[Federal Register Volume 59, Number 221 (Thursday, November 17, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-28398]


[[Page Unknown]]

[Federal Register: November 17, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration

 

Statement of Organization, Functions, and Delegations of 
Authority; Bureau of Policy Development

    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), (Federal Register, Vol. 59, No. 
60, pp. 14638-14641, dated Tuesday, March 29, 1994) is amended to 
reflect changes in the substructure of the Bureau of Policy Development 
(BPD). The BPD functional statement has not been changed. The remaining 
BPD substructure is being published to reflect the organizational 
changes resulting from streamlining efforts.
    The specific amendments to Part F are as follows:
     Section F.10.C.2. (Organization) is amended to read as 
follows:

2. Bureau of Policy Development
    a. Office of Correspondence
    (1) Division of Correspondence Development
    (2) Division of Correspondence Analysis and Resources
    b. Management and Systems Support Staff
    c. Office of Regulations
    (1) Division of Part A and Medicaid
    (2) Division of Part B and Operations
    d. Technology and Special Analysis Staff
    e. Office of Hospital Policy
    (1) Division of Prospective Payment System
    (2) Division of Hospital Services
    (3) Division of Cost Principles and Reporting
    (4) Division of End Stage Renal Disease
    f. Office of Physician and Ambulatory Care Policy
    (1) Division of Outpatient Surgery and Services
    (2) Division of Ambulatory Care Services
    (3) Division of Physician Services
    g. Office of Chronic Care and Insurance Policy
    (1) Division of Skilled Nursing Care
    (2) Division of Home Care and Therapy
    (3) Division of Beneficiary and Insurance Issues
    (4) Division of Durable Medical Equipment and Devices

     Section F.20.C.2. (Functions) is amended by deleting the 
statement and substructure in their entirety and replacing them with 
the new functional statements. The new functional statements read as 
follows:

a. Office Of Correspondence (FKA-4)

     Plans, directs, and coordinates the correspondence program 
for the bureau.
     Receives, controls, tracks, prepares and/or forwards to 
appropriate components, Bureau assignments from all sources, including 
the Department, HCFA and its components, the White House, members of 
Congress, State and local agencies, officials of professional 
organizations, representatives of providers of health care, regional 
offices, the mass media and correspondence from beneficiaries and their 
representatives.
     Assigns, controls, tracks, and coordinates all work 
assigned to, or generated within the Bureau, except regulations.
     Coordinates Bureau responses on all assignments requiring 
input from two or more offices.
     Prepares or coordinates the preparation of responses to 
Secretary and Administrator correspondence and Inspector General and 
General Accounting Office reports.
     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.
     Manages Bureau-wide internal control systems.
     Prepares responses to correspondence.
     Provides technical assistance upon request to components 
and field offices.
     Responsible for the input and control of all Bureau 
correspondence and Bureau management of the Correspondence Assignment 
Tracking and Control System (CATCS); represents the Bureau on any 
matters involving CATCS.

(1) Division of Correspondence Development (FKA-41)

     Analyzes incoming correspondence, prepares interim 
responses, as well as acknowledgement of referral letters, as needed.
     Identifies the issues that need to be addressed and 
determines what resources are needed to prepare final replies; as 
needed, consolidates information from the precedent language file 
(BRIEF), the Staff library, Bureau components (generally through draft 
language requests), and organizations outside of the Bureau.
     Develops final responses to correspondence received.
     Receives and responds to telephone inquiries.
     Receives and initiates telephone calls to offices of 
members of Congress and White House Staff as necessary to resolve 
problems, respond to Medicare and Medicaid inquiries, and negotiates 
due dates or otherwise expedites the work.

(2) Division of Correspondence Analysis and Resources (FKA-42)

     Develops methods and procedures for the distribution and 
processing of correspondence work performed in the Bureau.
     Acts as the focal point for Offices and Divisions 
preparing Bureau correspondence.
     Coordinates and prepares responses to issues or 
assignments requiring input from two or more Offices.
     Maintains operating instructions.
     Develops instructions on the use of computer terminals in 
the Office's work.
     Responsible for the input, control and Bureau management 
of all correspondence in the Correspondence Assignment Tracking and 
Control System (CATCS); represents the Bureau on any matters involving 
CATCS.
     Designs, maintains, implements, and reports on the 
correspondence appraisal program, a post release review of the replies 
prepared by the Division of Correspondence Development designed to 
insure a high quality product.
     Develops and maintains a sophisticated filing system and 
resource program, including a precedent language file, Office library, 
and manuals.
     Conducts beneficiary recontact programs to determine how 
beneficiaries receive and react to the replies Staff writers prepare.
     Tests and monitors a variety of writing styles and formats 
in an effort to improve replies to correspondence.
     Studies randomly selected correspondence to determine 
trends or concerns of inquirers and reports findings to the Office 
Director.
     Controls incoming correspondence; controls, types, and 
releases interim and final replies on each letter prepared by Office 
writers.
     Receives, controls, tracks and prepares responses to 
General Accounting Office and Inspector General reports, Freedom of 
Information Act requests and other correspondence on HCFA programs.
     Assists the Office Director in responding to requests from 
the Bureau Director or Deputy in matters concerning White House or 
Secretary inquiries.

b. Management and Systems Support Staff (FKA-5)

     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 
attention.
     Develops, coordinates, and directs a management program 
for the management analysis functions, internal financial management, 
personnel selection and placement, training and employee development, 
position control and staff 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.
     Develops 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, 
Local Area Networks, Telecommunications and Word Processing systems 
including identifying needs, procurement, evaluation, and maintaining 
liaison with the Bureau of Data Management and Strategy.

c. Office of Regulations (FKA-6)

     Conducts the HCFA process for developing regulations and 
plans corresponding work agendas.
     Drafts all HCFA regulations and HCFA rulings and related 
clearance documents.
     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.
     Works jointly with HCFA components and the Office of the 
General Counsel to identify and resolve issues associated with each 
regulation.
     Coordinates the review of regulations received for 
concurrence from other HCFA and Department of Health and Human 
Services' components and other government agencies and prepares the 
Bureau and HCFA response.
     Prepares needed studies to assure completion of regulatory 
flexibility analysis consistent with the Regulatory Flexibility Act and 
regulatory impact analysis for small rural hospitals.
     Manages the HCFA process for substantive review and 
clearance of regulations within HCFA, and with the Office of the 
General Counsel.
     Provides training to HCFA regulation writers and clerical 
staff.
     Maintains specialized word processing systems to assure 
efficient preparation of regulations documents.
     Manages public comment process and maintains official 
agency regulations files.
     Maintains current database of 42 Code of Federal 
Regulations, Part 400-End.

(1) Division of Part A and Medicaid (FKA-61)

     Reviews, analyzes and comments on specifications prepared 
by originating offices. Drafts, coordinates and clears payment and 
coverage regulations relating to Part A Medicare and special programs 
such as End Stage Renal Disease, Hospices, Home Health Agencies, Peer 
Review Organizations, Medicare Secondary Payer and Durable Medical 
Equipment. Also, drafts, coordinates and clears regulations related to 
eligibility for Medicare.
     Reviews, analyzes and comments on specifications prepared 
by originating offices. Drafts, coordinates and clears regulations 
related to the Medicaid program such as Medicaid payment to providers, 
practitioners, and suppliers of all services; coverage of services 
under Medicaid; and eligibility of individuals for Medicaid.
     Analyzes legislation related to Part A Medicare and 
Medicaid issues to determine necessity for changes in regulations.
     Ensures the content of regulations is consistent with 
Federal Register requirements.
     Negotiates and monitors schedules for preparation of 
regulations and coordinates with originating component the review of 
draft regulations, development of policy and analysis of issues. 
Negotiates resolution of policy issues necessary to meet regulation 
schedules.
     Analyzes the economic impact, costs, savings, and 
effectiveness of draft regulations, to assure compliance with the 
requirements of the Regulatory Flexibility Act, Executive Order 12606, 
the Impact on the Family, Executive Order 12612, Federalism and 
specific impact on small rural hospitals as required by Public Law 100-
203.
     Coordinates review of regulations received for concurrence 
and prepares Bureau and HCFA response.
     Indexes official regulation files to assist in post 
publication legal reviews.

(2) Division of Part B and Operations (FKA-62)

     Reviews, analyzes and comments on specifications prepared 
by originating offices. Drafts, coordinates and clears payment, 
coverage, and operations regulations relating to Physicians and 
Practitioners who are paid under the physician fee schedule, Outpatient 
Hospitals, Managed Care, Ambulatory Surgical Centers, Rural Health 
Clinics, Federally Qualified Health Centers, Alternative Service 
Delivery, and several Medicare Part B suppliers of products and 
services such as: laboratories, drugs, x-rays, ambulance services.
     Analyzes legislation related to Part B Medicare and all 
other assigned areas to determine necessity for changes in regulations.
     Ensures the content of regulations is consistent with 
Federal Register requirements.
     Negotiates and monitors schedules for preparation of 
regulations and coordinates with originating component the review of 
draft regulations, development of policy, and analysis of issues. 
Negotiates resolution of policy issues necessary to meet regulation 
schedules.
     Analyzes the economic impact, costs, savings, and 
effectiveness of draft regulations, to assure compliance with the 
requirements of the Regulatory Flexibility Act, and specific impact on 
small rural hospitals as required by Public Law 100-203.
     Coordinates review of regulations received for concurrence 
and prepares Bureau and HCFA response.
     Indexes official regulations files to assist in post 
publication legal reviews.

d. Technology and Special Analysis Staff (FKA-7)

     Evaluates policies, regulations, rulings and guidelines 
pertaining to the establishment of Medicare coverage and payment for 
new health care technologies and for preventive services, including 
mammography screening and covered inoculations.
     Initiates special technical and economic studies in 
response to identified problems in payment or coverage policy.
     Coordinates with other components, such as the Health 
Standards and Quality Bureau, the analysis of innovative treatment 
patterns, referral patterns and activities that improve health care 
status.
     Recommends legislative or other remedies to improve 
coverage and utilization effectiveness of new items and services.
     Coordinates activities of HCFA's Technology Advisory 
Committee (TAC) and disseminates policy changes and clarifications 
flowing from TAC meetings.
     Coordinates activities with the Agency for Health Care 
Policy Research and other HCFA components such as the Office of 
Research and Demonstrations, the Health Standards and Quality Bureau 
and the Bureau of Program Operations as they relate to the 
establishment of policies for reasonable and necessary medical services 
and with the Public Health Service on formal reviews of safety and 
effectiveness of new health care technologies. This will include such 
issues as appropriate use of physician practice guidelines and measures 
of cost-effectiveness.
     Prepares studies, and advise others on the preparation of 
studies, analyzing the cost-benefits of new technology to support 
changes in Medicare coverage and payment policy; also, reviews cost-
benefit studies prepared by others and develops the policy implications 
of these studies.
     Provide data analysis to support program policy changes in 
payment systems or in coverage of services, and to support Reports to 
Congress on program policy issues.
     Conducts economic research and develops or oversees the 
development of microsimulation models to ascertain the impact of 
national payment policies in areas such as inpatient/outpatient 
hospital services, hospital capital, physicians and other alternative 
types of medical delivery services.
     Works on major payment reform proposals as they relate to 
such issues as expenditure caps and use of preferred provider 
organization concepts under Medicare.
     Reviews all significant economic and medical research 
bearing on Medicare coverage and payment policies and prepares 
summaries of significant findings, emphasizing the policy situations.
     Serves as liaison to other agencies within the Department, 
other government organizations and industry groups regarding technical 
and economic policy issues and analysis.

e. Office of Hospital Policy (FKA3)

     Develops, evaluates, and maintains national policies, 
regulations and instructions on the coverage, payment and utilization 
effectiveness of items and services under the Medicare program provided 
for inpatients of hospitals, by End-Stage Renal Disease (ESRD) 
facilities, organ procurement agencies and transplantation centers; 
develops and evaluates provider reporting and accounting policy; 
assists in the development and evaluation of related legislation.
     Develops, evaluates, and maintains regulations, policies 
and instructions for payments to hospitals for inpatient services under 
the prospective payment system.
     Coordinates with and reviews recommendations from the 
Prospective Payment Assessment Commission.
     Coordinates with other components, such as the Health 
Standards and Quality Bureau in developing and evaluating health and 
safety standards for hospitals and ESRD providers or suppliers of 
health services under Medicare.
     Develops HCFA coding standards and policies for ICD-9 and 
10.
     Participates in the formulation and analysis of medical 
classification systems, such as Diagnosis Related Groups, mortality and 
other outcome groupings, and the Medicare Quality Indicator System.
     Formulates, maintains, and evaluates national policies 
pertaining to the exclusion of certain categories of hospitals and 
hospital costs from the prospective payment system (PPS) and 
requirements for exceptions and adjustments to PPS rates.
     Develops and evaluates policies for developing and 
applying rates of increase and total cost limitations to payment for 
hospital inpatient services.
     Develops and evaluates criteria for exceptions to rates of 
increase and total cost limitations to payment for hospital inpatient 
services.
     Reviews requests for exceptions to ESRD, Tax Equity and 
Fiscal Responsibility Act and capital payment limitations and 
recommends approval or disapproval.
     Develops and evaluates national policies, regulations, and 
instructions for payment/reimbursement for the costs incurred by 
providers of services and other classes of facilities under the health 
insurance program.
     Formulates and evaluates national policies for all 
Medicare program provider financial filing and reporting requirements.
     Establishes policy for implementing payment controls and 
cost containment programs.

(1) Division of Prospective Payment System (FKA31)

     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 
for 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 methods for classifying 
hospitals and hospital services to inpatients, including sole community 
hospitals, for determining prospective payments to hospitals and 
requirements for exceptions and adjustments to PPS rates.
     Formulates HCFA policy for development and maintenance of 
new and revised codes for the International Classification of 
Diseases--Ninth Revision--Clinical Modification (ICD-9-CM).
     Chairs, serves, or supports various committees such as the 
ICD-9-CM Coordination and Maintenance Committee, the National Committee 
on Vital and Health Statistics, the American Hospital Association 
Editorial Advisory Board for the Coding Clinic, and the HCFA coding 
work-group.
     Participates in the formulation and analysis of medical 
classification systems, such as Diagnosis Related Groups, mortality and 
other outcome groupings, and the Uniform Clinical Data Set.
     Prepares reports which analyze the effects of changes in 
coding policy on HCFA payments, quality of care, and changes in the 
case mix index.
     Serves as the principal organization within HCFA for the 
development, evaluation and implementation of the International 
Classification of Diseases, Tenth Revision.

(2) Division of Hospital Services (FKA32)

     Develops, evaluates and maintains policies, regulations, 
rulings and instructions pertaining to the capital prospective payment 
system for inpatient hospital services and payment for graduate medical 
education.
     Develops, evaluates and maintains criteria for exceptions 
to the established rates of increase and limitations on hospitals' 
costs for inpatient services and reviews fiscal intermediaries' 
recommendations on requests for exceptions.
     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 reviews Medicare coverage 
policies, conditions of participation, regulations, procedures and 
standards pertaining to services provided by hospitals (general, 
psychiatric, and swing bed hospitals as well as nonparticipating 
emergency hospitals--including hospital level of care, custodial care, 
active treatment in psychiatric hospitals, rehabilitation care in 
hospitals, alcohol and drug treatment, hospital care in lieu of 
nonavailable skilled nursing facility care and outpatient hospital 
services including psychiatric partial hospitalization services and 
outpatient services covered as inpatient services) and services in 
Christian Science Sanitoriums.
     Establishes the prospective payment rates applicable to 
capital-related costs for inpatient hospital services.
     Reviews and processes obligated capital determinations and 
extraordinary circumstances exception requests for additional payment 
under the capital prospective payment system.
     Monitors the impact of capital and graduate medical 
education payment methodologies on hospital classes and program 
payments.
     Analyzes and recommends legislative or administrative 
remedies to improve payment policies for graduate medical education and 
capital-related costs.
     Coordinates with staff on the Prospective Payment 
Assessment Commission and prepares an analysis and response to 
Commission recommendations pertaining to capital and graduate medical 
education.
     Formulates, maintains and evaluates national policies 
pertaining to the exclusion of certain categories of hospitals and 
hospital costs from the prospective payment system.

(3) Division of Cost Principles and Reporting (FKA33)

     Develops and evaluates national policies, regulations and 
instructions for payment/reimbursement 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 and develops policy directives and basic payment policy 
decision statements.
     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 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.
     Formulates the basic principles and policies for 
developing and applying limitations to the costs of health care.

(4) Division of End Stage Renal Disease (FKA34)

     Develops, evaluates and reviews policies, regulations and 
instructions concerning the coverage of renal dialysis and organ 
transplant services for Medicare beneficiaries, including the 
reasonableness, necessity and effectiveness of services furnished by 
these providers.
     Coordinates with other components, such as the Health 
Standards and Quality Bureau, the development and evaluation of health 
and safety standards for renal dialysis facilities and organ transplant 
centers.
     Analyzes payment data, develops, maintains and updates 
payment rates for End Stage Renal Disease (ESRD) services and covered, 
or related, transplantation services.
     Maintains continuing liaison with ESRD provider groups, 
organ procurement organizations, industry associations, patient 
organizations, medical associations, and other parties that relate to 
these specialty delivery systems.
     Participates in the development and evaluation of proposed 
legislation pertaining to the ESRD program and organ transplant issues.
     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.
     Develops and evaluates policies and regulations governing 
coverage and payment for transplants as well as the conditions to be 
met for Medicare approval of transplant centers.

f. Office of Physician and Ambulatory Care Policy (FKA4)

     Develops, evaluates and reviews national Medicare payment 
and coverage policy for physician and ambulatory care services, 
including physician and other practitioner services; radiology and 
diagnostic services; clinical laboratory, ambulance, drugs and other 
medical services; hospital outpatient and ambulatory surgical center 
(ASC) services; and special delivery systems, including rural health 
clinics (RHCs) and federally qualified health centers (FQHCs).
     Assists in the development and evaluation of related 
legislation concerning payment and coverage policies, including health 
and safety and utilization effectiveness standards, for physician and 
ambulatory care services.
     Serves as the principal organization within HCFA for 
evaluating the medical aspects of Medicare coverage issues. Coordinates 
with other components, such as the Health Standards and Quality Bureau, 
in developing and evaluating health quality and safety standards for 
physician and ambulatory care services under Medicare.
     Coordinates with and reviews recommendations from the 
Prospective Payment Assessment Commission and the Physician Payment 
Review Commission.
     Develops and maintains fee schedules for physician, 
radiology and diagnostic services.
     Develops and maintains fee schedules for independent 
laboratory services and ambulatory surgical centers.
     Develops payment policy for special forms of health care 
delivery such as hospital outpatient departments, ASCs, RHCs and FQHCs, 
including the development of prospective payment systems.
     Establishes policy for implementing payment controls and 
cost containment programs.
     Develops, evaluates, and reviews national Medicare 
coverage issues concerning the reasonableness and necessity for medical 
and related services.
     Participates in the formulation and use of medical codes 
under the HCFA Common Procedure Coding System and develops common 
medical coding standards and policy.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of Medicare coverage 
and payment policy to program contractors and the health care field.
     Identifies, studies, and makes recommendations for 
modifying Medicare payment and coverage policies and health and safety 
standards to reflect changes in beneficiary health care needs, program 
objectives, and the health care delivery system.

(1) Division of Outpatient Surgery and Services (FKA41)

     Develops and evaluates coverage and payment policies and 
participation requirements for hospital outpatient services and 
ambulatory surgical centers (ASCs).
     Develops, evaluates, and reviews regulations, manuals, 
program guidelines, and instructions required for the dissemination of 
program policies to program contractors and the health care field.
     Participates in the development and evaluation of proposed 
legislation pertaining to hospital outpatient services and ASCs.
     Formulates policies and principles for developing, 
evaluating and updating payment rates for hospital outpatient services 
and ASCs.
     Develops innovative payment policies and rate setting 
systems designed to promote efficiency and economy for ASC and hospital 
outpatient services, including the development of prospective payment 
systems, as appropriate.
     In cooperation with other components, such as the Health 
Standards and Quality Bureau, develops and evaluates health quality and 
safety standards for ASCs.
     Maintains continuing liaison with provider groups, 
industry associations, patient organizations, medical associations, and 
other parties that relate to outpatient facility services and ASCs.
     Provides interpretations of established policies and 
technical assistance to regional offices, State agencies, fiscal 
intermediaries, suppliers of services,congressional staff,and other 
departmental offices.
     Coordinates with and reviews recommendations from the 
Prospective Payment Assessment Commission.
     Coordinates with other components responsible for health 
and safety standards, program operations, and quality control, 
professional groups and standard setting organizations, and with other 
parties and individuals, as appropriate.
     Identifies, studies, and makes recommendations for 
modifying Medicare policies and providers' health and safety standards 
to reflect changes in beneficiary health care needs, program 
objectives, and the health care delivery system.
     Reviews policies developed by other components for their 
impact on hospital outpatient and ASC services.

(2) Division of Ambulatory Care Services (FKA42)

     Develops and evaluates coverage and payment policies and 
participation requirements for clinical laboratory services, ambulance 
services, drugs and special payment delivery systems, including rural 
health clinics and federally qualified health centers.
     Develops, evaluates, and reviews regulations, manuals, 
program guidelines, and instructions required for the dissemination of 
program policies to program contractors and the health care field.
     Participates in the development and evaluation of proposed 
legislation pertaining to clinical laboratory services, ambulance 
services, drugs and special payment delivery systems.
     Identifies, studies, and makes recommendations for 
modifying Medicare policies and providers' health and safety standards 
to reflect changes in beneficiary health care needs, program 
objectives, and the health care delivery system.
     Develops and maintains the fee schedule for clinical 
laboratory services.
     Establishes payment policies for blood, blood products and 
hemophilia clotting factors.
     Formulates payment methods for drugs provided by 
physicians (e.g., injectable drugs, vaccines, chemotherapy agents), and 
drugs used in connection with durable medical equipment.
     Develops innovative payment policies and rate setting 
systems designed to promote efficiency and economy for clinical 
laboratory services, ambulance services, drugs and special payment 
delivery systems.
     Maintains continuing liaison with provider groups, 
industry associations, patient organizations, medical associations, and 
other parties.
     Provides interpretations of established policies and 
technical assistance to regional offices, State agencies, fiscal 
intermediaries, suppliers of services, congressional staff, and other 
departmental offices.
     Coordinates with other components responsible for health 
and safety standards, program operations, and quality control, 
professional groups and standard setting organizations, and with other 
parties and individuals, as appropriate.
     Reviews policies developed by other components for their 
impact on clinical laboratory services, ambulance services, drugs and 
special payment delivery systems.

(3) Division of Physician Services (FKA43)

     Develops and maintains fee schedules for physician 
services, radiology and certain diagnostic services. This includes 
establishment and revision of relative value units, geographic 
adjusters, and site of service differentials.
     Formulates and evaluates national policies and health and 
safety standards for Medicare coverage and payment for physician 
services including the determination of policies related to the payment 
of provider-based physicians, teaching physicians, interns, and 
residents.
     Develops, evaluates and reviews policies, regulations, 
rulings and guidelines pertaining to services excluded from Medicare 
coverage.
     Develops, evaluates, and reviews national Medicare 
policies concerning reasonableness and necessity for services.
     Develops, evaluates, and reviews national Medicare payment 
policies, including global payment rates for surgical services and 
separate payment for supplies.
     Develops, evaluates and reviews national policies 
pertaining to the coverage of items and services furnished by 
physicians and services incident to the services of physicians.
     Develops recommendations for annual physician fee schedule 
revisions (e.g., relative values and geographic adjusters), including 
preparation of Federal Register notices and reports and recommendations 
to the Congress.
     Drafts program regulations, manuals, guidelines, and other 
general instructions related to the coverage and payment of physician 
services.
     Administers the Medicare Volume Performance Standards 
(MVPS), including preparing Federal Register notices with respect to 
the MVPS and update and developing annual reports and recommendations 
to the Congress.
     Participates in the development and evaluation of proposed 
legislation in the area of medical services coverage and payment and 
recommends alternatives that will improve current methods of payment 
and coverage, health and safety, and utilization effectiveness.
     Participates in the formulation and use of medical codes 
under the HCFA Common Procedure Coding System and develops common 
medical coding standards and policy.
     Coordinates with other HCFA bureaus, divisions, and 
offices, the Social Security Administration, and Departmental 
components in the development of coverage and payment policies for 
medical services.
     Provides interpretations of established policies and 
technical assistance to the Social Security Administration, 
Departmental and HCFA components, regional offices, intermediaries, 
carriers and State agencies.
     Coordinates with and reviews recommendations from the 
Physician Payment Review Commission.
     Identifies, studies, and makes recommendations for 
modifying Medicare coverage and payment policies to reflect changes in 
beneficiary health care needs, program objectives, and the health care 
delivery system.
     Initiates special studies in response to identified 
problems in payment or coverage of physician services.
     Reviews policies developed in other areas for their impact 
on physician payment.

g. Office of Chronic Care and Insurance Policy (FKA5)

     Develops and evaluates national Medicare policies and 
standards on the coverage of and payment methods for services provided 
by skilled nursing facilities, home health agencies, hospices, 
comprehensive outpatient rehabilitation facilities, community mental 
health centers, and outpatient rehabilitation therapy providers. 
Develops and evaluates requirements for participation of these 
providers in Medicare.
     Develops and evaluates national Medicare policies and 
standards on the coverage of mental health services, including partial 
hospitalization, clinical psychologists' services, and clinical social 
workers' services.
     Develops and evaluates national Medicare policies and 
principles for applying limitations to the costs of skilled nursing 
facilities. Develops criteria for exceptions to cost limitations and 
reviews and makes decisions on skilled nursing facility requests for 
such exceptions.
     Develops and evaluates national Medicare policies and 
standards on entitlement to hospital insurance and supplementary 
medical insurance, premium amounts and collection, general requirements 
for payment of claims, beneficiary rights and protections, limitation 
on liability, hearings and appeals, technical exclusions, and other 
technical issues.
     Develops and evaluates national Medicare policies and 
standards on Medicare as secondary payer, coordination of other payers' 
benefits with Medicare, and Medicare supplemental insurance (Medigap).
     Develops and evaluates national Medicare policies and 
standards on the coverage of and payment methods for durable medical 
equipment, orthotics, prosthetics, braces, splints, and other supplies 
and devices.

(1) Division of Skilled Nursing Care (FKA51)

     Develops and evaluates national Medicare policies and 
standards on the coverage of and payment methods for services provided 
by skilled nursing facilities. Develops and evaluates requirements for 
participation of skilled nursing facilities in Medicare and nursing 
facilities in Medicaid.
     Develops and evaluates national Medicare policies and 
principles for applying limitations to the costs of skilled nursing 
facilities. Develops criteria for exceptions to and exemptions from 
cost limitations. Reviews and makes decisions on skilled nursing 
facility requests for such exceptions or exemptions.
     Develops and evaluates national Medicare policies and 
standards on spell of illness, and the deductibles, coinsurance, and 
benefit limits applicable to skilled nursing facilities.
     Develops, evaluates, and reviews national Medicare 
policies and standards relating to subacute care.
     Participates in the development and evaluation of a 
prospective payment system for skilled nursing facility services.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of policies to Medicare 
contractors and the health care field.

(2) Division of Home Care and Therapy (FKA52)

     Develops and evaluates national Medicare policies and 
standards on the coverage of and payment methods for services provided 
by home health agencies, hospices, comprehensive outpatient 
rehabilitation facilities, community mental health centers, and 
outpatient rehabilitation therapy providers. Develops and evaluates 
requirements for participation of these providers in Medicare.
     Develops and evaluates national Medicare policies and 
standards on the coverage of mental health services, including partial 
hospitalization, clinical psychologists' services, and clinical social 
workers' services.
     Develops and evaluates national Medicare policies and 
standards on the deductibles, coinsurance, and benefit limits 
applicable to the provider and practitioner services described above.
     Develops, evaluates, and reviews national Medicare 
policies and standards relating to managed care organizations.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of policies to Medicare 
contractors and the health care field.

(3) Division of Beneficiary and Insurance Issues (FKA53)

     Develops and evaluates national Medicare policies and 
standards on entitlement to Medicare hospital insurance and 
supplementary medical insurance, premium amounts and collection, 
general requirements for payment of claims, beneficiary rights and 
protections, limitation on liability, hearings and appeals, technical 
exclusions, and other technical issues.
     Develops and evaluates national Medicare policies and 
standards on Medicare as secondary payer, coordination of other payers' 
benefits with Medicare, and Medicare supplemental insurance (Medigap).
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of policies to Medicare 
contractors, social security offices, and the health care field.
     Maintains liaison with other Federal agencies such as the 
Social Security Administration, the Department of Veterans Affairs, and 
the Office of Personnel Management to coordinate policies in areas of 
mutual concern.

(4) Division of Durable Medical Equipment and Devices (FKA54)

     Develops and evaluates national Medicare policies and 
standards on the coverage of and payment methods for durable medical 
equipment, orthotics, prosthetics, braces, splints, and other supplies 
and devices.
     Develops and evaluates national Medicare policies and 
standards concerning restrictions on referrals by physicians to 
entities in which they have an ownership interest.
     Provides administrative support and management for Levels 
2 and 3 of the Health Care Financing Administration's Common Procedure 
Coding System.
     Develops, evaluates, and reviews regulations, guidelines, 
and instructions required for the dissemination of policies to Medicare 
contractors and the health care field.

    Dated: November 1, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-28398 Filed 11-16-94; 8:45 am]
BILLING CODE 4120-01-P