State Plans for Medical Assistance and Payment to States1
State participation in Medicaid is voluntary; each state designs and administers its own Medicaid program, funded jointly by the state and the federal government. Despite a state’s relative autonomy to develop its own Medicaid program plan, Title XIX predicates federal approval of state plans on the inclusion of certain provisions, and conditions federal financing of the program on the satisfaction of certain requirements. The following is a summary of all the health information provisions that must be included in each plan to earn federal approval and enable the state and providers to receive federal funds and reimbursement for services provided to enrollees.
Collection, Creation and Use of Health Information
The use and disclosure of health information must be restricted to purposes directly connected with plan administration.2 Every provider must agree to keep complete records of the services furnished to Medicaid enrollees and to provide such information to the state or Secretary upon request.3 Every provider must document in the medical record whether an enrollee patient has an advance directive.4 With regard to the transmission of data, states are required to operate a mechanized claims processing and information retrieval system to electronically transmit data (including individual enrollee encounter data),5 which must be capable of developing patient and provider profiles that provide information about the use of covered services and items.6
There must be a plan to evaluate the quality and appropriateness of the care and services furnished to Medicaid enrollees.7 The state must implement pre- and post-payment claims review procedures that include review of patient data and the nature of the provided service.8 The state must establish procedures for preventing unnecessary utilization of services and ensuring that payments are consistent with efficiency, economy and quality of care.9 These procedures must include a screen and review process10 for every inpatient admission11 and a requirement that provider hospitals maintain a utilization program12 that evaluates the medical necessity of all admissions, the duration of stays and any professional services provided in the hospital.13 If the state covers health home services, the plan must include methods for tracking avoidable hospital readmissions and calculating savings that result from improved care coordination and management.14
Requirements for Mental Hospitals, Institutions for Mental Diseases and Intermediate Care Facilities for the Mentally Retarded (ICF-MRs)
At the time of an enrollee’s admission to an inpatient hospital, an inpatient mental hospital or an ICF-MR (or at the time of a patient’s application for medical assistance), a qualified medical professional must certify that the enrollee needs (or needed) services provided at the facility.15 Inpatient mental hospitals and ICF-MRs must maintain a program of regular medical review16 and periodic recertification17 of each patient’s continued need for services in the facility.18 The state must establish a medical review program where an independent team evaluates the professional management of the care and services provided to patients in mental hospitals and ICF-MRs.19 The state must develop individual plans for enrollee patients in institutions for mental diseases who are age 65 and older.20 These plans must include assurances that there will be initial and regular review of the patient’s needs and a periodic determination of his continued need for treatment in the institution.21 The plans must also provide for agreements with mental disease authorities arranging for access to patients and facilities, joint planning and development of alternative methods of care, furnishing information and making reports.22
Disclosure and Reporting of Health Information; Fraud and Abuse Provisions
The state is required to offer and provide child health screening services,23 and must report to the Secretary the number of children screened,24 the number referred for corrective treatment25 and the number that received dental services.26 If the state covers health home services, each designated provider must report to the state on all applicable quality measures.27 The state must have a mechanism to receive reports and compile data concerning alleged instances of fraud, waste, and abuse28 and must establish a Medicaid fraud control unit29 that investigates and prosecutes violations of all applicable fraud laws30 and maintains procedures for reviewing complaints of abuse or neglect of patients in health care facilities.31 Any information obtained from an electronic claims processing system that relates to fraud or abuse must be given to the fraud control unit.32 The state must comply with provider and supplier screening, oversight and reporting requirements. These requirements include complying with the national system for reporting criminal and civil convictions, sanctions, negative licensure actions and other adverse provider actions33 and providing information and access to information respecting sanctions taken against health care practitioners and providers by state licensing authorities.34 The state must also have a system of reporting any adverse action or finding involving a health care practitioner or entity at the conclusion of any formal proceedings, including a loss of a practitioner or entity’s license or a dismissal or closure resulting from the practitioner or entity surrendering its license or leaving the state.35 The state must provide the Secretary with access to such documents as may be necessary to determine the facts and circumstances concerning the adverse actions and determinations36 and the Secretary may subsequently provide this information to relevant authorities.37 Provider facilities may be subject to surveys conducted by the state and the Secretary to evaluate compliance with statutory provisions, and within 90 days of such a survey, the pertinent findings must be made public.38
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Footnotes
- 1. Social Security Act § 1902, 42 U.S.C. 1396a (available at http://www.ssa.gov/OP_Home/ssact/title19/1902.htm); Social Security Act § 1903, 42 U.S.C. 1396b (available at http://www.ssa.gov/OP_Home/ssact/title19/1903.htm).
- 2. Social Security Act §1902(a)(7)(A), 42 U.S.C. 1396a(a)(7)(A).
- 3. Social Security Act § 1902(a)(27), 42 U.S.C. 1396a(27).
- 4. Social Security Act § 1902(w)(1)(B), 42 U.S.C. 1396a(w)(1)(B).
- 5. Social Security Act § 1903(r)(1), 42 U.S.C. 1396b(r)(1).
- 6. Social Security Act § 1903(r)(2)(A), U.S.C. 1396b(r)(2)(A).
- 7. Social Security Act § 1902(a)(33)(A), 42 U.S.C. 1396a(a)(33)(A).
- 8. Social Security Act § 1902(a)(37)(B), 42 U.S.C. 1396a(a)(37)(B).
- 9. Social Security Act § 1902(a)(30)(A), 42 U.S.C. 1396a(a)(30(A).
- 10. Note: The screen and review process must be based on criteria established by independent medical professionals. Social Security Act § 1902(a)(30)(B)(i), 42 U.S.C. 1396a(a)(30)(B)(i).
- 11. Social Security Act § 1902(a)(30)(B)(i), 42 U.S.C. 1396a(a)(30(B)(i).
- 12. Social Security Act § 1903(i)(4), 42 U.S.C. 1396b(i)(4).
- 13. Social Security Act § 1861(k)(1), 42 U.S.C. 1395x(k)(1) (available at http://www.ssa.gov/OP_Home/ssact/title18/1861.htm).
- 14. Social Security Act § 1945, 42 U.S.C. 1396n (available at http://www.ssa.gov/OP_Home/ssact/title19/1945.htm).
- 15. Social Security Act § 1902(a)(44)(A), 42 U.S.C. 1396a(a)(44)(A).
- 16. Social Security Act § 1902(a)(26), 42 U.S.C. 1396a(a)(26) (inpatient mental hospital); Social Security Act § 1902(a)(31), 42 U.S.C. 1396a(a)(31) (ICF-MR).
- 17. See Social Security Act § 1903(g)(6)(A) (inpatient hospitals) and § 1903(g)(6)(B) (ICF-MRs) (schedules for review and recertifications).
- 18. Social Security Act § 1902(a)(44)(A), 42 U.S.C. 1396a(a)(44)(A).
- 19. Social Security Act § 1902(a)(26), 42 U.S.C. 1396a(a)(26) (inpatient mental hospitals); Social Security Act § 1902(a)(31), 42 U.S.C. 1396a(a)(31) (ICF-MR); Social Security Act § 1903(g)(1), 42 U.S.C. 1396b(g)(1).
- 20. Social Security Act § 1902(a)(20(B), 42 U.S.C. 1396a(a)(20)(B).
- 21. Social Security Act § 1902(a)(20)(B), 42 U.S.C. 1396a(a)(20)(B).
- 22. Social Security Act § 1902(a)(20)(A), 42 U.S.C. 1396a(a)(20)(A).
- 23. Social Security Act § 1902(a)(43)(B), 42 U.S.C. 1396a(a)(43)(B) (see SCHIP 2108(e) for additional requirements).
- 24. Social Security Act § 1902(a)(43)(D)(i), 42 U.S.C. 1396a(a)(43)(D)(i).
- 25. Social Security Act § 1902(a)(43)(D)(ii), 42 U.S.C. 1396a(a)(43)(D)(ii).
- 26. Social Security Act § 1902(a)(43)(D)(iii); 42 U.S.C. 1396a(a)(43)(D)(iii).
- 27. Social Security Act § 1945, 42 U.S.C. 1396n (available at http://www.ssa.gov/OP_Home/ssact/title19/1945.htm).
- 28. Social Security Act § 1902(a)(64), 42 U.S.C. 1396a(a)(64).
- 29. Social Security Act § 1902(a)(61), 42 U.S.C. 1396a(a)(61).
- 30. Social Security Act § 1903(q)(3), 42 U.S.C. 1396b(q)(3).
- 31. Social Security Act § 1903(q)(4)(A), 42 U.S.C. 1396b(q)(4)(A).
- 32. Social Security Act § 1903(r)(2)(B), 42 U.S.C. 1396b(r)(2)(B).
- 33. Social Security Act § 1902(a)(77), 42 U.S.C. 1396a(a)(77); Social Security Act § 1902(kk)(6), 42 U.S.C. 1396a(kk)(6).
- 34. Social Security Act § 1902(a)(49), 42 U.S.C. 1396a(a)(49).
- 35. Social Security Act § 1921(a)(1), 42 U.S.C. 1396r-2(a)(1) (available at http://www.ssa.gov/OP_Home/ssact/title19/1921.htm).
- 36. Social Security Act § 1921(a)(2), 42 U.S.C. 1396r-2(a)(2).
- 37. Social Security Act § 1921(b), 42 U.S.C. 1396r-2(b).
- 38. Social Security Act § 1902(a)(36), 42 U.S.C. 1396a(a)(36).