[Federal Register Volume 60, Number 148 (Wednesday, August 2, 1995)]
[Notices]
[Pages 39404-39409]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-18977]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Statement of Organization, Functions, and Delegations of 
Authority; Update of Regional Office Division Level Functional 
Statements

    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. 14658-14659, dated Tuesday, March 29, 1994) is being amended to 
reflect changes to the functional statements to the Division level 
components within the HCFA Regional Offices (ROs). Eight of the ROs 
propose to streamline their organizational structure in accordance with 
HCFA's Strategic Plan (SP) and the recommendations contained in the 
National Performance Review. Seattle plans to streamline as a 
demonstration project to last up to 18 months. Seattle will establish 
seven organizations, called Clusters, that will report to the Office of 
the Regional Administrator (ORA). The other ROs will retain the basic 
three division structure, including the Division of Health Standards 
and Quality (DHSQ), the Division of Medicaid, and the Division of 
Medicare, in each of the ROs affected by this proposal. The changes to 
the functional statements at the division level are minor and can best 
be characterized as updates and clarifications of functional 
responsibilities. The primary changes occur at the branch level where 
the ROs propose to realign components to improve services to 
beneficiaries, streamline their functions, to reduce the number of 
supervisory positions, enhance employee empowerment and meet the goals 
of the HCFA SP. The functional responsibilities of the Division of 
Medicare and the Division of Medicaid are the same in all regions, 
except Seattle, with minor variations indicated in the functional 
statements.
    The functional statements for DHSQ and the Divisions of Medicaid 
and Medicare in Denver and San Francisco are being republished. The 
functional statements for these two ROs will remain operational until 
revised by a proposal later in the year. There are thus four distinct 
functional statements for the DHSQ due to variations caused by the 
concentration of primary responsibility for medical review activities 
in three regions (Boston, Dallas, and Kansas City). The other ROs will 
continue to have responsibility for some aspects of medical review but 
will not have the primary responsibility for the function. The first 
statement applies to those ROs (New York, Philadelphia, Atlanta, and 
Chicago) that do not have primary responsibility for the medical review 
function. The second statement applies to two of the ROs that have 
primary medical review responsibility, Boston and Dallas. In both of 
these regions, the medical review function will be assigned to DHSQ. 
The third DHSQ statement applies to Kansas City, where the medical 
review function will be assigned to the immediate ORA rather than DHSQ. 
The fourth statement applies to the Denver and San Francisco which 
retain the current DHSQ functional responsibility until revised by a 
streamlining proposal later this year.
    The functional statements for DHSQ and the Division of Medicaid and 
the Division of Medicare in Denver and San Francisco are being 
republished to avoid confusion.
    The specific amendments to Part F. are as follows:
     Section F.10.D.6 (Organization) is amended to read as 
follows:
6. Office of the Regional Administrator
a1.  Division of Health Standards and Quality (FLD(2-5)A)
a2.  Division of Health Standards and Quality (FLD(1,6)A)
a3.  Division of Health Standards and Quality (FLD(7)A)
a4.  Division of Health Standards and Quality (FLD(8,9)A)
b1.  Division of Medicaid (FLD(1-4, 6-7)B)
b2.  Division of Medicaid and Managed Care (FLD(5)B)
b3.  Division of Medicaid (FLD(8-9)B)
c1.  Division of Medicare (FLD(1-7)C)
c2.  Division of Medicare (FLD(8-9)C)
d1.  Medicare Operations and Policy Cluster (FLDXD)
d2.  Medicaid Operations and Policy Cluster (FLDXE)
d3.  Program Fiscal Integrity Cluster (FLDXF)
d4.  Consumer Services and Information Cluster (FLDXG)
d5.  Managed Care Operations Cluster (FLDXH)
d6.  Health Care Quality Improvement Cluster (FLSXJ)
d7.  Certification Improvement Cluster (FLDXK)

    Section F.20.D.6.a (Functions) is amended to read as follows:
a1.  Division of Health Standards and Quality (FLD(2-5)A)
     Assures that health care services provided under the 
Medicare, Medicaid, and CLIA 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 or alternative sanctions 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 and monitors joint State survey agency/ESRD 
Network activities.
     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 
COBRA dumping, sanctions and civil money penalties.
     Actively participates in and takes a lead role in 
training, outreach and 

[[Page 39405]]
collaborative activities involving providers, provider groups, and 
State survey agencies, relating to quality of health care services.
     Provides leadership in the development, implementation and 
continuation of Continuous Quality Improvement activities for the State 
survey agencies and providers.
     Directs RO activities in support of HCFA's National 
Managed Care Program.

a2. Division of Health Standards and Quality (FLD(1,6)A)

     Oversees, monitors, coordinates, and evaluates the State 
Survey agencies, Peer Review Organizations (PROs), and ESRD Networks.
     Assures that health care provided under the Medicare, 
Medicaid, and CLIA programs are appropriate, of high quality, and meet 
recognized professional standards of care.
     Improves the quality of care provided to Medicare 
beneficiaries by administration of the PROs and ESRD Network programs, 
hereafter referred to as Quality Improvement Programs (QIPs). Under the 
Health Care Quality Improvement Program (HCQIP), QIPs collaborate with 
providers to identify and act upon opportunities for the quality of 
health care services.
     Oversees the negotiation and award of contracts for QIPs.
     Interprets and implements health and safety standards and 
evaluates, through surveillance, and surveys, their impact on the 
utilization and quality of health care services.
     Evaluates services to ensure protection of beneficiaries 
receiving health care services under the Medicare, Medicaid, and CLIA 
programs.
     Provides leadership and direction in beneficiary 
information and outreach activities concerning health care services, 
including information to enable beneficiaries to make informed health 
care choices.
     Determines program eligibility for all providers and 
suppliers under the Medicare program, and executes required agreements.
     Initiates, implements, and coordinates State related 
adverse actions and alternative remedies, including civil money 
penalties, and Federal activities against health care facilities not in 
compliance with Medicare or CLIA requirements.
     Makes final determination on all budget request submitted 
by State survey agencies.
     Establishes and maintains an extensive data and 
information gathering system involving all aspects of the certification 
program, CLIA, and QIPs.
     Authorizes investigation of complaints received from 
beneficiaries, the public, the Congress, the media, and other sources 
which allege deficiencies in the quality of care rendered by certified 
health care providers.
     Actively participates in and takes a lead role in 
training, outreach and collaborative activities involving providers, 
provider groups, health care professionals, professional 
reorganizations, consumer groups, and State survey agencies, relating 
to quality of health care services.
     Provides leadership in the development, implementation and 
continuation of continuous Quality Improvement activities for the State 
survey agencies and providers.
     Provides leadership in the quality improvement aspects of 
HCFA's National Managed Care Program.
     Develops and conducts training programs for the State 
survey agencies.
     Provides clinical assistance and technical direction to 
QIPs in the selection and evaluation of project, and develops, executes 
and measures HCFA directed cooperative clinical projects.

a3. Division of Health Standards and Quality (FLD(7)A)

     Oversees, monitors, and evaluates the State survey 
agencies and Medicaid State agencies.
     Assures that health care services provided under the 
Medicare, Medicaid, and CLIA programs are furnished in the most 
effective manner consistent with recognized professional standards of 
care.
     Interprets and implements health and safety standards and 
evaluates, through surveillance, assessments and surveys, their impact 
on the utilization and quality of health care services.
     Determines approval, denial, or termination of all 
provider and supplier certification actions under the Medicare program.
     Implements and coordinates State, Contractor, and carrier 
activities related to adverse sanctions and alternative remedies.
     Makes final determination on all budget requests submitted 
by State survey agencies.
     Establishes and maintains an extensive data and 
information gathering system involving all aspects of the 
certification.
     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.
     Actively participates in and takes a lead role in 
training, outreach and collaborative activities involving providers, 
provider groups, and State survey agencies, relating to quality of 
health care services.
     Provides leadership in the development, implementation and 
continuation of continuous Quality Improvement activities for the State 
survey agencies and providers.

a4.  Division of Health Standards and Quality (FLD(8,9)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.

b1. Division of Medicaid (FLD(1-4,6-7)B)

     Plans, manages and provides Federal leadership to State 
agencies in program development, implementation, maintenance, and the 
regulatory review of State Medicaid program management activities under 
title XIX of the Social Security Act.
     Plans, directs, coordinates, and approves Medicaid State 
agency data processing systems (including MMIS)), proposals, 
modifications, operations, 

[[Page 39406]]
contracts, and reviews. Assists Medicaid State agencies in developing 
innovative automated data processing health care systems. Assures the 
propriety of Federal expenditures.
     Reviews, evaluates, and determines acceptability of audit 
findings and recommendations and takes necessary clearance and closure 
actions.
     Maintains day-to-day liaison with State agencies and 
monitors their Medicaid program activities and practices by conducting 
periodic program management and financial reviews to assure State 
adherence to Federal law and regulations.
     Reviews, approves, recommends disapproval, and maintains 
official State plans and plan amendments for medical assistance.
     Reviews, approves, and monitors State payment systems and 
determines the allowablity of claims for Federal financial 
participation. Takes action to disallow claims when expenditures are 
not in accordance with Federal requirements and defends such action 
before the Departmental Appeals Board and in court. Defers payment 
action on questionable State claims for allowability.
     Reviews States' Medicaid quarterly estimates and statement 
of expenditures and recommends the amount to be estimated and allowed 
in the quarterly grants.
     Implements title XIX special initiatives and special or 
experimental programs such as Maternal and Child Health, Acquired 
Immune Deficiency Syndrome, statewide 1115 waivers, Freedom of Choice 
Waivers (1915(b), Home and Community Based Services Waivers (1915c), 
and operations of major management initiatives.
     Provides consistent guidance, technical assistance, and 
policy interpretation to States on Medicaid program and financial 
issues.
     Responds to beneficiary, Congressional, provider, and 
public inquiries concerning Medicaid issues, including Freedom of 
Information Act requests.
     Conducts customer outreach and service initiatives.
     Reviews and approves managed care contracts and prepaid 
health plans.

b2. Division of Medicaid and Managed Care (FLD(5)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.
     Directs activities in support of the Medicare managed care 
program including technical support and oversight of these plans.
     Reviews, approves or recommends for disapproval, and 
monitors State institutional payment plans and systems (after CO 
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, managed care 
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.

b3. Division of Medicaid (FLD(8-9)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 CO 
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.

c1. Division of Medicare (FLD(1-7)C)

     Directs Medicare program administration through working 
relationship with contractors, providers, physicians, beneficiaries, 
the Social Security Administration district offices, the Administration 
on Aging, the Office of Inspector General, and other Federal agencies, 
as well as local and national 

[[Page 39407]]
organizations and individuals, as required.
     Directs the review and revaluation 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.
     Monitor all aspects of contractor performance including 
claims/bills processing; coverage decisions; Medical Review; the 
detection of fraud, abuse, and waste in the Medicare Program; 
overpayment identification and collection; Medicare Secondary Payer 
(MSP); provider payment and audit; payment to physicians and suppliers; 
and electronic media claims.
     Coordinates on-going contractor fiscal management 
activities, including subcontracting, cash management activities, and 
compliance with the Chief Financial Officers Act.
     Negotiates and approves Medicare contractor budget and 
budget modifications.
     Directs and coordinates Medicare contractor system and 
workload transaction activities. Provides advice in the development of 
the Medicare Transaction System (MTS).
     Evaluates Medicare contractor performance and prepares 
annual Report of Contractor Performance.
     Manages beneficiary, provider, and public information 
programs.
     Recommends renewals, non-renewals, rescissions, and 
terminations of Medicare contracts.
     Coordinates the ESRD program.

c2. Division of Medicare (FLD(8, 9)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.

d1. Medicare Operations and Policy Cluster (FLDXD)

     Directs and coordinates the assessment of Medicare fiscal 
intermediary contractor performance to ensure compliance with their 
Medicare contracts. Oversees corrective action and resolution of 
operational problems.
     Integrates program integrity considerations into all 
aspects of contractor operations to manage trust fund and general fund 
expenditures in a responsible manner, referring potential fraud cases 
for development and action to the Program Fiscal Integrity Cluster.
     Applies data analysis to assess risk and/or vulnerability 
of payment policies to ensure appropriateness of program expenditures 
and recommends policy and procedure changes to CO as needed.
     Monitors, evaluates, and assesses Medicare contractors' 
performance.
     Recommends renewals, non-renewals, rescissions, and 
terminations of Medicare contracts.
     Monitors the Medicare Common Working File host 
contractor's performance and oversees the operations and interfaces of 
the host and satellites.
     Provides specialized technical support and expertise to 
Medicare contractors and other HCFA components in such areas as ESRD, 
rural health clinics, Part B payment, medical review, coverage, and 
coding issues.
     Oversees and evaluates Part B payment changes and Part A 
and Part B medical review activities.
     Directs the review of Medicare contractor data processing 
systems, proposals, and modifications.
     Reviews, negotiates, and recommends approval of contractor 
budgets, modifications to budget allotments, and final settlement of 
contractor costs.
     Monitors Medicare contractor banking activities and 
recommends approval of contractor banking agreements.
     Maintains letter of credit and allotment controls on 
Medicare contractors to monitor funds drawn for administrative 
purposes.
     Provides technical assistance to Medicare contractors in 
implementing corrective actions, resolving operational problems, 
improving their contract performance, and in implementing special HCFA 
initiatives.
     Conducts special studies of contractor's performance and 
identifies opportunities for improving contractor's effectiveness.
     Coordinates and provides guidance to Medicare contractors 
and providers/suppliers in resolving billing, payment, coverage, claims 
processing, and customer service issues.
     Evaluates proposed regulatory and policy changes to the 
Medicare program and makes recommendations for CO consideration.
     Provides specialized technical support and oversight in 
such areas as Part A and Part B appeals.

d2. Medicaid Operations and Policy Cluster (FLDXE)

     Directs and coordinates the assessment of Medicaid State 
agencies compliance with the Medicaid State plans, with the exception 
of institutional payment State plans.
     Provides specialized technical support and expertise to 
Medicaid State agencies and other HCFA components including those 
related to non-institutional payment; early and periodic screening, 
diagnosis, and treatment; third-party liability; eligibility, 
entitlement, and coverage of health services; the Vaccines for Children 
program, and maternal and infant health.
     Provides technical assistance to State agencies in 
implementing corrective actions, resolving problems, and improving the 
effectiveness of their performance.
     Negotiates compliance issues and other problems with State 
agency management.
     Reviews and approves Medicaid State plan amendments, 
except for institutional payment State plans.
     Oversees, coordinates, and assesses the operation of State 
Medicaid Home and Community-Based Services Waivers.
     Provides highly specialized technical direction and 
assistance to States regarding computer systems applications, 
particularly for the Medicaid Management Information System (MMIS) and 
the Family Assistance Management Information System procurement, 
development, and installations. 

[[Page 39408]]


d3. Program Fiscal Integrity Cluster (FLDXF)

     Conducts annual System Performance Reviews on MMIS 
computer systems to validate their compliance with Federal 
specifications as well as to confirm their ongoing eligibility for 
enhanced Federal funding.
     Oversees fiscal operations of the Medicare and Medicaid 
programs.
     Provides leadership and technical assistance to Medicaid 
State agencies in the development and maintenance of their Medicaid 
financial management activities, including the recovery of Medicaid 
overpayments, Medicaid utilization control; and inspection of care 
reviews.
     Conducts periodic comprehensive on-site financial reviews 
to assure State adherence to Federal laws, regulations, and State 
plans. Provides technical expertise and guidance in the financial 
system and cost allocation areas.
     Reviews State quarterly statements of expenditures and 
recommends appropriate actions (including acceptance, deferral or 
disallowance) on amounts claimed; and in a case of disallowance, 
prepares HCFA position for Departmental Appeals Board.
     Reviews State Medicaid budget estimates projecting future 
Federal funding requirements and recommends appropriate State funding 
levels to CO.
     Reviews, approves, or recommends disapproval, and monitors 
State institutional payment plans and systems for hospitals and nursing 
facilities, and determines the allowability or nonallowability of 
claims for Federal financial participation (FFP); and where State 
expenditures have not been made in accordance with an approved plan or 
Federal requirements, takes action to disallow such claims.
     Reviews the effectiveness of specific Medicaid program 
areas operated by State agencies, using data analysis techniques to 
assess whether the State program meets intent.
     Together with State agency staff, develops studies to help 
the State assess its own effectiveness.
     Participates with CO components in the development and 
design of quality measurements of the Medicaid program's effectiveness.
     Evaluates Medicare contractor's activities involving 
Medicare Secondary Payor (MSP) performance and negotiates MSP 
subrogation cases.
     Monitors and negotiates the settlement and resolution of 
audit findings pertaining to the Medicare or Medicaid programs which 
originate from HHS' Office of Inspector General or the General 
Accounting Office.
     Conducts quality assurance reviews of Medicare contractor 
claims payment operations.
     Monitors Medicare contractor overpayment identification 
and collection activities, pursues collection of overpayments referred 
to the RO, authorizes extended repayment schedules, assists regional 
counsel in bankruptcy cases; prepares overpayment cases for offset 
against Medicaid payments and Internal Revenue Service refunds; and 
refers cases to the Department of Justice for possible litigation as 
appropriate.
     Provides technical assistance to Medicare contractors, 
Medicaid State agencies, and other HCFA components in the area of 
Medicare and Medicaid payment and fiscal administration.
     Performs special studies of Medicare institutional payment 
practices and recommends corrective action to close loopholes 
identified.
     Conducts the Medicare cost report evaluation program.
     Recommends approval or disapproval of common audit 
agreements, rural referral centers, and sole community provider 
exemption requests.
     Performs reviews of allowability of costs claimed by 
Medicare contractors on the Final Administrative Cost Reports.
     Monitors and reviews Medicare contractors compliance with 
the Chief Financial Officer's Act.
     Directs the region's efforts to develop and refer cases of 
suspected fraud in Medicare and Medicaid, maintaining close contact 
with OIG, Medicaid fraud units at State Agencies, and the Department of 
Justice.
     Coordinates fraud and abuse activities with other HCFA 
ROs, Medicare contractors, other third party payers, and CO.
     Reviews the effectiveness of specific Medicaid program 
areas operated by State agencies, using data analysis techniques to 
assess whether the State program meets intent.

d4. Consumer Services and Information Cluster (FLDXG)

     Ensures that Medicare and Medicaid beneficiaries are 
informed of HCFA program benefits, rights, and responsibilities through 
a comprehensive marketing strategy to varied audiences.
     Monitors, evaluates, and assesses the performance of 
Medicare contractors in their beneficiary outreach and service 
organizations.
     Coordinates the operation of a public information and 
outreach programs directed at beneficiary groups, professional 
organizations, advocacy organizations, other health care entities, and 
the media.
     Directs the implementation of HCFA beneficiary services 
initiatives, such as the Medigap, Retired Senior Volunteer Programs, 
Information Counseling Assistance grants, and Qualified Medicare 
Beneficiary (QMB) programs.
     Provides direction, technical assistance, and training to 
the Social Security Administration district offices concerning Medicare 
entitlement, post-entitlement, and beneficiary education functions, and 
monitors the performance of these functions.
     Coordinates and controls the processing of responses to 
all beneficiary, provider, and Congressional inquiries.
     Provides specialized technical support and oversight in 
such areas as QMB and buy in.
     Works closely with local congressional and Governor's 
offices to provide a full array of constituent services and support.

d5. Managed Care Operations Cluster (FLDXH)

     Conducts a broad range of activities to oversee the 
operation of Medicare and Medicaid managed care plans to protect access 
to care and to enhance access to care, especially in rural or other 
undeserved areas.
     Provides leadership and oversight of health care delivery 
systems in Medicare and Medicaid that depart from the traditional fee-
for-service model.
     Provides technical advice to health care plans that want 
to enter into risk and cost contracts for Medicare.
     Evaluates applications from managed care plans to become 
Medicare risk or cost contractors and/or expand operations to assure 
compliance with applicable laws and regulations; recommends approval or 
denial of such applications.
     Reviews and approves managed care plan marketing materials 
to assure adherence to laws and regulations and to assure that Medicare 
beneficiaries receive appropriate and clear information about the 
plans' benefit package and consumer protection.
     Assures contract compliance through periodic monitoring of 
plan performance.
     In cases of non-compliance, approves corrective action 
plan from the managed care plans and monitors adherence to the 
corrective action plan.
     Maintains ongoing relations with managed care plans in the 
region and works with central office to resolve problems plans have 
with HCFA policy 

[[Page 39409]]
or procedures; recommends changes to CO in policy and procedures as 
appropriate.
     Operates a program of beneficiary services that includes 
direct contact with the Medicare beneficiary to resolve problems with 
particular plans, contract through congressional offices concerning 
beneficiary problems, and contact plans to resolve beneficiary 
problems.
     Resolves systems problems that affect beneficiary 
eligibility/entitlement under a particular managed care plan.
     Receives and evaluates complaints from beneficiaries 
concerning quality of care and refers such complaints to PROS for 
further investigation as appropriate.
     Conducts data analysis of plan performance indicators to 
determine whether plans need technical assistance or corrective action.
     Through ongoing information gathering in the health care 
marketplace, provides early warning to CO on polices that might impede 
the risk contracting in Medicare as commercial/public member limits and 
rate setting.
     Provides leadership and technical support to States in 
designing and implementing Medicaid managed care programs.
     Evaluates requests for freedom of choice waivers for 
Medicaid managed care plans to assure that access to care is maintained 
or enhanced and that projected costs comply with applicable law and 
regulation.
     Reviews and approves contracts between States and 
providers to assure compliance with Federal law and regulation.
     Provides early technical assistance to States that plan to 
apply for Section 1115 waivers to implement Statewide health care 
reform.
     Works closely with CO to evaluate requests for Section 
1115 waivers, assuming a lead role when the waiver is approved and 
implementation begins.
     Provides ongoing technical assistance to States with 
active statewide Section 1115 waivers to assure that conditions of the 
waiver are adhered to and that access to care is adequate.
     Provides technical assistance to States in finding 
creative and new methods of delivering Medicaid services through a 
variety of managed care arrangements.

d6. Health Care Quality Improvement Cluster (FLDXJ)

     Assures that medical care, paid for by Federal Medicare 
funds, is medically necessary and meets recognized professional 
standards and quality of care through funding and the monitoring of 
Peer Review Organizations (PROs) and ESRD Networks in a multi-regional 
geographic area.
     Provides leadership to PROs and networks to design 
projects that will improve care to Medicare beneficiaries.
     Maintains knowledge of HCFA data bases, as well as other 
large health related data bases, and uses these to evaluate care 
provided to the Medicare population.
     Oversees the PROs' development of local quality studies to 
assure scientific merit and program relevance.
     Encourages PROs and ESRD networks to work with providers 
to use the results of local quality studies to fashion interventions to 
improve care.
     Conducts special regionwide studies to evaluate care 
provided to Medicare beneficiaries, including beneficiary groups which 
may have special health care needs, and works through PROs to help 
providers design interventions to improve care.
     Disseminates useful information to providers and to 
beneficiaries to improve quality of care.
     Convenes groups at the local level to collaborate on 
studies involving the quality of care provided to the Medicare, 
Medicaid, and managed care populations; this includes bringing together 
variously funded sources such as universities, foundations, and State 
offices with similar interests in quality of care.
     Participates in the negotiation and award of contracts to 
PROs.
     Prepares technical and budget evaluations of contract 
proposals received from PROs, and makes judgments to commit Federal 
funds for program implementation.
     Monitors and assesses the overall quality performance of 
PROs including success in using local projects to improve care for 
Medicare beneficiaries.

d7. Certification Improvement Cluster (FLDXK)

     Manages the State agency evaluation program and assesses 
the performance of the State survey agency in their survey and 
certification review process for compliance with performance standards.
     Works with the States to design internal quality assurance 
programs.
     Negotiates State agency agreements and issues substantive 
regional guidelines containing policy and procedural interpretations 
relating to certification activities.
     Evaluates complaints from the public, media, Congress, and 
others alleging deficient standards in provider facilities, and 
instructs State agencies to investigate, as appropriate.
     Makes final recommendations on all initial budget and 
supplemental budget requests submitted by State agencies.
     Takes adverse actions against non-complying Medicare 
facilities.
     Establishes and maintains a data and information gathering 
system involving all aspects of the certification program.
     Conducts Federal surveys of providers and suppliers of 
health services to ensure that State monitoring is satisfactory.
     Performs or authorizes validation surveys in accredited 
institutions to determine their compliance with Federal standards.
     Conducts surveillance and assessment of State agency 
operations regarding quality of care, and assists them in developing 
the capability to provide direct assistance to providers and suppliers 
of health services in the improvement of their performance.
     Conducts studies, pilot projects, and experimental 
programs and assists in implementing techniques designed to improve the 
survey and certification process and peer review systems.
     Conducts training of State surveyors as needed and 
indicated by Federal monitoring.

    Dated: July 19, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 95-18977 Filed 8-1-95; 8:45 am]
BILLING CODE 4120-01-P