[Title 42 CFR ]
[Code of Federal Regulations (annual edition) - October 1, 2005 Edition]
[From the U.S. Government Printing Office]
[[Page i]]
42
Parts 400 to 429
Revised as of October 1, 2005
Public Health
________________________
Containing a codification of documents of general
applicability and future effect
As of October 1, 2005
With Ancillaries
Published by
Office of the Federal Register
National Archives and Records
Administration
A Special Edition of the Federal Register
[[Page ii]]
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[[Page iii]]
Table of Contents
Page
Explanation................................................. v
Title 42:
Chapter IV--Centers for Medicare & Medicaid
Services, Department of Health and Human Services 3
Finding Aids:
Material Approved for Incorporation by Reference........ 1249
Table of CFR Titles and Chapters........................ 1251
Alphabetical List of Agencies Appearing in the CFR...... 1269
List of CFR Sections Affected........................... 1279
[[Page iv]]
----------------------------
Cite this Code: CFR
To cite the regulations in
this volume use title,
part and section number.
Thus, 42 CFR 400.200
refers to title 42, part
400, section 200.
----------------------------
[[Page v]]
EXPLANATION
The Code of Federal Regulations is a codification of the general and
permanent rules published in the Federal Register by the Executive
departments and agencies of the Federal Government. The Code is divided
into 50 titles which represent broad areas subject to Federal
regulation. Each title is divided into chapters which usually bear the
name of the issuing agency. Each chapter is further subdivided into
parts covering specific regulatory areas.
Each volume of the Code is revised at least once each calendar year
and issued on a quarterly basis approximately as follows:
Title 1 through Title 16.................................as of January 1
Title 17 through Title 27..................................as of April 1
Title 28 through Title 41...................................as of July 1
Title 42 through Title 50................................as of October 1
The appropriate revision date is printed on the cover of each
volume.
LEGAL STATUS
The contents of the Federal Register are required to be judicially
noticed (44 U.S.C. 1507). The Code of Federal Regulations is prima facie
evidence of the text of the original documents (44 U.S.C. 1510).
HOW TO USE THE CODE OF FEDERAL REGULATIONS
The Code of Federal Regulations is kept up to date by the individual
issues of the Federal Register. These two publications must be used
together to determine the latest version of any given rule.
To determine whether a Code volume has been amended since its
revision date (in this case, October 1, 2005), consult the ``List of CFR
Sections Affected (LSA),'' which is issued monthly, and the ``Cumulative
List of Parts Affected,'' which appears in the Reader Aids section of
the daily Federal Register. These two lists will identify the Federal
Register page number of the latest amendment of any given rule.
EFFECTIVE AND EXPIRATION DATES
Each volume of the Code contains amendments published in the Federal
Register since the last revision of that volume of the Code. Source
citations for the regulations are referred to by volume number and page
number of the Federal Register and date of publication. Publication
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Code a note has been inserted to reflect the future effective date. In
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inserted following the text.
OMB CONTROL NUMBERS
The Paperwork Reduction Act of 1980 (Pub. L. 96-511) requires
Federal agencies to display an OMB control number with their information
collection request.
[[Page vi]]
Many agencies have begun publishing numerous OMB control numbers as
amendments to existing regulations in the CFR. These OMB numbers are
placed as close as possible to the applicable recordkeeping or reporting
requirements.
OBSOLETE PROVISIONS
Provisions that become obsolete before the revision date stated on
the cover of each volume are not carried. Code users may find the text
of provisions in effect on a given date in the past by using the
appropriate numerical list of sections affected. For the period before
January 1, 2001, consult either the List of CFR Sections Affected, 1949-
1963, 1964-1972, 1973-1985, or 1986-2000, published in 11 separate
volumes. For the period beginning January 1, 2001, a ``List of CFR
Sections Affected'' is published at the end of each CFR volume.
INCORPORATION BY REFERENCE
What is incorporation by reference? Incorporation by reference was
established by statute and allows Federal agencies to meet the
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to materials already published elsewhere. For an incorporation to be
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This material, like any other properly issued regulation, has the force
of law.
What is a proper incorporation by reference? The Director of the
Federal Register will approve an incorporation by reference only when
the requirements of 1 CFR part 51 are met. Some of the elements on which
approval is based are:
(a) The incorporation will substantially reduce the volume of
material published in the Federal Register.
(b) The matter incorporated is in fact available to the extent
necessary to afford fairness and uniformity in the administrative
process.
(c) The incorporating document is drafted and submitted for
publication in accordance with 1 CFR part 51.
Properly approved incorporations by reference in this volume are
listed in the Finding Aids at the end of this volume.
What if the material incorporated by reference cannot be found? If
you have any problem locating or obtaining a copy of material listed in
the Finding Aids of this volume as an approved incorporation by
reference, please contact the agency that issued the regulation
containing that incorporation. If, after contacting the agency, you find
the material is not available, please notify the Director of the Federal
Register, National Archives and Records Administration, Washington DC
20408, or call 202-741-6010.
CFR INDEXES AND TABULAR GUIDES
A subject index to the Code of Federal Regulations is contained in a
separate volume, revised annually as of January 1, entitled CFR Index
and Finding Aids. This volume contains the Parallel Table of Statutory
Authorities and Agency Rules (Table I). A list of CFR titles, chapters,
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also included in this volume.
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The Federal Register Index is issued monthly in cumulative form.
This index is based on a consolidation of the ``Contents'' entries in
the daily Federal Register.
A List of CFR Sections Affected (LSA) is published monthly, keyed to
the revision dates of the 50 CFR titles.
[[Page vii]]
REPUBLICATION OF MATERIAL
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appearing in the Code of Federal Regulations.
INQUIRIES
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Raymond A. Mosley,
Director,
Office of the Federal Register.
October 1, 2005.
[[Page ix]]
THIS TITLE
Title 42--Public Health is composed of three volumes. The parts in
these volumes are arranged in the following order: Parts 1-399, parts
400-429 and part 430 to end. The first volume (parts 1-399) contains
current regulations issued under chapter I--Public Health Service (HHS).
The second volume (parts 400-429) includes regulations issued under
chapter IV--Centers for Medicare & Medicaid Services (HHS) and the third
volume (part 430 to end) contains the remaining regulations in chapter
IV and the regulations issued under chapter V by the Office of Inspector
General-Health Care (HHS). The contents of these volumes represent all
current regulations codified under this title of the CFR as of October
1, 2005.
The OMB control numbers for the Centers for Medicare & Medicaid
Services appear in Sec. 400.310 of chapter IV. For the convenience of
the user subpart C consisting of Sec. Sec. 400.300-400.310 is reprinted
in the Finding Aids section of the third volume.
For this volume, Robert J. Sheehan was Chief Editor. The Code of
Federal Regulations publication program is under the direction of
Frances D. McDonald, assisted by Alomha S. Morris.
[[Page 1]]
TITLE 42--PUBLIC HEALTH
(This book contains parts 400 to 429)
--------------------------------------------------------------------
Part
chapter iv--Centers for Medicare & Medicaid Services,
Department of Health and Human Services................... 400
[[Page 3]]
CHAPTER IV--CENTERS FOR MEDICARE
& MEDICAID SERVICES,
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
--------------------------------------------------------------------
Editorial Note: Nomenclature changes to chapter IV appear at 62 FR
46037, Aug. 29, 1997; 66 FR 39452, July 31, 2001; and 67 FR 36540, May
24, 2002.
SUBCHAPTER A--GENERAL PROVISIONS
Part Page
400 Introduction; definitions................... 5
401 General administrative requirements......... 9
402 Civil money penalties, assessments, and
exclusions.............................. 23
403 Special programs and projects............... 36
SUBCHAPTER B--MEDICARE PROGRAM
405 Federal health insurance for the aged and
disabled................................ 83
406 Hospital insurance eligibility and
entitlement............................. 246
407 Supplementary medical insurance (SMI)
enrollment and entitlement.............. 262
408 Premiums for supplementary medical insurance 272
409 Hospital insurance benefits................. 289
410 Supplementary medical insurance (SMI)
benefits................................ 316
411 Exclusions from Medicare and limitations on
Medicare payment........................ 376
412 Prospective payment systems for inpatient
hospital services....................... 452
413 Principles of reasonable cost reimbursement;
payment for end-stage renal disease
services; prospectively determined
payment rates for skilled nursing
facilities.............................. 602
414 Payment for Part B medical and other health
services................................ 742
415 Services furnished by physicians in
providers, supervising physicians in
teaching settings, and residents in
certain settings........................ 792
416 Ambulatory surgical services................ 809
[[Page 4]]
417 Health maintenance organizations,
competitive medical plans, and health
care prepayment plans................... 820
418 Hospice care................................ 913
419 Prospective payment system for hospital
outpatient department services.......... 933
420 Program integrity: Medicare................. 946
421 Intermediaries and carriers................. 956
422 Medicare advantage program.................. 969
423 Voluntary medicare prescription drug benefit 1086
424 Conditions for Medicare payment............. 1190
426 Reviews of local and national coverage
determinations.......................... 1219
[[Page 5]]
SUBCHAPTER A_GENERAL PROVISIONS
PART 400_INTRODUCTION; DEFINITIONS--Table of Contents
Subpart A [Reserved]
Subpart B_Definitions
Sec.
400.200 General definitions.
400.202 Definitions specific to Medicare.
400.203 Definitions specific to Medicaid.
Subpart C_OMB Control Numbers for Approved Collections of Information
400.300 Scope.
400.310 Display of currently valid OMB control numbers.
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh) and 44 U.S.C. Chapter 35.
Subpart A [Reserved]
Subpart B_Definitions
Sec. 400.200 General definitions.
In this chapter, unless the context indicates otherwise--
Act means the Social Security Act, and titles referred to are titles
of that Act.
Administrator means the Administrator, Centers for Medicare &
Medicaid Services (CMS), formerly the Health Care Financing
Administration (HCFA).
ALJ stands for administrative law judge.
Area means the geographical area within the boundaries of a State,
or a State or other jurisdiction, designated as constituting an area
with respect to which a Professional Standards Review Organization or a
Utilization and Quality Control Peer Review Organization has been or may
be designated.
CMP stands for competitive medical plan.
Conditions of participation includes requirements for participation
as the latter term is used in part 483 of this chapter.
Condition level deficiencies includes deficiencies with respect to
``level A requirements'' as the latter term is used in parts 442 and 483
of this chapter.
CORF stands for comprehensive outpatient rehabilitation facility.
CFR stands for Code of Federal Regulations.
CMS stands for Centers for Medicare & Medicaid Services, formerly
the Health Care Financing Administration (HCFA).
CY stands for calendar year.
DAB stands for Departmental Appeals Board.
Department means the Department of Health and Human Services (HHS),
formerly the Department of Health, Education, and Welfare.
ESRD stands for end-stage renal disease.
FDA stands for the Food and Drug Administration.
FQHC means Federally qualified health center.
FR stands for Federal Register.
FY stands for fiscal year.
HCPP stands for health care prepayment plan.
HHS stands for the Department of Health and Human Services.
HHA stands for home health agency.
HMO stands for health maintenance organization.
ICF stands for intermediate care facility.
ICF/MR stands for intermediate care facility for the mentally
retarded.
Medicaid means medical assistance provided under a State plan
approved under title XIX of the Act.
Medicare means the health insurance program for the aged and
disabled under title XVIII of the Act.
NCD stands for national coverage determination.
OASDI stands for the Old Age, Survivors, and Disability Insurance
program under title II of the Act.
OIG stands for the Department's Office of the Inspector General.
QDWI stands for Qualified Disabled and Working Individual.
QIO stands for quality improvement organization.
QMB stands for Qualified Medicare Beneficiary.
Qualified Disabled and Working Individual means an individual who--
[[Page 6]]
(1) Is eligible to enroll for Medicare Part A under section 1818A of
the Act.
(2) Has income, as determined in accordance with SSI methodologies,
that does not exceed 200 percent of the Federal poverty guidelines (as
defined and revised annually by the Office of Management and Budget) for
a family of the size of the individual's family;
(3) Has resources, as determined in accordance with SSI
methodologies, that do not exceed twice the relevant maximum amount
established, for SSI eligibility, for an individual or for an individual
and his or her spouse; and
(4) Is not otherwise eligible for Medicaid.
Qualified Medicare Beneficiary means an individual who--
(1) Is entitled to Medicare Part A, with or without payment of
premiums, but is not entitled solely because he or she is eligible to
enroll as a QDWI;
(2) Has resources, as determined in accordance with SSI
methodologies, that do not exceed twice the maximum amount established
for SSI eligibility; and
(3) Has income, as determined in accordance with SSI methodologies,
that does not exceed 100 percent of the Federal poverty guidelines.
Quality improvement organization means an organization that has a
contract with CMS, under part B of title XI of the Act, to perform
utilization and quality control review of the health care furnished, or
to be furnished, to Medicare beneficiaries.
Regional Administrator means a Regional Administrator of CMS.
Regional Office means one of the regional offices of CMS.
RHC stands for rural health clinic.
RRB stands for Railroad Retirement Board.
Secretary means the Secretary of Health and Human Services.
SNF stands for skilled nursing facility.
Social security benefits means monthly cash benefits payable under
section 202 or 223 of the Act.
SSA stands for Social Security Administration.
United States means the fifty States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa,
and the Northern Mariana Islands.
U.S.C. stands for United States Code.
[48 FR 12534, Mar. 25, 1983, as amended at 49 FR 7206, Feb. 27, 1984; 50
FR 15326 and 15358, Apr. 17, 1985; 50 FR 41886, Oct. 16, 1985; 51 FR
43197, Dec. 1, 1986; 52 FR 27764, July 23, 1987; 56 FR 8852, Mar. 1,
1991; 56 FR 38077, Aug. 12, 1991; 57 FR 24975, June 12, 1992; 57 FR
55912, Nov. 25, 1992; 63 FR 35065, June 26, 1998; 63 FR 52611, Oct. 1,
1998; 63 FR 68690, Dec. 14, 1998; 66 FR 39452, July 31, 2001; 67 FR
36540, May 24, 2002]
Sec. 400.202 Definitions specific to Medicare.
As used in connection with the Medicare program, unless the context
indicates otherwise--
Beneficiary means a person who is entitled to Medicare benefits.
Carrier means an entity that has a contract with CMS to determine
and make Medicare payments for Part B benefits payable on a charge basis
and to perform other related functions.
Critical access hospital (CAH) means a facility designated by HFCA
as meeting the applicable requirements of section 1820 of the Act and of
subpart F of part 485 of this chapter.
Departmental Appeals Board means: (1) Except as provided in
paragraphs (2) and (3) of this definition, a Board established in the
office of the Secretary, whose members act in panels to provide
impartial review of disputed decisions made by operating components of
the Department or by ALJs.
(2) For purposes of review of ALJ decisions under part 405, subparts
G and H; part 417, subpart Q; part 422, subpart M; and part 478, subpart
B of this chapter, the Medicare Appeals Council designated by the Board
Chair.
(3) For purposes of part 426 of this chapter, a Member of the Board
and, at the discretion of the Board Chair, any other Board staff
appointed by the Board Chair to perform a review under that part.
Entitled means that an individual meets all the requirements for
Medicare benefits.
Essential access community hospital (EACH) means a hospital
designated by CMS as meeting the applicable requirements of section 1820
of the Act and of subpart G of part 412 of this chapter, as in effect on
September 30, 1997.
[[Page 7]]
GME stands for graduate medical education.
Hospital insurance benefits means payments on behalf of, and in rare
circumstances directly to, an entitled individual for services that are
covered under Part A of title XVIII of the Act.
Intermediary means an entity that has a contract with CMS to
determine and make Medicare payments for Part A or Part B benefits
payable on a cost basis and to perform other related functions.
Local coverage determination (LCD) means a decision by a fiscal
intermediary or a carrier under Medicare Part A or Part B, as
applicable, whether to cover a particular service on an intermediary-
wide or carrier-wide basis in accordance with section 1862(a)(1)(A) of
the Act. An LCD may provide that a service is not reasonable and
necessary for certain diagnoses and/or for certain diagnosis codes. An
LCD does not include a determination of which procedure code, if any, is
assigned to a service or a determination with respect to the amount of
payment to be made for the service.
Medicare Part A means the hospital insurance program authorized
under Part A of title XVIII of the Act.
Medicare Part B means the supplementary medical insurance program
authorized under Part B of title XVIII of the Act.
Medicare Part C means the choice of Medicare benefits through
Medicare Advantage plans authorized under Part C of the title XVIII of
the Act.
Medicare Part D means the voluntary prescription drug benefit
program authorized under Part D of title XVIII of the Act.
National coverage determination (NCD) means a decision that CMS
makes regarding whether to cover a particular service nationally under
title XVIII of the Act. An NCD does not include a determination of what
code, if any, is assigned to a service or a determination with respect
to the amount of payment to be made for the service.
Nonparticipating supplier means a supplier that does not have an
agreement with CMS to participate in Part B of Medicare in effect on the
date of the service.
Participating supplier means a supplier that has an agreement with
CMS to participate in Part B of Medicare in effect on the date of the
service.
Payment on an assignment-related basis means payment for Part B
services--
(1) To a physician or other supplier that accepts assignment from
the beneficiary, in accordance with Sec. 424.55 or Sec. 424.56 of this
chapter;
(2) To a physician or other supplier after the beneficiary's death,
in accordance with Sec. 424.64(c)(1) of this chapter; or
(3) To an entity that pays the physician or other supplier under a
health benefit plan, in accordance with Sec. 424.66 of this chapter.
Provider means a hospital, a CAH, a skilled nursing facility, a
comprehensive outpatient rehabilitation facility, a home health agency,
or a hospice that has in effect an agreement to participate in Medicare,
or a clinic, a rehabilitation agency, or a public health agency that has
in effect a similar agreement but only to furnish outpatient physical
therapy or speech pathology services, or a community mental health
center that has in effect a similar agreement but only to furnish
partial hospitalization services.
Railroad retirement benefits means monthly benefits payable to
individuals under the Railroad Retirement Act of 1974 (45 U.S.C.
beginning at section 231).
Services means medical care or services and items, such as medical
diagnosis and treatment, drugs and biologicals, supplies, appliances,
and equipment, medical social services, and use of hospital, CAH, or SNF
facilities.
Supplementary medical insurance benefits means payment to or on
behalf of an entitled individual for services covered under Part B of
title XVIII of the Act.
Supplier means a physician or other practitioner, or an entity other
than a
[[Page 8]]
provider, that furnishes health care services under Medicare.
[48 FR 12534, Mar. 25, 1983, as amended at 48 FR 56024, Dec. 16, 1983;
49 FR 3658, Jan. 30, 1984; 51 FR 43197, Dec. 1, 1986; 52 FR 27764, July
23, 1987; 55 FR 24567, June 18, 1990; 56 FR 8852, Mar. 1, 1991; 58 FR
30666, May 26, 1993; 59 FR 6576, Feb. 11, 1994; 60 FR 63175, Dec. 8,
1995; 62 FR 46025, Aug. 29, 1997; 62 FR 59098, Oct. 31, 1997; 63 FR
35065, June 26, 1998; 68 FR 63715, Nov. 11, 2003; 70 FR 4525, Jan. 28,
2005]
Sec. 400.203 Definitions specific to Medicaid.
As used in connection with the Medicaid program, unless the context
indicates otherwise--
Applicant means an individual whose written application for Medicaid
has been submitted to the agency determining Medicaid eligibility, but
has not received final action. This includes an individual (who need not
be alive at the time of application) whose application is submitted
through a representative or a person acting responsibly for the
individual.
Federal financial participation (FFP) means the Federal Government's
share of a State's expenditures under the Medicaid program.
FMAP stands for the Federal medical assistance percentage, which is
used to calculate the amount of Federal share of State expenditures for
services.
Medicaid agency or agency means the single State agency
administering or supervising the administration of a State Medicaid
plan.
Nursing facility (NF), effective October 1, 1990, means an SNF or an
ICF participating in the Medicaid program.
PCCM stands for primary care case manager.
PCP stands for primary care physician.
Provider means either of the following:
(1) For the fee-for-service program, any individual or entity
furnishing Medicaid services under an agreement with the Medicaid
agency.
(2) For the managed care program, any individual or entity that is
engaged in the delivery of health care services and is legally
authorized to do so by the State in which it delivers the services.
Recipient means an individual who has been determined eligible for
Medicaid.
Services means the types of medical assistance specified in section
1905(a) of the Act and defined in subpart A of part 440 of this chapter.
State means the several States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa
and the Northern Mariana Islands.
State plan or the plan means a comprehensive written commitment by a
Medicaid agency, submitted under section 1902(a) of the Act, to
administer or supervise the administration of a Medicaid program in
accordance with Federal requirements.
[48 FR 12534, Mar. 25, 1983, as amended at 50 FR 33029, Aug. 16, 1985;
56 FR 8852, Mar. 1, 1991; 57 FR 29155, June 30, 1992; 67 FR 41094, June
14, 2002]
Subpart C_OMB Control Numbers for Approved Collections of Information
Source: 49 FR 4477, Feb. 7, 1984, unless otherwise noted.
Sec. 400.300 Scope.
This subpart collects and displays control numbers assigned by the
Office of Management and Budget (OMB) to collections of information
contained in CMS regulations, in accordance with OMB's regulations for
controlling paperwork burdens on the public, 5 CFR part 1320. CMS
intends that the subpart comply with the requirements of section 3507(f)
of the Paperwork Reduction Act of 1980, 44 U.S.C. chapter 35 which
requires that agencies shall not engage in a ``collection of
information'' without obtaining a control number from OMB.
Sec. 400.310 Display of currently valid OMB control numbers.
------------------------------------------------------------------------
Current OMB
Sections in 42 CFR that contain collections of information control Nos.
------------------------------------------------------------------------
403.510................................................... 0938--0641
405.509................................................... 0938--0666
405.512................................................... 0938--0008
405.2112, 405.2123, 405.2134, 405.2136-405.2140, 405.2171. 0938--0386
409.43.................................................... 0938--0365
410.105................................................... 0938--0267
411.25, 411.32............................................ 0938--0564
[[Page 9]]
411.54.................................................... 0938--0558
411.165................................................... 0938--0564
411.404, 411.406.......................................... 0938--0465
411.408................................................... 0938--0566
412.42.................................................... 0938--0666
412.92.................................................... 0938--0477
412.105................................................... 0938--0456
412.230, 412.232, 412.234, 412.236, 412.254, 412.260, 0938--0573
412.266, 412.278.........................................
415.60.................................................... 0938--0301
415.162................................................... 0938--0301
416.43.................................................... 0938--0506
416.47.................................................... 0938--0266
and
0938--0506
417.126................................................... 0938--0472
417.436, 417.801.......................................... 0938--0610
418.22, 418.24, 418.28, 418.56, 418.58, 418.70, 418.74.... 0938--0302
418.30, 418.82, 418.83, 418.96, 418.100................... 0938--0475
418.96, 418.100........................................... 0938--0302
421.117................................................... 0938--0542
424.3..................................................... 0938--0008
424.5, 424.7, 424.20...................................... 0938--0454
424.22.................................................... 0938--0489
424.32, 424.34............................................ 0938--0008
431.17.................................................... 0938--0467
431.50, 431.52, 431.55.................................... 0938--0247
431.107................................................... 0938--0610
431.306................................................... 0938--0467
431.625................................................... 0938--0247
431.630................................................... 0938--0445
431.800................................................... 0938--0247
431.806, 431.830, 431.432, 431.834, 431.836............... 0938--0438
432.50.................................................... 0938--0459
433.36, 433.37............................................ 0938--0247
433.68, 433.74............................................ 0938--0618
433.110, 433.112-433.114, 433.116, 433.117, 433.119- 0938--0247
433.121, 433.123, 433.127, 433.130, 433.131, 433.135.....
433.138................................................... 0938--0502
0938--0553
and
0938--0555
433.139................................................... 0938--0459
0938--0554
and
0938--0555
434.27.................................................... 0938--0572
434.28.................................................... 0938--0610
435.1, 435.910, 435.919, 435.920, 435.940, 435.945, 0938--0247
435.948, 435.952, 435.953, 435.955, 435.960, 435.965,
435.1003, 441.11, 441.15, 441.20.........................
441.56, 441.58, 441.60, 441.61............................ 0938--0354
441.302................................................... 0938--0449
441.303................................................... 0938--0272
and
0938--0449
441.351, 441.352, 441.353, 441.356, 441.365............... 0938--0613
442.505................................................... 0938--0366
447.31.................................................... 0938--0287
447.45, 447.50, 447.51, 447.52............................ 0938--0247
447.53.................................................... 0938--0429
447.55.................................................... 0938--0247
447.253................................................... 0938--0366
0938--0523
and
0938--0556
447.255................................................... 0938--0193
447.272, 447.299.......................................... 0938--0618
447.302, 447.331, 447.332, 447.333........................ 0938--0247
456.80.................................................... 0938--0247
456.654................................................... 0938--0445
456.700, 456.705, 456.709, 456.711, 456.712............... 0938--0659
462.102, 462.103.......................................... 0938--0526
466.70, 466.72, 466.74.................................... 0938--0445
466.78.................................................... 0938--0445
and
0938--0665
466.80, 466.94............................................ 0938--0445
473.18, 473.34, 473.36, 473.42............................ 0938--0443
476.104, 476.105, 476.116, 476.134........................ 0938--0426
481.61.................................................... 0938--0328
482.12, 482.21, 482.22, 482.27, 482.30, 482.41, 482.43, 0938--0328
482.53, 482.56, 482.57, 482.60, 482.62...................
483.10.................................................... 0938--0610
483.410, 483.420, 483.440, 483.460, 483.470............... 0938--0366
484.1, 484.2.............................................. 0938--0365
484.10.................................................... 0938--0365
and
0938--0610
484.12, 484.14, 484.16, 484.18, 484.30, 484.32, 484.34, 0938--0365
484.36, 484.48, 484.52...................................
485.56, 485.58, 485.60, 485.64, 485.66.................... 0938--0267
and
0938--0538
485.709, 485.711, 485.717, 485.719, 485.721, 487.723, 0938--0336
485.725, 485.727.........................................
486.104, 486.106, 486.110................................. 0938--0338
486.155, 486.161, 486.163................................. 0938--0336
488.10.................................................... 0938--0646
488.18.................................................... 0938--0667
488.26.................................................... 0938--0646
489.20.................................................... 0938--0564
and
0938--0667
489.24.................................................... 0938--0334
0938--0663
and
0938--0667
489.102................................................... 0938--0610
491.9, 491.10............................................. 0938--0334
493.35, 493.37, 493.39, 493.43, 493.45, 493.47, 493.49,
493.51, 493.53,..........................................
493.55, 493.60, 493.61, 493.62, 493.63.................... 0938--0612
493.614, 493.633, 494.634................................. 0938--0607
493.801-493.1285, 493.1425, 493.1701, 493.1703, 493.1705, 0938--0612
493.1707, 493.1709, 493.1711, 493.1713, 493.1715,
493.1717, 493.1719, 493.1721, 493.1775, 493.1776,
493.1777, 493.1780, 493.2001.............................
494.52, 494.54, 494.56, 494.58, 494.64.................... 0938--0608
498.22, 498.40, 498.58, 498.82............................ 0938--0508
1004.40, 1004.50, 1004.60, 1004.70........................ 0938--0444
------------------------------------------------------------------------
[60 FR 50445, Sept. 29, 1995, as amended at 60 FR 63188, Dec. 8, 1995]
PART 401_GENERAL ADMINISTRATIVE REQUIREMENTS--Table of Contents
Subpart A [Reserved]
Subpart B_Confidentiality and Disclosure
Sec.
401.101 Purpose and scope.
401.102 Definitions.
401.105 Rules for disclosure.
401.106 Publication.
[[Page 10]]
401.108 CMS rulings.
401.110 Publications for sale.
401.112 Availability of administrative staff manuals.
401.116 Availability of records upon request.
401.118 Deletion of identifying details.
401.120 Creation of records.
401.126 Information or records that are not available.
401.128 Where requests for records may be made.
401.130 Materials available at social security district offices and
branch offices.
401.132 Materials in field offices of the Office of Hearings and
Appeals, SSA.
401.133 Availability of official reports on providers and suppliers of
services, State agencies, intermediaries, and carriers under
Medicare.
401.134 Release of Medicare information to State and Federal agencies.
401.135 Release of Medicare information to the public.
401.136 Requests for information or records.
401.140 Fees and charges.
401.144 Denial of requests.
401.148 Administrative review.
401.152 Court review.
Subparts C-E [Reserved]
Subpart F_Claims Collection and Compromise
401.601 Basis and scope.
401.603 Definitions.
401.605 Omissions not a defense.
401.607 Claims collection.
401.613 Compromise of claims.
401.615 Payment of compromise amount.
401.617 Suspension of collection action.
401.621 Termination of collection action.
401.623 Joint and several liability.
401.625 Effect of CMS claims collection decisions on appeals.
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh). Subpart F is also issued under the authority of the
Federal Claims Collection Act (31 U.S.C. 3711).
Subpart A [Reserved]
Subpart B_Confidentiality and Disclosure
Source: 46 FR 55696, Nov. 12, 1981, unless otherwise noted.
Sec. 401.101 Purpose and scope.
(a) The regulations in this subpart:
(1) Implement section 1106(a) of the Social Security Act as it
applies to the Centers for Medicare & Medicaid Services (CMS). The rules
apply to information obtained by officers or employees of CMS in the
course of administering title XVIII of the Social Security Act
(Medicare), information obtained by Medicare intermediaries or carriers
in the course of carrying out agreements under sections 1816 and 1842 of
the Social Security Act, and any other information subject to section
1106(a) of the Social Security Act;
(2) Relate to the availability to the public, under 5 U.S.C. 552, of
records of CMS and its components. They set out what records are
available and how they may be obtained; and
(3) Supplement the regulations of the Department of Health and Human
Services relating to availability of information under 5 U.S.C. 552,
codified in 45 CFR part 5, and do not replace or restrict them.
(b) Except as authorized by the rules in this subpart, no
information described in paragraph (a)(1) of this section shall be
disclosed. The procedural rules in this subpart (Sec. Sec. 401.106
through 401.152) shall be applied to requests for information which is
subject to the rules for disclosure in this subpart.
(c) Requests for information which may not be disclosed according to
the provisions of this subpart shall be denied under authority of
section 1106(a) of the Social Security Act and this subpart, and
furthermore, such requests which have been made pursuant to the Freedom
of Information Act shall be denied under authority of an appropriate
Freedom of Information Act exemption, 5 U.S.C. 552(b).
Sec. 401.102 Definitions.
For purposes of this subpart:
Act means the Social Security Act.
Freedom of Information Act rules means the substantive mandatory
disclosure provisions of the Freedom of Information Act, 5 U.S.C. 552
(including the exemptions from mandatory disclosure, 5 U.S.C. 552(b), as
implemented by the Department's public information regulation, 45 CFR
part 5, subpart F and by Sec. Sec. 401.106 to 401.152 of this subpart.
Person means a person as defined in the Administrative Procedure
Act, 5 U.S.C. 551(2). This includes State or local agencies, but does
not include
[[Page 11]]
Federal agencies or State or Federal courts.
Record has the same meaning as that provided in 45 CFR 5.5.
Subject individual means an individual whose record is maintained by
the Department in a system of records, as the terms ``individual,''
``record'', and ``system of records'' are defined in the Privacy Act of
1974, 5 U.S.C. 552a(a).
Sec. 401.105 Rules for disclosure.
(a) General rule. The Freedom of Information Act rules shall be
applied to every proposed disclosure of information. If, considering the
circumstances of the disclosure, the information would be made available
in accordance with the Freedom of Information Act rules, then the
information may be disclosed regardless of whether the requester or
recipient of the information has a statutory right to request the
information under the Freedom of Information Act, 5 U.S.C. 552, or
whether a request has been made.
(b) Application of the general rule. Pursuant to the general rule in
paragraph (a) of this section,
(1) Information shall be disclosed--
(i) To a subject individual when required by the access provision of
the Privacy Act, 5 U.S.C. 552a(d), as implemented by the Department
Privacy Act regulation, 45 CFR part 5b; and
(ii) To a person upon request when required by the Freedom of
Information Act, 5 U.S.C. 552;
(2) Unless prohibited by any other statute (e.g., the Privacy Act of
1974, 5 U.S.C. 552a(b), the Tax Reform Act of 1976, 26 U.S.C. 6103, or
section 1106(d) and (e) of the Social Security Act), information may be
disclosed to any requester or recipient of the information, including
another Federal agency or a State or Federal court, when the information
would not be exempt from mandatory disclosure under Freedom of
Information Act rules or when the information nevertheless would be made
available under the Department's public information regulation's
criteria for disclosures which are in the public interest and consistent
with obligations of confidentiality and administrative necessity, 45 CFR
part 5, subpart F, as supplemented by Sec. Sec. 401.106 to 401.152 of
this subpart.
[42 FR 14704, Mar. 16, 1977. Redesignated at 45 FR 74913, 74914, Nov.
13, 1980, and correctly redesignated at 46 FR 24551, May 1, 1981, as
amended at 46 FR 55697, Nov. 12, 1981]
Sec. 401.106 Publication.
(a) Methods of publication. Materials required to be published under
the provisions of The Freedom of Information Act, 5 U.S.C. 552 (a)(1)
and (2) are published in one of the following ways:
(1) By publication in the Federal Register of CMS regulations, and
by their subsequent inclusion in the Code of Federal Regulations;
(2) By publication in the Federal Register of appropriate general
notices;
(3) By other forms of publication, when incorporated by reference in
the Federal Register with the approval of the Director of the Federal
Register; and
(4) By publication of indexes of precedential orders and opinions
issued in the adjudication of claims, statements of policy and
interpretations which have been adopted but have not been published in
the Federal Register, and of administrative staff manuals and
instructions to staff that affect a member of the public.
(b) Availability for inspection. Those materials which are published
in the Federal Register pursuant to 5 U.S.C. 552(a)(1) shall, to the
extent practicable and to further assist the public, be made available
for inspection at the places specified in Sec. 401.128.
[46 FR 55696, Nov. 12, 1981, as amended at 48 FR 22924, May 23, 1983]
Sec. 401.108 CMS rulings.
(a) After September 1981, a precedent final opinion or order or a
statement of policy or interpretation that has not been published in the
Federal Register as a part of a regulation or of a notice implementing
regulations, but which has been adopted by CMS as having precedent, may
be published in the Federal Register as a CMS Ruling and will be made
available in the publication entitled CMS Rulings.
(b) Precedent final opinions and orders and statements of policy and
interpretation that were adopted by CMS
[[Page 12]]
before October, 1981, and that have not been published in the Federal
Register are available in CMS Rulings.
(c) CMS Rulings are published under the authority of the
Administrator, CMS. They are binding on all CMS components, on all HHS
components that adjudicate matters under the jurisdiction of CMS, and on
the Social Security Administration to the extent that components of the
Social Security Administration adjudicate matters under the jurisdiction
of CMS.
[48 FR 22924, May 23, 1983, as amended at 70 FR 11472, Mar. 8, 2005; 70
FR 37702, June 30, 2005]
Sec. 401.110 Publications for sale.
The following publications containing information pertaining to the
program, organization, functions, and procedures of CMS may be purchased
from the Superintendent of Documents, Government Printing Office,
Washington, DC 20402.
(a) Titles 20, 42, and 45 of the Code of Federal Regulations.
(b) Federal Register issues.
(c) Compilation of the Social Security Laws.
(d) CMS Rulings.
(e) Social Security Handbook. The information in the Handbook is not
of precedent or interpretative force.
(f) Medicare/Medicaid Directory of Medical Facilities.
Sec. 401.112 Availability of administrative staff manuals.
All CMS administrative staff manuals and instructions to staff
personnel which contain policies, procedures, or interpretations that
affect the public are available for inspection and copying. A complete
listing of such materials is published in CMS Rulings. These manuals are
generally not printed in a sufficient quantity to permit sale or other
general distribution to the public. Selected material is maintained at
Social Security Administration district offices and field offices and
may be inspected there. See Sec. Sec. 401.130 and 401.132 for a listing
of this material.
Sec. 401.116 Availability of records upon request.
(a) General. In addition to the records made available pursuant to
Sec. Sec. 401.106, 401.108, 401.110 and 401.112, CMS will, upon request
made in accordance with this subpart, make identified records available
to any person, unless they are exempt from disclosure under the
provisions of section 552(b) of title 5, United States Code (see Sec.
401.126), or any other provision of law.
(b) Misappropriation, alteration, or destruction of records. No
person may remove any record made available to him for inspection or
copying under this part, from the place where it is made available. In
addition, no person may steal, alter, mutilate, obliterate, or destroy
in whole or in part, such a record. See sections 641 and 2071 of title
18 of the United States Code.
Sec. 401.118 Deletion of identifying details.
When CMS publishes or otherwise makes available an opinion or order,
statement of policy, or other record which relates to a private party or
parties, the name or names or other identifying details will be deleted.
Sec. 401.120 Creation of records.
Records will not be created by compiling selected items from the
files, and records will not be created to provide the requester with
such data as ratios, proportions, percentages, per capitas, frequency
distributions, trends, correlations, and comparisons. If such data have
been compiled and are available in the form of a record, the record
shall be made available as provided in this subpart.
Sec. 401.126 Information or records that are not available.
(a) Specific exemptions from disclosure. Pursuant to paragraph (b)
of 5 U.S.C. 552, certain classes of records are exempt from disclosure.
For some examples of the kinds of materials which are exempt, see
subpart F of the public information regulation of the Department of
Health and Human Services (45 CFR part 5) and the appendix to that
regulation.
(b) Materials exempt from disclosure by statute. Pursuant to
paragraph (b)(3) of
[[Page 13]]
5 U.S.C. 552, as amended, which exempts from the requirement for
disclosure matters that are exempted from disclosure by statute,
provided that such statute requires that the matters be withheld from
the public in such a manner as to leave no discretion on the issue, or
establishes particular criteria for withholding or refers to particular
types of matter to be withheld:
(1) Reports described in sections 1106 (d) and (e) of the Social
Security Act shall not be disclosed, except in accordance with the
provisions of sections 1106 (d) and (e). Sections 1106 (d) and (e)
provide for public inspection of certain official reports dealing with
the operation of the health programs established by titles XVIII and XIX
of the Social Security Act (Medicare and Medicaid), but require that
program validation survey reports and other formal evaluations of
providers of services shall not identify individual patients, individual
health care practitioners, or other individuals. Section 1106(e) further
requires that none of the reports shall be made public until the
contractor or provider whose performance is being evaluated has had a
reasonable opportunity to review that report and to offer comments. See
Sec. 401.133 (b) and (c);
(2)(i) Except as specified in paragraph (b)(2)(ii) of this section,
CMS may not disclose any accreditation survey or any information
directly related to the survey (including corrective action plans) made
by and released to it by the Joint Commission on Accreditation of
Healthcare Organizations, the American Osteopathic Association or any
other national accreditation organization that meets the requirements of
Sec. 488.6 or Sec. 493.506 of this chapter. Materials that are
confidential include accreditation letters and accompanying
recommendations and comments prepared by an accreditation organization
concerning the entities it surveys.
(ii) Exceptions.
(A) CMS may release the accreditation survey of any home health
agency; and
(B) CMS may release the accreditation survey and other information
directly related to the survey (including corrective action plans) to
the extent the survey and information relate to an enforcement action
(for example, denial of payment for new admissions, civil money
penalties, temporary management and termination) taken by CMS; and
(3) Tax returns and return information defined in section 6103 of
the Internal Revenue Code, as amended by the Tax Reform Act of 1976,
shall not be disclosed except as authorized by the Internal Revenue
Code.
(c) Effect of exemption. Neither 5 U.S.C. 552 nor this regulation
directs the withholding of any record or information, except to the
extent of the prohibitions in paragraph (b) of this section. Except for
material required to be withheld under the statutory provisions
incorporated in paragraph (b) of this section or under another statute
which meets the standards in 5 U.S.C. 552(b)(3), materials exempt from
mandatory disclosure will nevertheless be made available when this can
be done consistently with obligations of confidentiality and
administrative necessity. The disclosure of materials or records under
these circumstances in response to a specific request, however, is of no
precedent force with respect to any other request.
[46 FR 55696, Nov. 12, 1981, as amended at 58 FR 61837, Nov. 23, 1993]
Sec. 401.128 Where requests for records may be made.
(a) General. Any request for any record may be made to--
(1) Any CMS component;
(2) Director, Office of Public Affairs, CMS 313-H, Hubert H.
Humphrey Building, 200 Independence Avenue, Washington, DC 20201; or
(3) Director of Public Affairs in any Regional Office of the
Department of Health and Human Services.
The locations and service areas of these offices are as follows:
Region I--John F. Kennedy Federal Building, Boston, MA 02203.
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont.
Region II--26 Federal Plaza, New York, NY 10007. New York, New Jersey,
Puerto Rico, Virgin Islands.
Region III--Gateway Building, 3535 Market Street, Philadelphia, PA
19101. Delaware, Maryland, Pennsylvania, Virginia, West Virginia,
District of Columbia.
[[Page 14]]
Region IV--101 Marietta Street, Altanta, GA 30323. Alabama, Florida,
Georgia, Kentucky, Mississippi, North Carolina, South Carolina,
Tennessee.
Region V--300 South Wacker Drive, Chicago, IL 60606. Illinois, Indiana,
Michigan, Minnesota, Ohio, Wisconsin.
Region VI--1200 Main Tower Building, Dallas, TX 75202. Arkansas,
Louisiana, New Mexico, Oklahoma, Texas.
Region VII--601 East 12th Street, Kansas City, MO 64106. Iowa, Kansas,
Missouri, Nebraska.
Region VIII--Federal Office Building, 19th and Stout Streets, Denver, CO
80294. Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming.
Region IX--Federal Office Building, 50 United Nations Plaza, San
Francisco, CA 94102. Arizona, California, Hawaii, Nevada, Guam, Trust
Territory of Pacific Islands, American Samoa.
Region X--Arcade Plaza Building, 1321 Second Avenue, Seattle, WA 98101.
Alaska, Idaho, Oregon, Washington.
(b) Records pertaining to individuals. CMS maintains some records
pertaining to individuals. Disclosure of such records is generally
prohibited by section 1106 of the Social Security Act (42 U.S.C. 1306),
except as prescribed in Sec. 401.105 (See also Sec. 401.126(b)).
Requests for records pertaining to individuals may be addressed to:
Director, Office of Research, Demonstrations and Statistics, CMS,
Baltimore, Maryland 21235, when information is sought from the record of
a person who has participated in a research survey conducted by or for
CMS, Office of Research, Demonstrations and Statistics; or whose records
have been included by statistical sampling techniques in research and
statistical studies authorized by the Social Security Act in the field
of health care financing.
(c) Requests for materials listed in Sec. 401.130 or Sec. 401.132
or indexed in the CMS Rulings. A request to inspect and copy materials
listed in Sec. 401.130 or Sec. 401.132 or indexed in CMS Rulings may
be made to any district or branch office of the Social Security
Administration. If the specific material requested is not available in
the office receiving the request, the material will be obtained and made
available promptly.
Sec. 401.130 Materials available at social security district offices
and branch offices.
(a) Materials available for inspection. The following are available
or will be made available for inspection at the social security district
offices and branch offices:
(1) Compilation of the Social Security Laws.
(2) The Public Information Regulation of the Department of Health
and Human Services (45 CFR part 5).
(3) Medicare Program regulations issued by the Centers for Medicare
& Medicaid Services. 42 CFR chapter IV .
(4) CMS Rulings.
(5) Social Security Handbook.
(b) Materials available for inspection and copying. The following
materials are available or will be made available for inspection and
copying at the social security district offices and branch offices:
(1) Claims Manual of the Social Security Administration.
(2) Department Staff Manual on Organization, Department of Health
and Human Services, Part F, CMS.
(3) Parts 2 and 3 of the Part A
Intermediary Manual (Provider Services under Medicare CMS Pub. 13-2 and
13-3).
(4) Parts 2 and 3 of the Part B Intermediary Manual (Physician and
Supplier Services).
(5) Intermediary Letters Related to Parts 2 and 3 of the Part A and
Part B Intermediary Manuals.
(6) State Buy-In Handbook (State Enrollment of Eligible Individuals
under the Supplementary Medical Insurance Program) and Letters.
(7) Group Practice Prepayment Plan Manual (HIM-8) and Letters.
(8) State Operations Manual (HIM-7).
(9) CMS Letters to State Agencies on Medicare.
(10) Skilled Nursing Facility Manual (CMS Pub. 12).
(11) Hearing Officers Handbook (Supplementary Medical Insurance
Program--HIM-21).
(12) Hospital Manual (HIM-10).
(13) Home Health Agency Manual (HIM-11).
(14) Outpatient Physical Therapy Provider Manual (HIM-9).
[[Page 15]]
(15) Provider Reimbursement Manual (HIM-15).
(16) Audit Program Manuals for Hospital (HIM-16), Home Health Agency
(HIM-17), and Extended Care Facilities (HIM-18).
(17) Statements of deficiencies based upon survey reports of health
care institutions or facilities prepared after January 31, 1973, by a
State agency, and such reports (including pertinent written statements
furnished by such institution or facility on such statements of
deficiencies), as set forth in Sec. 401.133(a). Except as otherwise
provided for at Sec. Sec. 401.133 and 488.325 of this chapter for SNFs,
such statements of deficiencies, reports, and pertinent written
statements shall be available or made available only at the social
security district office and regional office servicing the area in which
the institution or facility is located, except that such statements of
deficiencies and pertinent written statements shall also be available at
the local public assistance offices servicing such area.
(18) Indexes to the materials listed in paragraph (a) of this
section and in this paragraph (b) and an index to the Bureau of Hearings
and Appeals Handbook.
[46 FR 55696, Nov. 12, 1981, as amended at 59 FR 56232, Nov. 10, 1994]
Sec. 401.132 Materials in field offices of the Office of Hearings and
Appeals, SSA.
(a) Materials available for inspection. The following materials are
available for inspection in the field offices of the Office of Hearings
and Appeals, SSA.
(1) Title 45 of the Code of Federal Regulations (including the
public information regulation of the Department of Health and Human
Services).
(2) Regulations of the Social Security Administration and CMS.
(3) Title 5, United States Code.
(4) Compilation of the Social Security Laws.
(5) CMS Rulings.
(6) Social Security Handbook.
(b) Handbook available for inspection and copying. The Office of
Hearings and Appeals Handbook is available for inspection and copying in
the field offices of the Office of Hearings and Appeals.
Sec. 401.133 Availability of official reports on providers and suppliers
of services, State agencies, intermediaries, and carriers under Medicare.
Except as otherwise provided for in Sec. 488.325 of this chapter
for SNFs, the following must be made available to the public under the
conditions specified:
(a) Statements of deficiencies and survey reports on providers of
services prepared by State agencies. (1) Statements of deficiencies
based upon official survey reports prepared after January 31, 1973, by a
State agency pursuant to its agreement entered into under section 1864
of the Social Security Act and furnished to CMS, which relate to a State
agency's findings on the compliance of a health care institution or
facility with the applicable provisions in section 1861 of the Act and
with the regulations, promulgated pursuant to those provisions, dealing
with health and safety of patients in those institutions and facilities;
and (2) State agency survey reports. The statement of deficiencies or
report and any pertinent written statements furnished by the institution
or facility on the statement of deficiencies shall be disclosed within
90 days following the completion of the survey by the State agency, but
not to exceed 30 days following the receipt of the report by CMS. (See
Sec. 401.130(b)(17)) for places where statements of deficiencies,
reports, and pertinent written statements will be available.)
(b) CMS reports on providers of services. Upon request in writing,
official reports and other formal evaluations (including followup
reviews), excluding references to internal tolerance rules and practices
contained therein, internal working papers or other informal memoranda,
prepared and completed after January 31, 1973, which relate to the
performance of providers of services under Medicare: Provided, That no
information identifying individual patients, physicians, or other
practitioners, or other individuals shall be disclosed under this
paragraph. Those reports and other evaluations shall be disclosed within
30 days following the final preparation thereof by CMS during which time
the providers of services shall be afforded a reasonable opportunity to
offer comments, and there
[[Page 16]]
shall be disclosed with those reports and evaluations any pertinent
written statements furnished CMS by those providers on those reports and
evaluations.
(c) Contractor performance review reports. Upon request in writing,
official contractor performance review reports and other formal
evaluations (including followup reviews), excluding references to
internal tolerance rules and practices contained therein, internal
working papers or other informal memoranda, prepared and completed after
January 31, 1973, which relate to the evaluation of the performance of
(1) intermediaries and carriers under their agreements entered into
pursuant to sections 1816 and 1842 of the Social Security Act and (2)
State agencies under their agreements entered into pursuant to section
1864 of the Act (including comparative evaluations of the performance of
those intermediaries, carriers, and State agencies). The latest Contract
Performance Review Report pertaining to a particular intermediary or
carrier, prepared prior to February 1, 1973, may also be disclosed to
any person upon request in writing. Those reports and evaluations shall
be disclosed within 30 days following their final preparation by CMS (or
30 days following the request therefor, in the case of the contract
performance review report prepared prior to February 1, 1973), during
which time those intermediaries, carriers, and State agencies, as the
case may be, shall be afforded a reasonable opportunity to offer
comments, and there shall be disclosed with those reports and
evaluations any pertinent written statements furnished CMS by those
intermediaries, carriers, on State agencies or those reports and
evaluations.
(d) Accreditation surveys. Upon written request, CMS will release
the accreditation survey and related information from an accreditation
organization meeting the requirements of Sec. 488.5, Sec. 488.6 or
Sec. 493.506 of this chapter to the extent the survey and information
relate to an enforcement action taken (for example, denial of payment
for new admission, civil money penalties, temporary management and
termination) by CMS;
(e) Upon written request, CMS will release the accreditation survey
of any home health agency.
[46 FR 55696, Nov. 12, 1981; 46 FR 59249, Dec. 4, 1981, as amended at 58
FR 61838, Nov. 23, 1993; 59 FR 56232, Nov. 10, 1994]
Sec. 401.134 Release of Medicare information to State and Federal
agencies.
(a) Except as provided in paragraph (b) of this section, the
following information may be released to an officer or employee of an
agency of the Federal or a State government lawfully charged with the
administration of a program receiving grants-in-aid under title V and
XIX of the Social Security Act for the purpose of administration of
those titles, or to any officer or employee of the Department of Army,
Department of Defense, solely for the administration of its Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS):
(1) Information, including the identification number, concerning
charges made by physicians, other practitioners, or suppliers, and
amounts paid under Medicare for services furnished to beneficiaries by
such physicians, other practioners, or suppliers, to enable the agency
to determine the proper amount of benefits payable for medical services
performed in accordance with those programs; or
(2) Information as to physicians or other practioners that has been
disclosed under Sec. 401.105.
(3) Information relating to the qualifications and certification
status of hospitals and other health care facilities obtained in the
process of determining whether, and certifying as to whether,
institutions or agencies meet or continue to meet the conditions of
participation of providers of services or whether other entities meet or
continue to meet the conditions for coverage of services they furnish.
(b) The release of such information shall not be authorized by a
fiscal intermediary or carrier.
(c) The following information may be released to any officer or
employee of an agency of the Federal or a State government lawfully
charged with the duty of conducting an investigation or prosecution with
respect to possible
[[Page 17]]
fraud or abuse against a program receiving grants-in-aid under Medicaid,
but only for the purpose of conducting such an investigation or
prosecution, or to any officer or employee of the Department of the
Army, Department of Defense, solely for the administration of its
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS),
provided that the agency has filed an agreement with CMS that the
information will be released only to the agency's enforcement branch and
that the agency will preserve the confidentiality of the information
received and will not disclose that information for other than program
purposes:
(1) The name and address of any provider of medical services,
organization, or other person being actively investigated for possible
fraud in connection with Medicare, and the nature of such suspected
fraud. An active investigation exists when there is significant evidence
supporting an initial complaint but there is need for further
investigation.
(2) The name and address of any provider of medical services,
organization, or other person found, after consultation with an
appropriate professional association or a program review team, to have
provided unnecessary services, or of any physician or other individual
found to have violated the assignment agreement on at least three
occasions.
(3) The name and address of any provider of medical services,
organization or other person released under paragraph (c)(1) or (2) of
this section concerning which an active investigation is concluded with
a finding that there is no fraud or other prosecutable offense.
Sec. 401.135 Release of Medicare information to the public.
The following shall be made available to the public under the
conditions specified:
(a) Information as to amounts paid to providers and other
organizations and facilities for services to beneficiaries under title
XVIII of the Act: Provided, That no information identifying any
particular beneficiaries shall be disclosed under this paragraph.
(b) The name of any provider of services or other person furnishing
services to Medicare beneficiaries who--
(1) Has been found by a Federal court to have been guilty of
submitting false claims in connection with Medicare; or
(2) Has been found by a carrier or intermediary, after consultation
with a professional medical association functioning external to program
administration or, if appropriate, the State medical authority, to have
been engaged in a pattern of furnishing services to beneficiaries which
are substantially in excess of their medical needs; except that the name
of any provider or other person shall not be disclosed pursuant to a
finding under this paragraph (b)(2) of this section, unless that
provider or other person has first been afforded a reasonable
opportunity to offer evidence on his behalf.
(c) Upon request in writing, cost reports submitted by providers of
services pursuant to section 1815 of the Act to enable the Secretary to
determine amounts due the providers.
Sec. 401.136 Requests for information or records.
(a) A request should reasonably identify the requested record by
brief description. Requesters who have detailed information which would
assist in identifying the records requested are urged to provide such
information in order to expedite the handling of the request. Envelopes
in which written requests are submitted should be clearly identified as
Freedom of Information requests. The request should include the fee or
request determination of the fee. When necessary, a written request will
be promptly forwarded to the proper office, and the requester will be
advised of the date of the receipt and identification and address of the
proper office.
(b) Determinations of whether records will be released or withheld
will be made within 10 working days from date of receipt of the request
in the office listed in Sec. 401.128 except where CMS extends this time
and sends notice of such extension to the requester. Such extension may
not exceed 10 additional working days and shall apply only where the
following unusual circumstances exist:
[[Page 18]]
(1) The need to search for and collect the requested records from
field facilities or other establishments that are separate from the
office processing the requests;
(2) The need to search for, collect, and appropriately examine a
voluminous amount of separate and distinct records which are requested
in a single request; or
(3) The need for consultation, which shall be conducted with all
practicable speed, with another agency having a substantial interest in
the request or among two or more components of CMS having a substantial
interest in the subject matter of the request.
(c) If an extension is made, the requester will be notified in
writing before the expiration of 10 working days from receipt of the
request and will be given an explanation of why the extension was
necessary and the date on which a determination will be made.
(d) Authority to extend the time limit with respect to any request
for information or records is granted to the Director, Office of Public
Affairs, CMS and to the Director of Public Affairs in any HHS Regional
Office. Those officers and employees of CMS who are listed in Sec.
401.144(a) as having authority to deny requests for information from
records maintained on individuals are granted authority to extend the
time limit for responding to requests for information from such records.
Sec. 401.140 Fees and charges.
(a) Statement of policy. It is CMS's policy to comply with certain
requests for information services without charge. Except as otherwise
determined pursuant to paragraph (c) of this section, fees will be
charged for the following services with respect to all other requests
for information from records which are reasonably identified by the
requesters:
(1) Reproduction, duplication, or copying of records;
(2) Searches for records; and
(3) Certification or authentication of records.
(b) Fee schedules. The fee schedule is as follows:
(1) Search for records. Three dollars per hour: Provided, however,
That no charge will be made for the first half hour.
(2) Reproduction, duplication, or copying of records. Ten cents per
page where such reproduction can be made by commonly available
photocopying machines. The cost of reproducing records which cannot be
so photocopied will be determined on an individual basis at actual cost.
(3) Certification or authentication of records. Three dollars per
certification or authentication.
(4) Forwarding materials to destination. Any special arrangements
for forwarding which are requested shall be charged at actual cost;
however, no charge will be made for postage.
(5) No charge will be made when the total amount does not exceed
five dollars.
(c) Waiver or reduction of fees. Waiver or reduction of the fees in
paragraph (b) of this section may be made upon a determination that such
waiver or reduction is in the public interest because furnishing the
information can be considered as primarily benefiting the general
public. Such determination may be made by the appropriate officer or
employee identified in Sec. 401.144.
(d) Sale of documents. On occasion, a previously printed document
may be available for sale to the public; the cost of supplying the
document is one cent per page unless the document is available for sale
from the Superintendent of Documents, in which case the price shall be
that determined by the Superintendent.
Sec. 401.144 Denial of requests.
(a) General authority. Only the Director, Office of Public Affairs,
CMS, and the Regional Directors of Public Affairs, HHS, are authorized
to deny written requests to obtain, inspect or copy any CMS information
or record.
(b) Forms of denials. (1) Oral requests may be dealt with orally,
but the requester should be advised that the oral response is not an
official determination and that an official determination may be
obtained only by submitting the request in writing. Appropriate
available assistance will be offered.
(2) Written Requests--Denials of written requests will be in writing
and will contain the reasons for the denial
[[Page 19]]
including, as appropriate, a statement that a document requested is
nonexistent or not reasonably described or is subject to one or more
clearly described exemption(s). Denials will also provide the requester
with appropriate information on how to exercise the right of appeal.
Sec. 401.148 Administrative review.
(a) Review by the Administrator. A person whose request has been
denied may initiate a review by filing a request for review with the
Administrator of CMS, 700 East High Rise Building, 6401 Security
Boulevard, Baltimore, Maryland 21235, within 30 days of receipt of the
determination to deny or within 30 days of receipt of records which are
in partial response to his request if a portion of a request is granted
and a portion denied, whichever is later. Upon receipt of a timely
request for review, the Administrator will review the decision in
question and the findings upon which it was based. Upon the basis of the
data considered in connection with the decision and whatever other
evidence and written argument is submitted by the person requesting the
review or which is otherwise obtained, the Administrator or his designee
will affirm or revise in whole or in part the findings and decision in
question. A decision to affirm the denial will be made only upon
concurrence of the Assistant Secretary for Public Affairs, or his
designee, after consultation with the General Counsel or his or her
designee, and the appropriate program policy official. Written notice of
the decision of the Administrator will be mailed to the person who
requested the review. A written decision will be made within 20 working
days from receipt of the request for review. Extension of the time limit
may be granted under the circumstances listed in Sec. 401.136(b) to the
extent that the maximum 10 days limit on extensions has not been
exhausted on the initial determination. The decision will include the
basis for it and will advise the requester of his right to judicial
review.
(b) Failure of the Administrator to comply with the time limits.
Failure of the Administrator to comply with the time limits set forth in
Sec. 401.136 and this section constitutes an exhaustion of the
requester's administrative remedies.
Sec. 401.152 Court review.
Where the Administrator upon review affirms the denial of a request
for records, in whole or in part, the requester may seek court review in
the district court of the United States pursuant to 5 U.S.C.
552(a)(4)(B).
Subparts C-E [Reserved]
Subpart F_Claims Collection and Compromise
Source: 48 FR 39064, Aug. 29, 1983, unless otherwise noted.
Sec. 401.601 Basis and scope.
(a) Basis. This subpart implements for CMS the Federal Claims
Collection Act (FCCA) of 1966 (31 U.S.C. 3711), and conforms to the
regulations (4 CFR parts 101-105) issued jointly by the General
Accounting Office and the Department of Justice that generally prescribe
claims collection standards and procedures under the FCCA for the
Federal government.
(b) Scope. Except as provided in paragraphs (c) through (f) of this
section, the regulations in this subpart describe CMS's procedures and
standards for the collection of claims in any amount, and the compromise
of, or the suspension or termination of collection action on, all claims
for money or property that do not exceed $100,000 or such higher amount
as the Attorney General may from time to time prescribe, exclusive of
interest, arising under any functions delegated to CMS by the Secretary.
(c) Amount of claim. CMS refers all claims that exceed $100,000 or
such higher amount as the Attorney General may from time to time
prescribe, exclusive of interest, to the Department of Justice or the
General Accounting Office for the compromise of claims, or the
suspension or termination of collection action.
(d) Related regulations--(1) Department regulations. DHHS
regulations applicable to CMS that generally implement
[[Page 20]]
the FCCA for the Department are located at 45 CFR part 30. These
regulations apply only to the extent CMS regulations do not address a
situation.
(2) CMS regulations. The following regulations govern specific debt
management situations encountered by CMS and supplement this subpart:
(i) Claims against Medicare beneficiaries for the recovery of
overpayments are covered in 20 CFR 404.515.
(ii) Adjustments in Railroad Retirement or Social Security benefits
to recover Medicare overpayments to individuals are covered in
Sec. Sec. 405.350--405.358 of this chapter.
(iii) Claims against providers, physicians, or other suppliers of
services for overpayments under Medicare and for assessment of interest
are covered in Sec. Sec. 405.377 and 405.378 of this chapter,
respectively.
(iv) Claims against beneficiaries for unpaid hospital insurance or
supplementary medical insurance premiums under Medicare are covered in
Sec. 408.110 of this chapter.
(v) State repayment of Medicaid funds by installments is covered in
Sec. 430.48 of this chapter.
(e) Collection and compromise under other statutes and at common
law. The regulations in this subpart do not--
(1) Preclude disposition by CMS of claims under statutes, other than
the FCCA, that provide for the collection or compromise of a claim, or
suspension or termination of collection action.
(2) Affect any rights that CMS may have under common law as a
creditor.
(f) Fraud. The regulations in this subpart do not apply to claims in
which there is an indication of fraud, the presentation of a false
claim, or misrepresentation on the part of a debtor or any other party
having an interest in the claim. CMS forwards these claims to the
Department of Justice for disposition under 4 CFR 105.1.
(g) Enforced collection. CMS refers claims to the Department of
Justice for enforced collection through litigation in those cases which
cannot be compromised or on which collection action cannot be suspended
or terminated in accordance with this subpart or the regulations issued
jointly by the Attorney General and the Comptroller General.
[48 FR 39064, Aug. 29, 1983, as amended at 52 FR 48123, Dec. 18, 1987;
57 FR 56998, Dec. 2, 1992; 61 FR 49271, Sept. 19, 1996; 61 FR 63748,
Dec. 2, 1996]
Sec. 401.603 Definitions.
For purposes of this subpart--
Claim means any debt owed to CMS.
Debtor means any individual, partnership, corporation, estate, trust
or other legal entity against which CMS has a claim.
Sec. 401.605 Omissions not a defense.
The failure of CMS to comply with the regulations in this subpart,
or with the related regulations listed in Sec. 401.601(d), is not
available as a defense to a debtor against whom CMS has a claim for
money or property.
Sec. 401.607 Claims collection.
(a) General policy. CMS recovers amounts of claims due from debtors,
including interest where appropriate, by--
(1) Direct collections in lump sums or in installments; or
(2) Offsets against monies owed to the debtor by the Federal
government where possible.
(b) Collection in lump sums. Whenever possible, CMS attempts to
collect claims in full in one lump sum. However, if CMS determines that
a debtor is unable to pay the claim in one lump sum, CMS may instead
enter into an agreement to accept regular installment payments.
(c) Collection in installments. Generally, CMS requires that all
claims to be satisfied by installment payments must be liquidated in
three years or less. If unusual circumstances exist, such as the
possibility of debtor insolvency, an installment agreement that extends
beyond three years may be approved.
(1) Debtor request. If a debtor desires to repay a claim in
installments, the debtor must submit--
(i) A request to CMS; and
(ii) Any information required by CMS to make a decision regarding
the request.
(2) CMS decision. CMS will determine the number, amount and
frequency of
[[Page 21]]
installment payments based on the information submitted by the debtor
and on other factors such as--
(i) Total amount of the claim;
(ii) Debtor's ability to pay; and
(iii) Cost to CMS of administering an installment agreement.
(d) Collection by offset. (1) CMS may offset, where possible, the
amount of a claim against the amount of pay, compensation, benefits or
other monies that a debtor is receiving or is due from the Federal
government.
(2) Under regulations at Sec. 405.350--405.358 of this chapter, CMS
may initiate adjustments in program payments to which an individual is
entitled under title II of the Act (Federal Old Age, Survivors, and
Disability Insurance Benefits) or under the Railroad Retirement Act of
1974 (45 U.S.C. 231) to recover Medicare overpayments.
[48 FR 39064, Aug. 29, 1983, as amended at 61 FR 49271, Sept. 19, 1996;
61 FR 63748, Dec. 2, 1996]
Sec. 401.613 Compromise of claims.
(a) Amount of compromise. HFCA requires that the amount to be
recovered through a compromise of a claim must--
(1) Bear a reasonable relation to the amount of the claim; and
(2) Be recoverable through enforced collection procedures.
(b) General factors. After considering the bases for a decision to
compromise a claim under paragraph (c) of this section, CMS may further
consider factors such as--
(1) The age and health of the debtor if the debtor is an individual;
(2) Present and potential income of the debtor; and
(3) Whether assets have been concealed or improperly transferred by
the debtor.
(c) Basis for compromise. Bases on which CMS may compromise a claim
include the following--
(1) Inability to pay. CMS may compromise a claim if it determines
that the debtor, or the estate of a deceased debtor, does not have the
present or prospective ability to pay the full amount of the claim
within a reasonable time.
(2) Litigative probabilities. CMS may compromise a claim if it
determines that it would be difficult to prevail in a case before a
court of law as a result of the legal issues involved or inability of
the parties to agree to the facts of the case. The amount that CMS
accepts in compromise under this provision will reflect--
(i) The likelihood that CMS would have prevailed on the legal
question(s) involved;
(ii) Whether and to what extent CMS would have obtained a full or
partial recovery of a judgment, depending on the availability of
witnesses, or other evidentiary support for CMS's claim; and
(iii) The amount of court costs that would be assessed to CMS.
(3) Cost of collecting the claim. CMS may compromise a claim if it
determines that the cost of collecting the claim does not justify the
enforced collection of the full amount. In this case, CMS may adjust the
amount it accepts as a compromise to allow an appropriate discount for
the costs of collection it would have incurred but for the compromise.
(d) Enforcement policy. CMS may compromise statutory penalties,
forfeitures, or debts established as an aid to enforcement or to compel
compliance, if it determines that its enforcement policy, in terms of
deterrence and securing compliance both present and future, is
adequately served by acceptance of the compromise amount.
Sec. 401.615 Payment of compromise amount.
(a) Time and manner of compromise. Payment by the debtor of the
amount that CMS has agreed to accept as a compromise in full settlement
of a claim must be made within the time and in the manner prescribed by
CMS. Accordingly, CMS will not settle a claim until the full payment of
the compromise amount has been made.
(b) Effect of failure to pay compromise amount. Failure of the
debtor to make payment, as provided by the compromise agreement,
reinstates the full amount of the claim, less any amounts paid prior to
the default.
(c) Prohibition against grace periods. CMS will not agree to
inclusion of a provision in an installment agreement that would permit
grace periods for
[[Page 22]]
payments that are late under the terms of the agreement.
Sec. 401.617 Suspension of collection action.
(a) General conditions. CMS may temporarily suspend collection
action on a claim if the following general conditions are met--
(1) Amount of future recovery. CMS determines that future collection
action may result in a recovery of an amount sufficient to justify
periodic review and action on the claim by CMS during the period of
suspension.
(2) Statute of limitations. CMS determines that--
(i) The applicable statute of limitations has been tolled, waived or
has started running anew; or
(ii) Future collections may be made by CMS through offset despite an
applicable statute of limitations.
(b) Basis for suspension. Bases on which CMS may suspend collection
action on a particular claim include the following--
(1) A debtor cannot be located; or
(2) A debtor--
(i) Owns no substantial equity in property;
(ii) Is unable to make payment on CMS's claim or is unable to effect
a compromise; and
(iii) Has future prospects that justify retention of the claim.
(c) Locating debtors. CMS will make every reasonable effort to
locate missing debtors sufficiently in advance of the bar of an
applicable statute of limitations to permit timely filing of a lawsuit
to recover the amount of the claim.
(d) Effect of suspension on liquidation of security. CMS will
liquidate security, obtained in partial recovery of a claim, despite a
decision under this section to suspend collection action against the
debtor for the remainder of the claim.
Sec. 401.621 Termination of collection action.
(a) General factors. After considering the bases for a decision to
terminate collection action under paragraph (b) of this section, CMS may
further consider factors such as--
(1) The age and health of the debtor if the debtor is an individual;
(2) Present and potential income of the debtor; and
(3) Whether assets have been concealed or improperly transferred by
the debtor.
(b) Basis for termination of collection action. Bases on which CMS
may terminate collection action on a claim include the following--
(1) Inability to collect a substantial amount of the claim. CMS may
terminate collection action if it determines that it is unable to
collect, or to enforce collection, of a significant amount of the claim.
In making this determination, CMS will consider factors such as--
(i) Judicial remedies available;
(ii) The debtor's future financial prospects; and
(iii) Exemptions available to the debtor under State or Federal law.
(2) Inability to locate debtor. In cases involving missing debtors,
CMS may terminate collection action if--
(i) There is no security remaining to be liquidated;
(ii) The applicable statute of limitations has run; or
(iii) The prospects of collecting by offset, whether or not an
applicable statute of limitations has run, are considered by CMS to be
too remote to justify retention of the claim.
(3) Cost of collection exceeds recovery. CMS may terminate
collection action if it determines that the cost of further collection
action will exceed the amount recoverable.
(4) Legal insufficiency. CMS may terminate collection action if it
determines that the claim is legally without merit.
(5) Evidence unavailable. CMS may terminate collection action if--
(i) Efforts to obtain voluntary payment are unsuccessful; and
(ii) Evidence or witnesses necessary to prove the claim are
unavailable.
Sec. 401.623 Joint and several liability.
(a) Collection action. CMS will liquidate claims as quickly as
possible. In cases of joint and several liability among two or more
debtors, CMS will not allocate the burden of claims payment among the
debtors. CMS will proceed with collection action against one
[[Page 23]]
debtor even if other liable debtors have not paid their proportionate
shares.
(b) Compromise. Compromise with one debtor does not release a claim
against remaining debtors. Furthermore, CMS will not consider the amount
of a compromise with one debtor to be a binding precedent concerning the
amounts due from other debtors who are jointly and severally liable on
the claim.
Sec. 401.625 Effect of CMS claims collection decisions on appeals.
Any action taken under this subpart regarding the compromise of a
claim, or suspension or termination of collection action on a claim, is
not an initial determination for purposes of CMS appeal procedures.
PART 402_CIVIL MONEY PENALTIES, ASSESSMENTS, AND EXCLUSIONS--Table of
Contents
Subpart A_General Provisions
Sec.
402.1 Basis and scope.
402.3 Definitions.
402.5 Right to a hearing before the final determination.
402.7 Notice of proposed determination.
402.9 Failure to request a hearing.
402.11 Notice to other agencies and other entities.
402.13 Penalty, assessment, and exclusion not exclusive.
402.15 Collateral estoppel.
402.17 Settlement.
402.19 Hearings and appeals.
402.21 Judicial review.
Subpart B_Civil Money Penalties and Assessments
402.105 Amount of penalty.
402.107 Amount of assessment.
402.109 Statistical sampling.
402.111 Factors considered determinations regarding the amount of
penalties and assessments.
402.113 When a penalty and assessment are collectible.
402.115 Collection of penalty or assessment.
Subpart C--Exclusions [Reserved]
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh).
Source: 63 FR 68690, Dec. 14, 1998, unless otherwise noted.
Subpart A_General Provisions
Sec. 402.1 Basis and scope.
(a) Basis. This part is based on the sections of the Act that are
specified in paragraph (c) of this section.
(b) Scope. This part--
(1) Provides for the imposition of civil money penalties,
assessments, and exclusions against persons that violate the provisions
of the Act specified in paragraph (c), (d), or (e) of this section; and
(2) Sets forth the appeal rights of persons subject to penalties,
assessments, or exclusion and the procedures for reinstatement following
exclusion.
(c) Civil money penalties. CMS or OIG may impose civil money
penalties against any person or other entity specified in paragraphs
(c)(1) through (c)(33) of this section under the identified section of
the Act. (The authorities that also permit imposition of an assessment
or exclusion are noted in the applicable paragraphs.)
(1) Sections 1833(h)(5)(D) and 1842(j)(2)--Any person that knowingly
and willfully, and on a repeated basis, bills for a clinical diagnostic
laboratory test, other than on an assignment-related basis. This
provision includes tests performed in a physician's office but excludes
tests performed in a rural health clinic. (This violation may also
include an assessment and cause exclusion.)
(2) Section 1833(i)(6)--Any person that knowingly and willfully
presents, or causes to be presented, a bill or request for payment for
an intraocular lens inserted during or after cataract surgery for which
the Medicare payment rate includes the cost of acquiring the class of
lens involved.
(3) Section 1833(q)(2)(B)--Any entity that knowingly and willfully
fails to provide information about a referring physician, including the
physician's name and unique physician identification number for the
referring physician, when seeking payment on an unassigned basis. (This
violation, if it occurs in repeated cases, may also cause an exclusion.)
(4) Sections 1834(a)(11)(A) and 1842(j)(2)--Any durable medical
equipment supplier that knowingly and willfully charges for a covered
service that
[[Page 24]]
is furnished on a rental basis after the rental payments may no longer
be made (except for maintenance and servicing) as provided in section
1834(a)(7)(A). (This violation may also include an assessment and cause
exclusion.)
(5) Sections 1834(a)(18)(B) and 1842(j)(2)--Any nonparticipating
durable medical equipment supplier that knowingly and willfully, in
violation of section 1834(a)(18)(A), fails to make a refund to Medicare
beneficiaries for a covered service for which payment is precluded due
to an unsolicited telephone contact from the supplier. (This violation
may also include an assessment and cause exclusion.)
(6) Sections 1834(b)(5)(C) and 1842(j)(2)--Any nonparticipating
physician or supplier that knowingly and willfully charges a Medicare
beneficiary more than the limiting charge, as specified in section
1834(b)(5)(B), for radiologist services. (This violation may also
include an assessment and cause exclusion.)
(7) Sections 1834(c)(4)(C) and 1842(j)(2)--Any nonparticipating
physician or supplier that knowingly and willfully charges a Medicare
beneficiary more than the limiting charge, as specified in section
1834(c)(4)(B), for mammography screening. (This violation may also
include an assessment and cause exclusion.)
(8) Sections 1834(h)(3) and 1842(j)(2)--Any supplier of prosthetic
devices, orthotics, and prosthetics that knowingly and willfully charges
for a covered prosthetic device, orthotic, or prosthetic that is
furnished on a rental basis after the rental payment may no longer be
made (except for maintenance and servicing). (This violation may also
include an assessment and cause exclusion.)
(9) Section 1834(j)(2)(A)(iii)--Any supplier of durable medical
equipment, including a supplier of prosthetic devices, prosthetics,
orthotics, or supplies, that knowingly and willfully distributes a
certificate of medical necessity in violation of section
1834(j)(2)(A)(i) or fails to provide the information required under
section 1834(j)(2)(A)(ii).
(10) Sections 1834(j)(4) and 1842(j)(2)--
(i) Any supplier of durable medical equipment, including a supplier
of prosthetic devices, prosthetics, orthotics, or supplies, that
knowingly and willfully fails to make refunds in a timely manner to
Medicare beneficiaries for services billed other than on an assignment-
related basis if--
(A) The supplier does not possess a Medicare supplier number;
(B) The service is denied in advance under section 1834(a)(15); or
(C) The service is determined not to be medically necessary or
reasonable.
(ii) These violations may also include an assessment and cause
exclusion.
(11) Sections 1842(b)(18)(B) and 1842(j)(2)--Any practitioner
specified in section 1842(b)(18)(C) (physician assistants, nurse
practitioners, clinical nurse specialists, certified registered nurse
anesthetists, certified nurse-midwives, clinical social workers, and
clinical psychologists) or other person that knowingly and willfully
bills or collects for any services by the practitioners on other than an
assignment-related basis. (This violation may also include an assessment
and cause exclusion.)
(12) Sections 1842(k) and 1842(j)(2)--Any physician who knowingly
and willfully presents, or causes to be presented, a claim or bill for
an assistant at cataract surgery performed on or after March 1, 1987 for
which payment may not be made because of section 1862(a)(15). (This
violation may also include an assessment and cause exclusion.)
(13) Sections 1842(l)(3) and 1842(j)(2)--Any nonparticipating
physician who does not accept payment on an assignment-related basis and
who knowingly and willfully fails to refund on a timely basis any
amounts collected for services that are not reasonable or medically
necessary or are of poor quality, in accordance with section
1842(l)(1)(A). (This violation may also include an assessment and cause
exclusion.)
(14) Sections 1842(m)(3) and 1842(j)(2)--(i) Any nonparticipating
physician, who does not accept payment for an elective surgical
procedure on an assignment-related basis and whose charge is at least
$500, who knowingly and willfully fails to--
[[Page 25]]
(A) Disclose the information required by section 1842(m)(1)
concerning charges and coinsurance amounts; and
(B) Refund on a timely basis any amount collected for the procedure
in excess of the charges recognized and approved by the Medicare
program.
(ii) This violation may also include an assessment and cause
exclusion.
(15) Sections 1842(n)(3) and 1842(j)(2)--Any physician who knowingly
and willfully, in repeated cases, bills one or more beneficiaries, for
purchased diagnostic tests, any amount other than the payment amount
specified in section 1842(n)(1)(A) or section 1842(n)(1)(B). (This
violation may also include an assessment and cause exclusion.)
(16) Section 1842(p)(3)(A)--Any physician or practitioner who
knowingly and willfully fails promptly to provide the appropriate
diagnosis code or codes upon request by CMS or a carrier on any request
for payment or bill not submitted on an assignment-related basis for any
service furnished by the physician. (This violation, if it occurs in
repeated cases, may also cause exclusion.)
(17) Sections 1848(g)(1)(B) and 1842(j)(2)--
(i) Any nonparticipating physician, supplier, or other person that
furnishes physicians' services and does not accept payment on an
assignment-related basis, that--
(A) Knowingly and willfully bills or collects in excess of the
limiting charge (as defined in section 1848(g)(2)) on a repeated basis;
or
(B) Fails to make an adjustment or refund on a timely basis as
required by section 1848(g)(1)(A)(iii) or (iv).
(ii) These violations may also include an assessment and cause
exclusion.
(18) Section 1848(g)(3)(B) and 1842(j)(2)--Any person that knowingly
and willfully bills for State plan approved physicians' services, as
defined in section 1848(j)(3), on other than an assignment-related basis
for a Medicare beneficiary who is also eligible for Medicaid (these
individuals include qualified Medicare beneficiaries). This provision
applies to services furnished on or after April 1, 1990. (This violation
may also include an assessment and cause exclusion.)
(19) Section 1848(g)(4)(B)(ii), 1842(p)(3), and 1842(j)(2)(A)--
(i) Any physician, supplier, or other person (except any person that
has been excluded from the Medicare program) that, for services
furnished after September 1, 1990, knowingly and willfully--
(A) Fails to submit a claim on a standard claim form for services
provided for which payment is made under Part B on a reasonable charge
or fee schedule basis; or
(B) Imposes a charge for completing and submitting the standard
claims form.
(ii) These violations, if they occur in repeated cases, may also
cause exclusion.
(20) Section 1862(b)(5)(C)--Any employer (other than a Federal or
other governmental agency) that, before October 1, 1998, willfully or
repeatedly fails to provide timely and accurate information requested
relating to an employee's group health insurance coverage.
(21) Section 1862(b)(6)(B)--Any entity that knowingly, willfully,
and repeatedly--
(i) Fails to complete a claim form relating to the availability of
other health benefit plans in accordance with section 1862(b)(6)(A); or
(ii) Provides inaccurate information relating to the availability of
other health benefit plans on the claim form.
(22) Section 1877(g)(5)--Any person that fails to report information
required by HHS under section 1877(f) concerning ownership, investment,
and compensation arrangements. (This violation may also include an
assessment and cause exclusion.)
(23) Sections 1879(h), 1834(a)(18), and 1842(j)(2)--
(i) Any durable medical equipment supplier, including a supplier of
prosthetic devices, prosthetics, orthotics, or supplies, that knowingly
and willfully fails to make refunds in a timely manner to Medicare
beneficiaries for services billed on an assignment-related basis if--
(A) The supplier did not possess a Medicare supplier number;
(B) The service is denied in advance under section 1834(a)(15) of
the Act; or
[[Page 26]]
(C) The service is determined not to be payable under section
1834(a)(17)(b) because of unsolicited telephone contacts.
(ii) These violations may also include an assessment and cause
exclusion.
(24) Section 1882(a)(2)--Any person that issues a Medicare
supplemental policy that has not been approved by the State regulatory
program or does not meet Federal standards on and after the effective
date in section 1882(p)(1)(C). (This violation may also include an
assessment and cause exclusion.)
(25) Section 1882(p)(8)--Any person that sells or issues Medicare
supplemental policies, on or after July 30, 1992, that fail to conform
to the NAIC or Federal standards established under section 1882(p).
(This violation may also include an assessment and cause exclusion.)
(26) Section 1882(p)(9)(C)--
(i) Any person that sells a Medicare supplemental policy and--
(A) Fails to make available for sale the core group of basic
benefits when selling other Medicare supplemental policies with
additional benefits; or
(B) Fails to provide the individual, before the sale of the policy,
an outline of coverage describing the benefits provided by the policy.
(ii) These violations may also include an assessment and cause
exclusion.
(27) Section 1882(q)(5)(C)--
(i) Any person that fails to--
(A) Suspend a Medicare supplemental policy at the policyholder's
request, if the policyholder applies for and is determined eligible for
medical assistance, and the policyholder provides notice within 90 days
of the eligibility determination; or
(B) Automatically reinstate the policy as of the date of termination
of medical assistance if the policyholder loses eligibility for medical
assistance and the policyholder provides notice within 90 days of loss
of eligibility.
(ii) These violations may also include an assessment and cause
exclusion.
(28) Section 1882(r)(6)(A)--Any person that fails to provide refunds
or credits as required by section 1882(r)(1)(B). (This violation may
also include an assessment and cause exclusion.)
(29) Section 1882(s)(4)--
(i) Any issuer of a Medicare supplemental policy that--
(A) Does not waive any time periods applicable to preexisting
conditions, waiting periods, elimination periods, or probationary
periods if the time periods were already satisfied under a preceding
Medicare supplemental policy; or
(B) Denies a policy, conditions the issuance or effectiveness of the
policy, or discriminates in the pricing of the policy based on health
status or other criteria as specified in section 1882(s)(2)(A).
(ii) These violations may also include an assessment and cause
exclusion.
(30) Section 1882(t)(2)--
(i) Any issuer of a Medicare supplemental policy that--
(A) Fails substantially to provide medically necessary services to
enrollees seeking the services through the issuer's network of entities;
(B) Imposes premiums on enrollees in excess of the premiums approved
by the State;
(C) Acts to expel an enrollee for reasons other than nonpayment of
premiums; or
(D) Does not provide each enrollee at the time of enrollment with
the specific information provided in section 1882(t)(1)(E)(i) or fails
to obtain a written acknowledgment from the enrollee of receipt of the
information (as required by section 1882(t)(1)(E)(ii)).
(ii) These violations may also include an assessment and cause
exclusion.
(31) Sections 1834(k)(6) and 1842(j)(2)--Any person or entity who
knowingly and willfully bills or collects for any outpatient therapy
services or comprehensive outpatient rehabilitation services on other
than an assignment-related basis. (This violation may also include an
assessment and cause exclusion.)
(32) Sections 1834(l)(6) and 1842(j)(2)--Any supplier of ambulance
services who knowingly and willfully bills or collects for any services
on other than an assignment-related basis. (This violation may also
include an assessment and cause exclusion.)
(33) Section 1806(b)(2)(B)--Any person who knowingly and willfully
fails to furnish a beneficiary with an itemized
[[Page 27]]
statement of items or services within 30 days of the beneficiary's
request.
(d) Assessments. CMS or OIG may impose assessments in addition to
civil money penalties for violations of the following statutory
sections:
(1) Section 1833: Paragraph (h)(5)(D).
(2) Section 1834: Paragraphs (a)(11)(A), (a)(18)(B), (b)(5)(C),
(c)(4)(C), (h)(3), (j)(4), (k)(6), and (l)(6).
(3) Section 1842: Paragraphs (k), (l)(3), (m)(3), and (n)(3).
(4) Section 1848: Paragraph (g)(1)(B).
(5) Section 1877: Paragraph (g)(5).
(6) Section 1879: Paragraph (h).
(7) Section 1882: Paragraphs (a)(2), (p)(8), (p)(9)(C), (q)(5)(C),
(r)(6)(A), (s)(3), and (t)(2).
(e) Exclusions. (1) CMS or OIG may exclude any person from
participation in the Medicare program on the basis of any of the
following violations of the statute:
(i) Section 1833: Paragraphs (h)(5)(D) and, in repeated cases,
(q)(2)(B).
(ii) Section 1834: Paragraphs (a)(11)(A), (a)(18)(B), (b)(5)(C),
(c)(4)(C), (h)(3), (j)(4), (k)(6), and (l)(6).
(iii) Section 1842: Paragraphs (b)(18)(B), (k), (l)(3), (m)(3),
(n)(3), and, in repeated cases, (p)(3)(B).
(iv) Section 1848: Paragraphs (g)(1)(B), (g)(3)(B), and, in repeated
cases, (g)(4)(B)(ii).
(v) Section 1877: Paragraph (g)(5).
(vi) Section 1879: Paragraph (h).
(vii) Section 1882: Paragraphs (a)(2), (p)(8), (p)(9)(C), (q)(5)(C),
(r)(6)(A), (s)(4), and (t)(2).
(2) CMS or OIG must exclude from participation in the Medicare
program any of the following, under the identified section of the Act:
(i) Section 1834(a)(17)(C)--Any supplier of durable medical
equipment and supplies that are covered under section 1834(a)(13) that
knowingly contacts Medicare beneficiaries by telephone regarding the
furnishing of covered services in violation of section 1834(a)(17)(A)
and whose conduct establishes a pattern of prohibited contacts as
described under section 1834(a)(17)(A).
(ii) Section 1834(h)(3)--Any supplier of prosthetic devices,
orthotics, and prosthetics that knowingly contacts Medicare
beneficiaries by telephone regarding the furnishing of prosthetic
devices, orthotics, or prosthetics in the same manner as in the
violation under section 1834(a)(17)(A) and whose conduct establishes a
pattern of prohibited contacts in the same manner as described in
section 1834(a)(17)(C).
(f) Responsible persons. (1) If CMS or OIG determines that more than
one person is responsible for any of the violations described in
paragraph (c) or paragraph (d) of this section, it may impose a civil
money penalty or a civil money penalty and assessment against any one of
those persons or jointly and severally against two or more of those
persons. However, the aggregate amount of the assessments collected may
not exceed the amount that could be assessed if only one person were
responsible.
(2) A principal is liable for penalties and assessments for the
actions of his or her agent acting within the scope of the agency.
(g) Time limits. Neither CMS nor OIG initiates an action to impose a
civil money penalty, assessment, or proceeding to exclude a person from
participation in the Medicare program unless it begins the action within
6 years from the date on which the claim was presented, the request for
payment was made, or the incident occurred.
[63 FR 68690, Dec. 14, 1998, as amended at 66 FR 49546, Sept. 28, 2001]
Sec. 402.3 Definitions.
For purposes of this part:
Assessment means the amount described in Sec. 402.107 and includes
the plural of that term.
Assignment-related basis means that the claim submitted by a
physician, supplier or other person is paid on the basis of an
assignment, whereby the physician, supplier or other person agrees to
accept the Medicare payment as payment in full for the services
furnished to the beneficiary and is precluded from charging the
beneficiary more than the deductible and coinsurance based upon the
approved Medicare fee amount. Additional obligations, including
obligations to make refunds in certain circumstances, are established at
section 1842(b)(3) of the Act.
Claim means an application for payment for a service for which the
Medicare or Medicaid program may pay.
[[Page 28]]
Covered means that a service is described as reasonable and
necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member. A service is not
covered if it is specifically identified as excluded from Medicare Part
B coverage or is not a defined Medicare Part B benefit.
Exclusion means the temporary or permanent barring of a person or
other entity from participation in the Medicare or State health care
program and that services furnished or ordered by that person are not
paid for under either program.
General Counsel means the General Counsel of HHS or his or her
designees.
Knowingly or knowingly and willfully means that a person, with
respect to information--
(1) Has actual knowledge of the information;
(2) Acts in deliberate ignorance of the truth or falsity of the
information; or
(3) Acts in reckless disregard of the truth or falsity of the
information; and
(4) No proof of specific intent is required.
Medicare supplemental policy means a policy guaranteeing that a
health plan will pay a policyholder's coinsurance and deductible and
will cover other limitations on payment imposed under title XVIII of the
Act and will provide additional health plan or non-Medicare coverage for
services up to a predefined benefit limit.
NAIC stands for the National Association of Insurance Commissioners.
Nonparticipating describes a physician, supplier, or other person
(excluding any provider of services) that, at the time of furnishing the
services to Medicare Part B beneficiaries, is not a participating
physician or supplier.
Participating describes a physician or supplier (excluding any
provider of services) that, before the beginning of any given year,
enters into an agreement with HHS that provides that the physician or
supplier will accept payment under the Medicare program on an
assignment-related basis for all services furnished to Medicare Part B
beneficiaries.
Penalty means the amount described in Sec. 402.105 and includes the
plural of that term.
Person means an individual, trust or estate, partnership,
corporation, professional association or corporation, or other entity,
public or private.
Physicians' services means the following Medicare covered
professional services:
(1) Surgery, consultation, home, office and institutional calls, and
other professional services performed by physicians.
(2) Services and supplies furnished ``incident to'' a physician's
professional services.
(3) Outpatient physical and occupational therapy services.
(4) Diagnostic x-ray tests and other diagnostic tests (excluding
clinical diagnostic laboratory tests).
(5) X-ray, radium, and radioactive isotope therapy, including
materials and services of technicians.
(6) Antigens prepared by a physician.
Radiologist service means radiology services performed only by, or
under the direction of, a physician who is certified, or eligible to be
certified, by the American Board of Radiology or for whom radiology
services account for at least 50 percent of the total amount of charges
made under part B of title XVIII of the Act.
Request for payment means an application submitted by a person to
any person for payment for a service.
Respondent means the person upon which CMS or OIG has imposed, or
proposes to impose, a civil money penalty, assessment, or exclusion.
Service includes--
(1) Any item, device, medical supply, or service claimed to have
been furnished to a patient and listed in an itemized claim for program
payment; or
(2) In the case of a claim based on costs, any entry or omission in
a cost report, books of account or other documents supporting the claim.
State includes the District of Columbia, Puerto Rico, the Virgin
Islands, Guam, American Samoa, the Northern Mariana Islands, and the
Trust Territory of the Pacific Islands.
Timely basis means that the adjustment to a bill or a refund is
considered ``on a timely basis'' if the physician, supplier, or other
person makes the adjustment or refund to the appropriate
[[Page 29]]
party no later than 30 days after the date the physician, supplier, or
other person is notified by the Medicare Part B contractor of the
violation and the requirement to refund any excess collections.
Sec. 402.5 Right to a hearing before the final determination.
CMS or OIG does not make a determination adverse to any person under
this part until the person has been given a written notice and
opportunity for the determination to be made on the record after a
hearing at which the person is entitled to be represented by counsel, to
present witnesses, and to cross-examine witnesses against the person.
Sec. 402.7 Notice of proposed determination.
(a) If CMS or OIG proposes a penalty and, as applicable, an
assessment, or proposes to exclude a respondent from participation in
Medicare in accordance with this part, it sends the respondent written
notice of its intent by certified mail, return receipt requested. The
notice includes the following information:
(1) Reference to the statutory basis or bases for the penalty,
assessment, exclusion, or any combination, as applicable.
(2)(i) A description of the claims, requests for payment, or
incidents with respect to which the penalty, assessment, and exclusion
are proposed; or
(ii) If CMS or OIG is relying upon statistical sampling to project
the number and types of claims or requests for payment and the dollar
amount, a description of the claims and requests for payment comprising
the sample and a brief description of the statistical sampling technique
CMS or OIG used.
(3) The reason why the claims, requests for payment, or incidents
are subject to a penalty and assessment.
(4) The amount of the proposed penalty and of any proposed
assessment.
(5) Any mitigating or aggravating circumstances that CMS or OIG
considered when it determined the amount of the proposed penalty and any
applicable assessment.
(6) Information concerning response to the notice, including--
(i) A specific statement of the respondent's right to a hearing; and
(ii) A statement that failure to request a hearing within 60 days
renders the proposed determination final and permits the imposition of
the proposed penalty and any assessment.
(iii) A statement that the debt may be collected through an
administrative offset.
(7) In the case of a respondent that has an agreement under section
1866 of the Act, notice that imposition of an exclusion may result in
termination of the provider's agreement in accordance with section
1866(b)(2)(C) of the Act.
Sec. 402.9 Failure to request a hearing.
(a) If the respondent does not request a hearing within 60 days of
receipt of the notice of proposed determination specified in Sec.
402.7, any civil money penalty, assessment, or exclusion becomes final
and CMS or OIG may impose the proposed penalty, assessment, or
exclusion, or any less severe penalty, assessment, or suspension.
(b) CMS or OIG notifies the respondent by certified mail, return
receipt requested, of any penalty, assessment, or exclusion that has
been imposed and of the means by which the respondent may satisfy the
judgment.
(c) The respondent has no right to appeal a penalty, assessment, or
exclusion for which he or she has not requested a hearing.
Sec. 402.11 Notice to other agencies and other entities.
(a) Whenever a penalty, assessment, or exclusion becomes final, CMS
or OIG notifies the following organizations and entities about the
action and the reasons for it:
(1) The appropriate State or local medical or professional
association.
(2) The appropriate quality improvement organization.
(3) As appropriate, the State agency responsible for the
administration of each State health care program (Medicaid, the Maternal
and Child Health Services Block Grant Program, and the Social Services
Block Grant Program).
(4) The appropriate Medicare carrier or fiscal intermediary.
[[Page 30]]
(5) The appropriate State or local licensing agency or organization
(including the Medicare and Medicaid State survey agencies).
(6) The long-term care ombudsman.
(b) For exclusions, CMS or OIG also notifies the public and
specifies the effective date.
Sec. 402.13 Penalty, assessment, and exclusion not exclusive.
Penalties, assessments, and exclusions imposed under this part are
in addition to any other penalties prescribed by law.
Sec. 402.15 Collateral estoppel.
(a) When a final determination that the respondent presented or
caused to be presented a claim or request for payment falling within the
scope of Sec. 402.1 has been rendered in any proceeding in which the
respondent was a party and had an opportunity to be heard, the
respondent is bound by that determination in any proceeding under this
part.
(b) A person who has been convicted (whether upon a verdict after
trial or upon a plea of guilty or nolo contendere) of a Federal crime
charging fraud or false statements is barred from denying the essential
elements of the criminal offense if the proceedings under this part
involve the same transactions.
Sec. 402.17 Settlement.
CMS or OIG has exclusive authority to settle any issues or case,
without the consent of the ALJ or the Secretary, at any time before a
final decision by the Secretary. Thereafter, the General Counsel has the
exclusive authority.
Sec. 402.19 Hearings and appeals.
The hearings and appeals procedures set forth in part 1005 of
chapter V of this title are available to any person that receives an
adverse determination under this part. For an appeal of a civil money
penalty, assessment, or exclusion imposed under this part, either CMS or
OIG may represent the government in the hearing and appeals process.
Sec. 402.21 Judicial review.
After exhausting all available administrative remedies, a respondent
may seek judicial review of a penalty, assessment, or exclusion that has
become final. The respondent may seek review only with respect to a
penalty, assessment, or exclusion with respect to which the respondent
filed an exception under Sec. 1005.21(c) of this title unless the court
excuses the failure or neglect to urge the exception in accordance with
section 1128A(e) of the Act because of extraordinary circumstances.
Subpart B_Civil Money Penalties and Assessments
Sec. 402.105 Amount of penalty.
(a) $2,000. Except as provided in paragraphs (b) through (g) of this
section, CMS or OIG may impose a penalty of not more than $2,000 for
each service, bill, or refusal to issue a timely refund that is subject
to a determination under this part and for each incident involving the
knowing, willful, and repeated failure of an entity furnishing a service
to submit a properly completed claim form or to include on the claim
form accurate information regarding the availability of other health
insurance benefit plans (Sec. 402.1(c)(21)).
(b) $1,000. CMS or OIG may impose a penalty of not more than $1,000
for the following:
(1) Per certificate of medical necessity knowingly and willfully
distributed to physicians on or after December 31, 1994 that--
(i) Contains information concerning the medical condition of the
patient; or
(ii) Fails to include cost information.
(2) Per individual about whom information is requested, for willful
or repeated failure of an employer to respond to an intermediary or
carrier about coverage of an employee or spouse under the employer's
group health plan (Sec. 402.1(c)(20)).
(c) $5,000. CMS or OIG may impose a penalty of not more than $5,000
for each violation resulting from the following:
(1) The failure of a Medicare supplemental policy issuer, on a
replacement
[[Page 31]]
policy, to waive any time periods applicable to pre-existing conditions,
waiting periods, elimination periods, or probationary periods that were
satisfied under a preceding policy (Sec. 402.1(c)(29)); and
(2) Any issuer of any Medicare supplemental policy denying a policy,
conditioning the issuance or effectiveness of the policy, or
discriminating in the pricing of the policy based on health status or
other criteria as specified in section 1882(s)(2)(A). (Sec.
402.1(c)(29)).
(d) $10,000. (1) CMS or OIG may impose a penalty of not more than
$10,000 for each day that reporting entity ownership arrangements is
late (Sec. 402.1(c)(22)).
(2) CMS or OIG may impose a penalty of not more than $10,000 for the
following violations that occur on or after January 1, 1997:
(i) Knowingly and willfully, and on a repeated basis, billing for a
clinical diagnostic laboratory test, other than on an assignment-related
basis (Sec. 402.1(c)(1)).
(ii) By any durable medical equipment supplier, knowingly and
willfully charging for a covered service that is furnished on a rental
basis after the rental payments may no longer be made (except for
maintenance and servicing) as provided in section 1834(a)(7)(A) (Sec.
402.1(c)(4)).
(iii) By any durable medical equipment supplier, knowingly and
willfully, in violation of section 1834(a)(18)(A), failing to make a
refund to Medicare beneficiaries for a covered service for which payment
is precluded due to an unsolicited telephone contact from the supplier
(Sec. 402.1(c)(5)).
(iv) By any nonparticipating physician or supplier, knowingly and
willfully charging a Medicare beneficiary more than the limiting charge,
as specified in section 1834(b)(5)(B), for radiologist services (Sec.
402.1(c)(6)).
(v) By any nonparticipating physician or supplier, knowingly and
willfully charging a Medicare beneficiary more than the limiting charge,
as specified in section 1834(c)(3), for mammography screening (Sec.
402.1(c)(7)).
(vi) By any supplier of prosthetic devices, orthotics, and
prosthetics, knowingly and willfully charging for a covered prosthetic
device, orthotic, or prosthetic that is furnished on a rental basis
after the rental payment may no longer be made (except for maintenance
and servicing) (Sec. 401.2(c)(8)).
(vii) By any supplier of durable medical equipment, including a
supplier of prosthetic devices, prosthetics, orthotics, or supplies,
knowingly and willfully failing to make refunds in a timely manner to
Medicare beneficiaries for services billed other than on an assigned-
related basis if--
(A) The supplier does not possess a Medicare supplier number;
(B) The service is denied in advance; or
(C) The service is determined not to be medically necessary or
reasonable (Sec. 402.1(c)(10)).
(viii) Knowingly and willfully billing or collecting for any
services on other than an assignment-related basis for practitioners
specified in section 1842(b)(18)(B) (Sec. 402.1(c)(11)).
(xix) By any physician, knowingly and willfully presenting, or
causing to be presented, a claim or bill for an assistant at cataract
surgery performed on or after March 1, 1987 for which payment may not be
made because of section 1862(a)(15) (Sec. 402.1(c)(12)).
(x) By any nonparticipating physician who does not accept payment on
an assignment-related basis, knowingly and willfully failing to refund
on a timely basis any amounts collected for services that are not
reasonable or medically necessary or are of poor quality, in accordance
with section 1842(l)(1)(A) (Sec. 402.1(c)(13)).
(xi) By any nonparticipating physician, who does not accept payment
for an elective surgical procedure on an assignment-related basis and
whose charge is at least $500, knowingly and willfully failing to--
(A) Disclose the information required by section 1842(m)(1)
concerning charges and coinsurance amounts; and
(B) Refund on a timely basis any amount collected for the procedure
in excess of the charges recognized and approved by the Medicare program
(Sec. 402.1(c)(14)).
(xii) By any physician, in repeated cases, knowingly and willfully
billing one or more beneficiaries, for purchased diagnostic tests, any
amount
[[Page 32]]
other than the payment amount specified in section 1842(n)(1)(A) or
section 1842(n)(1)(B) (Sec. 402.1(c)(15)).
(xiii) By any nonparticipating physician, supplier, or other person
that furnishes physicians' services and does not accept payment on an
assignment-related basis--
(A) Knowingly and willfully billing or collecting in excess of the
limiting charge (as defined in section 1843(g)(2)) on a repeated basis;
or
(B) Failing to make an adjustment or refund on a timely basis as
required by section 1848(g)(1)(A)(iii) or (iv) (Sec. 402.1(c)(17)).
(xiv) Knowingly and willfully billing for State plan approved
physicians' services on other than an assignment-related basis for a
Medicare beneficiary who is also eligible for Medicaid (Sec.
402.1(c)(18)).
(xv) By any supplier of durable medical equipment, including a
supplier of prosthetic devices, prosthetics, orthotics, or supplies,
knowingly and willfully failing to make refunds in a timely manner to
Medicare beneficiaries for services billed on an assignment-related
basis if--
(A) The supplier did not possess a Medicare supplier number;
(B) The service is denied in advance; or
(C) The service is determined not to be medically necessary or
reasonable (Sec. 402.1(c)(23)).
(3) CMS or OIG may impose a penalty of not more than $10,000 for
each violation, if a person or entity knowingly and willfully bills or
collects for outpatient therapy or comprehensive rehabilitation services
other than on an assignment-related basis.
(4) CMS or OIG may impose a penalty of not more than $10,000 for
each violation, if a person or entity knowingly and willfully bills or
collects for outpatient ambulance services other than on an assignment-
related basis.
(e) $15,000. CMS or OIG may impose a penalty of not more than
$15,000 if the seller of a Medicare supplemental policy is not the
issuer, for each violation described in paragraphs (f)(2) and (f)(3) of
this section (Sec. 402.1 (c)(25) and (c)(26)).
(f) $25,000. CMS or OIG may impose a penalty of not more than
$25,000 for each of the following violations:
(1) Issuance of a Medicare supplemental policy that has not been
approved by an approved State regulatory program or does not meet
Federal standards on and after the effective date in section
1882(p)(1)(C) of the Act (Sec. 402.1(c)(23)).
(2) Sale or issuance after July 30, 1992, of a Medicare supplemental
policy that fails to conform with the NAIC or Federal standards
established under section 1882(p) of the Act (Sec. 402.1(c)(25)).
(3) Failure to make the core group of basic benefits available for
sale when selling other Medicare supplemental plans with additional
benefits (Sec. 402.1(c)(26)).
(4) Failure to provide, before sale of a Medicare supplemental
policy, an outline of coverage describing the benefits provided by the
policy (Sec. 402.1(c)(26)).
(5) Failure of an issuer of a policy to suspend or reinstate a
policy, based on the policy holder's request, during entitlement to or
upon loss of eligibility for medical assistance (Sec. 402.1(c)(27)).
(6) Failure to provide refunds or credits for Medicare supplemental
policies as required by section 1882(r)(1)(B) (Sec. 402.1(c)(28)).
(7) By an issuer of a Medicare supplemental policy--
(i) Substantial failure to provide medically necessary services to
enrollees seeking the services through the issuer's network of entities;
(ii) Imposition of premiums on enrollees in excess of the premiums
approved by the State;
(iii) Action to expel an enrollee for reasons other than nonpayment
of premiums; or
(iv) Failure to provide each enrollee, at the time of enrollment,
with the specific information provided in section 1882(t)(1)(E)(i) or
failure to obtain a written acknowledgment from the enrollee of receipt
of the information (as required by section 1882(t)(1)(E)(ii)) (section
1882(t)(2)).
(g) $100. CMS or OIG may impose a penalty of not more than $100 for
each violation if the person or entity does not furnish an itemized
statement to a
[[Page 33]]
Medicare beneficiary within 30 days of the beneficiary's request.
[63 FR 68690, Dec. 14, 1998, as amended at 66 FR 49546, Sept. 28, 2001]
Sec. 402.107 Amount of assessment.
A person subject to civil money penalties specified in Sec.
402.1(c) may be subject, in addition, to an assessment. An assessment is
a monetary payment in lieu of damages sustained by HHS or a State
agency.
(a) The assessment may not be more than twice the amount claimed for
each service that was a basis for the civil money penalty, except for
the violations specified in paragraph (b) of this section that occur
before January 1, 1997.
(b) For the violations specified in this paragraph occurring after
January 1, 1997, the assessment may not be more than three times the
amount claimed for each service that was the basis for a civil money
penalty. The violations are the following:
(1) Knowingly and willfully billing, and on a repeated basis, for a
clinical diagnostic laboratory test, other than on an assignment-related
basis (Sec. 402.1(c)(1)).
(2) By any durable medical equipment supplier, knowingly and
willfully charging for a covered service that is furnished on a rental
basis after the rental payments may no longer be made (except for
maintenance and servicing) as provided in section 1834(a)(7)(A) (Sec.
402.1(c)(4)).
(3) By any durable medical equipment supplier, knowingly and
willfully failing, in violation of section 1834(a)(18)(A), to make a
refund to Medicare beneficiaries for a covered service for which payment
is precluded due to an unsolicited telephone contact from the supplier
(Sec. 402.1(c)(5)).
(4) By any nonparticipating physician or supplier, knowingly and
willfully charging a Medicare beneficiary more than the limiting charge,
as specified in section 1834(b)(5)(B), for radiologist services (Sec.
402.1(c)(6)).
(5) By any nonparticipating physician or supplier, knowingly and
willfully charging a Medicare beneficiary more than the limiting charge
as specified in section 1834(c)(3), for mammography screening (Sec.
402.1(c)(7)).
(6) By any supplier of prosthetic devices, orthotics, and
prosthetics, knowingly and willfully charging for a covered prosthetic
device, orthotic, or prosthetic that is furnished on a rental basis
after the rental payment may no longer be made (except for maintenance
and servicing) (Sec. 401.2(c)(8)).
(7) By any supplier of durable medical equipment, including a
supplier of prosthetic devices, prosthetics, orthotics, or supplies,
knowingly and willfully failing to make refunds in a timely manner to
Medicare beneficiaries for services billed other than on an assignment-
related basis if--
(i) The supplier does not possess a Medicare supplier number;
(ii) The service is denied in advance; or
(iii) The service is determined not to be medically necessary or
reasonable (Sec. 402.1(c)(10)).
(8) Knowingly and willfully billing or collecting for any services
on other than an assignment-related basis for a person or entity
specified in sections 1834(k)(6), 1834(l)(6), or 1842(b)(18)(B) (Sec.
402.1(c)(11), (c)(31), or (c)(32)).
(9) By any physician, knowingly and willfully presenting, or causing
to be presented, a claim or bill for an assistant at cataract surgery
performed on or after March 1, 1987 for which payment may not be made
because of section 1862(a)(15) (Sec. 402.1(c)(12)).
(10) By any nonparticipating physician who does not accept payment
on an assignment-related basis, knowingly and willfully failing to
refund on a timely basis any amounts collected for services that are not
reasonable or medically necessary or are of poor quality, in accordance
with section 1842(l)(1)(A) (Sec. 402.1(c)(13)).
(11) By any nonparticipating physician, who does not accept payment
for an elective surgical procedure on an assignment-related basis and
whose charge is at least $500, knowingly and willfully failing to--
(i) Disclose the information required by section 1842(m)(1)
concerning charges and coinsurance amounts; and
(ii) Refund on a timely basis any amount collected for the procedure
in excess of the charges recognized and approved by the Medicare program
(Sec. 402.1(c)(14)).
[[Page 34]]
(12) By any physician, in repeated cases, knowingly and willfully
billing one or more beneficiaries, for purchased diagnostic tests, any
amount other than the payment amount specified in section 1842(n)(1)(A)
or section 1842(n)(1)(B) (Sec. 402.1(c)(15)).
(13) By any nonparticipating physician, supplier, or other person
that furnishes physicians' services and does not accept payment on an
assignment-related basis--
(i) Knowingly and willfully billing or collecting in excess of the
limiting charge (as defined in section 1843(g)(2)) on a repeated basis;
or
(ii) Failing to make an adjustment or refund on a timely basis as
required by section 1848(g)(1)(A) (iii) or (iv) (Sec. 402.1(c)(17)).
(14) Knowingly and willfully billing for State plan approved
physicians' services on other than an assignment-related basis for a
Medicare beneficiary who is also eligible for Medicaid (Sec.
402.1(c)(18)).
(15) By any supplier of durable medical equipment, including
suppliers of prosthetic devices, prosthetics, orthotics, or supplies,
knowingly and willfully failing to make refunds in a timely manner to
Medicare beneficiaries for services billed on an assignment-related
basis if--
(i) The supplier did not possess a Medicare supplier number;
(ii) The service is denied in advance; or
(iii) The service is determined not to be medically necessary or
reasonable (Sec. 402.1(c)(23)).
[63 FR 68690, Dec. 14, 1998, as amended at 66 FR 49546, Sept. 28, 2001]
Sec. 402.109 Statistical sampling.
(a) Purpose. CMS or OIG may introduce the results of a statistical
sampling study to show the number and amount of claims subject to
sanction under this part that the respondent presented or caused to be
presented.
(b) Prima facie evidence. The results of the statistical sampling
study, if based upon an appropriate sampling and computed by valid
statistical methods, constitute prima facie evidence of the number and
amount of claims or requests for payment subject to sanction under Sec.
402.1.
(c) Burden of proof. Once CMS or OIG has made a prima facie case,
the burden is on the respondent to produce evidence reasonably
calculated to rebut the findings of the statistical sampling study. CMS
or OIG then has the opportunity to rebut this evidence.
Sec. 402.111 Factors considered in determinations regarding the amount
of penalties and assessments.
(a) Basic factors. In determining the amount of any penalty or
assessment, CMS or OIG takes into account the following:
(1) The nature of the claim, request for payment, or information
given and the circumstances under which it was presented or given.
(2) The degree of culpability, history of prior offenses, and
financial condition of the person submitting the claim or request for
payment or giving the information.
(3) The resources available to the person submitting the claim or
request for payment or giving the information.
(4) Such other matters as justice may require.
(b) Criteria to be considered. As guidelines for taking into account
the factors listed in paragraph (a) of this section, CMS or OIG
considers the following circumstances:
(1) Aggravating circumstances of the incident. An aggravating
circumstance is any of the following:
(i) The services or incidents were of several types, occurring over
a lengthy period of time.
(ii) There were many of these services or incidents or the nature
and circumstances indicate a pattern of claims or requests for payment
for these services or a pattern of incidents.
(iii) The amount claimed or requested for these services was
substantial.
(iv) Before the incident or presentation of any claim or request for
payment subject to imposition of a civil money penalty, the respondent
was held liable for criminal, civil, or administrative sanctions in
connection with a program covered by this part or any other public or
private program of payment for medical services.
(v) There is proof that a respondent engaged in wrongful conduct,
other
[[Page 35]]
than the specific conduct upon which liability is based, relating to
government programs or in connection with the delivery of a health care
service. (The statute of limitations governing civil money penalty
proceedings does not apply to proof of other wrongful conduct as an
aggravating circumstance.)
(2) Mitigating circumstances. The following circumstances are
mitigating circumstances:
(i) All the services or incidents subject to a civil money penalty
were few in number and of the same type, occurred within a short period
of time, and the total amount claimed or requested for the services was
less than $1,000.
(ii) The claim or request for payment for the service was the result
of an unintentional and unrecognized error in the process of presenting
claims or requesting payment and the respondent took corrective steps
promptly after discovering the error.
(iii) Imposition of the penalty or assessment without reduction
would jeopardize the ability of the respondent to continue as a health
care provider.
(3) Other matters as justice may require. Other circumstances of an
aggravating or mitigating nature are taken into account if, in the
interests of justice, they require either a reduction of the penalty or
assessment or an increase in order to ensure the achievement of the
purposes of this part.
(c) Effect of aggravating or mitigating circumstances. In
determining the amount of the penalty and assessment to be imposed for
every service or incident subject to a determination under Sec.
402.1(c)--
(1) If there are substantial or several mitigating circumstances,
the aggregate amount of the penalty and assessment is set at an amount
sufficiently below the maximum permitted by Sec. Sec. 402.105(a) and
402.107 to reflect that fact.
(2) If there are substantial or several aggravating circumstances,
the aggregate amount of the penalty and assessment is set at an amount
at or sufficiently close to the maximum permitted by Sec. Sec.
402.105(a) and 402.107 to reflect that fact.
(d)(1) The standards set forth in this section are binding, except
to the extent that their application would result in imposition of an
amount that would exceed limits imposed by the United States
Constitution.
(2) The amount imposed is not less than the approximate amount
required to fully compensate the United States, or any State, for its
damages and costs, tangible and intangible, including but not limited to
the costs attributable to the investigation, prosecution, and
administrative review of the case.
(3) Nothing in this section limits the authority of CMS or OIG to
settle any issue or case as provided by Sec. 402.19 or to compromise
any penalty and assessment as provided by Sec. 402.115.
Sec. 402.113 When a penalty and assessment are collectible.
A civil money penalty and assessment become collectible after the
earliest of the following:
(a) Sixty days after the respondent receives CMS's or OIG's notice
of proposed determination under Sec. 402.7, if the respondent has not
requested a hearing before an ALJ.
(b) Immediately after the respondent abandons or waives his or her
appeal right at any administrative level.
(c) Thirty days after the respondent receives the ALJ's decision
imposing a civil money penalty or assessment under Sec. 1005.20(d) of
this title, if the respondent has not requested a review before the DAB.
(d) If the DAB grants an extension of the period for requesting the
DAB's review, the day after the extension expires if the respondent has
not requested the review.
(e) Immediately after the ALJ's decision denying a request for a
stay of the effective date under Sec. 1005.22(b) of this title.
(f) If the ALJ grants a stay under Sec. 1005.22(b) of this title,
immediately after the judicial ruling is completed.
(g) Sixty days after the respondent receives the DAB's decision
imposing a civil money penalty if the respondent has not requested a
stay of the decision under Sec. 1005.22(b) of this title.
[[Page 36]]
Sec. 402.115 Collection of penalty or assessment.
(a) Once a determination by HHS has become final, CMS is responsible
for the collection of any penalty or assessment.
(b) The General Counsel may compromise a penalty or assessment
imposed under this part, after consultation with CMS or OIG, and the
Federal government may recover the penalty or assessment in a civil
action brought in the United States district court for the district
where the claim was presented or where the respondent resides.
(c) The United States or a State agency may deduct the amount of a
penalty and assessment when finally determined, or the amount agreed
upon in compromise, from any sum then or later owing to the respondent.
(d) Matters that were raised or that could have been raised in a
hearing before an ALJ or in an appeal under section 1128A(e) of the Act
may not be raised as a defense in a civil action by the United States to
collect a penalty under this part.
Subpart C--Exclusions [Reserved]
PART 403_SPECIAL PROGRAMS AND PROJECTS--Table of Contents
Subpart A [Reserved]
Subpart B_Medicare Supplemental Policies
Sec.
403.200 Basis and scope.
General Provisions
403.201 State regulation of insurance policies.
403.205 Medicare supplemental policy.
403.206 General standards for Medicare supplemental policies.
403.210 NAIC model standards.
403.215 Loss ratio standards.
State Regulatory Programs
403.220 Supplemental Health Insurance Panel.
403.222 State with an approved regulatory program.
Voluntary Certification Program: General Provisions
403.231 Emblem.
403.232 Requirements and procedures for obtaining certification.
403.235 Review and certification of policies.
403.239 Submittal of material to retain certification.
403.245 Loss of certification.
403.248 Administrative review of CMS determinations.
Voluntary Certification Program: Loss Ratio Provisions
403.250 Loss ratio calculations: General provisions.
403.251 Loss ratio date and time frame provisions.
403.253 Calculation of benefits.
403.254 Calculation of premiums.
403.256 Loss ratio supporting data.
403.258 Statement of actuarial opinion.
Subpart C_Recognition of State Reimbursement Control Systems
403.300 Basis and purpose.
403.302 Definitions.
403.304 Minimum requirements for State systems--discretionary approval.
403.306 Additional requirements for State systems--mandatory approval.
403.308 State systems under demonstration projects--mandatory approval.
403.310 Reduction in payments.
403.312 Submittal of application.
403.314 Evaluation of State systems.
403.316 Reconsideration of certain denied applications.
403.318 Approval of State systems.
403.320 CMS review and monitoring of State systems.
403.321 State systems for hospital outpatient services.
403.322 Termination of agreements for Medicare recognition of State
systems.
Subpart D [Reserved]
Subpart E_Beneficiary Counseling and Assistance Grants
403.500 Basis, scope, and definition.
403.501 Eligibility for grants.
403.502 Availability of grants.
403.504 Number and size of grants.
403.508 Limitations.
403.510 Reporting requirements.
403.512 Administration.
Subpart F [Reserved]
Subpart G_Religious Nonmedical Health Care Institutions_Benefits,
Conditions of Participation, and Payment
403.700 Basis and purpose.
403.702 Definitions and terms.
403.720 Conditions for coverage.
403.724 Valid election requirements.
[[Page 37]]
403.730 Condition of participation: Patient rights.
403.732 Condition of participation: Quality assessment and performance
improvement.
403.734 Condition of participation: Food services.
403.736 Condition of participation: Discharge planning.
403.738 Condition of participation: Administration.
403.740 Condition of participation: Staffing.
403.742 Condition of participation: Physical environment.
403.744 Condition of participation: Life safety from fire.
403.746 Condition of participation: Utilization review.
403.750 Estimate of expenditures and adjustments.
403.752 Payment provisions.
403.754 Monitoring expenditure level.
403.756 Sunset provision.
403.764 Basis and purpose of religious nonmedical health care
institutions providing home service.
403.766 Requirements for coverage and payment of RNHCI home services.
403.768 Excluded services.
403.770 Payments for home services.
Subpart H_Medicare Prescription Drug Discount Card and Transitional
Assistance Program
403.800 Basis and scope.
403.802 Definitions.
403.804 General rules for solicitation, application and Medicare
endorsement period.
403.806 Sponsor requirements for eligibility for endorsement.
403.808 Use of transitional assistance funds.
403.810 Eligibility and reconsiderations.
403.811 Enrollment, disenrollment, and associated endorsed sponsor
requirements.
403.812 HIPAA privacy, security, administrative data standards, and
national identifiers.
403.813 Marketing limitations and record retention requirements.
403.814 Special rules concerning Part C organizations and Medicare cost
plans and their enrollees.
403.815 Special rules concerning States.
403.816 Special rules concerning long-term care and I/T/U pharmacies.
403.817 Special rules concerning the territories.
403.820 Sanctions, penalties, and termination.
403.822 Reimbursement of transitional assistance and associated sponsor
requirements.
Authority: 42 U.S.C. 1395b-3 and Secs. 1102 and 1871 of the Social
Security Act (42 U.S.C. 1302 and 1395hh).
Subpart A [Reserved]
Subpart B_Medicare Supplemental Policies
Source: 47 FR 32400, July 26, 1982, unless otherwise noted.
Sec. 403.200 Basis and scope.
(a) Provisions of the legislation. This subpart implements, in part,
section 1882 of the Social Security Act. The intent of that section is
to enable Medicare beneficiaries to identify Medicare supplemental
policies that do not duplicate Medicare, and that provide adequate,
fairly priced protection against expenses not covered by Medicare. The
legislation establishes certain standards for Medicare supplemental
policies and provides two methods for informing Medicare beneficiaries
which policies meet those standards:
(1) Through a State approved program, that is, a program that a
Supplemental Health Insurance Panel determines to meet certain minimum
requirements for the regulation of Medicare supplemental policies; and
(2) In a State without an approved program, through certification by
the Secretary of policies voluntarily submitted by insuring
organizations for review against the standards.
(b) Scope of subpart. This subpart sets forth the standards and
procedures CMS will use to implement the voluntary certification
program.
General Provisions
Sec. 403.201 State regulation of insurance policies.
(a) The provisions of this subpart do not affect the right of a
State to regulate policies marketed in that State.
(b) Approval of a policy under the voluntary certification program,
as provided for in Sec. 403.235(b), does not authorize the insuring
organization to market a policy that does not conform to applicable
State laws and regulations.
Sec. 403.205 Medicare supplemental policy.
(a) Except as specified in paragraph (e) of this section, Medicare
supplemental (or Medigap) policy means a
[[Page 38]]
health insurance policy or other health benefit plan that--
(1) A private entity offers to a Medicare beneficiary; and
(2) Is primarily designed, or is advertised, marketed, or otherwise
purported to provide payment for expenses incurred for services and
items that are not reimbursed under the Medicare program because of
deductibles, coinsurance, or other limitations under Medicare.
(b) The term policy includes both policy form and policy as
specified in paragraphs (b)(1) and (b)(2) of this section.
(1) Policy form. Policy form is the form of health insurance
contract that is approved by and on file with the State agency for the
regulation of insurance.
(2) Policy. Policy is the contract--
(i) Issued under the policy form; and
(ii) Held by the policy holder.
(c) If the policy otherwise meets the definition in this section, a
Medicare supplemental policy includes-
(1) An individual policy;
(2) A group policy;
(3) A rider attached to an individual or group policy; or
(4) As of January 1, 2006, a stand-alone limited health benefit plan
or policy that supplements Medicare benefits and is sold primarily to
Medicare beneficiaries.
(d) Any rider attached to a Medicare supplemental policy becomes an
integral part of the basic policy.
(e) Medicare supplemental policy does not include a Medicare
Advantage plan, a Prescription Drug Plan under Part D, or any of the
other types of health insurance policies or health benefit plans that
are excluded from the definition of a Medicare supplemental policy in
section 1882(g)(1) of the Act.
[70 FR 4525, Jan. 28, 2005]
Sec. 403.206 General standards for Medicare supplemental policies.
(a) For purposes of the voluntary certification program described in
this subpart, a policy must meet--
(1) The National Association of Insurance Commissioners (NAIC) model
standards as defined in Sec. 405.210; and
(2) The loss ratio standards specified in Sec. 403.215.
(b) Except as specified in paragraph (c) of this section, the
standards specified in paragraph (a) of this section must be met in a
single policy.
(c) In the case of a nonprofit hospital or a medical association
where State law prohibits the inclusion of all benefits in a single
policy, the standards specified in paragraph (a) of the section must be
met in two or more policies issued in conjunction with one another.
Sec. 403.210 NAIC model standards.
(a) NAIC model standards means the National Association of Insurance
Commissioners (NAIC) ``Model Regulation to Implement the Individual
Accident and Insurance Minimum Standards Act'' (as amended and adopted
by the NAIC on June 6, 1979, as it applies to Medicare supplemental
policies). Copies of the NAIC model standards can be purchased from the
National Association of Insurance Commissioners at 350 Bishops Way,
Brookfield, Wisconsin 53004, and from the NIARS Corporation, 318
Franklin Avenue, Minneapolis, Minnesota 55404.
(b) The policy must comply with the provisions of the NAIC model
standards, except as follows--
(1) Policy, for purposes of this paragraph, means individual and
group policy, as specified in Sec. 403.205. The NAIC model standards
limit ``policy'' to individual policy.
(2) The policy must meet the loss ratio standards specified in Sec.
403.215.
[47 FR 32400, July 26, 1982; 49 FR 44472, Nov. 7, 1984]
Sec. 403.215 Loss ratio standards.
(a) The policy must be expected to return to the policyholders, in
the form of aggregate benefits provided under the policy--
(1) At least 75 percent of the aggregate amount of premiums in the
case of group policies; and
(2) At least 60 percent of the aggregate amount of premiums in the
case of individual policies.
(b) For purposes of loss ratio requirements, policies issued as a
result of solicitation of individuals through the mail or by mass media
advertising are considered individual policies.
[[Page 39]]
State Regulatory Programs
Sec. 403.220 Supplemental Health Insurance Panel.
(a) Membership. The Supplemental Health Insurance Panel (Panel)
consists of--
(1) The Secretary or a designee, who serves as chairperson, and
(2) Four State Commissioners or Superintendents of Insurance
appointed by the President. (The terms Commissioner or Superintendent of
Insurance include persons of similar rank.)
(b) Functions. (1) The Panel determines whether or not a State
regulatory program for Medicare supplemental health insurance policies
meets and continues to meet minimum requirements specified in section
1882 of the Social Security Act.
(2) The chairperson of the Panel informs the State Commissioners and
Superintendents of Insurance of all determinations made under paragraph
(b)(1) of this section.
Sec. 403.222 State with an approved regulatory program.
(a) A State has an approved regulatory program if the Panel
determines that the State has in effect under State law a regulatory
program that provides for the application of standards, with respect to
each Medicare supplemental policy issued in that State, that are equal
to or more stringent than those specified in section 1882 of the Social
Security Act.
(b) Policy issued in that State means--
(1) A group policy, if the holder of the master policy resides in
that State; and
(2) An individual policy, if the policy is--
(i) Issued in that State; or
(ii) Issued for delivery in that State.
(c) A policy issued in a State with an approved regulatory program
is considered to meet the NAIC model standards in Sec. 403.210 and loss
ratio standards in Sec. 403.215.
Voluntary Certification Program: General Provisions
Sec. 403.231 Emblem.
(a) The emblem is a graphic symbol, approved by HHS, that indicates
that CMS has certified a policy as meeting the requirements of the
voluntary certification program, specified in Sec. 403.232.
(b) Unless prohibited by the State in which the policy is marketed,
the insuring organization may display the emblem on policies certified
under the voluntary certification program.
(c) The manner in which the emblem may be displayed and the
conditions and restrictions relating to its use will be stated in the
letter with which CMS notifies the insuring organization that a policy
has been certified. The insuring organization must comply with these
conditions and restrictions.
(d) If a certified policy is issued in a State that later has an
approved regulatory program, as provided for in Sec. 403.222, the
insuring organization may display the emblem on the policy until the
earliest of the following--
(1) When prohibited by State law or regulation.
(2) When the policy no longer meets the requirements for Medicare
supplemental policies specified in Sec. 403.206.
(3) The date the insuring organization would be required to submit
material to CMS for annual review in order to retain certification, if
the State did not have an approved program (see Sec. 403.239).
Sec. 403.232 Requirements and procedures for obtaining certification.
(a) To be certified by CMS, a policy must meet--
(1) The NAIC model standards specified in Sec. 403.210;
(2) The loss ratio standards specified in Sec. 403.215; and
(3) Any State requirements applicable to a policy--
(i) Issued in that State; or
(ii) Marketed in that State.
(b) An insuring organization requesting certification of a policy
must submit the following to CMS for review--
(1) A copy of the policy form (including all the documents that
would constitute the contract of insurance that is proposed to be
marketed as a certified policy).
(2) A copy of the application form including all attachments.
(3) A copy of the uniform certificate issued under a group policy.
[[Page 40]]
(4) A copy of the outline of coverage, in the form prescribed by the
NAIC model standards.
(5) A copy of the Medicare supplement buyers' guide to be provided
to all applicants if the buyers' guide is not the CMS/NAIC buyers'
guide.
(6) A statement of when and how the outline of coverage and the
buyers' guide will be delivered and copies of applicable receipt forms.
(7) A copy of the notice of replacement and statement as to when and
how that notice will be delivered.
(8) A list of States in which the policy is authorized for sale. If
the policy was approved under a deemer provision in any State, the
conditions involved must be specified.
(9) A copy of the loss ratio calculations, as specified in Sec.
403.250.
(10) Loss ratio supporting data, as specified in Sec. 403.256.
(11) A statement of actuarial opinion, as specified in Sec.
403.258.
(12) A statement that the insuring organization will notify the
policyholders in writing, within the period of time specified in Sec.
403.245(c), if the policy is identified as a certified policy at the
time of sale and later loses certification.
(13) A signed statement in which the president of the insuring
organization, or a designee, attests that--
(i) The policy meets the requirements specified in paragraph (a) of
this section; and
(ii) The information submitted to CMS for review is accurate and
complete and does not misrepresent any material fact.
Sec. 403.235 Review and certification of policies.
(a) CMS will review policies that the insuring organization
voluntarily submits, except that CMS will not review a policy issued in
a State with an approved regulatory program under Sec. 403.222.
(b) If the requirements specified in Sec. 403.232 are met, CMS
will--
(1) Certify the policy; and
(2) Authorize the insuring organization to display the emblem on the
policy, as provided for in Sec. 403.231.
(c) If CMS certifies a policy, it will inform all State
Commissioners and Superintendents of Insurance of that fact.
Sec. 403.239 Submittal of material to retain certification.
(a) CMS certification of a policy that continues to meet the
standards will remain in effect, if the insuring organization files the
following material with CMS no later than the date specified in
paragraph (b) or (c) of this section--
(1) Any changes in the material, specified in Sec. 403.232(b), that
was submitted for previous certification.
(2) The loss ratio supporting data specified in Sec. 403.256(b).
(3) A signed statement in which the president of the insuring
organization, or a designee, attests that--
(i) The policy continues to meet the requirements specified in Sec.
403.232(a); and
(ii) The information submitted to CMS for review is accurate and
complete and does not misrepresent any material fact.
(b) Except as specified in paragraph (c) of this section, the
insuring organization must file the material with CMS no later than June
30 of each year. The first time the insuring organization must file the
material is no later than June 30 of the calendar year that follows the
year in which CMS--
(1) Certifies a new policy; or
(2) Certifies a policy that lost certification as provided in Sec.
403.245.
(c) If the loss ratio calculation period, used to calculate the
expected loss ratio for the last actuarial certification submitted to
CMS, ends before the June 30 date of paragraph (b) of this section, the
insuring organization must file the material with CMS no later then the
last day of that rate calculation period.
Sec. 403.245 Loss of certification.
(a) A policy loses certification if--
(1) The insuring organization withdraws the policy from the
voluntary certification program; or
(2) CMS determines that--
(i) The policy fails to meet the requirements specified in Sec.
403.232(a); or
(ii) The insuring organization has failed to meet the requirements
for submittal of material specified in Sec. 403.239.
[[Page 41]]
(b) If a policy loses its certification, CMS will inform all State
Commissioners and Superintendents of Insurance of that fact.
(c) If a policy that displays the emblem, or that has been marketed
as a certified policy without the emblem, loses certification, the
insuring organization must notify each holder of the policy, or of a
certificate issued under the policy, of that fact. The notice must be in
writing and sent by the earlier of--
(1) The date of the first regular premium notice after the date the
policy loses its certification; or
(2) 60 days after the date the policy loses its certification.
Sec. 403.248 Administrative review of CMS determinations.
(a) This section provides for administrative review if CMS
determines--
(1) Not to certify a policy; or
(2) That a policy no longer meets the standards for certification.
(b) If CMS makes a determination specified in paragraph (a) of this
section, it will send a notice to the insuring organization containing
the following information:
(1) That CMS has made such a determination.
(2) The reasons for the determination.
(3) That the insuring organization has 30 days from the date of the
notice to--
(i) Request, in writing, an administrative review of the CMS
determination; and
(ii) Submit additional information to CMS for review.
(4) That, if the insuring organization requests an administrative
review, CMS will conduct the review, as provided for in paragraph (c) of
this section.
(5) That, in a case involving loss of certification, the CMS
determination will go into effect 30 days from the date of the notice,
unless the insuring organization requests an administrative review. If
the insuring organization requests an administrative review, the policy
retains its certification until CMS makes a final determination.
(c) If the insuring organization requests an administrative review,
CMS will conduct the review as follows--
(1) A CMS official, not involved in the initial CMS determination,
will initiate and complete an administrative review within 90 days of
the date of the notice provided for in paragraph (b) of this section.
(2) The official will consider--
(i) The original material submitted to CMS for review, as specified
in Sec. 403.232(b) or Sec. 403.239(a); and
(ii) Any additional information, that the insuring organization
submits to CMS.
(3) Within 15 days after the administrative review is completed, CMS
will inform the insuring organization in writing of the final decision,
with an explanation of the final decision.
(4) If the final decision is that a policy lose its certification,
the loss of certification will go into effect 15 days after the date of
CMS's notice informing the insuring organization of the final decision.
Voluntary Certification Program: Loss Ratio Provisions
Sec. 403.250 Loss ratio calculations: General provisions.
(a) Basic formula. The expected loss ratio is calculated by
determining the ratio of benefits to premiums.
(b) Calculations. The insuring organization must calculate loss
ratios according to the provisions of Sec. Sec. 403.251, 403.253, and
403.254.
Sec. 403.251 Loss ratio date and time frame provisions.
(a) Initial calculation date means the first date of the period that
the insuring organization uses to calculate the policy's expected loss
ratio.
(1) The initial calculation date may be before, the same as, or
after the date the insuring organization sends the policy to CMS for
review, except--
(2) The initial calculation date must not be earlier than January 1
of the calendar year in which the policy is sent to CMS.
(b) Loss ratio calculation period means the period beginning with
the initial calculation date and ending with the
[[Page 42]]
last day of the period for which the insuring organization calculates
the policy's scale of premiums.
(c) To calculate ``present values'', the insuring organization may
ignore discounting (an actuarial procedure that provides for the impact
of a variety of factors, such as lapse of policies) for loss ratio
calculation periods not exceeding 12 months.
Sec. 403.253 Calculation of benefits.
(a) General provisions. (1) Except as provided for in paragraph
(a)(2) of this section, calculate the amount of ``benefits'' by--
(i) Adding the present values on the initial calculation date of--
(A) Expected incurred benefits in the loss ratio calculation period,
to--
(B) The total policy reserve at the last day of the loss ratio
calculation period: and
(ii) Subtracting the total policy reserve on the initial calculation
date from the sum of these values.
(2) To calculate the amount of ``benefits'' in the case of community
or pool rated individual or group policies rerated on an annual basis,
calculate the expected incurred benefits in the loss ratio calculation
period.
(b) Calculation of total policy reserve--(1) Option for calculation.
The insuring organization must calculate ``total policy reserve''
according to the provisions of paragraph (b) (2) or (3) of this section.
(2) Total policy reserve: Federal provisions. (i) ``Total policy
reserve'' means the sum of--
(A) Additional reserve; and
(B) The reserve for future contingent benefits.
(ii) Additional reserve means the amount calculated on a net level
reserve basis, using appropriate values to account for lapse, mortality,
morbidity, and interest, that on the valuation date represents--
(A) The present value of expected incurred benefits over the loss
ratio calculation period; less--
(B) The present value of expected net premiums over the loss ratio
calculation period.
(iii) Net premium means the level portion of the gross premium used
in calculating the additional reserve. On the day the policy is issued,
the present value of the series of those portions equals the present
value of the expected incurred claims over the period that the gross
premiums are computed to provide coverage.
(iv) Reserve for future contingent benefits means the amounts, not
elsewhere included, that provide for the extension of benefits after
insurance coverage terminates. These benefits--
(A) Are predicated on a health condition existing on the date
coverage ends;
(B) Accrue after the date coverage ends; and
(C) Are payable after the valuation date.
(3) Total policy reserve: State provisions. ``Total policy reserve''
means the total policy reserve calculated according to appropriate State
law or regulation.
Sec. 403.254 Calculation of premiums.
(a) General provisions. To calculate the amount of ``premiums'',
calculate the present value on the initial calculation date of expected
earned premiums for the loss ratio calculation period.
(b) Specific provisions. (1) Earned premium for a given period
means--
(i) Written premiums for the period; plus--
(ii) The total premium reserve at the beginning of the period;
less--
(iii) The total premium reserve at the end of the period.
(2) Written premiums in a period means--
(i) Premiums collected in that period; plus--
(ii) Premiums due and uncollected at the end of that period; less--
(iii) Premiums due and uncollected at the beginning of that period.
(3) Total premium reserve means the sum of--
(i) The unearned premium reserve;
(ii) The advance premium reserve; and
(iii) The reserve for rate credits.
(4) Unearned premium reserve means the portion of gross premiums due
that provide for days of insurance coverage after the valuation date.
[[Page 43]]
(5) Advance premium reserve means premiums received by the insuring
organization that are due after the valuation date.
(6) Reserve for rate credits means rate credits on a group policy
that--
(i) Accrue by the valuation date of the policy; and
(ii) Are paid or credited after the valuation date.
Sec. 403.256 Loss ratio supporting data.
(a) For purposes of requesting CMS certification under Sec.
403.232, the insuring organization must submit the following loss ratio
data to CMS for review--
(1) A statement of why the policy is to be considered, for purposes
of the loss ratio standards, an individual or a group policy.
(2) The earliest age at which policyholders can purchase the policy.
(3) The general marketing method and the underwriting criteria used
for the selection of applicants to whom coverage is offered.
(4) What policies are to be included under the one policy form, by
the dates the policies are issued.
(5) The loss ratio calculation period.
(6) The scale of premiums for the loss ratio calculation period.
(7) The expected level of earned premiums in the loss ratio
calculation period.
(8) The expected level of incurred claims in the loss ratio
calculation period.
(9) A description of how the following assumptions were used in
calculating the loss ratio.
(i) Morbidity.
(ii) Mortality.
(iii) Lapse.
(iv) Assumed increases in the Medicare deductible.
(v) Impact of inflation on reimbursement per service.
(vi) Interest.
(vii) Expected distribution, by age and sex, of persons who will
purchase the policy in the coming year.
(viii) Expected impact on morbidity by policy duration of--
(A) The process used to select insureds from among those that apply
for a policy; and
(B) Pre-existing condition clauses in the policy.
(b) For purposes of requesting continued CMS certification under
Sec. 403.239(a), the insuring organization must submit the following to
CMS--
(1) A description of all changes in the loss ratio data, specified
in paragraph (a) of this section, that occurred since CMS last reviewed
the policy.
(2) The past loss ratio experience for the policy, including the
experience of all riders and endorsements issued under the policy. The
loss ratio experience data must include earned premiums, incurred
claims, and total policy reserves that the insuring organization
calculates--
(i) For all years of issue combined; and
(ii) Separately for each calendar year since CMS first certified the
policy.
Sec. 403.258 Statement of actuarial opinion.
(a) For purposes of certification requests submitted under Sec.
403.232(b) and subsequent review as specified in Sec. 403.239(a),
statement of actuarial opinion means a signed declaration in which a
qualified actuary states that the assumptions used in calculating the
expected loss ratio are appropriate and reasonable, taking into account
actual policy experience, if any, and reasonable expectations.
(b) Qualified actuary means--
(1) A member in good standing of the American Academy of Actuaries;
or
(2) A person who has otherwise demonstrated his or her actuarial
competence to the satisfaction of the Commissioner or Superintendent of
Insurance of the domiciliary State of the insuring organization.
Subpart C_Recognition of State Reimbursement Control Systems
Source: 51 FR 15492, Apr. 24, 1986, unless otherwise noted.
Sec. 403.300 Basis and purpose.
(a) Basis. This subpart implements section 1886(c) of the Act, which
authorizes payment for Medicare inpatient hospital services in
accordance with a State's reimbursement control system rather than under
the Medicare
[[Page 44]]
reimbursement principles as described in CMS's regulations and
instructions.
(b) Purpose. Contained in this subpart are--
(1) The basic requirements that a State reimbursement control system
must meet in order to be approved by CMS;
(2) A description of CMS's review and evaluation procedures; and
(3) The conditions that apply if the system is approved.
Sec. 403.302 Definitions.
For purposes of this subpart--
Chief executive officer of a State means the Governor of the State
or the Governor's designee.
Existing demonstration project refers to demonstration projects
approved by CMS under the authority of section 402(a) of the Social
Security Amendments of 1967 (42 U.S.C. 1395b-1) or section 222(a) of the
Social Security Amendments of 1972 (42 U.S.C. 1395b-1 (note)) and in
effect on April 20, 1983 (the date of the enactment of Pub. L. 98-21
(Social Security Amendments of 1983)).
Federal hospital means a hospital that is administered by, or that
is under exclusive contract with, the Department of Defense, the
Veterans Administration, or the Indian Health Service.
State system or system refers to a State reimbursement control
system that is approved by CMS under the authority of section 1886(c) of
the Act and that satisfies the requirements described in this subpart.
Sec. 403.304 Minimum requirements for State systems--discretionary
approval.
(a) Discretionary approval by CMS. CMS may approve Medicare payments
under a State system, if CMS determines that the system meets the
requirements in paragraphs (b) and (c) of this section and, if
applicable paragraph (d) of this section.
(b) Requirements for State system. (1) An application for approval
of the system must be submitted to CMS by the Chief Executive Officer of
the State.
(2) The State system must apply to substantially all non-Federal
acute care hospitals in the State.
(3) All hospitals covered by the system must have and maintain a
utilization and quality control review agreement with a Quality
Improvement Organization, as required under section 1866(a)(1)(F) of the
Act and Sec. 466.78(a) of this chapter.
(4) Federal hospitals must be excluded from the State system.
(5) Nonacute care or specialty hospital (such as rehabilitation,
psychiatric, or children's hospitals) may, at the option of the State,
be excluded from the State system.
(6) The State system must apply to at least 75 percent of all
revenues or expenses--
(i) For inpatient hospital services in the State; and
(ii) For inpatient hospital services under the State's Medicaid
plan.
(7) Under the system, HMOs and competitive medical plans (CMPs), as
defined by section 1876(b) of the Act and part 417 of this chapter, must
be allowed to negotiate payment rates with hospitals.
(8) The system must limit hospital charges for Medicare
beneficiaries to deductibles, coinsurance or non-covered services.
(9) Unless a waiver is granted by CMS under Sec. 489.23 of this
chapter, the system must prohibit payment, as required under section
1862(a)(14) of the Act and Sec. 405.310(m) of this chapter, for
nonphysician services provided to hospital inpatients under Part B of
Medicare.
(10) The system must require hospitals to submit Medicare cost
reports or approved reports in lieu of Medicare cost reports as
required.
(11) The system must require--
(i) Preparation, collection, or retention by the State of reports
(such as financial, administrative, or statistical reports) that may be
necessary, as determined by CMS, to review and monitor the State's
assurances; and
(ii) Submission of the reports to CMS upon request.
(12) The system must provide hospitals an opportunity to appeal
errors that they believe have been made in the determination of their
payment rates. The system, if it is prospective may not permit providers
to file administrative appeals that would result
[[Page 45]]
in a retroactive revision of prospectively determined payment rates.
(c) Satisfactory assurances. The State must provide to CMS
satisfactory assurance as to the following:
(1) The system provides for equitable treatment of hospital patients
and hospital employees.
(2) The system provides for equitable treatment of all entities that
pay hospitals for inpatient hospital services, including Federal and
State programs. Under the requirement, the following conditions must be
met:
(i) Both the Medicare and Medicaid programs must participate under
the system.
(ii) The State must assure equitable and uniform treatment under the
system of third-party payors of inpatient hospital services in terms of
opportunity. Equitable opportunity must include, but need not be limited
to, participation in the system and availability of discounts. Criteria
under which discounts are made available must be equitably and uniformly
applied to all payors, except for discounts negotiated by HMOs and CMPs.
Discounts available to HMOs and CMPs as result of their statutory right
to negotiate payment rates independently of a State system, as described
in paragraph (b)(7) of this section, need not be available to other
payors.
(iii) The State must assure that all third-party payors that
participate under the system share in the system's risks and benefits.
(3) The amount of Medicare payments made under the system over 36-
month periods may not exceed the amount of Medicare payment that would
otherwise have been made under the Medicare principles of reimbursement
for Medicare items and services had the State system not been in effect.
States must submit the assurance and supporting data as required by
Sec. 403.320 to document that the payment limit is not exceeded. States
that have an existing Medicare demonstration project in effect on April
20, 1983, and that have requested approval of a State system under
section 1886(c)(4) of the Act, may elect to have the effectiveness of
the State system under this paragraph judged on the basis of the State
system's rate of increase or inflation in Medicare inpatient hospital
payments as compared to the national rate of increase or inflation for
such payments during the three cost reporting periods of the hospitals
in the State beginning on or after October 1, 1983.
(d) Additional cost-effectiveness assurance. If the assurances and
supporting data required under paragraph (c)(3) of this section are
insufficient to provide assurance satisfactory to CMS regarding the
cost-effectiveness of a State system, the State may additionally submit
one of the following assurances in order to meet the cost-effectiveness
test:
(1) State responsibility for excess payments. The State must agree
that each month Medicare intermediaries will disburse to the State's
hospital Federal funds that in the aggregate equal no more than would
have been disbursed in the absence of the State system. Any additional
funds necessary to pay hospitals for Medicare services required by the
State system will be paid to the intermediaries by the State. These
additional amounts will be refunded to the State by the intermediaries
to the extent that, in subsequent months, the State system requires a
smaller aggregate payment for Medicare services than would have been
paid in the absence of the State system.
(2) Limitations on payments. (i) The State must agree that if its
projections exceed what Medicare would pay in any particular period, the
State and CMS will establish and agreed upon payment schedule that will
limit payments under the State system based on a predetermined
percentage relationship between projected State payments and what
payments would have been under Medicare.
(ii) If deviation from the predetermined relationship described in
paragraph (d)(2)(i) of this section occurs, the State must further agree
that--
(A) Medicare payments would be capped automatically at payment
levels based on the rates used for the Medicare prospective payment
system and the State would be required to pay the difference to
individual hospitals in its system; or
(B) The State may provide by legislation or legally binding
regulations that
[[Page 46]]
any reduced payments to hospitals under the system that result from this
cost-effectiveness assurance will constitute full and final payment for
hospital services furnished to Medicare beneficiaries for the period
covered by these reduced payments.
Sec. 403.306 Additional requirements for State systems--mandatory
approval.
(a) General policy--(1) Mandatory approval. HFCA will approve an
application for Medicare reimbursement under a State system if the
system meets all of the requirements of Sec. 403.304 and of paragraph
(b) of this section.
(2) Exception. CMS may approve an application if the State system
meets all of the requirements of Sec. 403.304 but only some of the
requirements of paragraph (b) of this section.
(b) Additional requirements--(1) Operation of system. The system
must--
(i) Be operated directly by the State or by entity designated under
State law;
(ii) Provide for payments to hospitals using a methodology under
which--
(A) Prospectively determined payment rates are established; and
(B) Exceptions, adjustments, and methods for changes in methodology
are set forth;
(iii) Provide that a change by the State in the system that has the
effect of materially changing payments to hospitals can take effect only
upon 60 days notice to CMS and to the hospitals likely to be materially
affected by the change and upon CMS's approval of the change.
(2) Satisfactory assurances--(i) Admissions practice. The State must
assure that the operation of the system will not result in any change in
hospital admission practices that result in--
(A) A significant reduction in the proportion of patients receiving
hospital services covered under the system who have no third-party
coverage and who are unable to pay for hospital services;
(B) A significant reduction in the proportion of individuals
admitted to hospitals for inpatient hospital services for which payment
is less, or is likely to be less, than the anticipated charges for or
cost of the services;
(C) A refusal to admit patients who would be expected to require
unusually costly or prolonged treatment for reasons other than those
related to the appropriateness of the care available at the hospital; or
(D) A refusal to provide emergency services to any person who is in
need of emergency services, if the hospital provides the services.
(ii) Consultation with local government officials. The State must
provide documentation that it has consulted with local government
officials concerning the impact of the system on publicly owned or
operated hospitals.
Sec. 403.308 State systems under demonstration projects--mandatory
approval.
CMS will approve an application from a State for a State system if--
(a) The system was in effect prior to April 20, 1983 under an
existing demonstration project; and
(b) The minimum requirements and assurances for approval of a State
system are met under Sec. 403.304 (b)(1)-(10) and Sec. 403.304(c),
and, if appropriate Sec. 403.304(d).
Sec. 403.310 Reduction in payments.
(a) General rule. If CMS determines that the satisfactory assurances
required of a State under Sec. 403.304(c) and, if applicable, Sec.
403.304(d) have not been met, or will not be met, with respect to any
36-month period, CMS will reduce Medicare payments to individual
hospitals being reimbursed under the State's system or, if applicable,
under the Medicare payment system, in an amount equal to the amount by
which the Medicare payments under the system exceed the amount of
Medicare payments to such hospitals that otherwise would have been made
not using the State system. The amount of the recoupment will include,
when appropriate, interest charges computed in accordance with Sec.
405.378 of this chapter.
(b) Recoupment procedures. The amount of the overpayment will be
recouped on a proportionate basis from each of those hospitals that
received payments under the State system that exceeded the payments they
would
[[Page 47]]
have received under the Medicare payment system. Each hospital's share
of the aggregate excess payment will be determined on the basis of a
comparison of the hospital's proportionate share of the aggregate
payment received under the State system that is in excess of what the
aggregate payment would have been under the Medicare payment system.
Recoupments may be accomplished by a hospital's direct payment to the
Medicare program or by offsets to future payments made to the hospital.
(c) Alternative recoupment procedures. As an alternative to the
recoupment procedures described in paragraph (b) of this section and
subject to CMS's acceptance, the State may provide, by legislation or
legally binding regulations, procedures for the recoupment of the amount
of payments that exceed the amount of payments that otherwise would have
been paid by Medicare if the State system had not been in effect.
(d) Rule for existing Medicare demonstration projects. In cases of
existing Medicare demonstration projects where the expenditure test is
to be applied by a rate of increase factor, the amount of the excess
payment will be determined, for the three hospital cost reporting
periods beginning before October 1, 1986, by a comparison of the State
system's rate of increase to the national rate of increase. Recoupment
of excessive payments will be assessed and recouped as described in this
section.
[51 FR 15492, Apr. 24, 1986, as amended at 61 FR 63748, Dec. 2, 1996]
Sec. 403.312 Submittal of application.
The Chief Executive Officer of the State is responsible for--
(a) Submittal of the application to CMS for approval; and
(b) Supplying the assurances and necessary documentation as required
under Sec. Sec. 403.304 through 403.308.
Sec. 403.314 Evaluation of State systems.
CMS will evaluate all State applications for approval of State
systems and notify the State of its determination within 60 days.
Sec. 403.316 Reconsideration of certain denied applications.
(a) Request for reconsideration. If CMS denies an application for a
State system, the State may request that CMS reconsider the denial if
the State believes that its system meets all of the requirements for
mandatory approval under Sec. Sec. 403.304 and 403.306 or, in the case
of a State with a system operating under an existing demonstration
project, the applicable requirements of Sec. Sec. 403.304 and 403.308.
(b) Time limit. (1) The State must submit its request for
reconsideration within 60 days after the date of CMS's notice that the
application was denied.
(2) CMS will notify the State of the results of its reconsideration
within 60 days after it receives the request for reconsideration.
Sec. 403.318 Approval of State systems.
(a) Approval agreement. If CMS approves a State system, a written
agreement will be executed between CMS and the Chief Executive Officer
of the State. The agreement must incorporate any terms of the State's
application for approval of the system as agreed to by the parties and,
as a minimum, must contain provisions that require the following:
(1) The system is operated directly by the State or an entity
designated by State law.
(2) For purposes of the Medicare program, the State's system applies
only to Medicare payments for inpatient, and if applicable, outpatient
hospital services.
(3) The system conforms to applicable Medicare law and regulations
other than those relating to the amount of reimbursement for inpatient
hospital services, or for inpatient and outpatient services, whichever
the State system covers. Applicable regulations include, for example,
those describing Medicare benefits and entitlement requirements for
program beneficiaries, as explained in parts 406 and 409 of this
chapter; the requirements at part 405, subpart J of this chapter
specifying conditions of participation for hospitals; the requirements
at part 405, subparts A, G, and S of this chapter on Medicare program
administration; and
[[Page 48]]
all applicable fraud and abuse regulations contained in titles 42 and 45
of the CFR.
(4) The State must obtain CMS's approval of the State's reporting
forms and of provider cost reporting forms or other forms that have not
been approved by CMS but that are necessary for the collection of
required information.
(b) Effective date. An approved State system may not be effective
earlier than the date of the approval agreement, which may not be
retroactive.
Sec. 403.320 CMS review and monitoring of State systems.
(a) General rule. The State must submit an assurance and detailed
and quantitative studies of provider cost and financial data and
projections to support the effectiveness of its system, as required by
paragraphs (b) and (c) of this section.
(b) Required information. (1) Under Sec. 403.304(c)(3) an assurance
is required that the system will not result in greater payments over a
36-month period than would have otherwise been made under Medicare not
using such system. If a State that has an existing demonstration project
in effect on April 20, 1983 elects under Sec. 403.304(c)(3) to have the
effectiveness of its system judged on the basis of a rate of increase
factor, the State must submit an assurance that its rate of increase or
inflation in inpatient hospital payments does not exceed, for that
portion of the 36-month period that is subject to this test, the
national rate of increase or inflation in Medicare inpatient hospital
payments. The election of the rate of increase test applies only to the
three cost reporting periods beginning on or after October 1, 1983. At
the end of these cost reporting periods, the State must assure,
beginning with the first month after the expiration of the third cost
reporting period beginning after October 1, 1983, that payments under
its system will not exceed over the remainder of the 36-month period
what Medicare payments would have been.
(2) Estimates and data are required to support the State's
assurance, required under Sec. 403.304(c)(3), that expenditures under
the State system will not exceed what Medicare would have paid over a
36-month period. The estimates and projections of what Medicare would
have otherwise paid must take into account all the Medicare
reimbursement principles in effect at the time and, for any period in
which payments either exceed or are less than Medicare levels, the
values of interest the Medicare Trust Fund earned, or would have earned,
on these amounts. Upon application for approval, the State must submit
projections for each hospital for the first 12-month period covered by
the assurance, in both the aggregate and on a per discharge basis, of
Medicare inpatient expenditures under Medicare principles of
reimbursement and parallel projections of Medicare inpatient
expenditures under the State's system and the resulting cost or savings
to Medicare. The State must also submit separate statewide projections
for each year of the 36-month period, in both the aggregate and on a
weighted average discharge basis, of inpatient expenditures under the
State system and under the Medicare principles of reimbursement.
(3) The projection submitted under paragraph (b)(2) of this section
must include a detailed description of the methodology and assumptions
used to derive the expenditure amounts under both systems. In instances
where the assumptions are different under the projections cited in
paragraph (b)(2) of this section, the State must provide a detailed
explanation of the reasons for the differences. At a minimum, the
following separate data and assumptions are to be included in the
projections for the Medicare principles and for the State's system.
(i) The State system base year and the Medicare allowable and
reimbursable cost of each hospital that the State used to develop the
projections, including the amount of estimated pass through costs.
(ii) The categories of costs that are included in the State system
and are reimbursed differently under the State system than under the
Medicare system.
(iii) The number of Medicare and total base year discharges and
admissions for each hospital.
[[Page 49]]
(iv) The rate of change factor (and the method of application of
this factor) used to project the base year costs over the 36-month
period to which the assurance would apply.
(v) Any allowance for anticipated growth in the amount of services
from the base year (if applicable, the allowance must be presented in
separate estimates for population increases or for increases in rates of
admissions or both).
(vi) Any adjustment in which the State is permitted by CMS to take
into account previous reductions in the Medicare payment amounts that
were the result of the effectiveness of the State's system even though
Medicare was not a part of that system.
(vii) Appropriate recognition and projection of the time value of
trust fund expenditures for the period the State system expenditures
were either less than or exceeded the Medicare system payments.
(viii) States applying under a rate of increase effectiveness test
under Sec. 403.304(c)(3) must also submit data projecting the parallel
rates of increase during the requisite period.
(4) The projections must include both the aggregate payments and the
payments per discharge for the individual hospitals and for the State as
a whole.
(5) On a case-by-case basis. CMS may require additional data and
documentation as needed to complete its review and monitoring.
(6) For existing Medicare demonstration projects in effect on April
20, 1983, the assurance and data as required by paragraphs (a) and (b)
of this section, if appropriate, may be based on aggregate payments or
payments per inpatient admission or discharge. CMS will judge the
effectiveness of these systems on the basis of the rate of increase or
inflation in Medicare inpatient hospital payments compared to the
national rate of increase or inflation for such payments during the
State's hospitals' three cost reporting periods beginning on or after
October 1, 1983. The data submitted by the State for the period subject
to the rate of increase test must include the rate of increase
projection for that particular period of time. For the subsequent period
of time, the State must assure that payments under its system will not
exceed what Medicare payments would have been, as described in Sec.
403.304(c)(3).
(7) If the amount of Medicare payments under the State system
exceeds what would have been paid under the Medicare reimbursement
principles in any given year, the State must also submit quantitative
evidence that the system will result in expenditures that do not exceed
what Medicare expenditures would have been over the 36 month period
beginning with the first month that the State system is operating. For a
State that has an existing demonstration project in effect on April 20,
1983, and that elects under Sec. 403.304(c)(3) to have a rate of
increase test apply, if the State's rate of increase or inflation
exceeds the national rate of increase or inflation in a given year, the
State must submit quantitative evidence that, over 36 months, its
payments will not exceed the national rate of increase or inflation.
Furthermore, if payments under the State's system must be compared to
actual Medicare expenditures, at the end of the third cost reporting
period, as described in paragraph (b)(1) of this section, and payments
under the State's system exceed what Medicare would have paid in a given
year, the State must submit quantitative evidence that, over 36 months,
payments under its system will not exceed what Medicare would have paid.
(c) Review of assurances regarding expenditures. CMS will review the
State's assurances and data submitted under this section, as a
prerequisite to the approval of the State's system. CMS will compare the
State's projections of payment amounts to CMS data in order to determine
if the State's assurance is reasonable and fully supportable. If the CMS
data indicate that the State's system would result in payment amounts
that would be more then that which would have been paid under the
Medicare principles, the State's assurances would not be acceptable. For
States applying in accordance with Sec. 403.308, if CMS data indicate
that the State's system would result in a rate of increase or inflation
that would be more than the national rate of increase or inflation, the
State's assurances would not be acceptable.
[[Page 50]]
(d) Medicaid upper limit. In accordance with Sec. 447.253 of this
chapter, the State system may not result in aggregate payments for
Medicaid inpatient hospital services that would exceed the amount that
would have otherwise have been paid under the Medicare principles as
applied through the State system.
(e) Monitoring of Medicare expenditures. CMS will monitor on a
quarterly basis expenditures under the State's system as compared to
what Medicare expenditures would have been if the system had not been in
effect. If CMS determines at any time that the payments made under the
State's system exceed the States' projections, as established by the
satisfactory assurances required under Sec. 403.304(c) and, if
appropriate, the predetermined percentage relationship of the payments
as required under Sec. 403.304(d). CMS will--
(1) Conclude that payments under the State system over a 36-month
period will exceed what Medicare would have paid:
(2) Terminate the waiver; and
(3) Recoup overpayments to the affected hospitals in accordance with
the procedures described in Sec. 403.310.
Sec. 403.321 State systems for hospital outpatient services.
CMS may approve a State's application for approval of an outpatient
system if the following conditions are met:
(a) The State's inpatient system is approved.
(b) The State's outpatient application meets the requirements and
assurances for an inpatient system described in Sec. 403.304 (b) and
(c), and Sec. 403.306 (b)(1) and (b)(2)(ii).
(c) The State submits a separate application that provides separate
assurances and estimates and data in further support of its assurance
submitted under paragraph (b)(1) of Sec. 403.320, as follows:
(1) Upon application for approval, the State must submit estimates
and data that include, but are not limited to, projections for the first
12-month period covered by the assurance for each hospital, in both the
aggregate and on an average cost per service and payment basis, of
Medicare outpatient expenditures under Medicare principles of
reimbursement; parallel projections of Medicare outpatient expenditures
under the State system; and the resulting cost or savings to Medicare
independent of the State system for hospital inpatient services.
(2) The State must submit separate statewide projections for each
year of the 36-month period of the aggregate outpatient expenditures for
each system. The projections submitted under this paragraph must--
(i) Comply with the requirements of paragraphs (b) (3) and (5) of
Sec. 403.320 regarding a detailed description of the methodology used
to derive the expenditure amounts:
(ii) Include the data and assumptions set forth in paragraphs (b)(3)
(i), (ii), (iii), (iv), and (v) of Sec. 403.320; and
(iii) Include any assumption the State has adopted for establishing
the number of Medicare and total base year outpatient services for each
hospital.
(3) The State must provide a detailed explanation of the reasons for
any difference between the data or assumptions used for the separate
projections.
Sec. 403.322 Termination of agreements for Medicare recognition of State
systems.
(a) Termination of agreements. (1) CMS may terminate any approved
agreement if it finds, after the procedures described in this paragraph
are followed that the State system does not satisfactorily meet the
requirements of section 1886(c) of the Act or the regulations in this
subpart. A termination must be effective on the last day of a calendar
quarter.
(2) CMS will give the State reasonable notice of the proposed
termination of an agreement and of the reasons for the termination at
least 90 days before the effective date of the termination.
(3) CMS will give the State the opportunity to present evidence to
refute the finding.
(4) CMS will issue a final notice of termination upon a final review
and determination on the State's evidence.
(b) Termination by State. A State may voluntarily terminate a State
system by giving CMS notice of its intent to
[[Page 51]]
terminate. A termination must be effective on the last day of a calendar
quarter. The State must notify CMS of its intent to terminate at least
90 days before the effective date of the termination.
Subpart D [Reserved]
Subpart E_Beneficiary Counseling and Assistance Grants
Source: 59 FR 51128, Oct. 7, 1994, unless otherwise noted.
Sec. 403.500 Basis, scope, and definition.
(a) Basis. This subpart implements, in part, the provisions of
section 4360 of Public Law 101-508 by establishing a minimum level of
funding for grants made to States for the purpose of providing
information, counseling, and assistance relating to obtaining adequate
and appropriate health insurance coverage to individuals eligible to
receive benefits under the Medicare program.
(b) Scope of subpart. This subpart sets forth the following:
(1) Conditions of eligibility for the grant.
(2) Minimum levels of funding for those States qualifying for the
grants.
(3) Reporting requirements.
(c) Definition. For purposes of this subpart, the term ``State''
includes (except where otherwise indicated by the context) the 50
States, the District of Columbia, the Commonwealth of Puerto Rico, the
Virgin Islands, Guam, and American Samoa.
Sec. 403.501 Eligibility for grants.
To be eligible for a grant under this subpart, the State must have
an approved Medicare supplemental regulatory program under section 1882
of the Act and submit a timely application to CMS that meets the
requirements of--
(a) Section 4360 of Public Law 101-508 (42 USC 1395b-4);
(b) This subpart; and
(c) The applicable solicitation for grant applications issued by
CMS.
Sec. 403.502 Availability of grants.
CMS awards grants to States subject to availability of funds, and if
applicable, subject to the satisfactory progress in the State's project
during the preceding grant period. The criteria by which progress is
evaluated and the performance standards for determining whether
satisfactory progress has been made are specified in the terms and
conditions included in the notice of grant award sent to each State. CMS
advises each State as to when to make application, what to include in
the application, and provides information as to the timing of the grant
award and the duration of the grant award. CMS also provides an estimate
of the amount of funds that may be available to the State.
[65 FR 34985, June 1, 2000]
Sec. 403.504 Number and size of grants.
(a) General. For available grant funds, up to and including
$10,000,000, grants will be made to States according to the terms and
formula in paragraphs (b) and (c) of this section. For any available
grant funds in excess of $10,000,000, distribution of grants will be at
the discretion of CMS, and will be made according to criteria that CMS
will communicate to the States via grant solicitation. CMS will provide
information to each State as to what must be included in the application
for grant funds. CMS awards the following type of grants:
(1) New program grants.
(2) Existing program enhancement grants.
(b) Grant Award. Subject to the availability of funds, each eligible
State that submits an acceptable application receives a grant that
includes a fixed amount (minimum funding level) and a variable amount.
(1) A fixed portion is awarded to States in the following amounts:
(i) Each of the 50 States, $75,000.
(ii) The District of Columbia, $75,000.
(iii) Puerto Rico, $75,000.
(iv) American Samoa, $25,000.
(v) Guam, $25,000.
(vi) The Virgin Islands, $25,000.
(2) A variable portion, which is based on the number and location of
Medicare beneficiaries residing in the State is awarded to each State.
The variable amount a particular State receives is determined as set
forth in paragraph (c) of this section.
[[Page 52]]
(c) Calculation of variable portion of the grant. (1) CMS bases the
variable portion of the grant on--
(i) The amount of available funds, and
(ii) A comparison of each State with the average of all of the
States (except the State being compared) with respect to three factors
that relate to the size of the State's Medicare population and where
that population resides.
(2) The factors CMS uses to compare States' Medicare populations
comprise separate components of the variable amount. These factors, and
the extent to which they each contribute to the variable amount, are as
follows:
(i) Approximately 75 percent of the variable amount is based on the
number of Medicare beneficiaries living in the State as a percentage of
all Medicare beneficiaries nationwide.
(ii) Approximately 10 percent of the variable amount is based on the
percentage of the State's total population who are Medicare
beneficiaries.
(iii) Approximately 15 percent of the variable amount is based on
the percentage of the State's Medicare beneficiaries that reside in
rural areas (``rural areas'' are defined as all areas not included
within a Metropolitan Statistical Area).
(3) Based on the foregoing four factors (that is, the amount of
available funds and the three comparative factors), CMS determines a
variable rate for each participating State for each grant period.
(d) Submission of revised budget. A State that receives an amount of
grant funds under this subpart that differs from the amount requested in
the budget submitted with its application must submit a revised budget
to CMS, along with its acceptance of the grant award, that reflects the
amount awarded.
[59 FR 51128, Oct. 7, 1994, as amended at 65 FR 34986, June 1, 2000]
Sec. 403.508 Limitations.
(a) Use of grants. Except as specified in paragraph (b) of this
section, and in the terms and conditions in the notice of grant award, a
State that receives a grant under this subpart may use the grant for any
reasonable expenses for planning, developing, implementing, and/or
operating the program for which the grant is made as described in the
solicitation for application for the grant.
(b) Maintenance of effort. A State that receives a grant to
supplement an existing program (that is, an existing program enhancement
grant)--
(1) Must not use the grant to supplant funds for activities that
were conducted immediately preceding the date of the initial award of a
grant made under this subpart and funded through other sources
(including in-kind contributions).
(2) Must maintain the activities of the program at least at the
level that those activities were conducted immediately preceding the
initial award of a grant made under this subpart.
[59 FR 51128, Oct. 7, 1994, as amended at 65 FR 34986, June 1, 2000]
Sec. 403.510 Reporting requirements.
A State that receives a grant under this subpart must submit at
least one annual report to CMS and any additional reports as CMS may
prescribe in the notice of grant award. CMS advises the State of the
requirements concerning the frequency, timing, and contents of reports
in the notice of grant award that it sends to the State.
Sec. 403.512 Administration.
(a) General. Administration of grants will be in accordance with the
provisions of this subpart, 45 CFR part 92 (``Uniform Administrative
Requirements for Grants and Cooperative Agreements to State and Local
Governments''), 45 CFR 74.4, the terms of the solicitation, and the
terms of the notice of grant award. Except for the minimum funding
levels established by Sec. 403.504(b)(1), in the event of conflict
between a provision of the notice of grant award, any provision of the
solicitation, or of any regulation enumerated in 45 CFR 74.4 or in part
92, the terms of the notice of grant award control.
(b) Notice. CMS provides notice to each applicant regarding CMS's
decision on an application for grant funding under Sec. 403.504.
(c) Appeal. Any applicant for a grant under this subpart has the
right to appeal CMS's determination regarding its
[[Page 53]]
application. Appeal procedures are governed by the regulations at 45 CFR
part 16 (Procedures of the Departmental Grant Appeals Board).
Subpart F [Reserved]
Subpart G_Religious Nonmedical Health Care Institutions_Benefits,
Conditions of Participation, and Payment
Source: 64 FR 67047, Nov. 30, 1999, unless otherwise noted.
Sec. 403.700 Basis and purpose.
This subpart implements sections 1821; 1861(e), (y), and (ss); 1869;
and 1878 of the Act regarding Medicare payment for inpatient hospital or
posthospital extended care services furnished to eligible beneficiaries
in religious nonmedical health care institutions.
Sec. 403.702 Definitions and terms.
For purposes of this subpart, the following definitions and terms
apply:
Election means a written statement signed by the beneficiary or the
beneficiary's legal representative indicating the beneficiary's choice
to receive nonmedical care or treatment for religious reasons.
Excepted medical care means medical care that is received
involuntarily or required under Federal, State, or local laws.
FFY stands for Federal fiscal year.
Medical care or treatment means health care furnished by or under
the direction of a licensed physician that can involve diagnosing,
treating, or preventing disease and other damage to the mind and body.
It may involve the use of pharmaceuticals, diet, exercise, surgical
intervention, and technical procedures.
Nonexcepted medical care means medical care (other than excepted
medical care) that is sought by or for a beneficiary who has elected
religious nonmedical health care institution services.
Religious nonmedical care or religious method of healing means
health care furnished under established religious tenets that prohibit
conventional or unconventional medical care for the treatment of a
beneficiary, and the sole reliance on these religious tenets to fulfill
a beneficiary's total health care needs.
RNHCI stands for ``religious nonmedical health care institution,''
as defined in section 1861(ss)(1) of the Act.
Religious nonmedical nursing personnel means individuals who are
grounded in the religious beliefs of the RNHCI, trained and experienced
in the principles of nonmedical care, and formally recognized as
competent in the administration of care within their religious
nonmedical health care group.
Sec. 403.720 Conditions for coverage.
Medicare covers services furnished in an RNHCI if the following
conditions are met:
(a) The provider meets the definition of an RNHCI as defined in
section 1861(ss)(1) of the Act. That is, it is an institution that:
(1) Is described in section 501(c)(3) of the Internal Revenue Code
of 1986 and is exempt from taxes under section 501(a).
(2) Is lawfully operated under all applicable Federal, State, and
local laws and regulations.
(3) Furnishes only nonmedical nursing items and services to
beneficiaries who choose to rely solely upon a religious method of
healing and for whom the acceptance of medical services would be
inconsistent with their religious beliefs.
(4) Furnishes nonmedical items and services exclusively through
nonmedical nursing personnel who are experienced in caring for the
physical needs of nonmedical patients.
(5) Furnishes nonmedical items and services to inpatients on a 24-
hour basis.
(6) Does not furnish, on the basis of religious beliefs, through its
personnel or otherwise medical items and services (including any medical
screening, examination, diagnosis, prognosis, treatment, or the
administration of drugs) for its patients.
(7) Is not owned by, is not under common ownership with, or does not
have an ownership interest of 5 percent or more in, a provider of
medical treatment or services and is not affiliated with a provider of
medical treatment
[[Page 54]]
or services or with an individual who has an ownership interest of 5
percent or more in, a provider of medical treatment or services.
(Permissible affiliations are described at Sec. 403.738(c).)
(8) Has in effect a utilization review plan that sets forth the
following:
(i) Provides for review of the admissions to the institution, the
duration of stays, and the need for continuous extended duration of
stays in the institution, and the items and services furnished by the
institution.
(ii) Requires that reviews be made by an appropriate committee of
the institution that included the individuals responsible for overall
administration and for supervision of nursing personnel at the
institution.
(iii) Provides that records be maintained of the meetings,
decisions, and actions of the review committee.
(iv) Meets other requirements as the Secretary finds necessary to
establish an effective utilization review plan.
(9) Provides information CMS may require to implement section 1821
of the Act, including information relating to quality of care and
coverage decisions.
(10) Meets other requirements CMS finds necessary in the interest of
the health and safety of the patients who receive services in the
institution. These requirements are the conditions of participation in
this subpart.
(b) The provider meets the conditions of participation cited in
Sec. Sec. 403.730 through 403.746. (A provider may be deemed to meet
conditions of participation in accordance with part 488 of this
chapter.)
(c) The provider has a valid provider agreement as a hospital with
CMS in accordance with part 489 of this chapter and for payment purposes
is classified as an extended care hospital.
(d) The beneficiary has a condition that would make him or her
eligible to receive services covered under Medicare Part A as an
inpatient in a hospital or SNF.
(e) The beneficiary has a valid election as described in Sec.
403.724 in effect for Medicare covered services furnished in an RNHCI.
Sec. 403.724 Valid election requirements.
(a) General requirements. An election statement must be made by the
Medicare beneficiary or his or her legal representative.
(1) The election must be a written statement that must include the
following statements:
(i) The beneficiary is conscientiously opposed to acceptance of
nonexcepted medical treatment.
(ii) The beneficiary acknowledges that the acceptance of nonexcepted
medical treatment is inconsistent with his or her sincere religious
beliefs.
(iii) The beneficiary acknowledges that the receipt of nonexcepted
medical treatment constitutes a revocation of the election and may limit
further receipt of services in an RNHCI.
(iv) The beneficiary acknowledges that the election may be revoked
by submitting a written statement to CMS.
(v) The beneficiary acknowledges that revocation of the election
will not prevent or delay access to medical services available under
Medicare Part A in facilities other than RNHCIs.
(2) The election must be signed and dated by the beneficiary or his
or her legal representative.
(3) The election must be notarized.
(4) The RNHCI must keep a copy of the election statement on file and
submit the original to CMS with any information obtained regarding prior
elections or revocations.
(5) The election becomes effective on the date it is signed.
(6) The election remains in effect until revoked.
(b) Revocation of election. (1) A beneficiary's election is revoked
by one of the following:
(i) The beneficiary receives nonexcepted medical treatment for which
Medicare payment is requested.
(ii) The beneficiary voluntarily revokes the election and notifies
CMS in writing.
(2) The receipt of excepted medical treatment as defined in Sec.
403.702 does not revoke the election made by a beneficiary.
(c) Limitation on subsequent elections. (1) If a beneficiary's
election has been made and revoked twice, the following
[[Page 55]]
limitations on subsequent elections apply:
(i) The third election is not effective until 1 year after the date
of the most recent revocation.
(ii) Any succeeding elections are not effective until 5 years after
the date of the most recent revocation.
(2) CMS will not accept as the basis for payment of any claim any
elections executed on or after January 1 of the calendar year in which
the sunset provision described in Sec. 403.756 becomes effective.
Sec. 403.730 Condition of participation: Patient rights.
An RNHCI must protect and promote each patient's rights.
(a) Standard: Notice of rights. The RNHCI must do the following:
(1) Inform each patient of his or her rights in advance of
furnishing patient care.
(2) Have a process for prompt resolution of grievances, including a
specific person within the facility whom a patient may contact to file a
grievance. In addition, the facility must provide patients with
information about the facility's process as well as with contact
information for appropriate State and Federal resources.
(b) Standard: Exercise of rights. The patient has the right to:
(1) Be informed of his or her rights and to participate in the
development and implementation of his or her plan of care.
(2) Make decisions regarding his or her care, including transfer and
discharge from the RNHCI. (See Sec. 403.736 for discharge and transfer
requirements.)
(3) Formulate advance directives and expect staff who furnish care
in the RNHCI to comply with those directives, in accordance with part
489, subpart I of this chapter. For purposes of conforming with the
requirement in Sec. 489.102 that there be documentation in the
patient's medical records concerning advanced directives, the patient
care records of a beneficiary in an RNHCI are equivalent to medical
records held by other providers.
(c) Standard: Privacy and safety. The patient has the right to the
following:
(1) Personal privacy.
(2) Care in a safe setting.
(3) Freedom from verbal, psychological, and physical abuse, and
misappropriation of property.
(4) Freedom from the use of restraints.
(5) Freedom from involuntary seclusion.
(d) Standard: Confidentiality of patient records. For any patient
care records or election information it maintains on patients, the RNHCI
must establish procedures to do the following:
(1) Safeguard the privacy of any information that identifies a
particular patient. Information from, or copies of, records may be
released only to authorized individuals, and the RNHCI must ensure that
unauthorized individuals cannot gain access to or alter patient records.
Original patient care records must be released only in accordance with
Federal or State laws, court orders, or subpoenas.
(2) Maintain the records and information in an accurate and timely
manner.
(3) Ensure timely access by patients to the records and other
information that pertains to that patient.
(4) Abide by all Federal and State laws regarding confidentiality
and disclosure for patient care records and election information.
Sec. 403.732 Condition of participation: Quality assessment and
performance improvement.
The RNHCI must develop, implement, and maintain a quality assessment
and performance improvement program.
(a) Standard: Program scope. (1) The quality assessment and
performance improvement program must include, but is not limited to,
measures to evaluate:
(i) Access to care.
(ii) Patient satisfaction.
(iii) Staff performance.
(iv) Complaints and grievances.
(v) Discharge planning activities.
(vi) Safety issues, including physical environment.
(2) In each of the areas listed in paragraph (a)(1) of this section,
and any other areas the RNHCI includes, the RNHCI must do the following:
(i) Define quality assessment and performance improvement measures.
[[Page 56]]
(ii) Describe and outline quality assessment and performance
improvement activities appropriate for the services furnished by or in
the RNHCI.
(iii) Measure, analyze, and track performance that reflect care and
RNHCI processes.
(iv) Inform all patients, in writing, of the scope and
responsibilities of the quality assessment and performance improvement
program.
(3) The RNHCI must set priorities for performance improvement,
considering the prevalence of and severity of identified problems.
(4) The RNHCI must act to make performance improvements and must
track performance to assure that improvements are sustained.
(b) Standard: Program responsibilities. (1) The governing body,
administration, and staff are responsible for ensuring that the quality
assessment and performance improvement program addresses identified
priorities in the RNHCI and are responsible for the development,
implementation, maintenance, and performance improvement of assessment
actions.
(2) The RNHCI must include all programs, departments, functions, and
contracted services when developing, implementing, maintaining, and
evaluating the program of quality assessment and performance
improvement.
Sec. 403.734 Condition of participation: Food services.
The RNHCI must have an organized food service that is directed and
adequately staffed by qualified personnel.
(a) Standard: Sanitary conditions. The RNHCI must furnish food to
the patient that is obtained, stored, prepared, distributed, and served
under sanitary conditions.
(b) Standard: Meals. The RNHCI must serve meals that furnish each
patient with adequate nourishment in accordance with the recommended
dietary allowances of the Food and Nutrition Board of the National
Research Council, National Academy of Sciences. The RNHCI must do the
following:
(1) Furnish food that is palatable, attractive, and at the proper
temperature and consistency.
(2) Offer substitutes of similar nourishment to patients who refuse
food served or desire alternative choices.
(3) Furnish meals at regular times comparable to normal mealtimes in
the community. There must be no more than 14 hours between a substantial
evening meal and breakfast the following day.
(4) The RNHCI must offer snacks at bedtime.
Sec. 403.736 Condition of participation: Discharge planning.
The RNHCI must have in effect a discharge planning process that
applies to all patients. The process must assure that appropriate post-
institution services are obtained for each patient, as necessary.
(a) Standard: Discharge planning evaluation. (1) The RNHCI must
assess the need for a discharge plan for any patient identified as
likely to suffer adverse consequences if there is no planning and for
any other patient upon his or her request or at the request of his or
her legal representative. This discharge planning evaluation must be
initiated at admission and must include the following:
(i) An assessment of the possibility of a patient needing post-RNHCI
services and of the availability of those services.
(ii) An assessment of the probability of a patient's capacity for
self-care or of the possibility of the patient being cared for in the
environment from which he or she entered the RNHCI.
(2) The staff must complete the assessment on a timely basis so that
arrangements for post-RNHCI care are made before discharge and so that
unnecessary delays in discharge are avoided.
(3) The discharge planning evaluation must be included in the
patient's care record for use in establishing an appropriate discharge
plan. Staff must discuss the results of the discharge planning
evaluation with the patient or a legal representative acting on his or
her behalf.
(b) Standard: Discharge plan. (1) If the discharge planning
evaluation indicates a need for a discharge plan, qualified and
experienced personnel must
[[Page 57]]
develop or supervise the development of the plan.
(2) In the absence of a finding by the RNHCI that the beneficiary
needs a discharge plan, the beneficiary or his or her legal
representative may request a discharge plan. In this case, the RNHCI
must develop a discharge plan for the beneficiary.
(3) The RNHCI must arrange for the initial implementation of the
beneficiary's discharge plan.
(4) If there are factors that may affect continuing care needs or
the appropriateness of the discharge plan, the RNHCI must reevaluate the
beneficiary's discharge plan.
(5) The RNHCI must inform the beneficiary or legal representative
about the beneficiary's post-RNHCI care requirements.
(6) The discharge plan must inform the beneficiary or his or her
legal representative about the freedom to choose among providers of care
when a variety of providers is available that are willing to respect the
discharge preferences of the beneficiary or legal representative.
(c) Standard: Transfer or referral. The RNHCI must transfer or refer
patients in a timely manner to another facility (including a medical
facility if requested by the beneficiary, or his or her legal
representative) in accordance with Sec. 403.730(b)(2).
(d) Standard: Reassessment. The RNHCI must reassess its discharge
planning process on an ongoing basis. The reassessment must include a
review of discharge plans to ensure that they are responsive to
discharge needs.
[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]
Sec. 403.738 Condition of participation: Administration.
An RNHCI must have written policies regarding its organization,
services, and administration.
(a) Standard: Compliance with Federal, State, and local laws. The
RNHCI must operate in compliance with all applicable Federal, State, and
local laws, regulations, and codes including, but not limited to, those
pertaining to the following:
(1) Protection against discrimination on the basis of race, color,
national origin, age, or handicap (45 CFR parts 80, 84, and 91).
(2) Protection of human research subjects (45 CFR part 46).
(3) Application of all safeguards to protect against the possibility
of fraud and abuse (42 CFR part 455).
(4) Privacy of individually identifiable health information (45 CFR
part 164).
(b) Standard: Governing body. (1) The RNHCI must have a governing
body, or a person designated to function as a governing body, that is
legally responsible for establishing and implementing all policies
regarding the RNHCI's management and operation.
(2) The governing body must appoint the administrator responsible
for the management of the RNHCI.
(c) Standard: Affiliations and disclosure. (1) An affiliation is
permissible if it is between one of the following:
(i) An individual serving as an uncompensated director, trustee,
officer, or other member of the governing body of an RNHCI and a
provider of medical treatment or services.
(ii) An individual who is a director, trustee, officer, employee, or
staff member of an RNHCI and another individual, with whom he or she has
a family relationship, who is affiliated with (or has an ownership
interest in) a provider of medical treatment or services.
(iii) The RNHCI and an individual or entity furnishing goods or
services as a vendor to both providers of medical treatment or services
and RNHCIs.
(2) The RNHCI complies with the disclosure requirements of
Sec. Sec. 420.206 and 455.104 of this chapter.
(3) The RNHCI furnishes written notice, including the identity of
each new individual or company, to CMS at the time of a change, if a
change occurs in any of the following:
(i) Persons with an ownership or control interest, as defined in
Sec. Sec. 420.201 and 455.101 of this chapter.
(ii) The officers, directors, agents, or managing employees.
(iii) The religious entity, corporation, association, or other
company responsible for the management of the RNHCI.
[[Page 58]]
(iv) The RNHCI's administrator or director of nonmedical nursing
services.
[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]
Sec. 403.740 Condition of participation: Staffing.
The RNHCI must be staffed with qualified experienced personnel who
are present in sufficient numbers to meet the needs of the patients.
(a) Standard: Personnel qualifications. The RNHCI must ensure that
staff who supervise or furnish services to patients are qualified to do
so and that staff allowed to practice without direct supervision have
specific training to furnish these services.
(b) Standard: Education, training, and performance evaluation. (1)
The RNHCI must ensure that staff (including contractors and other
individuals working under arrangement) have the necessary education and
training concerning their duties so that they can furnish services
competently. This education includes, but is not limited to, training
related to the individual job description, performance expectations,
applicable organizational policies and procedures, and safety
responsibilities.
(2) Staff must demonstrate, in practice, the skills and techniques
necessary to perform their duties and responsibilities.
(3) The RNHCI must evaluate the performance of staff and implement
measures for improvement.
Sec. 403.742 Condition of participation: Physical environment.
A RNHCI must be designed, constructed, and maintained to ensure the
safety of the patients, staff, and the public.
(a) Standard: Buildings. The physical plant and the overall
environment must be maintained in a manner that ensures the safety and
well-being of the patients. The RNHCI must have the following:
(1) Emergency power for emergency lights, for fire detection and
alarm systems, and for fire extinguishing systems.
(2) Procedures for the proper storage and disposal of trash.
(3) Proper ventilation and temperature control and appropriate
lighting levels to ensure a safe and secure environment.
(4) A written disaster plan to address loss of power, water, sewage,
and other emergencies.
(5) Facilities for emergency gas and water supply.
(6) An effective pest control program.
(7) A preventive maintenance program to maintain essential
mechanical, electrical, and fire protection equipment operating in an
efficient and safe manner.
(8) A working call system for patients to summon aid or assistance.
(b) Standard: Patient rooms. Patient rooms must be designed and
equipped for adequate care, comfort, and privacy of the patient.
(1) Patient rooms must meet the following conditions:
(i) Accommodate no more than four patients.
(ii) Measure at least 80 square feet per patient in multiple patient
rooms and at least 100 square feet in single patient rooms.
(iii) Have direct access to an exit corridor.
(iv) Be designed or equipped to assure full visual privacy for each
patient.
(v) Have at least one window to the outside.
(vi) Have a floor at or above grade level.
(2) The RNHCI must furnish each patient with the following:
(i) A separate bed of proper size and height for the convenience of
the patient.
(ii) A clean, comfortable mattress.
(iii) Bedding appropriate to the weather and climate.
(iv) Functional furniture appropriate to the patient's needs and
individual closet space with clothes racks and shelves accessible to the
patient.
(3) CMS may permit variances in requirements specified in paragraphs
(b)(1)(i) and (ii) of this section relating to rooms on an individual
basis when the RNHCI adequately demonstrates in writing that the
variances meet the following:
(i) Are in accordance with the special needs of the patients.
(ii) Will not adversely affect patients' health and safety.
[[Page 59]]
Sec. 403.744 Condition of participation: Life safety from fire.
(a) General. An RNHCI must meet the following conditions:
(1) Except as otherwise provided in this section--
(i) The RNHCI must meet the applicable provisions of the 2000
edition of the Life Safety Code of the National Fire Protection
Association. The Director of the Office of the Federal Register has
approved the NFPA 101 [reg] 2000 edition of the Life Safety
Code, issued January 14, 2000, for incorporation by reference in
accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is
available for inspection at the CMS Information Resource Center, 7500
Security Boulevard, Baltimore, MD or at the National Archives and
Records Administration (NARA). For information on the availability of
this material at NARA, call 202-741-6030, or go to: http://
www.archives.gov/federal--register/code--of--federal--regulations/ibr--
locations.html. Copies may be obtained from the National Fire Protection
Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in
this edition of the Code are incorporated by reference, CMS will publish
notice in the Federal Register to announce the changes.
(ii) Chapter 19.3.6.3.2, exception number 2 of the adopted Life
Safety Code does not apply to an RNHCI.
(2)--(3) [Reserved]
(4) Notwithstanding any provisions of the 2000 edition of the Life
Safety Code to the contrary, the RNHCI may place alcohol-based hand rub
dispensers in its facility if--
(i) Use of alcohol-based hand rub dispensers does not conflict with
any State or local codes that prohibit or otherwise restrict the
placement of alcohol-based hand rub dispensers in health care
facilities;
(ii) The dispensers are installed in a manner that minimizes leaks
and spills that could lead to falls;
(iii) The dispensers are installed in a manner that adequately
protects against access by vulnerable populations; and
(iv) The dispensers are installed in accordance with chapter
18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety
Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued
by the Standards Council of the National Fire Protection Association on
April 15, 2004. The Director of the Office of the Federal Register has
approved NFPA Temporary Interim Amendment 00-1(101) for incorporation by
reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy
of the amendment is available for inspection at the CMS Information
Resource Center, 7500 Security Boulevard, Baltimore, MD and at the
Office of the Federal Register, 800 North Capitol Street NW., Suite 700,
Washington, DC. Copies may be obtained from the National Fire Protection
Association, 1 Batterymarch Park, Quincy, MA 02269. If any additional
changes are made to this amendment, CMS will publish notice in the
Federal Register to announce the changes.
(b) Exceptions. (1) If application of the Life Safety Code required
under paragraph (a)(1) of this section would result in unreasonable
hardship upon the RNHCI, CMS may waive specific provisions of the Life
Safety Code, but only if the waiver does not adversely affect the health
and safety of patients.
(2) If CMS finds that the fire and safety code imposed by State law
adequately protects patients in the institution, the provisions of the
Life Safety Code required in paragraph (a)(1) of this section do not
apply in that State.
(c) Phase-in period. Beginning March 13, 2006, an RNHCI must be in
compliance with Chapter 19.2.9, Emergency Lighting. Beginning March 13,
2006, Chapter 19.3.6.3.2, exception number 2 does not apply to RNHCIs.
[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 1385, Jan. 10, 2003; 69
FR 18803, Apr. 9, 2004; 69 FR 49240, Aug. 11, 2004; 70 FR 15237, Mar.
25, 2005]
Sec. 403.746 Condition of participation: Utilization review.
The RNHCI must have in effect a written utilization review plan to
assess the necessity of services furnished. The plan must provide that
records be maintained of all meetings, decisions, and actions by the
utilization review committee.
[[Page 60]]
(a) Standard: Utilization review plan. The utilization review plan
must contain written procedures for evaluating the following:
(1) Admissions.
(2) Duration of care.
(3) Continuing care of an extended duration.
(4) Items and services furnished.
(b) Standard: Utilization review committee. The committee is
responsible for evaluating each admission and ensuring that the
admission is necessary and appropriate. The utilization review plan must
be carried out by the utilization review committee, consisting of the
governing body, administrator or other individual responsible for the
overall administration of the RNHCI, the supervisor of nursing staff,
and other staff as appropriate.
(c) Standard: Utilization review committee role in RNHCI home
services. In addition to the requirements in paragraphs (a) and (b) of
this section, the utilization review committee is responsible for:
(1) The admission, and at least every 30 days, the continued care
review of each patient in the RHNCI home services program.
(2) Oversight and monitoring of the home services program, including
the purchase and utilization of designated durable medical equipment
items for beneficiaries in the program.
[64 FR 67047, Nov. 30, 1999, as amended at 69 FR 66419, Nov. 15, 2004]
Sec. 403.750 Estimate of expenditures and adjustments.
(a) Estimates. CMS estimates the level of expenditures for services
provided under this subpart before the start of each FFY beginning with
FFY 2000.
(b) Adjustments to payments. When the level of estimated
expenditures is projected to exceed the FFY trigger level as described
in paragraph (d) of this section, for the year of the projection,
payments to RNHCIs will be reduced by a proportional percentage to
prevent estimated expenditures from exceeding the trigger level. In
addition to reducing payments proportionally, CMS may impose alternative
adjustments.
(c) Notification of adjustments. CMS notifies participating RNHCIs
before the start of the FFY of the type and level of expenditure
reductions to be made and when these adjustments will apply.
(d) Calculation of trigger level. The trigger level for FFY 1998 is
$20,000,000. For subsequent FFYs, the trigger level is the unadjusted
trigger level increased or decreased by the carry forward as described
in Sec. 403.754(b). The unadjusted trigger level is the base year
amount (the unadjusted trigger level dollar amount for the prior FFY)
increased by the average consumer price index (the single numerical
value published monthly by the Bureau of Labor Statistics that presents
the relationship in United States urban areas for the current cost of
goods and services compared to a base year, to represent the change in
spending power) for the 12-month period ending on July 31 preceding the
beginning of the FFY.
Sec. 403.752 Payment provisions.
(a) Payment to RNHCIs. Payment for services may be made to an RNHCI
that meets the conditions for coverage described in Sec. 403.720 and
the conditions of participation described in Sec. Sec. 403.730 through
403.746. Payment is made in accordance with Sec. 413.40 of this chapter
to an RNHCI meeting these conditions.
(b) Review of estimates and adjustments. There is no administrative
or judicial review of the level of estimated expenditures or the
adjustments in payments described in Sec. Sec. 403.750(a) and (b).
(c) Effect on beneficiary liability. When payments are reduced in
accordance with Sec. 403.750(b), the RNHCI may bill the beneficiary the
amount of the Medicare reduction attributable to his or her covered
services.
(d) Notification of beneficiary liability. (1) The RNHCI must notify
the beneficiary in writing at the time of admission of any proposed or
current proportional Medicare adjustment. A beneficiary currently
receiving care in the RNHCI must be notified in writing at least 30 days
before the Medicare reduction is to take effect. The notification must
inform the beneficiary that the RNHCI can bill him or her for the
proportional Medicare adjustment.
(2) The RNHCI must, at time of billing, provide the beneficiary with
his or her liability for payment, based on a
[[Page 61]]
calculation of the Medicare reduction pertaining to the beneficiary's
covered services permitted by Sec. 403.750(b).
Sec. 403.754 Monitoring expenditure level.
(a) Tracking expenditures. Starting in FFY 1999 CMS begins
monitoring Medicare payments to RNHCIs.
(b) Carry forward. The difference between the trigger level and
Medicare expenditures for a FFY results in a carry forward that either
increases or decreases the unadjusted trigger level described in Sec.
403.750(d). In no case may the carry forward exceed $50,000,000 for an
FFY.
Sec. 403.756 Sunset provision.
(a) Effective date. Beginning with FFY 2002, if the level of
estimated expenditures for all RNHCIs exceeds the trigger level for 3
consecutive FFYs, CMS will not accept as the basis for payment of any
claim any election executed on or after January 1 of the following
calendar year.
(b) Notice of activation. A notice in the Federal Register will be
published at least 60 days before January 1 of the calendar year that
the sunset provision becomes effective.
(c) Effects of sunset provision. Only those beneficiaries who have a
valid election in effect before January 1 of the year in which the
sunset provision becomes effective will be able to claim Medicare
payment for care in an RNHCI, and only for RNCHI services furnished
during that election.
Sec. 403.764 Basis and purpose of religious nonmedical health care
institutions providing home service.
(a) Basis. This subpart implements sections 1821, 1861, 1861(e),
1861(m), 1861(y), 1861(ss) and 1861(aaa), 1869 and 1878 of the Act
regarding Medicare payment for items and services provided in the home
setting furnished to eligible beneficiaries by religious nonmedical
health care institutions (RNHCIs).
(b) Purpose. The home benefit provides for limited durable medical
equipment (DME) items and RNHCI services in the home setting that are
fiscally limited to $700,000 per calendar year, with an expiration date
of December 31, 2006, or the date on which the 2006 spending limit is
reached.
[69 FR 66419, Nov. 15, 2004]
Sec. 403.766 Requirements for coverage and payment of RNHCI home
services.
(a) Medicare Part A pays for RNHCI home services if the RNHCI
provider does the following:
(1) Submit a notice of intent to CMS to exercise the option of
providing home service.
(2) Provide RNHCI services to eligible beneficiaries,
(3) Arrange with suppliers to furnish appropriate DME items as
required to meet documented eligible beneficiary needs.
(4) Arrange for RNHCI nurse home visits to eligible beneficiaries.
(5) Have a utilization committee that assumes the additional
responsibility for the oversight and monitoring of the items and RNHCI
nursing services provided under the home benefit.
(6) Meet all applicable requirements set forth in subpart G of this
part.
(b) To be an eligible beneficiary to RNHCI home services the
beneficiary must:
(1) Have an effective election in place.
(2) Be confined to the home, as specified in Sec. 409.42(a) of this
chapter.
(3) Have a condition that makes him or her eligible to receive
services covered under Medicare home health.
(4) Receive home services and DME items from a RNHCI.
(5) Be responsible for deductible and coinsurance for DME, as
specified in Sec. 409.50 of this chapter.
[69 FR 66419, Nov. 15, 2004, as amended at 70 FR 16721, Apr. 1, 2005]
Sec. 403.768 Excluded services.
In addition to items and services excluded in Sec. 409.49 of this
chapter, items and services are also excluded if they are provided by:
(a) A HHA that is not a RNHCI.
(b) A supplier who is not providing RNHCI designated items under
arrangement with a RNHCI.
[[Page 62]]
(c) A nurse who is not providing RNHCI home nursing services under
arrangement with a RNHCI.
[69 FR 66419, Nov. 15, 2004]
Sec. 403.770 Payments for home services.
(a) The RNHCI nursing visits are paid at the modified low
utilization payment adjusted (LUPA) rate used under the home health
prospective payment system at Sec. 484.230 of this chapter.
(b) Appropriate DME items are paid as priced by Medicare, minus the
deductible and coinsurance liability of the beneficiary.
[69 FR 66419, Nov. 15, 2004]
Subpart H_Medicare Prescription Drug Discount Card and Transitional
Assistance Program
Source: 68 FR 69915, Dec. 15, 2003, unless otherwise noted.
Sec. 403.800 Basis and scope.
(a) Basis. This subpart is based on section 1860D-31 of the Social
Security Act (the Act).
(b) Scope. This subpart sets forth the standards and procedures CMS
uses to implement the Medicare Prescription Drug Discount Card and
Transitional Assistance Program.
Sec. 403.802 Definitions.
For purposes of this subpart, the following definitions apply:
Affiliated organization means an organization that is a legally
separate entity from the endorsed drug card sponsor and meets one of the
following conditions:
(1) The organization and the endorsed drug card sponsor are under
common control. Common control exists if another entity has the power,
directly or indirectly, to significantly influence or direct the actions
or policies of the organization and the endorsed drug card sponsor.
(2) The organization is under the control of the endorsed drug card
sponsor or the organization controls the endorsed drug card sponsor.
Control exists if an entity has the power, directly or indirectly, to
significantly influence or direct the actions or policies of another
entity.
(3) The organization possesses an ownership or equity interest of 5
percent or more in the endorsed drug card sponsor on both the date on
which the endorsed drug card sponsor markets the organization's Part D
plan, and the date on which the endorsed drug card sponsor signed its
endorsement contract with CMS.
Annual coordinated election period means the period beginning on
November 15, 2004 and ending on December 31, 2004, during which a
discount card enrollee may elect to disenroll from their current
endorsed discount card program and elect enrollment in another endorsed
discount card program effective January 1, 2005.
Applicant means the non-governmental, single legal organization or
entity doing business in the United States that is applying for Medicare
endorsement of its prescription drug discount card program, as described
in its application, to be operated by itself or in coordination with
subcontractors.
Application means the document submitted to CMS by an applicant that
seeks to demonstrate the applicant's compliance with the requirements
specified in this subpart in order to obtain Medicare endorsement of the
applicant's prescription drug discount card program.
Authorized representative means a person with legal authority to act
on behalf of an individual in making decisions related to the
individual's health care or the individual's enrollment in,
disenrollment from, and access to negotiated prices and transitional
assistance under the Medicare Prescription Drug Discount Card and
Transitional Assistance Program.
Covered discount card drug means any of the following: a drug that
may be dispensed only upon a prescription and that is described in
sections 1927(k)(2)(A)(i) through (iii) of the Act; a biological product
described in sections 1927(k)(2)(B)(i) through (iii) of the Act; insulin
described in section 1927(k)(2)(C) of the Act; the following medical
supplies associated with the injection of insulin: syringes, needles,
alcohol swabs, and gauze; a vaccine licensed under section 351 of the
Public
[[Page 63]]
Health Service Act; or any use of a covered discount card drug for a
medically accepted indication (as defined in section 1927(k)(6) of the
Act). The definition of covered discount card drug excludes the
following: agents when used for anorexia, weight loss, or weight gain;
agents when used to promote fertility; agents when used for cosmetic
purposes or hair growth; agents when used for the symptomatic relief of
cough and colds; prescription vitamins and mineral products, except
prenatal vitamins and fluoride preparations; nonprescription drugs;
outpatient drugs for which the manufacturer seeks to require that
associated tests or monitoring services be purchased exclusively from
the manufacturer or its designee as a condition of sale; barbiturates;
and benzodiazepines.
Discount card enrollee or enrollee or card enrollee means an
individual described in Sec. 403.810(a) who elects to enroll in a
Medicare-endorsed prescription drug discount card program.
Effective date means the date on which an enrollment or
disenrollment transaction becomes effective.
Enrollment period means the period beginning on the initial
enrollment date and ending on December 31, 2005.
Exclusive card program means an endorsed discount card program that
is offered by an exclusive card sponsor.
Exclusive card sponsor means an endorsed sponsor that also operates
one or more Medicare managed care plans and limits enrollment in its
endorsed discount card program to individuals described in Sec.
403.810(a) who are enrollees in one of the Medicare managed care plans
it offers.
Family size means one for individuals who are single, and two for
individuals who are married.
Federal Employee's Health Benefits Program plan means a plan under
chapter 89 of title 5 of the United States Code including the Retired
Federal Employee's Health Benefits Program.
Formulary means the list of specific drugs from among covered
discount card drugs for which an endorsed sponsor offers negotiated
prices to Medicare beneficiaries enrolled in its Medicare-endorsed
prescription drug discount card program.
Group enrollment means simultaneous enrollment of all or some of the
individuals described in sectioin 403.810(a) who are members of a
Medicare managed care plan into the exclusive card program offered by
the Medicare managed care organization.
HIPAA means the Health Insurance Portability and Accountability Act
of 1996, 42 U.S.C. 1320d and section 264 of Public Law 104-191.
Income means the components of an individual's adjusted gross income
(AGI), as defined under 26 U.S.C. section 62, and, to the extent not
included in the components of AGI, retirement and disability benefits,
or, if he or she is married, the sum of such income for the individual
and his or her spouse.
Initial enrollment date means the date established by the Secretary
on which endorsed sponsors may begin accepting beneficiaries' standard
enrollment forms.
Initial enrollment year means the period beginning on the initial
enrollment date and ending on December 31, 2004.
I/T/U pharmacy means a pharmacy operated by the Indian Health
Service, an Indian tribe or tribal organization, or an urban Indian
organization, all of which are defined in section 4 of the Indian Health
Care Improvement Act, 25 U.S.C. 1603.
Long-term care facility means a skilled nursing facility, as defined
in section 1819(a) of the Act, or nursing facility, as defined in
section 1919(a) of the Act.
Long-term care pharmacy means a pharmacy owned by or under contract
with a long-term care facility to provide prescription drugs to the
facility's residents.
Medicare cost plan means an organization that offers enrollment
under a reasonable cost reimbursement contract under section 1876(h) of
the Act.
Medicare managed care organization means a Part C organization
offering a Part C plan described in section 1851(a)(2)(A) of the Act or
a Medicare cost plan.
Medicare managed care plan means a plan described in section
1851(a)(2)(A) of the Act offered by a Part C organization or a Medicare
cost plan.
[[Page 64]]
Medicare Prescription Drug Discount Card and Transitional Assistance
Program or Medicare Drug Discount Card Program means the program
established under section 1860D-31 of the Act.
Medicare-endorsed prescription drug discount card program, or
endorsed program, or endorsed discount card program means any
prescription drug discount card program that has received Medicare
endorsement and whose endorsed sponsor has entered into a contract with
CMS.
Medicare-endorsed prescription drug discount card sponsor, or
endorsed sponsor, or endorsed discount card sponsor means any applicant
that has received endorsement from Medicare and entered into a contract
with CMS to operate an approved Medicare-endorsed discount card program.
Negotiated price means the discounted price for a covered discount
card drug offered by an endorsed sponsor, including any dispensing fee,
which takes into account negotiated price concessions, such as
discounts, direct or indirect subsidies, rebates, and direct or indirect
remunerations.
Network pharmacy means a licensed pharmacy that is not a mail order
pharmacy and that is under contract with an endorsed sponsor to provide
negotiated prices to its card enrollees and accept transitional
assistance as payment for covered discount card drugs provided to its
transitional assistance enrollees.
New Medicare managed care organization means an entity applying for
approval to enter into a new contract with CMS to offer a new,
coordinated care plan or plans as described in section 1851(a)(2)(A) of
the Act under Medicare Part C and an exclusive card program under the
Medicare Drug Discount Card Program.
Over-the-counter drug means a non-prescription drug.
Part C organization means an organization offering a Part C plan.
Part C plan means a plan described in section 1859(b)(1) of the Act.
Part D plan has the meaning given the term at Sec. 423.4.
Pharmacy network means the group of network pharmacies under
contract with an endorsed sponsor.
Poverty line means the income level defined in section 673(2) of the
Community Services Block Grant Act, 42 U.S.C. 9902(2), including any
revision required by such section, applicable to the family size
involved.
Rural means a five-digit zip code in which the population density is
less than 1000 persons per square mile.
Second enrollment year means the period beginning on January 1, 2005
and ending on December 31, 2005.
Solicitation means the application materials identified in the
notice CMS publishes in the Federal Register announcing its intention to
accept and consider applications from applicants seeking Medicare
endorsement for their prescription drug discount card programs.
Special election period means the period beginning the day after the
effective date of an individual's disenrollment from an endorsed
discount card program for one of the reasons listed in Sec.
403.811(b)(2). The length of any given election period will be specified
by CMS in a form and manner that supports the goals of the Medicare Drug
Discount Card Program.
Special endorsed sponsor means an endorsed sponsor who has received
special endorsement by CMS.
Special endorsement means an endorsement granted under Sec. 403.816
or Sec. 403.817.
Standard enrollment form means an enrollment form or other approved
process for enrolling individuals into an endorsed program that
incorporates the standard elements provided by CMS.
Subcontractor means an organization or entity doing business in the
United States with which an applicant or endorsed sponsor enters into a
contract or other legal arrangement in connection with the operation of
a prescription drug discount card program.
Suburban means a five-digit zip code in which the population density
is between 1000 and 3000 persons per square mile.
Transition period means the period beginning on January 1, 2006 and
ending, for individuals enrolled for coverage under Part D, on the
effective date of the individual's coverage, and for individuals not so
enrolled, on the last day
[[Page 65]]
of the initial Part D open enrollment period.
Transitional assistance means a subsidy that transitional assistance
enrollees may apply toward the cost of covered discount card drugs in
the manner described in Sec. 403.808(d).
Transitional assistance effective date means the date on which a
transitional assistance enrollee can access transitional assistance.
Transitional assistance enrollee means an individual described in
Sec. 403.810(b) who has applied for and been determined eligible for
transitional assistance and has enrolled in a discount card program.
Urban means a five-digit zip code in which the population density is
greater than 3000 persons per square mile.
[68 FR 69915, Dec. 15, 2003, as amended at 70 FR 52022, Sept. 1, 2005]
Sec. 403.804 General rules for solicitation, application and Medicare
endorsement period.
(a) Application. (1) Except as provided in paragraph (a)(2) of this
section, an applicant must submit an application to CMS by the deadline
announced in the solicitation to be eligible for Medicare endorsement of
its prescription drug discount card program. The applicant must certify
that based on best knowledge, information, and belief, the reported
information is accurate, complete, truthful, and supportable.
(2) A new Medicare managed care organization may simultaneously
apply to offer a new Part C plan or plans and an exclusive card program
after the deadline announced in the solicitation. New Medicare managed
care organizations seeking endorsement of their prescription drug
discount card programs must submit an application to CMS at the time
that they submit their Part C applications. New Medicare managed care
organizations will be eligible for endorsement provided CMS approves
their Part C application, the new Medicare managed care organizations
demonstrate to CMS that they meet the criteria under paragraph (b) of
this section, and the new Medicare managed care organizations
demonstrate that they will meet the requirements of paragraph (e)(2) of
this section.
(b) Eligibility to receive endorsement. Except as specified in
Sec. Sec. 403.814, 403.816 and 403.817, an applicant will be eligible
for endorsement if its application demonstrates to CMS's satisfaction
that the applicant meets the requirements of Sec. 403.806(a) and Sec.
403.806(b)(1) and that it would operate its endorsed program in a manner
consistent with the requirements of Sec. 403.806(b)(2) and (b)(3)
through Sec. 403.806(m). An applicant that submits a complete
application that meets all of the requirements of this subpart will be
eligible to enter into a contract with CMS to operate a Medicare-
endorsed prescription drug discount card program. Following the receipt
of its Medicare endorsement, an endorsed sponsor must comply with the
requirements of Sec. 403.806(b)(2) and (b)(3) through Sec. 403.806(m)
through the end of the transition period.
(c) Ability to subcontract with other organizations and entities.
(1) An applicant for endorsement may demonstrate that it meets the
requirements of this subpart by combining with subcontractors.
(2) Any subcontracts must be in final form satisfactory to CMS,
signed by all applicable parties, and filed with CMS before an endorsed
sponsor will be permitted to engage in any enrollment or information and
outreach.
(3) Once endorsed, an endorsed sponsor must ensure that its
subcontractors comply with all applicable requirements of this subpart.
(d) Period of endorsement. An applicant eligible to receive
endorsement will be required to sign a contract with CMS agreeing to
operate its approved Medicare-endorsed prescription drug discount card
program(s) until the end of the transition period.
(e)(1) Except as provided in paragraph (e)(2) of this section, we
expect an endorsed sponsor to be ready by June 8, 2004, to initiate
enrollment and fully operate its endorsed program in compliance with the
requirements of Sec. 403.806(b)(2) and (b)(3) through Sec. 403.806(m).
(2) A new Medicare managed care organization must be ready to
initiate enrollment and fully operate its exclusive card program in
compliance with the requirements of Sec. Sec. 403.806(b)(2) and
[[Page 66]]
(b)(3) through Sec. 403.806(m) upon approval of its Part C application
and application for Medicare endorsement of its prescription drug
discount card program.
Sec. 403.806 Sponsor requirements for eligibility for endorsement.
Except as specified in Sec. 403.814, Sec. 403.816, and Sec.
403.817, an endorsed sponsor must meet the following requirements:
(a) Applicant experience. (1) An applicant must be a non-
governmental, single legal entity doing business in the United States.
(2) An applicant must have 3 years of private sector experience in
the United States in pharmacy benefit management, which is defined to
mean--
(i) Adjudicating and processing claims for drugs at the point of
sale;
(ii) Negotiating with prescription drug manufacturers and others for
discounts, rebates, and/or other price concessions on prescription
drugs; and
(iii) Administering and tracking individuals' subsidies or benefits
in real time.
(3) A single legal entity which is either the applicant or a
subcontractor must, at the time of application for Medicare endorsement,
operate a pharmacy benefit program, a prescription drug discount card
program, a low-income drug assistance program, or a similar program that
serves at least 1 million covered lives.
(b) Financial stability and business integrity. (1) An applicant
must demonstrate a satisfactory record of the financial stability and
business integrity of itself, any subcontractors on whom the applicant
relies to satisfy the 3 years experience requirement in paragraph (a)(2)
of this section and the 1 million covered lives requirement in paragraph
(a)(3) of this section, and any subcontractors engaged by the applicant
to perform the following activities: develop the pharmacy network;
negotiate with manufacturers or pharmacies for rebates, discounts, or
other price concessions; handle eligibility for or enrollment in the
endorsed sponsor's endorsed discount card program and/or transitional
assistance; and administer transitional assistance.
(2) An endorsed sponsor and any subcontractors described in
paragraph (b)(1) of this section must maintain a satisfactory record of
financial stability and business integrity during the term of the
endorsed program.
(3) Medicare endorsement of a discount card program shall not be
construed to express or imply any opinion that an endorsed sponsor or
any subcontractor of an endorsed sponsor is in compliance with or not
liable under the False Claims Act, anti-kickback statute (section
1128B(b) of the Act), or other legal authorities for any improper
billing, claims submission, or related conduct.
(c) Compliance with applicable law. An endorsed sponsor must comply
with all applicable Federal and State laws, including the Federal anti-
kickback statute (section 1128B(b) of the Act).
(d) Prescription drug offering. An endorsed sponsor must comply with
the following discount, rebate, and formulary requirements:
(1) Offer all of its discount card enrollees negotiated prices on
covered discount card drugs, which may be limited to those covered
discount card drugs included on the endorsed sponsor's formulary.
(2) If the endorsed sponsor uses a formulary, offer a negotiated
price on at least one covered discount card drug in each of the lowest
level categories for each of the therapeutic groups representing the
drugs most commonly needed by Medicare beneficiaries as determined by
CMS. A specific covered discount card drug may not be used to fulfill
this requirement for more than one category.
(3) Offer a negotiated price on a generic drug in at least 55
percent of the lowest level categories in each of the therapeutic groups
representing the drugs most commonly needed by Medicare beneficiaries as
determined by CMS.
(4) In setting negotiated prices under this section, an endorsed
sponsor may vary its prices and the drugs included on the formulary by
pharmacy contract and enrollee characteristics, such as transitional
assistance eligibility status.
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(5) Synchronize changes in the list of, and negotiated prices for,
covered discount card drugs included in the endorsed sponsor's formulary
with formulary and negotiated prices published on a price comparison Web
site, as described in paragraph (i)(4)(v) of this section.
(6) Obtain rebates, discounts, or other price concessions from
manufacturers on covered discount card drugs and pass a share of such
concessions to enrollees through negotiated prices.
(7) Guarantee that network and mail order pharmacies provide the
lower of the negotiated price or usual and customary price when a
covered discount card drug for a negotiated price is available at the
point of sale.
(8) Guarantee that a network pharmacy, at the point of sale, inform
a discount card enrollee of any differential between the price of a
prescribed drug (if it is a covered discount card drug) and the price of
the lowest priced generic covered discount card drug that is
therapeutically equivalent and bioequivalent and available at such
pharmacy. Mail order pharmacies are to provide this information at the
time of delivery of the drug.
(9) Except during the week of November 15, 2004 (which coincides
with the beginning of the annual coordinated election period), ensure
that any increase in the negotiated price for a covered discount card
drug does not exceed an amount proportionate to the change in the drug's
average wholesale price (AWP), and/or an amount proportionate to the
changes in the endorsed sponsor's cost structure, including material
changes to any discounts, rebates, or other price concessions the
endorsed sponsor receives from a pharmaceutical manufacturer or
pharmacy.
(e) Transitional assistance administration. An endorsed sponsor must
administer transitional assistance funds, including any roll-over funds
as described in Sec. 403.808(f), for transitional assistance enrollees,
through the following procedures:
(1) Establish accounting procedures to manage the transitional
assistance funds for each transitional assistance enrollee.
(2) Ensure that transitional assistance funds are applicable to, and
only to, all covered discount card drugs available at the endorsed
sponsors' network and mail order pharmacies, regardless of formulary.
(3) Ensure that, at network and mail order pharmacies, transitional
assistance funds are applied at the lower of negotiated price (if any)
and the pharmacy's usual and customary price.
(4) Ensure that network pharmacies make available to the
transitional assistance enrollee, electronically or by telephone, at the
point-of-sale of covered discount card drugs, the amount of transitional
assistance remaining available to the transitional assistance enrollee.
Mail order pharmacies are to make this information available by
telephone.
(5) Maintain a toll-free telephone number that discount card
enrollees may use to determine their transitional assistance balances.
(6) Enforce coinsurance requirements described in Sec. 403.808(e)
and ensure that the portion of the price paid through coinsurance is not
deducted from the total transitional assistance funds available to the
discount card enrollee.
(f) Service area and pharmacy access. An endorsed sponsor must meet
the following requirements for its service area and its pharmacy
network:
(1) The service area must cover one or more States.
(2) The endorsed sponsor's discount card program must be available
to all eligible individuals residing in each State in the endorsed
sponsor's service area and may not be offered to individuals residing
outside of the United States.
(3) The endorsed sponsor must have a contracted pharmacy network,
consisting of pharmacies other than mail-order pharmacies, sufficient to
ensure that for beneficiaries residing in the endorsed sponsor's service
area the following requirements are satisfied:
(i) At least 90 percent of Medicare beneficiaries, on average, in
urban areas served by the endorsed program, live within 2 miles of a
network pharmacy;
(ii) At least 90 percent of Medicare beneficiaries, on average, in
suburban areas served by the endorsed program, live within 5 miles of a
network pharmacy; and
[[Page 68]]
(iii) At least 70 percent of Medicare beneficiaries, on average, in
rural areas served by the endorsed program, live within 15 miles of a
network pharmacy.
(4) The endorsed sponsor's pharmacy network may be supplemented by
pharmacies offering home delivery via mail-order, provided the
requirements of paragraph (f)(3) of this section are met.
(g) Information and outreach and customer service. (1) An endorsed
sponsor must provide through the Internet and some other tangible medium
(such as a mailing) to Medicare beneficiaries information and outreach
materials describing its endorsed drug card program, including the
following information--
(i) The enrollment fee;
(ii) Negotiated prices offered for covered discount card drugs;
(iii) If offered, discounts on over-the-counter drugs;
(iv) Any other products or services offered under the endorsement;
and
(v) Any other information that CMS determines is necessary for a
full description of the endorsed discount drug card program.
(2) An endorsed sponsor must include on a Web site the following:
(i) Information regarding when the Web site was last updated; and
(ii) A disclaimer that the information on the Web site may not be
current.
(3) An endorsed sponsor must use the following forms which
incorporate standard elements provided by CMS:
(i) An enrollment form (except as may be modified for an exclusive
card sponsor as discussed in Sec. 403.814(b)(5)(iii); and
(ii) An eligibility determination notice.
(4) An endorsed sponsor must provide to each enrollee a card that
complies with National Council for Prescription Drug Programs standards.
(5) An endorsed sponsor must meet the following requirements for the
review and approval of information and outreach materials:
(i) Comply with the Information and Outreach Guidelines published by
CMS except as provided in paragraph (g)(5)(vi) of this section.
(ii) Except as provided in paragraph (g)(5)(iii) of this section,
not distribute any information and outreach materials until or unless
they are approved by CMS.
(iii) If CMS does not disapprove the initial submission of
information and outreach materials within 30 days of receipt of these
materials, the materials are deemed approved under paragraph (g)(5)(ii)
of this section.
(iv) Information and outreach materials may discuss only products or
services inside the scope of endorsement, as described in paragraph (h)
of this section.
(v) Information and outreach materials include the same kinds of
materials described in 42 CFR 422.80(b), as well as the enrollment form,
eligibility determination form, and membership card described in
paragraphs (g)(3) and (g)(4) of this section, Web site content, and
information regarding discounts for over-the-counter drugs.
(vi) All materials related to products and services that are Part D
plans must comply with the requirements specified in Sec. 423.50 of
this chapter.
(6) An endorsed sponsor must maintain a toll-free customer call
center that is open during usual business hours and that provides
customer telephone service, including to pharmacists, in accordance with
standard business practices. The endorsed sponsor must inform enrollees
that the toll-free telephone number provides information on the amount
of remaining transitional assistance, in accordance with paragraph
(e)(5) of this section.
(7) An endorsed sponsor must provide a system to reduce the
likelihood of medical errors and adverse drug interactions and to
improve medication use.
(h) Products and services inside and outside the scope of the
endorsement. (1) An endorsed sponsor may provide, under the endorsement,
only those products and services inside the scope of the endorsement,
including conducting enrollment. An endorsed sponsor must ensure that
discount card enrollees are not charged any additional fee (other than
the enrollment fee allowed under Sec. 403.811(c)) for products or
services inside the scope of the endorsement.
[[Page 69]]
(2) Products and services inside the scope of the endorsement are
limited to--
(i) Products or services offered for no additional fee, other than
the enrollment fee allowed under Sec. 403.811(c), that are directly
related to a covered discount card drug; or
(ii) A discounted price for an over-the-counter drug.
(i) Reporting. (1) An endorsed sponsor must report to CMS on a
periodic basis information on the major features of the endorsed
sponsor's programs that correspond to the qualifications for
endorsement, including, but not limited to, information concerning--
(i) Savings from pharmacies and manufacturers obtained through
rebates, discounts, and other price concessions;
(ii) Savings shared with discount card enrollees by manufacturer, by
all retail pharmacies, by all mail order pharmacies, and by all brand
name and all generic covered discount card drugs;
(iii) Dispensing fees;
(iv) Certified (by the chief financial officer) financial accounting
records on transitional assistance used by the transitional assistance
enrollees in each month;
(v) Participant utilization and spending statements;
(vi) Utilization and spending for selected drugs;
(vii) Performance on customer service metrics such as call center
performance;
(viii) Grievance logs; and
(ix) Endorsed sponsor's compliance with the pharmacy network access
standards.
(2) An endorsed sponsor must provide notice of, and the rationale
for, negotiated price increases, except for increases during the week of
November 15, 2004, due to reasons other than changes in average
wholesale price (AWP).
(3) An endorsed sponsor must certify that based on best knowledge,
information, and belief, the reported information is accurate, complete,
truthful, and supportable.
(4) Through a price comparison Web site, an endorsed sponsor must
report the following information:
(i) Customer service hours;
(ii) Customer service contact information;
(iii) Endorsed program Web site address;
(iv) Annual enrollment fee; and
(v) Negotiated prices (including any applicable dispensing fee), for
every covered discount card drug included in the discount card program's
offering.
(5) CMS may require endorsed sponsors to submit, in standard
terminology, descriptions of other discount card related services they
provide, such as pharmacist services.
(j) Grievance process. An endorsed sponsor must establish and
maintain a grievance process. This process must be designed to track and
appropriately address in a timely manner enrollees' complaints about any
aspect of their endorsed program for which the endorsed sponsor is
responsible.
(k) Eligibility, enrollment, and disenrollment. (1) An endorsed
sponsor must make preliminary eligibility determinations in accordance
with Sec. 403.810 and conduct enrollment and disenrollment in
accordance with Sec. 403.811.
(l) Authorized representative. An endorsed sponsor must treat an
individual's authorized representative as the individual, if under
applicable law, the authorized representative has the legal authority to
act on behalf of the individual with respect to the action at issue.
(m) Other. An endorsed sponsor must meet the requirements of
Sec. Sec. 403.812, 403.813, and 403.822 of this subpart.
[68 FR 69915, Dec. 15, 2003, as amended at 70 FR 52023, Sept. 1, 2005]
Sec. 403.808 Use of transitional assistance funds.
(a) Individuals determined eligible for transitional assistance in
2004. Subject to paragraph (d) of this section, an individual who, in
calendar year 2004, is determined eligible for transitional assistance
under Sec. 403.810(b) is entitled to the following:
(1) $600 in calendar year 2004; and
(2) $600 in calendar year 2005.
(b) Individuals determined eligible for transitional assistance in
2005. Subject to
[[Page 70]]
paragraph (d) of this section, an individual who, in calendar year 2005,
is determined eligible for transitional assistance under Sec.
403.810(b) is entitled to one of the following amounts for calendar year
2005:
(1) If the complete application for the individual's transitional
assistance eligibility is received on or after January 1, 2005 and
before April 1, 2005, $600.
(2) If the complete application for the individual's transitional
assistance eligibility is received on or after April 1, 2005 and before
July 1, 2005, $450.
(3) If the complete application for the individual's transitional
assistance eligibility is received on or after July 1, 2005 and before
October 1, 2005, $300.
(4) If the complete application for the individual's transitional
assistance eligibility is received on or after October 1, 2005 and on or
before December 31, 2005, $150.
(c) Payment of enrollment fee. An individual found eligible for
transitional assistance is entitled to have CMS pay the annual
enrollment fee to the endorsed sponsor on his or her behalf.
(d) Conditions on use of transitional assistance. A transitional
assistance enrollee may access the transitional assistance described in
paragraphs (a) and (b) of this section only if the following conditions
are met:
(1) Except as provided in Sec. 403.814(b)(3)(v), the transitional
assistance funds are applied toward the cost of a covered discount card
drug obtained under the Medicare Prescription Drug Discount Card and
Transitional Assistance Program;
(2) The individual pays a coinsurance amount in accordance with
Sec. 403.808(e);
(3) The individual purchases the covered discount card drug on or
after the individual's transitional assistance effective date; and
(4) The individual is enrolled in the Medicare Prescription Drug
Discount Card and Transitional Assistance Program on the date the
individual's claim for the covered discount card drug is adjudicated.
(e) Coinsurance. If sufficient transitional assistance funds are
available, transitional assistance funds must be expended in accordance
with the following:
(1) For beneficiaries with incomes at or below 100 percent of the
poverty line, 95 percent of the price of a covered discount card drug
must be paid from the available transitional assistance funds.
(2) For beneficiaries with incomes greater than 100 percent but at
or below 135 percent of the poverty line, 90 percent of the price of a
covered discount card drug must be paid from the available transitional
assistance funds.
(f) Rollover. An individual with transitional assistance retains
access to any balance of transitional assistance not expended in a
calendar year during the next calendar year, up to and including the
transition period, if the individual--
(1) Remains in his or her current endorsed discount card program;
(2) Elects a new endorsed program in an Annual Coordinated Election
Period; or
(3) Is eligible for a Special Election Period under Sec.
403.811(b)(2) and elects a new endorsed discount card program during
such Special Election Period.
Sec. 403.810 Eligibility and reconsiderations.
(a) Eligibility for an endorsed discount card program. An individual
is eligible to enroll in an endorsed discount card program only if such
individual meets the following conditions:
(1) The individual is entitled to benefits, or enrolled, under
Medicare Part A or enrolled under Medicare Part B; and
(2) The individual, at the time of applying to enroll in an endorsed
discount card program, is not enrolled in a State medical assistance
program under Title XIX of the Act or under a waiver pursuant to section
1115 of the Act, under which the individual is entitled to any medical
assistance for outpatient prescribed drugs as described in section
1905(a)(12) of the Act, except as allowed in Sec. 403.817(d).
(b) Eligibility for transitional assistance. An individual is
eligible to receive transitional assistance if, at the time of applying
for transitional assistance, the individual meets the following
conditions:
(1) The individual meets the conditions in paragraph (a) of this
section;
[[Page 71]]
(2) The individual resides in one of the 50 States or the District
of Columbia;
(3) The individual's income is not more than 135 percent of the
poverty line applicable to the individual's family size;
(4) The individual does not have coverage for covered discount card
drugs under one or more of the following sources:
(i) A group health plan or health insurance coverage, as these terms
are defined under section 2791 of the Public Health Service Act, other
than a Part C plan or a group health plan consisting solely of excepted
benefits (such as a Medigap plan) as the term is defined under section
2791 of the Public Health Service Act;
(ii) Coverage provided under Chapter 55 of Title 10, United States
Code, including TRICARE; or
(iii) A Federal Employee's Health Benefits Program plan; and
(5) The individual (or the individual's authorized representative)
completes a standard enrollment form and signs and dates the form in
accordance with Sec. 403.811(a)(4). By signing the form, the individual
(or the individual's authorized representative) certifies, under penalty
of perjury, that, to the best of the individual's knowledge, the
information he or she provides on the form is accurate.
(c) Special rule for QMBs, SLMBs and QIs. An individual is deemed to
meet the income requirements in paragraph (b)(3) of this section if the
individual is enrolled under Title XIX of the Act as a--
(1) Qualified Medicare Beneficiary (QMB);
(2) Specified Low-Income Medicare Beneficiary (SLMB); or
(3) Qualified Individual (QI).
(d) Duration of eligibility determinations. An individual determined
eligible for the Medicare Prescription Drug Discount Card and
Transitional Assistance Program and, in the case of transitional
assistance enrollees, for transitional assistance, shall remain eligible
for the Medicare Prescription Drug Discount Card and Transitional
Assistance Program and, in the case of transitional assistance
enrollees, for transitional assistance for the duration of the
individual's enrollment in the Medicare Prescription Drug Discount Card
and Transitional Assistance Program.
(e) Drug card and transitional assistance benefits not treated as
benefits under other Federal programs. Any benefits received under the
Medicare Prescription Drug Discount Card and Transitional Assistance
Program must not be taken into account in determining an individual's
eligibility for, or the amount of benefits under, any other Federal
program.
(f) Verification of eligibility. (1) CMS will verify eligibility to
enroll in an endorsed discount card program or to receive transitional
assistance.
(2) If CMS is unable to verify an individual's eligibility or
ineligibility for transitional assistance, CMS can require the
individual to provide additional income information in a form and manner
specified by CMS as one condition of eligibility for transitional
assistance.
(g) Reconsideration. (1) If an individual is determined ineligible
to enroll in an endorsed discount card program under paragraph (a) of
this section or determined ineligible to receive transitional assistance
under paragraph (b) of this section, the individual (or the individual's
authorized representative) has a right to request that an independent
review entity under contract with CMS reconsider the determination.
(2) Reconsideration requests must be filed within 60 days from date
of notice of an ineligibility determination, unless the individual (or
the individual's authorized representative) can demonstrate good cause
for why the 60-day time frame should be extended.
(3) An individual (or the individual's authorized representative)
may submit additional documentary evidence or an explanation about his
or her eligibility in writing to the independent review entity, as part
of the reconsideration process.
(4) Reconsideration decisions shall be issued by the independent
review entity in writing and contain an explanation of the reasoning of
the decision.
[[Page 72]]
Sec. 403.811 Enrollment and disenrollment and associated endorsed
sponsor requirements.
(a) Enrollment process. (1) An individual (or an individual's
authorized representative) applying to enroll in an endorsed discount
card program must complete a standard enrollment form or other method
allowed by CMS and provide such information to the endorsed discount
card program in which the individual wishes to enroll.
(2) An individual electing to join an endorsed discount card program
that charges an annual enrollment fee, and who is not applying for
transitional assistance, must agree to pay the annual enrollment fee, if
any, in a form and manner determined by the endorsed card sponsor.
(3) An individual applying for transitional assistance at the time
that they apply for enrollment in an endorsed discount card program may
only enroll in the endorsed discount card program at that time if CMS
determines that the individual is eligible for transitional assistance.
Individuals not found eligible for transitional assistance may enroll in
an endorsed discount card program without applying for transitional
assistance after being notified of their ineligibility for transitional
assistance.
(4) An individual applying for transitional assistance must complete
a standard enrollment form and sign and date the form, certifying, under
penalty of perjury or similar sanction for false statements, as to the
accuracy of the information provided on the standard enrollment form.
(5) Except as provided in Sec. 403.811(b)(4), an individual who is
not currently enrolled in an endorsed card program seeking to enroll in
the Medicare Prescription Drug Discount Card and Transitional Assistance
Program may do so at any time during the enrollment period.
(6) An individual may not be enrolled in more than one endorsed
discount card program at a time.
(7) An individual may enroll in only one endorsed discount card
program per year during the enrollment period. An individual enrolling
during the initial enrollment year, with the exception of the
circumstances under paragraph (b)(2) of this section, may change
election for the second enrollment year during the annual coordinated
election period. During the second enrollment year, an individual may
enroll in only one endorsed discount card program, unless the individual
meets the circumstances described in paragraph (b)(2) of this section.
(8) An individual remains enrolled in an endorsed discount card
program elected unless--
(i) The individual is disenrolled under paragraph (b) of this
section;
(ii) The individual elects a new program during the Annual
Coordinated Election Period; or
(iii) The endorsed sponsor terminates its endorsed discount card
program, or is terminated.
(9) No new enrollment in an endorsed discount card program or
changing election of an endorsed discount card program is allowed during
the transition period.
(10) Except as specified in Sec. 403.814(b)(6)(i), an individual
may enroll in any endorsed discount card program, and only those
endorsed discount card programs, offered in the individual's State of
residence.
(11) In order to access negotiated prices or transitional
assistance, if applicable, an individual must be enrolled in an endorsed
discount card program. Access to negotiated prices begins with the
effective date of enrollment and ends with disenrollment. Access to
transitional assistance begins with the transitional assistance
effective date and ends for claims finalized on the date of
disenrollment.
(12) Except as provided in paragraph (b)(5) of this section, an
individual may apply for transitional assistance at any time during the
enrollment period.
(b) Disenrollment process. (1) An enrollee may voluntarily disenroll
at any time by notifying (or by having his authorized representative
notify) the endorsed sponsor.
(2) An enrolled individual who disenrolls during the enrollment
period under the following circumstances is granted a Special Election
Period in which the individual may enroll in another endorsed discount
card program during the enrollment period:
[[Page 73]]
(i) A move of residence outside the service area of the current
program;
(ii) A change in residence to or from a long-term care facility;
(iii) Enrollment in or disenrollment from a Part C plan or Medicare
cost plan;
(iv) An individual's current endorsed discount card program is
terminated or terminates; or
(v) Other exceptional circumstances, as defined by the Secretary.
(3) Notification in order to effect a disenrollment is not required
for an individual disenrolling from a terminating endorsed discount card
program or enrolling in or disenrolling from a Medicare managed care
plan offering an exclusive card program, or for individuals changing
endorsed discount card programs during the Annual Coordinated Election
Period.
(4) A drug discount card enrollee who disenrolls from an endorsed
discount card program other than for one of the reasons listed in
paragraph (b)(2) of this section will no longer be determined eligible
for the Medicare Prescription Drug Discount Card and Transitional
Assistance Program and, if he or she disenrolls in 2004, must re-apply
for the Medicare Prescription Drug Discount Card and Transitional
Assistance Program should he or she wish to enroll in another endorsed
discount card program for the second enrollment year.
(5) An individual receiving transitional assistance who voluntarily
disenrolls from an endorsed discount card program other than for one of
the reasons listed in paragraph (b)(2) of this section will forfeit any
transitional assistance remaining available to the individual on the
date of disenrollment, and, if he or she disenrolls in 2004, must re-
apply for transitional assistance for 2005 in order to receive
transitional assistance in 2005.
(6) A discount card enrollee other than a transitional assistance
enrollee may be involuntarily disenrolled from his or her endorsed
discount card program for failure to pay the annual enrollment fee on a
timely basis.
(7) A discount drug card enrollee other than a transitional
assistance enrollee may be charged another annual enrollment fee each
time the individual disenrolls from one endorsed discount card program
and enrolls in another endorsed discount card program during the
calendar year.
(c) Enrollment fees. (1) An endorsed sponsor may charge an annual
enrollment fee of no more than $30 to each individual enrolled in its
endorsed discount card program.
(2) An endorsed sponsor may not collect an enrollment fee from any
individual applying for or receiving transitional assistance.
(3) The annual enrollment fee must not be prorated for portions of
the year.
(4) An endorsed sponsor must charge a uniform enrollment fee to
every discount card eligible individual, or to the Secretary in the case
of individuals receiving transitional assistance, residing in a State.
(5) An endorsed sponsor must refund any enrollment fee collected
from a discount card enrollee, or any State that has paid the enrollment
fee on behalf of the discount card enrollee, during the calendar year
during which the individual is determined eligible to receive
transitional assistance.
(6) An endorsed sponsor may not charge an annual enrollment fee
during the transition period.
Sec. 403.812 HIPAA privacy, security, administrative data standards,
and national identifiers.
(a) HIPAA covered entities. An endorsed sponsor is a HIPAA covered
entity and must comply with the standards, implementation
specifications, and requirements in 45 CFR parts 160, 162, and 164 as
set forth in this section. Those functions of a endorsed sponsor the
performance of which are necessary or directly related to the operations
of the endorsed discount card program are covered functions for purposes
of applying to endorsed sponsors the standards, implementation
specifications, and requirements in 45 CFR parts 160, 162, and 164.
(b) HIPAA privacy requirements. An endorsed sponsor must comply with
the standards, implementation specifications, and requirements in the
Standards for Privacy of Individually Identifiable Health Information,
45 CFR
[[Page 74]]
parts 160 and 164, subparts A and E, in the same manner as a health
plan, except to the extent such requirements are temporarily waived by
the Secretary.
(c) Security requirements. (1) Standard. An endorsed sponsor must
comply with the applicable standards, implementation specifications, and
requirements in the HIPAA Security Rule, 45 CFR parts 160 and 164,
subparts A and C, in the same manner as other covered entities as of the
compliance date of such Rule.
(2) Attestation. An applicant in its application shall--
(i) Attest that, as of the initial enrollment date, it will have in
place appropriate administrative, technical, and physical safeguards to
protect the privacy of protected health information in accordance with
45 CFR 164.530(c); and
(ii) Attest that its information security measures will meet the
standards, implementation specifications, and requirements of 45 CFR
part 164 subparts A and C as of the initial enrollment date, or, if
unable to make this attestation, provide a plan for coming into
compliance with these requirements by the compliance date of the
Security Rule set forth in 45 CFR part 164, subpart C.
(d) Administrative data standards. An endorsed sponsor must comply
with any applicable standards, implementation specifications, and
requirements in the Standards for Electronic Transactions under 45 CFR
parts 160 and 162 subparts I through R.
(e) Unique identifiers. An endorsed sponsor must comply with any
applicable standards, implementation specifications, and requirements
regarding standard unique identifiers under 45 CFR parts 160 and 162 as
of the compliance date of any final rule for standard unique
identifiers.
(f) Applicability of other regulations. Nothing in this paragraph or
in Sec. 403.813 shall be deemed a modification of parts 160, 162 and
164 of title 45, Code of Federal Regulations or otherwise modify the
applicability of such regulations to other organizations or covered
entities independently subject to the mandates of HIPAA. If an endorsed
sponsor is also a health plan, health care provider, or health care
clearinghouse, nothing is this paragraph shall impair or otherwise
affect the application of HIPAA or parts 160, 162 and 164 of title 45,
Code of Federal Regulations to such entity and its performance of those
functions which make such entity a health plan, health care provider, or
health care clearinghouse.
Sec. 403.813 Marketing limitations and record retention requirements.
(a) Marketing limitations. (1) An endorsed sponsor may only market
the following:
(i) Those products and services offered under the endorsed program
that are inside the scope of endorsement defined in Sec. 403.806(h) and
permitted under Sec. 403.812(b).
(ii) A Part D plan offered by the endorsed sponsor or an affiliated
organization of the endorsed sponsor.
(2) An endorsed sponsor may not request that a drug card enrollee or
an individual seeking to enroll in its endorsed discount card program
authorize the endorsed sponsor to use or disclose individually
identifiable health information for purposes of marketing any product or
service not allowed under paragraph (a)(1) of this section.
(3) An endorsed sponsor may not co-mingle any materials related to
the marketing of products and services allowed under paragraph (a)(1) of
this section with other marketing materials.
(4) Following termination of an endorsed sponsor's endorsement under
Sec. Sec. 403.820(c), (d) or (e) or termination of the Medicare Drug
Discount Card and Transitional Assistance Program, a drug card
enrollee's individually identifiable health information collected or
maintained by an endorsed sponsor may not be used or disclosed for
purposes of marketing any product or service.
(b) Record retention standard. (1) An endorsed sponsor must retain
records that it creates, collects, or maintains while participating in
the Medicare Drug Discount Card and Transitional Assistance Program as
part of its operations of an endorsed program for at least 6 years
following termination of
[[Page 75]]
such program, or, in the event the endorsed sponsor's endorsement is
terminated under Sec. 420.820(c), (d), or (e) of this chapter at least
6 years following termination of such endorsement. The Secretary may
extend the six-year retention period if an endorsed sponsor's records
relate to an ongoing investigation, litigation, or negotiation by the
Secretary, the Department of Health and Human Services Office of
Inspector General, the Department of Justice, or a State, or such
documents otherwise relate to suspicions of fraud and abuse or
violations of Federal or State law.
(2) For the period during which an endorsed sponsor retains records
as specified in paragraph (b)(1) of this section, an endorsed sponsor
must continue to apply security and privacy protections to such records
and the information contained therein to the same extent endorsed
sponsors are required to do so under Sec. 403.812(b) and Sec.
403.812(c)(1) prior to termination.
[68 FR 69915, Dec. 15, 2003, as amended at 70 FR 52023, Sept. 1, 2005]
Sec. 403.814 Special rules concerning Part C organizations and Medicare
cost plans and their enrollees.
(a) General requirements. (1) A Part C organization and Medicare
cost plan may not require enrollment in an endorsed discount card
program as a condition for enrollment in its Part C plan or Medicare
cost plan.
(2) A Part C organization may subsidize the enrollment fee for an
endorsed discount card program, whether operated by the Part C
organization or another endorsed sponsor, for individuals described in
Sec. 403.810(a), provided that any such benefit is reflected in the
Part C organization's Adjusted Community Rate filing.
(b) Exclusive card sponsors. (1) A Medicare managed care
organization may elect to become an exclusive card sponsor by limiting
enrollment in its endorsed discount card program to individuals
described in Sec. 403.810(a) who are enrolled in any of its Medicare
managed care plans. The Medicare managed care organization must be the
applicant for endorsement in order to offer an exclusive card program.
Such an election must be made at the time of application for
endorsement.
(2) Except as noted in paragraphs (b)(3) and (b)(4) of this section,
an exclusive card sponsor must comply with all requirements for endorsed
sponsors noted in Sec. 403.804 and Sec. 403.806.
(3) An exclusive card sponsor is deemed to meet or is exempt from
certain specific requirements listed in Sec. 403.806 as follows:
(i) An exclusive card sponsor is deemed to meet the pharmacy network
requirement in Sec. 403.806(f)(3) if its pharmacy network is not
limited to mail-order pharmacies and is equivalent to the pharmacy
network used in its Medicare managed care plan and such pharmacy network
has been approved by the Secretary, or, if its Medicare managed care
plan does not use a pharmacy network, the Secretary determines that the
pharmacy network provides sufficient access to covered discount card
drugs at negotiated prices for discount card enrollees under the
standard set forth under 42 CFR 422.112 for a Part C organization
described in section 1851(a)(2)(A) of the Act, or under 42 CFR
417.416(e) for a Medicare cost plan.
(ii) An exclusive card sponsor is deemed to meet the service area
requirements in Sec. 403.806(f)(1) and (f)(2) if it operates in a
service area equivalent to its Medicare managed care plan's service
area.
(iii) An exclusive card sponsor is deemed to meet the requirement
for financial stability and business integrity in Sec. 403.806(b)
through compliance with Sec. 422.400 of this chapter (if a Part C
organization described in section 1851(a)(2)(A) of the Act) or
compliance with Sec. 417.120 and Sec. 417.122 of this chapter (if a
Medicare cost plan).
(iv) An exclusive card sponsor is deemed to meet the covered lives
requirement in Sec. 403.806(a)(3).
(v) An exclusive card sponsor is deemed to meet the requirements of
Sec. 403.806(e)(2) if it ensures that transitional assistance funds are
applied to, and only to, the cost to transitional assistance enrollees
of any covered discount card drugs obtained from a network or mail order
pharmacy included in the exclusive card sponsor's pharmacy network, and
at the option of the exclusive card sponsor, any covered discount card
drug obtained under an
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outpatient prescription drug benefit offered under the affiliated
Medicare managed care plan, including any deductibles, co-payments,
coinsurance, and other cost-sharing amounts for which transitional
assistance enrollees are responsible under the Medicare managed care
plan's outpatient prescription drug benefit.
(4) As the Secretary determines appropriate on a case-by-case basis,
any additional requirements discussed in Sec. 403.804 and Sec.
403.806, except for the requirements in Sec. 403.812 and Sec. 403.813,
may be waived or modified on behalf of an exclusive card sponsor if:
(i) The requirements are duplicative of or conflict with the
requirements that a Medicare managed care organization must meet either
under Part C or under section 1876 of Title XVIII of the Act; or
(ii) The waiver or modification is necessary to improve coordination
between benefits under the Medicare Prescription Drug Discount Card and
Transitional Assistance Program and the benefits either under Part C or
under section 1876 of Title XVIII of the Act.
(iii) The applicant seeking to become an exclusive card sponsor
requests such waivers or modifications in writing in a manner required
by the Secretary.
(5) An exclusive card sponsor may conduct group enrollment according
to the following rules:
(i) The exclusive card sponsor must seek CMS verification that its
Medicare managed care members are individuals described in Sec.
403.810(a) and enroll such individuals as a group into its exclusive
card program.
(ii) The exclusive card sponsor must give all individuals it is
enrolling as a group the opportunity to decline enrollment, and the
opportunity to apply for transitional assistance.
(iii) The exclusive card sponsor may use a modified version of the
standard enrollment form described in Sec. 403.806(g)(3) or other CMS-
approved process for group enrollment in its endorsed discount card
program.
(6) An individual enrolled in a Medicare managed care plan offered
by a Medicare managed care organization offering an exclusive card
program to individuals enrolled in such Medicare managed care plan is
subject to the following requirements:
(i) The individual may enroll only in the endorsed discount card
program offered by his or her Medicare managed care organization.
(ii) If the exclusive card sponsor group elects to group enroll into
an exclusive card program members of the Medicare managed plan, the
individual must actively decline enrollment to avoid enrollment in the
exclusive card program.
(c) Non-uniformity of Benefits. Implementation of the Medicare
Prescription Drug Discount Card and Transitional Assistance Program,
including the provision of transitional assistance and the payment or
waiver of any enrollment fee by a Part C organization, will not be taken
into account in applying the uniform premium and uniform benefits
requirement in sections 1854(c) and 1854(f)(1)(D) of the Act and 42 CFR
422.100(d)(2) and 42 CFR 422.312(b)(2).
Sec. 403.815 Special rules concerning States.
(a) Optional State payment of enrollment fee. (1) A State may enter
into payment arrangements with endorsed sponsors to provide payment of
some or all of endorsed discount card programs' enrollment fees for some
or all of the State's individuals described in Sec. 403.810(a) who are
not transitional assistance enrollees, provided the enrollment fees are
paid directly by the State to the endorsed sponsor.
(2) Expenditures made by a State for enrollment fees described in
paragraph (a)(1) of this section must not be treated as State
expenditures for which Federal matching payments are available under
titles XIX or XXI of the Act.
(b) Optional State payment of coinsurance. (1) A State may enter
into payment arrangements with pharmacies to provide payment of some or
all of coinsurance amounts described in Sec. 403.808(e) for some or all
of the State's transitional assistance enrollees, provided the
coinsurance amounts are paid directly by the State to the pharmacy.
(2) Expenditures made by a State for coinsurance described in
paragraph
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(b)(1) of this section must not be treated as State expenditures for
which Federal matching payments are available under titles XIX or XXI of
the Act.
(c) Coinsurance for Qualified Medicare Beneficiaries. For
transitional assistance enrollees who are qualified Medicare
beneficiaries, any coinsurance liability under Sec. 403.808(e) must not
be treated as Medicare cost-sharing coinsurance, under section
1905(p)(3)(B) of the Act, for which a State would otherwise be required
to pay.
(d) State data. (1) A State must provide data on a monthly basis in
an electronic format as determined necessary by the Secretary to
effectuate the verification of beneficiary eligibility for the Medicare
Prescription Drug Discount Card and Transitional Assistance Program.
(2) Expenditures made by a State in complying with the requirements
of paragraph (d)(1) of this section will be treated as State
expenditures for which Federal matching payments are available under
section 1903(a)(7) of the Act.
Sec. 403.816 Special rules concerning long-term care and I/T/U
pharmacies.
(a) In general. (1) An applicant for endorsement may submit an
application to become a special endorsed sponsor for long-term care and/
or for I/T/U pharmacies.
(2) Of qualified applicants, the Secretary will select at least two
of the best-qualified applicants for special endorsement for long-term
care and at least two of the best-qualified applicants for special
endorsement for I/T/U pharmacies.
(3) Applicants for special endorsement for long-term care must
demonstrate in their applications that they meet the requirements in
paragraph (b) of this section.
(4) Applicants for special endorsement for I/T/U pharmacies must
demonstrate in their applications that they meet the requirements in
paragraph (d) of this section.
(b) Long-term care. A special endorsed sponsor for long-term care
must--
(1) Apply transitional assistance toward the cost of covered
discount card drugs obtained by transitional assistance enrollees who
reside in long-term care facilities and who receive such prescription
drugs through long-term care pharmacies;
(2) Offer contractual arrangements to any long-term care pharmacy
seeking reimbursement from transitional assistance for covered discount
card drugs provided by such pharmacy to transitional assistance
enrollees who reside in long-term care facilities;
(3) Process any submitted claims from network pharmacies and out-of-
network long-term care pharmacies that supply covered discount card
drugs to transitional assistance enrollees who reside in long-term care
facilities, when such enrollees have unspent transitional assistance
remaining;
(4) Include special terms and conditions in its contracts with
network pharmacies that are long-term care pharmacies to facilitate
access to and the administration of transitional assistance to
transitional assistance enrollees residing in long-term care facilities,
including, but not limited to the following--
(i) Waiving penalties against long-term care pharmacies for
submitting late claims to the special endorsed sponsor due to the
pharmacy's coordination of benefits activities; and
(ii) Permitting a long-term care pharmacy to limit its services to
only transitional assistance enrollees who reside in a long-term care
facility served by the long-term care pharmacy.
(5) Except as noted in paragraph (c) of this section, comply with
all requirements for endorsed sponsors noted in Sec. Sec. 403.804 and
403.806.
(c) Waiver of requirements. (1) The following requirements will not
apply to or will be waived for special endorsed sponsors providing
transitional assistance to long-term care residents:
(i) Section 403.806(d) (relating to the prescription drug offering)
shall not apply to long-term care pharmacies in the special endorsed
sponsor's network; and
(ii) Section 403.806(e)(4) (requiring information about the amount
of transitional assistance remaining) shall not apply to long-term care
pharmacies in the special endorsed sponsor's network.
(2)(i) As the Secretary determines appropriate on a case-by-case
basis, any
[[Page 78]]
additional requirements discussed in Sec. Sec. 403.804 and 403.806,
except for the requirements in Sec. Sec. 403.812 and 403.813, may be
waived or modified on behalf of a special endorsed sponsor for long-term
care if the waiver or modification is--
(A) Necessary to enable the applicant to either initiate enrollment
activities under the special endorsement within 6 months of enactment of
section 1860D-31 of the Act, or accommodate the unique needs of long-
term care pharmacies; or
(B) Compliance with the requirement(s) in question would be
impracticable or inefficient.
(ii) Applicants to become special endorsed sponsors for long-term
care must request such waivers or modifications in writing in a manner
required by the Secretary.
(d) I/T/U pharmacies. A special endorsed sponsor for I/T/U
pharmacies must--
(1) Apply transitional assistance toward the cost of covered
discount card drugs obtained by transitional assistance enrollees who
are American Indians and Alaska Natives and who receive prescription
drugs through I/T/U pharmacies as allowed under paragraph (d)(2) of this
section;
(2) Offer contractual arrangements to any I/T/U pharmacy that is in
the special endorsed sponsor's service area and seeking reimbursement
from transitional assistance for covered discount card drugs provided by
such pharmacy to transitional assistance enrollees who are also American
Indians/Alaska Natives;
(3) Include special terms and conditions in its contracts with
network I/T/U pharmacies to facilitate access to and the administration
of transitional assistance for transitional assistance enrollees who are
American Indians/Alaska Natives, including, but not limited to the
following:
(i) Permitting an I/T/U pharmacy to limit its services to only those
transitional assistance enrollees who are American Indians/Alaska
Natives, and
(ii) Allowing an I/T/U pharmacy to select which drugs to stock,
which may be a more limited set than other retail pharmacies.
(4) Except as noted in paragraph (e) of this section, comply with
all requirements for endorsed sponsors noted in Sec. Sec. 403.804 and
403.806.
(e) Waiver of requirements. (1) The following requirements will not
apply to or will be waived for special endorsed sponsors providing
transitional assistance through I/T/U pharmacies:
(i) Section 403.806(d) (relating to the prescription drug offering)
shall not apply to I/T/U pharmacies in the special endorsed sponsor's
network; and
(ii) Section 403.806(e)(4) (requiring information about the amount
of transitional assistance remaining) shall not apply to I/T/U
pharmacies in the special endorsed sponsor's network.
(2)(i) As the Secretary determines appropriate on a case-by-case
basis, any additional requirements discussed in Sec. Sec. 403.804 and
403.806, except for the requirements in Sec. Sec. 403.812 and 403.813,
may be waived or modified on behalf of a special endorsed sponsor for I/
T/U pharmacies if the waiver or modification is--
(A) Necessary to enable the applicant to either initiate enrollment
activities under the special endorsement within 6 months of enactment of
section 1860D-31 of the Act, or accommodate the unique needs of I/T/U
pharmacies; or
(B) Compliance with the requirement(s) in question would be
impracticable or inefficient.
(ii) Applicants to become special endorsed sponsors for I/T/U
pharmacies must request such waivers or modifications in writing in a
manner required by the Secretary.
Sec. 403.817 Special rules concerning the territories.
(a) In general. (1) An applicant for endorsement may submit an
application to become a special endorsed sponsor for all of the
territories.
(2) Of qualified applicants, the Secretary will select at least one
of the best-qualified applicants to receive a special endorsement for
the territories.
(3) Applicants for special endorsement for the territories must
demonstrate in their applications that they meet the requirements in
paragraph (b) of this section.
(b) Requirements. (1) Negotiated prices. A special endorsed sponsor
for residents of the territories must provide
[[Page 79]]
access to negotiated prices in the territories.
(2) Transitional assistance. Any transitional assistance in the
territories must be in accordance with paragraph (e) of this section.
(3) Requirements, exception. Except as specified in paragraph (c) of
this section, a special endorsed sponsor for the territories must meet
the requirements of Sec. Sec. 403.804 and 403.806.
(c) Waiver of requirements and alternative requirements. (1) Section
403.806(d)(8) (requiring information about price differentials) shall
not apply to pharmacies located in the territories and which are in the
special endorsed sponsor's pharmacy network.
(2) Sections 403.806(f)(2) and (f)(3) will be deemed met if the
special endorsed sponsor makes a good faith effort to secure the
participation of retail and mail order pharmacies throughout a
territory.
(3)(i) As the Secretary determines appropriate on a case-by-case
basis, any additional requirements discussed in Sec. Sec. 403.804 and
403.806, except for the requirements in Sec. Sec. 403.812 and 403.813,
may be waived or modified on behalf of a special endorsed sponsor for
the territories if--
(A) Such waiver is necessary to enable the applicant to either
initiate enrollment activities under the special endorsement within 6
months of enactment of section 1860D-31 of the Act, or accommodate the
unique needs of pharmacies in the territories; or
(B) Compliance with the requirement(s) in question would be
impracticable or inefficient.
(ii) Applicants to become special endorsed sponsors for the
territories must request such waivers or modifications in writing in a
manner required by the Secretary.
(d) Other exceptions. A special endorsed sponsor for the territories
may enroll in its endorsed discount card program Medicaid enrollees with
coverage for outpatient prescription drugs, as described in Sec.
403.810(a)(2).
(e) Transitional assistance provided by Territories. (1)
Transitional assistance in the territories may be administered only
according to a plan submitted by a territory and approved by CMS.
(2) Territories choosing to provide transitional assistance must
submit a plan to CMS within 90 days of the publication of this
regulation. The plan must--
(i) Describe how funds allocated to the territory are to be used to
cover the cost of covered discount card drugs obtained by individuals
who reside in the territory, who are entitled to benefits under Medicare
Part A or enrolled under Medicare Part B, and who have income at or
below 135 percent of the poverty line for the contiguous United States;
and
(ii) Describe how the territory will ensure that amounts received
under the allotment are to be used only to provide covered discount card
drugs to those individuals determined eligible for transitional
assistance, as described in paragraph (e)(2)(i) of this section, and
(iii) Provide such written assurance for the requirements in
paragraph (e)(2)(ii) of this section.
(3) CMS will review and approve plans submitted and make allotments
to territories with approved plans.
(4) CMS may request reports or information to substantiate that the
territories have administered the program consistent with the
territory's approved transitional assistance plan.
Sec. 403.820 Sanctions, penalties, and termination.
(a) Intermediate sanctions. (1) For the violations listed in
paragraph (a)(3) of this section, the following intermediate sanctions
may be imposed on any endorsed sponsor:
(i) Suspension of enrollment of Medicare beneficiaries.
(ii) Suspension of information and outreach activities to Medicare
beneficiaries.
(2) Duration of sanctions. The intermediate sanctions continue in
effect until CMS is satisfied that the deficiency on which the
determination was based has been corrected and is not likely to recur.
(3) Sanctionable violations. The violations for which intermediate
sanctions may be imposed are as follows:
(i) Substantial failure to maintain a contracted retail pharmacy
network meeting the requirements of Sec. 403.806(f);
[[Page 80]]
(ii) Substantial failure to comply with CMS Information and Outreach
Guidelines;
(iii) Substantial failure to provide discount card enrollees with
negotiated prices consistent with information reported to CMS for the
price comparison Web site and/or reported by the endorsed sponsor;
(iv) Except during the week of November 15, 2004 (which coincides
with the beginning of the annual coordinated election period),
substantial failure to ensure that the negotiated price for a covered
discount card drug does not exceed an amount proportionate to the change
in the drug's average wholesale price (AWP), and/or an amount
proportionate to changes in the card sponsor's cost structure (including
material changes to any discounts, rebates, or other price concessions
the sponsor receives from a pharmaceutical manufacturer or pharmacy);
(v) Charging drug card enrollees additional fees beyond a $30
enrollment fee;
(vi) Charging transitional assistance enrollees any enrollment fee;
(vii) Charging a coinsurance more than 5 percent for those at or
below 100 percent of the poverty line, or 10 percent for those above 100
percent but at or below 135 percent of the poverty line;
(viii) Substantial failure to administer properly the transitional
assistance funding for transitional assistance enrollees;
(ix) Substantial failure to provide CMS or its designees with
requested information related to the endorsed sponsor's endorsed
discount card operations; or
(x) Failure to otherwise substantially comply with the requirements
of this subpart, including failing to perform the operational
requirements of this program or the failure to submit an acceptable plan
of correction within the timeframe specified by CMS.
(4) Written notice of proposed sanctions.
(i) Prior to imposing sanctions, CMS will send a written notice to
the endorsed sponsor stating the nature and basis of the proposed
sanction.
(ii) CMS will send a copy of the notice in paragraph (a)(4)(i) of
this section to the Office of the Inspector General.
(iii) CMS will allow the endorsed sponsor 15 days from the receipt
of notice to provide evidence that it has not committed an act or
omission that may fairly be characterized as a basis for sanction.
(iv) Should an endorsed sponsor present evidence described in
paragraph (a)(4)(iii) of this section and by the time limit described in
that paragraph, a CMS official not involved in the original sanction
determination shall review the evidence and provide the endorsed sponsor
a concise written decision setting forth the factual and legal basis for
the decision that affirms or rescinds the original determination.
(5) Effective date of sanction.
(i) A sanction is effective 15 days after the date that the endorsed
sponsor is notified of the sanction or, if the endorsed sponsor timely
seeks reconsideration of that sanction decision, on the date specified
in the notice of CMS's reconsideration determination.
(ii) The sanction remains in effect until CMS notifies the endorsed
sponsor that CMS is satisfied that the basis for imposing the sanction
has been corrected and is not likely to recur.
(b) Civil monetary penalties. (1) OIG penalties. The Office of the
Inspector General (OIG) may impose civil monetary penalties in
accordance with 42 CFR parts 1003 and 1005 in addition to, or in place
of, sanctions that CMS may impose, as described in paragraph (a) of this
section, against an endorsed sponsor whom it determines has knowingly--
(i) Misrepresented or falsified information in information and
outreach or comparable material provided to program enrollee or other
persons;
(ii) Charged a program enrollee in violation of the terms of the
endorsement contract; or
(iii) Used transitional assistance funds in any manner that is
inconsistent with the purpose of the transitional assistance program.
(2) CMS penalties. If CMS determines that an endorsed sponsor has
engaged in conduct that it knows or should know constitutes a violation
as described in paragraph (a)(3) of this section, where the failure to
perform involves the operational requirements of the program, CMS may
impose civil
[[Page 81]]
monetary penalties in accordance with 42 CFR parts 1003 and 1005 in
addition to, or in place of, the sanctions that CMS may impose, as
described in paragraph (a) of this section.
(3) CMS or the OIG may impose civil monetary penalties of no more
than $10,000 for each violation.
(c) Termination of endorsement by CMS. (1) CMS may terminate the
endorsement contract at any time with notice on the following bases:
(i) Any of the bases for the imposition of intermediate sanctions as
stated in paragraph (a)(3) of this section; or
(ii) The endorsed sponsor engaged in false or misleading information
and outreach practices; or
(iii) The endorsed sponsor fails to comply with the requirement of
Sec. 403.804(e).
(2) CMS shall provide the endorsed sponsor written notice of
termination 30 days prior to the CMS-determined effective date of the
termination at which time the endorsed sponsor must do the following:
(i) Provide its discount card enrollees notice of the termination
within 10 days of receiving notice from CMS;
(ii) Continue to provide services to its discount card enrollees for
90 days after the discount card enrollees were sent the notice of
termination from the endorsed sponsor; and
(iii) Suspend all information and outreach and enrollment activities
once enrollees have received the notice of termination.
(3) Corrective action plan. Before terminating a contract, CMS shall
provide the endorsed sponsor with reasonable opportunity to develop and
receive CMS approval of a corrective action plan to correct the
deficiencies that are the basis of the proposed termination.
(d) Termination by endorsed sponsor--(1) Cause for termination. The
endorsed sponsor may terminate its endorsement contract if CMS fails
substantially to carry out the terms of the contract.
(2) Card sponsor notice. The endorsed sponsor must give advance
notice as follows:
(i) To CMS, at least 90 days prior to the intended date of
termination. This notice must specify the reasons why the endorsed
sponsor is requesting contract termination; and
(ii) To its discount card enrollees, by mail, at least 60 days prior
to the termination effective date. This notice must include a written
description of alternative endorsed discount card programs that serve
the discount card enrollee's address.
(3) Effective date of termination. The effective date of the
termination is determined by CMS and is at least 90 days after the date
CMS receives the endorsed sponsor's notice of intent to terminate.
(e) Termination by mutual consent. (1) A contract may be modified or
terminated at any time by written mutual consent.
(2) If the contract is terminated by mutual consent, the endorsed
sponsor must provide notice to its discount card enrollees as provided
in paragraph (d)(2) of this section.
(3) If the contract is modified by mutual consent, the endorsed
sponsor must provide notice to its discount card enrollees of any
changes that CMS determines are appropriate for notification within
timeframes specified by CMS.
(f) Appeal of contract determinations. (1) Scope. This section
establishes the procedures for reviewing the following contract
determinations:
(i) A determination that an applicant is not qualified to enter into
a contract with CMS under section 1860D-31 of the Act; and
(i) A determination to terminate a contract with an endorsed sponsor
in accordance with paragraph (c) of this section.
(2) Notice of determination. When CMS makes an initial contract
determination, it gives the endorsed sponsor or applicant written notice
specifying--
(i) The reasons for the determination; and
(ii) The endorsed sponsor's or applicant's right to request
reconsideration.
(3) Effect of contract determination. The contract determination is
final and binding unless a timely request for a reconsideration hearing
is filed under this section.
[[Page 82]]
(4) Right to reconsideration. An endorsed sponsor whose contract is
terminated or an applicant denied endorsement may request a hearing for
reconsideration of the CMS contract determination.
(5) Method and place for filing a request. A request for a
reconsideration hearing must be made in writing and filed with the CMS
Central Office.
(6) Time for filing a request. The request for a reconsideration
hearing must be filed within 15 days from the date of the notice of the
initial determination.
(7) Appointment of hearing officer. CMS shall appoint a hearing
officer to conduct the reconsideration. The hearing officer shall be a
representative of the Administrator and not otherwise a party to the
contract determination.
(8) Conduct of hearing. The endorsed sponsor or applicant may be
represented by counsel and may present evidence and examine witnesses. A
complete recording of the proceedings will be made and transcribed.
(9) Reconsideration determination. A reconsideration determination
is a new determination that--
(i) Is based on a review of the contract determination, the evidence
and findings upon which it was based, and any other written evidence
submitted before notice of the reconsidered determination is mailed,
including facts relating to the status of the endorsed sponsor
subsequent to the contract determination; and
(ii) Affirms, reverses, or modifies the initial contract
determination.
(10) Notice of reconsidered determination. As soon as practicable
after the close of the hearing, the hearing officer issues a written
reconsideration determination that contains the following:
(i) Findings with respect to the applicant's qualifications to enter
into or an endorsed sponsor's qualifications to remain under a contract
with CMS under section 1860D-31 of the Act;
(ii) A statement of the specific reasons for the reconsidered
determination.
(11) Effect of reconsidered determination. A reconsidered
determination is final and binding on the parties and is not subject to
judicial review.
(g) Compliance with HIPAA. Failure of an endorsed sponsor to comply
with HIPAA and/or the standards, implementation specifications, and
requirements in 45 CFR parts 160, 162, and 164, as established in Sec.
403.812, shall be a violation of HIPAA and may be enforced under
sections 1176 and 1177 of the Act.
Sec. 403.822 Reimbursement of transitional assistance and associated
sponsor requirements.
(a) A Transitional Assistance Account is created within the Federal
Supplementary Medical Insurance Trust Fund and kept separate from all
other funds within that fund.
(b) The Managing Trustee of the Transitional Assistance Account
shall pay on a monthly basis from the Account the amounts certified by
CMS as necessary to make payments for transitional assistance as allowed
in Sec. 403.808.
(c) Endorsed sponsors must routinely account to CMS for the
transitional assistance provided to the transitional assistance
enrollees for finalized (not pending, or denied) claims up to the
allowed balance provided by CMS to the sponsor.
(d) Payment transactions will be audited by the Secretary or his
agent.
(e) Federal funding in excess of the amount of the balance included
in CMS's system is not permitted.
[[Page 83]]
SUBCHAPTER B_MEDICARE PROGRAM
PART 405_FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED--Table of
Contents
Subpart A [Reserved]
Subpart B_Medical Services Coverage Decisions That Relate to Health Care
Technology
Sec.
405.201 Scope of subpart and definitions.
405.203 FDA categorization of investigational devices.
405.205 Coverage of a non-experimental/investigational (Category B)
device.
405.207 Services related to a noncovered device.
405.209 Payment for a non-experimental/investigational (Category B)
device.
405.211 Procedures for Medicare contractors in making coverage decisions
for a non-experimental/investigational (Category B) device.
405.213 Re-evaluation of a device categorization.
405.215 Confidential commercial and trade secret information.
Subpart C_Suspension of Payment, Recovery of Overpayments, and Repayment
of Scholarships and Loans
General Provisions
405.301 Scope of subpart.
Liability for Payments to Providers and Suppliers, and Handling of
Incorrect Payments
405.350 Individual's liability for payments made to providers and other
persons for items and services furnished the individual.
405.351 Incorrect payments for which the individual is not liable.
405.352 Adjustment of title XVIII incorrect payments.
405.353 Certification of amount that will be adjusted against individual
title II or railroad retirement benefits.
405.354 Procedures for adjustment or recovery--title II beneficiary.
405.355 Waiver of adjustment or recovery.
405.356 Principles applied in waiver of adjustment or recovery.
405.357 Notice of right to waiver consideration.
405.358 When waiver of adjustment or recovery may be applied.
405.359 Liability of certifying or disbursing officer.
Suspension and Recoupment of Payment to Providers and Suppliers and
Collection and Compromise of Overpayments
405.370 Definitions.
405.371 Suspension, offset, and recoupment of Medicare payments to
providers and suppliers of services.
405.372 Proceeding for suspension of payment.
405.373 Proceeding for offset or recoupment.
405.374 Opportunity for rebuttal.
405.375 Time limits for, and notification of, administrative
determination after receipt of rebuttal statement.
405.376 Suspension and termination of collection action and compromise
of claims for overpayment.
405.377 Withholding Medicare payments to recover Medicaid overpayments.
405.378 Interest charges on overpayment and underpayments to providers,
suppliers, and other entities.
Repayment of Scholarships and Loans
405.380 Collection of past-due amounts on scholarship and loan programs.
Subpart D_Private Contracts
405.400 Definitions.
405.405 General rules.
405.410 Conditions for properly opting-out of Medicare.
405.415 Requirements of the private contract.
405.420 Requirements of the opt-out affidavit.
405.425 Effects of opting-out of Medicare.
405.430 Failure to properly opt-out.
405.435 Failure to maintain opt-out.
405.440 Emergency and urgent care services.
405.445 Renewal and early termination of opt-out.
405.450 Appeals.
405.455 Application to Medicare+Choice contracts.
Subpart E_Criteria for Determining Reasonable Charges
405.500 Basis.
405.501 Determination of reasonable charges.
405.502 Criteria for determining reasonable charges.
405.503 Determining customary charges.
405.504 Determining prevailing charges.
405.505 Determination of locality
405.506 Charges higher than customary or prevailing charges or lowest
charge levels.
[[Page 84]]
405.507 Illustrations of the application of the criteria for determining
reasonable charges.
405.508 Determination of comparable circumstances; limitation.
405.509 Determining the inflation-indexed charge.
405.511 Reasonable charges for medical services, supplies, and
equipment.
405.512 Carriers' procedural terminology and coding systems.
405.515 Reimbursement for clinical laboratory services billed by
physicians.
405.517 Payment for drugs and biologicals that are not paid on a cost or
prospective payment basis.
405.520 Payment for a physician assistant's, nurse practitioner's, and
clinical nurse specialists' services and services furnished
incident to their professional services.
405.534 Limitation on payment for screening mammography services.
405.535 Special rule for nonparticipating physicians and suppliers
furnishing screening mammography services before January 1,
2002.
Subpart F [Reserved]
Subpart G_Reconsiderations and Appeals Under Medicare Part A
405.701 Basis, purpose and definitions.
405.702 Notice of initial determination.
405.704 Actions which are initial determinations.
405.705 Actions which are not initial determinations.
405.706 Decisions of utilization review committees.
405.708 Effect of initial determination.
405.710 Right to reconsideration.
405.711 Time and place of filing request for reconsideration.
405.712 Extension of time to request reconsideration.
405.714 Withdrawal of request for reconsideration.
405.715 Reconsidered determination.
405.716 Notice of reconsidered determination.
405.717 Effect of a reconsidered determination.
405.718 Expedited appeals process.
405.720 Hearing; right to hearing.
405.722 Time and place of filing request for a hearing.
405.724 Departmental Appeals Board (DAB) review.
405.730 Court review.
405.732 Review of a national coverage determination (NCD).
405.740 Principles for determining the amount in controversy.
405.745 Amount in controversy ascertained after reconsideration.
405.747 Dismissal of request for hearing; amount in controversy less
than $100.
405.750 Time period for reopening initial, revised, or reconsidered
determinations and decisions or revised decisions of an ALJ or
the Departmental Appeals Board (DAB); binding effect of
determination and decisions.
405.753 Appeal of a categorization of a device.
Subpart H_Appeals Under the Medicare Part B Program
405.801 Part B appeals--general description.
405.802 Definitions.
405.803 Initial determination.
405.804 Notice of initial determination.
405.805 Parties to the initial determination.
405.806 Effect of initial determination.
405.807 Request for review of initial determination.
405.808 Parties to the review.
405.809 Opportunity to submit evidence.
405.810 Review determination.
405.811 Notice of review determination.
405.812 Effect of review determination.
405.815 Amount in controversy for carrier hearing, ALJ hearing and
judicial review.
405.817 Principles for determining amount in controversy.
405.821 Request for carrier hearing.
405.822 Parties to a carrier hearing.
405.823 Carrier hearing officer.
405.824 Disqualification of carrier hearing officer.
405.825 Location of carrier hearing.
405.826 Notice of carrier hearing.
405.830 Conduct of the carrier hearing.
405.831 Waiver of right to appear at carrier hearing and present
evidence.
405.832 Dismissal of request for carrier hearing.
405.833 Record of carrier hearing.
405.834 Carrier hearing officer's decision.
405.835 Effect of carrier hearing officer's decision.
405.836 Authority of the carrier hearing officer.
405.841 Reopening initial or review determination of the carrier, and
decision of a carrier hearing officer.
405.842 Notice of reopening and revision.
405.850 Change of ruling or legal precedent.
405.853 Expedited appeals process.
405.855 ALJ hearing.
405.856 Departmental Appeals Board (DAB) review.
405.857 Court review.
405.860 Review of a national coverage determination (NCD).
405.870 Appointment of representative.
405.871 Qualifications of representatives.
405.872 Authority of representatives.
405.874 Appeals of carrier decisions that supplier standards are not
met.
[[Page 85]]
405.877 Appeal of a categorization of a device.
Subpart I_Determinations, Redeterminations, Reconsiderations, and
Appeals Under Original Medicare (Parts A and B)
405.900 Basis and scope.
405.902 Definitions.
405.904 Medicare initial determinations, redeterminations and appeals:
General description.
405.906. Parties to the initial determinations, redeterminations,
reconsiderations, hearings and reviews.
405.908 Medicaid State agencies.
405.910 Appointed representatives.
405.912 Assignment of appeal rights.
Initial Determinations
405.920 Initial determinations.
405.921 Notice of initial determination.
405.922 Time frame for processing initial determinations.
405.924 Actions that are initial determinations.
405.926 Actions that are not initial determinations.
405.927 Initial determinations subject to the reopenings process.
405.928 Effect of the initial determination.
Redeterminations
405.940 Right to a redetermination.
405.942 Time frame for filing a request for a redetermination.
405.944 Place and method of filing a request for a redetermination.
405.946 Evidence to be submitted with the redetermination request.
405.948 Conduct of a redetermination.
405.950 Time frame for making a redetermination.
405.952 Withdrawal or dismissal of a request for a redetermination.
405.954 Redetermination.
405.956 Notice of a redetermination.
405.958 Effect of a redetermination.
Reconsideration
405.960 Right to a reconsideration.
405.962 Time frame for filing a request for a reconsideration.
405.964 Place and method of filing a request for a reconsideration.
405.966 Evidence to be submitted with the reconsideration request.
405.968 Conduct of a reconsideration.
405.970 Time frame for making a reconsideration.
405.972 Withdrawal or dismissal of a request for a reconsideration.
405.974 Reconsideration.
405.976 Notice of a reconsideration.
405.978 Effect of a reconsideration.
Reopenings
405.980 Reopenings of initial determinations, redeterminations, and
reconsiderations, hearings and reviews.
405.982 Notice of a revised determination or decision.
405.984 Effect of a revised determination or decision.
405.986 Good cause for reopening.
Expedited Access to Judicial Review
405.990 Expedited access to judicial review.
ALJ Hearings
405.1000 Hearing before an ALJ: General rule.
405.1002 Right to an ALJ hearing.
405.1004 Right to ALJ review of QIC notice of dismissal.
405.1006 Amount in controversy required to request an ALJ hearing and
judicial review.
405.1008 Parties to an ALJ hearing.
405.1010 When CMS or its contractors may participate in an ALJ hearing.
405.1012 When CMS or its contractors may be a party to a hearing.
405.1014 Request for an ALJ hearing.
405.1016 Time frames for deciding an appeal before an ALJ.
405.1018 Submitting evidence before the ALJ hearing.
405.1020 Time and place for a hearing before an ALJ.
405.1022 Notice of a hearing before an ALJ.
405.1024 Objections to the issues.
405.1026 Disqualification of the ALJ.
405.1028 Prehearing case review of evidence submitted to the ALJ.
405.1030 ALJ hearing procedures.
405.1032 Issues before an ALJ.
405.1034 When an ALJ may remand a case to the QIC.
405.1036 Description of an ALJ hearing process.
405.1037 Discovery.
405.1038 Deciding a case without a hearing before an ALJ.
405.1040 Prehearing and posthearing conferences.
405.1042 The administrative record.
405.1044 Consolidated hearing before an ALJ.
405.1046 Notice of an ALJ decision.
405.1048 The effect of an ALJ's decision.
405.1050 Removal of a hearing request from an ALJ to the MAC.
405.1052 Dismissal of a request for a hearing before an ALJ.
405.1054 Effect of dismissal of a request for a hearing before an ALJ.
Applicability of Medicare Coverage Policies
405.1060 Applicability of nation coverage determinations (NCDs).
[[Page 86]]
405.1062 Applicability of local coverage determinations and other
policies not binding on the ALJ and MAC.
405.1063 Applicability of CMS rulings.
405.1064 ALJ decisions involving statistical samples.
Medicare Appeals Council Review
405.1100 Medicare Appeals Council review: General.
405.1102 Request for MAC review when an ALJ issues decision or
dismissal.
405.1104 Request for MAC review when an ALJ does not issue a decision
timely.
405.1106 Where a request for review or escalation may be filed.
405.1108 MAC actions when request for review or escalation is filed.
405.1110 MAC reviews on its own motion.
405.1112 Content of request for review.
405.1114 Dismissal of request for review.
405.1116 Effect of dismissal of request for MAC review or request for
hearing.
405.1118 Obtaining evidence from the MAC.
405.1120 Filling briefs with the MAC.
405.1122 What evidence may be submitted to the MAC.
405.1124 Oral argument.
405.1126 Case remanded by the MAC.
405.1128 Action of the MAC.
405.1130 Effect of the MAC's decision.
405.1132 Request for escalation to Federal district court.
405.1134 Extension of time to file action in Federal district court.
405.1136 Judicial review.
405.1138 Case remanded by a Federal district court.
405.1140 MAC review of ALJ decision in a case remanded by a Federal
district court.
Subpart J_Expedited Determinations and Reconsiderations of Provider
Service Terminations, and Procedures for Inpatient Hospital Discharges
405.1200 Notifying beneficiaries of provider service terminations.
405.1202 Expedited determination procedures.
405.1204 Expedited reconsiderations.
405.1206 Expedited determinations for inpatient hospital discharges.
405.1208 Hospital requests expedited QIO review.
Subparts K-Q [Reserved]
Subpart R_Provider Reimbursement Determinations and Appeals
405.1801 Introduction.
405.1803 Intermediary determination and notice of amount of program
reimbursement.
405.1804 Matters not subject to administrative or judicial review under
prospective payment.
405.1805 Parties to intermediary determination.
405.1807 Effect of intermediary determination.
405.1809 Intermediary hearing procedures.
405.1811 Right to intermediary hearing; time, place, form, and content
of request for intermediary hearing.
405.1813 Failure to timely request an intermediary hearing.
405.1815 Parties to the intermediary hearing.
405.1817 Hearing officer or panel of hearing officers authorized to
conduct intermediary hearing; disqualification of officers.
405.1819 Conduct of intermediary hearing.
405.1821 Prehearing discovery and other proceedings prior to the
intermediary hearing.
405.1823 Evidence at intermediary hearing.
405.1825 Witnesses at intermediary hearing.
405.1827 Record of intermediary hearing.
405.1829 Authority of hearing officer(s) at intermediary hearing.
405.1831 Intermediary hearing decision and notice.
405.1833 Effect of intermediary hearing decision.
405.1835 Right to Board hearing.
405.1837 Group appeal.
405.1839 Amount in controversy.
405.1841 Time, place, form, and content of request for Board hearing.
405.1842 Expediting Board proceedings.
405.1843 Parties to Board hearing.
405.1845 Composition of Board.
405.1847 Disqualification of Board members.
405.1849 Establishment of time and place of hearing by the Board.
405.1851 Conduct of Board hearing.
405.1853 Prehearing discovery and other proceedings prior to the Board
hearing.
405.1855 Evidence at Board hearing.
405.1857 Subpoenas.
405.1859 Witnesses.
405.1861 Oral argument and written allegations.
405.1863 Administrative policy at issue.
405.1865 Record of Board hearing.
405.1867 Sources of Board's authority.
405.1869 Scope of Board's decision-making authority.
405.1871 Board hearing decision and notice.
405.1873 Board's jurisdiction.
405.1875 Administrator's review.
405.1877 Judicial review.
405.1881 Appointment of representative.
405.1883 Authority of representative.
405.1885 Reopening a determination or decision.
405.1887 Notice of reopening.
405.1889 Effect of a revision.
[[Page 87]]
Subparts S-T [Reserved]
Subpart U_Conditions for Coverage of Suppliers of End-Stage Renal
Disease (ESRD) Services
405.2100 Scope of subpart.
405.2101 Objectives of the end-stage renal disease (ESRD) program.
405.2102 Definitions.
405.2110 Designation of ESRD networks.
405.2111 [Reserved]
405.2112 ESRD network organizations.
405.2113 Medical review board.
405.2114 [Reserved]
405.2120 Minimum utilization rates: general.
405.2121 Basis for determining minimum utilization rates.
405.2122 Types and duration of classification according to utilization
rates.
405.2123 Reporting of utilization rates for classification.
405.2124 Calculation of utilization rates for comparison with minimal
utilization rates(s) and notification of status.
405.2130 Condition: Minimum utilization rates.
405.2131 Condition: Provider status: Renal transplantation center or
renal dialysis center.
405.2132 [Reserved]
405.2133 Condition: Furnishing data and information for ESRD program
administration.
405.2134 Condition: Participation in network activities.
405.2135 Condition: Compliance with Federal, State, and local laws and
regulations.
405.2136 Condition: Governing body and management.
405.2137 Condition: Patient long-term program and patient care plan.
405.2138 Condition: Patients' rights and responsibilities.
405.2139 Condition: Medical records.
405.2140 Condition: Physical environment.
405.2150 Condition: Reuse of hemodialyzers and other dialysis supplies.
405.2160 Condition: Affiliation agreement or arrangement.
405.2161 Condition: Director of a renal dialysis facility or renal
dialysis center.
405.2162 Condition: Staff of a renal dialysis facility or renal dialysis
center.
405.2163 Condition: Minimal service requirements for a renal dialysis
facility or renal dialysis center.
405.2164 Conditions for coverage of special purpose renal dialysis
facilities.
405.2170 Condition: Director of a renal transplantation center.
405.2171 Condition: Minimal service requirements for a renal
transplantation center.
405.2180 Termination of Medicare coverage.
405.2181 Alternative sanctions.
405.2182 Notice of sanction and appeal rights: Termination of coverage.
405.2184 Notice of appeal rights: Alternative sanctions.
Subparts V-W [Reserved]
Subpart X_Rural Health Clinic and Federally Qualified Health Center
Services
405.2400 Basis.
405.2401 Scope and definitions.
405.2402 Basic requirements.
405.2403 Content and terms of the agreement with the Secretary.
405.2404 Terminations of agreements.
405.2410 Application of Part B deductible and coinsurance.
405.2411 Scope of benefits.
405.2412 Physicians' services.
405.2413 Services and supplies incident to a physician's services.
405.2414 Nurse practitioner and physician assistant services.
405.2415 Services and supplies incident to nurse practitioner and
physician assistant services.
405.2416 Visiting nurse services.
405.2417 Visiting nurse services: Determination of shortage of agencies.
Federally Qualified Health Center Services
405.2430 Basic requirements.
405.2434 Content and terms of the agreement.
405.2436 Termination of agreement.
405.2440 Conditions for reinstatement after termination by CMS.
405.2442 Notice to the public.
405.2444 Change of ownership.
405.2446 Scope of services.
405.2448 Preventive primary services.
405.2450 Clinical psychologist and clinical social worker services.
405.2452 Services and supplies incident to clinical psychologist and
clinical social worker services.
Payment for Rural Health Clinic and Federally Qualified Health Center
Services
405.2460 Applicability of general payment exclusions.
405.2462 Payment for rural health clinic and Federally qualified health
center services.
405.2463 What constitutes a visit.
405.2464 All-inclusive rate.
405.2466 Annual reconciliation.
405.2468 Allowable costs.
405.2470 Reports and maintenance of records.
405.2472 Beneficiary appeals.
Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 1886(k)
of the Social Security
[[Page 88]]
Act (42 U.S.C. 1302, 1395x, 1395y(a), 1395hh, 1395kk, 1395rr and
1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C.
263a).
Subpart A [Reserved]
Subpart B_Medical Services Coverage Decisions That Relate to Health Care
Technology
Authority: Secs. 1102, 1862 and 1871 of the Social Security Act as
amended (42 U.S.C.1302, 1395y, and 1395hh).
Source: 60 FR 48423, Sept. 19, 1995, unless otherwise noted.
Sec. 405.201 Scope of subpart and definitions.
(a) Scope. This subpart establishes that--
(1) CMS uses the FDA categorization of a device as a factor in
making Medicare coverage decisions; and
(2) CMS may consider for Medicare coverage certain devices with an
FDA-approved investigational device exemption (IDE) that have been
categorized as non-experimental/investigational (Category B).
(b) Definitions. As used in this subpart--
Class I refers to devices for which the general controls of the
Food, Drug, and Cosmetic Act, such as adherence to good manufacturing
practice regulations, are sufficient to provide a reasonable assurance
of safety and effectiveness.
Class II refers to devices that, in addition to general controls,
require special controls, such as performance standards or postmarket
surveillance, to provide a reasonable assurance of safety and
effectiveness.
Class III refers to devices that cannot be classified into Class I
or Class II because insufficient information exists to determine that
either special or general controls would provide reasonable assurance of
safety and effectiveness. Class III devices require premarket approval.
Contractors refers to carriers, fiscal intermediaries, and other
entities that contract with CMS to review and adjudicate claims for
Medicare services.
Experimental/investigational (Category A) device refers to an
innovative device believed to be in Class III for which ``absolute
risk'' of the device type has not been established (that is, initial
questions of safety and effectiveness have not been resolved and the FDA
is unsure whether the device type can be safe and effective).
IDE stands for investigational device exemption. An FDA-approved IDE
application permits a device, which would otherwise be subject to
marketing clearance, to be shipped lawfully for the purpose of
conducting a clinical trial in accordance with 21 U.S.C. 360j(g) and 21
CFR parts 812 and 813.
Non-experimental/investigational (Category B) device refers to a
device believed to be in Class I or Class II, or a device believed to be
in Class III for which the incremental risk is the primary risk in
question (that is, underlying questions of safety and effectiveness of
that device type have been resolved), or it is known that the device
type can be safe and effective because, for example, other manufacturers
have obtained FDA approval for that device type.
PMA stands for ``premarket approval'' and refers to a marketing
application for a Class III device, which includes all information
submitted with or incorporated by reference in the application in
accordance with 21 U.S.C. 360e and 360j and 21 CFR 814.3(e).
Sponsor refers to a person or entity that initiates, but does not
conduct, an investigation under an IDE.
Sec. 405.203 FDA categorization of investigational devices.
(a) The FDA assigns a device with an FDA-approved IDE to one of two
categories:
(1) Experimental/Investigational (Category A) Devices.
(2) Non-Experimental/Investigational (Category B) Devices.
(b) The FDA notifies CMS, when it notifies the sponsor, that the
device is categorized by FDA as experimental/investigational (Category
A) or non-experimental/investigational (Category B).
(c) CMS uses the categorization of the device as a factor in making
Medicare coverage decisions.
[[Page 89]]
Sec. 405.205 Coverage of a non-experimental/investigational (Category B)
device.
(a) For any device that meets the requirements of the exception at
Sec. 411.15(o) of this chapter, the following procedures apply:
(1) The FDA notifies CMS, when it notifies the sponsor, that the
device is categorized by FDA as non-experimental/investigational
(Category B).
(2) CMS uses the categorization of the device as a factor in making
Medicare coverage decisions.
(b) If the FDA becomes aware that a categorized device no longer
meets the requirements of the exception at Sec. 411.15(o) of this
chapter, the FDA notifies the sponsor and CMS and the procedures
described in paragraph (a)(2) of this section apply.
Sec. 405.207 Services related to a noncovered device.
(a) When payment is not made. Medicare payment is not made for
medical and hospital services that are related to the use of a device
that is not covered because CMS determines the device is not
``reasonable'' and ``necessary'' under section 1862(a)(1)(A) of the Act
or because it is excluded from coverage for other reasons. These
services include all services furnished in preparation for the use of a
noncovered device, services furnished contemporaneously with and
necessary to the use of a noncovered device, and services furnished as
necessary after-care that are incident to recovery from the use of the
device or from receiving related noncovered services.
(b) When payment is made. Medicare payment may be made for--
(1) Covered services to treat a condition or complication that
arises due to the use of a noncovered device or a noncovered device-
related service; or
(2) Routine care services related to experimental/investigational
(Category A) devices as defined in Sec. 405.201(b); and furnished in
conjunction with an FDA-approved clinical trial. The trial must meet
criteria established through the national coverage determination
process; and if the trial is initiated before January 1, 2010, the
device must be determined as intended for use in the diagnosis,
monitoring or treatment of an immediately life-threatening disease or
condition.
(3) Routine care services related to a non-experimental/
investigational (Category B) device defined in Sec. 405.201(b) that is
furnished in conjunction with an FDA-approved clinical trial.
[60 FR 48423, Sept. 19, 1995, as amended at 69 FR 66420, Nov. 15, 2004]
Sec. 405.209 Payment for a non-experimental/investigational (Category B)
device.
Payment under Medicare for a non-experimental/investigational
(Category B) device is based on, and may not exceed, the amount that
would have been paid for a currently used device serving the same
medical purpose that has been approved or cleared for marketing by the
FDA.
Sec. 405.211 Procedures for Medicare contractors in making coverage
decisions for a non-experimental/investigational (Category B) device.
(a) General rule. In their review of claims for payment, Medicare
contractors are bound by the statute, regulations, and all CMS
administrative issuances, including all national coverage decisions.
(b) Potentially covered non-experimental/investigational (Category
B) devices. Medicare contractors may approve coverage for any device
with an FDA-approved IDE categorized as a non-experimental/
investigational (Category B) device if all other coverage requirements
are met.
(c) Other considerations. Medicare contractors must consider whether
any restrictions concerning site of service, indications for use, or any
other list of conditions for coverage have been placed on the device's
use.
Sec. 405.213 Re-evaluation of a device categorization.
(a) General rules. (1) Any sponsor that does not agree with an FDA
decision that categorizes its device as experimental/investigational
(Category A) may request re-evaluation of the categorization decision.
(2) A sponsor may request review by CMS only after the requirements
of paragraph (b) of this section are met.
[[Page 90]]
(3) No reviews other than those described in paragraphs (b) and (c)
of this section are available to the sponsor.
(4) Neither the FDA original categorization or re-evaluation
(described in paragraph (b) of this section) nor CMS's review (described
in paragraph (c) of this section) constitute an initial determination
for purposes of the Medicare appeals processes under part 405, subpart G
or subpart H, or parts 417, 473, or 498 of this chapter.
(b) Request to FDA. A sponsor that does not agree with the FDA's
categorization of its device may submit a written request to the FDA at
any time requesting re-evaluation of its original categorization
decision, together with any information and rationale that it believes
support recategorization. The FDA notifies both CMS and the sponsor of
its decision.
(c) Request to CMS. If the FDA does not agree to recategorize the
device, the sponsor may seek review from CMS. A device sponsor must
submit its request in writing to CMS. CMS obtains copies of relevant
portions of the application, the original categorization decision, and
supplementary materials. CMS reviews all material submitted by the
sponsor and the FDA's recommendation. CMS reviews only information in
the FDA record to determine whether to change the categorization of the
device. CMS issues a written decision and notifies the sponsor of the
IDE and the FDA.
Sec. 405.215 Confidential commercial and trade secret information.
To the extent that CMS relies on confidential commercial or trade
secret information in any judicial proceeding, CMS will maintain
confidentiality of the information in accordance with Federal law.
Subpart C_Suspension of Payment, Recovery of Overpayments, and Repayment
of Scholarships and Loans
Authority: Secs. 1102, 1815, 1833, 1842, 1866, 1870, 1871, 1879, and
1892 of the Social Security Act (42 U.S.C. 1302, 1395g, 1395l, 1395u,
1395cc, 1395gg, 1395hh, 1395pp, and 1395ccc) and 31 U.S.C. 3711.
Source: 31 FR 13534, Oct. 20, 1966, unless otherwise noted.
Redesignated at 42 FR 52826, Sept. 30, 1977.
General Provisions
Sec. 405.301 Scope of subpart.
This subpart sets forth the policies and procedures for handling of
incorrect payments and recovery of overpayments.
[54 FR 41733, Oct. 11, 1989]
Liability for Payments To Providers or Suppliers and Handling of
Incorrect Payments
Sec. 405.350 Individual's liability for payments made to providers
and other persons for items and services furnished the individual.
Any payment made under title XVIII of the Act to any provider of
services or other person with respect to any item or service furnished
an individual shall be regarded as a payment to the individual, and
adjustment shall be made pursuant to Sec. Sec. 405.352 through 405.358
where:
(a) More than the correct amount is paid to a provider of services
or other person and the Secretary determines that:
(1) Within a reasonable period of time, the excess over the correct
amount cannot be recouped from the provider of services or other person,
or
(2) The provider of services or other person was without fault with
respect to the payment of such excess over the correct amount, or
(b) A payment has been made under the provisions described in
section 1814(e) of the Act, to a provider of services for items and
services furnished the individual.
(c) For purposes of paragraph (a)(2) of this section, a provider of
services or other person shall, in the absence of evidence to the
contrary, be deemed to be without fault if the determination of the
carrier, the intermediary, or the Centers for Medicare & Medicaid
Services that more than the correct amount was paid was made subsequent
to the third year following the year in
[[Page 91]]
which notice was sent to such individual that such amount had been paid.
[41 FR 1492, Jan. 8, 1976. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 61 FR 49271, Sept. 19, 1996]
Sec. 405.351 Incorrect payments for which the individual is not liable.
Where an incorrect payment has been made to a provider of services
or other person, the individual is liable only to the extent that he has
benefited from such payment.
Sec. 405.352 Adjustment of title XVIII incorrect payments.
Where an individual is liable for an incorrect payment (i.e., a
payment made under Sec. 405.350(a) or Sec. 405.350(b)) adjustment is
made (to the extent of such liability) by:
(a) Decreasing any payment under title II of the Act, or under the
Railroad Retirement Act of 1937, to which the individual is entitled; or
(b) In the event of the individual's death before adjustment is
completed, by decreasing any payment under title II of the Act, or under
the Railroad Retirement Act of 1937 payable to the estate of the
individual or to any other person, that are based on the individual's
earnings record (or compensation).
[31 FR 13534, Oct. 20, 1966, as amended by 41 FR 1492, Jan. 8, 1976.
Redesignated at 42 FR 52826, Sept. 30, 1977]
Sec. 405.353 Certification of amount that will be adjusted against
individual title II or railroad retirement benefits.
As soon as practicable after any adjustment is determined to be
necessary, the Secretary, for purposes of this subpart, shall certify
the amount of the overpayment or payment (see Sec. 405.350) with
respect to which the adjustment is to be made. If the adjustment is to
be made by decreasing subsequent payments under the Railroad Retirement
Act of 1937, such certification shall be made to the Railroad Retirement
Board.
Sec. 405.354 Procedures for adjustment or recovery--title II beneficiary.
The procedures applied in making an adjustment or recovery in the
case of a title II beneficiary are the applicable procedures of 20 CFR
404.502.
[31 FR 13534, Oct. 20, 1966, as amended at 32 FR 18027, Dec. 16, 1967.
Redesignated at 42 FR 52826, Sept. 30, 1977]
Sec. 405.355 Waiver of adjustment or recovery.
(a) The provisions of Sec. 405.352 may not be applied and there may
be no adjustment or recovery of an incorrect payment (i.e., a payment
made under Sec. 405.350(a) or Sec. 405.350(b)) in any case where such
incorrect payment has been made with respect to an individual who is
without fault, or where such adjustment or recovery would be made by
decreasing payments to which another person who is without fault is
entitled as provided in section 1870(b) of the Act where such adjustment
or recovery would defeat the purpose of title II or title XVIII of the
Act or would be against equity and good conscience. (See 20 CFR 404.509
and 404.512.)
(b) Adjustment or recovery of an incorrect payment (or only such
part of an incorrect payment as may be determined to be inconsistent
with the purposes of Title XVIII of the Act) against an individual who
is without fault shall be deemed to be against equity and good
conscience if the determination that such payment was incorrect was made
subsequent to the third year following the year in which notice of such
payment was sent to such individual. (See Sec. Sec. 405.330-405.332 for
conditions under which payment may be made for items or services
furnished after October 30, 1972 which are noncovered by reasons of
Sec. 405.310 (g) and (k).)
[41 FR 1493, Jan. 8, 1976. Redesignated at 42 FR 52826, Sept. 30, 1977]
Sec. 405.356 Principles applied in waiver of adjustment or recovery.
The principles applied in determining waiver of adjustment or
recovery (Sec. 405.355) are the applicable principles of Sec. 405.358
and 20 CFR 404.507-404.509, 404.510a, and 404.512.
[61 FR 49271, Sept. 19, 1996]
Sec. 405.357 Notice of right to waiver consideration.
Whenever an initial determination is made that more than the correct
[[Page 92]]
amount of payment has been made, notice of the provisions of section
1870(c) of the Act regarding waiver of adjustment or recovery shall be
sent to the overpaid individual and to any other individual against whom
adjustment or recovery of the overpayment is to be effected (see Sec.
405.358).
[61 FR 49271, Sept. 19, 1996]
Sec. 405.358 When waiver of adjustment or recovery may be applied.
Section 1870(c) of the Act provides that there shall be no
adjustment or recovery in any case where an incorrect payment under
title XVIII (hospital and supplementary medical insurance benefits) has
been made (including a payment under section 1814(e) of the Act with
respect to an individual:
(a) Who is without fault, and
(b) Adjustment or recovery would either:
(1) Defeat the purposes of title II or title XVIII of the Act, or
(2) Be against equity and good conscience.
[61 FR 49271, Sept. 19, 1996]
Sec. 405.359 Liability of certifying or disbursing officer.
No certifying or disbursing officer shall be held liable for any
amount certified or paid by him to any provider of services or other
person:
(a) Where the adjustment or recovery of such amount is waived (see
Sec. 405.355), or
(b) Where adjustment (see Sec. 405.352) or recovery is not
completed prior to the death of all persons against whose benefits such
adjustment is authorized.
Suspension and Recoupment of Payment to Providers and Suppliers and
Collection and Compromise of Overpayments
Sec. 405.370 Definitions.
For purposes of this subpart, the following definitions apply:
Offset. The recovery by Medicare of a non-Medicare debt by reducing
present or future Medicare payments and applying the amount withheld to
the indebtedness. (Examples are Public Health Service debts or Medicaid
debts recovered by CMS).
Recoupment. The recovery by Medicare of any outstanding Medicare
debt by reducing present or future Medicare payments and applying the
amount withheld to the indebtedness.
Suspension of payment. The withholding of payment by an intermediary
or carrier from a provider or supplier of an approved Medicare payment
amount before a determination of the amount of the overpayment exists.
[61 FR 63745, Dec. 2, 1996]
Sec. 405.371 Suspension, offset, and recoupment of Medicare payments
to providers and suppliers of services.
(a) General. Medicare payments to providers and suppliers, as
authorized under this subchapter (excluding payments to beneficiaries),
may be--
(1) Suspended, in whole or in part, by CMS, an intermediary, or a
carrier if CMS, the intermediary, or the carrier possesses reliable
information that an overpayment or fraud or willful misrepresentation
exists or that the payments to be made may not be correct, although
additional evidence may be needed for a determination; or
(2) Offset or recouped, in whole or in part, by an intermediary or a
carrier if the intermediary, carrier, or CMS has determined that the
provider or supplier to whom payments are to be made has been overpaid.
(b) Steps necessary for suspension of payment, offset, and
recoupment. Except as provided in paragraph (c) of this section, CMS,
the intermediary, or carrier suspends payments only after it has
complied with the procedural requirements set forth at Sec. 405.372.
The intermediary or carrier offsets or recoups payments only after it
has complied with the procedural requirements set forth at Sec.
405.373.
(c) Suspension of payment in the case of unfiled cost reports. If a
provider has failed to timely file an acceptable cost report, payment to
the provider is immediately suspended in whole or in part until a cost
report is filed and determined by the intermediary to be acceptable. In
the case of an unfiled cost report, the provisions of Sec. 405.372 do
not
[[Page 93]]
apply. (See Sec. 405.372(a)(2) concerning failure to furnish other
information.)
[61 FR 63746, Dec. 2, 1996, as amended at 67 FR 66813, Nov. 1, 2002]
Sec. 405.372 Proceeding for suspension of payment.
(a) Notice of intention to suspend--(1) General rule. Except as
provided in paragraphs (a)(2) through (a)(4) of this section, if the
intermediary, carrier, or CMS has determined that a suspension of
payments under Sec. 405.371(a)(1) should be put into effect, the
intermediary or carrier must notify the provider or supplier of the
intention to suspend payments, in whole or in part, and the reasons for
making the suspension.
(2) Failure to furnish information. The notice requirement of
paragraph (a)(1) of this section does not apply if the intermediary or
carrier suspends payments to a provider or supplier in accordance with
section 1815(a) or section 1833(e) of the Act, respectively, because the
provider or supplier has failed to submit information requested by the
intermediary or carrier that is needed to determine the amounts due the
provider or supplier. (See Sec. 405.371(c) concerning failure to file
timely acceptable cost reports.)
(3) Harm to Trust Funds. A suspension of payment may be imposed
without prior notice if CMS, the intermediary, or carrier determines
that the Medicare Trust Funds would be harmed by giving prior notice.
CMS may base its determination on an intermediary's or carrier's belief
that giving prior notice would hinder the possibility of recovering the
money.
(4) Fraud or misrepresentation. If the intended suspension of
payment involves suspected fraud or misrepresentation, CMS determines
whether to impose the suspension and if prior notice is appropriate. CMS
directs the intermediary or carrier as to the timing and content of the
notification to the provider or supplier. CMS is the real party in
interest and is responsible for the decision. CMS may base its decision
on information from the intermediary, carrier, law enforcement agencies,
or other sources. CMS determines whether the information is reliable.
(b) Rebuttal--(1) If prior notice is required. If prior notice is
required under paragraph (a) of this section, the intermediary or
carrier must give the provider or supplier an opportunity for rebuttal
in accordance with Sec. 405.374. If a rebuttal statement is received
within the specified time period, the suspension of payment goes into
effect on the date stated in the notice, and the procedures and
provisions set forth in Sec. 405.375 apply. If by the end of the period
specified in the notice no statement has been received, the suspension
goes into effect automatically, and the procedures set forth in
paragraph (c) of this section are followed.
(2) If prior notice is not required. If, under the provisions of
paragraphs (a)(2) through (a)(4) of this section, a suspension of
payment is put into effect without prior notice to the provider or
supplier, the intermediary or carrier must, once the suspension is in
effect, give the provider or supplier an opportunity to submit a
rebuttal statement as to why the suspension should be removed.
(c) Subsequent action. If a suspension of payment is put into
effect, the intermediary, carrier, or CMS takes timely action after the
suspension to obtain the additional evidence it may need to make a
determination as to whether an overpayment exists or the payments may be
made. The intermediary, carrier, or CMS makes all reasonable efforts to
expedite the determination. As soon as the determination is made, the
intermediary or carrier informs the provider or supplier and, if
appropriate, the suspension is rescinded or any existing recoupment or
offset is adjusted to take into account the determination.
(d) Duration of suspension of payment--(1) General rule. Except as
provided in paragraphs (d)(2) and (d)(3) of this section, a suspension
of payment is limited to 180 days, starting with the date the suspension
begins.
(2) 180-day extension. (i) An intermediary, a carrier, or, in cases
of fraud and misrepresentation, OIG or a law enforcement agency, may
request a one-time only extension of the suspension period for up to 180
additional days if it is unable to complete its examination of the
information or investigation, as appropriate, within the 180-
[[Page 94]]
day time limit. The request must be submitted in writing to CMS.
(ii) Upon receipt of a request for an extension, CMS notifies the
provider or supplier of the requested extension. CMS then either extends
the suspension of payment for up to an additional 180 days or determines
that the suspended payments are to be released to the provider or
supplier.
(3) Exceptions to the time limits. (i) The time limits specified in
paragraphs (d)(1) and (d)(2) of this section do not apply if the case
has been referred to, and is being considered by, the OIG for
administrative action (for example, civil money penalties).
(ii) CMS may grant an extension in addition to the extension
provided under paragraph (d)(2) of this section if the Department of
Justice submits a written request to CMS that the suspension of payment
be continued based on the ongoing investigation and anticipated filing
of criminal and/or civil actions. At a minimum, the request must include
the following:
(A) Identification of the entity under suspension.
(B) The amount of time needed for continued suspension in order to
implement the criminal and/or civil proceedings.
(C) A statement of why and/or how criminal and/or civil actions may
be affected if the requested extension is not granted.
(e) Disposition of suspended payments. Payments suspended under the
authority of Sec. 405.371(b) are first applied to reduce or eliminate
any overpayments determined by the intermediary, carrier, or CMS,
including any interest assessed under the provisions of Sec. 405.378,
and then applied to reduce any other obligation to CMS or to HHS. In the
absence of a legal requirement that the excess be paid to another
entity, the excess is released to the provider or supplier.
[61 FR 63746, Dec. 2, 1996]
Sec. 405.373 Proceeding for offset or recoupment.
(a) General rule. Except as specified in paragraph (b) of this
section, if the intermediary, carrier, or CMS has determined that an
offset or recoupment of payments under Sec. 405.371(a)(2) should be put
into effect, the intermediary or carrier must--
(1) Notify the provider or supplier of its intention to offset or
recoup payment, in whole or in part, and the reasons for making the
offset or recoupment; and
(2) Give the provider or supplier an opportunity for rebuttal in
accordance with Sec. 405.374.
(b) Paragraph (a) of this section does not apply if the
intermediary, after furnishing a provider a written notice of the amount
of program reimbursement in accordance with Sec. 405.1803, recoups
payment under paragraph (c) of Sec. 405.1803. (For provider rights in
this circumstance, see Sec. Sec. 405.1809, 405.1811, 405.1815,
405.1835, and 405.1843.)
(c) Actions following receipt of rebuttal statement. If a provider
or supplier submits, in accordance with Sec. 405.374, a statement as to
why an offset or recoupment should not be put into effect on the date
specified in the notice, the intermediary or carrier must comply with
the time limits and notification requirements of Sec. 405.375.
(d) No rebuttal statement received. If, by the end of the time
period specified in the notice, no statement has been received, the
recoupment or offset goes into effect automatically.
(e) Duration of recoupment or offset. If a recoupment or offset is
put into effect, it remains in effect until the earliest of the
following:
(1) The overpayment and any assessed interest are liquidated.
(2) The intermediary or carrier obtains a satisfactory agreement
from the provider or supplier for liquidation of the overpayment.
(3) The intermediary or carrier, on the basis of subsequently
acquired evidence or otherwise, determines that there is no overpayment.
[61 FR 63747, Dec. 2, 1996]
Sec. 405.374 Opportunity for rebuttal.
(a) General rule. If prior notice of the suspension of payment,
offset, or recoupment is given under Sec. 405.372 or Sec. 405.373, the
intermediary or carrier must give the provider or supplier an
opportunity, before the suspension, offset, or recoupment takes effect,
to submit any statement (to include any pertinent information) as to why
it should
[[Page 95]]
not be put into effect on the date specified in the notice. Except as
provided in paragraph (b) of this section, the provider or supplier has
at least 15 days following the date of notification to submit the
statement.
(b) Exception. The intermediary or carrier may for cause--
(1) Impose a shorter period for rebuttal; or
(2) Extend the time within which the statement must be submitted.
[61 FR 63747, Dec. 2, 1996]
Sec. 405.375 Time limits for, and notification of, administrative
determination after receipt of rebuttal statement.
(a) Submission and disposition of evidence. If the provider or
supplier submits a statement, under Sec. 405.374, as to why a
suspension of payment, offset, or recoupment should not be put into
effect, or, under Sec. 405.372(b)(2), why a suspension should be
terminated, CMS, the intermediary, or carrier must within 15 days, from
the date the statement is received, consider the statement (including
any pertinent evidence submitted), together with any other material
bearing upon the case, and determine whether the facts justify the
suspension, offset, or recoupment or, if already initiated, justify the
termination of the suspension, offset, or recoupment. Suspension,
offset, or recoupment is not delayed beyond the date stated in the
notice in order to review the statement.
(b) Notification of determination. The intermediary or carrier must
send written notice of the determination made under paragraph (a) of
this section to the provider or supplier. The notice must--
(1) In the case of offset or recoupment, contain rationale for the
determination; and
(2) In the case of suspension of payment, contain specific findings
on the conditions upon which the suspension is initiated, continued, or
removed and an explanatory statement of the determination.
(c) Determination is not appealable. A determination made under
paragraph (a) of this section is not an initial determination and is not
appealable.
[61 FR 63747, Dec. 2, 1996]
Sec. 405.376 Suspension and termination of collection action and
compromise of claims for overpayment.
(a) Basis and purpose. This section contains requirements and
procedures for the compromise of, or suspension or termination of
collection action on, claims for overpayments against a provider or a
supplier under the Medicare program. It is adopted under the authority
of the Federal Claims Collection Act (31 U.S.C. 3711). Collection and
compromise of claims against Medicare beneficiaries are explained at 20
CFR 404.515.
(b) Definitions. As used in this section, debtor means a provider of
services or a physician or other supplier of services that has been
overpaid under title XVIII of the Social Security Act. It includes an
individual, partnership, corporation, estate, trust, or other legal
entity.
(c) Basic conditions. A claim for recovery of Medicare overpayments
against a debtor may be compromised, or collection action on it may be
suspended or terminated, by the Centers for Medicare & Medicaid Services
(CMS) if;
(1) The claim does not exceed $100,000, or such higher amount as the
Attorney General may from time to time prescribe, exclusive of interest;
and
(2) There is no indication of fraud, the filing of a false claim, or
misrepresentation on the part of the debtor or any director, partner,
manager, or other party having an interest in the claim.
(d) Basis for compromise. A claim may be compromised for one or more
of the following reasons:
(1) The debtor, or the estate of a deceased debtor, does not have
the present or prospective ability to pay the full amount within a
reasonable time;
(2) The debtor refuses to pay the claim in full and the United
States is unable to collect the full amount within a reasonable time by
legal proceedings;
(3) There is real doubt the United States can prove its case in
court; or
(4) The cost of collecting the claim does not justify enforced
collection of the full amount.
[[Page 96]]
(e) Basis for termination of collection action. Collection action
may be terminated for one or more of the following reasons:
(1) The United States cannot enforce collection of any significant
sum;
(2) The debtor cannot be located, there is no security to be
liquidated, the statute of limitations has run, and the prospects of
collecting by offset are too remote to justify retention of the claim;
(3) The cost of further collection action is likely to exceed any
recovery;
(4) It is determined the claim is without merit; or
(5) Evidence to substantiate the claim is no longer available.
(f) Basis for suspension of collection action. Collection action may
be suspended for either of the following reasons if future collection
action is justified based on potential productivity, including
foreseeable ability to pay, and size of claim:
(1) The debtor cannot be located; or
(2) The debtor is unable to make payments on the claim or to fulfill
an acceptable compromise.
(g) Factors considered. In determining whether a claim will be
compromised, or collection action terminated or suspended, CMS will
consider the following factors:
(1) Age and health of the debtor, present and potential income,
inheritance prospects, possible concealment or fraudulent transfer of
assets, and the availability of assets which may be reached by enforced
collection proceedings, for compromise under paragraph (d)(1) of this
section, termination under paragraph (e)(1) of this section, and
suspension under paragraph (f)(2) of this section;
(2) Applicable exemptions available to a debtor and uncertainty
concerning the price of the property in a forced sale, for compromise
under paragraph (d)(2) of this section and termination under paragraph
(e)(1) of this section; and
(3) The probability of proving the claim in court, the probability
of full or partial recovery, the availability of necessary evidence, and
related pragmatic considerations, for compromise under paragraph (d)(3)
of this section.
(h) Amount of compromise. The amount accepted in compromise will be
reasonable in relation to the amount that can be recovered by enforced
collection proceedings.
Consideration shall be given to the following:
(1) The exemptions available to the debtor under State or Federal
law;
(2) The time necessary to collect the overpayment;
(3) The litigative probabilities involved; and
(4) The administrative and litigative costs of collection where the
cost of collecting the claim is a basis for compromise.
(i) Payment of compromise--(1) Time and manner. Payment of the
amount that CMS has agreed to accept as a compromise in full settlement
of a Medicare overpayment claim must be made within the time and in the
manner prescribed by CMS. An overpayment claim is not compromised or
settled until the full payment of the compromised amount has been made
within the time and in the manner prescribed by CMS.
(2) Failure to pay compromised amount. Failure of the debtor or the
estate to make payment as provided by the comprise reinstates the full
amount of the overpayment claim, less any amounts paid prior to the
default.
(j) Effect of compromise, or suspension, or termination of
collection action. Any action taken by CMS under this section regarding
the compromise of an overpayment claim, or termination or suspension of
collection action on an overpayment claim, is not an initial
determination for purposes of the appeal procedures under subparts G, H,
and R of this part.
[43 FR 59381, Dec. 20, 1978, as amended at 57 56998, Dec. 2, 1992.
Redesignated and amended at 61 FR 63745, 63747, Dec. 2, 1996]
Sec. 405.377 Withholding Medicare payments to recover Medicaid
overpayments.
(a) Basis and purpose. This section implements section 1885 of the
Act, which provides for withholding Medicare payments to certain
Medicaid providers that have not arranged to repay Medicaid overpayments
as determined by the Medicaid State agency or have
[[Page 97]]
failed to provide information necessary to determine the amount (if any)
of overpayments.
(b) When withholding may be used. CMS may withhold Medicare payment
to offset Medicaid overpayments that a Medicaid agency has been unable
to collect if--
(1) The Medicaid agency has followed the procedure specified in
Sec. 447.31 of this chapter; and
(2) The institution or person is one described in paragraph (c) of
this section and either--
(i) Has not made arrangements satisfactory to the Medicaid agency to
repay the overpayment; or
(ii) Has not provided information to the Medicaid agency necessary
to enable the agency to determine the existence or amount of Medicaid
overpayment.
(c) Institutions or persons affected. Withholding under paragraph
(b) of this section may be made with respect to any of the following
entities that has or had in effect an agreement with a Medicaid agency
to furnish services under an approved Medicaid State plan:
(1) An institutional provider that has in effect an agreement under
section 1866 of the Act. (Part 489 (Provider and Supplier Agreements)
implements section 1866 of the Act.)
(2) A physician or supplier that has accepted payment on the basis
of an assignment under section 1842(b)(3)(B)(ii) of the Act. (Section
424.55 sets forth the conditions a supplier agrees to in accepting
assignment.)
(d) Amount to be withheld. (1) CMS contacts the appropriate
intermediary or carrier to determine the amount of Medicare payment to
which the institution or person is entitled.
(2) CMS may require the intermediary or carrier to withhold Medicare
payments to the institution or person by the lesser of the following
amounts:
(i) The amount of the Medicare payments to which the institution or
person would otherwise be entitled.
(ii) The total Medicaid overpayment to the institution or person.
(e) Notice of withholding. If CMS intends to withhold payments under
this section, it notifies by certified mail, return receipt requested,
the institution or person and the appropriate intermediary or carrier of
the intention to withhold Medicare payments and follows the procedure in
Sec. 405.374. The notice includes--
(1) Identification of the institution or person; and
(2) The amount of Medicaid overpayment to be withheld from payments
to which the institution or person would otherwise be entitled under
Medicare.
(f) Termination of withholding. CMS terminates the withholding if--
(1) The Medicaid overpayment is completely recovered;
(2) The institution or person enters into an agreement satisfactory
to the Medicaid agency to repay the overpayment; or
(3) The Medicaid agency determines that there is no overpayment
based on newly acquired evidence or a subsequent audit.
(g) Disposition of funds withheld. CMS releases amounts withheld
under this section to the Medicaid agency to be applied against the
Medicaid overpayment made by the State agency.
[61 FR 63747, Dec. 2, 1996]
Sec. 405.378 Interest charges on overpayment and underpayments to
providers, suppliers, and other entities.
(a) Basis and purpose. This section, which implements sections
1815(d) and 1833(j) of the common law and Act, and authority granted
under the Federal Claims Collection Act, provides for the charging and
payment of interest on overpayments and underpayments to Medicare
providers, suppliers, HMOs, competitive medical plans (CMPs), and health
care prepayment plans (HCPPs).
(b) Basic rules. (1) CMS will charge interest on overpayments, and
pay interest on underpayments, to providers and suppliers of services
(including physicians and other practitioners), except as specified in
paragraphs (f) and (h) of this section.
(2) Interest accrues from the date of the final determination as
defined in paragraph (c) of this section, and either is charged on the
overpayment balance or paid on the underpayment balance for each full
30-day period that payment is delayed.
(c) Definition of final determination. (1) For purposes of this
section, any of the
[[Page 98]]
following constitutes a final determination:
(i) A Notice of Amount of Program Reimbursement (NPR) is issued, as
discussed in Sec. Sec. 405.1803, 417.576, and 417.810, and either--
(A) A written demand for payment is made; or
(B) A written determination of an underpayment is made by the
intermediary after a cost report is filed.
(ii) In cases in which an NPR is not used as a notice of
determination (that is, primarily under part B), one of the following
determinations is issued--
(A) A written determination that an overpayment exists and a written
demand for payment;
(B) A written determination of an underpayment; or
(C) An Administrative Law Judge (ALJ) decision that reduces the
amount of an overpayment below the amount that CMS has already
collected.
(iii) Other examples of cases in which an NPR is not used are
carrier reasonable charge determinations under subpart E of this part,
interim cost settlements made for HMOs, CMPs, and HCPPs under Sec. Sec.
417.574 and 417.810(e) of this chapter, and initial retroactive
adjustment determinations under Sec. 413.64(f)(2) of this chapter. In
the case of interim cost settlements and initial retroactive adjustment
determinations, if the debtor does not dispute the adjustment
determination within the timeframe designated in the notice of the
determination (generally at least 15 days), a final determination is
deemed to have been made. If the provider or supplier does dispute
portions of the determination, a final determination is deemed to have
been made on those portions when the intermediary issues a new
determination in response to the dispute.
(iv) The due date of a timely-filed cost report that indicates an
amount is due CMS, and is not accompanied by payment in full. (If an
additional overpayment or underpayment is determined by the carrier or
intermediary, a final determination on the additional amount is made in
accordance with paragraphs (c)(1)(i), (c)(1)(ii), or (c)(1)(iii), of
this section.)
(v) With respect to a cost report that is not filed on time, the day
following the date the cost report was due (plus a single extension of
time not to exceed 30 days if granted for good cause), until the time as
a cost report is filed. (When the cost report is subsequently filed,
there is an additional determination as specified in paragraphs (c)(1)
(i), (ii), (iii), or (iv) of this section.)
(2) Except as required by any subsequent administrative or judicial
reversal, interest accrues from the date of final determination as
specified in this subsection.
(d) Rate of interest. (1) The interest rate on overpayments and
underpayments is the higher of--
(i) The rate as fixed by the Secretary of the Treasury after taking
into consideration private consumer rates of interest prevailing on the
date of final determination as defined in paragraph (c) of this section
(this rate is published quarterly in the Federal Register by the
Department under 45 CFR 30.13(a)); or
(ii) The current value of funds rate (this rate is published
annually in the Federal Register by the Secretary of the Treasury,
subject to quarterly revisions).
(2) [Reserved]
(e) Accrual of interest. (1) If a cost report is filed that does not
indicate an amount is due CMS but the intermediary makes a final
determination that an overpayment exists, or if a carrier makes a final
determination that an overpayment to a physician or supplier exists,
interest will accrue beginning with the date of such final
determination. Interest will continue to accrue during periods of
administrative and judicial appeal and until final disposition of the
claim.
(2)(i) If a cost report is filed and indicates that an amount is due
CMS, interest on the amount due will accrue from the due date of the
cost report unless--
(A) Full payment on the amount due accompanies the cost report; or
(B) The provider and the intermediary agree in advance to liquidate
the overpayment through a reduction in interim payments over the next
30-day period.
[[Page 99]]
(ii) If the intermediary determines an additional overpayment during
the cost settlement process, interest will accrue from the date of each
determination.
(iii) The interest rate on each of the final determinations of an
overpayment will be the rate of interest in effect on the date the
determination is made.
(3) In the case of a cost report that is not filed on time, interest
also will accrue on a determined overpayment from the day following the
due date of the report (plus a single extension of time not to exceed 30
days if granted for good cause, as specified in Sec. 413.24(f)) of this
chapter, to the time the cost report is filed.
(4) If an intermediary or a carrier makes a final determination that
an underpayment exists, interest to the provider or the supplier will
accrue from the date of notification of the underpayment.
(f) Waiver of interest charges. (1) When an intermediary or a
carrier makes a final determination that an overpayment or underpayment
exists, as specified in paragraphs (e)(1), (e)(2)(ii), and (e)(4)--
(i) Interest charges will be waived if the overpayment or
underpayment is completely liquidated within 30 days from the date of
the final determination.
(ii) CMS may waive interest charges if it determines that the
administrative cost of collecting them exceeds the interest charges.
(2) Interest will not be waived for that period of time during which
the cost report was due but remained unfiled for more than 30 days, as
specified in paragraph (e)(3) of this section.
(g) Rules applicable to partial payments. If an overpayment is
repaid in installments or recouped by withholding from several payments
due the provider or supplier of services--
(1) Each payment or recoupment will be applied first to accrued
interest and then to the principal; and
(2) After each payment or recoupment, interest will accrue on the
remaining unpaid balance.
(h) Exceptions to applicability. (1) The provisions of this section
do not apply to the time period for which interest is payable under
Sec. 413.64(j) of this chapter because the provider seeks judicial
review of a decision of the Provider Reimbursement Review Board, or a
subsequent reversal, affirmance, or modification of that decision by the
Administrator. Prior to that time, until the provider seeks judicial
review, interest accrues at the rate specified in this section on
outstanding unpaid balances resulting from final determinations as
defined in paragraph (c) of this section.
(2) If an overpayment or an underpayment determination is reversed
administratively or judicially, and the reversal is no longer subject to
appeal, appropriate adjustments will be made with respect to the
overpayment or underpayment and the amount of interest charged.
(i) Nonallowable cost. As specified in Sec. Sec. 412.113 and
413.153 of this chapter, interest accrued on overpayments and interest
on funds borrowed specifically to repay overpayments are not considered
allowable costs, up to the amount of the overpayment, unless the
provider had made a prior commitment to borrow funds for other purposes
(for example, capital improvements).
(See Sec. 413.153(a)(2) of this chapter for exceptions based on
administrative or judicial reversal.)
[47 FR 54814, Dec. 6, 1982, as amended at 49 FR 36102, Sept. 14, 1984;
49 FR 44472, Nov. 7, 1984; 51 FR 34792, Sept. 30, 1986; 56 FR 31336,
July 10, 1991. Redesignated at 61 FR 63745, Dec. 2, 1996; 69 FR 45607,
July 30, 2004]
Repayment of Scholarships and Loans
Sec. 405.380 Collection of past-due amounts on scholarship and loan
programs.
(a) Basis and purpose. This section implements section 1892 of the
Act, which authorizes the Secretary to deduct from Medicare payments for
services amounts considered as past-due obligations under the National
Health Service Corps Scholarship program, the Physician Shortage Area
Scholarship program, and the Health Education Assistance Loan program.
(b) Offsetting against Medicare payment. (1) Medicare carriers and
intermediaries offset against Medicare payments in accordance with the
signed
[[Page 100]]
repayment agreement between the Public Health Service and individuals
who have breached their scholarship or loan obligations and who--
(i) Accept Medicare assignment for services;
(ii) Are employed by or affiliated with a provider, HMO, or
Competitive Medical Plan (CMP) that receives Medicare payment for
services; or
(iii) Are members of a group practice that receives Medicare payment
for services.
(2) For purposes of this section, ``provider'' includes all entities
eligible to receive Medicare payment in accordance with an agreement
under section 1866 of the Act.
(c) Beginning of offset. (1) The Medicare carrier offsets Medicare
payments beginning six months after it notifies the individual or the
group practice of the amount to be deducted and the particular
individual to whom the deductions are attributable.
(2) The Medicare intermediary offsets payments beginning six months
after it notifies the provider, HMO, CMP or group practice of the amount
to be deducted and the particular individuals to whom the deductions are
attributable. Offset of payments is made in accordance with the terms of
the repayment agreement. If the individual ceases to be employed by the
provider, HMO, or CMP, or leaves the group practice, no deduction is
made.
(d) Refusal to offset against Medicare payment. If the individual
refuses to enter into a repayment agreement, or breaches any provision
of the agreement, or if Medicare payment is insufficient to maintain the
offset collection according to the agreed upon formula, then--
(1) The Department, within 30 days if feasible, informs the Attorney
General; and
(2) The Department excludes the individual from Medicare until the
entire past due obligation has been repaid, unless the individual is a
sole community practitioner or the sole source of essential specialized
services in a community and the State requests that the individual not
be excluded.
[57 FR 19092, May 4, 1992]
Subpart D_Private Contracts
Authority: Secs. 1102, 1802, and 1871 of the Social Security Act (42
U.S.C. 1302, 1395a, and 1395hh).
Source: 63 FR 58901, Nov. 2, 1998, unless otherwise noted.
Sec. 405.400 Definitions.
For purposes of this subpart, the following definitions apply:
Beneficiary means an individual who is enrolled in Part B of
Medicare.
Emergency care services means services furnished to an individual
for treatment of an ``emergency medical condition'' as that term is
defined in Sec. 422.2 of this chapter.
Legal representative means one or more individuals who, as
determined by applicable State law, has the legal authority to enter
into the contract with the physician or practitioner on behalf of the
beneficiary.
Opt-out means the status of meeting the conditions specified in
Sec. 405.410.
Opt-out period means the 2-year period beginning on the effective
date of the affidavit as specified by Sec. 405.410(c)(1) or Sec.
405.410(c)(2), as applicable.
Participating physician means a ``physician'' as defined in this
section who has signed an agreement to participate in Part B of
Medicare.
Physician means a doctor of medicine; doctor of osteopathy; doctor
of dental surgery or of dental medicine; doctor of podiatric medicine;
or doctor of optometry who is legally authorized to practice medicine,
osteopathy, dental surgery, dental medicine, podiatric medicine, or
optometry by the State in which he performs such function and who is
acting within the scope of his license when he performs such functions.
Practitioner means a physician assistant, nurse practitioner,
clinical nurse specialist, certified registered nurse anesthetist,
certified nurse midwife, clinical psychologist, or clinical social
worker, who is currently legally authorized to practice in that capacity
by each State in which he or she furnishes services to patients or
clients.
Private contract means a document that meets the criteria specified
in Sec. 405.415.
[[Page 101]]
Properly opt-out means to complete, without defect, the requirements
for opt-out as specified in Sec. 405.410.
Properly terminate opt-out means to complete, without defect, the
requirements for terminating opt-out as specified in Sec. 405.445.
Urgent care services means services furnished to an individual who
requires services to be furnished within 12 hours in order to avoid the
likely onset of an emergency medical condition.
[63 FR 58901, Nov. 2, 1998, as amended at 69 FR 1116, Jan. 7, 2004]
Sec. 405.405 General rules.
(a) A physician or practitioner may enter into one or more private
contracts with Medicare beneficiaries for the purpose of furnishing
items or services that would otherwise be covered by Medicare, provided
the conditions of this subpart are met.
(b) A physician or practitioner who enters into at least one private
contract with a Medicare beneficiary under the conditions of this
subpart, and who submits one or more affidavits in accordance with this
subpart, opts-out of Medicare for a 2-year period unless the opt-out is
terminated early according to Sec. 405.445. The physician's or
practitioner's opt-out may be renewed for subsequent 2-year periods.
(c) Both the private contracts described in paragraph (a) of this
section and the physician's or practitioner's opt-out described in
paragraph (b) of this section are null and void if the physician or
practitioner fails to properly opt-out in accordance with the conditions
of this subpart.
(d) Both the private contracts described in paragraph (a) of this
section and the physician's or practitioner's opt-out described in
paragraph (b) of this section are null and void for the remainder of the
opt-out period if the physician or practitioner fails to remain in
compliance with the conditions of this subpart during the opt-out
period.
(e) Services furnished under private contracts meeting the
requirements of this subpart are not covered services under Medicare,
and no Medicare payment will be made for such services either directly
or indirectly, except as permitted in accordance with Sec. 405.435(c).
Sec. 405.410 Conditions for properly opting-out of Medicare.
The following conditions must be met for a physician or practitioner
to properly opt-out of Medicare:
(a) Each private contract between a physician or a practitioner and
a Medicare beneficiary that is entered into prior to the submission of
the affidavit described in paragraph (b) of this section must meet the
specifications of Sec. 405.415.
(b) The physician or practitioner must submit an affidavit that
meets the specifications of Sec. 405.420 to each Medicare carrier with
which he or she would file claims absent completion of opt-out.
(c) A nonparticipating physician or a practitioner may opt-out of
Medicare at any time in accordance with the following:
(1) The 2-year opt-out period begins the date the affidavit meeting
the requirements of Sec. 405.420 is signed, provided the affidavit is
filed within 10 days after he or she signs his or her first private
contract with a Medicare beneficiary.
(2) If the physician or practitioner does not timely file any
required affidavit, the 2-year opt-out period begins when the last such
affidavit is filed. Any private contract entered into before the last
required affidavit is filed becomes effective upon the filing of the
last required affidavit and the furnishing of any items or services to a
Medicare beneficiary under such contract before the last required
affidavit is filed is subject to standard Medicare rules.
(d) A participating physician may properly opt-out of Medicare at
the beginning of any calendar quarter, provided that the affidavit
described in Sec. 405.420 is submitted to the participating physician's
Medicare carriers at least 30 days before the beginning of the selected
calendar quarter. A private contract entered into before the beginning
of the selected calendar quarter becomes effective at the beginning of
the selected calendar quarter and the furnishing of any items or
services to a Medicare beneficiary
[[Page 102]]
under such contract before the beginning of the selected calendar
quarter is subject to standard Medicare rules.
Sec. 405.415 Requirements of the private contract.
A private contract under this subpart must:
(a) Be in writing and in print sufficiently large to ensure that the
beneficiary is able to read the contract.
(b) Clearly state whether the physician or practitioner is excluded
from Medicare under sections 1128, 1156, or 1892 or any other section of
the Social Security Act.
(c) State that the beneficiary or his or her legal representative
accepts full responsibility for payment of the physician's or
practitioner's charge for all services furnished by the physician or
practitioner.
(d) State that the beneficiary or his or her legal representative
understands that Medicare limits do not apply to what the physician or
practitioner may charge for items or services furnished by the physician
or practitioner.
(e) State that the beneficiary or his or her legal representative
agrees not to submit a claim to Medicare or to ask the physician or
practitioner to submit a claim to Medicare.
(f) State that the beneficiary or his or her legal representative
understands that Medicare payment will not be made for any items or
services furnished by the physician or practitioner that would have
otherwise been covered by Medicare if there was no private contract and
a proper Medicare claim had been submitted.
(g) State that the beneficiary or his or her legal representative
enters into this contract with the knowledge that he or she has the
right to obtain Medicare-covered items and services from physicians and
practitioners who have not opted-out of Medicare, and that the
beneficiary is not compelled to enter into private contracts that apply
to other Medicare-covered services furnished by other physicians or
practitioners who have not opted-out.
(h) State the expected or known effective date and expected or known
expiration date of the opt-out period.
(i) State that the beneficiary or his or her legal representative
understands that Medigap plans do not, and that other supplemental plans
may elect not to, make payments for items and services not paid for by
Medicare.
(j) Be signed by the beneficiary or his or her legal representative
and by the physician or practitioner.
(k) Not be entered into by the beneficiary or by the beneficiary's
legal representative during a time when the beneficiary requires
emergency care services or urgent care services. (However, a physician
or practitioner may furnish emergency or urgent care services to a
Medicare beneficiary in accordance with Sec. 405.440.)
(l) Be provided (a photocopy is permissible) to the beneficiary or
to his or her legal representative before items or services are
furnished to the beneficiary under the terms of the contract.
(m) Be retained (original signatures of both parties required) by
the physician or practitioner for the duration of the opt-out period.
(n) Be made available to CMS upon request.
(o) Be entered into for each opt-out period.
Sec. 405.420 Requirements of the opt-out affidavit.
An affidavit under this subpart must:
(a) Be in writing and be signed by the physician or practitioner.
(b) Contain the physician's or practitioner's full name, address,
telephone number, national provider identifier (NPI) or billing number,
if one has been assigned, uniform provider identification number (UPIN)
if one has been assigned, or, if neither an NPI nor a UPIN has been
assigned, the physician's or practitioner's tax identification number
(TIN).
(c) State that, except for emergency or urgent care services (as
specified in Sec. 405.440), during the opt-out period the physician or
practitioner will provide services to Medicare beneficiaries only
through private contracts that meet the criteria of paragraph Sec.
405.415 for services that, but for their provision under a private
contract, would have been Medicare-covered services.
(d) State that the physician or practitioner will not submit a claim
to Medicare for any service furnished to a Medicare beneficiary during
the opt-
[[Page 103]]
out period, nor will the physician or practitioner permit any entity
acting on his or her behalf to submit a claim to Medicare for services
furnished to a Medicare beneficiary, except as specified in Sec.
405.440.
(e) State that, during the opt-out period, the physician or
practitioner understands that he or she may receive no direct or
indirect Medicare payment for services that he or she furnishes to
Medicare beneficiaries with whom he or she has privately contracted,
whether as an individual, an employee of an organization, a partner in a
partnership, under a reassignment of benefits, or as payment for a
service furnished to a Medicare beneficiary under a Medicare+Choice
plan.
(f) State that a physician or practitioner who opts-out of Medicare
acknowledges that, during the opt-out period, his or her services are
not covered under Medicare and that no Medicare payment may be made to
any entity for his or her services, directly or on a capitated basis.
(g) State a promise by the physician or practitioner to the effect
that, during the opt-out period, the physician or practitioner agrees to
be bound by the terms of both the affidavit and the private contracts
that he or she has entered into.
(h) Acknowledge that the physician or practitioner recognizes that
the terms of the affidavit apply to all Medicare-covered items and
services furnished to Medicare beneficiaries by the physician or
practitioner during the opt-out period (except for emergency or urgent
care services furnished to the beneficiaries with whom he or she has not
previously privately contracted) without regard to any payment
arrangements the physician or practitioner may make.
(i) With respect to a physician who has signed a Part B
participation agreement, acknowledge that such agreement terminates on
the effective date of the affidavit.
(j) Acknowledge that the physician or practitioner understands that
a beneficiary who has not entered into a private contract and who
requires emergency or urgent care services may not be asked to enter
into a private contract with respect to receiving such services and that
the rules of Sec. 405.440 apply if the physician furnishes such
services.
Sec. 405.425 Effects of opting-out of Medicare.
If a physician or practitioner opts-out of Medicare in accordance
with this subpart for the 2-year period for which the opt-out is
effective, the following results obtain:
(a) Except as provided in Sec. 405.440, no payment may be made
directly by Medicare or by any Medicare+Choice plan to the physician or
practitioner or to any entity to which the physician or practitioner
reassigns his right to receive payment for services.
(b) The physician or practitioner may not furnish any item or
service that would otherwise be covered by Medicare (except for
emergency or urgent care services) to any Medicare beneficiary except
through a private contract that meets the requirements of this subpart.
(c) The physician or practitioner is not subject to the requirement
to submit a claim for items or services furnished to a Medicare
beneficiary, as specified in Sec. 424.5(a)(6) of this chapter, except
as provided in Sec. 405.440.
(d) The physician or practitioner is prohibited from submitting a
claim to Medicare for items or services furnished to a Medicare
beneficiary except as provided in Sec. 405.440.
(e) In the case of a physician, he or she is not subject to the
limiting charge provisions of Sec. 414.48 of this chapter, except for
services provided under Sec. 405.440.
(f) The physician or practitioner is not subject to the prohibition-
on-reassignment provisions of Sec. 414.80 of this chapter, except for
services provided under Sec. 405.440.
(g) In the case of a practitioner, he or she is not prohibited from
billing or collecting amounts from beneficiaries (as provided in 42
U.S.C. 1395u(b)(18)(B)).
(h) The death of a beneficiary who has entered into a private
contract (or whose legal representative has done so) does not invoke
Sec. 424.62 or Sec. 424.64 of this chapter with respect to the
physician or practitioner with whom the
[[Page 104]]
beneficiary (or legal representative) has privately contracted.
(i) The physician or practitioner who has not been excluded under
sections 1128, 1156, or 1892 of the Social Security Act may order,
certify the need for, or refer a beneficiary for Medicare-covered items
and services, provided the physician or practitioner is not paid,
directly or indirectly, for such services (except as provided in Sec.
405.440).
(j) The physician or practitioner who is excluded under sections
1128, 1156, or 1892 of the Social Security Act may not order, prescribe,
or certify the need for Medicare-covered items and services except as
provided in Sec. 1001.1901 of this title, and must otherwise comply
with the terms of the exclusion in accordance with Sec. 1001.1901
effective with the date of the exclusion.
Sec. 405.430 Failure to properly opt-out.
(a) A physician or practitioner fails to properly opt-out if--
(1) Any private contract between the physician or practitioner and a
Medicare beneficiary, that was entered into before the affidavit
described in Sec. 405.420 was filed, does not meet the specifications
of Sec. 405.415; or
(2) He or she fails to submit the affidavit(s) in accordance with
Sec. 405.420.
(b) If a physician or practitioner fails to properly opt-out in
accordance with paragraph (a) of this section, the following results
obtain:
(1) The physician's or practitioner's attempt to opt-out of Medicare
is nullified, and all of the private contracts between the physician or
practitioner and Medicare beneficiaries for the two-year period covered
by the attempted opt-out are deemed null and void.
(2) The physician or practitioner must submit claims to Medicare for
all Medicare-covered items and services furnished to Medicare
beneficiaries, including the items and services furnished under the
nullified contracts. A nonparticipating physician is subject to the
limiting charge provisions of Sec. 414.48 of this chapter. A
participating physician is subject to the limitations on charges of the
participation agreement he or she signed.
(3) The practitioner may not reassign any claim except as provided
in Sec. 424.80 of this chapter.
(4) The practitioner may neither bill nor collect an amount from the
beneficiary except for applicable deductible and coinsurance amounts.
(5) The physician or practitioner may make another attempt to
properly opt-out at any time.
Sec. 405.435 Failure to maintain opt-out.
(a) A physician or practitioner fails to maintain opt-out under this
subpart if, during the opt-out period--
(1) He or she knowingly and willfully--
(i) Submits a claim for Medicare payment (except as provided in
Sec. 405.440); or
(ii) Receives Medicare payment directly or indirectly for Medicare-
covered services furnished to a Medicare beneficiary (except as provided
in Sec. 405.440).
(2) He or she fails to enter into private contracts with Medicare
beneficiaries for the purpose of furnishing items and services that
would otherwise be covered by Medicare, or enters into contracts that
fail to meet the specifications of Sec. 405.415; or
(3) He or she fails to comply with the provisions of Sec. 405.440
regarding billing for emergency care services or urgent care services;
or
(4) He or she fails to retain a copy of each private contract that
he or she has entered into for the duration of the opt-out period for
which the contracts are applicable or fails to permit CMS to inspect
them upon request.
(b) If a physician or practitioner fails to maintain opt-out in
accordance with paragraph (a) of this section, and fails to demonstrate,
within 45 days of a notice from the carrier of a violation of paragraph
(a) of this section, that he or she has taken good faith efforts to
maintain opt-out (including by refunding amounts in excess of the charge
limits to beneficiaries with whom he or she did not sign a private
contract), the following results obtain, effective 46 days after the
date of the notice, but only for the remainder of the opt-out period:
(1) All of the private contracts between the physician or
practitioner and Medicare beneficiaries are deemed null and void.
[[Page 105]]
(2) The physician's or practitioner's opt-out of Medicare is
nullified.
(3) The physician or practitioner must submit claims to Medicare for
all Medicare-covered items and services furnished to Medicare
beneficiaries.
(4) The physician or practitioner or beneficiary will not receive
Medicare payment on Medicare claims for the remainder of the opt-out
period, except as provided in paragraph (c) of this section.
(5) The physician is subject to the limiting charge provisions of
Sec. 414.48 of this chapter.
(6) The practitioner may not reassign any claim except as provided
in Sec. 424.80 of this chapter.
(7) The practitioner may neither bill nor collect any amount from
the beneficiary except for applicable deductible and coinsurance
amounts.
(8) The physician or practitioner may not attempt to once more meet
the criteria for properly opting-out until the 2-year opt-out period
expires.
(c) Medicare payment may be made for the claims submitted by a
beneficiary for the services of an opt-out physician or practitioner
when the physician or practitioner did not privately contract with the
beneficiary for services that were not emergency care services or urgent
care services and that were furnished no later than 15 days after the
date of a notice by the carrier that the physician or practitioner has
opted-out of Medicare.
Sec. 405.440 Emergency and urgent care services.
(a) A physician or practitioner who has opted-out of Medicare under
this subpart need not enter into a private contract to furnish emergency
care services or urgent care services to a Medicare beneficiary.
Accordingly, a physician or practitioner will not be determined to have
failed to maintain opt-out if he or she furnishes emergency care
services or urgent care services to a Medicare beneficiary with whom the
physician or practitioner has not previously entered into a private
contract, provided the physician or practitioner complies with the
billing requirements specified in paragraph (b) of this section.
(b) When a physician or practitioner who has not been excluded under
sections 1128, 1156, or 1892 of the Social Security Act furnishes
emergency care services or urgent care services to a Medicare
beneficiary with whom the physician or practitioner has not previously
entered into a private contract, he or she:
(1) Must submit a claim to Medicare in accordance with both 42 CFR
part 424 and Medicare instructions (including but not limited to
complying with proper coding of emergency or urgent care services
furnished by physicians and practitioners who have opted-out of
Medicare).
(2) May collect no more than--
(i) The Medicare limiting charge, in the case of a physician; or
(ii) The deductible and coinsurance, in the case of a practitioner.
(c) Emergency care services or urgent care services furnished to a
Medicare beneficiary with whom the physician or practitioner has
previously entered into a private contract (that is, entered into before
the onset of the emergency medical condition or urgent medical
condition), are furnished under the terms of the private contract.
(d) Medicare may make payment for emergency care services or urgent
care services furnished by a physician or practitioner who has properly
opted-out when the services are furnished and the claim for services is
made in accordance with this section. A physician or practitioner who
has been excluded must comply with the regulations at Sec. 1001.1901
(Scope and effect of exclusion) of this title when he or she furnishes
emergency services to beneficiaries and may not bill and be paid for
urgent care services.
Sec. 405.445 Renewal and early termination of opt-out.
(a) A physician or practitioner may renew opt-out by filing an
affidavit with each carrier with which he or she would file claims
absent completion of opt-out, provided the affidavits are filed within
30 days after the current opt-out period expires.
(b) To properly terminate opt-out a physician or practitioner must:
(1) Not have previously opted out of Medicare.
[[Page 106]]
(2) Notify all Medicare carriers, with which he or she filed an
affidavit, of the termination of the opt-out no later than 90 days after
the effective date of the opt-out period.
(3) Refund to each beneficiary with whom he or she has privately
contracted all payment collected in excess of:
(i) The Medicare limiting charge (in the case of physicians); or
(ii) The deductible and coinsurance (in the case of practitioners).
(4) Notify all beneficiaries with whom the physician or practitioner
entered into private contracts of the physician's or practitioner's
decision to terminate opt-out and of the beneficiaries' right to have
claims filed on their behalf with Medicare for the services furnished
during the period between the effective date of the opt-out and the
effective date of the termination of the opt-out period.
(c) When the physician or practitioner properly terminates opt-out
in accordance with paragraph (b), he or she will be reinstated in
Medicare as if there had been no opt-out, and the provision of Sec.
405.425 shall not apply unless the physician or practitioner
subsequently properly opts out.
(d) A physician or practitioner who has completed opt-out on or
before January 1, 1999 may terminate opt-out during the 90 days
following January 1, 1999 if he or she notifies all carriers to whom he
or she would otherwise submit claims of the intent to terminate opt-out
and complies with paragraphs (b)(3) and (4) of this section. Paragraph
(c) of this section applies in these cases.
Sec. 405.450 Appeals.
(a) A determination by CMS that a physician or practitioner has
failed to properly opt-out, failed to maintain opt-out, failed to timely
renew opt-out, failed to privately contract, or failed to properly
terminate opt-out is an initial determination for purposes of Sec.
405.803.
(b) A determination by CMS that no payment can be made to a
beneficiary for the services of a physician who has opted-out is an
initial determination for purposes of Sec. 405.803.
Sec. 405.455 Application to Medicare+Choice contracts.
An organization that has a contract with CMS to provide one or more
Medicare+Choice (M+C) plans to beneficiaries (part 422 of this chapter):
(a) Must acquire and maintain information from Medicare carriers on
physicians and practitioners who have opted-out of Medicare.
(b) Must make no payment directly or indirectly for Medicare covered
services furnished to a Medicare beneficiary by a physician or
practitioner who has opted-out of Medicare.
(c) May make payment to a physician or practitioner who furnishes
emergency or urgent care services to a beneficiary who has not
previously entered into a private contract with the physician or
practitioner in accordance with Sec. 405.440.
Subpart E_Criteria for Determining Reasonable Charges
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh).
Source: 32 FR 12599, Aug. 31, 1967, unless otherwise noted.
Redesignated at 42 FR 52826, Sept. 30, 1977.
Sec. 405.500 Basis.
Subpart E is based on the provisions of the following sections of
the Act: Section 1814(b) provides for Part A payment on the basis of the
lesser of a provider's reasonable costs or customary charges. Section
1832 establishes the scope of benefits provided under the Part B
supplementary medical insurance program. Section 1833(a) sets forth the
amounts of payment for supplementary medical insurance services on the
basis of the lesser of a provider's reasonable costs or customary
charges. Section 1834(a) specifies how payments are made for the
purchase or rental of new and used durable medical equipment for
Medicare beneficiaries. Section 1834(b) provides for payment for
radiologist services on a fee schedule basis. Section 1834(c) provides
for payments and standards for screening mammography. Section 1842(b)
sets forth the provisions for a carrier to enter into a contract with
the Secretary and to make determinations
[[Page 107]]
with respect to Part B claims. Section 1842(h) sets forth the
requirements for a physician or supplier to voluntarily enter into an
agreement with the Secretary to become a participating physician or
supplier. Section 1842(i) sets forth the provisions for the payment of
Part B claims. Section 1848 establishes a fee schedule for payment of
physician services. Section 1861(b) sets forth the inpatient hospital
services covered by the Medicare program. Section 1861(s) sets forth
medical and other health services covered by the Medicare program.
Section 1861(v) sets forth the general authority under which CMS may
establish limits on provider costs recognized as reasonable in
determining Medicare program payments. Section 1861(aa) sets forth the
rural health clinic services and Federally qualified health center
services covered by the Medicare program. Section 1861(jj) defines the
term ``covered osteoporosis drug.'' Section 1862(a)(14) lists services
that are excluded from coverage. Section 1866(a) specifies the terms for
provider agreements. Section 1881 authorizes special rules for the
coverage of and payment for services furnished to patients with end-
stage renal disease. Section 1886 sets forth the requirements for
payment to hospitals for inpatient hospital services. Section 1887 sets
forth requirements for payment of provider-based physicians and payment
under certain percentage arrangements. Section 1889 provides for
Medicare and Medigap information by telephone.
[60 FR 63175, Dec. 8, 1995]
Sec. 405.501 Determination of reasonable charges.
(a) Except as specified in paragraphs (b), (c), and (d) of this
section, Medicare pays no more for Part B medical and other health
services than the ``reasonable charge'' for such service. The reasonable
charge is determined by the carriers (subject to any deductible and
coinsurance amounts as specified in Sec. Sec. 410.152 and 410.160 of
this chapter).
(b) Part B of Medicare pays on the basis of ``reasonable cost'' (see
part 413 of this chapter) for certain institutional services, certain
services furnished under arrangements with institutions, and services
furnished by entities that elect to be paid on a cost basis (including
health maintenance organizations, rural health clinics, Federally
qualified health centers and end-stage renal disease facilities).
(c) Carriers will determine the reasonable charge on the basis of
the criteria specified in Sec. 405.502, and the customary and
prevailing charge screens in effect when the service was furnished.
(Also see Sec. Sec. 415.55 through 415.70 and Sec. Sec. 415.100
through 415.130 of this chapter, which pertain to the determination of
reimbursement for services performed by hospital-based physicians.)
However, when services are furnished more than 12 months before the
beginning of the fee screen year (January 1 through December 30) in
which a request for payment is made, payment is based on the customary
and prevailing charge screens in effect for the fee screen year that
ends immediately preceding the fee screen year in which the claim or
request for payment is made.
(d) Payment under Medicare Part B for durable medical equipment and
prosthetic and orthotic devices is determined in accordance with the
provisions of subpart D of part 414 of this chapter.
[47 FR 63274, Dec. 31, 1981, as amended at 51 FR 34978, Oct. 1, 1986; 51
FR 37911, Oct. 27, 1986; 54 FR 9003, Mar. 2, 1989; 57 FR 24975, June 12,
1992; 57 FR 33896, July 31, 1992; 57 FR 57688, Dec. 7, 1992; 60 FR
63176, Dec. 8, 1995]
Sec. 405.502 Criteria for determining reasonable charges.
(a) Criteria. The law allows for flexibility in the determination of
reasonable charges to accommodate reimbursement to the various ways in
which health services are furnished and charged for. The criteria for
determining what charges are reasonable include:
(1) The customary charges for similar services generally made by the
physician or other person furnishing such services.
(2) The prevailing charges in the locality for similar services.
(3) In the case of physicians' services, the prevailing charges
adjusted to reflect economic changes as provided under Sec. 405.504 of
this subpart.
[[Page 108]]
(4) In the case of medical services, supplies, and equipment that
are reimbursed on a reasonable charge basis (excluding physicians'
services), the inflation-indexed charge as determined under Sec.
405.509.
(5) [Reserved]
(6) In the case of medical services, supplies, and equipment
(including equipment servicing) that the Secretary judges do not
generally vary significantly in quality from one supplier to another,
the lowest charge levels at which such services, supplies, and equipment
are widely and consistently available in a locality.
(7) Other factors that may be found necessary and appropriate with
respect to a category of service to use in judging whether the charge is
inherently reasonable. This includes special reasonable charge limits
(which may be either upper or lower limits) established by CMS or a
carrier if it determines that the standard rules for calculating
reasonable charges set forth in this subpart result in the grossly
deficient or excessive charges. The determination of these limits is
described in paragraphs (g) and (h) of this section.
(8) In the case of laboratory services billed by a physician but
performed by an outside laboratory, the payment levels established in
accordance with the criteria stated in Sec. 405.515.
(9) Except as provided in paragraph (a)(10) of this section, in the
case of services of assistants-at-surgery as defined in Sec. 405.580 in
teaching and non-teaching settings, charges that are not more than 16
percent of the prevailing charge in the locality, adjusted by the
economic index, for the surgical procedure performed by the primary
surgeon. Payment is prohibited for the services of an assistant-at-
surgery in surgical procedures for which CMS has determined that
assistants-at-surgery on average are used in less than 5 percent of such
procedures nationally.
(10) In the case of services of assistants at surgery that meet the
exception under Sec. 415.190(c)(2) or (c)(3) of this chapter because
the physician is performing a unique, necessary, specialized medical
service in the total care of a patient during surgery, reasonable
charges consistent with prevailing practice in the carrier's service
area rather than the special assistant at surgery rate.
(b) Comparable services limitation. The law also specifies that the
reasonable charge cannot be higher than the charge applicable for a
comparable service under comparable circumstances to the carriers' own
policyholders and subscribers.
(c) Application of criteria. In applying these criteria, the
carriers are to exercise judgment based on factual data on the charges
made by physicians to patients generally and by other persons to the
public in general and on special factors that may exist in individual
cases so that determinations of reasonable charge are realistic and
equitable.
(d) Responsibility of Administration and carriers. Determinations by
carriers of reasonable charge are not reviewed on a case-by-case basis
by the Centers for Medicare & Medicaid Services, although the general
procedures and performance of functions by carriers are evaluated. In
making determinations, carriers apply the provisions of the law under
broad principles issued by the Centers for Medicare & Medicaid Services.
These principles are intended to assure overall consistency among
carriers in their determinations of reasonable charge. The principles in
Sec. Sec. 405.503 through 405.507 establish the criteria for making
such determinations in accordance with the statutory provisions.
(e) Determination of reasonable charges under the End-Stage Renal
Disease (ESRD) Program--(1) General. Reasonable charges for renal-
related items and services (furnished in connection with transplantation
or dialysis) must be related to costs and allowances that are reasonable
when the treatments are furnished in an effective and economical manner.
(2) Nonprovider (independent) dialysis facilities. Reasonable
charges for renal-related items and services furnished before August 1,
1983 must be determined related to costs and charges prior to July,
1973, in accordance with the regulations at Sec. 405.541. Items and
services related to outpatient maintenance dialysis that are furnished
after that date are paid for in accordance with Sec. Sec. 405.544 and
413.170 of this chapter.
[[Page 109]]
(3) Provider services and (hospital-based) dialysis facilities.
Renal-related items and services furnished by providers, or by ESRD
facilities based in hospitals, before August 1, 1983 are paid for under
the provider reimbursement provisions found generally in part 413 of
this chapter. Items and services related to outpatient maintenance
dialysis that are furnished after that date are paid for in accordance
with Sec. Sec. 405.544 and 413.170 of this chapter.
(4) Physicians' services. Reasonable charges for renal-related
physicians' services must be determined considering charges made for
other services involving comparable physicians' time and skill
requirements, in accordance with regulations at Sec. Sec. 405.542 and
405.543.
(5) Health maintenance organizations (HMOs). For special rules
concerning the reimbursement of ESRD services furnished by risk-basis
HMOs, or by facilities owned or operated by or related to such HMOs by
common ownership or control, see Sec. Sec. 405.2042(b)(14) and
405.2050(c).
(f) Determining payments for certain physician services furnished in
outpatient hospital settings--(1) General rule. If physician services of
the type routinely furnished in physicians' offices are furnished in
outpatient hospital settings before January 1, 1992, carriers determine
the reasonable charge for those services by applying the limits
described in paragraph (f)(5) of this section.
(2) Definition. As used in this paragraph (f), outpatient settings
means--
(i) Hospital outpatient departments, including clinics and emergency
rooms; and
(ii) Comprehensive outpatient rehabilitation facilities.
(3) Services covered by limits. The carrier establishes a list of
services routinely furnished in physicians' offices in the area. The
carrier has the discretion to determine which professional services are
routinely furnished in physicians' offices, based on current medical
practice in the area. Listed below are some examples of routine services
furnished by office-based physicians.
Examples
Review of recent history, determination of blood pressure,
ausculation of heart and lungs, and adjustment of medication.
Brief history and examination, and initiation of diagnostic and
treatment programs.
Treatment of an acute respiratory infection.
(4) Services excluded from limits. The limits established under this
paragraph do not apply to the following:
(i) Rural health clinic services.
(ii) Surgical services included on the ambulatory surgical center
list of procedures published under Sec. 416.65(c) of this chapter.
(iii) Services furnished in a hospital emergency room after the
sudden onset of a medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) such that the absence of
immediate medical attention could reasonably be expected to result in--
(A) Placing the patient's health in serious jeopardy;
(B) Serious impairment to bodily functions; or
(C) Serious dysfunction of any bodily organ or part.
(iv) Anesthesiology services and diagnostic and therapeutic
radiology services.
(v) Federally qualified health center services paid under the rules
in part 405 subpart X.
(5) Methodology for developing limits--(i) Development of a charge
base. The carrier establishes a charge base for each service identified
as a routine office-based physician service. The charge base consists of
the prevailing charge in the locality for each such service adjusted by
the economic index. The carrier uses the prevailing charges that apply
to services by nonspecialists in office practices in the locality in
which the outpatient setting is located.
(ii) Calculation of the outpatient limits. The carrier calculates
the charge limit for each service by multiplying the charge base amount
for each service by .60.
(6) Application of limits. The reasonable charge for physician
services of the type described in paragraph (f)(3) of this section that
are furnished in an outpatient setting is the lowest of the
[[Page 110]]
actual charges, the customary charges in accordance with Sec. 405.503,
the prevailing charges applicable to these services in accordance with
Sec. 405.504, or the charge limits calculated in paragraph (f)(5)(ii)
of this section.
(g) Determination of payment amounts in special circumstances--(1)
General. (i) For purposes of this paragraph, a ``category of items or
services'' may consist of a single item or service or any number of
items or services.
(ii) CMS or a carrier may determine that the standard rules for
calculating payment amounts set forth in this subpart for a category of
items or services identified in section 1861(s) of the Act (other than
physician services paid under section 1848 of the Act and those items
and services for which payment is made under a prospective payment
system, such as outpatient hospital or home health) will result in
grossly deficient or excessive amounts. A payment amount will not be
considered grossly excessive or deficient if it is determined that an
overall payment adjustment of less than 15 percent is necessary to
produce a realistic and equitable payment amount. For CMS initiated
adjustments, CMS will publish in the Federal Register an analysis of
payment adjustments that exceed $100 million per year in compliance with
Executive Order 12866. If CMS makes adjustments that have a significant
effect on a substantial number of small entities, it will publish an
analysis in compliance with the Regulatory Flexibility Act.
(iii) If CMS or the carrier determines that the standard rules for
calculating payment amounts for a category of items or services will
result in grossly deficient or excessive amounts, CMS, or the carrier,
may establish special payment limits that are realistic and equitable
for a category of items or services. If CMS makes a determination, it is
considered a national determination. A carrier determination is one made
by a carrier/intermediary or groups of carriers/intermediaries even if
the determination applies to all State fees.
(iv) The limit on the payment amount is either an upper limit to
correct a grossly excessive payment amount or a lower limit to correct a
grossly deficient payment amount.
(v) The limit is either a specific dollar amount or is based on a
special method to be used in determining the payment amount.
(vi) Except as provided in paragraph (h) of this section, a payment
limit for a given year may not vary by more than 15 percent from the
payment amount established for the preceding year.
(vii) Examples of excessive or deficient payment amounts. Examples
of the factors that may result in grossly deficient or excessive payment
amounts include, but are not limited to, the following:
(A) The marketplace is not competitive. This includes circumstances
in which the marketplace for a category of items or services is not
truly competitive because a limited number of suppliers furnish the item
or service.
(B) Medicare and Medicaid are the sole or primary sources of payment
for a category of items or services.
(C) The payment amounts for a category of items or services do not
reflect changing technology, increased facility with that technology, or
changes in acquisition, production, or supplier costs.
(D) The payment amounts for a category of items or services in a
particular locality are grossly higher or lower than payment amounts in
other comparable localities for the category of items or services,
taking into account the relative costs of furnishing the category of
items or services in the different localities.
(E) Payment amounts for a category of items or services are grossly
higher or lower than acquisition or production costs for the category of
items or services.
(F) There have been increases in payment amounts for a category of
items or services that cannot be explained by inflation or technology.
(G) The payment amounts for a category of items or services are
grossly higher or lower than the payments made for the same category of
items or services by other purchasers in the same locality.
[[Page 111]]
(H) A new technology exists which is not reflected in the existing
payment allowances.
(2) Establishing a limit. In establishing a payment limit for a
category of items or services, CMS or a carrier considers the available
information that is relevant to the category of items or services and
establishes a payment amount that is realistic and equitable. The
factors CMS or a carrier consider in establishing a specific dollar
amount or special payment method for a category of items or services may
include, but are not limited to, the following:
(i) Price markup. This is the relationship between the retail and
wholesale prices or manufacturer's costs of a category of items or
services. If information on a particular category of items or services
is not available, CMS or a carrier may consider the markup on a similar
category of items or services and information on general industry
pricing trends.
(ii) Differences in charges. CMS or a carrier may consider the
differences in charges for a category of items or services made to non-
Medicare and Medicare patients or to institutions and other large volume
purchasers.
(iii) Costs. CMS or a carrier may consider resources (for example,
overhead, time, acquisition costs, production costs, and complexity)
required to produce a category of items or services.
(iv) Use. CMS or a carrier may impute a reasonable rate of use for a
category of items or services and consider unit costs based on efficient
use.
(v) Payment amounts in other localities. CMS or a carrier may
consider payment amounts for a category of items or services furnished
in another locality.
(3) Notification of limits--(i) National limits. CMS publishes in
the Federal Register proposed and final notices announcing a special
payment limit described in paragraph (g) of this section before it
adopts the limit. The notices set forth the criteria and circumstances,
if any, under which a carrier may grant an exception to a payment limit
for a category of items or services.
(ii)(A) Carrier-level limits. A carrier proposing to establish a
special payment limit for a category of items or services must inform
the affected suppliers and Medicaid agencies of the proposed payment
amounts, the factors it considered in proposing the particular limit, as
described in paragraphs (g)(1) through (g)(4) of this section, and
solicit comments. The notice must also consider the following:
(1) The effects on the Medicare program, including costs, savings,
assignment rates, beneficiary liability, and quality of care.
(2) What entities would be affected such as classes of providers or
suppliers and beneficiaries.
(3) How significantly would these entities be affected.
(4) How would the adjustment affect beneficiary access to items or
services.
(B) The carrier must evaluate the comments it receives. The carrier
must notify CMS in writing of any final limits it plans to establish.
CMS will acknowledge in writing to the carrier that it received the
carrier's notification. After the carrier has received CMS's
acknowledgement, the carrier must inform the affected suppliers and
State Medicaid agencies of any final limits it establishes. The
effective date for a final payment limit may apply to services furnished
at least 60 days after the date that the carrier notifies affected
suppliers and State Medicaid agencies of the final limit.
(4) Use of valid and reliable data. In determining whether a payment
amount is excessive or deficient and in establishing an appropriate
payment amount, valid and reliable data will be used. To ensure the use
of valid and reliable data, CMS or the carrier must meet the following
criteria to the extent applicable:
(i) Develop written guidelines for data collection and analysis;
(ii) Ensure consistency in any survey to collect and analyze pricing
data.
(iii) Develop a consistent set of survey questions to use when
requesting retail prices.
(iv) Ensure that sampled prices fully represent the range of prices
nationally.
(v) Consider the geographic distribution of Medicare beneficiaries.
[[Page 112]]
(vi) Consider relative prices in the various localities to ensure
that an appropriate mix of areas with high, medium, and low consumer
prices was included.
(vii) Consider criteria to define populous State, less populous
State, urban area, and rural area.
(viii) Consider a consistent approach in selecting retail outlets
within selected cities.
(ix) Consider whether the distribution of sampled prices from
localities surveyed is fully representative of the distribution of the
U.S. population.
(x) Consider the products generally used by beneficiaries and
collect prices of these products.
(xi) When using wholesale costs, consider the cost of the services
necessary to furnish a product to beneficiaries.
(5) If CMS or a carrier makes a payment adjustment of more than 15
percent spread over multiple years, CMS or the carrier will review
market prices in the years subsequent to the year that the initial
reduction is effective in order to ensure that further reductions
continue to be appropriate.
(h) Special payment limit adjustments greater than 15 percent of the
payment amount. In addition to applying the general rules under
paragraphs (g)(1) through (g)(4) of this section, CMS applies the
following rules in establishing a payment adjustment greater than 15
percent of the payment amount for a category of items or services within
a year:
(1) Potential impact of special limit. CMS considers the potential
impact on quality, access, beneficiary liability, assignment rates, and
participation of suppliers.
(2) Supplier consultation. Before making a determination that a
payment amount for a category of items or services is not inherently
reasonable by reason of its grossly excessive or deficient amount, CMS
consults with representatives of the supplier industry likely to be
affected by the change in the payment amount.
(3) Publication of national limits. If CMS determines under
paragraph (h) of this section to establish a special payment limit for a
category of items or services, it publishes in the Federal Register the
proposed and final notices of a special payment limit before it adopts
the limit. The notices set forth the criteria and circumstances, if any,
under which a carrier may grant an exception to the limit for the
category of items or services.
(i) Proposed notice. The proposed notice--
(A) Explains the factors and data that CMS considered in determining
that the payment amount for a category of items or services is grossly
excessive or deficient;
(B) Specifies the proposed payment amount or methodology to be
established for a category of items or services;
(C) Explains the factors and data that CMS considered in determining
the payment amount or methodology, including the economic justification
for a uniform fee or payment limit if it is proposed;
(D) Explains the potential impacts of a limit on a category of items
or services as described in paragraph (h)(1) of this section; and
(E) Allows no less than 60 days for public comment on the proposed
payment limit for the category of items or services.
(ii) Final notice. The final notice--
(A) Explains the factors and data that CMS considered, including the
economic justification for any uniform fee or payment limit established;
and
(B) Responds to the public comments.
(i) Paramedic intercept ambulance services. (1) CMS establishes its
payment allowance on a carrier-wide basis by using the median allowance
from all localities within an individual carrier's jurisdiction.
(2) CMS's payment allowance is equal to the advanced life support
rate minus 40 percent of the basic life support rate.
(3) CMS bases payment on the lower of the actual charge or the
amount described in paragraph (i)(1) and (i)(2) of this section.
(Secs. 1102, 1814(b), 1833(a), 1842(b), and (h), and 1871, 1903(i)(1) of
the Social Security Act; 49 Stat. 647, as amended, 79 Stat. 296, 302,
310, 331; 86 Stat. 1395, 1454; 42 U.S.C. 1302, 1395u(b), 1395hh,
1396b(i)(1).
[32 FR 12599, Aug. 31, 1967]
Editorial Note: For Federal Register citations affecting Sec.
405.502, see the List of CFR Sections Affected, which appears in the
[[Page 113]]
Finding Aids section of the printed volume and on GPO Access.
Sec. 405.503 Determining customary charges.
(a) Customary charge defined. The term ``customary charges'' will
refer to the uniform amount which the individual physician or other
person charges in the majority of cases for a specific medical procedure
or service. In determining such uniform amount, token charges for
charity patients and substandard charges for welfare and other low
income patients are to be excluded. The reasonable charge cannot, except
as provided in Sec. 405.506, be higher than the individual physician's
or other person's customary charge. The customary charge for different
physicians or other persons may, of course, vary. Payment for covered
services would be based on the actual charge for the service when, in a
given instance, that charge is less than the amount which the carrier
would otherwise have found to be within the limits of acceptable charges
for the particular service. Moreover, the income of the individual
beneficiary is not to be taken into account by the carrier in
determining the amount which is considered to be a reasonable charge for
a service rendered to him. There is no provision in the law for a
carrier to evaluate the reasonableness of charges in light of an
individual beneficiary's economic status.
(b) Variation of charges. If the individual physician or other
person varies his charges for a specific medical procedure or service,
so that no one amount is charged in the majority of cases, it will be
necessary for the carrier to exercise judgment in the establishment of a
``customary charge'' for such physician or other person. In making this
judgment, an important guide, to be utilized when a sufficient volume of
data on the physician's or other person's charges is available, would be
the median or midpoint of his charges, excluding token and substandard
charges as well as exceptional charges on the high side. A significant
clustering of charges in the vicinity of the median amount might
indicate that a point of such clustering should be taken as the
physician's or other person's ``customary'' charge. Use of relative
value scales will help in arriving at a decision in such instances.
(c) Use of relative value scales. If, for a particular medical
procedure or service, the carrier is unable to determine the customary
charge on the basis of reliable statistical data (for example, because
the carrier does not yet have sufficient data or because the performance
of the particular medical procedure or service by the physician or other
person is infrequent), the carrier may use appropriate relative value
scales to determine the customary charge for such procedure or service
in relation to customary charges of the same physician or person for
other medical procedures and services.
(d) Revision of customary charge. A physician's or other person's
customary charge is not necessarily a static amount. Where a physician
or other person alters his charges, a revised pattern of charges for his
services may develop. Where on the basis of adequate evidence, the
carrier finds that the physician or other person furnishing services has
changed his charge for a service to the public in general, the customary
charge resulting from the revised charge for the service should be
recognized as the customary charge in making determinations of
reasonable charges for such service when rendered thereafter to
supplementary insurance beneficiaries. If the new customary charge is
not above the top of the range of prevailing charges (see Sec.
405.504(a)), it should be deemed to be reasonable by the carrier,
subject to the provisions of Sec. 405.508.
Sec. 405.504 Determining prevailing charges.
(a) Ranges of charges. (1) In the case of physicians' services
furnished beginning January 1, 1987, the prevailing charges for a
nonparticipating physician as defined in this paragraph will be no
higher than the same level that was set for services furnished during
the previous calendar year for a physician who was a participating
physician during that year. A nonparticipating physician is a physician
who has not entered into an agreement with the Medicare program to
accept payment on an assignment-related basis (in accordance with Sec.
424.55 of this chapter)
[[Page 114]]
for all items and services furnished to individuals enrolled under Part
B of Medicare during a given calendar year.
(2) No charge for Part B medical or other health services may be
considered to be reasonable if it exceeds the higher of:
(i) The prevailing charge for similar services in the same locality
in effect on December 31, 1970, provided such prevailing charge had been
found acceptable by CMS; or
(ii) The prevailing charge that, on the basis of statistical data
and methodology acceptable to CMS, would cover:
(A) 75 percent of the customary charges made for similar services in
the same locality during the 12-month period of July 1 through June 30
preceding the fee screen year (January 1 through December 31) in which
the service was furnished; or
(B) In the case of services furnished more than 12 months before the
beginning of the fee screen year (January 1 through December 31) in
which the claim or request for payment is submitted, 75 percent of the
customary charges made for similar services in the same locality during
the 12 month period of July 1 through June 30 preceding the fee screen
year that ends immediately preceding the fee screen year in which the
claim or request for payment is submitted.
(3)(i) In the case of physicians' services, furnished before January
1, 1992, each prevailing charge in each locality may not exceed the
prevailing charge determined for the FY ending June 30, 1973 (without
reference to the adjustments made in accordance with the economic
stabilization program then in effect), except on the basis of
appropriate economic index data that demonstrate the higher prevailing
charge level is justified by:
(A) Changes in general earnings levels of workers that are
attributable to factors other than increases in their productivity; and
(B) changes in expenses of the kind incurred by physicians in office
practice. The office-expense component and the earnings component of
such index shall be given the relative weights shown in data on self-
employed physicians' gross incomes.
Example. The available data indicate the office-expense and earnings
components of the index should be given relative weights of 40 percent
and 60 percent, respectively, and it is calculated that the aggregate
increase in expenses of practice for a particular July through June
period was 112 percent over the expenses of practice for calendar year
1971 and the increase in earnings (less increases in workers'
productivity was 110 percent over the earnings for calendar year 1971.
The allowable increase in any prevailing charge that could be recognized
during the next fee screen year would be 110.8 percent
((.40x112)+(.60)x110)=110.8) above the prevailing charge recognized for
fiscal year 1973.
(ii)(A) If the increase in the prevailing charge in a locality for a
particular physician service resulting from an aggregate increase in
customary charges for that service does not exceed the index determined
under paragraph (a)(3)(i) of this section, the increase is permitted and
any portion of the allowable increase not used is carried forward and is
a basis for justifying increases in that prevailing charge in the
future. However, if the increase in the prevailing charge exceeds the
allowable increase, the increase will be reduced to the allowable
amount. Further increases will be justified only to the degree that they
do not exceed further rises in the economic index. The prevailing charge
for physicians' services furnished during the 15-month period beginning
July 1, 1984 may not exceed the prevailing charge for physicians'
services in effect for the 12-month period beginning July 1, 1983. The
increase in prevailing charges for physicians' services for subsequent
fee screen years similarly may not reflect the rise in the economic
index that would have otherwise been provided for the period beginning
July 1, 1984, and must be treated as having fully provided for the rise
in the economic index which would have been otherwise taken into
account.
(B) Notwithstanding the provisions of paragraphs (a)(3)(i) and
(ii)(A) of this section, the prevailing charge in the case of a
physician service in a particular locality determined pursuant to
paragraphs (a)(2) and (3)(i) of this section for the fiscal year
beginning July 1, 1975, and for any subsequent fee
[[Page 115]]
screen years, if lower than the prevailing charge for the fiscal year
ending June 30, 1975, by reason of the application of economic index
data, must be raised to such prevailing charge which was in effect for
the fiscal year ending June 30, 1975. (If the amount paid on any claim
processed by a carrier after the original reasonable charge update for
the fiscal year beginning July 1, 1975, and prior to the adjustments
required by the preceding sentence, was at least $1 less than the amount
due pursuant to the preceding sentence, the difference between the
amount previously paid and the amount due shall be paid within 6 months
after December 31, 1975; however, no payment shall be made on any claim
where the difference between the amount previously and the amount due
shall be paid within 6 months after December 31, 1975; however, no
payment shall be made on any claim where the difference between the
amount previously paid and the amount due is less than $1.)
(iii) If, for any reason, a prevailing charge for a service in a
locality has no precise counterpart in the carrier's charge data for
calendar year 1971 (the data on which the prevailing charge calculations
for fiscal year 1973 were based), the limit on the prevailing charge
will be estimated, on the basis of data and methodology acceptable to
CMS, to seek to produce the effect intended by the economic index
criterion. The allowance or reduction of an increase in a prevailing
charge for any individual medical item or service may affect the
allowance or reduction of an increase in the prevailing charges for
other items or services if, for example, the limit on the prevailing
charge is estimated, or if the prevailing charges for more than one item
or service are established through the use of a relative value schedule
and dollar conversion factors.
(b) Variation in range of prevailing charges. The range of
prevailing charges in a locality may be different for physicians or
other persons who engage in a specialty practice or service than for
others. Existing differentials in the level of charges between different
kinds of practice or service could, in some localities, lead to the
development of more than one range of prevailing charges for application
by the carrier in its determinations of reasonable charges. Carrier
decisions in this respect should be responsive to the existing patterns
of charges by physicians and other persons who render covered services,
and should establish differentials in the levels of charges between
different kinds of practice or service only where in accord with such
patterns.
(c) Re-evaluation and adjustment of prevailing charges.
Determinations of prevailing charges by the carrier are to be re-
evaluated and adjusted from time to time on the basis of factual
information about the charges made by physicians and other persons to
the public in general. This information should be obtained from all
possible sources including a carrier's experience with its own programs
as well as with the supplementary medical insurance program.
(d) Computation and issuance of the MEI after CY 1992--(1) For
update years after CY 1992, the MEI is a physician input price index, in
which the annual percent changes for the direct-labor price components
are adjusted by an annual percent change in a 10-year moving average
index of labor productivity in the nonfarm business sector.
(2) The MEI is constructed, using as a base year, CY 1989 weights
and annual percent changes in the economic price proxies as shown on the
following chart:
Medicare Economic Index Expenditure Categories, Weights, and Price
Proxies
------------------------------------------------------------------------
1989 weights
Expense category \1\,\2\ Price proxy \3\
(percent)
------------------------------------------------------------------------
Total...................... 100.0
1. Physician's Own Time (net 54.2
income, general earnings).
a. Wages and Salaries...... 45.3 Average hourly
earnings, total
private non-farm.\4\
b. Fringe Benefits......... 8.8 Employment Cost Index,
fringe benefits,
private non-farm.\4\
[[Page 116]]
2. Physician Practice Expense.. 45.8
a. Non-physician Employee 16.3
Compensation.
(1) Wages and Salaries. 13.8 Employment Cost Index,
wages and salaries
weighted for
occupational mix of
non-physician
employees.\4\
(2) Fringe Benefits.... 2.5 Employment Cost Index,
fringe benefits, white
collar.\4\
b. Office Expense.......... 10.3 CPI-U, housing.
c. Medical Materials and 5.2 PPI, ethical drugs;
Supplies. PPI, surgical
appliances and
supplies; and CPI-U
medical equipment and
supplies (equally
weighted).
d. Professional Liability 4.8 CMS survey of change in
Insurance. average liability
premiums for $100,000/
$300,000 liability
coverage among 9 major
insurers.
e. Medical Equipment....... 2.3 PPI, medical
instruments and
equipment.
f. Other Professional 6.9
Expense.
(1) Professional Car... 1.4 CPI-U, private
transportation.
(2) Other.............. 5.5 CPI-U, all items less
food and energy.
------------------------------------------------------------------------
\1\ Sources: Martin L. Gonzalez, ed.: Physician Marketplace Statistics,
Fall, 1990. Center for Health Policy Research, Chicago, American
Medical Association, 1990; Mark Holoweiko, ``Practice Expenses Take
the Leap of the Decade,'' Medical Economics, November 12, 1990; and
CMS, OACT special study.
\2\ Due to rounding, weights may not sum to 100.0%
\3\ All price proxies are for annual percent changes for the 12 months
ending June 30th.
\4\ Annual percent change values for Physicians' Own Time and Non-
physician Employee Compensation are net of the change in the 10-year
moving average of output per man-hour to exclude changes in non-farm
business sector labor productivity.
(3) If there is no methodological change, CMS publishes a notice in
the Federal Register to announce the annual increase in the MEI before
the beginning of the update year to which it applies. If there are
changes in the base year weights or price proxies, or if there are any
other MEI methodological changes, they are published in the Federal
Register with an opportunity for public comment.
[32 FR 12600, Aug. 31, 1967, as amended at 40 FR 25447, June 16, 1975;
42 FR 18275, Apr. 6, 1977. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 43 FR 4430, Feb. 2, 1978; 47 FR 63274, Dec. 31, 1982; 51
FR 34978, Oct. 1, 1986; 53 FR 6648, Mar. 2, 1988; 57 FR 55912, Nov. 25,
1992]
Sec. 405.505 Determination of locality.
``Locality'' is the geographical area for which the carrier is to
derive the reasonable charges or fee schedule amounts for services or
items. Usually, a locality may be a State (including the District of
Columbia, a territory, or a Commonwealth), a political or economic
subdivision of a State, or a group of States. It should include a cross
section of the population with respect to economic and other
characteristics. Where people tend to gravitate toward certain
population centers to obtain medical care or service, localities may be
recognized on a basis constituting medical services areas (interstate or
otherwise), comparable in concept to ``trade areas.'' Localities may
differ in population density, economic level, and other major factors
affecting charges for services. Carriers therefore shall delineate
localities on the basis of their knowledge of local conditions. However,
distinctions between localities are not to be so finely made that a
locality includes only a very limited geographic area whose population
has distinctly similar income characteristics (e.g., a very rich or very
poor neighborhood within a city).
[57 FR 27305, June 18, 1992]
Sec. 405.506 Charges higher than customary or prevailing charges or
lowest charge levels.
A charge which exceeds the customary charge of the physician or
other person who rendered the medical or other health service, or the
prevailing charge in the locality, or an applicable lowest charge level
may be found to be reasonable, but only where there are unusual
circumstances, or medical complications requiring additional time,
effort or expense which support an additional charge, and only if it is
acceptable medical or medical service practice in the locality to make
an extra charge in such cases. The
[[Page 117]]
mere fact that the physician's or other person's customary charge is
higher than prevailing would not justify a determination that it is
reasonable.
(Secs. 1102, 1842(b) and 1871, 1903(i)(1) of the Social Security Act; 49
Stat. 647, 79 Stat. 302, 310, 331; 86 Stat. 1395, 1454; (42 U.S.C. 1302,
1395u(b), 1395hh, 1396b(i)(1)))
[43 FR 32300, July 26, 1978]
Sec. 405.507 Illustrations of the application of the criteria for
determining reasonable charges.
The following examples illustrate how the general criteria on
customary charges and prevailing charges might be applied in determining
reasonable charges under the supplementary medical insurance program.
Basically, these examples demonstrate that, except where the actual
charge is less, reasonable charges will reflect current customary
charges of the particular physician or other person within the ranges of
the current prevailing charges in the locality for that type and level
of service:
The prevailing charge for a specific medical procedure ranges from
$80 to $100 in a certain locality.
Doctor A's bill is for $75 although he customarily charges $80 for
the procedure.
Doctor B's bill is his customary charge of $85
Doctor C's bill is his customary charge of $125
Doctor D's bill is for $100, although he customarily charges $80,
and there are no special circumstances in the case.
The reasonable charge for Doctor A would be limited to $75 since
under the law the reasonable charge cannot exceed the actual charge,
even if it is lower than his customary charge and below the prevailing
charges for the locality.
The reasonable charge for Doctor B would be $85, because it is his
customary charge and it falls within the range of prevailing charges for
that locality.
The reasonable charge for Doctor C could not be more than $100, the
top of the range of prevailing charges.
The reasonable charge for Doctor D would be $80, because that is his
customary charge. Even though his actual charge of $100 falls within the
range of prevailing charges, the reasonable charge cannot exceed his
customary charge in the absence of special circumstances.
Sec. 405.508 Determination of comparable circumstances; limitation.
(a) Application of limitation. The carrier may not in any case make
a determination of reasonable charge which would be higher than the
charge upon which it would base payment to its own policyholders for a
comparable service in comparable circumstances. The charge upon which it
would base payment, however, does not necessarily mean the amount the
carrier would be obligated to pay. Under certain circumstances, some
carriers pay amounts on behalf of individuals who are their
policyholders, which are below the customary charges of physicians or
other persons to other individuals. Payment under the supplementary
medical insurance program would not be limited to these lower amounts.
(b) When comparability exists. ``Comparable circumstances,'' as used
in the Act and this subpart, refers to the circumstances under which
services are rendered to individuals and the nature of the carrier's
health insurance programs and the method it uses to determine the
amounts of payments under these programs. Generally, comparability would
exist where:
(1) The carrier bases payment under its program on the customary
charges, as presently constituted, of physicians or other persons and on
current prevailing charges in a locality, and
(2) The determination does not preclude recognition of factors such
as speciality status and unusual circumstances which affect the amount
charged for a service.
(c) Responsibility for determining comparability. Responsibility for
determining whether or not a carrier's program has comparability will in
the first instance fall upon the carrier in reporting pertinent
information about its programs to the Centers for Medicare & Medicaid
Services. When the pertinent information has been reported, the Centers
for Medicare & Medicaid Services will advise the carrier whether any of
its programs have comparability.
[[Page 118]]
Sec. 405.509 Determining the inflation-indexed charge.
(a) Definition. For purposes of this section, inflation-indexed
charge means the lowest of the fee screens used to determine reasonable
charges (as determined in Sec. 405.503 for the customary charge, Sec.
405.504 for the prevailing charge, this section for the inflation-
indexed charge, and Sec. 405.511 for the lowest charge level) for
services, supplies, and equipment reimbursed on a reasonable charge
basis (excluding physicians' services), that is in effect on December 31
of the previous fee screen year, updated by the inflation adjustment
factor, as described in paragraph (b) of this section.
(b) Application of inflation adjustment factor to determine
inflation-indexed charge. (1) For fee screen years beginning on or after
January 1, 1987, the inflation-indexed charge is determined by updating
the fee screen used to determine the reasonable charges in effect on
December 31 of the previous fee screen year by application of an
inflation adjustment factor, that is, the annual change in the level of
the consumer price index for all urban consumers, as compiled by the
Bureau of Labor Statistics, for the 12-month period ending on June 30 of
each year.
(2) For services, supplies, and equipment furnished from October 1,
1985 through December 31, 1986 the inflation adjustment factor is zero.
(c) The inflation-indexed charge does not apply to any services,
supplies, or equipment furnished after December 31, 1991, that are
covered under or limited by the fee schedule for physicians' services
established under section 1848 of the Act and part 415 of this chapter.
These services are subject to the Medicare Economic Index described in
Sec. 415.30 of this chapter.
[51 FR 34979, Oct. 1, 1986; 51 FR 37911, Oct. 27, 1986, as amended at 56
FR 59621, Nov. 25, 1991]
Sec. 405.511 Reasonable charges for medical services, supplies, and
equipment.
(a) General rule. (1) A charge for any medical service, supply, or
equipment (including equipment servicing) that in the judgment of CMS
generally does not vary significantly in quality from one supplier to
another (and that is identified by a notice published in the Federal
Register) may not be considered reasonable if it exceeds:
(i) The customary charge of the supplier (see Sec. 405.503);
(ii) The prevailing charge in the locality (see Sec. 405.504);
(iii) The charge applicable for a comparable service and under
comparable circumstances to the policyholders or subscribers of the
carrier (see Sec. 405.508);
(iv) The lowest charge level at which the item or service is widely
and consistently available in the locality (see paragraph (c) of this
section); or
(v) The inflation-indexed charge, as determined under Sec. 405.509,
in the case of medical services, supplies, and equipment that are
reimbursed on a reasonable charge basis (excluding physicians'
services).
(2) In the case of laboratory services, paragraph (a)(1) of this
section is applicable to services furnished by physicians in their
offices, by independent laboratories (see Sec. 405.1310(a)) and to
services furnished by a hospital laboratory for individuals who are
neither inpatients nor outpatients of a hospital. Allowance of
additional charges exceeding the lowest charge level can be approved by
the carrier on the basis of unusual circumstances or medical
complications in accordance with Sec. 405.506.
(b) Public notice of items and services subject to the lowest charge
level rule. Before the Secretary determines that lowest charge levels
should be established for an item or service, notice of the proposed
determination will be published with an opportunity for public comment.
The descriptions or specifications of items or services in the notice
will be in sufficient detail to permit a determination that items or
services conforming to the descriptions will not vary significantly in
quality.
(c) Calculating the lowest charge level. The lowest charge level at
which an item or service is widely and consistently available in a
locality is calculated by the carrier in accordance with instructions
from CMS as follows:
(1) For items or services furnished on or before December 31, 1986.
(i) A lowest charge level is calculated for each identified item or
service in January and July of each year.
[[Page 119]]
(ii) The lowest charge level for each identified item or service is
set at the 25th percentile of the charges (incurred or submitted on
claims processed by the carrier) for that item or service, in the
locality designated by the carrier for this purpose, during the second
calendar quarter preceding the determination date. Accordingly, the
January calculations will be based on charges for the July through
September quarter of the previous calendar year, and the July
calculations will be based on charges for the January through March
quarter of the same calendar year.
(2) For items or services furnished on or after January 1, 1987.
(i) A lowest charge level is calculated for each identified item or
service in January of each year.
(ii) The lowest charge level for each identified item or service is
set at the 25th percentile of the charges (incurred or submitted on
claims processed by the carrier) for that item or service, in the
locality designated by the carrier for this purpose, during the 3-month
period of July 1 through September 30 preceding the fee screen year
(January 1 through December 31) for which the item or service was
furnished.
(3) Lowest charge levels for laboratory services. In setting lowest
charge levels for laboratory services, the carrier will consider only
charges made for laboratory services performed by physicians in their
offices, by independent laboratories which meet coverage requirements,
and for services furnished by a hospital laboratory for individuals who
are neither inpatients nor outpatients of a hospital.
(d) Locality. Subject to the approval of the Secretary, the carrier
may designate its entire service area as the locality for purposes of
this section, or may otherwise modify the localities used for
calculating prevailing charges. (The modified locality for an item or
service will also be used for calculating the prevailing charge for that
item or service.)
(Secs. 1102, 1842(b) and 1871, 1903(i)(1) of the Social Security Act; 49
Stat. 647, 79 Stat. 302, 310, 331, 86 Stat. 1395, 1454 (42 U.S.C. 1302,
1395u(b), 1395hh, 1396b(i)(1)))
[43 FR 32300, July 26, 1978, as amended at 50 FR 40174, Oct. 1, 1985; 51
FR 34979, Oct. 1, 1986]
Sec. 405.512 Carriers' procedural terminology and coding systems.
(a) General. Procedural terminology and coding systems are designed
to provide physicians and third party payers with a common language that
accurately describes the kinds and levels of services provided and that
can serve as a basis for coverage and payment determinations.
(b) Modification of terminology and/or coding systems. A carrier
that wishes to modify its system of procedural terminology and coding
shall submit its request to the Centers for Medicare & Medicaid Services
with all pertinent data and information for approval before the revision
is implemented. The Centers for Medicare & Medicaid Services will
evaluate the proposal in the light of the guidelines specified in
paragraph (c) of this section and such other considerations as may be
pertinent, and consult with the Assistant Secretary for Health. The
Centers for Medicare & Medicaid Services will approve such a revision if
it determines that the potential advantages of the proposed new system,
outweigh the disadvantages.
(c) Guidelines. The following considerations and guidelines are
taken into account in evaluating a carrier's proposal to change its
system of procedural terminology and coding:
(1) The rationale for converting to the new terminology and coding;
(2) The estimated short-run and long-run impact on the cost of the
health insurance program, other medical care costs, administrative
expenses, and the reliability of the estimates;
(3) The degree to which the conversion to the proposed new
terminology and coding can be accomplished in a way that permits full
implementation of the reasonable charge criteria in accordance with the
provisions of this subpart;
(4) The degree to which the proposed new terminology and coding are
accepted by physicians in the carrier's area (physician acceptance is
assumed only if a majority of the Medicare and non-Medicare bills and
claims completed by physicians in the area and submitted to the carrier
can reasonably be expected to utilize the proposed new terminology and
coding);
[[Page 120]]
(5) The extent to which the proposed new terminology and coding
system is used by the carrier in its non-Medicare business;
(6) The clarity with which the proposed system defines its
terminology and whether the system lends itself to:
(i) Accurate determinations of coverage;
(ii) Proper assessment of the appropriate level of payment; and
(iii) Meeting the carrier's or Professional Standards Review
Organizations' review needs and such other review needs as may be
appropriate;
(7) Compatibility of the new terminology and coding system with
other systems that the carrier and other carriers may utilize in the
administration of the Medicare program--e.g., its compatibility with
systems and statistical requirements and with the historical data in the
carrier's processing system; and
(8) Compatibility of the proposed system with the carriers methods
for determining payment under the fee schedule for physicians' services
for services which are identified by a single element of terminology but
which may vary in content.
[40 FR 7639, Feb. 21, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 59 FR 10298, Mar. 4, 1994]
Sec. 405.515 Reimbursement for clinical laboratory services billed by
physicians.
This section implements section 1842(h) of the Social Security Act,
which places a limitation on reimbursement for markups on clinical
laboratory services billed by physicians. If a physician's bill, or a
request for payment for a physician's services, includes a charge for a
laboratory test for which payment may be made under this part, the
amount payable with respect to the test shall be determined as follows
(subject to the coinsurance and deductible provisions at Sec. Sec.
410.152 and 410.160 of this chapter):
(a) If the bill or request for payment indicates that the test was
personally performed or supervised either by the physician who submitted
the bill (or for whose services the request for payment was made), or by
another physician with whom that physician shares his or her practice,
the payment will be based on the physician's reasonable charge for the
test (as determined in accordance with Sec. 405.502).
(b) If the bill or request for payment indicates that the test was
performed by an outside laboratory, and identifies both the laboratory
and the amount the laboratory charged, payment for the test will be
based on the lower of--
(1) The laboratory's reasonable charge for the service (as
determined in accordance with Sec. 405.502), or
(2) The amount that the laboratory charged the physician for the
service.
(c) If the bill or request for payment does not indicate that the
conditions specified in paragraph (a) of this section were met, and does
not identify both the laboratory and the amount the laboratory charged,
payment will be based on the lowest charge at which the carrier
estimates the test could have been secured from a laboratory serving the
physician's locality. The carrier will estimate this lowest amount twice
a year by (i) obtaining lists of charges laboratories make to physicians
from as many commercial laboratories serving the carrier's area as
possible (including laboratories in other States from which tests may be
obtained by physicians in the carrier's service area) and (ii)
establishing a schedule of lowest prices based on this information. The
carrier will take into consideration specific circumstances, such as a
need for emergency services that may be costlier than routine services,
in making the estimate in a particular case. However, in no case may
this estimate be higher than the lowest customary charge for commercial
laboratories, or when applicable to the laboratory service, the lowest
charge level determined in accordance with Sec. 405.511, in the
carrier's service area.
(d) When a physician bills, in accordance with paragraph (b) or (c)
of this section, for a laboratory test and indicates that it was
performed by an independent laboratory, a nominal payment will also be
made to the physician for collecting, handling, and shipping the
specimen to the laboratory, if the physician bills for such a service.
[46 FR 42672, Aug. 24, 1981, as amended at 51 FR 41351, Nov. 14, 1986]
[[Page 121]]
Sec. 405.517 Payment for drugs and biologicals that are not paid on
a cost or prospective payment basis.
(a) Applicability. (1) Payment for drugs and biologicals before
January 1, 2004. Payment for a drug or biological that is not paid on a
cost or prospective payment basis is determined by the standard
methodology described in paragraph (b) of this section. Examples of when
this procedure applies include a drug or biological furnished incident
to a physician's service, a drug or biological furnished by an
independent dialysis facility that is not included in the ESRD composite
rate set forth in Sec. 413.170(c) of this chapter, and a drug or
biological furnished as part of the durable medical equipment benefit.
(2) Payment for drugs and biologicals on or after January 1, 2004.
Effective January 1, 2004, payment for drugs and biologicals that are
not paid on a cost or prospective payment basis are paid in accordance
with Part 414, subpart I of this chapter.
(3) Payment for drugs and biologicals on or after January 1, 2005.
Effective January 1, 2005, payment for drugs and biologicals that are
not paid on a cost or prospective payment basis are paid in accordance
with part 414, subpart K of this chapter.
(b) Methodology. Payment for a drug or biological described in
paragraph (a) of this section is based on the lower of the actual charge
on the Medicare claim for benefits or 95 percent of the national average
wholesale price of the drug or biological.
(c) Multiple-source drugs. For multiple-source drugs and
biologicals, for purposes of this regulation, the average wholesale
price is defined as the lesser of the median average wholesale price for
all sources of the generic forms of the drug or biological or the lowest
average wholesale price of the brand name forms of the drug or
biological.
[63 FR 58905, Nov. 2, 1998, as amended at 69 FR 1116, Jan. 7, 2004; 69
FR 66420, Nov. 15, 2004]
Sec. 405.520 Payment for a physician assistant's, nurse practitioner's,
and clinical nurse specialists' services and services furnished incident
to their professional services.
(a) General rule. A physician assistant's, nurse practitioner's, and
clinical nurse specialists' services, and services and supplies
furnished incident to their professional services, are paid in
accordance with the physician fee schedule. The payment for a physician
assistants' services may not exceed the limits at Sec. 414.52 of this
chapter. The payment for a nurse practitioners' and clinical nurse
specialists' services may not exceed the limits at Sec. 414.56 of this
chapter.
(b) Requirements. Medicare payment is made only if all claims for
payment are made on an assignment-related basis in accordance with Sec.
424.55 of this chapter, that sets forth, respectively, the conditions
for coverage of physician assistants' services, nurse practitioners'
services and clinical nurse specialists' services, and services and
supplies furnished incident to their professional services.
(c) Civil money penalties. Any person or entity who knowingly and
willingly bills a Medicare beneficiary amounts in excess of the
appropriate coinsurance and deductible is subject to a civil money
penalty as described in Sec. Sec. 402.1(c)(11), 402.105(d)(2)(viii),
and 402.107(b)(8) of this chapter.
[63 FR 58905, Nov. 2, 1998, as amended at 66 FR 49547, Sept. 28, 2001]
Sec. 405.534 Limitation on payment for screening mammography services.
The provisions in paragraphs (a), (b), and (c) of this section apply
for services provided from January 1, 1991 until December 31, 2001.
Screening mammography services provided after December 31, 2001 are paid
under the physician fee schedule in accordance with Sec. 414.2 of this
chapter.
(a) Basis and scope. This section implements section 1834(c) of the
Act by establishing a limit on payment for screening mammography
examinations. There are three categories of billing for screening
mammography services. Those categories and the payment limitations on
each are set forth
[[Page 122]]
in paragraphs (b) through (d) of this section.
(b) Global or complete service billing representing both the
professional and technical components of the procedure. If a fee is
billed for a global service, the amount of payment subject to the
deductible is equal to 80 percent of the least of the following:
(1) The actual charge for the service.
(2) The amount established for the global procedure for a diagnostic
bilateral mammogram under the fee schedule for physicians' services set
forth at part 414, subpart A.
(3) The payment limit for the procedure. For screening mammography
services furnished in CY 1994, the payment limit is $59.63. On January 1
of each subsequent year, the payment limit is updated by the percentage
increase in the Medicare Economic Index (MEI) and reflects the
relationship between the relative value units for the professional and
technical components of a diagnostic bilateral mammogram under the fee
schedule for physicians' services.
(c) Professional component billing representing only the physician's
interpretation for the procedure. If the professional component of
screening mammography services is billed separately, the amount of
payment for that professional component, subject to the deductible, is
equal to 80 percent of the least of the following:
(1) The actual charge for the professional component of the service.
(2) The amount established for the professional component of a
diagnostic bilateral mammogram under the fee schedule for physicians'
services.
(3) The professional component of the payment limit for screening
mammography services described in paragraph (b)(3) of this section.
(d) Technical component billing representing other resources
involved in furnishing the procedure. If the technical component of
screening mammography services is billed separately, the amount of
payment, subject to the deductible, is equal to 80 percent of the least
of the following:
(1) The actual charge for the technical component of the service.
(2) The amount established for the technical component of a
diagnostic bilateral mammogram under the fee schedule for physicians'
services.
(3) The technical component of the payment limit for screening
mammography services described in paragraph (b)(3) of this section.
[55 FR 53521, Dec. 31, 1990, as amended at 59 FR 49833, Sept. 30, 1994;
66 FR 55328, Nov. 1, 2001]
Sec. 405.535 Special rule for nonparticipating physicians and suppliers
furnishing screening mammography services before January 1, 2002.
The provisions in this section apply for screening mammography
services provided from January 1, 1991 until December 31, 2001.
Screening mammography services provided after December 31, 2001 are
physician services pursuant to Sec. 414.2 of this chapter paid under
the physician fee schedule. If screening mammography services are
furnished to a beneficiary by a nonparticipating physician or supplier
that does not accept assignment, a limiting charge applies to the
charges billed to the beneficiary. The limiting charge is the lesser of
the following:
(a) 115 percent of the payment limit set forth in Sec.
405.534(b)(3), (c)(3), and (d)(3) (limitations on the global service,
professional component, and technical component of screening mammography
services, respectively).
(b) The limiting charge for the global service, professional
component, and technical component of a diagnostic bilateral mammogram
under the fee schedule for physicians' services set forth at Sec.
414.48(b) of this chapter.
[59 FR 49833, Sept. 30, 1994, as amended at 62 FR 59098, Oct. 31, 1997;
66 FR 55328, Nov. 1, 2001]
Subpart F [Reserved]
Subpart G_Reconsiderations and Appeals Under Medicare Part A
Authority: Secs. 1102, 1155, 1869(b), 1871, 1872, and 1879 of the
Social Security Act (42 U.S.C. 1302, 1320c-4, 1395ff(b), 1395hh, 1395ii,
and 1395pp).
Source: 37 FR 5814, Mar. 22, 1972, unless otherwise noted.
Redesignated at 42 FR 52826, Sept. 30, 1977.
[[Page 123]]
Sec. 405.701 Basis, purpose and definitions.
(a) This subpart implements section 1869 of the Social Security Act.
Section 1869(a) provides that the Secretary will make determinations
about the following matters, and section 1869(b) provides for a hearing
for an individual who is dissatisfied with the Secretary's determination
as to:
(1) Whether the individual is entitled to hospital insurance (part
A) or supplementary medical insurance (part B) under title XVIII of the
Act; or
(2) The amount payable under hospital insurance.
(b) This subpart establishes the procedures governing initial
determinations, reconsidered determinations, hearings, and final agency
review, and the reopening of determinations and decisions that are
applicable to matters arising under paragraph (a) of this section.
(c) Subparts J and R of 20 CFR part 404 (dealing with
determinations, the administrative review process and representation of
parties) are also applicable to matters arising under paragraph (a) of
this section, except to the extent that specific provisions are
contained in this subpart.
(d) Definitions. As used in subpart G of this part, the term--
Appellant designates the beneficiary, provider or other person or
entity that has filed an appeal concerning a particular determination of
benefits under Medicare part A. Designation as an appellant does not in
itself convey standing to appeal the determination in question.
Common issues of law and fact, with respect to the aggregation of
claims by two or more appellants to meet the minimum amount in
controversy needed for a hearing, occurs when the claims sought to be
aggregated are denied or reduced for similar reasons and arise from a
similar fact pattern material to the reason the claims are denied.
Delivery of similar or related services, with respect to the
aggregation of claims by two or more provider appellants to meet the
minimum amount in controversy needed for a hearing, means like or
coordinated services or items provided to the same beneficiary by the
appellants.
[55 FR 11020, Mar. 26, 1990, as amended at 59 FR 12181, Mar. 16, 1994]
Sec. 405.702 Notice of initial determination.
After a request for payment under part A of title XVIII of the Act
is filed with the intermediary by or on behalf of the individual who
received inpatient hospital services, extended care services, or home
health services, and the intermediary has ascertained whether the items
and services furnished are covered under part A of title XVIII, and
where appropriate, ascertained and made payment of amounts due or has
ascertained that no payments were due, the individual will be notified
in writing of the initial determination in his case. In addition, if the
items or services furnished such individual are not covered under part A
of title XVIII by reason of Sec. 411.15(g) or Sec. 411.15(k) and
payment may not be made for such items or services under Sec. 411.400
only because the requirements of Sec. 411.400(a)(2) are not met, the
provider of services which furnished such items or services will be
notified in writing of the initial determination in such individual's
case. These notices shall be mailed to the individual and the provider
of services at their last known addresses and shall state in detail the
basis for the determination. Such written notices shall also inform the
individual and the provider of services of their right to
reconsideration of the determination if they are dissatisfied with the
determination.
[55 FR 11020, Mar. 26, 1990]
Sec. 405.704 Actions which are initial determinations.
(a) Applications and entitlement of individuals. An initial
determination with respect to an individual includes the following--
(1) A determination with respect to entitlement to hospital
insurance or supplementary medical insurance;
(2) A disallowance of an individual's application for entitlement to
hospital or supplementary medical insurance, if the individual fails to
submit evidence
[[Page 124]]
requested by SSA to support the application. (SSA will specify in the
initial determination the conditions of entitlement that the applicant
failed to establish by not submitting the requested evidence);
(3) A denial of a request for withdrawal of an application for
hospital or supplementary medical insurance;
(4) A denial of a request for cancellation of a ``request for
withdrawal''; and
(5) A determination as to whether an individual, previously
determined to be entitled to hospital or supplementary medical
insurance, is no longer entitled to such benefits, including a
determination based on nonpayment of premiums.
(b) Requests for payment by or on behalf of individuals. An initial
determination with respect to an individual includes any determination
made on the basis of a request for payment by or on behalf of the
individual under part A of Medicare, including a determination with
respect to:
(1) The coverage of items and services furnished;
(2) The amount of an applicable deductible;
(3) The application of the coinsurance feature;
(4) The number of days of inpatient hospital benefits utilized
during a spell of illness or for purposes of the inpatient psychiatric
hospital 190-day lifetime maximum;
(5) The number of days of the 60-day lifetime reserve utilized for
inpatient hospital coverage;
(6) The number of days of posthospital extended care benefits
utilized;
(7) The number of home health visits utilized;
(8) The physician certification requirement;
(9) The request for payment requirement;
(10) The beginning and ending of a spell of illness, including a
determination made under the presumptions established under Sec.
409.60(c)(2) of this chapter, as specified in Sec. 409.60(c)(4) of this
chapter.
(11) The medical necessity of services (See parts 466 and 473 of
this chapter for provisions pertaining to initial and reconsidered
determinations made by a QIO);
(12) When services are excluded from coverage as custodial care
(Sec. 411.15(g)) or as not reasonable and necessary (Sec. 411.15(k)),
whether the individual or the provider of services who furnished the
services, or both, knew or could reasonably have been expected to know
that the services were excluded from coverage (see Sec. 411.402);
(13) Any other issues having a present or potential effect on the
amount of benefits to be paid under part A of Medicare, including a
determination as to whether there has been an overpayment or
underpayment of benefits paid under part A, and if so, the amount
thereof; and
(14) Whether a waiver of adjustment or recovery under sections 1870
(b) and (c) of the Act is appropriate when an overpayment of hospital
insurance benefits or supplementary medical insurance benefits
(including a payment under section 1814(e) of the Act) has been made
with respect to an individual.
(c) Initial determination with respect to a provider of services. An
initial determination with respect to a provider of services shall be a
determination made on the basis of a request for payment filed by the
provider under part A of Medicare on behalf of an individual who was
furnished items or services by the provider, but only if the
determination involves the following:
(1) A finding by the intermediary that such items or services are
not covered by reason of Sec. 411.15(g) or Sec. 411.15(k); and
(2) A finding by the intermediary that either such individual or
such provider of services, or both, knew or could reasonably have been
expected to know that such items or services were excluded from coverage
under the program.
[55 FR 11020, Mar. 26, 1990]
Sec. 405.705 Actions which are not initial determinations.
An initial determination under Part A of Medicare does not include
determinations relating to:
(a) The reasonable cost of items or services furnished under Part A
of Medicare;
[[Page 125]]
(b) Whether an institution or agency meets the conditions for
participation in the program;
(c) Whether an individual is qualified for use of the expedited
appeals process as provided in Sec. 405.718;
(d) An action regarding compromise of a claim arising under the
Medicare program, or termination or suspension of collection action on
such a claim under the Federal Claims Collection Act of 1966 (31 U.S.C.
3711). See 20 CFR 404.515 for overpayment claims against an individual,
Sec. 405.376 for overpayment claims against a provider, physician or
other supplier, and Sec. 408.110 for claims concerning unpaid Medicare
premiums;
(e) The transfer or discharge of residents of skilled nursing
facilities in accordance with Sec. 483.12 of this chapter; or
(f) The preadmission screening and annual resident review processes
required by part 483 subparts C and E of this chapter.
[45 FR 73932, Nov. 7, 1980; 46 FR 24565, May 1, 1981, as amended at 52
FR 22454, June 12, 1987; 52 FR 48123, Dec. 18, 1987; 57 FR 56504, Nov.
30, 1992; 61 FR 63749, Dec. 2, 1996]
Sec. 405.706 Decisions of utilization review committees.
(a) General rule. A decision of a utilization review committee is a
medical determination by a staff committee of the provider or a group
similarly composed and does not constitute a determination by the
Secretary within the meaning of section 1869 of the Act. The decision of
a utilization review committee may be considered by CMS along with other
pertinent medical evidence in determining whether or not an individual
has the right to have payment made under Part A of title XVIII.
(b) Applicability under the prospective payment system. CMS may
consider utilization review committee decisions related to inpatient
hospital services paid for under the prospective payment system (see
part 412 of this chapter) only as those decisions concern:
(1) The appropriateness of admissions resulting in payments under
subparts D, E and G of part 412 of this chapter.
(2) The covered days of care involved in determinations of outlier
payments under Sec. 412.80(a)(1)(i) of this chapter; and
(3) The necessity of professional services furnished in high cost
outliers under Sec. 412.80(a)(1)(ii) of this chapter.
[48 FR 39831, Sept. 1, 1983]
Sec. 405.708 Effect of initial determination.
(a) The initial determination under Sec. 405.704 (a) or (b) shall
be binding upon the individual on whose behalf payment under part A has
been requested or, if such individual is deceased, upon the
representative of such individual's estate, unless it is reconsidered in
accordance with Sec. Sec. 405.710 through 405.717 or revised in
accordance with Sec. 405.750. Such individual (or the representative of
such individual's estate if the individual is deceased) shall be the
party to such initial determination.
(b) The initial determination under Sec. 405.704(c) shall be
binding upon the provider of services unless it is reconsidered in
accordance with Sec. Sec. 405.710 through 405.717 or revised in
accordance with Sec. 405.750. Such provider of services shall be the
party to such initial determination.
[55 FR 11021, Mar. 26, 1990, as amended at 62 FR 25855, May 12, 1997]
Sec. 405.710 Right to reconsideration.
(a) An individual who is a party to an initial determination, as
specified in Sec. 405.704 (a) and (b), (or if such individual is
deceased, the representative of such individual's estate) and who is
dissatisfied with the initial determination may request a
reconsideration of such determination in accordance with Sec. 405.711
regardless of the amount in controversy.
(b) A provider of services who is a party to an initial
determination (as specified in Sec. 405.704(c)) and who is dissatisfied
with such initial determination may request a reconsideration of such
determination in accordance with Sec. 405.711, regardless of the amount
in controversy, but only if the individual on whose behalf the request
for payment was made has indicated in writing that he does not intend to
request reconsideration of the intermediary's initial determination on
such request for payment, or if the intermediary has made a finding (see
Sec. 405.704(c)) that such individual did not know or could
[[Page 126]]
not reasonably have been expected to know that the expenses incurred for
the items or services for which such request for payment was made were
not reimbursable by reason of Sec. 411.15(g) or Sec. 411.15(k).
[55 FR 11021, Mar. 26, 1990]
Sec. 405.711 Time and place of filing request for reconsideration.
The request for reconsideration shall be made in writing and filed
at an office of the SSA or the CMS or, in the case of a qualified
railroad retirement beneficiary (see 20 CFR 404.368) filed at an office
of the Railroad Retirement Board, within 60 days after the date of
receipt of notice of initial determination, unless such time is extended
as provided in Sec. 405.712. A request for reconsideration which is
filed with the intermediary which received the request for payment
submitted on behalf of the individual is considered to have been filed
with the CMS as of the date it is filed with the intermediary. For
purposes of this section, the date of receipt of notice of the initial
determination shall be presumed to be 5 days after the date of such
notice, unless there is a reasonable showing to the contrary.
[41 FR 47917, Nov. 1, 1976. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 62 FR 25855, May 12, 1997]
Sec. 405.712 Extension of time to request reconsideration.
If a party to an initial determination desires to file a request for
reconsideration after the time for filing such request in accordance
with Sec. 405.711 has passed, such party may file a petition with the
SSA or the CMS or, in the case of a qualified railroad retirement
beneficiary, with the Railroad Retirement Board, for an extension of
time for the filing of such request. Such petition shall be in writing
and shall state the reasons why the request for reconsideration was not
filed within the required time. For good cause shown, the CMS may extend
the time for filing the request for reconsideration.
[37 FR 5814, Mar. 22, 1972. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 62 FR 25855, May 12, 1997]
Sec. 405.714 Withdrawal of request for reconsideration.
A request for reconsideration may be withdrawn by the party to the
initial determination who filed the request or by his representative
provided that the withdrawal is made in writing and filed at an office
of the SSA or the CMS or, in the case of a qualified railroad retirement
beneficiary, with the Railroad Retirement Board prior to the date of the
mailing of the notice of reconsidered determination. A withdrawal filed
with the intermediary which received the request for payment submitted
on behalf of the individual is considered to have been filed with the
CMS as of the date it is filed with the intermediary.
[40 FR 1025, Jan. 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 62 FR 25855, May 12, 1997]
Sec. 405.715 Reconsidered determination.
(a) In reconsidering an initial determination, the CMS shall review
such initial determination, the evidence and findings upon which such
determination was based, and any additional evidence submitted to the
SSA or the CMS or otherwise obtained by the intermediary or the CMS; and
shall make a determination affirming or revising, in whole or in part,
such initial determination.
(b) If the request for reconsideration is filed by an individual
with respect to an initial determination specified in Sec.
405.704(b)(12), the provider of services who furnished the items or
services shall, prior to the making of the reconsidered determination,
be made a party thereto. If pursuant to Sec. 405.710(b) a request for
reconsideration is filed by a provider of services with respect to an
individual determination under Sec. 405.704(c), the individual who was
furnished the items or services shall, prior to the making of the
reconsidered determination, be made a party thereto.
[55 FR 11021, Mar. 26, 1990, as amended at 62 FR 25855, May 12, 1997]
Sec. 405.716 Notice of reconsidered determination.
Written notice of the reconsidered determination shall be mailed by
the CMS to the parties and their representatives at their last known
addresses.
[[Page 127]]
Such notice shall state the specific reasons for the reconsidered
determination and shall advise the parties of their right to a hearing
if the amount in controversy is $100 or more, or, if appropriate, advise
them of the requirements for use of the expedited appeals process (see
Sec. 405.718).
[40 FR 53387, Nov. 18, 1975. Redesignated at 42 FR 52826, Sept. 30,
1977, as amended at 62 FR 25855, May 12, 1997]
Sec. 405.717 Effect of a reconsidered determination.
The reconsidered determination is binding upon all parties unless--
(a) A request for a hearing is filed with SSA or CMS within 60 days
after the date of receipt of notice of the reconsidered determination by
the parties (for purposes of this section, the date of receipt of notice
of the reconsidered determination is presumed to be 5 days after the
date of the notice, unless it is shown that the notice was received
earlier or later); or
(b) The reconsidered determination is revised in accordance with
Sec. 405.750; or
(c) The expedited appeals process is used in accordance with Sec.
405.718.
[62 FR 25852, May 12, 1997]
Sec. 405.718 Expedited appeals process.
(a) Conditions for use of expedited appeals process (EAP). A party
may use the EAP to request court review in place of an administrative
law judge (ALJ) hearing or Departmental Appeals Board (DAB) review if
the following conditions are met:
(1) CMS has made a reconsideration determination; an ALJ has made a
hearing decision; or DAB review has been requested, but a final decision
has not been issued.
(2) The filing entity is a party referred to in Sec. 405.718(d).
(3) The party has filed a request for an ALJ hearing in accordance
with Sec. 405.722, or DAB review in accordance with 20 CFR 404.968.
(4) The amount remaining in controversy is $1,000 or more.
(5) If there is more than one party to the reconsideration
determination or hearing decision, each party concurs, in writing, with
the request for the EAP.
(b) Content of the request for EAP. The request for the EAP:
(1) Alleges that there are no material issues of fact in dispute;
and
(2) Asserts that the only factor precluding a decision favorable to
the party is a statutory provision that is unconstitutional or a
regulation, national coverage decision under section 1862(a)(1) of the
Act, or CMS Ruling that is invalid.
(c) Place and time for requesting an EAP--(1) Place for filing
request. The person must file a written request--
(i) At an office of SSA or CMS; or
(ii) If the person is in the Philippines, at the Veterans
Administration Regional Office or with an ALJ; or
(iii) If the person is a qualified railroad retirement beneficiary,
at an office of the Railroad Retirement Board.
(2) Time of filing request. The party may file a request for the
EAP--
(i) If the party has requested a hearing, at any time prior to
receipt of the notice of the ALJ's decision;
(ii) Within 60 days after the date of receipt of notice of the ALJ's
decision or dismissal, unless the time is extended in accordance with
the standards set out in 20 CFR 404.925(c). For purposes of this
section, the date of receipt of the notice is presumed to be 5 days
after the date on the notice, unless it is shown that the notice was
received later; or
(iii) If the party has requested DAB review, at any time prior to
receipt of notice of the Board's decision.
(d) Parties to the EAP. The parties to the EAP are the persons who
were parties to the reconsideration determination and, if appropriate,
to the hearing.
(e) Determination on request for EAP. (1) For EAP requests initiated
at the ALJ level, an ALJ determines whether all conditions of paragraphs
(a) and (b) of this section are met.
(2) If a hearing decision has been issued, the DAB determines
whether all conditions of paragraphs (a) and (b) of this section are
met.
(f) ALJ or DAB certification for the EAP. If the party meets the
requirements for the EAP, the ALJ or the DAB, as appropriate, certifies
the case in writing stating that:
(1) The facts involved in the claim are not in dispute;
[[Page 128]]
(2) Except as indicated in paragraph (f)(3) of this section, CMS's
interpretation of the law is not in dispute;
(3) The sole issue(s) in dispute is the constitutionality of a
statutory provision or the validity of a regulation, CMS Ruling, or
national coverage decision based on section 1862(a)(1) of the Act.
(4) Except for the provision challenged, the right(s) of the party
is established; and
(5) The determination or decision made by the ALJ or DAB is final
for purposes of seeking judicial review.
(g) Effect of ALJ or DAB certification. (1) Following the issuance
of the certification described in paragraph (f) of this section, the
party waives completion of the remaining steps of the administrative
appeals process.
(2) The 60-day period for filing a civil suit in a Federal district
court begins on the date of receipt of the ALJ or DAB certification.
(h) Effect of a request for EAP that does not result in
certification. If a request for the EAP does not meet all the conditions
for use of the process, the ALJ or DAB so advises the party and treats
the request as a request for hearing or DAB review, as appropriate.
[62 FR 25852, May 12, 1997]
Sec. 405.720 Hearing; right to hearing.
A person has a right to a hearing regarding any initial
determination made under Sec. 405.704 if:
(a) Such initial determination has been reconsidered by the CMS;
(b) Such person was a party to the reconsidered determination;
(c) Such person or his representative has filed a written request
for a hearing in accordance with the procedure described in Sec.
405.722; and
(d) The amount in controversy is $100 or more.
[40 FR 1025, Jan. 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 62 FR 25855, May 12, 1997]
Sec. 405.722 Time and place of filing request for a hearing.
The request for a hearing shall be made in writing and filed at an
office of the SSA or the CMS or with a ALJ, or, in the case of a
qualified railroad retirement beneficiary, at an office of the Railroad
Retirement Board. Such request must be filed within 60 days after the
date of receipt of notice of the reconsidered determination by such
individual, except where the time is extended as provided in 20 CFR
404.933(c). For purposes of this section, the date of receipt of notice
of the reconsidered determination shall be presumed to be 5 days after
the date of such notice, unless there is a reasonable showing to the
contrary.
[45 FR 73933, Nov. 7, 1980, as amended at 62 FR 25855, May 12, 1997]
Sec. 405.724 Departmental Appeals Board (DAB) review.
Regulations beginning at 20 CFR 404.967 regarding SSA Appeals
Council Review are also applicable to DAB review of matters addressed by
this subpart.
[62 FR 25852, May 12, 1997]
Sec. 405.730 Court review.
(a) To the extent authorized by sections 1869, 1876(c)(5)(B), and
1879(d) of the Act, a party to a Departmental Appeals Board (DAB)
decision or an ALJ decision if the DAB does not review the ALJ decision,
may obtain a court review if the amount remaining in controversy is
$1,000 or more. A party may obtain court review by filing a civil action
in a district court of the United States in accordance with the
provisions of section 205(g) of the Act. The filing procedure is set
forth at 20 CFR 422.210.
(b) A party to a reconsidered determination or an ALJ hearing
decision may obtain a court review if the amount in controversy is
$1,000 or more, and he or she requests and meets the conditions for the
expedited appeals process set forth in Sec. 405.718.
[62 FR 25852, May 12, 1997]
Sec. 405.732 Review of a national coverage determination (NCD).
(a) General rule. (1) An NCD is a determination by the Secretary for
whether or not a particular item or service is covered nationally under
title XVIII of the Act.
(2) An NCD does not include a determination of what code, if any, is
assigned to a particular item or service
[[Page 129]]
covered under title XVIII or a determination for the amount of payment
made for a particular item or service.
(3) NCDs are made under section 1862(a)(1) of the Act or other
applicable provisions of the Act.
(4) An NCD is binding on all Medicare carriers, fiscal
intermediaries, QIOs, HMOs, CMPs, HCPPs, the Medicare Appeals Council,
and ALJs.
(b) Review by ALJ. (1) An ALJ may not disregard, set aside, or
otherwise review an NCD.
(2) An ALJ may review the facts of a particular case to determine
whether an NCD applies to a specific claim for benefits and, if so,
whether the NCD has been applied correctly to the claim.
(c) Review by Court. For initial determinations and NCD challenges
under section 1862(a)(1) of the Act, arising before October 1, 2002, a
court's review of an NCD is limited to whether the record is incomplete
or otherwise lacks adequate information to support the validity of the
decision, unless the case has been remanded to the Secretary to
supplement the record regarding the NCD. In these cases, the court may
not invalidate an NCD except upon review of the supplemental record.
[68 FR 63715, Nov. 7, 2003]
Sec. 405.740 Principles for determining the amount in controversy.
(a) Individual appellants. For the purpose of determining whether an
individual appellant meets the minimum amount in controversy needed for
a hearing ($100), the following rules apply:
(1) The amount in controversy is computed as the actual amount
charged the individual for the items and services in question, less any
amount for which payment has been made by the intermediary and less any
deductible and coinsurance amounts applicable in the particular case.
(2) A single beneficiary may aggregate claims from two or more
providers to meet the $100 hearing threshold and a single provider may
aggregate claims for services provided to one or more beneficiaries to
meet the $100 hearing threshold.
(3) In either of the circumstances specified in paragraph (a)(2) of
this section, two or more claims may be aggregated by an individual
appellant only if the claims have previously been reconsidered and a
request for hearing has been made within 60 days after receipt of the
reconsideration determination(s).
(4) When requesting a hearing, the appellant must specify in his or
her appeal request the specific claims to be aggregated.
(b) Two or more appellants. As specified below, under section
1869(b)(2) of the Act, two or more appellants may aggregate their claims
together to meet the minimum amount in controversy needed for a hearing
($100). The right to aggregate under this statutory provision applies to
claims for items and services furnished on or after January 1, 1987.
(1) The aggregate amount in controversy is computed as the actual
amount charged the individual(s) for the items and services in question,
less any amount for which payment has been made by the intermediary and
less any deductible and coinsurance amounts applicable in the particular
case.
(2) In determining the amount in controversy, two or more appellants
may aggregate their claims together under the following circumstances:
(i) Two or more beneficiaries may combine claims representing
services from the same or different provider(s) if the claims involve
common issues of law and fact;
(ii) Two or more providers may combine their claims if the claims
involve the delivery of similar or related services to the same
beneficiary; or
(iii) Two or more providers may combine their claims if the claims
involve common issues of law and fact with respect to services furnished
to two or more beneficiaries.
(iv) In any of the circumstances specified in paragraphs (b)(2)(i)
through (b)(2)(iii) of this section, the claims may be aggregated only
if the claims have previously been reconsidered and a request for
hearing has been made within 60 days after receipt of the
reconsideration determination(s). Moreover, in the request for hearing,
the appellants must specify the claims that they seek to aggregate.
[[Page 130]]
(c) The determination as to whether the amount in controversy is
$100 or more is made by the administrative law judge (ALJ).
(d) In determining the amount in controversy under paragraph (b) of
this section, the ALJ also makes the determination as to what
constitutes ``similar or related services'' or ``common issues of law
and fact.''
(e) When a civil action is filed by either an individual appellant
or two or more appellants, the Secretary may assert that the aggregation
principles contained in this subpart may be applied to determine the
amount in controversy for judicial review ($1000).
(f) Notwithstanding the provisions of paragraphs (a)(1) and (b)(1)
of this section, when payment is made for certain excluded services
under Sec. 411.400 of this chapter or the liability of the beneficiary
for those services is limited under Sec. 411.402 of this chapter, the
amount in controversy is computed as the amount that would have been
charged the beneficiary for the items or services in question, less any
deductible and coinsurance amounts applicable in the particular case,
had such expenses not been paid pursuant to Sec. 411.400 of this
chapter or had such liability not been limited pursuant to Sec. 411.402
of this chapter.
(g) Under this subpart, an appellant may not combine part A and part
B claims together to meet the requisite amount in controversy for a
hearing. HMO, CMP and HCPP appellants under part 417 of this chapter may
combine part A and part B claims together to meet the requisite amounts
in controversy for a hearing.
[59 FR 12181, Mar. 16, 1994]
Sec. 405.745 Amount in controversy ascertained after reconsideration.
For the purpose of determining whether a party to a reconsidered
determination is entitled to a hearing, the amount in controversey after
the reconsideration action rather than the amount in controversy
initially at issue shall be controlling.
[40 FR 1026, Jan. 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]
Sec. 405.747 Dismissal of request for hearing; amount in controversy
less than $100.
The ALJ shall, without holding a hearing, dismiss the request for
hearing if the request for hearing plainly shows that less than $100 is
in controversy. If a hearing is held and the ALJ finds that the amount
in controversy is less than $100, the ALJ shall dismiss the request for
hearing and will not rule on the substantive issues involved in the
appeal.
[37 FR 5814, Mar. 23, 1972. Redesignated at 42 FR 52826, Sept. 30, 1977,
as amended at 62 FR 25855, May 12, 1997]
Sec. 405.750 Time period for reopening initial, revised, or reconsidered
determinations and decisions or revised decisions of an ALJ or the
Departmental Appeals Board (DAB); binding effect of determination and
decisions.
(a) Reopenings concerning applications and entitlement. A
determination, or decision, or revised determination or decision made by
the SSA concerning any matter under Sec. 405.704(a), may be reopened
and revised under 20 CFR 404.988 (Conditions for reopening).
(b) Reopenings concerning a request for payment. An initial,
revised, or reconsidered determination of CMS, or a decision or revised
decision of an ALJ or of the DAB, with respect to an individual's right
concerning a request for payment under Medicare Part A, which is
otherwise binding under 20 CFR 404.955 or 404.981 and Sec. Sec. 405.708
or 405.717 of this subpart may be reopened:
(1) Within 12 months from the date of the notice of the initial or
reconsidered determination to the party to such determination;
(2) After such 12-month period, but within 4 years after the date of
the notice of the initial determination to the individual, upon
establishment of good cause for reopening such determination or decision
(see 20 CFR 404.988(b) and 404.989); or
(3) At any time, when:
(i) Such initial, revised, or reconsidered determination or such
decision or revised decision is unfavorable, in whole or in part, to the
party thereto, but only for the purpose of correcting clerical error or
error on the face of the
[[Page 131]]
evidence on which such determination or decision was based; or
(ii) Such initial, revised, or reconsidered determination or such
decision or revised decision was procured by fraud or similar fault of
the beneficiary or some other person.
[45 FR 73933, Nov. 7, 1980, as amended at 61 FR 32348, June 24, 1996; 62
FR 25853, 25855, May 12, 1997]
Sec. 405.753 Appeal of a categorization of a device.
(a) CMS's acceptance of the FDA categorization of a device as an
experimental/investigational (Category A) device under Sec. 405.203 is
a national coverage decision under section 1862(a)(1) of the Act.
(b) CMS's acceptance of the FDA categorization of a device as an
experimental/investigational (Category A) device under Sec. 405.203 is
an aspect of an initial determination that, under section 1862 of the
Act, payment may not be made.
(c) In accordance with section 1869(b)(3)(A) of the Act, CMS's
acceptance of the FDA categorization of a device as an experimental/
investigational (Category A) device under Sec. 405.203 may not be
reviewed by an administrative law judge.
[60 FR 48424, Sept. 19, 1995]
Subpart H_Appeals Under the Medicare Part B Program
Authority: Secs. 1102, 1842(b)(3)(C), 1869(b), and 1871 of the
Social Security Act (42 U.S.C. 1302, 1395u(b)(3)(C), 1395ff(b), and
1395hh).
Source: 32 FR 18028, Dec. 16, 1967, unless otherwise noted.
Redesignated at 42 FR 52826, Sept. 30, 1977.
Sec. 405.801 Part B appeals--general description.
(a) The Medicare carrier makes an initial determination when a
request for payment for Part B benefits is submitted. If an individual
beneficiary is dissatisfied with the initial determination, he or she
may request, and the carrier will perform, a review of the claim.
Following the carrier's review determination, the beneficiary may obtain
a carrier hearing if the amount remaining in controversy is at least
$100. The beneficiary is also entitled to a carrier hearing without the
benefit of a review determination when the initial request for payment
is not being acted upon with reasonable promptness (as defined in Sec.
405.802). Following the carrier hearing, the beneficiary may obtain a
hearing before an ALJ if the amount remaining in controversy is at least
$500. If the beneficiary is dissatisfied with the decision of the ALJ,
he or she may request the Departmental Appeals Board (DAB) to review the
case. Following the action of the DAB, the beneficiary may file suit in
Federal district court if the amount remaining in controversy is at
least $1,000.
(b) The rights of a beneficiary under paragraph (a) of this section
to appeal the carrier's initial determination are granted also to--
(1) A physician or supplier that furnishes services to a beneficiary
and that accepts an assignment from the beneficiary, or
(2) A physician who meets the conditions of section 1842(l)(1)(A) of
the Act pertaining to refund requirements for nonparticipating
physicians who have not taken assignment on the claim(s) at issue.
(c) Procedures governing the determinations by SSA as to whether an
individual has met basic Part B entitlement requirements are covered in
subpart G of this part and 20 CFR part 404, subpart J. Subparts J and R
of 20 CFR part 404 are also applicable to ALJ, DAB, and judicial review
conducted under subpart H, except to the extent that specific provisions
are contained in this subpart.
[62 FR 25853, May 12, 1997]
Sec. 405.802 Definitions.
As used in subpart H of this part, the term--
After receipt of the notice means 5 days after the date on the
notice, unless it is shown that the notice was received earlier or
later.
Appellant designates the beneficiary, assignee or other person or
entity that has filed an appeal concerning a particular determination of
benefits under Medicare part B. Designation as an appellant does not in
itself convey standing to appeal the determination in question.
[[Page 132]]
Assignee means a physician or supplier who furnishes services to a
beneficiary under Medicare part B and who has accepted a valid
assignment executed by the beneficiary.
Assignment means the transfer by the assignor of his or her claim
for payment to the assignee in return for the latter's promise not to
charge more for his or her services than the carrier finds to be the
reasonable charge or other approved amount.
Assignor means a beneficiary under Medicare part B whose physician
or supplier has taken assignment of a claim.
Carrier means an organization which has entered into a contract with
the Secretary pursuant to section 1842 of the Act and which is
authorized to make determinations with respect to part B of title XVIII
of the Act. For purposes of this subpart, the term carrier also refers
to an intermediary that has entered into a contract with the Secretary
under section 1816 of the Act and is authorized to make determinations
with respect to part B provider services, as specified in Sec. 421.5(c)
of this chapter.
Common issues of law and fact, with respect to the aggregation of
claims by two or more appellants to meet the minimum amount in
controversy needed for an ALJ hearing, occurs when the claims sought to
be aggregated are denied or reduced for similar reasons and arise from a
similar fact pattern material to the reason the claims are denied.
Delivery of similar or related services, with respect to the
aggregation of claims by two or more physician/supplier appellants to
meet the minimum amount in controversy needed for an ALJ hearing, means
like or coordinated services or items provided to the same beneficiary
by the appellants.
Representative means an individual meeting the conditions described
in Sec. Sec. 405.870 through 405.871.
With reasonable promptness means within a period of 60 consecutive
days after the receipt by the carrier of a request for payment.
[59 FR 12182, Mar. 16, 1994, as amended at 62 FR 25853, May 12, 1997]
Sec. 405.803 Initial determination.
(a) Carriers make initial determinations regarding claims for
benefits under Medicare Part B.
(b) An initial determination for purposes of this subpart includes
determinations such as the following:
(1) Whether services furnished are covered.
(2) Whether the deductible has been met.
(3) Whether the receipted bill or other evidence of payment is
acceptable.
(4) Whether the charges for services furnished are reasonable.
(5) If the services furnished to a beneficiary by a physician or a
supplier pursuant to an assignment under Sec. 424.55 of this chapter
are not covered because they are determined to be not reasonable and
necessary under Sec. 411.15(k) of this chapter, whether the
beneficiary, physician or supplier, or a physician who meets the
requirements of Sec. 411.408, knew or could reasonably have been
expected to know at the time the services were furnished that the
services were not covered.
(c) The following are not initial determinations for purposes of
this subpart:
(1) Any issue or factor for which SSA or CMS has sole
responsibility, for example, whether an independent laboratory meets the
conditions for coverage of services; whether a Medicare overpayment
claim should be compromised, or collection action terminated or
suspended.
(2) Any issue or factor which relates to hospital insurance benefits
under Medicare Part A.
[62 FR 25853, May 12, 1997]
Sec. 405.804 Notice of initial determination.
After a carrier has made an initial determination on a request for
payment written notice of this determination shall be mailed to each
party to the determination at his last known address. The notice of the
determination shall inform each party to the determination of his right
to have such determination reviewed.
[[Page 133]]
Sec. 405.805 Parties to the initial determination.
The parties to the initial determination (see Sec. 405.803) may be
any party described in Sec. 405.802.
[64 FR 52670, Sept. 30, 1999]
Sec. 405.806 Effect of Initial Determination.
The initial determination is binding upon all parties to the claim
for benefits unless the determination is--
(a) Reviewed in accordance with Sec. Sec. 405.810 through 405.812;
or
(b) Revised as a result of a reopening in accordance with Sec.
405.841.
[62 FR 25853, May 12, 1997]
Sec. 405.807 Request for review of initial determination.
(a) General. A party to an initial determination by a carrier, that
is dissatisfied with the initial determination and wants to appeal the
matter, may request that the carrier review the determination. The
request for review by the party to an initial determination must clearly
indicate that he or she is dissatisfied with the initial determination
and wants to appeal the matter. The request for review does not
constitute a waiver of the party's right to a hearing (under Sec.
405.815) after the review.
(b) Place and method of filing a request. A request by a party for a
carrier to review the initial determination may be made in one of the
following ways:
(1) In writing and filed at an office of the carrier, SSA, or CMS.
(2) By telephone to the telephone number designated by the carrier
as the appropriate number for the receipt of requests for review.
(c) Time of filing request. (1) The carrier must provide a period of
6 months after the date of the notice of the initial determination
within which the party to the initial determination may request a
review.
(2) The carrier may, upon request by the party, extend the period
for requesting the review of the initial determination.
[64 FR 52670, Sept. 30, 1999]