[Federal Register Volume 59, Number 60 (Tuesday, March 29, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-7346]


[[Page Unknown]]

[Federal Register: March 29, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration

 

Statement of Organization, Functions, and Delegations of 
Authority; Substructure Reorganization of the Health Care Financing 
Administration

    Part F of the Statement of Organization, Functions, and Delegations 
of Authority for the Department of Health and Human Services, Health 
Care Financing Administration (HCFA) is amended to reflect the 
establishment of the subordinate organizational structure for HCFA 
which was recently approved. Although the Bureaus/Offices have recently 
been published, the entire set of HCFA's functional statements are 
being republished to facilitate the amendment of Part F of the 
Department statement. Included in this document are the new functional 
statements for the subcomponents of HCFA.
    The specific amendments to Part F are:
     Section F.10., Health Care Financing Administration 
(Organization) is amended to read as follows:

Section F.10., Health Care Financing Administration (Organization)

    The Health Care Financing Administration (HCFA) is an Operating 
Division of the Department. It is headed by an Administrator, HCFA, who 
is appointed by the President and reports to the Secretary. It consists 
of the following organizational elements:

A. Office of the Administrator (FA).
    1. Provider Reimbursement Review Board (FA-1).
    2. Equal Employment Opportunity Staff (FA-3).
    3. Executive Secretariat (FA-4).
    4. Office of Legislative and Inter-Governmental Affairs (FAA).
    a. Division of Congressional Affairs (FAA1).
    b. Division of Hearings & Policy Presentation (FAA2).
    c. Division of Medicare Part A Analysis (FAA3).
    d. Division of Medicare Part B Analysis (FAA4).
    e. Division of Medicaid Analysis (FAA5).
    f. Division of Intergovernmental Affairs (FAA6).
    5. Medicaid Bureau (FAB).
    a. Executive Operations Staff (FAB-1).
    b. Medicaid Special Program Initiatives Staff (FAB-2).
    c. Office of Medicaid Management (FAB1).
    (1). Division of Financial Management (FAB11).
    (2). Division of Program Performance (FAB12).
    (3). Division of Payment Systems (FAB13).
    d. Office of Medicaid Policy (FAB2).
    (1). Division of Payment Policy (FAB21).
    (2). Division of Coverage Policy (FAB22).
    (3). Division of Eligibility Policy (FAB23).
    6. Office of Managed Care (FAC).
    a. Operational Analysis Staff (FAC-1).
    b. Office of Managed Care Policy and Planning (FAC1).
    (1). Division of Managed Care Policy and Evaluation (FAC11).
    (2). Division of Planning and Promotion for Managed Care 
(FAC12).
    c. Medicaid Managed Care Office (FAC2).
    d. Office of Managed Care Operations (FAC3).
    (1). Division of Payment and Operations Support (FAC31).
    (2). Division of Operations (FAC32).
    (3). Division of Finance (FAC33).
B. Associate Administrator for Customer Relations and Communications 
(FF).
    1. Office of Beneficiary Services (FFA).
    2. Office of Public Affairs (FFB).
    a. Freedom of Information Division (FFB1).
    b. Division of Public Appearances (FFB2).
    3. Office of Public Liaison (FFC).
    a. Division of Professional and Business Affairs (FFC1).
    b. Division of Media Relations (FFC2).
C. Associate Administrator for Policy (FK).
    1. Special Analysis Staff (FK-1).
    2. Bureau of Policy Development (FKA).
    a. Regulations Staff (FKA-1).
    b. Office Of Regulations Management (FKA-2).
    c. Office of Program Support (FKA-3).
    (1) Executive Secretariat (FKA-31).
    (2) Inquiries Staff (FKA-32).
    (3) Program Liaison Staff (FKA-33).
    d. Office of Payment Policy (FKA1).
    (1) Division of Medical Services Payment (FKA11).
    (2) Division of Hospital Payment Policy (FKA12).
    (3) Division of Payment and Reporting Policy (FKA13).
    (4) Division of Special Payment Programs (FKA14).
    e. Office of Coverage and Eligibility Policy (FKA2).
    (1) Division of Provider Services Coverage Policy (FKA21).
    (2) Division of Medical Services Coverage Policy (FKA22).
    (3) Division of Medicare Eligibility Policy (FKA23).
    3. Office of Research and Demonstrations (FKB).
    a. Office of Demonstrations and Evaluations (FKB1).
    (1) Division of Long-Term Care Experimentation (FKB11).
    (2) Division of Hospital Experimentation (FKB12).
    (3) Division of Health Systems and Special Studies (FKB13).
    b. Office of Research (FKB2).
    (1) Division of Beneficiary Studies (FKB21).
    (2) Division of Payment and Economic Studies (FKB22).
    (3) Division of Program Studies (FKB23).
    c. Office of Operations Support (FKB3).
    (1) Division of Research and Demonstrations Systems Support 
(FKB31).
    (2) Division of Program Support (FKB32).
    4. Office of the Actuary (FKC).
    a. Office of Medicare and Medicaid Cost Estimates (FKC1).
    (1) Division of Hospital Insurance (FKC11).
    (2) Division of Supplementary Medical Insurance (FKC12).
    (3) Division of Medicaid Cost Estimates (FKC13).
    b. Office of National Health Statistics (FKC2).
    (1) Division of Health Cost Analysis (FKC21).
    (2) Division of Survey Analysis (FKC22).
D. Associate Administrator for Operations and Resource Management 
(FL).
    1. Office of the Attorney Advisor (FL-1).
    2. Office of Planning and Support (FL-2).
    3. Office of Financial and Human Resources (FLA).
    a. Management Planning and Analysis Staff (FLA-1).
    b. Office of Financial Management (FLA1).
    (1) Division of Accounting (FLA11).
    (2) Division of Budget (FLA12).
    c. Office of Human Resources (FLA2).
    (1) Division of Information and Organizational Management 
(FLA21).
    (2) Division of Performance Management and Development (FLA22).
    (3) Division of Staffing and Employee Services (FLA23).
    d. Office of Acquisitions and Grants (FLA3).
    (1) Division of Health Standards Contracts (FLA31).
    (2) Division of Contracts and Grants (FLA32).
    e. Office of Administrative Services (FLA4).
    (1) Division of Facilities Management (FLA41).
    (2) Division of Safety and Property Management (FLA42).
    (3) Division of Telecommunications and Graphics Services 
(FLA43).
    (4) Division of Printing and Distribution Services (FLA44).
    4. Bureau of Program Operations (FLB).
    a. Executive Secretariat (FLB-1).
    b. Issuances Staff (FLB-3).
    c. Office of Contracting and Financial Management (FLB1).
    (1) Division of Acquisitions and Contracts (FLB11).
    (2) Division of Financial Management (FLB12).
    (3) Division of Contractor Planning and Management (FLB13).
    (4) Division of Account Management and Collection (FLB14).
    d. Office of Medicare Benefits Administration (FLB2).
    (1) Division of Utilization Analysis (FLB21).
    (2) Division of Entitlement and Benefit Coordination (FLB22).
    (3) Division of Audit and Payment Management (FLB23).
    (4) Division of Medigap Operations (FLB24).
    e. Office of Program Operations Procedures (FLB3).
    (1) Division of Claims Processing Procedures (FLB31).
    (2) Division of Claims Processing Requirements (FLB32).
    (3) Division of Appeals and Communications (FLB33).
    (4) Division of Operational Systems Development (FLB34).
    f. Office of Quality and Evaluation (FLB4).
    (1) Division of Quality Programs (FLB41).
    (2) Division of Standards (FLB42).
    (3) Division of Program Evaluation (FLB43).
    (4) Division of Reports and Information Management (FLB44).
    5. Bureau of Data Management and Strategy (FLC).
    a. Office of Information Resources Management (FLC1).
    (1) Division of Information Systems Management (FLC11).
    (2) Division of ADP Planning and Resources Management (FLC12).
    b. Office of Statistics and Data Management (FLC2).
    (1) Division of Payment Policy Support (FLC21).
    (2) Decision Support Division (FLC22).
    (3) Division of Special Programs (FLC23).
    c. Office of Program Systems (FLC3).
    (1) Division of Program Management Systems (FLC31).
    (2) National Claims History Division (FLC32).
    (3) Division of Medicaid Statistics (FLC33).
    d. Office of Enrollment Systems (FLC4).
    (1) Division of Enrollment Applications (FLC41).
    (2) Division of Capitation and Collection Systems (FLC42).
    (3) Division of Medicare Operations Support (FLC43).
    e. Office of Information Technology (FLC5).
    (1) Division of Administrative Systems (FLC51).
    (2) Division of Office Automation Systems (FLC52).
    f. Office of Computer Operations (FLC6).
    (1) Division of Data Center Services (FLC61).
    (2) Division of Data Communications and Distributed Services 
(FLC62).
    6. Office of the Regional Administrators (FLD(I-X)).
    a. Division of Health Standards and Quality (FLD(I-X)A).
    b. Division of Medicaid (FLD(I-X)B).
    c. Division of Medicare (FLD(I-X)C).
    7. Health Standards and Quality Bureau (FLE).
    a. Management Resources Staff (FLE-1).
    b. Office of Peer Review (FLE1).
    (1) Division of Program Operations (FLE11).
    (2) Division of Review Programs (FLE12).
    (3) Division of Systems Management (FLE13).
    (4) Division of Program Assessment and Information (FLE14).
    c. Office of Survey and Certification (FLE2).
    (1) Division of Long-Term Care Services (FLE21).
    (2) Division of Systems Management and Data Analysis (FLE22).
    (3) Division of Program Operations (FLE23).
    (4) Division of Laboratory Standards and Performance (FLE24).
    (5) Division of Hospitals, Home Health, and Ambulatory Services 
(FLE25).

     Section F.20., Health Care Financing Administration 
(Functions) is amended by deleting the statement in its entirety and 
replacing it with the following statements. The following statements 
provide the overall organizational structure of the Health Care 
Financing Administration. The new HCFA organizational structure is 
described as follows:

A. Office of the Administrator (FA)

     The Administrator directs the planning, coordination, and 
implementation of the programs under Titles XI, XVIII, and XIX of the 
Social Security Act and related statutes, as amended, and directs the 
development of effective relationships between these programs and 
private and federally supported health-related programs.
     Within broad Department of Health and Human Services 
policy and guidelines, the Administrator oversees the establishment of 
program goals and objectives and the development of policies, standards 
and guidelines; evaluates progress in the administration of HCFA 
programs; and ensures that required actions are taken to direct or 
redirect efforts to achieve program objectives.
     The Administrator works with the States, other Federal 
agencies and other concerned nongovernmental organizations in 
administering health care financing programs.
     The Administrator is assisted by a general deputy, who 
functions with full authority during the Administrator's absence.

1. Provider Reimbursement Review Board (FA-1)

     The Provider Reimbursement Review Board (Board) is 
organizationally assigned to the HCFA for administrative support.
     The Board, after determining that it has jurisdiction, 
conducts hearings to resolve disputes on cost and prospective payment 
submitted by Medicare providers under Section 1878 of the Social 
Security Act.
     Upon the completion of these hearings, the Board renders 
impartial decisions on these appeals. This is the initial step in the 
judicial review process.
     Provides staff support to the Medicare Geographic 
Classification Review Board (MGCRB) and conducts Medicare and Medicaid 
hearings on behalf of the Secretary or the Administrator that are not 
within the jurisdiction of the Department Appeals Board, the Social 
Security Administration's Office of Hearings and Appeals, or the 
States.

2. Equal Employment Opportunity Staff (FA-3)

     Provides principal advisory services to the Administrator 
concerning equal employment opportunity (EEO) and civil rights policies 
and programs.
     Develops EEO and voluntary civil rights compliance policy 
for HCFA and assesses the Agency's compliance with applicable equal 
opportunity statutes, executive orders, regulations and policies.
     Identifies policy and operational issues and proposes 
solutions for resolving these issues.
     Serves as the central liaison point with the Department on 
EEO and civil rights issues.
     Coordinates the development of HCFA affirmative EEO plans 
and evaluates their implementation by HCFA components.
     Promotes EEO special emphasis programs and activities 
affecting the concerns of minority groups, women, and individuals with 
disabilities.
     Provides for conciliation and adjudication of informal and 
formal discrimination complaints by means of EEO counseling, formal 
hearings, issuance of final decisions, etc.
     Manages, coordinates and monitors HCFA's equal employment 
opportunity activities working directly with bureau and office 
personnel.

3. Executive Secretariat (FA-4)

     Assists the HCFA Administrator in the resolution of agency 
program and administrative policy matters through memoranda, action 
documents, or correspondence.
     Monitors HCFA performance in developing necessary 
documents for the Administrator's review.
     Manages the clearance system and reviews documents for 
consistency with the Administrator's and Secretary's assignments, 
previous decisions on related matters, and editorial standards.
     Facilitates the resolution of issues connected with 
matters forwarded to the Administrator.
     Operates the agency-wide correspondence tracking and 
control system, and provides guidance and technical assistance on 
standards for content of correspondence and memoranda.
     Serves as a primary focal point for liaison with the 
Executive Secretariat in the Office of the Secretary on HCFA 
correspondence and special administrative matters.

4. Office of Legislative and Inter-Governmental Affairs (FAA)

     The Office of Legislative and Inter-Governmental Affairs 
provides leadership and executive direction within HCFA for legislative 
planning and congressional and intergovernmental affairs.
     Develops and evaluates recommendations concerning 
legislative proposals for changes in health care financing.
     Develops the long-range HCFA legislative plans.
     Coordinates activities with the Office of the Assistant 
Secretary for Legislation (ASL) and serves as the ASL's principal 
contact point on legislative and congressional relations, and 
intergovernmental affairs.
     Manages HCFA involvement in congressional hearings.
     Provides technical, analytical, and advisory services to 
HCFA components, to the Department, to other elements of the Executive 
Branch, and other government agencies interested in health care 
financing legislation, congressional relations, and intergovernmental 
affairs.
     In conjunction with the ASL, provides information services 
to congressional committees, individual Congressmen, and private 
organizations on health care financing legislation.
     Provides leadership for HCFA in the area of 
intergovernmental affairs.
     Advises the Administrator on program matters which affect 
other units and levels of government.
     In coordination with the Department's Inter-Governmental 
Affairs office, the Regional Directors, and other HCFA offices, meets 
with key State and local officials in order to strengthen HCFA's 
relationships with other governmental jurisdictions and to resolve 
sensitive intergovernmental problems and issues. Reviews and consults 
with State and local officials regarding proposed HCFA policy and 
operational issuances. Assists States and localities in requesting and 
obtaining technical materials, assistance, and support from appropriate 
HCFA components. Upon State requests, coordinates the exchange of HCFA 
staff with State and local agencies.
     Develops and provides briefings on intergovernmental 
affairs issues for HCFA staff.
     Briefs State and local agencies on HCFA's mission, 
organization, and functions.
a. Division of Congressional Affairs (FAA1)
     Serves as the HCFA focal point for all congressional 
liaison activities. Coordinates HCFA's congressional liaison activities 
with the Office of the Assistant Secretary for Legislation (ASL).
     Responds to congressional inquiries and constituent 
concerns related to Medicare, Medicaid, and other health care financing 
issues. Organizes briefings for Congressmen, congressional staff and 
the public on specific issues and prepares reports on these issues for 
higher level management.
     Notifies Congress of specific HCFA activities of interest 
to Members.
     Provides advice to the Director, Office of Legislative & 
Inter-Governmental Affairs (OLIGA), the Administrator, and other HHS 
policy officials on the resolution of sensitive congressional issues.
     Prepares legislative histories and congressional profiles 
used by HCFA senior staff in preparation for congressional hearings.
     Prepares a variety of summary reports on congressional 
legislative activities and inquiries for use by the Director, OLIGA, 
the Administrator, and other HHS policy officials.
     Maintains the HCFA legislative reference library. Provides 
legislative reference and research services to HCFA, the Department, 
and the general public.
b. Division of Hearings & Policy Presentation (FAA2)
     In preparation for congressional hearings, drafts 
testimony to be used by the Administrator, the Secretary, and other HHS 
policy officials.
     Serves as the principle HCFA contact point with the Office 
of the Assistant Secretary for Legislation on congressional hearings 
and coordinates the preparation for such hearings, working with other 
Office of Legislative & Inter-Governmental Affairs and HCFA components.
     Clears other departmental and Administration testimony 
that has a bearing on Medicare, Medicaid, or other health care 
financing programs.
     Reviews other written products such as bill reports, 
studies, policy statements, etc., for clarity, presentation, and 
consistency with overall HCFA policy.
     Develops policy presentations for the general media in 
consultation with the Office of the Associate Administrator for 
Customer Relations & Communications.
c. Division of Medicare Part A Analysis (FAA3)
     Conducts legislative, economic, and policy analyses 
related to Medicare Part A issues. Substantive areas include Medicare 
Part A benefits, eligibility, payment, and financing, and other cross-
cutting parts of Medicare and the health delivery system that have an 
effect on Medicare Part A.
     Coordinates the development of Medicare Part A legislative 
proposals and develops the technical specifications for such 
legislation.
     Plans, develops, and directs the strategy to enhance the 
enactment of the Administration's Medicare Part A legislative program.
     Analyzes and reviews Medicare Part A regulations, issue 
papers, Office of the Inspector General reports, reports to Congress, 
and other policy documents for the Director, Office of Legislative & 
Inter-Governmental Affairs (OLIGA).
     Designs and conducts long-range Medicare Part A policy 
studies as well as other special projects, such as representing HCFA or 
OLIGA on task forces, outside commissions or policy panels in assigned 
areas.
     Working with the Office of the Assistant Secretary for 
Legislation (ASL), provides (or coordinates) technical consultative 
services to congressional members, their staff and the public on 
Medicare Part A legislation and related HCFA activities.
     Recommends the HCFA and HHS position on Medicare Part A 
legislation likely to be considered by Congress. Develops bill reports 
and coordinates comments from other HCFA and HHS components. Clears 
enrolled bill reports and recommends Presidential veto or signature. 
Prepares legislative summaries of newly enacted legislation and 
selected congressional bills.
     Monitors all Medicare Part A congressional legislative 
activity, with an emphasis on Budget Reconciliation and other major 
legislation.
     Assists in the preparation of Medicare Part A briefing 
materials, background, and testimony for HCFA and HHS policy officials' 
appearances at congressional hearings.
     Provides assistance to other offices within OLIGA to 
ensure consistent, coordinated analyses and responses. Provides input 
to cross-cutting projects.
d. Division of Medicare Part B Analysis (FAA4)
     Conducts legislative, economic, and policy analyses 
related to Medicare Part B issues. Substantive areas include Medicare 
Part B benefits, eligibility, payment, and financing, and other cross-
cutting parts of Medicare and the health delivery system that have an 
effect on Medicare Part B.
     Coordinates the development of Medicare Part B legislative 
proposals and develops the technical specifications for such 
legislation.
     Plans, develops, and directs the strategy to enhance the 
enactment of the Administration's Medicare Part B legislative program.
     Analyzes and reviews Medicare Part B regulations, issue 
papers, Office of the Inspector General reports, reports to Congress, 
and other policy documents for the Director, Office of Legislative & 
Inter-Governmental Affairs (OLIGA).
     Designs and conducts long-range Medicare Part B policy 
studies as well as other special projects, such as representing HCFA or 
OLIGA on task forces, outside commissions or policy panels in assigned 
areas.
     Working with the Office of the Assistant Secretary for 
Legislation, provides (or coordinates) technical consultative services 
to congressional members, their staff and the public on Medicare Part B 
legislation and related HCFA activities.
     Recommends the HCFA and HHS position on Medicare Part B 
legislation likely to be considered by Congress. Develops bill reports 
and coordinates comments from other HCFA and HHS components. Clears 
enrolled bill reports and recommends Presidential veto or signature. 
Prepares legislative summaries of newly enacted legislation and 
selected congressional bills.
     Monitors all Medicare Part B congressional legislative 
activity, with an emphasis on Budget Reconciliation and other major 
legislation.
     Assists in the preparation of Medicare Part B briefing 
materials, background, and testimony for HCFA and HHS policy officials' 
appearances at congressional hearings.
     Provides assistance to other offices within OLIGA to 
ensure consistent, coordinated analyses and responses. Provides input 
to cross-cutting projects.
e. Division of Medicaid Analysis (FAA5)
     Conducts legislative, economic, and policy analyses 
related to the Medicaid program. Substantive areas include Medicaid 
eligibility, payment, coverage, financing, the impact on Medicaid of 
changes to Public Health Service, and welfare programs, and the health 
care of low income individuals.
     Coordinates the development of Medicaid legislative 
proposals and develops the technical specifications for such 
legislation. Plans, develops, and directs legislative strategy to 
enhance the enactment of the Administration's legislative program for 
the Medicaid program.
     Analyzes and reviews Medicaid regulations, issue papers, 
Office of the Inspector General reports, reports to Congress, and other 
policy documents for the Director, Office of Legislative & Inter-
Governmental Affairs (OLIGA).
     Designs and conducts long-range Medicaid policy studies as 
well as special projects, such as representing HCFA or OLIGA on task 
forces, outside commissions or policy panels in assigned areas.
     Working with the Office of the Assistant Secretary for 
Legislation, provides (or coordinates) technical consultative services 
to congressional members, their staff and the public on Medicaid 
legislation and related HCFA activities.
     Recommends the HCFA and HHS position on Medicaid 
legislation likely to be considered by Congress. Develops bill reports 
and coordinates comments from other HCFA and HHS components. Clears 
enrolled bill reports and recommends Presidential veto or signature. 
Prepares legislative summaries of newly enacted legislation and 
selected congressional bills.
     Monitors all Medicaid congressional legislative 
activities, with an emphasis on Budget Reconciliation and other major 
legislation.
     Prepares Medicaid briefing materials, background, and 
testimony for HCFA and HHS policy officials' appearances at 
congressional hearings.
     Provides assistance to other offices within OLIGA to 
ensure consistent, coordinated analyses and responses. Provides input 
to cross-cutting projects.
f. Division of Intergovernmental Affairs (FAA6)
     Provides leadership for HCFA in the area of 
intergovernmental affairs.
     Advises the Director, Office of Legislative & Inter-
Governmental Affairs, on all policy and program matters which affect 
other units and levels of government.
     In coordination with the Department's Intergovernmental 
Affairs office, the Principal Regional Directors, and other HCFA 
offices, meets with key State and local officials in order to 
strengthen HCFA's relationships with other governmental jurisdictions 
and to resolve sensitive intergovernmental problems and issues.
     Reviews and consults with State and local officials 
regarding proposed HCFA policy and operational issuances.
     Assesses the impact on State and localities of HCFA 
actions involving penalties, disallowances, compliance actions, or new 
performance standards.
     Assists States and localities in requesting and obtaining 
technical materials, assistance, and support from appropriate HCFA 
components.
     Upon State requests, arranges for the exchange of HCFA 
staff with State and local agencies.
     Develops and provides briefings on intergovernmental 
affairs issues for HCFA staff.
     Briefs State and local agencies on HCFA's mission, 
organization, and functions.

5. Medicaid Bureau (FAB)

     Directs the planning, coordination, and implementation of 
the Medicaid program under Title XIX of the Social Security Act and 
related statutes, as amended, except for Medicaid managed health care.
     Formulates, evaluates, and prepares policies, 
specifications for regulations, instructions, preprints and procedures 
related to Medicaid eligibility, coverage, and payment activities; 
makes recommendations for legislative changes; and, reviews State plan 
amendments and makes recommendations on approvals/disapprovals.
     Oversees, coordinates, processes and assesses the 
operation of State Medicaid Home and Community-Based Services Waivers.
      Administers the State grants process for administrative 
and program payments, including budget preparation by States.
     Provides Medicaid payment policy for administrative costs, 
availability of Federal Financial Participation (FFP) and designation 
of appropriate FFP rates.
     Develops and monitors planning, development and 
implementation of Medicaid program operations in regional offices and 
State Medicaid agencies.
     Develops and promulgates policies and procedures for the 
proper maintenance, review, and approval of State plans and their 
amendments.
     Monitors State compliance with State plan and oversees the 
compliance process.
     Develops requirements, standards, procedures, guidelines, 
and methodologies pertaining to the review and evaluation of State 
agencies' automated systems.
     Develops, operates, and manages a program for the 
performance evaluation of Medicaid State agencies and fiscal agents.
     Implements Medicaid maternal and infant health initiative 
and the Early and Periodic Screening, Diagnostic, and Treatment program 
through coordination of HCFA resources and activities with those of the 
Public Health Service and other national organizations, monitoring 
program performance, effective interagency and interprogram liaison, 
guidance, and technical assistance.
     Provides technical assistance to States, regional offices, 
and other interested groups in all special Medicaid initiatives. 
Coordinates with HCFA's Office of Legislative and Inter-Governmental 
Affairs on all issues that affect States.
     Coordinates with the Office of Research and Demonstrations 
HCFA review and management of State waiver requests and projects.
a. Executive Operations Staff (FAB-1)
     Advises the Medicaid Bureau (MB) managers on 
organizational design and implementation; requests to establish 
positions; and delegations of management and program administration 
authorities.
     Establishes and implements integrated and coordinated MB 
work planning. Plans and monitors the execution of major Bureau program 
initiatives through the administration of the Bureau's work planning to 
ensure fairness and equity among components and to assure that 
measurable and verifiable outputs are provided.
     Interprets administrative budgetary policies and 
limitations and develops and issues guidelines and instructions to MB 
managers for budget formulation and execution. Executes the budget for 
the bureau through the issuance of staff and dollar controls, budget 
allowances for administrative expenditures, and employment ceilings to 
bureau components.
     Provides services and liaison with the Office of Financial 
& Human Resources related to procurement; space acquisition, 
utilization and management; telephone systems; records; publications; 
forms printing; and reprographics.
     Directs a bureau-wide tracking and control system for 
legislation, regulations, instructions and correspondence; and provides 
training and technical assistance on standards for content of written 
documents.
     Serves as the focal point for the General Accounting 
Office and the Office of the Inspector General reports relating to MB; 
and coordinates other operational reviews of, and within, MB (e.g., 
internal control reviews).
     Provides bureau support and represents MB on issues 
related to microcomputer systems.
b. Medicaid Special Program Initiatives Staff (FAB-2)
      Implements Medicaid maternal and infant health initiative 
and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 
program through coordination of HCFA resources and activities with 
those of the Public Health Service and other national organizations, 
monitoring program performance, effective interagency and interprogram 
liaison, guidance, and technical assistance.
     Serves as HCFA liaison and manager of the Medicaid 
Maternal and Child Health Technical Advisory Group.
     Assists in developing Medicaid participation in 
alternative service and delivery methods (e.g., collaboration and 
pluralistic funding of health care for varied Human Immuno Virus/
Acquired Immune Deficiency Syndrome (AIDS)-infected Medicaid 
Recipients) and conducts reconnaissance and analyses to identify 
emerging and potential problem areas (e.g., financing community 
substance abuse programs).
     Provides technical assistance to States, regional offices, 
and other interested groups in all special Medicaid initiatives.
     Evaluates the effect of proposed legislation on sensitive 
and special Medicaid issues (i.e., EPSDT and AIDS) and recommends new 
or amended legislation in regard to these special areas.
c. Office of Medicaid Management (FAB1)
     Provides oversight, coordinates, and formulates the 
national Medicaid medical assistance and administrative costs budgets 
and justifications. Develops and maintains budget preparation and 
execution policies and procedures used by States and regional offices.
     Administers the State grants process for administrative 
and program payments including regional office disallowances.
     Develops and monitors Medicaid automated systems 
requirements, standards, procedures, guidelines, and methodologies. 
Directs review, evaluation, and assessment of the operation, 
development, and funding of Medicaid State agency automated systems, 
including the claims processing and information retrieval and 
integrated eligibility systems, and coordinates systems requirements 
for Federal programs such as Child Health Assurance, Child Support 
Enforcement, food stamps, and Aid to Families with Dependent Children.
     Provides oversight and coordinates the Medicaid State plan 
preprint process. Assists components in the development, publication, 
timely issuance to States, and maintenance of the master copy of State 
plan preprints.
     Provides oversight of planning, development, 
implementation, and monitors Medicaid program operations in regional 
offices and State Medicaid agencies including drug rebate program, 
Systematic Alien Verification for Entitlement System, national Medicaid 
eligibility quality control program, Medicaid Drug Use Review program, 
State claims processing and payment operations, and third party 
liability activities.
(1) Division of Financial Management (FAB11)
     Provides oversight and coordinates the national Medicaid 
medical assistance and administrative costs budgets and justifications. 
Develops and maintains budget preparation and execution policies and 
procedures used by States and regional offices.
     Establishes policies and procedures by which Medicaid 
State agencies and regional offices submit quarterly budget estimates 
and reports and administers the State grants process for administrative 
and program payments.
     Reviews all State claims for Federal payment under Title 
XIX of the Social Security Act including regional office disallowances 
of State claims.
     Serves as the focal point for the defense of disallowance 
decisions before the Department Appeals Board.
     Provides oversight and manages the national State 
Performance Evaluation and Comprehensive Test of Reimbursement Under 
Medicaid review process.
     Provides the definitive HCFA interpretation of Medicaid 
payment policy for administrative costs. Responsible for operational 
policies regarding availability of Federal Financial Participation 
(FFP), designation of appropriate FFP rates, and for issuing 
interpretations to regional offices regarding operational FFP issues.
     Directs regional office financial reviews and audits of 
State agencies and oversees the Medicaid claims processing review 
activity.
     Provides oversight, administration, and maintenance of the 
Medicaid Budget and Expenditure System.
(2) Division of Program Performance (FAB12)
     Develops, implements, and operates the national Medicaid 
eligibility quality control program to determine the effectiveness of 
Medicaid State agencies' performance in the area of eligibility 
determinations.
     Provides documentation and analysis necessary to initiate 
and support actions on disallowances, penalties, and corrective action 
requirements, and adjudication of appeals of disallowances and 
penalties.
     Develops, implements, and coordinates a system for 
reviewing the States' performance of the Income Eligibility 
Verification System (IEVS) requirements. Develops and interprets 
regulations and policies for States to establish IEVS.
     Develops, coordinates, and promulgates operational policy 
for utilizing the Systematic Alien Verification for Entitlement system.
     Provides expertise on sampling, precision, universe 
identification, and other technical statistical issues in support of 
the Medicaid quality control and assessment programs.
     Develops and promulgates policies and procedures for the 
proper maintenance, review, and approval of State plans and their 
amendments. Monitors State compliance to State plan and oversees the 
compliance process.
     Ensures adherence to all Automated Data Processing (ADP) 
security measures, policies, and procedures; assists with the 
development, modification, and review of HCFA ADP policies as they 
apply to Medicaid.
     Directs the bureau's ADP activities relating to 
development, implementation, and administration of mainframe ADP 
systems programs.
     Provides oversight and coordinates the Medicaid State plan 
preprint process. Assists components in the development, publication, 
timely issuance to States, and maintenance of the master copy of State 
plan preprints.
     Develops procedures with the Social Security 
Administration concerning Medicaid eligibility operational issues such 
as transfer of resources, deemed Supplemental Security Income 
recipients and the State Data Exchange.
(3) Division of Payment Systems (FAB13)
     Provides bureau support in the development and 
implementation of new systems that interface with other HCFA components 
or involve mainframe computers.
     Develops the requirements, standards, procedures, 
guidelines, methodologies, and test criteria pertaining to the review, 
evaluation, and assessment of operations, development, and funding of 
State agency automation, claims processing and information retrieval 
and integrated eligibility systems to determine their compliance with 
published Federal requirements.
     Reviews State agency requests for Federal Financial 
Participation (FFP) in the costs of operating Medicaid claims 
processing, information retrieval systems, and development and 
operations of the integrated eligibility systems.
     Reviews State agency FFP requests for Medicaid Management 
Information Systems and interdepartmental integrated eligibility 
systems for approval.
     Plans, develops, and monitors systems requirements for 
Medicaid and coordinates systems requirements for related Federal 
programs such as Child Health Assurance, Child Support Enforcement, 
Food Stamps, and Aid to Families with Dependent Children.
     Provides operational and systems support for 
implementation of the Medicaid drug rebate program. Maintains liaison 
with and provides technical assistance to drug manufacturers, Medicaid 
State agencies, pharmaceutical associations, private sector vendors and 
other parties regarding the drug rebate program. Prepares an annual 
report to Congress regarding drug product and expenditure information.
     Serves as the focal point for Medicaid third party 
liability, qualified Medicare beneficiary, and Drug Use Review 
operating instructions and policy guidance to Medicaid State agencies 
and regional offices.
     Coordinates with all State Medicaid agencies, in 
conjunction with HCFA regional offices, implementation of system coding 
and other changes related to the Medicare program's Physician Payment 
Reform initiative and other data initiatives such as common coding, 
uniform billing, and electronic media claims formats.
d. Office of Medicaid Policy (FAB2)
     Formulates, evaluates and prepares policies, 
specifications for regulations, instructions, preprints, and procedures 
related to Medicaid eligibility, coverage, and payment activities.
     Makes recommendations for legislative changes to improve 
program policy and ease of administration.
     Reviews State plan amendments and makes recommendations on 
approvals/disapprovals.
     Oversees, coordinates, processes, and assesses the 
operation of State Medicaid Home and Community-Based Services Waivers.
(1) Division of Payment Policy (FAB21)
     Formulates and evaluates policies, regulations, 
instructions, and procedures related to Medicaid coverage activities. 
Prepares regulations, manuals, program guidelines, State plan 
preprints, and general instructions related to Medicaid institutional 
and non-institutional payment policy.
     Provides interpretations of Medicaid payment policies to 
regional offices, congressional staffs, other Departments of the 
Federal government, interest groups and State agencies.
     Develops, evaluates, and reviews Medicaid policies, 
regulations, guidelines, and instructions pertaining to provider and 
other facility payment under the Medicaid program including, for 
example, Medicaid institutional payment plans, Medicaid community 
provider rates, Medicaid payment of such entities as rural health 
clinics and federally qualified health centers and capitated rates for 
Medicaid managed care organizations.
     Formulates and evaluates policies and procedures related 
to Medicaid payment for long-term care, physician services, 
practitioner services, case management, obstetrical and pediatric 
services, pharmaceuticals, supplies and equipment such as hearing aids, 
eyeglasses, durable medical equipment, laboratory, and other medical 
services.
     Participates in the development and evaluation of proposed 
legislation in the area of Medicaid payment.
     Reviews State plan amendment requests under Medicaid.
     Analyzes and recommends legislative or other remedies to 
improve the effectiveness of Medicaid payment policies.
     Reviews, with the Office of Research and Demonstrations, 
research and demonstration agendas in the area of Medicaid payment.
(2) Division of Coverage Policy (FAB22)
     Formulates and evaluates policies, regulations, 
instructions, and procedures related to Medicaid coverage activities. 
Prepares specifications for regulations, manuals, program guidelines, 
State plan preprints, and general instructions related to these areas.
     Provides interpretations of Medicaid coverage policies to 
regional offices, congressional staffs, other departmental offices, 
other Departments of the Federal government, interest groups and State 
agencies.
     Develops, evaluates, and reviews all Medicaid coverage 
policies, regulations, and procedures.
     Develops, evaluates, and reviews policies, regulations, 
and procedures pertaining to States' requests for approval of waivers 
of Medicaid requirements to provide home and community-based services 
and makes recommendations whether the waivers should be approved or 
disapproved.
     Develops, evaluates, and reviews national coverage 
policies concerning Medicaid medical service contracts, interagency 
agreements, and prior authorizations.
     Reviews coverage related Medicaid State plan amendment 
requests.
     Identifies, studies, and makes recommendations for 
modifying Medicaid coverage policies to reflect changes in recipient 
health care needs, program objectives, and the health care delivery 
system.
(3) Division of Eligibility Policy (FAB23)
     Develops, interprets, and evaluates policies pertaining to 
all conditions under which recipients are eligible to have their health 
care services covered under Medicaid, the rights and responsibilities 
of recipients and applicants, and other special eligibility and 
technical issues.
     Evaluates the effect of proposed legislation on current 
eligibility policies and recommends specifications for new or proposed 
legislation on eligibility.
     Provides consultation regarding State plan amendments and 
waiver requests and prepares State plan disapproval actions.
     Prepares specifications for regulations, preprints, and 
manual instructions pertaining to Medicaid eligibility policy.

6. Office of Managed Care (FAC)

     Provides national direction and executive leadership for 
managed health care operations, including health maintenance 
organizations (HMOs), prepaid health plans (PHPs), primary care case 
management programs, competitive medical plans (CMPs), and other 
capitated health organizations.
      Serves as the departmental focal point in the areas of 
managed health care plan qualification, including quality assurance, 
ongoing regulation, State and employer compliance efforts, Medicare and 
Medicaid HMO, Medicare CMP contracting and Medicaid freedom of choice 
waivers.
     Develops national managed care policies and objectives for 
the development, qualification, and ongoing compliance of HMOs and 
CMPs.
     Plans, coordinates, and directs the development and 
preparation of related legislative proposals, regulatory proposals, and 
policy documents. Formulates, evaluates, and prepares policies, 
specifications for regulations, instructions, preprints, and procedures 
related to managed health care. Makes recommendations for legislative 
changes to improve managed health care program policy.
a. Operational Analysis Staff (FAC-1)
     Identifies and analyzes issues, problems, and trends 
related to the Office of Managed Care (OMC) operations.
     Develops OMC operational policy manuals, standard 
operating procedures, and other instructions and issuances. Assists the 
Office of Managed Care Policy & Planning (OMCPP) in the development of 
policy and regulatory proposals.
     Performs special studies and projects for OMC in the areas 
of payment, operations, and finance.
     Responds to operational policy questions generated by OMC 
staff, regional offices, contractors, and other HCFA or departmental 
components.
     Establishes and maintains liaison with trade associations, 
State regulatory agencies, OMCPP, and departmental components, such as 
the Office of the General Counsel.
b. Office of Managed Care Policy and Planning (FAC1)
     Develops national policies and objectives for the 
development, qualification, and ongoing compliance of Health 
Maintenance Organizations (HMOs) and Comprehensive Medical Plans 
(CMPs). Plans, coordinates, and directs the development and preparation 
of related legislative proposals, regulatory proposals, and policy 
documents.
     Acts as the focal point for all managed health care 
research, demonstration, and evaluation study activity within and 
external to the Department.
     Develops and implements programs to encourage greater 
access of Federal Medicare beneficiaries to HMOs and other prepaid 
health plans.
     Monitors and analyzes Federal activities and policies 
regarding Federal beneficiaries in Medicare, CHAMPUS, and the Federal 
Employees Health Benefits' programs. Coordinates the development and 
implementation of health education and health promotion programs in 
managed health care plans.
     Coordinates the Department's efforts to move toward a 
pluralistic health care delivery system.
     Conducts special studies of managed health care plans 
operations and operating data and identifies trends and develops 
performance measures which can be used by the Office of Managed Care 
Operations and by the industry to assess the development and operation 
of managed health care plans.
     Develops and issues technical guidance documents for use 
by the industry in the development of managed health care plans and the 
improvement of operations in existing managed health care plans.
     Develops and maintains close relationships with national 
organizations representing the managed health care plans industry to 
enhance technical assistance capability and to establish appropriate 
performance measures.
     Plans, coordinates, and directs the development and 
preparation of managed care legislative proposals, regulatory 
proposals, and policy documents and performs strategic policy and 
planning functions and other special tasks as required by the 
Administrator.
     Provides liaison staff for activities with other Federal 
programs and agencies, health care professional associations, and trade 
associations.
(1) Division of Managed Care Policy and Evaluation (FAC11)
     Develops and coordinates legislative proposals, regulatory 
specifications, and other policy documents to establish managed health 
care national policies and to address the Agency objectives for the 
development, qualification, contracting, and ongoing compliance of 
health maintenance organizations (HMOs), comprehensive medical plans 
(CMPs), preferred provider organizations (PPOs), and other managed 
systems of health care.
     Analyzes the manner in which the Agency objectives and 
policies are tied into pending or existing managed health care 
legislation and regulations. Evaluates national trends and their 
possible effect on Agency-wide activities.
     Reviews and analyzes policies regarding Federal 
beneficiaries in Medicare, CHAMPUS, and the Federal Employees Health 
Benefits' programs for coordination with managed health care programs.
     Reviews and analyzes coordinated internal and external 
health care research, demonstration, and evaluation study activities.
     Develops presentation material for use with congressional 
committees and with the Office of Management and Budget related to the 
program and appropriation legislation affecting the managed health care 
objectives of the Administration.
(2) Division of Planning and Promotion for Managed Care (FAC12)
     Develops and implements activities to promote managed 
health care programs to Health Maintenance Organizations (HMOs), 
Comprehensive Medical Plans (CMPs), preferred provider organizations 
(PPOs), employers, insurance companies, managed health care 
associations/organizations, and other professional medical and private 
groups, including Federal beneficiary and consumer groups.
     Develops and coordinates managed health care education and 
promotional programs within the Agency/Department to encourage greater 
access of Federal Medicare beneficiaries to HMOs, CMPs, PPOs, and other 
managed health care organizations. Supports the Agency/Department's 
efforts to move toward a pluralistic health care delivery system.
     Develops and supports the maintenance of close working 
relationships with national organizations representing the managed 
health care industry to enhance technical assistance options and to 
promote appropriate managed health care performance measurement 
standards.
     Develops, coordinates, and supports strategic planning 
activities for the managed health care program in the Agency and any 
other specific managed health care planning initiatives.
     Establishes and maintains a system to monitor the planning 
schedule to assure appropriate coordination and completion of managed 
health care activities within the Agency.
     Supports the liaison activities for the Agency for managed 
health care programs with other Federal/State programs and agencies, 
health care professional organizations/associations, trade 
associations, and consumer groups.
c. Medicaid Managed Care Office (FAC2)
     Serves as the operational focal point for all Medicaid 
managed care activities.
     Formulates, evaluates, and prepares policies, 
specifications for regulations, instructions, preprints, and procedures 
related to Medicaid managed health care, including waivers.
     Makes recommendations for legislative changes to improve 
managed health care program policy.
     Provides oversight of, and assistance to, State Medicaid 
agencies on all managed health care issues, including Medicaid managed 
health care contracting activities. Provides technical assistance to 
State regulators.
     Serves as the focal point and repository for State laws 
and regulations dealing with Health Maintenance Organizations (HMOs), 
group medical practice, insurance, licensing, foundations, service 
corporations, certificate of need, and reserve requirement statutes.
     Develops guidelines, policies, and procedures for use by 
the regional offices when reviewing and approving/disapproving State 
Medicaid agency contracts with managed health care plans.
     Formulates and evaluates policies and procedures related 
to HMOs and other managed health care contracts and freedom of choice 
waiver programs including the preparation of recommendations for 
waivers of freedom of choice and other State plan exception 
requirements; monitoring of approved HMOs and other managed health care 
contracts and freedom of choice waivers and recommendations for the 
removal of waivers; State plan/waiver processing policy; and other 
related issues.
     Evaluates and assures the cost-effectiveness of approved 
Medicaid freedom of choice waivers through review of State program and 
cost reports, independent assessments, and regional compliance/
validation reviews.
d. Office of Managed Care Operations (FAC3)
     Provides national direction and executive leadership for 
managed health care operations, including health maintenance 
organizations (HMOs), comprehensive medical plans (CMPs), and other 
capitated health organizations.
     Develops national operations objectives for the 
qualification and ongoing compliance of managed health care plans.
     Develops long- and short-range program operational goals 
and objectives.
     Serves as the departmental focal point in the areas of 
managed health care plan qualification, ongoing regulation, employer 
compliance efforts, and Medicare HMO and CMP risk contracting.
     Administers Medicare managed care contracts, the 
capitation formula, and payment policies.
     Oversees the operation of the managed health care 
information system.
     Determines the amounts of payments to be made to managed 
health care plans and the amounts, methods, and frequency of 
retroactive adjustments.
     Incorporates a prospective payment system for managed 
health care through the implementation of the Tax Equity and Fiscal 
Responsibility Act risk contracts.
     Evaluates cost reporting methodologies and conducts a 
continuing audit program to determine the final program liability for 
cost contracts.
     Administers beneficiary enrollment and disenrollment 
including coordination with beneficiary groups and other HCFA and HHS 
components.
(1) Division of Payment and Operations Support (FAC31)
     Manages the national Medicare beneficiary enrollment and 
disenrollment operations.
     Ensures timely and accurate payment to managed health care 
plans.
     Plans, develops, operates, and evaluates the operational 
and management information systems supporting the Medicare managed 
health care program.
     Conducts special analyses of specific managed health care 
plans and management information systems to identify problems and 
determine the need for new or enhanced systems design.
     Establishes national operational policy, procedures, and 
instructions for system specifications and data exchange methods which 
define and automate the managed health care plans' enrollment, 
disenrollment, and other systems operations.
     Serves as liaison with the Bureau of Data Management and 
Strategy and other HCFA Central Office and regional office components 
in their implementation and evaluation of the management information 
systems.
(2) Division of Operations (FAC32)
     Directs the qualification applications process for Health 
Maintenance Organizations (HMOs) under the requirements of section 1301 
of the Public Health Service Act (PHS Act).
     Coordinates with and provides technical assistance to the 
regional offices on the monitoring of Medicare HMOs and Comprehensive 
Medical Plans.
     Manages and monitors the processing of Medicare managed 
health care contract reconsiderations.
     Investigates and evaluates applicants' conformance with 
legal and financial requirements for qualification for Medicare 
contracts under section 1301 of the PHS Act, section 1833 and section 
1876 of the Social Security Act, and related regulations.
     Coordinates Program Advisory Council activities, including 
obtaining regional office reports and recommendations, incorporating 
information from Central Office reviewers, and issuing approval of 
initial applications and renewals. Coordinates and makes 
recommendations on nonrenewals, terminations, and revocations based on 
information and analysis provided by regional offices.
     Implements new legislation and regulations regarding 
managed health care operations.
     Assures compliance with section 1310 of the PHS Act by 
employers with the mandatory offering of a managed health care plan 
alternative in employer health benefit plans.
     In consultation with the regional offices, establishes 
performance standards and evaluates the plans' performance.
     Provides training for and guidance of regional offices in 
activities related to managed health care. Also provides training and 
workshops for HMOs.
     Establishes and maintains liaison with appropriate State 
and Federal regulatory agencies for coordination of qualification, 
contract, and monitoring issues.
(3) Division of Finance (FAC33)
     Establishes interim payment rates, retroactively adjusts 
payments, and performs end-of-year settlements for all cost-based 
contracting plans.
     Reviews initial Adjusted Community Rate proposals.
     Trains and guides the audit contractor who performs the 
desk review of the Health Maintenance Organization (HMO) and 
Comprehensive Medical Plan (CMP) cost reports.
     Provides operational input for legislative and regulatory 
proposals and standard operating procedures related to cost methodology 
and fiscal responsibility.
     Establishes national financial standards for federally 
qualified HMOs and CMPs and assures that these entities comply with 
these requirements.
     Establishes national standards for the protection of 
enrolles in the event of HMO or CMP insolvency. Assures that HMOs and 
CMPs comply with these standards.
     Develops procedures to improve or revise the payment 
methodologies and processes of Medicare contractors and financial 
reviews of HMOs and CMPs.
     Manages the plan qualification fiscal soundness and 
insolvency protection reviews process.

B. Associate Administrator for Customer Relations and Communications 
(FF)

     The Associate Administrator for Customer Relations and 
Communications is responsible for the effective direction and 
implementation of HCFA policies, rules, and procedures in the areas of: 
customer relations and program communication.
     Advises HCFA components concerning the services, 
requirements, and initiatives relating to HCFA beneficiaries; liaison 
with external medical, dental, and allied health practitioners, 
institutional providers of health services, and academic institutions 
responsible for the education of health care professionals; and 
directing the public affairs activities of HCFA.

1. Office of Beneficiary Services (FFA)

     Provides advisory services to the Associate Administrator 
for Customer Relations and Communications and HCFA components 
concerning the services for, needs of, and initiatives relating to HCFA 
beneficiaries.
     Promotes an awareness of the concerns of children, the 
elderly, and needy among the HCFA components responsible for developing 
program policies, regulations, and legislative proposals. Analyzes the 
impact of proposed HCFA policies, regulations, and instructions on 
beneficiaries. Maintains close working relationships with HCFA central 
and regional components, the Social Security Administration District 
Offices, the Public Health Service, other Federal agencies, State 
agencies, and beneficiary consumer groups to identify and assess the 
need for information, benefits and services; the impact of proposed 
HCFA actions; and the effects that operating systems and programs have 
on the health care system programs and current and future 
beneficiaries.
     Presents the overall HCFA mission and promotes its 
acceptance by beneficiaries and representatives of their constituent 
organizations.
     Participates with other HCFA components in the development 
and implementation of program objectives and strategies pertaining to 
beneficiary services.
     Through direct contact with children, the elderly, the 
needy and/or their representative groups determines their understanding 
of HCFA's programs and services and conveys this information to HCFA 
components.
     Responds to beneficiary referrals concerning accessing and 
utilizing the Agency's health care financing programs.
     Plans, directs, and coordinates the production of radio, 
television, and film products, and the preparation of general-purpose 
publications.
     Reviews and clears all print, audiovisual, and exhibit 
plans and material intended for external dissemination and serves as 
clearance liaison with the Office of the Secretary, Office of the 
Assistant Secretary for Public Affairs.

2. Office of Public Affairs (FFB)

     Plans, directs and coordinates the public affairs 
activities of HCFA including: speech writing, public appearances, 
Administrator's meetings, special AACRC projects as well as conducting 
evaluations and analysis.
     Provides advice and counsel from a public affairs 
perspective to the AACRC and all HCFA components.
     Administers the Freedom of Information Act and Privacy Act 
responsibilities for HCFA.
a. Freedom of Information Division (FFB1)
     Conducts activities necessary to the receipt, management, 
response, and reporting requirements of the Department under the 
Freedom of Information Act (FOIA) regarding all correspondence received 
by HCFA.
     Maintains an orderly log of all FOIA requests received by 
the Agency, refers requests to the proper components within 
headquarters, the regions, or among carriers and intermediaries for the 
collection of the documents requested, prepares replies to requesters 
including denials of information as permitted under FOIA, and drafts 
briefing materials and responses in connection with appeals of denial 
decisions.
     Consults with the Office of the General Counsel and the 
Department of Health and Human Services' Freedom of Information Officer 
regarding denials, releases, and appeals.
     Provides guidance for FOIA coordinators in HCFA central 
and regional office components and maintains up-to-date knowledge of 
Federal Court decisions interpreting FOIA.
     Prepares guidelines and Medicare and Medicaid manual 
changes regarding FOIA program, keeps track of any charges levied for 
FOIA research activities, and assures prompt payment.
b. Division of Public Appearances (FFB2)
     Responsible for the efficient handling of speaking 
requests received by top HCFA management.
     Logs requests, recommends acceptance or denial of 
invitations and coordinates correspondence for all invitations.
     Arranges the scheduling of speaking appearances, compiles 
briefing information, ensures that talking points or speeches are 
prepared as necessary, and conducts follow-up activities such as 
arranging for transcripts, courtesy correspondence, reprint 
permissions, photographs, and biographies.
     Recommends speaking opportunities and forums consistent 
with Agency goals and objectives and overall public affairs plans.
     Advises the Division of Media Relations on potential news 
opportunities stemming from public appearances and speaking 
engagements.

3. Office of Public Liaison (FFC)

     Directs and implements HCFA policies, rules, and 
procedures in the areas of liaison with external medical, dental, and 
allied health practitioners, institutional providers of health 
services, and business and academic institutions responsible for the 
education of health care professionals.
     Plans, directs and coordinates media relations.
a. Division of Professional and Business Affairs (FFC1)
     Maintains liaison with external medical, dental, and 
allied health practitioners, institutional providers of health 
services, representatives of the business and insurance community, and 
academic institutions responsible for the education of health care 
professionals.
     Provides professional knowledge and makes recommendations 
to the Director, Office of Public Liaison (OPL) and manages the 
development of policies, regulations, procedures, and legislative 
proposals which affect the health care field.
     Serves as the focal point in HCFA for external health care 
groups to gain an understanding of HCFA objectives.
     Evaluates and transmits suggestions and criticisms from 
the health care field to the Director.
     OPL promotes an exchange of viewpoints between the health 
care field and HCFA components.
b. Division of Media Relations (FFC2)
     Maintains relations with the nation's news media including 
nationwide press, radio, television, wire services, and individual 
reporters, writers, editors, and individual publications and 
broadcasters.
     Provides writing and editing services necessary in 
conducting the public affairs activities of the Agency.
     Develops and carries out a general plan for providing 
information to the public through the news media and for promoting and 
disseminating information on specific HCFA-related topics, issues, and 
activities.
     Responds to inquiries from the news media through 
correspondence, telephone, and direct interviews and arranges for 
interviews and similar response from senior Agency staff.
     Prepares drafts and obtains clearances for press releases 
and statements for the news media.
     Drafts publications, fact sheets, reports, leaflets, 
pamphlets, white papers, scripts, articles, and other background 
materials for distribution to the general public on HCFA programs and 
related topics.
     Prepares and edits articles for submission to external 
periodicals and publications on HCFA programs and prepares materials as 
needed for internal employee communications such as the HCFA 
Newsletter.

C. Associate Administrator for Policy (FK)

     The Associate Administrator for Policy is responsible for 
the effective direction and implementation of the development and 
review of policies and regulations pertaining to all HCFA programs 
including HCFA's research and demonstrations activities.
     Conducts research and develops legislative proposals 
designed to reform and make improvements in the health care delivery 
system and develops the technical specifications for such legislation.
     Performs actuarial, economic and demographic studies to 
predict HCFA program expenditures under current law and under proposed 
modifications to current law.

1. Special Analysis Staff (FK-1)

     Conducts legislative, economic and policy analyses related 
to the private health insurance industry and the overall structure of 
health care financing and reform.
     Analyzes and reviews current literature regarding the 
state of the nation's health policy in order to develop national trend 
analyses for future HCFA program directions.
     Plans and develops future HCFA program policy in order to 
assist in the development of legislative strategies that will enhance 
the Department's legislative program.
     Coordinates policy development and research relating to 
legislative proposals designed to reform and make improvements in the 
health care delivery system including the technical specifications for 
such legislation.

2. Bureau of Policy Development (FKA)

     Establishes national program policy on all issues of 
Medicare payment including provider payment policy, provider accounting 
and audit policy, and physician and medical services payment policy.
     Develops, evaluates, and reviews national policies and 
standards concerning the coverage and utilization effectiveness of 
items and services under the Medicare program provided by hospitals, 
long-term care facilities, hospices, End Stage Renal Disease 
facilities, home health agencies, alternative health care 
organizations, comprehensive outpatient rehabilitation facilities, 
physicians, health practitioners, clinics, laboratories, and other 
health care providers and suppliers.
     Serves as the principal organization within HCFA for 
evaluating the medical aspects of Medicare coverage issues and for 
developing provider conditions of participation.
     Develops, evaluates, and reviews national Medicare 
coverage issues concerning reasonableness and necessity for medical and 
related services.
     Develops, interprets, and evaluates program policies 
pertaining to Medicare eligibility, Medicare secondary payer policies 
and other technical issues.
     Develops regulations for the Medicare and Medicaid 
programs.
     Manages the HCFA system for developing regulations, 
setting regulation priorities, and corresponding work agenda.
     In cooperation with the Office of the General Counsel, 
coordinates litigation affecting the Medicare program.
a. Regulations Staff (FKA-1)
     Drafts all HCFA regulations and related clearance 
documents and HCFA rulings.
     Establishes and assures compliance with editorial 
standards for clarity and uniformity of HCFA regulations and with the 
requirements of the Office of the Federal Register.
     Recommends schedules for the development of regulations, 
tracks progress against these schedules, and develops routine and 
special reports on HCFA's regulatory activities.
     Negotiates resolution of policy issues with originating 
component to meet regulations schedules. Obtains clearances of draft 
regulations from initiating bureaus.
     Coordinates the Bureau of Policy Development's (BPD) 
review of regulations received for concurrence from other HCFA 
components and prepares BPD's response.
     Reviews draft regulations and completes needed studies to 
assure compliance with the requirements for regulatory impact analysis 
of Executive Order 12612, the Regulatory Flexibility Act, and small 
rural hospital impact.
     Maintains specialized word processing systems to assure 
efficient preparation of regulations documents.
     Maintains official agency regulations files. Maintains 
current compilation of 42 Code of Federal Regulations, Part 400-End.
b. Office Of Regulations Management (FKA-2)
     Manages the HCFA process for developing regulations, 
setting regulation priorities, and corresponding work agendas.
     Coordinates for the Administrator the development of all 
policy documents associated with specific regulations under 
development.
     Negotiates work plans with major HCFA operating components 
for the development of each regulation and monitors performance through 
a computerized tracking system.
     Works jointly with HCFA and the Office of the General 
Counsel to identify and resolve all issues associated with each 
regulation.
     Manages the HCFA process for substantive review and 
clearance of regulations within HCFA, and with the Office of the 
General Counsel.
     Establishes editorial and technical standards for writing 
regulations.
     Reviews each regulation to ensure consistency with Federal 
Register technical requirements, editorial standards, and policy 
agreements reached during the development of the regulation.
     Serves as liaison on regulation issues to the Office of 
the Secretary, the Office of the General Counsel, other Department and 
Federal agencies, and the Federal Register. Provides training to HCFA 
regulation writers and clerical staff.
c. Office of Program Support (FKA-3)
     Directs the planning, development, and coordination of a 
comprehensive program of management activities including: financial 
management, management analysis and information, field liaison, Freedom 
of Information operations, and an executive secretariat for the Bureau.
     Prepares responses to all Medicare public inquiries 
addressed to or referred to the Bureau.
     Serves as principal advisor to the Director, as well as 
the Bureau's executive staff, on the full range of management and 
related administrative issues.
     Responsible for handling highly sensitive and complex 
assignments requiring the Director's and Deputy Director's personal 
attention often involving inter-Bureau and office coordination and 
direction.
(1) Executive Secretariat (FKA-31)
     Assigns, controls, tracks, and coordinates all work 
assigned to, or generated within the bureau, except regulations.
     Prepares regular reports on bureau and component 
performance on significant bureau activities and accomplishments and 
long-range calendar events.
     Reviews all action documents submitted to the Office of 
Program Support to assure accuracy and completeness of staff work and 
general readiness for the action requested.
     Coordinates bureau responses to: (1) Requests for 
background and briefing materials, (2) requests for comments on 
experimentation and demonstration proposals, and (3) Audit and Service 
Delivery Assessment reports.
     Prepares or coordinates the preparation of responses to 
Secretary and Administrator correspondence.
     Handles bureau Freedom of Information requests, 
determining what information may and may not be released to the public, 
and ensuring that bureau replies are fully responsive.
     Coordinates the development, implementation, and 
maintenance of the bureau's work planning system.
     Manages bureau-wide internal control systems.
(2) Inquiries Staff (FKA-32)
     Plans, directs, and coordinates an inquiries program for 
the bureau.
     Receives controls, analyzes, and prepares responses to 
inquiries from beneficiaries and their representatives, the White 
House, members of Congress, State and local agencies, officials of 
professional organizations, and the mass media.
     Analyzes trends in public thinking and reports possible 
policy implications to management.
     Provides technical assistance upon request to components 
and field offices.
(3) Program Liaison Staff (FKA-33)
     Evaluates the impact of policy development and issuance 
processes on regional operations, and determines whether policies and 
instructions are being adequately and consistently carried out by the 
regional offices.
     Responds promptly to requests from the regional offices 
for specific policy guidance and provides general policy 
interpretations.
     Develops, coordinates, and directs a management program 
for the management analysis functions, internal financial management, 
manpower selection and placement, training and employee development, 
position control and manpower utilization.
     Develops and issues Bureau-wide problem area reporting, 
coordination of Bureau operational planning activities, and a variety 
of administrative support services, including property and space 
management.
     Designs and evaluates Bureau management information 
systems, conducts management information and project management 
monitoring studies, and administers the Bureau's reports management 
program.
     Responsible for the Bureau's Automatic Data Processing, 
Telecommunications and Word Processing systems including identifying 
needs, procurement, evaluation, and maintaining liaison with the Bureau 
of Data Management and Strategy, Office of Computer Operations.
d. Office of Payment Policy (FKA1)
     Establishes national Medicare policy on all payment issues 
including provider and other facility payment, reporting and accounting 
policy, and physician and medical services payment policy, and assists 
in the development and evaluation of related legislation.
     Develops, evaluates, and maintains regulations, policies, 
and standards for payments to hospitals for inpatient services under 
the prospective payment system.
     Coordinates with and reviews recommendations from the 
Prospective Payment Assessment Commission and the Physician Payment 
Review Commission.
     Develops policies for physician fee schedules and 
reasonable charges for physician and medical services payment.
     Develops and maintains fee schedules for independent 
laboratory and ambulatory surgical centers.
     Develops payment policy for special forms of health care 
delivery such as hospital outpatient departments, health maintenance 
organizations, rural health clinics, hospices, health care prepayment 
plans, and comprehensive health centers.
     Establishes payment policies as they apply to the End-
Stage Renal Disease (ESRD) Program.
     Establishes policy for implementing payment controls and 
cost containment programs.
     Reviews requests for exceptions to payment limitations and 
recommends approval or disapproval.
(1) Division of Medical Services Payment (FKA11)
     Formulates and evaluates national policies and standards 
for Medicare payment and fiscal standards for physician services, 
practitioner services, pharmaceuticals, supplies and equipment such as 
hearing aids, eyeglasses, durable medical equipment, and other medical 
services.
     Develops policies for reasonable charges for physician and 
medical services payment.
     Drafts program regulations, manuals, guidelines, and other 
general instructions related to medical services payment.
     Coordinates with other HCFA bureaus, divisions, and 
offices, the Social Security Administration, and other Departmental 
components in the development of payment policies for medical services.
     Coordinates with and reviews recommendations from the 
Physician Payment Review Commission.
     Participates in the development and evaluation of proposed 
legislation in the area of medical services payment and recommends 
alternatives to current methods of payment.
     Provides interpretations of established policies and 
technical assistance to Departmental and HCFA components, regional 
offices, fiscal intermediaries, and carriers.
(2) Division of Hospital Payment Policy (FKA12)
     Develops, evaluates, and maintains regulations, policies 
and standards for payments to hospitals for inpatient services under 
the prospective payment system (PPS).
     Develops, evaluates, and maintains policies pertaining to 
the determination of appropriate amounts of prospective payments to 
hospitals for services furnished to inpatients.
     Works with the Prospective Payment Assessment Commission 
of PPS and reviews the Commission's recommendations on and basis for 
rates of payments.
     Develops, evaluates, and maintains policies pertaining to 
the appropriate methods for determining the amount of payments for cost 
items associated with inpatient hospital services but not yet within 
the prospective payment rates and develops policies for bringing such 
excepted cost items under PPS.
     Develops, evaluates, and maintains policies for 
determining and applying rates of increase and limitations to the costs 
of hospitals for services furnished to inpatients.
     Develops, evaluates, and maintains methods for classifying 
hospitals and hospital services to inpatients, including sole community 
hospitals, for the purpose of applying rates of increase and 
limitations on hospitals' costs and for determining prospective 
payments to hospitals.
     Develops, evaluates, and maintains criteria for exceptions 
to the established rates of increase and limitations on hospitals' cost 
for inpatient services and reviews fiscal intermediaries' 
recommendations on requests for exceptions.
     Prepares regulations, program guidelines, and instructions 
related to PPS and those excepted items or adjustments to the system 
that are paid on a cost-payment basis to hospitals for inpatient 
services.
     Works with other offices in the bureau, HCFA, the 
Department, and the Prospective Payment Assessment Commission to 
improve hospital efficiency and reduce Medicare expenditures.
     Review policies and operational guidelines and 
instructions developed by other components for their impact on the 
policies governing PPS and limitations on payment for hospital services 
to inpatients.
     Participates in the development and evaluation of proposed 
legislation pertaining to PPS and cost containment for hospital 
services to inpatients.
     Provides interpretations of established policies and other 
policy and technical assistance to regional offices, State agencies, 
Medicare contractors, hospitals, hospital associations, congressional 
staff, departmental offices, and others on policy issues relating to 
PPS and cost containment policies for hospital inpatient services.
     Assists in the Administration's professional relations and 
public information activities to foster understanding and acceptance of 
the PPS.
(3) Division of Payment and Reporting Policy (FKA13)
     Develops and evaluates national policies, regulations, and 
standards for payment of the costs incurred by providers of services 
and other classes of facilities under the health insurance program.
     Initiates and collaborates in the development and review 
of legislative proposals on general Medicare payment policies, 
interprets law (considering intent), and develops policy directives and 
basic payment policy decision statements which derive from such 
applicable law and which are reflective of the minimum requirements of 
such law (i.e., the broad parameters).
     Develops and issues implementing instructions consistent 
with overall Medicare payment policy, directives, and specifications.
     Reviews alternative payment and rate-setting systems for 
potential adaptation to the health insurance program.
     Establishes policies, principles, and guidelines related 
to circumstances requiring atypical payment practices.
     Plans, develops, and maintains a continuing program of 
surveillance and evaluation of HCFA general payment policies, and 
billing procedures at Central Office, regional offices, intermediary, 
and carrier levels which impact on Office functions in order to 
identify emerging problems and to develop and promulgate corrective 
policies and procedures.
     Formulates and evaluates national policies for all 
Medicare program provider financial filing and reporting requirements.
     Develops policies pertaining to the use of all cost 
reporting forms, schedules, and related instructions necessary for 
paying health care institutions.
     Develops policies pertaining to the validity of accounting 
policies and procedures.
     Develops and maintains a system of internal controls for 
the validation of policy decisions.
     Formulates the basic principles and policies for 
developing and applying limitations to the costs of health care.
     Develops and evaluates the criteria for exceptions to the 
limitations and reviews and makes decisions on the intermediary 
recommendations on providers' requests for exceptions.
(4) Division of Special Payment Programs (FKA14)
     Formulates and evaluates payment policies for services 
under the End-Stage Renal Disease (ESRD) program, ambulatory surgical 
centers and other special delivery systems, including capitation 
organizations, non-provider based comprehensive health centers, 
hospices and rural health clinics.
     Prepares regulations, manuals, program guidelines, and 
other general instructions in these policy areas.
     Establishes payment policies and procedures for ESRD 
services, transplantation, physician payment, kidney acquisition 
including payments, organ procurement, histocompatibility services, 
home and self-dialysis training, and other medical items and services 
related to the ESRD program.
     Establishes policies, procedures, and criteria for payment 
exceptions for ESRD facilities.
     Processes such requests and determines which ESRD 
facilities should be granted exceptions to national payment rates.
     Analyzes payment data, develops payment rates for ESRD 
services and other special payment delivery systems, and updates rates.
     Maintains continuing liaison with ESRD provider groups, 
industry associations, patient organizations, medical associations, and 
other parties that relate to special delivery systems.
     Participates in the development and evaluation of proposed 
legislation pertaining to the ESRD program and organ transplant issues.
     Formulates and evaluates national policies for the payment 
of special methods of health service delivery.
     Develops policies pertaining to determining the payment 
basis, including reasonable costs and charges, where appropriate, for 
the services of these facilities.
     Formulates the basic principles and policies for 
developing and applying limitations to the costs of health care.
e. Office of Coverage and Eligibility Policy (FKA2)
     Develops, evaluates, and reviews national policies and 
standards concerning the coverage and utilization effectiveness of 
items and services under the Medicare program provided by hospitals, 
skilled nursing facilities, hospices, End-Stage Renal Disease 
facilities, home health agencies, alternative health care 
organizations, comprehensive outpatient rehabilitation facilities, 
physicians, health practitioners, clinics, laboratories, and other 
health care providers and suppliers.
     Serves as the principal organization within HCFA for 
evaluating the medical aspects of Medicare coverage issues and for 
health quality and safety standards.
     Develops, evaluates, and reviews national Medicare 
coverage issues concerning the reasonableness and necessity for medical 
and related services.
     Develops, evaluates, and reviews health and safety 
standards for providers and suppliers of health services under 
Medicare.
     Develops common medical coding standards and policy.
     Participates in the formulation and use of medical codes 
including: International Classification of Diseases--Ninth Revision--
Clinical Modification, HCFA Common Procedure Coding System, and 
Diagnosis Related Groups.
     Develops, evaluates, and reviews national Medicare 
policies concerning the coverage of new and unusual items and services 
and those medical items and services which are excluded from coverage.
     Develops, interprets, and evaluates policies relating to 
the conditions under which aged and disabled individuals and End-Stage 
Renal Disease patients are eligible to have their health care covered 
under the Medicare program and the rights available to these 
beneficiaries.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of Medicare coverage 
and eligibility policies to program contractors and the health care 
field.
     Identifies, studies, and makes recommendations for 
modifying Medicare coverage and eligibility policies and health and 
safety standards to reflect changes in beneficiary health care needs, 
program objectives, and the health care delivery system.
     Conducts ongoing analyses of innovative treatment 
patterns, referral patterns, and activity that improve health care 
outcomes.
     Analyses and recommends legislative or other remedies to 
improve coverage, eligibility, health and safety standards, and 
utilization effectiveness.
(1) Division of Provider Services Coverage Policy (FKA21)
     Develops, evaluates, and reviews national Medicare 
policies and standards concerning the coverage of services and the 
conditions of participation for hospitals, skilled nursing facilities, 
home health agencies, hospices, and other providers of services.
     Develops, evaluates, and reviews national Medicare 
policies concerning the coverage of mental health, alcoholism and drug 
treatment, utilization review, and physician certification, and prior 
authorization requirements.
     Coordinates Medicare coverage policies and Peer Review 
Organization requirements.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of program policies to 
program contractors and the health care field.
     Identifies, studies, and makes recommendations for 
modifying Medicare coverage policies and providers' health and safety 
standards to reflect changes in beneficiary health care needs, program 
objectives, and the health care delivery system.
     Analyzes and recommends legislative or other remedies to 
improve coverage, health and safety, and utilization effectiveness.
(2) Division of Medical Services Coverage Policy (FKA22)
     Develops, evaluates, and reviews national Medicare 
policies and health and safety standards concerning the coverage of 
items and services which are provided by physicians, nonphysician 
practitioners, ambulatory surgical centers, health maintenance 
organizations, comprehensive medical plans, rural health clinics, 
comprehensive outpatient rehabilitation facilities, outpatient physical 
therapy/occupational therapy/speech pathology providers and other 
alternative health care organizations.
     Develops, evaluates, and reviews national Medicare 
policies and health and safety standards concerning the coverage of 
medical and other health services including supplies, drugs, 
rehabilitative services, eyeglasses, laboratory services, x-ray 
services, ambulance services, second opinions, new and unusual items 
and services, dialysis and transplant services for Medicare 
beneficiaries with End-Stage Renal Disease, and those medical items and 
services which are excluded from coverage.
     Develops, evaluates, and reviews national Medicare 
policies concerning reasonableness and necessity for services.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of program policies to 
program contractors and the health care field.
     Identifies, studies, and makes recommendations for 
modifying Medicare coverage policies to reflect changes in beneficiary 
health care needs, program objectives, and the health care delivery 
system.
     Recommends legislative or other remedies to improve 
coverage, health and safety, and utilization effectiveness.
     Coordinates with other components responsible for the 
Medicaid program, health and safety standards, program operations, 
quality control, and other parties and individuals, as appropriate.
(3) Division of Medicare Eligibility Policy (FKA23)
     Develops, interprets, and evaluates policies relating to 
the conditions under which aged and disabled individuals and End-Stage 
Renal Disease patients are eligible to have their health care covered 
under the Medicare program and the rights available to these 
beneficiaries.
     Prepares policy materials for issuance in program manuals 
and instructional materials, and for the development of regulations.
     Reviews eligibility aspects of special research and 
demonstration projects as needed.
     Participates in assessing the needs for legislation and 
makes recommendations accordingly.
     Develops and interprets policy related to entitlement 
aspects of part A and part B buy-in.
3. Office of Research and Demonstrations (FKB)
     Provides leadership and executive direction within HCFA 
for a wide range of health care financing research and demonstration 
activities.
     Develops, tests and evaluates new payment methods, 
coverage policies and delivery mechanisms in Medicare, Medicaid and 
other health care programs.
     Has primary responsibility for managing HCFA's Medicare 
and Medicaid demonstration waiver authorities including the Federal 
review, approval, and oversight of State health reform waivers.
     Develops new and innovative ways to reform the quality, 
efficiency, and cost effectiveness of Federal, State and private health 
care financing programs.
     Works closely with the Associate Administrator for Policy, 
other Bureau/Office Directors, and high level staff outside HCFA to 
insure that the Agency's objectives and long range planning in these 
areas are accomplished.
     Participates with departmental components in a wide range 
of experimental health care delivery projects.
     Performs claims adjudication, payment, and data collection 
for demonstration projects.
     Undertakes research to facilitate informed program and 
policy decisions designed to make improvements in the health care 
delivery system.
a. Office of Demonstrations and Evaluations (FKB1)
     Plans and directs the development, implementation, 
monitoring and evaluation of demonstration projects designed to test 
the costs and effectiveness of alternative payment methods, delivery 
systems, benefit packages, or provider status in the Medicare and 
Medicaid programs.
     Develops and reviews innovative approaches to the delivery 
of HCFA health care programs; coordinates with State and local 
governments, providers, beneficiaries, researchers and program staff in 
the implementation of projects; and assesses and synthesizes the 
results of projects to determine their impact on the programs and 
participants.
     Recommends modifications to existing program policy and 
legislation.
     Provides technical advice and consultation to other 
Federal and external organizations on potential experimental projects 
and publishes results and analyses of experimental findings.
(1) Division of Long-Term Care Experimentation (FKB11)
     Directs and manages the development, implementation, 
monitoring, and evaluation of demonstrations and experiments which test 
innovative long-term care financing arrangements, delivery systems, and 
combinations of services provided to Medicare beneficiaries and 
Medicaid recipients.
     Conducts demonstrations involving health maintenance 
organizations, prospective payment of home health agencies, competitive 
bidding for home health agencies, and capitation experiments.
     Conducts and evaluates demonstrations which test 
alternative delivery systems and whether the coordination and 
management of an appropriate mix of health and social services directed 
at individual client needs will reduce institutionalization and costs 
without sacrificing quality of care.
     Provides technical support and advice to HCFA and 
departmental components in regard to long-term care issues.
     Makes available research findings to assist in policy 
formulation and program initiatives, and publishes analyses of findings 
resulting from demonstration projects.
(2) Division of Hospital Experimentation (FKB12)
     Directs and manages the development, implementation, 
monitoring, and evaluation of intramural and extramural hospital 
financing and payment studies and experiments such as prospective and 
incentive payment experimentation for hospitals.
     Directs and manages the study, development, testing, and 
evaluation of hospital alternative payment systems such as refinement 
in diagnosis-specific payment and capitated payment rates.
     Conducts studies and demonstrations on entire facilities 
or specific areas such as out-patient departments and hospital capital 
investment.
     Directs studies and demonstrations which focus on 
hospital-based and hospital-related activities including physician, 
home health, skilled nursing, independent laboratories, and other 
services that result in greater costs effectiveness.
(3) Division of Health Systems and Special Studies (FKB13)
     Directs and manages the development, implementation, 
monitoring, and evaluation of intramural and extramural financing and 
payment, organization, and operational studies related to health care 
delivery systems.
     Directs the development, testing, and evaluation of cost-
effective alternatives to existing institutional and ambulatory care 
patterns.
     Directs the development and evaluation of cross-cutting 
special studies in such areas as combining long-term care and acute 
care financing, providing of durable medical equipment, managing end-
stage renal disease, and minimizing fraud and abuse.
6. Office of Research (FKB2)
     Directs the development and conduct of research and 
evaluation studies concerning the impact of Federal financing programs 
on the health care industry, program beneficiaries, and health care 
providers, including physicians.
     Directs and designs analytical studies to be undertaken by 
internal staff and outside contractors/grantees in a wide variety of 
economic and financial aspects of health care delivery in the United 
States, including the structure of the drug, medical supplies and 
health insurance industries and the financing of capital investment.
     Provides technical support to HCFA and departmental 
components in research design, sampling design, mathematical and 
statistical analysis, and the application of economic analysis.
     Makes available research findings to assist in the 
formulation of payment and other policy questions and publishes results 
and analyses of these findings.
(1) Division of Beneficiary Studies (FKB21)
     Designs and conducts intramural and extramural research 
studies and surveys to test hypotheses relating to beneficiary 
utilization and to determine factors underlying patterns and trends in 
utilization of HCFA programs.
     Develops and conducts evaluations of HCFA programs to 
enable the Administrator, the Department and Congress to determine how 
well HCFA policies and actions affect the attainment of HCFA's goals to 
ensure that quality medical care is delivered to its beneficiary 
population in the most cost effective manner.
     Assesses the impact of HCFA programs on health care costs, 
programs expenditures, HCFA beneficiaries, providers of services and 
the total health care system.
     Designs and directs the development of special data bases 
and tabulations to support research and policy activities.
     Provides analyses on complex beneficiary data sets for the 
Medicaid program, health care planners and other users external to 
HCFA.
(2) Division of Payment and Economic Studies (FKB22)
     Conducts research to determine the influences which 
current and alternative payment methods have on the economic, financial 
and behavioral characteristics of providers (e.g., the effects on 
physician productivity under alternative methods of payment).
     Conducts research directed toward the development and 
application of new, improved methods, quantitative models and other 
technical tools for determining the costs and benefits to providers, 
patients, and financing programs associated with alternative payment 
schemes.
     Participates in monitoring grants and the grants award 
process in those areas related to hospital costs and physician payment.
     Provides technical assistance and makes findings from 
research available to assist in policy formulation, recommendations and 
program initiatives.
     Conducts research on factors which affect the demand for 
and supply of services including supplies of staffpower and the 
structure and future of the health care delivery systems.
     Undertakes research to further the understanding of the 
organization of the health industry, including the drug industry, the 
insurance industry and the equipment producers.
     Assesses the likely implications of trends in these 
industries as they affect health care coverage either in benefits or 
beneficiary population.
     Examines the role of capital in the expansion and 
replacement of plant and equipment in the health care sector and the 
effects of alternative sources and costs of capital in this regard.
     Provides analysis of payment alternatives for major 
provider groups and makes recommendations for policy changes in payment 
activities.
     Assists in the implementation of payment changes.
(3) Division of Program Studies (FKB23)
     Directs the design and development of the Medicare and 
Medicaid statistical systems to provide ongoing data for the research 
and evaluation program.
     Consults with and provides technical direction to 
professional staff and management in the development of research data 
bases as a by-product of the administrative record system.
     Designs and develops the production of periodic 
statistical tabulations to assess the characteristics of the 
beneficiaries and the utilization and costs of program benefits.
     Designs and writes periodic analytical reports to 
disseminate data and to describe patterns and trends for program 
evaluation and policy direction.
c. Office of Operations Support (FKB3)
     Directs the research and demonstrations project grant, 
cooperative agreement and procurement programs.
     Directs and plans ongoing research publications and 
information resources programs.
     Performs claims adjudication, payment, and data collection 
for demonstration projects.
     Participates with departmental components in a wide range 
of experimental health care delivery projects.
     Provides a setting for testing proposed policies and 
procedures which impact on fiscal intermediary operations and provides 
the capacity for serving specialized providers.
     Directs the Office of Research & Demonstrations' 
correspondence, tracking, and control system and responds to ORDs' 
Freedom of Information requests.
     Coordinates the development of, and responses to, 
regulations related to ORD.
(1) Division of Research and Demonstrations Systems Support (FKB31)
     Serves as fiscal intermediary for experiments and 
demonstrations conducted under legislative authorities in the Social 
Security Act, Public Health Service Act, and related legislation.
     Also serves as fiscal intermediary for former direct-
dealing providers who were terminated from the Medicare program and 
have final cost reports and bills yet to be processed.
     Performs a wide range of duties related to the 
development, implementation, and ongoing operation of the 
demonstrations.
     Provides technical advice and assistance prior to the 
start of the demonstrations and throughout the period of the 
experiment, to other bureaus and agencies in developing service 
definitions, payments protocols, contracts, and reporting mechanisms.
     Assists in the design and establishment of information 
systems for compiling demonstration payment and service data for 
evaluator use.
     Develops cost reporting and billing systems.
     Acts as liaison between governmental agencies, service 
contractors, and Medicare carriers and intermediaries participating in 
demonstration activities.
     Provides systems support to other components of the Office 
of Research & Demonstration (ORD). Performs other support duties as 
requested.
     Carries out project management; by directing project teams 
in the analysis, design, and implementation of management information 
systems which are ORD program-oriented.
(2) Division of Program Support (FKB32)
     Plans, organizes, and administers the extramural ORD 
research and demonstration (grants, cooperative agreements, and 
contracts) program assuring that both technical and administrative 
requirements are met.
     Plans and directs an ongoing publications dissemination 
and information resources program.
     Provides assistance in the coordination and production of 
major written documents, plans, and reports.

4. Office of the Actuary (FKC)

     Conducts and directs the actuarial program for HCFA and 
directs the development of and methodologies for macroeconomic analysis 
of health care financing issues.
      Performs actuarial, economic and demographic studies to 
predict HCFA program expenditures under current law and under proposed 
modifications to current law.
      Provides program estimates for use in the President's 
budget and for reports required by Congress.
     Studies questions concerned with financing present and 
future health programs, evaluates operations of the Federal Hospital 
Insurance Trust Fund and Supplementary Medical Insurance Trust Fund and 
performs microanalyses for the purpose of assessing the impact of 
various health care financing factors upon the costs of Federal 
programs.
     Develops and conducts studies to estimate and project 
national and area health expenditures.
     Analyzes trend data sources such as the Consumer Price 
Index to develop projections of health care costs.
     Analyzes data on physicians' costs and charges to develop 
payment indices and monitors expansion of service and inflation of 
costs in the health care sector.
     Publishes cost projections and economic analyses, and 
provides actuarial, technical advice and consultation to HCFA 
components, governmental components, Congress and outside 
organizations.
a. Office of Medicare and Medicaid Cost Estimates (FKC1)
     Prepares cost estimates for the Hospital Insurance (HI) 
program, the Supplementary Medical Insurance (SMI) program, and the 
Medicaid program for use in the President's budget.
     Evaluates the operations of the Medicare trust funds 
particularly relating to outlays and program solvency.
     Develops such variables as the Part B premium rates, the 
inpatient hospital deductible, the Part A premium rate for voluntary 
enrolles, and the physicians' economic index applicable to prevailing 
fees.
     Develops the payment rates for the annual update of the 
adjusted average per capita cost (AAPCC) ratebook, which is used to pay 
health maintenance organizations that enter into a risk contract with 
HCFA to provide benefits to Medicare enrolles.
     Provides cost estimates for the Medicaid program, 
including the development of cost estimates for proposed changes in 
Medicaid or in programs affecting Medicaid, and overall Medicaid 
program costs for years after the current budget year.
     Serves as technical consultant throughout the Government 
on Medicare and Medicaid cost estimate issues.
(1) Division of Hospital Insurance (FKC11)
     Prepares cost estimates for the Hospital Insurance (HI) 
program for use in the President's budget.
     Evaluates operations of the Medicare HI trust fund 
concerning income and outgo, and the necessary tax rates for program 
solvency.
     Develops such variables as Part A inpatient hospital 
deductible and the Part A premium rate for voluntary enrolles.
     Computes estimates of the impact of modifications in 
program benefits and financing.
     Serves as technical consultant throughout the Government 
on Medicare HI cost estimate issues.
(2) Division of Supplementary Medical Insurance (FKC12)
     Prepares cost estimates for the Supplementary Medical 
Insurance (SMI) program for use in the President's budget.
     Evaluates operations of the Medicare SMI trust fund 
concerning income and outgo, the necessary premium, and actuarial rates 
for program solvency.
     Develops such variables as the Part B premium rate and the 
physicians' economic index applicable to prevailing fees.
     Computes estimates of the impact of modifications in 
program benefits and financing.
     Serves as technical consultant throughout the Government 
on Medicare SMI cost estimate issues.
(3) Division of Medicaid Cost Estimates (FKC13)
     Provides cost estimates for the Medicaid program, 
including the development of cost estimates for proposed changes in 
Medicaid or in programs affecting Medicaid, and overall Medicaid 
program costs for years after the current budget year.
     Develops forecasts of Medicaid expenditures for 
incorporation into the HCFA budget development process.
     Provides actuarial consultation to other components of 
HCFA concerning various proposals and programs affecting the future of 
the Medicaid program.
     Studies actuarial approaches and techniques, and develops 
data to assist in the development of program forecasts.
     Serves as technical consultant throughout the Government 
on Medicaid cost estimate issues.
b. Office of National Health Statistics (FKC2)
     Develops, maintains and makes analytical use of the 
National Health Accounts (NHA) which include annual estimates and 
publication of National Health Expenditures (NHE) and periodic 
estimates and publication of NHE by age groupings or by region.
     Provides technical support for HCFA regulatory processes, 
especially those related to payment systems or reform.
     Develops, analyzes and publishes, health sector models and 
associated estimates which allow assessments of historical 
relationships and projections of current law or evaluation of the 
impact of proposed changes to the current system.
     Conducts and evaluates surveys containing information 
relevant to the health care system.
(1) Division of Health Cost Analysis (FKC21)
     Maintains the National Health Accounts. Provides an 
interdisciplinary approach to data collection, manipulation and 
analysis, and interpretation of national, and regional health use, 
costs and payment sources, both public and private.
     Estimates and disseminates annual national health 
expenditures estimates, periodic estimates of health expenditures by 
region or State, and produces quarterly ``health indicators'' measures.
     Provides technical support for HCFA regulatory processes, 
especially those related to payment systems or reform.
     Provides technical analysis and data for Agency, 
Department, or Administration initiatives.
     Responds to requests for information and analysis on the 
health sector and its relationship to the general economy.
(2) Division of Survey Analysis (FKC22)
     Plans and manages the Medicare Current Beneficiary Survey. 
Provides all the in-house activities needed for survey management, data 
analysis, and coordination and information dissemination.
     Conducts and evaluates surveys containing information 
relevant to the health care system.
     Develops, maintains, and analyses the statistical 
reliability and representation of the Medicare Current Beneficiary 
Survey. Assures that sample replenishment reflects population and sub-
group profiles.
     Develops and provides analysis of the survey methodology 
and techniques in conjunction with the survey contractor. Establishes 
an interdisciplinary approach to data collection, manipulation and 
analysis and interpretation.
     Provides technical analysis and data for Agency, 
Department, or Administration initiatives.
     Responds to requests for information and analysis on the 
health sector as it relates to survey data.

D. Associate Administrator for Operations and Resource Management 
(FL)

     The Associate Administrator for Operations and Resource 
Management (AAORM) is responsible for the effective direction, 
coordination and implementation of all aspects of Headquarters and 
regional program operations and resource management activities.
     The program operational functions include the Medicare 
financial management systems; the development, negotiation, execution 
and management of contracts with Medicare contractors; enforcement of 
health quality and safety standards for providers and suppliers of 
health care services; the administration of professional review and 
other medical review programs; the evaluation of contractors and State 
agencies against performance standards; and the statistically based 
quality control programs which measure the financial integrity of 
Medicare.
     The 10 Regional Administrators report to the AAORM through 
the Deputy Associate Administrator for Operations and Resource 
Management.
     The resource management responsibilities include 
developing and implementing HCFA's policies, rules and procedures in 
the areas of financial, personnel and contracts management, project 
grant administration, management evaluation and analysis and 
administrative services; the nationwide operation of a centralized 
Automated Data Processing (ADP) and telecommunications facility; 
establishing and maintaining computerized records supporting HCFA 
programs; developing and coordinating information and statistical plans 
and policies; and maintaining a statistical data system which will 
provide program accountability data to the Administrator, HCFA, 
Congress, and the public.

 1. Office of the Attorney Advisor (FL-1)

     The Office of the Attorney Advisor is attached to AAORM 
for administrative issues but continues to report to the Administrator, 
HCFA, for substantive issues.
     The Attorney Advisor recommends initiation of ``own motion 
review'' of Provider Reimbursement Review Board decisions and of 
Medicare Geographical Classification Review Board (MGCRB) decisions.
     Evaluates cases under ``own motion review'' and recommends 
the disposition of such cases by the Administrator.
     Evaluates and makes recommendations for disposition of 
MGCRB decisions appealed to the Administrator.

2. Office of Planning and Support  (FL-2)

     Develops and manages systems for integrating and focusing 
all Operations and Resource Management's efforts and capabilities 
toward achieving initiatives of the HCFA Administrator and the 
Associate Administrator for Operations and Resource Management (AAORM).
     Establishes and implements the integrated and coordinated 
AAORM-wide management planning, workplanning, and performance 
monitoring processes.
     Formulates policies and positions on management programs 
having AAORM-wide impact, including financial management; budget 
preparation and execution; resource utilization; and management and 
organizational analysis. Coordinates the preparation and execution of 
the AAORM-wide budget. Furnishes financial management advice to AAORM 
and provides liaison on AAORM fiscal matters with HCFA's Office of 
Financial and Human Resources.
     Coordinates and monitors the development of AAORM-wide 
automated data processing plans and information strategies. Designs, 
develops, and manages Operations and Resource Management-wide 
information systems.
     Develops and implements AAORM program and administrative 
delegations of authority.
     Ensures regional office input to the development, review 
and clearance of program policies, procedures, and instructions.

3. Office of Financial and Human Resources (FLA)

    Provides HCFA-wide policy direction, coordination and control in 
the areas of budget, financial and accounting operations, personnel, 
management evaluation and analysis, administrative services, project 
grants, contracting and procurement, audit resolution, and 
workplanning. Develops and promulgates HCFA policy in these areas and 
executes these policies throughout HCFA; also assures consistency with 
departmental policy. Designs systems support for personnel management, 
financial management, procurement, and facilities management programs 
within HCFA. The Director serves as the Chief Financial Officer and the 
Deputy Ethics Counselor for the Agency.
a. Management Planning and Analysis Staff (FLA-1)
     Provides Agency-wide services, policy, direction, and 
coordination with respect to HCFA's management analysis, planning, and 
control programs including: workplanning, management analysis, 
productivity improvement, Privacy Act, internal controls, Office of 
Inspector General audit resolutions functions, advisory and assistance 
services certification, contracting of commercial and industrial 
activities, the administrative issuances system, memoranda of 
understanding and interagency agreements, delegations of authority, and 
reduction of paperwork programs.
     Conducts special studies and analyses concerning Agency-
wide and cross-cutting OFHR issues and other broad-based administrative 
issues.
     Advises the OFHR Director in management analysis 
activities.
     Develops, reviews, analyzes, and maintains existing or 
proposed Agency-wide delegations of authority.
     Provides services, policy direction, and coordination 
regarding the HCFA paperwork reduction activities.
b. Office of Financial Management (FLA1)
     Provides financial and accounting services, leadership, 
and policy direction for HCFA's financial management program. Operates 
the Agency's accounting and financial reporting activities and 
processes all obligations and expenditure documents including employee 
payroll and travel costs.
     Prepares, justifies, and executes the HCFA program and 
administrative budget. Coordinates with officials at the Department and 
at the Office of Management and Budget to resolve budget issues. 
Provides advice and assistance to HCFA components in the development 
and justification of their annual budgets.
     Manages the HCFA financial and manpower resource 
allocation activities. Prepares reports and other resource allocation 
control mechanisms for the Director, OFHR, and other HCFA Senior Staff.
(1) Division of Accounting (FLA11)
     Plans, directs and operates the HCFA accounting, fiscal 
and financial reporting functions.
     Administers and operates the HCFA accounting system. 
Establishes policy for the allocation of costs among appropriations. 
Develops methodologies to determine costs by program, organization and 
source of funds.
     Performs accounting functions for all appropriations, fund 
warrants, apportionments, allotments and allowances. Processes all 
obligations and expenditure documents, including verification of 
entitlement for all commercial and intergovernmental financial 
transactions for the compensation and related cost of personnel 
(payroll), and for employee travel and transportation (domestic and 
foreign).
     Reviews time and attendance reports prior to transmittal 
to the Central Payroll Office, resolves employee leave and payroll 
problems, and conducts a time and attendance report preparation 
training program.
     Performs accounting for all grants issued to fund 
programs, and schedules payments by check to those grantees not funded 
through Departmental Federal Assistance Financing System (DFAFS).
     Reviews and reconciles grantees' advance accounts on the 
basis of verified expenditures.
     Monitors and reconciles data generated in Agency 
appropriations as a result of entries made in the Regional Accounting 
System.
     Provides cashier services, processes collections, and 
maintains accounts receivable control records.
     Develops accounting policy and procedures for HCFA.
(2) Division of Budget (FLA12)
     Consolidates, prepares, and executes HCFA's budget and 
operates HCFA's budget system. Serves as the central information point 
for all budgetary matters including interagency agreements impacting on 
HCFA's funding and transfer of funds to and from other agencies. 
Provides advice on the reporting of program and financial data 
necessary for the presentation and defense of budget requests.
     Provides advice, guidance, and assistance to HCFA 
components in the development of budget justification materials and 
analysis including current services budgeting and other budgetary 
principles required by the Office of the Secretary, HHS, the Office of 
Management and Budget, and Congress. Provides technical direction to 
HCFA regional components on all budgetary matters.
     Develops budget control systems necessary to insure that 
appropriate measures are in place to prevent violations of the Anti-
Deficiency Act.
     Maintains and monitors an allotment and allowance system 
sufficient to pinpoint responsibility and accountability for Federal 
funds.
     Provides staff expertise in the review and analysis of 
budgetary, operational, legislative, or regulatory proposals by HCFA 
operating components. Reviews these proposals to determine the fiscal 
impact on, and consistency with, HCFA and departmental management and 
programmatic objectives.
     Develops financial management policy as it relates to 
HCFA's programmatic objectives. Certifies the cost impact of all 
proposed program and demonstration waivers.
     Reviews financial data and makes recommendations as to the 
effectiveness of the waiver and potential termination or nonrenewal 
actions.
     Directs the allocation of HCFA's staffing resources among 
HCFA components, issues employment ceilings, and directs HCFA's 
manpower management system. Assures the validity of cost allocation 
data and monitors adherence to financial management policies among HCFA 
components.
c. Office of Human Resources (FLA2)
     Provides services, leadership, direction, and control with 
respect to personnel and related services within HCFA.
     Serves as the principle advisor to the Director of the 
Office of Financial and Human Resources on the operation of HCFA's 
personnel system, including recruitment and placement, position 
classification, personnel management evaluation, performance appraisal, 
employee development and training, employee relations, ethics 
functions, and labor relations.
     Administers the Agency special emphasis placement and 
executive personnel programs.
     Serves in a leadership role in providing authoritative 
advice and assistance to management officials in carrying out their 
position management responsibilities.
     Provides for an employee counseling service for employees 
in HCFA Central Office.
     Provides services, policy direction, and coordination with 
respect to the organizational analysis activities.
     Provides direct service and establishes policy for other 
HCFA components with respect to health and activities related to health 
matters.
(1) Division of Information and Organizational Management (FLA21)
     Coordinates all personnel information management 
activities for the Office of Human Resources. Administers and operates 
the Department's automated personnel/payroll system, Improved 
Management of Personnel Administration through Computer Technology 
(IMPACT), as it applies to HCFA components.
     Develops human resource functional requirements for and 
access to HCFA's Comprehensive Personnel System. Provides systems 
support and technical assistance on all other automated data processing 
and office automation activities that relate to human resources 
functions.
     Plans, directs, and implements a comprehensive HCFA 
position classification and position management program for all 
positions GS-15 and below in the Central and Regional Offices. Inputs 
data into the automated personnel system and prepares statistical 
information and reports relating to the position management and 
classification program.
     Conducts the HCFA-wide organizational analysis program. 
Studies HCFA's organizational and functional arrangements and develops 
plans for assimilating new or modified functions into the HCFA 
organization.
     Conducts in-depth analyses of new legislation affecting 
HCFA for the purposes of determining the affect on HCFA's 
organizational structure. Develops recommendations for organizational 
changes, and submits proposals to upper management's consideration.
(2) Division of Performance Management and Development (FLA22)
     Provides leadership, direction, and control with respect 
to HCFA's employee training and career development activities, 
performance management, and awards programs in both headquarters and 
the regions.
     Provides management advisory service concerning the 
regulatory and procedural aspects of implementing the assigned 
programs.
     Serves as an Agency representative in dealing with 
employee/management/union organizations, the Department of Health and 
Human Services, and other Federal agencies on the issues concerning the 
Division's programs.
     Plans, coordinates, and executes a wide range of major 
studies and projects involving performance management, employee 
development, and awards issues of Agency-wide magnitude.
(3) Division of Staffing and Employee Services (FLA23)
     Provides service to all central office HCFA components in 
the areas of recruitment, in-service staffing, selective placement, and 
pre-employment investigations, and personnel security clearances for 
all types of appointments and all occupational classes and levels of 
work (except Senior Executive Service, Schedule C, and related 
appointments).
     Provides advice, guidance, and consultation to HCFA 
supervisory and management officials on such issues as optimal staffing 
mixes, recruitment sources, and qualification factors.
     Interprets regulations, guides, directives, and bulletins 
related to staffing and personnel services.
     Establishes and maintains the employment data base for 
routine and special reports and statistical studies related to the 
employee population.
     Plans and controls the central system for all personnel 
and payroll employee transaction processes, (except U.S. Savings 
Bonds), serves as the official custodian for all personnel folder 
clearances, confidential reports, employment agreements and other 
related areas.
     Plans, administers, and evaluates HCFA-wide employee 
benefits, health, and wellness program activities.
     Provides general employee counseling on such matters as 
retirement, life insurance, health plans, workers' compensation claims, 
and unemployment compensation claims.
     Serves as the central HCFA reference point for inquiries, 
guidance, and interpretation on employee benefits, health, and wellness 
matters.
     Processes insurance claims and annuity applications for 
retirees and survivors of deceased employees. Processes the full range 
of employee benefit and payroll transaction documents, with the 
exception of U.S. Savings Bonds.
     Directs programs for occupational health services, 
employee health enhancement, physical fitness, and blood assurance 
programs. Plans and administers the Agency's contract for the Employee 
Assistance Program.
     Directs and administers HCFA's child care initiative. 
Directs the Agency's Voluntary Leave Transfer and Video Display 
Terminal Eye Care Programs.
     Under direction of the HCFA Deputy Ethics Officer, plans 
and administers the entire ethics program for both central and regional 
offices. Reviews financial disclosure reports prior to departmental 
submittal and coordinates outside activity requests and approvals.
     Directs and coordinates all Agency medical determinations 
related to employability issues, such as fitness for duty and 
reasonable accommodation.
d. Office of Acquisitions and Grants (FLA3)
     Provides procurement services for other HCFA components 
including project grant, contract, and small purchase solicitation, 
award, and administration; cost and advisory function; and procurement-
related training. Monitors the annual HCFA contract plan and prepares 
and submits required reports.
     Solicits, negotiates, analyzes, and coordinates proposal 
evaluation and prepares and awards contracts. Provides HCFA cost 
advisory and audit services on pre-award and post-award grant and 
procurement actions to ensure conformance to legal and regulatory 
requirements.
     Performs all HCFA cost/price analysis and evaluation 
required for the review, negotiation, award administration, and close-
out of grants and contracts. Provides field audit capability during the 
pre-award and close-out phases of contract and grant activities.
     Coordinates and acts as liaison with the Defense Contract 
Audit Agency, Department of Health and Human Services (HHS) Audit 
Agency, Office of the General Counsel, and other HHS agencies to obtain 
required audit support and resolution.
     Coordinates and/or conducts training for contracts and 
grant personnel and project officers in HCFA components. Provides 
services, policy direction, and coordination with respect to HCFA's 
advisory and assistance services contracting.
(1) Division of Health Standards Contracts (FLA31)
     Provides acquisition services in support of HCFA's Peer 
Review Organization (PRO) and End-Stage Renal Disease (ESRD) contracts, 
including guidance and assistance to the Health Standards and Quality 
Bureau.
     Solicits, negotiates, analyzes, and coordinates proposal 
evaluations and prepares awards documents.
     Conducts post-award coordination, administration 
(including progress report and voucher monitoring), modifications, and 
all contract closeout functions.
     Provides guidance and assistance to incumbent and 
prospective contractors.
     Assists in the direction of related procurement preference 
programs wherever applicable.
     Participates in monitoring PRO/ESRD annual contract plans 
and prepares and submits required reports.
     As required, on specific PRO/ESRD contract actions, serves 
as liaison and provides information and documentation to the 
Department, Congress, and other Government agencies.
     Develops PRO/ESRD specific policies and procedures and 
provides guidance to PRO/ESRD program offices.
(2) Division of Contracts and Grants (FLA32)
     Provides contracting support, guidance, and assistance to 
all HCFA components and prospective contractors. Issues policy and 
procedural guidance to program staff in contracts and grants areas.
     Assists in the direction of related small, disadvantaged, 
8(a), (minority contracts), labor surplus area, and women-owned 
business contracting efforts. Provides HCFA project (discretionary) 
grants and cooperative agreements services.
     Solicits, analyzes, and coordinates proposal evaluations 
and negotiates, prepares, and awards contracts. Directs the post-award 
coordination, administration and modification, and participates in the 
close-out of contracts.
     Serves as the HCFA liaison with the Department's Office of 
Procurement, Assistance and Logistics, the Office of the General 
Counsel, other Department of Health and Human Services' components, 
Congress, other Government agencies, and private parties in contract, 
grant, and cooperative agreement matters.
     Monitors the annual contract plans and assists in the 
preparation and submittal of required reports. Provides HCFA project 
(discretionary) grants and cooperative agreements services.
     Receives applications, operates the application referral 
system, reviews the system for compliance with law, policies, and cost 
principles, performs site visits, obtains clearances, negotiates and 
issues grant awards, maintains funds control records and master grant 
files.
     Provides HCFA small purchasing services, guidance, and 
assistance to all HCFA components.
e. Office of Administrative Services (FLA4)
     Provides services, policy direction, coordination, and 
broad operational control of HCFA's voice telecommunication services, 
administrative services, single-site planning, printing and 
distribution services, conference management, records and mail 
services, facilities management, space management, property management, 
real property management, and related support services.
     Conducts extensive analyses in the areas of facilities 
management, property management, real property management, 
environmental safety and security, and space planning for HCFA's single 
site.
     Determines the overall impact, budget and administrative, 
of changes in the areas of facilities management, property management, 
real property management, environmental safety and security, and space 
planning.
     Coordinates and handles graphics services for the Agency.
(1) Division of Facilities Management (FLA41)
     Provides direct services and establishes policy for other 
HCFA components with respect to facilities management, real property 
management, space management, supplies, space acquisition, management 
and maintenance, conference facilities, and parking.
     Develops comprehensive budget estimates for and management 
of centralized facilities management funds.
     Conducts extensive analyses in the areas of facilities 
management, space management, real property management, property 
management, environmental safety and security, printing and 
distribution management for HCFA's single site.
     Analyzes and determines the budget and administrative 
impact of changes in the areas of facilities management, space 
management, real property management, property management, 
environmental safety and security, printing and distribution 
management.
     Coordinates all Information Resources Center activities.
(2) Division of Safety and Property Management (FLA42)
     Provides direct service and establishes/implements 
policies and procedures for the HCFA personal property and supply 
management programs.
     Maintains and operates the warehouse and the computerized 
property management and accountability system.
     Provides direct service and establishes/implements 
policies and procedures for environmental safety nationwide, emergency 
preparedness, civil defense, tort claims, and accident and fire 
prevention.
     Conducts special studies and analyses in the areas of 
personal property and supply management, and environmental safety and 
security.
(3) Division of Telecommunications and Graphics Services (FLA43)
     Manages all activities associated with the operation of 
HCFA's nationwide voice telecommunications system.
     Conducts extensive research, studies, and analyses 
associated with voice telecommunications activities in HCFA.
     Develops policies and procedures for nationwide 
implementation and operation of various voice telecommunications 
systems in HCFA.
     Develops policies, standards, and procedures for HCFA's 
graphics management program.
     Provides graphics services to the Agency.
     Serves as the Agency's liaison on all matters concerning 
graphics policy and the acquisition of graphics supplies and services.
(4) Division of Printing and Distribution Services (FLA44)
     Provides printing, reprographic, distribution, and forms 
management services for HCFA.
     Conducts research, planning, and analyses to determine 
Agency needs for photocopying equipment and printing services.
     Develops policies, standards, and procedures for HCFA's 
printing, reprographics, forms, and distribution programs.
     Obtains printing, binding, and distribution services from 
private vendors under contracts negotiated and entered into by the 
Government Printing Office (GPO).
     Manages and maintains centralized program (except for 
research and demonstrations) for the distribution, printing, and 
reproduction of forms and other printed materials.
     Manages HCFA's acquisition, leasing and utilization of 
copying equipment.
     Provides HCFA liaison on all forms, distribution, and 
printing matters with the HHS, the Government Printing Office and the 
Congressional Joint Committee on Printing.
4. Bureau of Program Operations (FLB)
     Provides direction and technical guidance for the 
nationwide administration of the Medicare health care financing 
programs.
     Develops, negotiates, executes, and manages contracts with 
Medicare contractors.
     Manages the Medicare financial management system and 
national budgets for Medicare contractors.
     Establishes national policies and procedures for the 
procurement of claims processing and related services from the private 
sector.
     Defines the relative responsibilities of all parties in 
the health care financing operations and designs the operational 
systems which link these parties.
     Directs the establishment of standards of performance for 
contractors. Compiles operational and performance data for recurring 
and special reports to reflect status and trends in program operations 
effectiveness.
     Prepares recommendations regarding terminations, awards, 
penalties, non-renewals, or other appropriate contract actions.
     Establishes national policy and procedures for the 
recovery of overpayments.
     Directs the processing of Part A beneficiary appeals and 
issues instructions and guidance for resolving beneficiary 
overpayments.
     Following coordination with pertinent HCFA components, 
notifies carriers and fiscal intermediaries of findings resulting from 
quality control programs.
     Makes recommendations to the Associate Administrator for 
Operations and Resource Management regarding financial penalties 
authorized and determined appropriate under regulations.
     Assists Medicare contractors in improving the management 
of Federally required quality control programs.
     Identifies significant trends and priority problems 
through comprehensive analyses of program operations and performance 
and evaluates findings surfaced through various assessment programs.
     Develops and conducts comprehensive analyses and studies 
of selected areas of policy and operations to evaluate the 
appropriateness, cost effectiveness, or other impact resulting from the 
implementation of law, regulations, policies, or operational procedures 
and systems.
     Develops recommendations for specific policy or 
operational improvements based on assessment findings.
     Coordinates, monitors, and evaluates all corrective action 
initiatives resulting from program assessment findings.
     Develops program-wide policies, regulations, procedures, 
guidelines, and studies dealing with program oversight and improvement.
     Coordinates the preparation of manuals and other policy 
issuances required to meet the instructional and informational needs of 
providers, contractors, State Agencies, Regional Offices, Peer Review 
Organizations, the Social Security Administration, and other audiences 
directly involved in the administration of HCFA programs.
a. Executive Secretariat (FLB-1)
     Coordinates, for the Bureau Director, matters concerning 
bureau policy in the administration of the Medicare program.
     Directs studies to identify problems in such areas as 
inconsistencies of interpretation and application of Medicare 
legislation, regulations and policy. Recommends solutions to such 
problems and initiates necessary corrective action.
     Directs the management of the bureau's assignment control 
system including the receipt, review, coordination, and control of all 
correspondence, assignments, written congressional and public 
inquiries, and the preparation of responsive replies for the signature 
of the Secretary of Health and Human Services, Administrator of HCFA, 
the Bureau Director, and other high level management officials.
     Serves as the primary focal point for the bureau on 
operational as well as administrative inquiries, including telephone 
inquiries from Presidential Staffs, congressional offices, other 
Government agencies, private institutions, and individuals seeking 
information concerning the various regulations and policies of the 
bureau.
     Establishes and maintains contact with HCFA's Executive 
Secretariat in the Office of Executive Operations, the Congressional 
Liaison Office, the Office of the General Counsel, and with other HCFA 
components and Federal departments and agencies, to obtain or provide 
information and coordinate correspondence replies.
     Provides bureau-wide guidance and technical assistance on 
related procedures and standards for content of memoranda and 
correspondence.
b. Issuances Staff (FLB-3)
     The Director, Issuances Staff assures the exchange of 
important information among HCFA components and the Office of the 
Secretary.
     Prepares or coordinates the preparation of written 
documents in order to assist the Director, Bureau of Program Operations 
in resolving HCFA program and administrative policy issues.
     Coordinates the preparation of manuals and other policy 
issuances required to meet the instructional and informational needs of 
providers, contractors, State agencies, regional offices, Peer Review 
Organizations, the Social Security Administration, and other audiences 
directly involved in the administration of HCFA programs.
     Manages the HCFA system for developing regulations, 
setting regulation priorities, and corresponding work agendas.
     Serves as the HCFA Federal Register contact point.
c. Office of Contracting and Financial Management (FLB1)
     Administers contracts with private organizations to 
perform various aspects of Medicare program operations falling under 
the bureau's area of responsibility.
     Develops, negotiates, maintains, and modifies primary 
contracts and agreements with intermediaries, carrier, and other 
organizations authorized under Title XVIII of the Social Security Act.
     Provides direction and guidance to Central Office and 
Regional Office staff on Medicare intermediary and carrier contracts 
and contracting activities under the bureau's area of responsibility.
     Establishes policies and procedures to be used by all 
Medicare intermediary and carrier contractors in the procurement of 
equipment, facilities management, software, and other services.
     Establishes the policies and procedure by which Medicare 
intermediary and carrier contractors and regional offices prepare and 
submit periodic budget estimates.
     In consultation with other HCFA and bureau components, 
develops and negotiates the national budget for Medicare contractors, 
including workload estimates.
     Controls and manages the Medicare cash flow and related 
banking activities.
     Reviews periodic contractor expenditure reports to 
evaluate Medicare intermediary and carrier budget execution and 
determines the allowability of costs.
     Prepares analysis of Medicare intermediary and carrier 
expenditure trends and patterns.
     Reviews regional office and contractor performance in 
determining the correct amount of provider, physician, and supplier 
overpayments, and assists contractors in negotiations related to the 
acceptability of techniques for determining the amount of an 
overpayment and the methods of recovery.
     Prepares cases when compromises are not appropriate and 
overpayments are collectable and assists the HCFA Claims Collection 
Officer in preparing such cases for disposition.
     Prepares manual instructions concerning the procedures for 
the recovery of provider, physician and supplier overpayments.
     Designs, implements, and maintains a Medicare overpayment 
tracking system.
     Plans, directs, and coordinates operational policy and 
procedures for the establishment and maintenance of premium billing and 
collection.
     Develops plans for possible transitions between new and 
current contractors, and manages transition activities in coordination 
with the regional offices.
     Plans, develops, and directs Medicare intermediary and 
carrier operating contracting experiments.
(1) Division of Acquisitions and Contracts (FLB11)
     Develops, maintains, negotiates, and modifies all 
agreements with intermediaries, and contracts with carriers as 
authorized under Title XVIII of the Social Security Act.
     Develops procedures for the award, non-renewal, 
termination, extension, and amendment of Medicare contracts.
     Represents the bureau in processing contractor claims 
resulting from changes in contract requirements or other disputes 
involving the selection or non-selection of contractors.
     Directs contract-related surveys requested by both the 
Executive and Legislative Branches of the Federal Government.
     Directs and guides Central Office and Regional Office 
staff on contracts and contract procurement and maintains an oversight 
role on regional activity in the areas of Title XVIII contracting.
     Coordinates Fiscal Intermediary Group and Carrier 
Representative Group activities.
     Serves as a HCFA resource in regard to technical Medicare 
contracting issues concerning matters.
     Reviews the Bureau's contractors' requests for change 
orders and adjustments in price, determines where liquidated damages 
should be assessed against contractor and takes proper action.
     Develops and directs policy regarding regional 
intermediary concept such as for Home Health Agencies.
     Develops necessary regulations and other issuances dealing 
with Medicare contract administration.
     Provides liaison with contractor management.
     Provides leadership in litigation activities related to 
contract disputes.
(2) Division of Financial Management (FLB12)
     Provides leadership in developing, implementing, and 
evaluating policies and procedures for the Medicare contractor budget 
process.
     Formulates and approves the national budget for Medicare 
contractor administrative costs.
     Develops, implements, and monitors cash management letter-
of-credit procedures for contractors and servicing banks.
     Develops, implements, and monitors fund control for the 
Medicare contractor administrative costs.
     Sets requirements and procedures for contractors and 
regional offices to prepare and submit periodic budget estimates and 
reports.
     Participates in negotiations and approval of all related 
price adjustments and reviews periodic contractor expenditure reports 
to evaluate budget execution and determination of the allowability of 
costs.
     Designs, maintains, and as necessary, prepares 
specifications to revise the Medicare financial administration and 
benefit payment systems.
     Analyzes contractor administrative cost data and trends.
     Directs and prepares instructions to guide regional office 
performance to assure consistency in implementation of financial 
policy.
(3) Division of Contractor Planning and Management (FLB13)
     Plans, develops, and directs contracting experiments that 
involve HCFA contractors, agencies, and separate contracts with 
commercial organizations.
     Develops plans for possible transitions between new and 
current contractors and provides oversight of these transition 
activities in coordination with the regional offices.
     Assists, manages, monitors, and provides oversight of 
contractor transition activities in coordination with the regional 
offices, and carries out plans for transition between new and old 
contractors.
     Evaluates implementation proposals associated with 
Medicare electronic data processing (EDP) facility management 
procurement, software acquisitions, and major systems changes and 
testing.
     Provides technical assistance to regional offices with 
respect to Medicare EDP procurements and reviews, proposed hardware and 
software modifications, and equipment upgrades.
     Incorporates current procurement and operating policy as 
well as lessons learned from prior transitions into the implementation 
sections of Request for Proposals and subsequent transitions.
     Evaluates Medicare claims processing contracting 
arrangements, formulates plans for improvement, and carries out these 
improvement plans.
(4) Division of Account Management and Collection (FLB14)
     Directs the nationwide administration of the institutional 
and physician and supplier recovery activity.
     Develops regulations, policies, procedures, guidelines, 
and recommendations for regional offices and HCFA contractors to assure 
timely and accurate provider overpayment identification, interest 
assessment, collection, and reduction of incidence of overpayment.
     Assures that the accounting practices, recovery 
procedures, and collection activities of regional offices and 
contractors properly and sufficiently implement the providers 
overpayment recovery policies, procedures, and regulations of HCFA, the 
Department of Health and Human Services, the General Accounting Office, 
the Department of Justice, and all applicable Federal statutes.
     Plans, develops, and issues operational policy, 
specifications, requirements, procedures, and instructional material to 
administer Third Party agreements for enrollment and premium payments 
for States, Office of Personnel Management (OPM), third party groups, 
professional organizations, carriers and intermediaries, and Social 
Security Administration, the Medicare Lock-Box premium collection for 
Medicare beneficiaries, and the direct billed beneficiaries.
     Assists in the negotiation and modification of agreements 
for third party and direct billing premium collection operations. 
Manages lock-box contracts for collection of State buy-in and third 
party group premiums, and for collection of direct billed beneficiary 
premiums.
     Resolves premium collection problems for States, OPM, 
third party groups and beneficiaries.
     Develops procedures and provides training and assistance 
to regional offices for the review and evaluation of the institutional 
provider, physician, supplier, and beneficiary overpayment recovery, 
and third party systems.
     Serves as the Agency systems manager for premium 
collection requirements.
d. Office of Medicare Benefits Administration (FLB2)
     Oversees the operations and administration of various 
Medicare program areas including Medigap, Medicare Secondary Payer 
(MSP), audit and payment management, benefit integrity, entitlement, 
medical review, and utilization analysis.
     Develops, implements, and administers MSP and Medigap 
operational policy. Analyzes and evaluates specific operating policy 
and procedures in the MSP and Medigap programs and initiates proposals 
to better achieve program objectives.
     Reviews, analyzes, and prepares recommendations regarding 
approval or disapproval of State regulatory programs for Medicare 
supplemental health insurance to ensure compliance with the Social 
Security Act. Conducts the mandatory Certification Program in those 
States not having an approved regulatory program.
     Develops, implements, and monitors the Medicare SELECT 
direct contracting option for medical necessity determinations.
     Reviews State regulatory programs for Medicare 
supplemental insurance and Medicare supplemental health insurance 
policies for compliance with the Social Security Act.
     Develops national MSP budget and annual savings goals, 
enforces MSP provisions and supports MSP litigation and post pay 
activities.
     Plans and develops methods to improve and enhance the 
audit and payment management functions and makes recommendations for 
improvements in the management of the audit program. Analyzes 
regulations, executive orders, policies, and legislative proposals and 
assesses their financial impact on the audit budget.
     Develops, implements, and maintains programs and systems 
to ensure that Medicare benefits are paid within the meaning of 
applicable law, regulations, and program policy and to ensure that 
internal or external allegations of fraudulent or abusive behavior are 
promptly acknowledged, developed, and disposed of including referral to 
the Office of Inspector General.
     Directs the development and issuance of specifications, 
requirements, procedures, forms, and instructional material to 
implement and maintain operational systems for Part A and Part B 
medical review and utilization analysis.
     Develops the national budget for intermediary and carrier 
medical review activities, linking programmatic expectations with 
funding requirements and available resources.
     Implements new legislation impacting on the medical review 
processes and/or Medicare covered services.
     Serves as the Agency systems manager for entitlement 
requirements.
(1) Division of Utilization Analysis (FLB21)
     Directs the development of analytical studies, tools, and 
methodologies, for assessing health care utilization, beneficiary 
episodes of care, quality of care, patterns, and trends to improve the 
effectiveness of the medical review program.
     Directs the development and issuance of specifications, 
requirements, procedures, forms, and instructional material to 
implement and maintain operational systems for Part A and Part B 
medical review and utilization analysis.
     Designs edits and specifications for contractor medical 
review screens, systems and reports, including nationally mandated 
screens and reports, and conducts ongoing analysis of the effectiveness 
of national requirements.
     Utilizes the National Claims History Database to analyze 
and compare utilization patterns and to assess national trends in the 
provision of care to the Medicare population.
     Develops the national budget for intermediary and carrier 
medical review activities linking programmatic expectations with 
funding requirements.
     Reviews proposed policy, payment, and legislative 
proposals to evaluate the operational impact on the Medical Review and 
Utilization Review (MR/UR) program. Implements new legislation 
affecting MR/UR and develops program safeguards for new and revised 
procedures.
     Provides contractors with analytical techniques for 
analysis of provider specific data, development of cost effective 
review methodologies, and clarification of Medicare policies. Monitors 
development and use of contractor MR/UR policies and implementation of 
MR directives and provides training and technical support to 
contractors.
     Directs contractor workgroups to develop, enhance, and 
maintain the most effective MR/UR program.
     Assists with the development of contractor performance 
standards to assess the effectiveness of the contractor's MR/UR 
program.
     Provides technical support and assistance to the bureau, 
other HCFA and non-HCFA components on contractor MR/UR programs.
     Serves as liaison with representatives of the health care 
industry on MR/UR issues to obtain expert input into policy 
development, to promote understanding of the MR/UR program, and to 
ensure that HCFA's MR/UR processes are compatible with health 
practices.
(2) Division of Entitlement and Benefit Coordination (FLB22)
     Develops, implements, and administers Medicare Secondary 
Payer (MSP) operational policy for coordinating Medicare benefits with 
other health insurance benefits. Analyzes and evaluates specific 
operating policy and procedural problems in the benefit coordination 
program and initiates proposals to better achieve program objectives.
     Plans and directs operational liaison and outreach 
activities, including public relations, publications, conferences, and 
presentations.
     Develops national MSP budget and annual performance 
objectives and priorities. Analyzes contractors' MSP expenditures and 
goal performance.
     Participates in the design, performance, and analysis of 
evaluations of contractor MSP performance assessment.
     Enforces MSP provisions and supports MSP litigation and 
post pay activities.
     Monitors regional office and contractor operations on 
negotiation, waiver, and compromise of liability settlements where 
Medicare has a claim for recovery of prior conditional payments.
     Designs and conducts special projects to improve national 
coordination of Medicare benefits with other health coverage.
     Develops and monitors the ongoing operations of a data 
match of the Internal Revenue Service and Social Security 
Administration data to identify MSP cases. Coordinates MSP operations 
with HCFA and non-HCFA governmental components and with other payers 
and their representative organizations, particularly State insurance 
departments and the National Association of Insurance Commissioners and 
like organizations.
     Develops operational policy and instructional material for 
the establishment and maintenance of Medicare entitlement.
     Conducts studies and demonstrations to improve the 
systems, methods, and procedures for establishing and maintaining 
entitlement information. Develops and recommends entitlement related 
legislative and policy proposals.
     Develops procedures for issuing and reissuing health 
insurance cards, monitoring records maintenance and correction, and 
processing voluntary and other identification problems from the 
Medicare claim process.
     Serves as the Agency systems manager for entitlement 
requirements.
(3) Division of Audit and Payment Management (FLB23)
     Analyzes regulations, executive orders, policies, and 
legislative proposals and assesses their financial impact on the audit 
budget. Develops the plan, necessary audit programs, guidelines and 
instructions for the implementation of current and future legislation, 
regulations, and court orders.
     Plans and develops methods to improve and enhance the 
audit function and makes recommendations for improvements in management 
of the audit program, including the identification and implementation 
of automated data processing programs in the desk review, audit, and 
settlement activities.
     Develops rationale for the audit and payment management 
portion of the current and future national contractor budgets. 
Establishes and monitors return ratio requirements for provider audits 
to assure maximum return on investment expenditures.
     Reviews and analyzes Contractor Auditing and Settlement 
Reports to determine the effectiveness of contractor audit and payment 
performance and compliance with established audit guidelines, 
priorities, funding limitations, and workload objectives.
     Researches and responds to all Office of Inspector General 
and General Accounting Office payment and financial audit reports and 
studies. Prepares position papers and reports offering alternative 
methods of resolution.
(4) Division of Medigap Operations (FLB24)
     Develops, implements, and administers Medigap operational 
policy.
     Analyzes State laws and regulations for Medicare 
supplemental health insurance to ensure compliance with the Social 
Security Act.
     Conducts the mandatory Certification Program in those 
States not having an approved regulatory program. Reviews and analyzes 
Medicare supplemental health insurance policies for compliance with the 
Social Security Act and recommends that certification be granted or 
denied.
     Develops, implements, and monitors the Medicare SELECT 
direct contracting option for medical necessity determinations.
     Conducts periodic operational reviews of State regulatory 
programs for continued operational compliance the Social Security Act. 
Monitors States' application and enforcement of standards; i.e., 
simplification standards, anti-duplication standards, loss ratios and 
premium standards, pre-existing conditions and medical underwriting 
limitation standards.
     Provides liaison with governmental entities (both Federal 
and State) regulating other payers for health care and their 
representative organizations, particularly State insurance departments 
and the National Association of Insurance Commissioners and like 
organizations. Serves as liaison with internal HCFA and departmental 
components, the General Accounting Office, and the Office of Inspector 
General on Medigap issues.
     Provides service, advice, guidance, and consultation 
directly, and through joint efforts with other HCFA components and 
Medicare contractors, to States, other Government entities, employers, 
insurers, providers, physicians, beneficiaries, and their 
representative organizations, to insure the Medigap program is 
understood.
     Prepares and assists in preparation of various reports to 
Congress on Medigap related issues.
     Coordinates the Medigap Federal penalty provisions 
referenced in the Social Security Act.
e. Office of Program Operations Procedures (FLB3)
     Develops and administers the specification, requirements, 
methods, systems, standards, procedures, and budget guidelines to 
implement and maintain the operational systems for the Medicare program 
including detailed definitions of the relative responsibilities of 
providers, contractors, HCFA, and the beneficiaries of the Medicare 
program.
     Reviews and evaluates systems, systems plans and 
proposals, and Automated Data Processing acquisition and modifications 
involving carriers and intermediaries.
     Develops and promulgates specification and requirements 
for contractor processing of beneficiary and provider appeals.
     Develops specifications and recommends budget necessary 
for more effective methods to process Medicare claims.
     Reviews proposed policy, payment, and legislative 
proposals to evaluate the operational impact on claims processing and 
appeals activities including the development of cost estimates for the 
implementation of such proposals.
     Develops and maintains forms and electronic formats used 
by intermediaries and carriers to process claims.
     Develops, maintains, and disperses a quarterly task 
management plan which reviews contractor budget workload and 
initiatives.
(1) Division of Claims Processing Procedures (FLB31)
     Directs the development and issuance of specifications, 
requirements, procedures, and instructional material to implement and 
maintain operational systems for processing Medicare claims and 
defining their applications to Medicare carriers, Medicare 
intermediaries, providers, physicians, other independent medical 
professionals, suppliers of service, beneficiaries, and HCFA.
     Maintains the intermediary and carrier instructional 
manuals including the Common Working File (CWF) interface instructions 
for processing claims from Medicare providers, physicians, other 
independent medical professionals, and suppliers of services.
     Reviews proposed policy, payment, and legislative 
proposals to evaluate the operational impact on Medicare claims 
processing operations.
     Implements new legislation impacting on Medicare claims 
processing operations.
     Develops the discharge data set specifying required 
information to be provided by intermediaries to Peer Review 
Organizations (PRO) in support of PRO medical review activities.
     Maintains liaison with representatives of the health care 
industry to ensure the HCFA processes are compatible with the 
industry's administration practices.
     Develops bill processing edits for intermediaries, 
carriers, and the CWF processing of Medicare claims.
     Develops instructions for and maintains and monitors 
supplier numbering clearinghouse.
(2) Division of Claims Processing Requirements (FLB32)
     Prepares general systems plans and develops requirements 
for the detailed design and programming for claims processing modules 
to be used by Medicare contractors.
     Plans, conducts, and evaluates studies aimed at long-range 
improvements in electronic claims processing systems, methods, and 
procedures as they relate to the administration of the Medicare program 
and integration of operations within the framework of HCFA policies, 
goals, and objectives to promote efficiency and cost effectiveness.
     Develops programs to promote acceptance and usage of 
electronic claims processing, electronic funds transfer, and electronic 
remittance advice.
     Develops cost estimates for proposed legislation and 
regulations.
     Participates in the review and evaluation of systems-
related applications project.
     Participates in the government-wide national disaster 
planning initiative and review of Medicare contractors' systems 
security.
     Develops and maintains billing forms and formats used by 
intermediaries and carriers.
     Serves as HCFA focal point with American National 
Standards Institute on electronic claims processing formats used by the 
health insurance industry.
     Reviews proposed policy, payment, and legislative 
proposals to evaluate the operational impact on claims processing 
activities, including the development of cost estimates for the 
implementation of such proposals.
     Develops budget guidelines and cost estimates for Medicare 
claims processing activities.
     Develops, maintains, and disperses a quarterly workload 
plan as it relates to budget initiatives.
(3) Division of Appeals and Communications (FLB33)
     Plans, develops, and issues operating policy, 
specifications, procedural requirements, and other materials to 
implement, maintain, or revise the appeals process for Part A and B 
claims.
     Develops, monitors, and approves formats and messages for 
the Medicare Explanation of Medicare Benefits.
     Plans, conducts, and evaluates studies to streamline and 
make more effective the appeals process and to develop both long-range 
and short-range improvements in systems, methods, and procedures 
relating to beneficiary and provider communications.
     Initiates improvements and develops procedures for 
providing beneficiary and provider services for telephone, written, and 
personal contacts by Medicare contractors and other field facilities.
     Develops standard language for use by Medicare contractors 
in communicating with beneficiaries and providers.
     Reviews proposed policy, payment, and legislative 
proposals to evaluate the operational impact on the appeals process for 
Part A and Part B claims.
     Identifies management's information needs for data 
relating to Administrative Law Judge's (ALJ) decisions concerning both 
Part A and B claims and initiates appropriate actions for establishing 
or modifying the reporting and information systems to satisfy these 
needs (i.e., ALJ database, reversal reports, and decision reports).
     Develops procedures for conforming with the Privacy Act 
including maintaining a system of records for the Federal Register, 
clearing requests for information, and developing agreements with the 
States on releasing information.
(4) Division of Operational Systems Development (FLB34)
     Designs, develops, and manages, at the national level, 
activities required to enhance systems for improvement of the Medicare 
eligibility systems, Part A and Part B claims processing systems, and 
the Medicare program database.
     Prepares systems plans and develops policies for the 
design, implementation, and evaluation of shared systems and 
standardized modules for use by Medicare carriers, intermediaries, and 
hosts.
     Directs the design, development testing, and 
implementation of innovative system enhancements to the Common Working 
File (CWF) shared claims processing systems resulting in improvements 
to the national Medicare claims payment process.
     Provides national analysis and planning for changes to CWF 
and standard systems as required by legislative initiatives.
     Evaluates HCFA-wide systems plans for their impact on 
functions related to Part A and Part B of Medicare.
     Integrates systems changes within the framework of HCFA 
policies, goals, and objectives in an efficient and cost effective 
manner and coordinates system changes with other HCFA components, the 
Social Security Administration, HCFA regional offices, provider groups, 
and other affected organizations.
f. Office of Quality and Evaluation (FLB4)
     Designs and implements evaluation programs to assess and 
improve the overall effectiveness and quality of Medicare contractor 
operations.
     Designs, develops, implements, monitors and, as necessary, 
revises performance standards for measuring and evaluating all aspects 
of Medicare contractor operations.
     Develops and applies policies, standards, and guidelines 
for quality assurance programs to provide uniform and comparative 
evaluation of contractor performance in areas of program eligibility 
and payment, bill and claim payment, audit, beneficiary services, and 
other contractor activities.
     Designs and monitors systems of internal controls and 
standards for Medicare contractors to ensure the Medicare program is 
adequately safeguarded against inappropriate expenditures.
     Develops, conducts, and/or directs Central Office and/or 
regional office participation in quality assurance reviews and studies 
of selected areas of contractor operations and evaluates policy and 
operations to improve program operations and implement policy and 
legislative directives.
     Designs, establishes, and maintains reporting and 
information management systems for Medicare contractor program 
operations and administrative data.
     Provides data and systems analysis support for the 
production and interpretation of program operations and performance 
indicators.
     Serves as the focal point for Medicare intermediary and 
carrier contractor performance for the contracting officer.
(1) Division of Quality Programs (FLB41)
     Develops, implements, directs, and operates national 
quality assurance programs to determine the effectiveness and quality 
of Medicare contractors' operations, including claims payment, and 
payments to institutional providers.
     Evaluates the quality of contractor audits/settlements of 
cost-based, prospective, and alternate payment systems, and oversees 
chain providers' home office costs.
     Assures uniform national assessment of Medicare 
contractors' compliance with claims payment performance standards and 
program requirements.
     Develops and publishes guides and requirements for the 
direction on Medicare payment evaluation and quality assurance 
programs.
     Establishes, develops, implements, and operates a 
comprehensive system for analyzing quality assurance program results 
and for evaluating and assuring adherence to requirements for operating 
Medicare claims payment quality assurance and evaluation programs.
     Reviews established Medicare payment quality assurance and 
evaluation programs and implements appropriate enhancements reflecting 
operations, legislative, and administrative changes.
     Identifies inaccurate or inconsistent performance, and 
reviews and approves corrective action planning and monitoring.
(2) Division of Standards (FLB42)
     Develops, operates, and manages a program of qualitative 
and quantitative standards and requirements for Medicare contractors, 
including the development and implementation of contractor performance 
evaluation programs for intermediaries, carriers, Regional Home Health 
Intermediaries, and Common Working File Host.
     Quantifies and describes acceptable levels of performance 
by which Medicare contractors are evaluated.
     Negotiates with regional offices, contractors, providers, 
other HCFA components, and national public and private professional 
organizations to arrive at proposed or revised performance standards or 
requirements prior to their formal issuance.
     Assures that new program and performance standards and 
subsequent modifications are incorporated into the performance 
evaluation programs and related reports.
     Reviews program instructions and makes recommendations to 
issuing components to ensure guidelines contain effective safeguards 
and standards for ensuring accurate implementation.
     Analyzes all quantitative and qualitative standards and 
program requirements to assess their operational validity and makes 
recommendations for appropriate changes.
     Serves as the focal point for Medicare intermediary and 
carrier contractor performance for the contracting officer.
     Designs, develops, implements, and operates a national 
system for collecting and reporting results of performance as measured 
against established standards.
     Initiates, interprets, evaluates, and maintains data on 
each Medicare contractor in terms of compliance with performance 
requirements.
     Designs, develops, and conducts special projects and/or 
coordinates with other HCFA components on the conduct of special 
projects which have an impact on contractor performance evaluation.
(3) Division of Program Evaluation (FLB43)
     Conducts in-depth evaluations of selected programmatic 
areas to determine whether established policy and operational criteria 
are effectively and accurately met.
     Conducts special surveys in critical areas, identifying 
problems and barriers to problem resolution, and develops and 
recommends alternative solutions to promote program quality.
     Analyzes trends and identifies problems or potential 
problems requiring program action.
     Initiates, interprets, evaluates, and maintains data on 
each Medicare contractor in terms of compliance with program 
initiatives and performance requirements, administrative expenditures, 
and implementation of program and operating policies, systems, and 
procedures.
     Develops, conducts, and/or directs Central Office and/or 
regional office participation in quality assurance reviews and studies 
of selected areas of contractor operations to improve operations.
     Uses statistical databases and applications to analyze, 
evaluate, and make recommendations towards improving program 
operations, including operational efficiency.
(4) Division of Reports and Information Management (FLB44)
     Designs, establishes, and maintains reporting and 
information management systems for Medicare contractor program 
operations and administrative data.
     Reviews contractors' reporting systems for consistency and 
the ability to transmit the required information and prepares the 
appropriate reporting requirements.
     Prepares written interpretations and analyses of operating 
data to provide other bureau components with information necessary in 
conducting program and performance evaluations.
     Develops the specifications for an automated operational 
data system for Medicare contractor program operations.
     Prepares recurring and special reports on the status and 
trends in program administration and operational effectiveness.
     Provides technical assistance to regional offices and 
contractors on reporting requirements.
     Monitors systems of internal controls for use by Medicare 
contractors to ensure the Medicare program is adequately safeguarded 
against inappropriate expenditures.
     Directs the bureau's microcomputer activities including: 
providing technical assistance to the bureau components applications, 
developing automation strategy based on long term needs and new 
initiatives, documenting requirements and coordinating design, 
development, end user training, and implementation activities with the 
Bureau of Data Management and Strategy.

5. Bureau of Data Management and Strategy (FLC)

     Serves as the focal point for the management of HCFA's 
information resources.
     Provides Agency-wide information management, decision 
support, automated data processing (ADP), and data communication 
services essential to the management and administration of HCFA 
programs.
     Provides technical information planning and developmental 
review of HCFA data collection initiatives.
     Collects, analyzes, and disseminates data on beneficiary 
eligibility, enrollment entitlement, and medical utilization.
     Collects and maintains data on Medicare contractor claims 
processing workloads and maintains contractor quality assurance and 
performance evaluation systems.
     Manages statistical data systems on HCFA programs to 
support policy and program decisions.
     Coordinates the development of special purpose statistical 
data bases and tabulations required for assessing 1) the impact of 
proposals which change health care financing programs, 2) the 
characteristics of HCFA beneficiaries and 3) the utilization and cost 
of program benefits.
     Provides applications software support to HCFA 
headquarters and Regional Offices in administrative/program management 
systems.
     The Director serves as HCFA's Principal IRM Official and 
is responsible for overseeing the Agency's IRM programs including those 
of the Medicare contractors, Peer Review Organizations, and End Stage 
Renal Disease Networks.
     Directs the HCFA ADP systems security program including 
its application to Medicare contractors.
     Develops common coding standards and quality assurance 
monitoring mechanisms.
     Negotiates and administers agreements and provides ADP 
liaison between HCFA users and other external organizations for the 
provisions of ADP capacity and support services.
     Provides support and data handling capability to control/
examine, audit, investigate, and process/release a variety of provider 
billing, query, enrollment, and premium billing correspondence and 
transactions.
a. Office of Information Resources Management (FLC1)
     Plans, organizes, and coordinates the activities required 
to maintain a HCFA-wide Information Resources Management (IRM) program 
including the management of funds to support IRM operations and 
information systems development activities.
     Formulates and executes the HCFA IRM common expense budget 
and Information Technology Systems plans and budgets in conjunction 
with HCFA-wide budgetary submissions to the Department.
     Develops and maintains a process to administer, document, 
and monitor the software and hardware changes planned and implemented 
within HCFA.
     Provides systematic identification, assessment, and 
certification of new, revised, or existing HCFA information systems and 
processes in accordance with HCFA policies, standards, information 
plans, and department requirements.
     Develops, coordinates, and directs the HCFA automated data 
processing (ADP) Systems Security Program to ensure the protection of 
HCFA systems and ADP equipment.
     Designs, evaluates, and performs analyses related to HCFA-
wide data administration and database administration improvement 
projects.
     Negotiates and administers agreements and provides ADP 
liaison between HCFA users, the Social Security Administration, and 
other external organizations for the provision of ADP capacity and 
support services.
     Formulates strategies, prepares procurement documents, and 
performs contract administration activities for major contractual 
agreements in support of Agency IRM requirements.
(1) Division of Information Systems Management (FLC11)
     Directs the planning, design, and maintenance of 
information systems development standards and database administration 
policies and standards, including review of work products for 
compliance with standards, and the support of the Standards Board 
activities.
     Plans, directs, and coordinates the development and 
maintenance of a project management and software metrics program to 
monitor, evaluate, and improve the information systems development 
processes for HCFA. Directs the establishment and maintenance of the 
HCFA IRM systems inventory.
     Directs and coordinates the performance of post-
implementation reviews for Agency systems to validate that all systems 
components are maintained concurrently with the operational systems.
     Formulates strategies and performs contract administration 
activities for major software contractual agreements across all phases 
of the information systems development life cycle.
     Formulates strategies and performs contract administration 
activities for major IRM contractual agreements.
(2) Division of ADP Planning and Resources Management (FLC12)
     Plan, develops, and implements HCFA-wide policies, 
procedures and analyses related to IRM planning and ADP resource 
management.
     Formulates and assures compliance with HCFA's IRM Plan and 
associated long range strategic and operational plans. Formulates and 
executes the HCFA Information Technology System (ITS) 5-year plan and 
the HCFA ADP common expense budget.
     Develops, implements, and maintains a HCFA-wide financial 
management program to fund and support IRM operations and information 
systems development activities, all HCFA equipment and related IRM/ADP 
services.
     Administers the HCFA project management program and 
performs Agency-wide resource accounting functions to assess and 
monitor ADP resource utilization.
     Develops, coordinates, and directs the HCFA ADP Systems 
Security Program.
     Negotiates and administers agreements between HCFA users 
and other external organizations for the provision of ADP/IRM support 
services.
     Coordinates HCFA's participation in the Federal 
Information Processing Standards Program and administers HCFA's ADP/IRM 
Contract Administration Program.
b. Office of Statistics and Data Management (FLC2)
     Performs strategic planning to enhance program data and 
analysis to meet program policy development and program assessment 
requirements.
     Develops, disseminates and monitors data release policies 
for HCFA.
     Identifies, documents, and measures the trends in the 
reliability of program decision support data and information needed to 
support HCFA's policy development, research, and program assessment 
goals.
     Represents the Agency as the primary contact with the 
Department, other Federal agencies, the health care community, and the 
public for the use and release of HCFA program data.
     Plans, organizes, and coordinates data development and 
information analysis activities required to identify, develop, 
implement, and document decision support and statistical analysis 
processes.
     Provides decision support information and analysis to meet 
the Agency's research, actuarial, legislative, economic, and policy 
analysis; and the objectives of the Department's Medical Treatment 
Effectiveness initiative.
(1) Division of Payment Policy Support (FLC21)
     Develops strategic short- and long-range plans to acquire 
the data necessary to meet program payment policy development and 
assessment requirements.
     Organizes and analyzes data to develop the information 
systems necessary to support the Agency's and the Department's needs 
for HCFA program data in support of payment policy analysis and related 
research.
     Defines, develops, and implements quality assurance 
procedures covering decision support processes to measure and improve 
the reliability and usefulness of program data for decision support and 
statistical analysis. Develops statistical analyses and trend data to 
monitor data reporting and data reliability.
     Provides technical data analysis and processing support 
required to develop payment rates to advise Senior HCFA management of 
the information necessary to evaluate the effectiveness of current and 
proposed health care financing systems, the implications of 
experimental financing methods on providers and physicians, the cost 
aspect of the effectiveness of care being received by beneficiaries, 
and the monetary effects of new legislation on alternative 
reimbursement methodologies.
(2) Decision Support Division (FLC22)
     Develops strategic short- and long-range plans to define, 
acquire, and measure the reliability of the data and information 
necessary to support intramural and extramural health services research 
to advance the Department's mission. Reviews legislation to define the 
program decision support activities needed to implement and monitor 
legislatively-mandated health services research initiatives and program 
changes.
     Defines, develops, and implements quality assurance 
programs to measure trends and improve the reliability and usefulness 
of Medicare program data.
     Plans, organizes, and coordinates activities required to 
define the sources, uses and reliability of HCFA data to support 
research, program administration and evaluation, actuarial and 
statistical initiatives, and the Department's needs for HCFA program 
data in health services, medical effectiveness and epidemiologic 
research.
     Performs liaison function to advise researchers, program 
analysts, and actuaries on the sources, uses and limitations of program 
data. Provides technical data analysis and processing assistance 
required to effectively use HCFA program data for decision support.
     Analyzes and organizes information analysis describing the 
Medicare and Medicaid programs and national health care expenditures 
and develops information dissemination systems necessary to support the 
Agency's need for Medicare and Medicaid program data.
     Develops and maintains the sample data sets necessary to 
support beneficiary-based program surveys and assessments, including 
support to the Medicare Beneficiary Health Status Registry, the Current 
Beneficiary Survey, and the Medicare History Sample, and the Peer 
Review Organizations.
     Participates in the development and establishment of data 
standards used for HCFA programs, including beneficiary enrollment, 
uniform billing, uniform coding systems, and common reporting systems 
(e.g., Common Working File).
(3) Division of Special Programs (FLC23)
     Develops strategic short- and long-range plans to define 
and acquire institutional financial data and special medical data on 
specific Medicare populations.
     Analyzes and organizes data to develop the information 
systems necessary to support the Agency's and the Department's special 
program data and information requirements.
     Designs, develops, implements, and operates special 
program data collection and processing systems, e.g., Hospital Cost 
Report Information System (HCRIS) and End Stage Renal Disease (ESRD) 
Program Management and Medical Information System (PMMIS), to identify 
and meet special program data and information needs.
     Defines, develops, and implements quality assurance 
programs pertaining to special program systems to improve the 
reliability and usefulness of program decision support and statistical 
data.
     Identifies and implements processes and procedures that 
will take maximum advantage of the multi-tier data processing 
architecture, as well as to maximize the efficient use of the mainframe 
to process large scale special program applications.
     Represents the bureau as primary contact for special 
program data collection and use issues within the Department and with 
outside groups.
c. Office of Program Systems (FLC3)
     Handles the receipt, control, edit, quality assurance, and 
basic monitoring of common working file claims data and input data 
relating to program management systems, including development and 
maintenance of ADP application telecommunications software providing 
access and front end quality control.
     Performs the planning, organization, and coordination 
activities required to build and control HCFA's National Claims History 
databases (NCHDB) for both the Medicare and Medicaid programs and 
related hardware requirements.
     Implements and maintains the centralized provider survey, 
certification (including clinical labs), and billing databases which 
provide on-line query and reply capabilities through a national 
telecommunications network.
     Provides standard and ad hoc data files and reports on 
health standards and quality data, intermediary and provider 
statistical and reimbursement data, and information regarding chain 
ownership data.
     Designs, implements, maintains, and ensures the continuing 
operations of software applications which provide access and array NCH 
and Program Management (PM) data in accordance with the ongoing program 
management needs of HCFA.
     Develops short- and long-range NCHDB and PM IRM plans to 
ensure that the proper hardware and software is available to meet the 
Agency's NCH and PM operations support needs and to support budget 
development and life cycle planning.
     Defines and coordinates an NCHDB and PM quality assurance 
program to ensure that the databases are reliable for use in program 
development and evaluating ongoing program operations.
     Designs, implements, and maintains a number of computer 
systems that are used by HCFA to monitor the performance of the fiscal 
intermediary contracting community.
(1) Division of Program Management Systems (FLC31)
     Handles the receipt, control, edit, quality assurance, and 
basic monitoring of input data relating to program management systems.
     Implements and maintains the centralized provider survey, 
certification (including clinical labs), and billing databases which 
provide on-line query and reply capabilities through a national 
telecommunications network.
     Provides standard and ad hoc data files and reports on 
health standards and quality data, intermediary and provider 
statistical and reimbursement data, and information regarding chain 
ownership data.
     Maintains and enhances the systems that enable HCFA to 
monitor the quality of claims processing in carrier and intermediary 
sites.
     Designs, implements, maintains, and ensures the continuing 
operations of software applications which array Program Management (PM) 
data in accordance with the ongoing program management needs of HCFA.
     Negotiates user requirements and develops design 
alternatives, systems specifications, test, conversion and 
implementation plans, operation plans (e.g., HDC support requirements), 
and documentation for PM and related applications.
     Defines and coordinates a PM data quality assurance 
program including the development of process controls, edits and 
statistical measures to ensure that the databases are reliable for use 
in program development and evaluating ongoing program operations.
     Manages PM database administration activities directed 
toward ensuring the integrity of the databases.
     Participates in the development and establishment of data 
standards used for HCFA programs, including uniform billing, uniform 
coding systems and common reporting systems.
(2) National Claims History Division (FLC32)
     Manages and directs the receipt, control, editing, quality 
assurance, and basic monitoring of the common working file claims and 
program liability data.
     Performs the planning, organization, technical 
consultation, and coordination activities required to design, develop, 
document control, and ensure the integrity of HCFA's National Claims 
History database (NCHDB) for the Medicare program and related hardware 
requirements.
     Defines systems accesses, interfaces, and operational 
requirements to ensure the efficient development and use of the NCHDB 
for program purposes.
     Negotiates user requirements and develops design 
alternatives, systems specifications, test, conversion and 
implementation plans, operation plans (e.g., HDC support requirements), 
and documentation for the NCHDB and related applications.
     Defines and coordinates an NCHDB and beneficiary record 
quality assurance program including the development of process 
controls, edits, and statistical measures to ensure database validity 
and integrity for use in program development and evaluating ongoing 
program operations. Defines and coordinates a beneficiary record 
quality assurance program to ensure the consistency of data maintained 
at the Common Working File sites with the enrollment databases.
     Manages NCH database administration activities directed 
toward ensuring the integrity of the databases.
     Participates in the development and establishment of data 
standards used for HCFA programs, including uniform billing, uniform 
coding systems, and common reporting systems.
(3) Division of Medicaid Statistics (FLC33)
     Manages and directs the receipt, control, edit, quality 
assurance, and basic monitoring of input data relating to the Medicaid 
Statistical Information System (MSIS) and the HCFA-2082.
     Performs the planning, organization, technical 
consultation, and coordination activities required to design, develop, 
document control, and ensure the integrity of HCFA's National Claims 
History database (NCHDB) for the Medicaid program and related hardware 
requirements.
     Provides standard and ad hoc data files and reports on 
Medicaid data.
     Designs, implements, and maintains the Medicaid drug 
information databases.
     Develops, implements and maintains ADP application 
telecommunications software to provide access and front end quality 
control for the various systems maintained in the branch.
     Designs, implements, maintains, and ensures the continuing 
operations of software applications which array Medicaid data in 
accordance with the ongoing program management needs of HCFA.
     Develops short- and long-range Medicaid IRM plans to 
ensure that the proper hardware and software is maintained to meet the 
Agency's PM operations support needs.
     Negotiates user requirements and develops design 
alternatives, systems specifications, test, conversion and 
implementation plans, operation plans (e.g., HDC support requirements), 
and documentation for Medicaid and related applications.
     Defines and coordinates a Medicaid data quality assurance 
program including the development of process controls, edits, and 
statistical measures to ensure that the databases are reliable for use 
in program development and evaluating ongoing program operations.
     Identifies and implements processes and procedures that 
will take maximum advantage of HCFA's multi-level data processing 
architecture; e.g., taking advantage of the microcomputers to put data 
and application development at the desk-top where appropriate, as well 
as to maximize the efficient use of the mainframe to process large-
scale applications.
d. Office of Enrollment Systems (FLC4)
     Performs the planning, organization, and coordination 
activities required to build and control HCFA's Medicare Enrollment 
database (EDB) and related hardware requirements and software 
applications.
     Designs, implements, maintains, and ensures the continuing 
operations of software applications which develop EDB data in 
accordance with the ongoing program management needs of HCFA, including 
the ADP operations to prepare bills for the receipt and processing of 
Medicare premium remittances and the generation of Health Insurance 
cards.
     Defines and negotiates user requirements, design 
alternatives, systems specifications, test, conversion and 
implementation plans, operation plans and documentation for the EDB and 
related applications.
     Defines and coordinates an EDB quality assurance program, 
including the development of process controls, edits, and statistical 
measures to ensure that the database is reliable for use in program 
operations and development.
     Coordinates operational and program development 
requirements for data about Medicare Enrollment with other components 
within HCFA, the Department, other Federal agencies and local 
governments, the private sector and the public. This includes support 
for the Common Working File by maintaining and providing accurate and 
timely information regarding beneficiary enrollment status for Medicare 
claims processing purposes.
(1) Division of Enrollment Applications (FLC41)
     Responsible for the integration and coordination of all 
EDB database design, development, and management activities.
     Assures the viability of the databases including 
maintenance, backup, recovery, on-line access, etc.
     Responsible for the integration of the EDB database(s) 
with other database systems; planned/proposed systems software efforts; 
and overall IRM policies.
     Provides a technical review point within the Office of 
Enrollment Systems to insure adequate control, testing, validation, and 
documentation of all applications database software within the office.
     Receives, controls, edits, and validates transactions 
which affect HCFA's authoritative record of enrollment in the Medicare 
program.
     Coordinates operational and program development 
requirements for data about Medicare Enrollment with other components 
within HCFA, the Department, other Federal agencies and local 
governments, the private sector and the public. This includes support 
for the Common Working File by maintaining and providing accurate and 
timely information regarding beneficiary enrollment status for Medicare 
claims processing purposes.
(2) Division of Capitation and Collection Systems (FLC42)
     Bills and collects Medicare premiums from the direct-
paying beneficiary population and from third-party payers such as State 
agencies, private groups and the Office of Personnel Management.
     Insures that premium-related entitlement data received 
from other sources (such as the Social Security Administration) is 
validated and applied properly to HCFA's authoritative database of 
Medicare enrollment information.
     Enables and records enrollment in and disenrollment from 
health maintenance organizations and other group health plans.
     Computes the individual capitation amounts due for each 
beneficiary enrolled in a group health plan, and communicates that 
information to other automated processes that provide for paying the 
plans.
     Notifies beneficiaries of their enrollment in group health 
plans, and supports solicitation of beneficiary participation in 
managed health care delivery systems.
(3) Division of Medicare Operations Support (FLC43)
     Oversees clerical operations and manages work requests to 
resolve data errors.
     Oversees the receipt, resolution, and response to 
correspondence concerning Health Insurance questions from a wide 
variety of sources including beneficiaries, Congressional Offices, 
Social Security Offices, States, the Railroad Retirement Board (RRB) 
and others.
     Directs review of Part B payment records and 
reconciliation related to Medicare billing exceptions and a multitude 
of exceptions created between SSA, HCFA, and RRB exchange of data.
     Provides clerical support to process accretions and 
deletions for State Buy-In and third party beneficiaries; ensures 
investigation of Medicare premium problem cases.
     Directs the processing of applications for enrollment of 
individuals to receive Supplemental Medical Insurance benefits.
     Coordinates the planning, design, and implementation of 
major work processes involving outside components. Resolves problems 
related to Medicare insurance with other HCFA components, regional 
offices, and SSA components.
e. Office of Information Technology (FLC5)
     Provides applications software support to HCFA 
headquarters and regional offices in administrative management systems.
     Serves as focal point for the personal computing and 
office information systems technology used throughout the agency.
     Develops short and long range plans for administrative, 
personnel, and financial systems.
     Manages all aspects of the Agency's investment in 
microcomputing technology.
     Develops and manages the Agency's ADP training program.
(1) Division of Administrative Systems (FLC51)
     Provides applications software support to HCFA 
headquarters and regional offices in administrative management systems.
     Provides applications software services to other HCFA 
components in the development of administrative systems, including 
those utilizing microcomputer technology. Responsible for the macro 
design and evaluation of prototype administrative systems.
     Develops short and long range plans for administrative, 
personnel, and financial systems.
     Develops approriate standards and guidelines to govern the 
development and ongoing support of administrative systems.
(2) Division of Office Automation Systems (FLC52)
     Serves as focal point for the personal computing and 
office information systems technology use throughout the Agency.
     Develops the acquisition strategy for personal computing 
hardware, software, and services in HCFA-both central and regional 
offices.
     Manages all aspects of the Agency's investment in 
microcomputing technology.
     Develops the Agency strategy for acquisition and use of 
office information systems technology including the HCFA-wide office 
automation and electronic mail capabilities.
     Develops user requirements, plans, and implements use of 
office information systems technology including text management, 
imaging, and executive information systems.
     Develops and manages the Agency's ADP training program.
f. Office of Computer Operations (FLC6)
     Directs the planning, budgeting, evaluation, procurement, 
operation, maintenance, control, and security of all centralized 
automated data processing (ADP) and data communications (DC) equipment 
and services for HCFA's Data Center (HDC) which includes: DC activities 
and equipment; centralized large-scale computers; nationally 
distributed departmental minicomputers; vendor supplied operating 
systems; utility software; OCO utilization of the Facilities Management 
Contract; and various intra/inter Agency agreements.
     Advises the bureau and HCFA executive staff on ADP and DC 
issues and concerns and represents HCFA in dealings with Federal and 
non-Federal agencies and organizations in these areas.
     Serves as the Agency's final technical authority for the 
approval of the purchase, lease, and maintenance of all ADP and DC 
equipment and systems.
     Manages the HDC and DC resource planning function to 
ensure the availability of resources for Agency approved projects.
     Develops HDC and DC plans and policies and provides 
program direction to HCFA staff and contractor support organizations to 
ensure that the Agency mission is efficiently and effectively met.
(1) Division of Data Center Services (FLC61)
     Directs the planning, budgeting, operation, maintenance 
control, and security for the HCFA Data Center (HDC) data processing 
resources and related support facilities (backup power, environmental 
systems, fire protection, etc.).
     Develops standards and policies for efficient use of the 
HDC. Effects these policies and standards through software and hardware 
controls.
     Manages, evaluates, installs, and maintains HDC operating 
systems software, utility software products, and data base management 
systems.
     Plans, organizes, schedules, and controls activities 
required to maintain a contingency and disaster recovery plan for the 
HDC.
     Develops HDC operations policies, operational plans, and 
technical guidelines, and provides program direction to contractor 
support organizations to ensure that the Agency mission is efficiently 
and effectively met.
     Develops and maintains the HCFA-wide accounting and 
chargeback system for HDC and DC users, determining and/or recommending 
the allocation of resources to the user community. Oversees the 
resource billing to non-HCFA users of the HDC.
(2) Division of Data Communications and Distributed Services (FLC62)
     Directs and manages HCFA's data communications (DC) and 
minicomputer systems at central and regional HCFA sites, including the 
Agency-wide installations/relocations of microcomputer, minicomputer, 
and DC equipment.
     Manages the evaluation and implementation of minicomputer 
hardware, operating system, and utility software products. Establishes 
workload planning and controls and schedules services to be provided.
     Assists in the evaluation and implementation of 
application software and other office automation products for operation 
on the minicomputer systems.
     Conducts studies to determine DC network requirements and 
provides technical advice and consultation to the DC user community.
     Directs and manages the HCFA Data Center (HDC) action desk 
providing on-line assistance for resolving HDC user problems.
     Develops DC, minicomputer, and action desk operating plans 
and policies and provides program direction to contractor support 
organizations to ensure that the Agency mission is efficiently and 
effectively met.

6. Office of the Regional Administrators (FLD(I-X))

     The Office of the Regional Administrator manages regional 
operation in each of the Health Care Financing Administration's (HCFA) 
10 regions.
     The Regional Administrators provide executive leadership 
and guidance on behalf of the Associate Administrator for Operations 
and Resource Management to HCFA components at the regional level.
     Implements national policy at the regional level.
     Assures the effective administration of HCFA programs 
including Medicare, Medicaid, Peer Review Organizations (PROs), HMOs/
CMPs, quality control, and certification of institutional providers in 
a major geographical area.
     Participates in the formulation of new policy and 
recommends changes in existing national policy for HCFA programs.
     Develops and implements a professional relations program 
within the region for all HCFA programs and serves as the principal 
HCFA contact for all professional organizations such as hospital and 
medical associations.
     At the regional level, takes action to implement HCFA 
national initiatives undertaken to integrate HCFA program operations 
and is responsible for coordination of HCFA programs with other 
departmental components and Federal agencies.
     Coordinates with the Department's Regional Director to 
assure effective relationships with State and local governments. 
Manages all administrative activities for HCFA components and 
coordinates such activities with the Regional Administrative Support 
Center.
     Initiates and directs the implementation of special 
regional and headquarters projects affecting HCFA programs.
     Directs regional responsibilities relating to experimental 
and demonstration projects.
     Oversees a beneficiary services program within the region 
for HCFA programs.
     Provides regional perspective to the Administrator, 
Associate Administrators, Bureau Directors, and Staff Office Directors 
in the development of HCFA policies, programs, and objectives.
a. Division of Health Standards and Quality (FLD(I-X)A)
     Assures that health care services provided under the 
Medicare and Medicaid programs are furnished in the most effective and 
efficient manner consistent with recognized professional standards of 
care.
     Interprets and implements health safety standards and 
evaluates their impact on utilization and quality of health care 
services.
     Determines approval and denial of all provider and 
supplier certification actions under the Medicare program.
     Initiates and implements remedial actions, including 
termination of agreements against health care facilities not in 
compliance with Medicare requirements.
     Makes final determination on all initial and supplemental 
budget requests submitted by State survey agencies.
     Monitors and evaluates State activities related to 
Medicare and Medicaid survey and certification.
     Oversees, monitors, and evaluates Peer Review 
Organizations (PROs), including recommendations for contract renewal, 
extension, and modification.
     Recommends approval or withholding of monthly voucher 
payments to PROs.
     Authorizes investigation of complaints received from the 
public, the Congress, the media, and other sources which allege 
deficiencies in the quality of care rendered by certified health care 
providers.
     Coordinates State survey agency activities related to 
sanctions and civil money penalties.
b. Division of Medicaid (FLD(I-X)B)
     Provides Federal leadership to State agencies in program 
implementation, maintenance, and regulatory review of State Medicaid 
program management activities under Title XIX of the Social Security 
Act.
     Assures the propriety of Federal Medicaid expenditures 
and, where appropriate, takes action to disallow claims.
     Consults with and provides guidance to States on 
appropriate matters including the interpretation of Federal 
requirements, options available to States under these requirements, and 
information on practices in other States.
     Provides consistent policy guidance to States on Medicaid 
program administration and the amount, duration, scope, and payment for 
health services under the State program.
     Monitors State agency Medicaid activities by conducting 
periodic program management and financial reviews to assure State 
adherence to Federal laws and regulations.
     Reviews, approves, and maintains official State plans and 
State plan amendments for medical assistance.
     Reviews, approves or recommends for disapproval, and 
monitors State institutional payment plans and systems (after central 
office concurrence for hospitals and long term care facilities).
     Reviews States' quarterly statements of expenditures and 
recommends appropriate action on amounts claimed.
     Defers payment action on questionable State claims for 
allowability.
     Issues orders suspending Federal financial participation 
on unallowable State Title XIX payments and defends disallowance 
actions at Departmental Appeals Board.
     Plans, directs, and coordinates the review and approval of 
Medicaid State agency data processing systems, proposals, 
modifications, operations, and contracts.
     Implements Title XIX special initiatives, such as Maternal 
and Child Health, Acquired Immune Deficiency Syndrome, Prepaid Health 
Plans, Health Maintenance Organization contracts, and other special or 
experimental programs and operations of major management initiatives.
     Performs Medicaid eligibility quality control reviews over 
State Medicaid eligibility and inspection of care practices to assure 
their ongoing compliance with Medicaid laws and regulations.
c. Division of Medicare (FLD(I-X)C)
     Directs Medicare program administration through working 
relationship with contractors, providers, physicians, the Social 
Security Administration regional offices, the Administration on Aging, 
the Office of Inspector General, and other local and national 
organizations and individuals, as required.
     Directs the review and evaluation of the effectiveness of 
the Medicare program.
     Directs activities in support of the Managed Care Program 
including technical support and oversight of Health Maintenance 
Organizations, and other prepaid contractors.
     Monitors all aspects of contractor performance including 
claims processing, coverage decisions, overpayment identification and 
collection, Medicare secondary payor, provider payment and audit, 
payment to physicians and suppliers, and electronic media claims.
     Coordinates ongoing contractor fiscal management 
activities, including subcontracting.
     Negotiates and approves Medicare contractor budget 
modifications.
     Evaluates Medicare contractor performance and prepares 
annual contractor evaluation report.
     Manages beneficiary, provider, and public information 
programs.
     Recommends renewals, non-renewals, recessions, and 
terminations of Medicare contracts.
7. Health Standards and Quality Bureau (FLE)
     Provides leadership and overall programmatic direction for 
implementation and enforcement of health quality and safety standards 
for providers and suppliers of health care services and evaluates their 
impact on the utilization, quality and cost of health care services.
     Plans, develops and establishes procedures and guidelines 
for administering and evaluating the nationwide Medicare and Medicaid 
survey and certification program.
     Monitors and validates the process for certifying that 
participating providers and suppliers are in compliance with 
established conditions and standards.
     Responsible for implementation and operation of 
professional review and other medical review programs.
     Administers a comprehensive system for assessment of 
individual professional and medical review organizations to determine 
compliance with program requirements and to document the effectiveness 
and impact of their activities.
     Establishes specifications for information and data 
reporting, collection and systems requirements for the survey and 
certification, professional review and other medical review activities.
a. Management Resources Staff (FLE-1)
     Directs and manages the bureau's management and 
administrative operations including facilities management, space 
utilization, records, publications, travel, correspondence, printing, 
mail distribution, regulations and issuances control, equipment 
management, supply operations, facilities maintenance, safety, 
security, telephone systems and parking.
     Plans, directs, and administers the Wang office automation 
activities for all Associate Administrator for Operations & Resource 
Management bureaus including access to shared and local data bases, and 
other office information activities.
     Plans, directs and coordinates the bureau's correspondence 
and public inquiries activities and all related paperwork management 
functions.
     Administers the bureau's personnel utilization and 
position management programs as well as the bureau's training and staff 
development programs.
     Develops annual and long-range administrative budgets and 
operating plans for the Health Standards and Quality Bureau.
     Reviews and processes requests for procurement or purchase 
and provides required contract support, service and consultation.
     Initiates and develops financial data and analytical 
reports on operations.
     Allocates and reprograms approved funds within the Bureau 
policies and guides to assist program divisions in formulating budget 
estimates.
     Develops, implements and maintains a management planning 
and control program for the bureau to ensure the efficient and 
effective utilization of available resources including: (a) bureau-wide 
workplanning and work measurement systems, (b) organization and 
operational analysis studies and (c) coordination and control of a 
variety of planning, reporting and monitoring systems required by the 
Office of Management and Budget, Department of Health and Human 
Services and other HCFA components.
     Researches and evaluates new management concepts and 
techniques for improving the bureau's management practices and 
operations.
b. Office of Peer Review (FLE1)
     Coordinates implementation of peer review and other 
medical review organizations.
     Develops and interprets policies related to the conduct of 
peer review at various levels of care.
     Develops and implements operational procedures and 
instructions relating to fiscal management of peer review programs, 
including the principles of payment for review, development of program 
related budgets, accounting procedures, reports management, statistical 
reporting, geographic variations of medical treatments, and auditing 
requirements applicable to such peer review organizations.
     Develops, implements, and maintains data systems in 
support of the Office of Peer Review data requirements for the 
management of the peer review program and contracts.
     Establishes guidelines relating to the oversight of peer 
review and other medical review organizations.
     Evaluates and provides advice and assistance to regional 
offices in overseeing fiscal and program management activities.
     Directs and oversees the End-Stage Renal Disease program 
and the Uniform Clinical Data Set function.
(1) Division of Program Operations (FLE11)
     Provides overall programmatic and technical management of 
contracts and any other financial agreements with organizations 
conducting medical reviews including establishment of expenditure 
levels, final approval of funding requests and resolution of audit 
findings.
     Provides program guidance and assistance to regional 
office staff in performance of their responsibilities.
     Develops and monitors plans for funding of Peer Review 
Organizations (PROs).
     Defines reporting requirements for PROs and other medical 
review entities.
     Develops, implements and administers a comprehensive 
system for assessment of individual PROs to determine compliance with 
program requirements and to document the effectiveness and impact of 
their activities.
     Initiates and designs studies to analyze data provided 
through the Office of Peer Review data systems on routine and as needed 
bases.
(2) Division of Review Programs (FLE12)
     Develops and interprets review methodologies and systems 
for all programs related to Peer Review Organizations' review of 
medical necessity, reasonableness, quality, and appropriateness of 
services (e.g., ancillary, inpatient, outpatient, or suppliers of 
practitioner care) reimbursed under Titles XVIII and XIX of the Social 
Security Act.
     Develops and interprets policies related to the conduct of 
peer review at various levels of care.
     Communicates and interprets HCFA's medical review policies 
to peer and other medical review organizations and provides or arranges 
for the provision of technical assistance.
     Develops and interprets operational policies for the 
involvement of physicians and other health care professionals in the 
conduct of peer review.
     Develops, with other Office of Peer Review components, 
criteria for objective setting and the application of norms, criteria 
and standards of peer review.
     Develops criteria for evaluation of peer review.
     Develops and interprets medical review policies regarding 
the impact of review on technical issues such as waiver of liability, 
inappropriate level of care, ``grace days,'' and denials of payment 
based on medical necessity and substandard quality with attendant 
reconsiderations and appeals.
     Monitors legislative, regulatory and operational 
developments related to medical review.
     Identifies and initiates necessary changes resulting from 
such developments.
     Develops legislative agenda and proposals related to 
statutory changes in medical review policies or procedures.
     Serves as a technical resource within the bureau for 
resolving medical review issues and providing assistance on other 
program decision areas.
(3) Division of Systems Management (FLE13)
     Establishes national policies for collection and 
processing of peer review data and directs and monitors the End Stage 
Renal Disease (ESRD) Network program.
     Designs, operates, monitors, maintains and, as necessary, 
revises the Peer Review Organization (PRO) Management Information 
System (PMIS), which includes a variety of data in support of the 
Office of Peer Review (OPR) and regional office medical review branch 
Automatic Data Processing (ADP) requirements.
     Responsible for the central office and regional Dispersed 
Terminal Network which is used to access other HCFA data systems.
     Designs, tests, and implements new component subsystems 
using both personal computers and mainframe hardware; develops data 
input and output requirements, as well as specifications for the 
modification of systems processes to adapt to new forms, policies, 
procedures, and subsystems.
     Develops and installs the necessary procedures for report 
and quality control, including screening, editing, logic, and 
consistency.
     Analyzes and designs methodology for submission of data to 
OPR ADP systems.
     Designs, tests, implements, and maintains automated 
software systems, manual systems, and data bases with emphasis on 
assuring the accuracy of reported information and retrieval 
capabilities supportive of program and management information needs.
     Consults with other components to identify existing or 
planned data systems strategic to management and program activities.
     Plans and develops new systems to generate management and 
analytical information from PRO deliverables and other data sources and 
meet the needs of management.
     Performs the Systems Security Officer functions for HSQB.
     Provides technical assistance in implementing and 
maintaining ADP systems to other components and the ROs through 
conducting regional workshops and training sessions; developing 
technical assistance materials; and maintaining ongoing liaison with 
affected systems personnel.
     Responds to special nonroutine requests for PMIS data from 
congressional committees, general public, professional organizations, 
and other government offices.
     Manages the interface of OPR data with external components 
and organizations to ensure the compatibility of data systems with HCFA 
data policy, as articulated by the Bureau of Data Management and 
Strategy.
     Directs and reviews all aspects of the ESRD Network 
program including quality assurance initiatives, data gathering, 
contractor performance, organ procurement, fiscal procedures, liaison 
with Congress and outside organizations, and technical assistance to 
the ESRD organizations.
(4) Division of Program Assessment and Information (FLE14)
     Oversees a variety of research techniques to review the 
quality of care activities in health care settings.
     Directs the development of strategies for improving the 
assessment of quality of health care through research and analytical 
techniques.
     Directs and monitors the research, assessment, and 
dissemination of information on the quality of care.
     Develops data and information dissemination protocols to 
provide feedback to the public and the professional medical community 
on the quality of care provided to Medicare beneficiaries.
     Maintains liaison with other HCFA components, the 
Department of Health and Human Services, Congress, and external 
professional and medical organizations.
c. Office of Survey and Certification (FLE2)
     Develops and establishes procedures and oversees the 
implementation and enforcement of health and safety standards for 
providers and suppliers of health services under Medicare and Medicaid.
     Administers and monitors the nationwide Medicare and 
Medicaid provider and supplier certification program.
     Develops procedures/guidelines for regional certification 
responsibilities under Medicare and Medicaid.
     Monitors and validates the application of health and 
safety standards and the adherence to Medicare and Medicaid policies by 
State survey agencies and other approved accrediting bodies.
     Monitors and evaluates regional performance of oversight 
responsibilities in survey and certification.
     Reviews the validity and effectiveness of existing 
standards.
     Develops and analyzes national data on the administration 
of the Medicare and Medicaid standards and certification program and 
develops methods for improvement.
     Conducts surveyor training, informational and other 
initiatives for improving the performance of State survey agencies and 
the providers and suppliers under the Medicare and Medicaid program.
(1) Division of Long-Term Care Services (FLE21)
     Directs and coordinates activities that implement, enforce 
and monitor health quality and safety standards and other health care 
procedures for long term care facilities under Medicare and Medicaid.
     Coordinates and applies regulations, procedures and 
guidelines for the improvement of standards enforcement and validation 
processes.
     Reviews and analyzes existing standards to determine their 
initial and continued effectiveness and impact on utilization, quality 
and cost of long-term care services and initiates new or revised 
instructions or standards, as necessary.
     Reviews and maintains guidelines and instructions for 
interpretation, implementation and enforcement of health quality and 
safety standards by the regional offices and State survey agencies.
     Prepare provider participation materials and instructions.
     Develops survey and certification forms utilized by State 
survey agencies in the survey and certification process.
     Monitors the enforcement of health quality and safety 
standards and compliance with established policy by State survey 
agencies and accrediting organizations whose standards and enforcement 
processes are deemed to meet Federal requirements for the Medicare and 
Medicaid programs.
     Maintains liaison with professional groups and standards 
setting organizations.
     Serves as the focal point for responding to regional 
office, State agency, congressional, organizational and individual 
inquiries relating to application of health and safety requirements and 
certification procedures for participating providers.
(2) Division of Systems Management and Data Analysis (FLE22)
     Maintains Section 1864 Agreements and oversees regional 
office (RO) 1864 negotiations and approval.
     Responsible for financial operations, including funding 
requirements and budget justifications, of the Medicare and Medicaid 
State certification program.
     Designs, tests and manages the centralized Medicare/
Medicaid Automated Certification System (MMACS) to provide program 
related and health management information on all providers and 
suppliers participating in the Medicare and Medicaid programs.
     Develops data input and output requirements and 
specifications for modification of computer processing activities.
     Provides technical assistance and training to central and 
RO personnel on the operation of MMACS equipment, use of forms, and 
utilization of data output.
     Develops new approaches for survey and certification on 
the basis of needs identified through MMACS data, RO direct surveys, 
comments from State survey agencies and other program areas.
     Tests improvements in the State agencies (SAs) 
certification process including modification of reporting procedures, 
utilization of personnel and use of financial incentives.
     Develops procedures for evaluating the effectiveness of RO 
performance and oversight of State survey agency performance.
     Collects and analyzes data derived from MMACS for use by 
ROs and SAs in pinpointing specific certification problems and for 
development of criteria and procedures to assess the quality of care 
being provided by Medicare and Medicaid providers.
     Collects, analyzes and studies data provided from the 
MMACS data system on a routine and special basis for use by ROs and SAs 
to identify specific certification and health and safety problems.
     Develops criteria and procedures through data analysis to 
assess the quality of care being provided by Medicare and Medicaid 
providers.
(3) Division of Program Operations (FLE23)
     Reviews State agency (SA) performance by conducting onsite 
reviews and assisting regional offices in program and administrative 
reviews.
     Reviews SA certification process with a view to improve 
management of the survey and certification process.
     Performs special studies to improve the survey and 
certification process and prepare guidelines and instructions for 
regional office (RO) and SA use.
     Develops procedures for the administration of provider 
agreements and revises, as needed, the State Operations and Regional 
Office Manuals.
     Maintains a system of communications to SAs and ROs 
relating to provider survey and certification and SA management.
     Develops and conducts surveyor training and other 
initiatives for improving the performance of State survey agencies and 
the providers and suppliers under the Medicare and Medicaid programs.
     Updates existing training materials to state of the art 
techniques.
(4) Division of Laboratory Standards and Performance (FLE24)
     Directs and coordinates activities that implement, 
enforce, and monitor the provisions of the Clinical Laboratory 
Improvement Amendments of 1988 (CLIA) and the Medicare laboratory 
program.
     Prepares regulation specifications for laboratory 
standards including comment review and summaries.
     Prepares and implements interpretive guidelines, survey 
procedures, forms, and related sections of the Regional Office Manual 
and the State Operations Manual.
     Reviews and recommends approval for proficiency testing 
programs and monitors their performance.
     Reviews and recommends approval for accreditation and 
State licensure programs and monitors their performance. Develops and 
administers the cytology proficiency testing program, as required.
     Assists in the design of data systems and in the 
evaluation of CLIA data. Conducts studies and prepares reports to 
Congress on laboratory, proficiency testing, and accreditation program 
performance.
     Prepares and participates in CLIA surveyor training.
     Responds to regional office, State survey agency, 
congressional, organizational, and individual inquiries relating to the 
application of laboratory requirements and certification procedures.
     Executes and participates in a comprehensive interagency 
agreement with the Public Health Service to exchange technical 
information in the management of CLIA.
     Manages procurement related to the CLIA survey process.
     Provides liaison and support to other HCFA components, HHS 
components, and other governmental agencies such as the Department of 
Defense and the Veterans Administration on issues to implement and 
operate CLIA, including the survey process, user fees, appeals process, 
application procedures, forms development, data collection, regulatory 
issues relating to payment and compliance, and other related issues.
     Represents HCFA in presentations and meetings with outside 
interested individuals and organizations on CLIA matters involving 
laboratory standards and performance.
(5) Division of Hospitals, Home Health, and Ambulatory Services (FLE25)
     Directs and coordinates activities that implement, 
enforce, and monitor health quality and safety standards and other 
health care procedures for acute care providers and suppliers under 
Medicare and Medicaid. These providers and suppliers include hospitals, 
rural health clinics, End-Stage Renal Disease facilities, physical 
therapists in independent practice, and home health agencies, etc.
     Coordinates and applies regulations, procedures, and 
guidelines for the improvement of standards enforcement and validation 
processes.
     Reviews and analyzes existing standards to determine their 
initial and continued effectiveness and impact on utilization, quality, 
and cost of provider and supplier services and initiates new or revised 
instructions or standards, as necessary.
     Reviews and maintains guidelines and instructions for 
interpretation, implementation, and enforcement of health quality and 
safety standards by the regional offices and State survey agencies.
     Prepares provider and supplier participation materials and 
instructions.
     Develops survey and certification forms and procedures 
utilized by State survey agencies in the survey and certification 
process.
     Monitors the enforcement of health quality and safety 
standards and compliance with established policy by State survey 
agencies and other accrediting organizations whose standards and 
enforcement processes are deemed to meet Federal requirements for the 
Medicare and Medicaid programs.
     Conducts liaison with other government organizations, 
professional groups, and standards setting organizations.
     Serves as the focal point for responding to regional 
office, State Agency, congressional, organizational, and individual 
inquiries relating to the application of health and safety requirements 
and certification procedures for participating acute care providers and 
suppliers.

    Dated: March 16, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-7346 Filed 3-28-94; 8:45 am]
BILLING CODE 4120-01-P