01-22821. Statement of Organization, Functions, and Delegations of Authority

Part F of the Statement of Organization, Functions, and Delegations of Authority for the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS), (Federal Register, Vol. 62, No. 85, pp. 24120-24126 dated Friday, May 2, 1997) is amended to reflect changes to the organizational structure of CMS by replacing the Center for Beneficiary Services and the Center for Health Plans and Providers with the Center for Beneficiary Choices and the Center for Medicare Management. Also, it transfers managed care audit responsibility from the Office of Financial Management to the Center for Beneficiary Choices, and also transfers the Quality Measurement and Health Assessment Group from the Office of Clinical Standards and Quality to the Center for Beneficiary Choices.

The specific amendments to part F are described below:

• Section F.10. (Organization) is amended to read as follows:

1. Press Office (FAC)

2. Center for Beneficiary Choices (FAE)

3. Office of Legislation (FAF)

4. Center for Medicare Management (FAH)

5. Office of Equal Opportunity and Civil Rights (FAJ)

6. Office of Strategic Planning (FAK)

7. Office of Communications and Operations Support (FAL)

8. Office of Clinical Standards and Quality (FAM)

9. Office of the Actuary (FAN)

10. Center for Medicaid and State Operations (FAS)

11. Northeastern Consortium (FAU)

12. Southern Consortium (FAV)

13. Midwestern Consortium (FAW)

14. Western Consortium (FAX)

15. Office of Internal Customer Support (FBA)

16. Office of Information Services (FBB)

17. Office of Financial Management (FBC)

• Section F.20. (Functions) is amended by deleting the functional statements in their entirety for the Center for Beneficiary Services, Center for Health Plans and Providers, and the Quality Measurement and Health Assessment Group within the Office of Clinical Standards and Quality. The new functional statements read as follows:

2. Center for Beneficiary Choices (FAE)

• Serves as the focal point for all Agency interactions with beneficiaries, their families, care givers, health care providers, and others operating on their behalf concerning improving beneficiary ability to make informed decisions about their health and about program benefits administered by the Agency. These activities include strategic and implementation planning, execution, assessment, and communications.
• Assesses beneficiary and other consumer needs, develops and oversees activities targeted to meet these needs, and documents and disseminates results of these activities. These activities focus on Agency beneficiary service goals and objectives and include: development of baseline and ongoing monitoring information concerning populations affected by Agency programs; development of performance measures and assessment programs; design and implementation of beneficiary services initiatives; development of communications channels and feedback mechanisms within the Agency and between the Agency and its beneficiaries and their representatives; and close collaboration with other Federal and state agencies and other stakeholders with a shared interest in better serving our beneficiaries.
• Develops national policy for all Medicare Parts A, B, and C beneficiary eligibility, enrollment, and entitlement; rights and protections; dispute resolution process; as well as policy for managed care enrollment and disenrollment to ensure the effective administration of the Medicare program, including the development of related legislative proposals.
• Oversees the development of privacy and confidentiality policies pertaining to the collection, use, and release of individually identifiable data.
• Coordinates beneficiary centered information, education, and service initiatives.
• Develops and tests new and innovative methods to improve beneficiary aspects of health care delivery systems through Title XVIII, XIX, and XXI demonstrations and other creative approaches to meeting the needs of Agency beneficiaries.
• Ensures that, in coordination with other Centers and Offices, the activities of Medicare contractors, including managed care plans, agents, and state agencies, meet the Agency's requirements on matters concerning beneficiaries and other consumers.
• Plans and administers the contracts and grants related to beneficiary and customer service, including the State Health Insurance Assistance Program grants.
• Formulates strategies to advance overall beneficiary communications goals and coordinates the design and publication process for all beneficiary centered information, education, and service initiatives.
• Builds a range of partnerships with other national organizations for effective consumer outreach, awareness, and education efforts in support of Agency programs.
• Serves as the focal point for all Agency interactions with managed health care organizations for issues relating to Agency programs, policy, and operations.
• Develops national policies and procedures related to the development, qualification, and compliance of health maintenance organizations, competitive medical plans and other health care delivery systems and purchasing arrangements (such as prospective pay, case management, differential payment, selective contracting, etc.) necessary to ensure the effective administration of the Agency's programs, including the development of statutory proposals.
• Handles all phases of contracts with managed health care organizations eligible to provide care to Medicare beneficiaries.
• Coordinates the administration of individual benefits to ensure appropriate focus on long-term care, where applicable, and assumes responsibility for the operational and demonstration efforts related to the payment aspects of long-term care and post-acute care services.
• Designs and conducts payment, purchasing, and benefits demonstrations.

4. Center for Medicare Management (FAH)

• Serves as the focal point for all Agency interactions with health care providers, intermediaries, and carriers for issues relating to Agency fee-for-service (FFS) policies and operations.
• Monitors providers' and other entities' conformance with quality standards (other than those directly related to survey and certification); policies related to scope of benefits; and other statutory, regulatory, and contractual provisions.
• Based on program data, develops payment mechanisms, administrative mechanisms, and regulations to ensure that CMS is purchasing medically necessary services under FFS.
• Writes payment and benefit-related instructions for Medicare contractors.
• Defines the scope of Medicare benefits and develops national FFS payment policies, as necessary, to ensure the effective administration of the Agency's programs, including the development of related statutory proposals.
• Develops Agency medical coding policies related to FFS payments.
• Provides administrative support to the Practicing Physician Advisory Council.
• Coordinates provider, physician, and contractor centered information, education, and service initiatives.
• Serves as the CMS lead for Medicare carrier and fiscal intermediary (FI) management, oversight, budget, and performance issues.
• Functions as CMS liaison for all Medicare carrier and FI program issues and, in close collaboration with the regional offices and other CMS components, coordinates the agency-wide contractor activities.
• Manages contractor instructions, workload, and change management process.
• Collaborates with other CMS components to establish ongoing performance expectations for Medicare contractors (carriers and FIs) consistent with the agency's goals; interprets, evaluates, and provides information on Medicare contractors in terms of ongoing compliance with performance requirements and expectations; evaluates compliance with issued instructions; evaluates contractor-specific performance and/or integrity issues; and evaluates/monitors corrective action, if necessary.
• Manages, monitors, and provides oversight of contractor (carriers and FIs) transition activities including replacement of departing contractors and the resulting transfer of workload, functional realignments, and geographic workload carveouts.
• Maintains and provides accurate contractor specific information. Develops and implements long-term FFS contractor strategy, tactical plans, and other planning documents.
• Serves as lead on current/proposed legislation in order to determine impact on provider and contractor operations.
• Develops national policy and implementation of all Medicare Part A, Part B, and Part C premium billing and collection activities and coordination of benefits to assure effective administration of FFS aspects of the Medicare program.

Dated: September 6, 2001.

Thomas A. Scully,

Administrator, Centers for Medicare & Medicaid Services.