
Monitors all aspects of contractor performance including
claims processing, coverage decisions, overpayment identification and
collection, Medicare secondary payor, provider payment and audit,
payment to physicians and suppliers, and electronic media claims.
Coordinates ongoing contractor fiscal management
activities, including subcontracting.
Negotiates and approves Medicare contractor budget
modifications.
Evaluates Medicare contractor performance and prepares
annual contractor evaluation report.
Manages beneficiary, provider, and public information
programs.
Recommends renewals, non-renewals, recessions, and
terminations of Medicare contracts.
d1. Medicare Operations and Policy Cluster (FLDXD)
Directs and coordinates the assessment of Medicare fiscal
intermediary contractor performance to ensure compliance with their
Medicare contracts. Oversees corrective action and resolution of
operational problems.
Integrates program integrity considerations into all
aspects of contractor operations to manage trust fund and general fund
expenditures in a responsible manner, referring potential fraud cases
for development and action to the Program Fiscal Integrity Cluster.
Applies data analysis to assess risk and/or vulnerability
of payment policies to ensure appropriateness of program expenditures
and recommends policy and procedure changes to CO as needed.
Monitors, evaluates, and assesses Medicare contractors'
performance.
Recommends renewals, non-renewals, rescissions, and
terminations of Medicare contracts.
Monitors the Medicare Common Working File host
contractor's performance and oversees the operations and interfaces of
the host and satellites.
Provides specialized technical support and expertise to
Medicare contractors and other HCFA components in such areas as ESRD,
rural health clinics, Part B payment, medical review, coverage, and
coding issues.
Oversees and evaluates Part B payment changes and Part A
and Part B medical review activities.
Directs the review of Medicare contractor data processing
systems, proposals, and modifications.
Reviews, negotiates, and recommends approval of contractor
budgets, modifications to budget allotments, and final settlement of
contractor costs.
Monitors Medicare contractor banking activities and
recommends approval of contractor banking agreements.
Maintains letter of credit and allotment controls on
Medicare contractors to monitor funds drawn for administrative
purposes.
Provides technical assistance to Medicare contractors in
implementing corrective actions, resolving operational problems,
improving their contract performance, and in implementing special HCFA
initiatives.
Conducts special studies of contractor's performance and
identifies opportunities for improving contractor's effectiveness.
Coordinates and provides guidance to Medicare contractors
and providers/suppliers in resolving billing, payment, coverage, claims
processing, and customer service issues.
Evaluates proposed regulatory and policy changes to the
Medicare program and makes recommendations for CO consideration.
Provides specialized technical support and oversight in
such areas as Part A and Part B appeals.
d2. Medicaid Operations and Policy Cluster (FLDXE)
Directs and coordinates the assessment of Medicaid State
agencies compliance with the Medicaid State plans, with the exception
of institutional payment State plans.
Provides specialized technical support and expertise to
Medicaid State agencies and other HCFA components including those
related to non-institutional payment; early and periodic screening,
diagnosis, and treatment; third-party liability; eligibility,
entitlement, and coverage of health services; the Vaccines for Children
program, and maternal and infant health.
Provides technical assistance to State agencies in
implementing corrective actions, resolving problems, and improving the
effectiveness of their performance.
Negotiates compliance issues and other problems with State
agency management.
Reviews and approves Medicaid State plan amendments,
except for institutional payment State plans.
Oversees, coordinates, and assesses the operation of State
Medicaid Home and Community-Based Services Waivers.
Provides highly specialized technical direction and
assistance to States regarding computer systems applications,
particularly for the Medicaid Management Information System (MMIS) and
the Family Assistance Management Information System procurement,
development, and installations.
[[Page 39408]]
d3. Program Fiscal Integrity Cluster (FLDXF)
Conducts annual System Performance Reviews on MMIS
computer systems to validate their compliance with Federal
specifications as well as to confirm their ongoing eligibility for
enhanced Federal funding.
Oversees fiscal operations of the Medicare and Medicaid
programs.
Provides leadership and technical assistance to Medicaid
State agencies in the development and maintenance of their Medicaid
financial management activities, including the recovery of Medicaid
overpayments, Medicaid utilization control; and inspection of care
reviews.
Conducts periodic comprehensive on-site financial reviews
to assure State adherence to Federal laws, regulations, and State
plans. Provides technical expertise and guidance in the financial
system and cost allocation areas.
Reviews State quarterly statements of expenditures and
recommends appropriate actions (including acceptance, deferral or
disallowance) on amounts claimed; and in a case of disallowance,
prepares HCFA position for Departmental Appeals Board.
Reviews State Medicaid budget estimates projecting future
Federal funding requirements and recommends appropriate State funding
levels to CO.
Reviews, approves, or recommends disapproval, and monitors
State institutional payment plans and systems for hospitals and nursing
facilities, and determines the allowability or nonallowability of
claims for Federal financial participation (FFP); and where State
expenditures have not been made in accordance with an approved plan or
Federal requirements, takes action to disallow such claims.
Reviews the effectiveness of specific Medicaid program
areas operated by State agencies, using data analysis techniques to
assess whether the State program meets intent.
Together with State agency staff, develops studies to help
the State assess its own effectiveness.
Participates with CO components in the development and
design of quality measurements of the Medicaid program's effectiveness.
Evaluates Medicare contractor's activities involving
Medicare Secondary Payor (MSP) performance and negotiates MSP
subrogation cases.
Monitors and negotiates the settlement and resolution of
audit findings pertaining to the Medicare or Medicaid programs which
originate from HHS' Office of Inspector General or the General
Accounting Office.
Conducts quality assurance reviews of Medicare contractor
claims payment operations.
Monitors Medicare contractor overpayment identification
and collection activities, pursues collection of overpayments referred
to the RO, authorizes extended repayment schedules, assists regional
counsel in bankruptcy cases; prepares overpayment cases for offset
against Medicaid payments and Internal Revenue Service refunds; and
refers cases to the Department of Justice for possible litigation as
appropriate.
Provides technical assistance to Medicare contractors,
Medicaid State agencies, and other HCFA components in the area of
Medicare and Medicaid payment and fiscal administration.
Performs special studies of Medicare institutional payment
practices and recommends corrective action to close loopholes
identified.
Conducts the Medicare cost report evaluation program.
Recommends approval or disapproval of common audit
agreements, rural referral centers, and sole community provider
exemption requests.
Performs reviews of allowability of costs claimed by
Medicare contractors on the Final Administrative Cost Reports.
Monitors and reviews Medicare contractors compliance with
the Chief Financial Officer's Act.
Directs the region's efforts to develop and refer cases of
suspected fraud in Medicare and Medicaid, maintaining close contact
with OIG, Medicaid fraud units at State Agencies, and the Department of
Justice.
Coordinates fraud and abuse activities with other HCFA
ROs, Medicare contractors, other third party payers, and CO.
Reviews the effectiveness of specific Medicaid program
areas operated by State agencies, using data analysis techniques to
assess whether the State program meets intent.
d4. Consumer Services and Information Cluster (FLDXG)
Ensures that Medicare and Medicaid beneficiaries are
informed of HCFA program benefits, rights, and responsibilities through
a comprehensive marketing strategy to varied audiences.
Monitors, evaluates, and assesses the performance of
Medicare contractors in their beneficiary outreach and service
organizations.
Coordinates the operation of a public information and
outreach programs directed at beneficiary groups, professional
organizations, advocacy organizations, other health care entities, and
the media.
Directs the implementation of HCFA beneficiary services
initiatives, such as the Medigap, Retired Senior Volunteer Programs,
Information Counseling Assistance grants, and Qualified Medicare
Beneficiary (QMB) programs.
Provides direction, technical assistance, and training to
the Social Security Administration district offices concerning Medicare
entitlement, post-entitlement, and beneficiary education functions, and
monitors the performance of these functions.
Coordinates and controls the processing of responses to
all beneficiary, provider, and Congressional inquiries.
Provides specialized technical support and oversight in
such areas as QMB and buy in.
Works closely with local congressional and Governor's
offices to provide a full array of constituent services and support.
d5. Managed Care Operations Cluster (FLDXH)
Conducts a broad range of activities to oversee the
operation of Medicare and Medicaid managed care plans to protect access
to care and to enhance access to care, especially in rural or other
undeserved areas.
Provides leadership and oversight of health care delivery
systems in Medicare and Medicaid that depart from the traditional fee-
for-service model.
Provides technical advice to health care plans that want
to enter into risk and cost contracts for Medicare.
Evaluates applications from managed care plans to become
Medicare risk or cost contractors and/or expand operations to assure
compliance with applicable laws and regulations; recommends approval or
denial of such applications.
Reviews and approves managed care plan marketing materials
to assure adherence to laws and regulations and to assure that Medicare
beneficiaries receive appropriate and clear information about the
plans' benefit package and consumer protection.
Assures contract compliance through periodic monitoring of
plan performance.
In cases of non-compliance, approves corrective action
plan from the managed care plans and monitors adherence to the
corrective action plan.
Maintains ongoing relations with managed care plans in the
region and works with central office to resolve problems plans have
with HCFA policy
[[Page 39409]]
or procedures; recommends changes to CO in policy and procedures as
appropriate.
Operates a program of beneficiary services that includes
direct contact with the Medicare beneficiary to resolve problems with
particular plans, contract through congressional offices concerning
beneficiary problems, and contact plans to resolve beneficiary
problems.
Resolves systems problems that affect beneficiary
eligibility/entitlement under a particular managed care plan.
Receives and evaluates complaints from beneficiaries
concerning quality of care and refers such complaints to PROS for
further investigation as appropriate.
Conducts data analysis of plan performance indicators to
determine whether plans need technical assistance or corrective action.
Through ongoing information gathering in the health care
marketplace, provides early warning to CO on polices that might impede
the risk contracting in Medicare as commercial/public member limits and
rate setting.
Provides leadership and technical support to States in
designing and implementing Medicaid managed care programs.
Evaluates requests for freedom of choice waivers for
Medicaid managed care plans to assure that access to care is maintained
or enhanced and that projected costs comply with applicable law and
regulation.
Reviews and approves contracts between States and
providers to assure compliance with Federal law and regulation.
Provides early technical assistance to States that plan to
apply for Section 1115 waivers to implement Statewide health care
reform.
Works closely with CO to evaluate requests for Section
1115 waivers, assuming a lead role when the waiver is approved and
implementation begins.
Provides ongoing technical assistance to States with
active statewide Section 1115 waivers to assure that conditions of the
waiver are adhered to and that access to care is adequate.
Provides technical assistance to States in finding
creative and new methods of delivering Medicaid services through a
variety of managed care arrangements.
d6. Health Care Quality Improvement Cluster (FLDXJ)
Assures that medical care, paid for by Federal Medicare
funds, is medically necessary and meets recognized professional
standards and quality of care through funding and the monitoring of
Peer Review Organizations (PROs) and ESRD Networks in a multi-regional
geographic area.
Provides leadership to PROs and networks to design
projects that will improve care to Medicare beneficiaries.
Maintains knowledge of HCFA data bases, as well as other
large health related data bases, and uses these to evaluate care
provided to the Medicare population.
Oversees the PROs' development of local quality studies to
assure scientific merit and program relevance.
Encourages PROs and ESRD networks to work with providers
to use the results of local quality studies to fashion interventions to
improve care.
Conducts special regionwide studies to evaluate care
provided to Medicare beneficiaries, including beneficiary groups which
may have special health care needs, and works through PROs to help
providers design interventions to improve care.
Disseminates useful information to providers and to
beneficiaries to improve quality of care.
Convenes groups at the local level to collaborate on
studies involving the quality of care provided to the Medicare,
Medicaid, and managed care populations; this includes bringing together
variously funded sources such as universities, foundations, and State
offices with similar interests in quality of care.
Participates in the negotiation and award of contracts to
PROs.
Prepares technical and budget evaluations of contract
proposals received from PROs, and makes judgments to commit Federal
funds for program implementation.
Monitors and assesses the overall quality performance of
PROs including success in using local projects to improve care for
Medicare beneficiaries.
d7. Certification Improvement Cluster (FLDXK)
Manages the State agency evaluation program and assesses
the performance of the State survey agency in their survey and
certification review process for compliance with performance standards.
Works with the States to design internal quality assurance
programs.
Negotiates State agency agreements and issues substantive
regional guidelines containing policy and procedural interpretations
relating to certification activities.
Evaluates complaints from the public, media, Congress, and
others alleging deficient standards in provider facilities, and
instructs State agencies to investigate, as appropriate.
Makes final recommendations on all initial budget and
supplemental budget requests submitted by State agencies.
Takes adverse actions against non-complying Medicare
facilities.
Establishes and maintains a data and information gathering
system involving all aspects of the certification program.
Conducts Federal surveys of providers and suppliers of
health services to ensure that State monitoring is satisfactory.
Performs or authorizes validation surveys in accredited
institutions to determine their compliance with Federal standards.
Conducts surveillance and assessment of State agency
operations regarding quality of care, and assists them in developing
the capability to provide direct assistance to providers and suppliers
of health services in the improvement of their performance.
Conducts studies, pilot projects, and experimental
programs and assists in implementing techniques designed to improve the
survey and certification process and peer review systems.
Conducts training of State surveyors as needed and
indicated by Federal monitoring.
Dated: July 19, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 95-18977 Filed 8-1-95; 8:45 am]
BILLING CODE 4120-01-P
