[Federal Register Volume 78, Number 188 (Friday, September 27, 2013)]
[Notices]
[Pages 59704-59706]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-23659]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3111-N]
Medicare, Medicaid, and CLIA Programs; Clinical Laboratory
Improvement Amendments of 1988 Exemption of Laboratories Licensed by
the State of Washington
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice announces that laboratories located in and
licensed by the State of Washington that possess a valid license under
the Medical Test Site law, Chapter 70.42 of the Revised Code of
Washington, are exempt from the requirements of the Clinical Laboratory
Improvement Amendments of 1988 (CLIA) for a period of 6 years.
DATES: The exemption granted by this notice is effective from September
27, 2013 to September 27, 2019.
FOR FURTHER INFORMATION CONTACT: Sandra Farragut, (410) 786-3531.
SUPPLEMENTARY INFORMATION:
I. Background and Legislative Authority
Section 353 of the Public Health Service Act (PHSA), as amended by
the Clinical Laboratory Improvement Amendments of 1988 (CLIA) (Pub. L.
100-578), which was enacted on October 31, 1988, generally provides
that no laboratory may perform tests on human specimens for the
diagnosis, prevention or treatment of any disease or impairment of, or
assessment of the health of, human beings unless it has a certificate
to perform that category of tests issued by the Secretary of the
Department of Health and Human Services (HHS). Under section 1861(s) of
the Social Security Act (the Act), the Medicare program will only pay
for laboratory services if the laboratory has a CLIA certificate.
Section 1902(a)(9)(C) of the Act requires that state Medicaid plans pay
only for laboratory services furnished by CLIA-certified laboratories.
Thus, although subject to specified exemptions and exceptions,
laboratories generally must have a current and valid CLIA certificate
to test human specimens for medical purposes noted above to be eligible
for payment for those tests from the Medicare or Medicaid programs.
Regulations implementing section 353 of the PHSA are contained in 42
CFR part 493.
Section 353(p) of the PHSA provides for the exemption of
laboratories from CLIA requirements in states that enact legal
requirements that are equal to or more stringent than CLIA's statutory
and regulatory requirements. Section 353(p) of the PHSA is implemented
in subpart E of our regulations at 42 CFR part 493. Sections 493.551
and 493.553 provide that we may exempt from CLIA requirements, for a
period not to exceed 6 years, all state-licensed or -approved
laboratories in a state if the state licensure program meets the
specified conditions. Section 493.559 provides that we will publish a
notice in the Federal Register when we grant exemption to an approved
state licensure program. It also provides that the notice will include
the following:
The basis for granting the exemption.
A description of how the laboratory requirements are equal
to or more stringent than those of CLIA.
The term of approval, not to exceed 6 years.
State of Washington's Application for CLIA Exemption of Its
Laboratories
The State of Washington has applied for exemption of its
laboratories from CLIA program requirements. The State of Washington
submitted all of the applicable information and attestations required
by Sec. 493.551, Sec. 493.553, and Sec. 493.557 for state licensure
programs seeking exemption of their licensed laboratories from CLIA
program requirements.
Examples of documents and information submitted include: a
comparison of its laboratory licensure requirements with comparable
CLIA condition-level requirements (that is, a crosswalk); and a
description of the following: Its inspection process; its proficiency
testing monitoring process; its data management and analysis system;
its investigative and response procedures for complaints received
against laboratories; and its policy regarding announced and
unannounced inspections.
CMS Analysis of Washington's Application and Supporting Documentation
To determine whether we should grant a CLIA exemption to
laboratories licensed by a state, we review the application and
additional documentation that the state submits to us and conducts a
detailed and in-depth comparison of the state licensure program and
CLIA's statutory and regulatory requirements to determine whether the
state program meets the requirements at subpart E of part 493.
In summary, the state generally must demonstrate that:
It has state laws in effect that provide for a state
licensure program that has requirements that are equal to or more
stringent than CLIA condition-level requirements for laboratories.
It has implemented a state licensure program with
requirements that are equal to or more stringent than the CLIA
condition-level requirements such that a
[[Page 59705]]
laboratory licensed by the state program would meet the CLIA condition-
level requirements if it were inspected against those requirements.
The requirements under that state licensure program meet
or exceed the requirements of Sec. 493.553, Sec. 493.555, and Sec.
493.557(b) and is suitable for approval by us under Sec. 493.551. For
example, among other things, the program would need to:
++ Demonstrate that it has enforcement authority and administrative
structures and resources adequate to enforce its laboratory
requirements.
++ Permit us or our agents to inspect laboratories within the
state.
++ Require laboratories within the state to submit to inspections
by us or our agents as a condition of licensure.
++ Agree to pay any costs associated with our activities to
validate their state licensure program as well as the state's pro rata
share of the general overhead to develop and implement CLIA as
specified in Sec. 493.645(a), Sec. 493.646(b), and Sec. 493.557(b).
++ Take appropriate enforcement action against laboratories found
by us or our agents out of compliance with requirements comparable to
CLIA condition-level requirements, as specified in Sec. 493.557(b).
As specified in our regulations at Sec. 493.555 and Sec.
493.557(b), our review of a state licensure program includes (but is
not necessarily limited to) an evaluation of the following:
Whether the state's requirements for laboratories are
equal to or more stringent than the CLIA condition-level requirements.
The state's inspection process requirements to determine
the following:
++ The comparability of the full inspection and complaint
inspection procedures to those of CMS.
++ The state's enforcement procedures for laboratories found to be
out of compliance with its requirements.
The ability of the state to provide us with electronic
data and reports with the adverse or corrective actions resulting from
proficiency testing (PT) results that constitute unsuccessful
participation in CMS-approved PT programs and with other data we
determine to be necessary for validation review and assessment of the
state's inspection process requirements.
The state's agreement with us to ensure that the agreement
obligates the state to do the following:
++ Notify us within 30 days of the action taken against any CLIA-
exempt laboratory that has had its licensure or approval withdrawn or
revoked or been in any way sanctioned.
++ Notify us within 10 days of any deficiency identified in a CLIA-
exempt laboratory in cases when the deficiency poses an immediate
jeopardy to the laboratory's patients or a hazard to the general
public.
++ Notify each laboratory licensed by the state under its approved
state licensure program within 10 days of a withdrawal of our approval
of the state's licensure program, and the resulting loss of the
laboratory's exemption from CLIA based on its licensure under that
program.
++ Provide us with written notification of any changes in the
state's licensure (or approval) and inspection requirements.
++ Disclose to us or our agent any laboratory's PT results in
accordance with the state's confidentiality requirements.
++ Take appropriate enforcement action against laboratories that we
or our agents find to be out of compliance with CLIA condition-level
requirements in a validation survey, and report these enforcement
actions to us.
++ Notify us of all newly licensed laboratories, and any changes in
the specialties and subspecialties for which any laboratory performs
testing, within 30 days.
++ Provide us, as requested, inspection schedules for validation
purposes.
In keeping with the process described above, we evaluated the
application and supporting materials that were submitted by Washington
State to verify that the laboratories licensed through its program will
meet or exceed the requirements of the following subparts of part 493:
Subpart H, Participation in Proficiency Testing for Laboratories
Performing Nonwaived Testing; Subpart J, Facility Administration for
Nonwaived Testing; Subpart K, Quality Systems for Nonwaived Testing,
Subpart M, Personnel for Nonwaived Testing; Subpart Q, Inspection; and
Subpart R, Enforcement Procedures.
We found that Washington State's laboratory licensure program
requirements mapped to all the CLIA condition-level requirements. Its
licensure program's inspection process and proficiency testing
monitoring processes were adequate. Other materials that were submitted
demonstrated compliance with the other above-referenced requirements of
subpart E of part 493. As a result, we concluded that the submitted
documents supported exempting laboratories licensed under that program
from the CLIA program requirements. Furthermore, a review of our
validation inspections conducted by our regional office in Seattle,
Washington, supported this conclusion.
The federal validation inspections of CLIA-exempt laboratories, as
specified in Sec. 493.563, were conducted on a representative sample
basis, as well as in response to any substantial allegations of
noncompliance (complaint inspections). The outcome of those validation
inspections has been, and will continue to be our principal tool for
verifying that the laboratories located in, and licensed by the state
are in compliance with CLIA requirements.
Our regional office in Seattle, Washington, has conducted
validation inspections of a representative sample (approximately 5
percent) of the laboratories inspected by the Washington State Office
of Laboratory Quality Assurance (LQA). The validation inspections were
primarily of the concurrent type; that is, our surveyors accompanied
Washington State's inspectors, each inspecting against his or her
agency's respective regulations. Analysis of the validation data
revealed no significant differences between the state and federal
findings. The validation surveys verified that the State of Washington
inspection process covers all CLIA conditions applicable to each
laboratory being inspected and also verified that the state laboratory
licensure requirements meet or exceed CLIA condition-level
requirements. Our validation surveys found the state inspectors highly
skilled and qualified. The LQA inspected laboratories in a timely
fashion; that is, all laboratories were inspected within the required
24-month cycle. All parameters monitored by our Seattle office to date
indicate that the State of Washington is meeting all requirements for
approval of CLIA exemption. This federal monitoring will continue as an
on-going process.
Conclusion
Based on review of the documents submitted by the Washington state
licensure program pursuant to the requirements of subpart E of part
493, as well as the outcome of the validation inspections conducted by
our regional office in Seattle, we find that the State of Washington's
licensure program meets the requirements of 42 CFR 493.551(a), and
that, as a result, we may exempt from CLIA program requirements all
state-licensed or -approved laboratories.
Approval of the CLIA exemption for laboratories located in and
licensed by the State of Washington laboratory licensure program is
subject to removal if we determine that the outcome of a
[[Page 59706]]
comparability review or a validation review inspection is not
acceptable, as described under Sec. 493.573 and Sec. 493.575, or if
the State of Washington fails to pay the required fee every 2 years as
required under Sec. 493.646.
Laboratory Data
In accordance with our regulations at Sec. 493.557(b)(8), the
approval of this exemption for laboratories located in and licensed by
the State of Washington is conditioned on the State of Washington's
continued compliance with the assertions made in its application,
especially the provision of information to us about changes to a
laboratory's specialties or subspecialties based on the state's survey,
and changes to a laboratory's certification status, such as a change
from a CLIA certificate of compliance to a CLIA certificate of waiver.
Required Administrative Actions
CLIA is a user-fee funded program. The registration fee paid by
laboratories is intended to cover the cost of the development and
administration of the program. However, when a state's application for
exemption is approved, we do not charge a fee to laboratories in the
state. The state's share of the costs associated with CLIA must be
collected from the state, as specified in Sec. 493.645.
The State of Washington must pay for the following:
Costs of federal inspections of laboratories in the state
to verify that Washington State's laboratory licensure program
requirements are equivalent to or more stringent than those in the CLIA
program, and that they are enforced in an appropriate manner. The
average federal hourly rate is multiplied by the total hours required
to perform federal validation surveys within the state.
Costs incurred for federal surveys, including
investigations of complaints that are substantiated. We will bill the
State of Washington on a semiannual basis.
The State of Washington's proportionate share of the costs
associated with establishing, maintaining, and improving the CLIA
computer system, based on the portion of those services from which the
State of Washington received direct benefit or which contributed to the
CLIA program in the state. Thus, the State of Washington is being
charged for a portion of our direct and indirect costs of administering
the CLIA program. Such costs will be incurred by CMS, the Centers for
Disease Control and Prevention (CDC), the Food and Drug Administration
(FDA) and contractors working on behalf of these respective agencies.
To estimate the State of Washington's proportionate share of the
general overhead costs to develop and implement CLIA, we determined the
ratio of laboratories in the state to the total number of laboratories
nationally. Approximately 1.5 percent of the registered laboratories
are in the State of Washington. We determined that a corresponding
percentage of the applicable CMS, CDC, FDA, and their respective
contractor costs should be borne by the State of Washington.
The State of Washington has agreed to pay the state's pro rata
share of the anticipated overhead costs and costs of actual validation
(including complaint investigation surveys). A final reconciliation for
all laboratories and all expenses will be made. We will reimburse the
state for any overpayment or bill it for any balance.
II. Approval
In light of the foregoing, we grant approval of the State of
Washington's laboratory licensure program under subpart E. All
laboratories located in and licensed by the State of Washington under
the Medical Test Site law, Chapter 70.42 of the Revised Code of
Washington, are CLIA-exempt for all specialties and subspecialties
until September 27, 2019.
Authority: Section 353(p) of the Public Health Service Act (42
U.S.C. 263a).
Dated: August 8, 2013.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2013-23659 Filed 9-26-13; 8:45 am]
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