[Federal Register Volume 74, Number 134 (Wednesday, July 15, 2009)]
[Proposed Rules]
[Pages 34467-34487]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-16538]
[[Page 34467]]
-----------------------------------------------------------------------
Part III
Department of Health and Human Services
-----------------------------------------------------------------------
Centers for Medicare & Medicaid Services
-----------------------------------------------------------------------
42 CFR Parts 431, 447, and 457
Medicaid Program and Children's Health Insurance Program (CHIP);
Revisions to the Medicaid Eligibility Quality Control and Payment Error
Rate Measurement Programs; Proposed Rule
Federal Register / Vol. 74, No. 134 / Wednesday, July 15, 2009 /
Proposed Rules
[[Page 34468]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 431, 447, and 457
[CMS-6150-P]
RIN 0938-AP69
Medicaid Program and Children's Health Insurance Program (CHIP);
Revisions to the Medicaid Eligibility Quality Control and Payment Error
Rate Measurement Programs
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: This proposed rule would implement provisions from the
Children's Health Insurance Program Reauthorization Act of 2009
(CHIPRA) (Pub. L. 111-3) with regard to the Medicaid Eligibility
Quality Control (MEQC) and Payment Error Rate Measurement (PERM)
programs. This proposed rule would also codify several procedural
aspects of the process for estimating improper payments in Medicaid and
the Children's Health Insurance Program (CHIP).
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on August 14, 2009.
ADDRESSES: In commenting, please refer to file code CMS-6150-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions for
``Comment or Submission'' and enter the filecode to find the document
accepting comments.
2. By regular mail. You may mail written comments (one original and
two copies) to the following address only:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-6150-P, P.O. Box 8020, Baltimore, MD
21244-8020.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments (one
original and two copies) to the following address only:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-6150-P, Mail Stop C4-26-05, 7500
Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to either of the following addresses:
a. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue,
SW., Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey (HHH)
Building is not readily available to persons without Federal Government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. 7500 Security Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call (410) 786-9994 in advance to schedule your arrival with one
of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
Submission of comments on paperwork requirements. You may submit
comments on this document's paperwork requirements by following the
instructions at the end of the ``Collection of Information
Requirements'' section in this document.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Elizabeth Lindner, (410) 786-7481, or
Jessica Woodard, (410) 786-9249.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
A. Medicaid Eligibility Quality Control Program
The Medicaid Eligibility Quality Control (MEQC) program is set
forth in section 1903(u) of the Social Security Act (the Act) and
requires States to report to the Secretary the ratio of States'
erroneous excess payments for medical assistance to total expenditures
for medical assistance. Section 1903(u) of the Act also sets a 3-
percent threshold for improper payments in any fiscal year and the
Secretary may withhold payments to States based on the amount of
improper payments that exceed the threshold.
B. The Improper Payments Information Act of 2002
The Improper Payments Information Act of 2002 (IPIA) (Pub. L. 107-
300, enacted on November 26, 2002) requires the heads of Federal
agencies to annually review programs they oversee to determine if they
are susceptible to significant erroneous payments. If any programs are
found to be susceptible to significant improper payments, then the
agency must estimate the amount of improper payments, report those
estimates to the Congress, and submit a report on actions the agency is
taking to reduce erroneous expenditures. The IPIA directed the Office
of Management and Budget (OMB) to provide guidance on implementation.
OMB defines ``significant erroneous payments'' as annual erroneous
payments in the program exceeding both 2.5 percent of program payments
and $10 million (OMB M-06-23, Appendix C to OMB Circular A-123, August
10, 2006). For those programs found to be susceptible to significant
erroneous payments, Federal agencies must provide the estimated amount
of improper payments and report on what actions the agency is taking to
reduce them, including setting targets for future erroneous payment
levels and a timeline by which the targets will be reached.
The Medicaid program and the Children's Health Insurance Program
(CHIP) were identified as programs at risk for significant erroneous
payments. The Department of Health and Human Services (DHHS) reports
the estimated
[[Page 34469]]
error rates for the Medicaid and CHIP programs in its annual
Performance and Accountability Report (PAR) to Congress.
C. Regulatory History
1. Medicaid Eligibility Quality Control Program
Sections 431.800 through 431.865 set forth the regulatory
requirements for States to conduct the annual MEQC measurement. A
Medicaid State Operations letter (93-58) dated July 23, 1993
implemented MEQC pilots that allowed States to conduct special studies
that would take the place of the ``traditional'' MEQC review. States
conducting pilot reviews are not subject to the threshold and
disallowance provisions under section 1903(u) of the Act as long as the
special studies continue.
Currently, the MEQC program consists of the following:
MEQC traditional--Operating MEQC under 42 CFR 431.800
through 431.865 and selecting a random sample of all Medicaid
applicants and enrollees and reviewing them under guidance in the State
Medicaid Manual.
MEQC pilots--Operating MEQC under a special study, a
target population and providing oversight to reduce and prevent errors
and improve program administration.
MEQC waivers--Operating MEQC as a part of a CMS approved
section 1115 waiver and reviewing beneficiaries included in the
research and demonstration project.
2. Payment Error Rate Measurement (PERM) Program
Section 1102(a) of the Act authorizes the Secretary to establish
such rules and regulations as may be necessary for the efficient
administration of the Medicaid and CHIP programs. The Medicaid statute
at section 1902(a)(6) of the Act and the CHIP statute at section
2107(b)(1) of the Act require States to provide information that the
Secretary finds necessary for the administration, evaluation, and
verification of the States' programs. Also, section 1902(a)(27) of the
Act (and Sec. 457.950 of the regulations) requires providers to submit
information regarding payments and claims as requested by the
Secretary, State agency, or both. Under the authority of these
statutory provisions, we published in the August 27, 2004 Federal
Register (69 FR 52620) a proposed rule to comply with the requirements
of the IPIA and the OMB guidance. The proposed rule set forth
provisions for all States to annually estimate improper payments in
their Medicaid and CHIP programs and to report the State-specific error
rates for purposes of our computing the national improper payment
estimates for these programs.
In the October 5, 2005 Federal Register (70 FR 58260), we published
an interim final rule with comment period (IFC). The IFC responded to
public comments on the proposed rule, and informed the public of our
national contracting strategy and of our plan to measure improper
payments in a subset of States. Our State selection process ensures
that a State is measured once, and only once, every 3 years for each
program.
In response to the public comments from the October 5, 2005 IFC, we
published a second IFC in the August 28, 2006 Federal Register (71 FR
51050), which reiterated our national contracting strategy to estimate
improper payments in both Medicaid and CHIP fee-for-service (FFS) and
managed care, and set forth and invited further comments on State
requirements for estimating improper payments due to errors in Medicaid
and CHIP eligibility determinations. We also announced that a State's
Medicaid and CHIP programs would be reviewed in the same year.
In the August 31, 2007 Federal Register (72 FR 50490), we published
a final rule for the PERM program, which implements the IPIA
requirements. The August 31, 2007 final rule responded to the public
comments on the August 28, 2006 IFC and finalized State requirements
for submitting claims to the Federal contractors that conduct FFS and
managed care reviews. The final rule also finalized State requirements
for conducting eligibility reviews and estimating payment error rates
due to errors in eligibility determinations.
D. Children's Health Insurance Program Reauthorization Act of 2009
On February 4, 2009, the Children's Health Insurance Program
Reauthorization Act of 2009 (CHIPRA) (Pub. L. 111-3) was enacted.
(Please note, as a result of this legislation, that the program
formerly known as the ``State Children's Health Insurance Program
(SCHIP)'' is now referred to as the ``Children's Health Insurance
Program (CHIP)''). Sections 203 and 601 of the CHIPRA relate to the
PERM program.
Section 203 of the CHIPRA establishes an error rate measurement
with respect to the enrollment of children under the express lane
eligibility option. The law directs States not to include children
enrolled using the express lane eligibility option in data or samples
used for purposes of complying with the MEQC and PERM requirements.
Provisions for States' express lane eligibility option will be set
forth in a future rulemaking document.
Section 601 of the CHIPRA provides for a 90 percent Federal match
for Children's Health Insurance Program (CHIP) spending related to PERM
administration and excludes such spending from the 10 percent
administrative cap. (Section 2105(c)(2) of the CHIP statute gives
States the ability to use an amount up to 10 percent of the CHIP
benefit expenditures for outreach efforts, additional services other
than the standard benefit package for low-income children, and
administrative costs.)
The CHIPRA requires a new PERM rule and delays any calculation of a
PERM error rate for CHIP until 6 months after the new PERM rule is
effective. Additionally, the CHIPRA provides that States that were
scheduled for PERM measurement in fiscal year (FY) 2007 may elect to
accept a CHIP PERM error rate determined in whole or in part on the
basis of data for FY 2007, or may elect instead to consider its PERM
measurement conducted for FY 2010 as the first fiscal year for which
PERM applies to the State for CHIP. Similarly, the CHIPRA provides that
States that were scheduled for PERM measurement in FY 2008 may elect to
accept a CHIP PERM error rate determined in whole or in part on the
basis of data for FY 2008, or may elect instead to consider its PERM
measurement conducted for FY 2011 as the first fiscal year for which
PERM applies to the State for CHIP.
The CHIPRA requires that the new PERM rule include the following:
Clearly defined criteria for errors for both States and
providers.
Clearly defined processes for appealing error
determinations.
Clearly defined responsibilities and deadlines for States
in implementing any corrective action plans.
Requirements for State verification of an applicant's
self-declaration or self-certification of eligibility for, and correct
amount of, medical assistance under Medicaid or child health assistance
under CHIP.
State-specific sample sizes for application of the PERM
requirements.
In addition, the CHIPRA aims to harmonize the PERM and MEQC
programs and provides States with the option to apply PERM data
resulting from its eligibility reviews for meeting MEQC requirements
and vice versa, with certain conditions.
[[Page 34470]]
E. CMS Response to the CHIPRA
As required by the CHIPRA, we are proposing revised MEQC and PERM
provisions in this proposed rule.
Section 601(b) of the CHIPRA states that ``the Secretary shall not
calculate or publish any national or State-specific error rate based on
the application of the payment error rate measurement (in this section
referred to as `PERM') requirements to CHIP until after the date that
is 6 months after the date on which a new final rule (in this section
referred to as the `new final rule') promulgated after the date of the
enactment of this Act and implementing such requirements in accordance
with the requirements of subsection (c) is in effect for all States.''
The CHIP error rate for the FY 2008 cycle was scheduled to be published
in the FY 2009 PAR (in November 2009), which is less than 6 months
after the expected promulgation and effective date of this new final
rule. Therefore, the publication of any CHIP error rates for FY 2008 is
delayed until at least 6 months after the final rule implementing the
CHIPRA requirements for PERM is effective.
As noted above, section 601(d) of the CHIPRA provides that States
that were scheduled for PERM measurement in FY 2007 may elect to accept
a CHIP PERM error rate determined in whole or in part on the basis of
data for FY 2007, or may elect instead to consider its PERM measurement
conducted for FY 2010 as the first fiscal year for which PERM applies
to the State for CHIP. In addition, the CHIPRA provides that States
that were scheduled for PERM measurement in FY 2008 may elect to accept
a CHIP PERM error rate determined in whole or in part on the basis of
data for FY 2008, or may elect instead to consider its PERM measurement
conducted for FY 2011 as the first fiscal year for which PERM applies
to the State for CHIP.
Accordingly, a State measured in the FY 2007 cycle that elects to
accept the PERM error rate for its CHIP program determined in whole or
in part on the basis of data for FY 2007 is required to notify CMS of
its intentions through an acceptance form provided to all States in a
State Health Official letter. Similarly, a State measured in the FY
2008 cycle that elects to accept the PERM error rate for its CHIP
program determined in whole or in part on the basis of data for FY 2008
is required to notify CMS of its intentions through an acceptance form
provided to all States in a State Health Official letter. If a State
measured in the FY 2007 or FY 2008 cycles elects to reject the CHIP
PERM rate determined during those cycles, they do not need to notify
CMS of this decision. However, information from those cycles will not
be used to calculate the State-specific sample sizes and CMS will rely
on the standard assumptions for determining sample size.
In order for section 601(d) of the CHIPRA to be read in harmony
with the IPIA, which requires a CHIP PERM error rate to be calculated
annually, we believe that the appropriate reading of section 601(d) of
the CHIPRA, construing the law as a whole and giving effect to all
language of the CHIPRA, is that a State may only elect to reject the
PERM error rate for the State's CHIP program for FY 2007 or FY 2008 and
instead have its PERM error rate for its CHIP program measured in FY
2010 or FY 2011, respectively. A State scheduled for PERM measurement
in FY 2008 will still have its PERM error rate for its Medicaid program
measured.
Additionally, States scheduled for PERM measurement in FY 2009 will
have the CHIP program reviewed and error rates calculated after the
final rule is in effect. Furthermore, the FY 2009 Medicaid measurement
is proceeding with no delays as a result of the CHIPRA, and FY 2009
Medicaid error rates will be calculated under the new final rule.
II. Provisions of the Proposed Regulations
As a result of the CHIPRA, we are proposing a nomenclature change
to parts 431, 447, and 457. The program formerly known as the ``State
Children's Health Insurance Program (SCHIP)'' is now referred to as the
``Children's Health Insurance Program (CHIP).'' We are also proposing
the following revisions to the current PERM provisions:
A. Sample Sizes
Section 601(f) of the CHIPRA requires us to establish State-
specific sample sizes for application of the PERM requirements with
respect to CHIP for fiscal years beginning with the first fiscal year
that begins on or after the date on which the new final rule is in
effect for all States, on the basis of such information as the
Secretary determines appropriate. In establishing such sample sizes,
the Secretary shall, to the greatest extent practicable: (1) Minimize
the administrative cost burden on States under Medicaid and CHIP; and
(2) maintain State flexibility to manage such programs.
To comply with the IPIA, the PERM program must estimate a national
Medicaid and a national CHIP error rate that covers the 50 States and
District of Columbia. Consistent with OMB's precision requirements
defined in its IPIA guidance, the estimated national error rate for
each program must be bound by a 90 percent confidence interval of 2.5
percentage points in either direction of the estimate. Since States
administer Medicaid and CHIP and make payments for services rendered
under the programs, we collect State-level information at a high level
of confidence (the estimated error rate for a State must be bound by a
95 percent confidence interval of 3 percentage points in either
direction). To estimate the national error rate, as well as State-
specific error rates, reviews are conducted in three areas for both the
Medicaid and CHIP programs: (1) Fee-for-service (FFS), (2) managed
care, and (3) program eligibility. The FFS and managed care reviews are
referred to jointly as the ``claims review,'' while the program
eligibility review is referred to as the ``eligibility review.''
Samples of payments made on a FFS and managed care basis for the
claims review and samples of beneficiaries for the eligibility review
are drawn each year in order to calculate a national error rate that
meets the precision requirements described in OMB Guidance (OMB M-06-
23, Appendix C to OMB Circular A-123, August 10, 2006). The preferred
method is to achieve the precision goal with the smallest sample size
possible, so as to reduce the staff burden on States, the Federal
government, beneficiaries, and providers. We determined that the most
efficient method, statistically, is to draw a sample of States and then
draw a sample of payments from the payments made by the sampled States.
The process for drawing a sample of States is described in detail in
the preamble to the August 31, 2007 final rule (72 FR 50490). We are
not proposing modifications to the current approach, which samples 17
States per year for a PERM measurement cycle. This rulemaking addresses
the State-specific sample sizes for samples of claims and beneficiaries
within a State.
In light of the new CHIPRA requirements, we are proposing to add
new Sec. 431.972, to describe more fully the claims sampling
procedures used for the claims review, as well as the process for
establishing State-specific sample sizes for PERM, although we note
that the execution of these responsibilities would remain with CMS and
the Federal contractors, not with the States. Under the Secretary's
authority at section 1102(a) of the Act and in order to effectively
implement the IPIA, we are also proposing that these sampling
[[Page 34471]]
procedures apply to both Medicaid and CHIP.
We are also proposing to revise Sec. 431.978 to provide additional
guidance on State Medicaid and CHIP eligibility sample sizes by
clarifying the process for establishing State-specific sample sizes.
1. Fee-for-Service (FFS) and Managed Care
a. Universe Definition
In order to implement the IPIA and related requirements (OMB M-06-
23, Appendix C to OMB Circular A-123, August 10, 2006) that require
Federal agencies to estimate the amount of improper payments in
programs with significant erroneous payments (which includes Medicaid
and CHIP), in the current Sec. 431.970(a)(1) we require States to
submit ``[a]ll adjudicated fee-for-service (FFS) and managed care
claims information, on a quarterly basis, from the review year,'' so
that a sample of payments can be reviewed and from the review findings
CMS can estimate the amount of improper payments in each program. We
propose to remove the word ``all'' from Sec. 431.970(a)(1) because
certain types of payments are excluded from PERM sampling and review
for technical reasons. This requirement has been further clarified
through instructions issued by CMS to the States.
For the PERM claims review component, the ``claims universe'' is
defined in the new Sec. 431.972 as including payments that were
originally paid (paid claims) and for which payment was requested but
denied (denied claims) during the Federal fiscal year, and for which
there was Federal financial participation (FFP) (or would have been if
the claim had not been denied) through Title XIX of the Act (Medicaid)
or Title XXI of the Act (CHIP). Depending on the context in which it is
used, the claims universe may refer to either all of the adjudicated
FFS claims during the fiscal year under review, or all of the managed
care capitation payments made during the fiscal year under review, for
Medicaid or CHIP.
Due to the significant variation in State systems for processing,
paying, and claiming reimbursement for medical services under Medicaid
and CHIP, we are not proposing to include a more specific claims
universe description in regulation. Rather, States should refer to more
detailed claims universe specifications that will be published by CMS
in separate instructions at the beginning of each PERM measurement
cycle. However, we are proposing that States must establish controls to
ensure that the FFS, managed care, and eligibility universes are
complete and accurate. For example, this would include the comparisons
between the PERM universes and the State's CMS-64 and CMS-21 financial
reports.
b. Stratification
In FY 2006, we measured only the error rate for the FFS component
of Medicaid. To obtain the required precision levels while minimizing
the sample size, and therefore reducing the burden on States, the
claims universe for FFS payments for Medicaid was stratified by service
category and a stratified random sample was drawn for each State. In FY
2007 and beyond, we measure the error rates for Medicaid FFS, Medicaid
managed care, CHIP FFS, and CHIP managed care separately (to the extent
that a State has each of these programs). We also stratify each
universe by dollars rather than service category.
Under this stratification and sampling approach, all payments in
each universe are sorted from largest to smallest payment amounts. The
payments are then divided into strata such that the total payments in
each stratum are the same. For example, if five strata are used, the
total dollars in each stratum would equal 20 percent of the total
dollars in the universe. The first stratum would contain the highest
dollar-valued payments, and the last stratum would contain the smallest
dollar-valued payments, including all zero-paid and denied claims
(denials have a zero dollar amount, and therefore, would appear in the
stratum with the smallest dollar values). An equal number of FFS claims
or managed care payments are then drawn from each stratum, which means
the sample would include proportionately more high-dollar payments and
proportionately fewer low-dollar payments and denials, compared to
their representation in the universe. This overweighting of higher-
dollar payments (which is taken into account when calculating error
rates) enables us to draw a smaller sample size that has a reasonable
probability of meeting the precision requirements, compared to a
perfectly random sample or a sample stratified by service type. In this
manner, we reduce burden on States, the Federal government,
beneficiaries, and providers.
c. Fee-for-Service and Managed Care Sample Size
In order to establish State-specific sample sizes, we are proposing
that the annual sample size in a State's first PERM cycle (referred to
as ``initial sample'' or ``base sample'') would be 500 FFS claims and
250 managed care payments.
We determined this initial sample size based on the experience of
the PERM pilot study and our requirement that the estimated error rate
for a State must be bound by a 95 percent confidence interval of 3
percentage points in either direction. Specifically, the sample size is
calculated assuming that the universe is ``infinite'' and the error
rate for FFS is 5 percent and the error rate for managed care is 3
percent. (Once the universe contains more than approximately 10,000
sampling units, it can be treated as if it were infinite. Statistically
speaking, beyond a universe of approximately 10,000 sampling units,
universe size does not affect sample size.) Using these assumptions and
historical information on payment variation in FFS and managed care
from previous PERM cycles, we have determined that an annual sample of
500 FFS and 250 managed care payments per State per program should meet
our State-level precision requirements with reasonable probability.
However, States with Medicaid or CHIP PERM universes under 10,000
line items or capitation payments can petition CMS for an annual sample
size smaller than the base sample size in the initial PERM year or
beyond. While the universe can be treated as if it were infinite if its
size exceeds 10,000 sampling units, if the total universe from which
the total (full year) sample is drawn is less than 10,000 sampling
units, the sample size may be reduced by the finite population
correction factor. A State that anticipates that the total number of
payments in the FFS or managed care universe for either Medicaid or
CHIP will be less than 10,000 payments over the Federal fiscal year may
notify CMS before the fiscal year being measured and include
information on the anticipated universe size for their State. Our
contractor will develop a modified sampling plan for that program in
that State.
The State-specific annual sample size in the base PERM year is
based on an assumed error rate of 5 percent. If a State's actual PERM
error rates in a cycle reveals that precision goals can be achieved in
future PERM cycles with either lower or higher sample sizes than
indicated by the original assumptions, sample sizes after the first
PERM cycle may vary among States according to each State's demonstrated
ability, based on PERM experience, to meet desired precision goals.
[[Page 34472]]
In subsequent years, we will provide our contractor with
information on each State's error rate and payment variation in the
previous cycle. Our contractor will review each State's prior PERM
cycle claims error rate and payment variation to determine if a smaller
or larger claims sample size will be required to meet the precision
goal established for that PERM cycle. Our contractor will develop a
State-specific sample size for each program in each State. If
information from a previous cycle is not available for a particular
State or program within the State, the contractor will use the ``base
sample'' size of 500 FFS claims and 250 managed care payments. For
States measured in the FY 2007 or FY 2008 cycle that elect to accept
their State-specific CHIP PERM error rate determined during those
cycles, FY 2007 or FY 2008 would be considered their first PERM cycle
for purposes of sample size calculation for CHIP. Therefore, these
States would be considered for an adjusted sample size in their next
year of measurement after the publication of the new final rule. For
States measured in the FY 2007 or FY 2008 cycle that elect to reject
their State-specific CHIP PERM error rate determined during those
cycles, information from those cycles would not be used to calculate
the State-specific sample sizes and the ``base sample'' size of 500 FFS
claims and 250 managed care payments would be used.
We are proposing to establish a maximum sample size for Medicaid or
CHIP FFS or managed care of 1,000 claims. Additionally, as discussed
above, a State with a claims universe of less than 10,000 sampling
units in a program may notify CMS and the annual sample size will be
reduced by the finite population correction factor for any PERM cycle.
We believe that by taking into consideration prior cycle PERM error
rates, as well as the finite population correction factor in
establishing State-specific sample sizes, the States' administrative
cost burden will be reduced and the program will be manageable at the
State level.
2. Eligibility
The eligibility sampling requirements are described in Sec.
431.978. The universe for the eligibility component is case-based, not
claims-based. The case as a sampling unit only applies to the
eligibility component. For PERM eligibility, the ``universe'' is the
total number of Medicaid or CHIP cases, which, as discussed later in
this proposed rule, is comprised of all beneficiaries, both individuals
and families. The eligibility sampling plan and procedures state that
the total eligibility sample size must be estimated to achieve within a
3 percent precision level at 95 percent confidence interval for the
eligibility component of the program.
For PERM eligibility, the initial sample size is calculated under
the assumption that the error rate is 5 percent and the universe is
greater than 10,000 total cases. This means that the desired precision
requirements will be achieved with a high probability if the actual
error rate is 5 percent or less. For this reason, an annual sample of
504 active cases and 204 negative cases should be selected in a State's
base PERM year to meet State-level precision requirements with a high
probability. Appendix D of the PERM Eligibility Review Instructions
elaborates on the theory of sample size at the State-level for the
dollar-weighted active case error rates, and is on the CMS Web site at
http://www.cms.hhs.gov/perm/downloads/PERM_Eligibility_Review_Guidance.pdf.
Eligibility sampling is performed by the States, and States have
the opportunity to adjust their eligibility sample size based on the
eligibility error rate in the previous PERM cycle. After a State's base
PERM year, we will determine, with input from the State, a sample size
that will meet desired precision goals at lower or higher sample sizes
based on the outcome of the State's previous PERM cycle. The sample
size could either increase or decrease given the results of the
previous year. We are proposing to establish a maximum sample size for
eligibility at 1,000 cases. States must submit an eligibility sampling
plan by August 1st before the fiscal year being measured and include a
proposed sample size for their State. Our contractor will review and
approve all eligibility sampling plans. The State must notify CMS that
it will be using the same plan from the previous review year if the
plan is unchanged. However, we will review State sampling plans from
prior cycles in each PERM cycle to ensure that information is accurate
and up-to-date. States will be asked for revisions when necessary.
As in the claims universe, States with PERM eligibility universes
under 10,000 cases can notify CMS for a reduced eligibility sample size
for either the base year or any subsequent PERM cycle.
Additionally, section 203 of the CHIPRA describes the State option
to enroll children in CHIP based on findings of an express lane agency
that has conducted simplified eligibility determinations. Under section
203(a)(13)(E) of the CHIPRA, an error rate measurement will be created
with respect to the enrollment of children under the express lane
eligibility option. The law directs States not to include children
enrolled using the express lane eligibility option starting April 1,
2009, in data or samples used for purposes of complying with MEQC and
PERM requirements. Provisions for States' express lane option will be
set forth in a future rulemaking document.
We are proposing to revise Sec. 431.814 and Sec. 431.978 to
reflect the changes and clarifications specified above.
B. Error Criteria
Under the PERM program, we identify improper payments through
claims reviews and eligibility reviews. For the claims review, we
perform the following: (1) A data processing review of a sample of FFS
and managed care payments to ensure the payments were processed and
paid in accordance with State and Federal policy; and (2) a medical
review of a sample of FFS payments to ensure that the services were
medically necessary, coded correctly, and provided and documented in
accordance with State and Federal policy. For the eligibility review,
we rely on States to review a sample of beneficiary cases to ensure
that they were eligible for the program and for any services received
and paid for by Medicaid or CHIP (as applicable). The PERM eligibility
review also considers negative cases (cases where eligibility was
denied or terminated). A negative case is in error if the case was
improperly denied or incorrectly terminated. However, because there are
no payments associated with these cases, only a case error rate is
calculated. These errors are not factored into the PERM error rate,
which is a payment error rate.
Under the IPIA, to be considered an improper payment, the error
made must affect payment under applicable Federal policy and State
policy. Improper payments include both overpayments and underpayments.
A payment is also considered improper where it cannot be discerned
whether the payment was proper as a result of insufficient or lack of
documentation.
Consistent with the IPIA, the PERM error rate itself does not
distinguish between ``State'' and ``provider'' errors; all dollars in
error identified through PERM reviews contribute to the State error
rate. In practice, the data processing and eligibility reviews focus on
determinations made by State systems and personnel, while the medical
review focuses on documentation maintained and claims submitted by
providers.
[[Page 34473]]
Section 601(c)(1)(A) of the CHIPRA requires CMS to promulgate a new
final rule that includes clearly defined criteria for errors for both
States and providers. Accordingly, we are proposing to add Sec.
431.960, ``Types of payment errors,'' to clarify that State or provider
errors for purposes of the PERM error rate must affect payment under
applicable Federal policy and State policy, and to generally categorize
data processing errors and eligibility determination errors as State
errors and medical review errors as provider errors. The data
processing errors, medical review errors, and eligibility determination
errors may include, but are not limited to, the types of improper
payments discussed below.
1. Claims Review Error Criteria
a. Data Processing Errors (Generally State Errors)
i. Duplicate Item
The sampled line item/claim is an exact duplicate of another line
item/claim that was previously paid (for example, same patient, same
provider, same date of service, same procedure code, and same
modifier).
ii. Non-Covered Service
The State policy indicates that the service is not payable by
Medicaid or CHIP under the State plan and/or the beneficiary is not in
the coverage category for that service.
iii. Fee-for-Service Claim for a Managed Care Service
The beneficiary is enrolled in a managed care organization that
should have covered the service, but the sampled service was
inappropriately paid by the Medicaid or CHIP FFS component.
iv. Third-Party Liability
The service should have been paid by a third party and was
inappropriately paid by Medicaid or CHIP.
v. Pricing Error
Payment for the service does not correspond with the pricing
schedule on file for the date of service.
vi. Logic Edit
A system edit was not in place based on policy or a system edit was
in place but was not working correctly and the claim line was paid (for
example, incompatibility between gender and procedure).
vii. Data Entry Errors
A claim/line item is in error due to clerical errors in the data
entry of the claim.
viii. Managed Care Rate Cell Error
The beneficiary was enrolled in managed care and payment was made,
but for the wrong rate cell.
ix. Managed Care Payment Error
The beneficiary was enrolled in managed care and assigned to the
correct rate cell, but the amount paid for that rate cell was
incorrect.
x. Other Data Processing Error
Errors not included in any of the above categories.
b. Medical Review Errors (Generally Provider Errors)
i. No Documentation
The provider did not respond to the request for records within the
required timeframe.
ii. Insufficient Documentation
There is not enough documentation to support the service.
iii. Procedure Coding Error
The procedure was performed but billed using an incorrect procedure
code and the result affected the payment amount.
iv. Diagnosis Coding Error
According to the medical record, the diagnosis was incorrect and
resulted in a payment error--as in a Diagnosis Related Group (DRG)
error.
v. Unbundling
The provider separately billed and was paid for the separate
components of a procedure code when only one inclusive procedure code
should have been billed and paid.
vi. Number of Unit(s) Error
The incorrect number of units was billed for a particular
procedure/service, National Drug Code (NDC) units, or revenue code.
vii. Medically Unnecessary Service
The service was medically unnecessary based upon the documentation
of the patient's condition in the medical record.
viii. Policy Violation
A policy is in place regarding the service or procedure performed
and medical review indicates that the service or procedure is not in
agreement with the documented policy.
ix. Administrative/Other Medical Review Error
A payment error was determined by the medical review but does not
fit into one of the other medical review error categories, including
State-specific non-covered services.
c. Eligibility Errors (Generally State Errors)
i. Not Eligible
An individual beneficiary or family is receiving benefits under the
program but does not meet the State's categorical and financial
criteria in the first 30 days of eligibility being verified.
ii. Eligible With Ineligible Services
An individual beneficiary or family meets the State's categorical
and financial criteria for receipt of benefits under the Medicaid or
CHIP program but was not eligible to receive particular services. An
example of ``eligible with ineligible services'' would be a person
eligible under the medically needy group who received services not
provided to the medically needy group.
iii. Undetermined
A beneficiary case subject to a Medicaid or CHIP eligibility
determination review under PERM and which a definitive determination of
eligibility could not be made.
iv. Liability Overstated
The beneficiary paid too much toward his liability amount or cost
of institutional care and the State paid too little.
v. Liability Understated
Beneficiary paid too little toward his liability amount or cost of
institutional care and the State paid too much.
vi. Managed Care Error 1
Ineligible for managed care--Upon verification of residency and
program eligibility, the beneficiary is enrolled in managed care but is
not eligible for managed care.
vii. Managed Care Error 2
Eligible for managed care but improperly enrolled--Beneficiary is
eligible for both the program and for managed care but not enrolled in
the correct managed care plan as of the month eligibility is being
verified.
viii. Improper Denial
The application for program benefits was denied by the State for
not meeting the categorical and/or financial eligibility requirements
but upon review is found to be eligible.
ix. Improper Termination
Based on a completed redetermination, the State determines an
existing beneficiary no longer meets the program's categorical and/or
[[Page 34474]]
financial eligibility requirements and is terminated but upon review is
found to still be eligible.
2. Definitions
Based on the criteria identified in section II.B.1 of this proposed
rule, we are proposing to add the following definitions for ``provider
error'' and ``State error'' to Sec. 431.958.
Provider error includes, but is not limited to, an improper payment
made due to lack of or insufficient documentation, incorrect coding,
improper billing (for example, unbundling, incorrect number of units),
a payment that is in error due to lack of medical necessity, or
evidence that the service was not provided in compliance with
documented State or Federal policy.
State error includes, but is not limited to the following:
A payment that is in error due to incorrect processing
(for example, duplicate of an earlier payment, payment for a non-
covered service, payment for an ineligible beneficiary).
Incorrect payment amount (for example, incorrect fee
schedule or capitation rate applied, incorrect third-party liability
applied).
A payment error resulting from services being provided to
an individual who--
++ Was ineligible when authorized or when he or she received
services;
++ Was eligible for the program but was ineligible for certain
services he or she received; or
++ Had not met applicable beneficiary liability requirements when
authorized eligible or paid too much toward actual liability.
++ Had a lack of sufficient documentation to make a definitive
determination of eligibility or ineligibility.
C. Self-Declaration of Eligibility
Section 601(c)(2) of the CHIPRA requires that the payment error
rate determined for a State shall not take into account payment errors
resulting from the State's verification of an applicant's self-
declaration or self-certification of eligibility for, and the correct
amount of, medical assistance or child health assistance, if the State
process for verifying an applicant's self-declaration or self-
certification satisfies the requirements for such process applicable
under regulations promulgated by the Secretary or otherwise approved by
the Secretary.
Accordingly, we are proposing to specify in the new Sec. 431.960
that the dollars paid in error due to the eligibility error is the
measure of the payment error. A State eligibility error does not result
from the State's verification of an applicant's self-declaration or
self-certification of eligibility for, and the correct amount of,
medical assistance or child health assistance, if the State process for
verifying an applicant's self-declaration or self-certification
satisfies the requirements for such process applicable under
regulations at Sec. 457.380 of this chapter, in CMS approved State
Plans, or otherwise approved by the Secretary.
We also propose to modify Sec. 431.980 to provide review
requirements for acceptable self-declaration. We would also modify the
PERM eligibility instructions, found at http://www.cms.hhs.gov/perm/downloads/PERM_Eligibility_Review_Guidance.pdf. These instructions,
which clarify and provide additional guidance in implementing the
regulations, reflect the new review procedures for self declaration.
Currently, States are required to review the case record and
independently verify elements of eligibility where evidence is missing,
or outdated and likely to change, or otherwise as needed. The
instructions and the regulation would provide that ``a self-declaration
statement for Medicaid or CHIP is acceptable verification for the PERM
reviews for elements of eligibility in which State policy allows for
self-declaration. A self-declaration statement must be--
Present in the record;
Not outdated (more than 12 months old);
In a valid, State approved format; and
Consistent with other facts in the case record.
A State may verify eligibility through a new self-declaration
statement, depending on State policies on self-declaration. We propose
that if a new self-declaration statement cannot be obtained for the
PERM review, the State may verify eligibility using third party
sources, for example, documentation listed in section 7269 of the State
Medicaid Manual. Verifying a self-declaration statement with third
party verification when a beneficiary does not provide a new self-
declaration statement is the only new review procedure being added.
After all minimum efforts listed in the eligibility instructions have
been exhausted, a case should be cited as Undetermined if sufficient
documentation cannot be obtained to complete the eligibility review. We
are proposing that these Undetermined cases would not be included in
the State-specific payment error rate. However, we are proposing to
specify in the new Sec. 431.960 that these errors be tracked
nationally by including these Undetermined cases in the national
program payment error rates.
D. Difference Resolution and Appeals Process
Section 601(c)(1)(B) of the CHIPRA requires CMS to include in the
new final rule for PERM a clearly defined process for appealing error
determinations by review contractors or State agency and personnel
responsible for the development, direction, implementation, and
evaluation of eligibility reviews and associated activities.
1. Medical and Data Processing Review
The October 5, 2005 IFC established the difference resolution
process, which is codified at Sec. 431.998. Medical reviews and data
processing reviews for FFS and managed care payments are conducted by
an independent Federal contractor. States supply relevant policies but
do not participate in the review; States are notified of all error
findings. The difference resolution process is the mechanism by which a
State may try to resolve with the Federal contractor differences in the
Federal contractor's error findings; the State may appeal to CMS if it
cannot resolve the difference in findings with the Federal contractor.
In accordance with the CHIPRA, we are providing more detail in this
proposed rule by proposing the timeline associated with the difference
resolution and CMS appeals processes. We are also revising the heading
of Sec. 431.998 to read, ``Difference resolution and appeal process,''
which more accurately describes the regulation.
We are proposing to revise Sec. 431.998 to explain that the State
may file, in writing, a request with the Federal contractor to resolve
differences in the Federal contractor's findings based on medical or
data processing reviews of FFS and managed care claims in Medicaid or
CHIP within 10 business days after the disposition report of claims
review findings is posted on the contractor's Web site. Additionally,
the State may appeal to CMS for a final resolution within 5 business
days from the date the contractor's finding as a result of the
difference resolution is posted on its Web site.
In addition to establishing the timeline for the difference
resolution and appeal processes, we are proposing to eliminate the
dollar threshold for engaging in the CMS appeals process. Section
431.998 currently provides that States may apply to the Federal
contractor to resolve differences in
[[Page 34475]]
findings and may appeal to CMS for final resolution for any claims in
which the State and Federal contractor cannot resolve the difference in
findings, as long as the difference in findings is in the amount of
$100 or more. We established the $100 threshold in order to prevent de
minimis disputes and to ensure that appeals to CMS were substantial
enough to warrant reconsideration. We were also concerned that a large
volume of small-dollar appeals would prevent the States from receiving
timely decisions on their appeals.
Information from the FY 2006 and FY 2007 PERM cycles on the number
of total claims (including those with errors less than $100) submitted
to the Federal contractor for difference resolution and on the number
appealed to CMS for final resolution suggests that the volume of
appeals will not substantially increase if CMS allows appeals of errors
of less than $100. Because all errors regardless of their dollar amount
ultimately contribute to a State's error rate and hence the national
error rate, we are proposing to remove the $100 threshold set forth in
Sec. 431.998(b)(1).
2. Eligibility
As stated in the current PERM regulations at Sec. 431.974(a)(2),
personnel responsible for PERM eligibility sampling and review ``must
be functionally and physically separate from the State agencies and
personnel that are responsible for Medicaid and CHIP policy and
operations, including eligibility determinations.'' The intent of this
provision was to ensure the independence of the review in order to
achieve an unbiased error rate. We provided further clarification in
the preamble of the August 2007 final rule, indicating that the agency
responsible for PERM could be under the same umbrella agency that
oversees policy, operations and determinations but the two agencies
cannot report to the same supervisor.
We would further clarify that qualified staff with knowledge of
State eligibility policies may be used to conduct the eligibility
reviews, but the staff that is chosen must be independent from the
staff that oversees policy and operations. Further, the PERM
eligibility instructions ask States to provide assurance that the
agency or contracting entity responsible for the eligibility reviews is
independent of the State agency responsible for eligibility
determination and enrollment. The State is responsible for ensuring the
integrity of the eligibility reviews, but we do not preclude the
independent State agency from sharing or reporting the eligibility
findings to other agencies or stakeholders.
Provided that agency independence could cause a difference in
findings between the independent agency and other stakeholder agencies
at the State level, we propose that appeals for eligibility review
findings should be conducted in accordance with the State's appeal
process, as eligibility reviews are conducted at the State level.
In consideration of States that may not have a State appeals
process in place, we are also proposing to make State findings
available to each respective State's stakeholders (that is, the State
Medicaid or CHIP agency), with certain limitations, for the period
between the final monthly payment findings submission and eligibility
error rate calculation, for example, April 15th through June 15th after
the fiscal year being measured or according to the eligibility
timeline. We propose facilitating documentation exchange between the
State Medicaid or CHIP agency and the independent State agency
conducting the PERM eligibility reviews to resolve differences. If any
eligibility appeals issues involve Federal policy, States can appeal to
CMS for resolution. If our decision causes an erroneous payment finding
to be made, any resulting recoveries will be governed by Sec.
431.1002.
Other stakeholder agencies may document their differences in
writing to the independent State agency for consideration. If
resolutions of differences occur during the PERM cycle, eligibility
findings can be updated to reflect the resolution. If differences are
not resolved by the deadline for eligibility findings to be submitted
to CMS (July 1), the documentation of the difference can be submitted
to CMS for consideration no sooner than 60 days and no later than 90
days after the deadline for eligibility findings.
We are also seeking comment on other ways that we can implement an
eligibility appeals process for which we can provide consistent
oversight.
E. Harmonization of Medicaid Eligibility Quality Control (MEQC) and
PERM Programs
1. Options for Applying PERM and MEQC Data
Section 601(e)(2) of the CHIPRA requires that, once this final rule
is effective for all States, States will be given the option to elect,
for purposes of determining the erroneous excess payments for medical
assistance ratio applicable to the State for a fiscal year under
section 1903(u) of the Act, to substitute data resulting from the
application of the PERM requirements to the State for data obtained
from the application of the MEQC requirements to the State with respect
to a fiscal year. Because under section 601(b) of the CHIPRA, there
shall be no calculation or publication of any national or State-
specific CHIP error rates until 6 months after the final rule becomes
effective, States will not have the option to substitute PERM data for
MEQC data until 6 months after this final rule is effective.
We considered several interpretations of the CHIPRA requirements
that would allow States the option to substitute MEQC data for PERM
data and vice versa for purposes of the PERM Medicaid eligibility
reviews, but would also retain two separate, independent processes
(MEQC and PERM), which are governed by separate statutes and
regulations. As PERM is required to meet specific statistical precision
requirements and the MEQC error rate is not, we do not believe it is
feasible to incorporate the MEQC error rate into a State's overall PERM
error rate. Therefore, we interpret ``data'' as the sample, eligibility
review findings, and payment findings as measured under MEQC or PERM.
We will calculate separate rates for each program. We are proposing to
amend Sec. 431.806 and Sec. 431.812 of the MEQC regulations. These
proposed amendments would provide for the State's option in its PERM
year to use their samples, eligibility findings and payment findings as
measured using PERM sampling and review requirements to meet their MEQC
review requirement. States operating under MEQC waivers and pilot
programs cannot use this option. Therefore, to provide requirements for
implementing a pilot or waiver MEQC program, we are proposing revisions
to the MEQC regulation at Sec. 431.812. We are proposing that States
that choose to substitute PERM data for MEQC data, would still have two
eligibility error rates calculated -- one for MEQC using MEQC
measurement requirements and one for PERM using PERM requirements. We
are proposing to revise Sec. 431.806 of the MEQC regulations to
require that a State plan provide a State plan amendment for States
opting to use PERM for MEQC in a State's PERM cycle.
We are proposing to amend Sec. 431.812 of the MEQC regulation to
provide that States substituting PERM data for MEQC data must use a
sampling plan that meets the requirements of Sec. 431.978 of the PERM
regulation and perform active
[[Page 34476]]
case reviews in accordance with Sec. 431.980 of the PERM regulation.
We are proposing that States with CHIP stand alone programs will
only have the option to substitute PERM Medicaid data to meet MEQC
requirements under Sec. 431.812(a) through (e) since CHIP stand alone
programs are not reviewed under MEQC.
We are also proposing that States with Medicaid and Title XXI
Medicaid expansion programs may use Medicaid and CHIP PERM reviews to
meet the MEQC requirements described under Sec. 431.812(a) through
(e), as both Medicaid and Title XXI Medicaid expansion programs are
reviewed under MEQC. States with Title XXI Medicaid expansion programs
must combine their Medicaid and CHIP PERM findings to calculate one
MEQC error rate. The data must be kept separate for purposes of
calculating the PERM error rate.
In addition, we are proposing that States with combination CHIP
programs, in which a portion of their CHIP cases are under a stand
alone program and a portion of their CHIP cases are under a Title XXI
Medicaid expansion program, may use the PERM Medicaid eligibility
reviews and the portion of the PERM CHIP eligibility reviews under
Title XXI Medicaid expansion programs to meet their MEQC requirement.
The Federal contractor will combine the CHIP case findings under the
Title XXI Medicaid expansion program and CHIP stand alone findings to
calculate one PERM CHIP error rate. The Title XXI Medicaid expansion
portion of the PERM data must be included with the Medicaid PERM data
to calculate the MEQC error rate.
Section 601(e)(3) of the CHIPRA provides that for purposes of
satisfying the requirements of the PERM regulation relating to Medicaid
eligibility reviews, a State may elect to substitute data obtained
through MEQC reviews conducted in accordance with section 1903(u) of
the Act for data required for purposes of PERM requirements, but only
if the State MEQC reviews are based on a broad, representative sample
of Medicaid applicants or enrollees in the States. The CHIPRA's general
effective date of April 1, 2009 applies to this provision. Therefore,
as of April 1, 2009, States have the option to substitute MEQC data for
PERM data so long as the MEQC reviews are based on a broad,
representative sample of Medicaid applicants or enrollees in the
States.
We interpret ``broad, representative sample of Medicaid applicants
or enrollees'' to mean that States must develop the MEQC universe
according to requirements at Sec. 431.814 in order to consider the
option to use one program's findings to meet the requirements for the
other. Under Sec. 431.814, States must sample from a universe of all
Medicaid and Title XXI Medicaid expansion beneficiaries (except for the
exclusions provided in Sec. 431.814(c)(4)). States operating MEQC
pilots or waivers will need to continue operating PERM separately from
MEQC.
We are proposing that States with CHIP stand alone programs only
have the option to substitute Medicaid MEQC data to meet the PERM
Medicaid eligibility review requirement, as CHIP stand alone is not
reviewed under the MEQC review.
We are also proposing that States with Title XXI Medicaid expansion
programs may use their MEQC reviews described in Sec. 431.812(a)
through (e) to meet both the PERM Medicaid and CHIP eligibility review
requirements, as both Medicaid and Title XXI Medicaid expansion are
reviewed under MEQC. Title XXI Medicaid expansion data must be
separated from the MEQC Medicaid data to calculate a PERM CHIP error
rate.
We are also proposing that States with combination programs in
which a portion of their CHIP cases are under a stand alone program and
a portion of their CHIP cases are under a Title XXI Medicaid expansion
program may use the MEQC reviews described under Sec. 431.812 (a)
through (e) to meet the PERM Medicaid eligibility review requirement
and the portion of the PERM CHIP eligibility review requirement under
Title XXI Medicaid expansion. However, the stand alone portion of the
CHIP universe must remain separate and stratified, as defined in Sec.
431.978(d)(3), as CHIP stand alone is not a part of the harmonization
of PERM and MEQC. The Federal contractor, who we are proposing will
calculate State eligibility error rates, will combine the Title XXI
Medicaid expansion and CHIP stand alone findings to calculate one PERM
CHIP error rate.
In addition, we are proposing to amend Sec. 431.980 to allow for
States in their PERM year the option to use their MEQC samples,
eligibility findings, and payment findings to meet their PERM
eligibility review requirement. MEQC reporting requirements to the CMS
Regional Offices remain the same, including reporting the error
findings for the two 6-month review periods, but States will also be
required to comply with the PERM eligibility reporting deadlines by
posting error findings to the PERM Error Rate Tracking (PERT) Web site
or other electronic eligibility findings repository specified by CMS.
We are proposing that States that choose to substitute MEQC data for
PERM data, will still have two eligibility error rates calculated--one
for MEQC using MEQC measurement requirements and one for PERM using
PERM requirements.
States that choose to substitute MEQC data must ensure that the
Medicaid and Title XXI Medicaid expansion sample sizes meet PERM
precision requirements when they are separated. States must also note
that if using MEQC data, any cases sampled under Sec. 431.814(c)(4)
must be excluded from the PERM sample. For example, State-only funded
cases, should be reported separately.
States that choose to substitute MEQC or PERM data should note that
although two error rates are calculated, only the MEQC error rate will
be subject to disallowances under section 1903(u) of the Act. PERM does
not have a threshold for eligibility errors and any improper payments
identified during the eligibility measurement are subject to recovery
according to Sec. 431.1002 of the regulations.
If a State chooses to substitute PERM or MEQC data, the State may
not dispute error findings or the eligibility error rate based on the
possibility that findings would not have been in error had the other
review methodology been used.
We are also seeking comments on the following alternative process
for the substitution of MEQC and PERM data: States would select one
annual sample that meets MEQC minimum sample requirements and PERM
confidence and precision requirements. The State would conduct both an
MEQC review and a PERM review on each applicable case. This would
ensure a clear distinction between an MEQC error and a PERM eligibility
error, and will be the basis for the MEQC error rate and the PERM
eligibility error rate. We are also seeking comment on other possible
methods for substitution of data.
States that choose to substitute MEQC data may only claim the
regular administrative matching rate for performing the MEQC procedures
for Medicaid and Title XXI Medicaid expansion cases. The 90 percent
PERM enhanced administrative matching rate will only be applicable to
States conducting PERM reviews for CHIP cases.
2. Definition of a Case
Section 431.958 currently defines a case as an ``individual
beneficiary.'' States are required to sample and conduct eligibility
and payment reviews for an individual beneficiary even if the State
grants eligibility at the family
[[Page 34477]]
level. However, sampling at the individual beneficiary level has proven
to be difficult for States from a programming perspective.
Many States receive, review, and grant eligibility based on an
application for an entire family, which could be for one person or
multiple people. Dividing the family unit for PERM eligibility sampling
has been difficult for States to achieve. In addition, the CHIPRA
requires MEQC and PERM harmonization to reduce the burden on States.
The MEQC regulation, at Sec. 431.804, defines an active case, in
pertinent part, as an ``individual [beneficiary] or family.'' Changing
the definition of a case for PERM eligibility to include both
individual beneficiaries and families will support the harmonization
process by making it easier for States to utilize their new option of
substituting PERM data for MEQC data, and vice versa.
Therefore, we are proposing to revise the definition of a case in
Sec. 431.958 to mean an individual or family.
3. Error Rate Calculation: State Responsibility for Calculating Error
Rates
Section 431.988 requires, as part of the PERM eligibility review
process, for States to calculate and report case and payment error
rates for active cases and case error rates for negative cases. As
originally envisioned, States retained responsibility for sampling
cases, conducting eligibility reviews, collecting payment information
for errors, and calculating eligibility error rates. States were to
report final eligibility error rates to CMS, which will forward the
information to the Federal contractor for inclusion in the overall
State and national error rates.
In practice, States have found it difficult to calculate the
eligibility error rates. In most cases, States lack the necessary
statistical or technical expertise to execute the error rate
calculation formulas provided in the PERM eligibility instructions.
During the FY 2007 cycle, the Federal contractor provided substantial
technical assistance to the States to assist them in conducting these
calculations including developing a spreadsheet that States could use
to perform the required calculations. Several States requested that,
rather than have the Federal contractor provide a spreadsheet that the
States merely populate and return to CMS, the Federal contractor
perform the required calculations.
Initially, we did not consider it feasible for the Federal
contractor to conduct the PERM eligibility error rate calculations
because the States conduct the reviews and maintain the case and
payment error data. However, during FY 2007, we developed a centralized
reporting system for monthly case and payment error data. The Federal
contractor can access the centralized system to conduct the eligibility
error rate calculations.
Given the difficulties States have experienced in calculating the
PERM eligibility error rates and that there are now mechanisms and
processes for the Federal contractor to calculate these error rates, we
are proposing to revise Sec. 431.988(b)(1) and (b)(2) by replacing
``rates'' with ``data'' to read as follows: ``The agency must report by
July 1 following the review year, information as follows: (1) Case and
payment error data for active cases; and (2) Case error data for
negative cases.''
We maintain that this approach will reduce the burden on the States
and more accurately reflect current practice, which is that the Federal
contractor calculates the eligibility error rates used in the
generation of the PERM error rate, as well as the State and national-
level error rates. We will continue to require States to report data to
the centralized reporting system and will provide States with a
spreadsheet or similar calculator that can be used to estimate their
own eligibility error rates, but will not require States to submit
these estimates to CMS.
F. Corrective Action Plans
Section 601(c)(1)(C) of the CHIPRA requires CMS to provide defined
responsibilities and deadlines for States in implementing corrective
action plans.
1. Corrective Action Plan Due Dates
We are proposing to revise Sec. 431.992 to provide that States
would be required to submit to CMS and implement the corrective action
plan for the fiscal year it was reviewed no later than 60 calendar days
from the date the State's error rate is posted to the CMS Contractor's
Web site. State error rates will be posted to the Web site no later
than November 15 of each calendar year.
2. Types of Plans
In addition to measuring programs at risk for significant improper
payments, the IPIA also requires a report on Federal agency actions
taken to reduce improper payments. Since States administer Medicaid and
CHIP and make payments for services rendered under these programs, it
is necessary that States take corrective actions to reduce improper
payments at the State level. We issued a State Health Official letter
in October 2007 to all States detailing the corrective action process
under PERM, which can be found on the CMS PERM Web site at http://www.cms.hhs.gov/PERM/Downloads/Corrective_Action_Plan.pdf.
The corrective action process is the means by which States take
administrative actions to reduce errors which cause misspent Medicaid
and CHIP dollars. The corrective action process involves analyzing
findings from the PERM measurement, identifying root causes of errors
and developing corrective actions designed to reduce major error
causes, and trends in errors or other factors for purposes of reducing
improper payments.
Development, implementation, and monitoring of the corrective
action plan are the responsibility of the States. In order to develop
an effective corrective action plan, States must perform data and
program analysis, as well as plan, implement, monitor, and evaluate
corrective actions. We are proposing to revise Sec. 431.992 to define
States' responsibilities for these activities as explained below.
(1) Data Analysis--States must conduct data analysis such as
reviewing clusters of errors, general error causes, characteristics,
and frequency of errors. States must also consider improper payments
associated with errors. Data analysis may sort the predominant payment
errors and number of errors as follows:
Type--general classification (for example, FFS, managed
care, eligibility).
Element--specific type of classification (for example, no
documentation errors, duplicate claims, ineligible cases due to excess
income).
Nature--cause of error (for example, providers not
submitting medical records, lack of systems edits, unreported changes
in income that caused ineligibility). For the eligibility component,
States must analyze both active and negative case errors and also
causes for undetermined case findings.
(2) Program Analysis--States must review the findings of the data
analysis to determine the specific programmatic causes to which errors
are attributed (for example, a provider's lack of understanding of
section 1902(a)(27) of the Act and Sec. 457.950 of the regulations
requiring providers to submit information regarding payments and claims
as requested by the Secretary, State agency, or both) and to identify
root error causes. The States may need to analyze the agency's
operational policies and procedures and identify those policies or
procedures that contribute to errors, for example,
[[Page 34478]]
policies that are unclear, or there is a lack of operational oversight
at the local level.
(3) Corrective Action Planning--States must determine the
corrective actions to be implemented that address the root error
causes.
(4) Implementation and Monitoring--States must implement the
corrective actions in accordance with an implementation schedule.
States must develop an implementation schedule for each corrective
action initiative and implement those actions. The implementation
schedule must identify major tasks, key personnel responsible for each
activity, and must include a timeline for each action including target
implementation dates, milestones, and monitoring.
(5) Evaluation--States must evaluate the effectiveness of the
corrective action by assessing improvements in operations,
efficiencies, and the incidence of payment errors or number of errors.
Subsequent corrective action plans that are submitted as a result of
the State's next measurement must include updates on the following
previous actions: (1) Effectiveness of implemented corrective actions
using concrete data; (2) discontinued or ineffective actions, and
actions not implemented and what actions were used as replacements; (3)
findings on short-term corrective actions; and (4) the status of the
long-term corrective actions.
In addition, we are proposing that CMS would review and approve the
corrective action plans submitted by States, and may request regular
updates on the approved corrective actions. We are soliciting public
comments on the timeline and process associated with this review and
approval.
III. Additional Issues Soliciting Public Comments
We are exploring options for the future management of the CHIP and
Medicaid PERM programs. We welcome input on components of the program.
When submitting input, please address the following details:
Data source;
Sampling methodology;
Medical and data processing reviews;
Reporting;
Appeals.
We are soliciting public comments and may consider them in a future
rulemaking effort.
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We are soliciting public comment on each of these issues for the
following sections of this document that contain information collection
requirements (ICRs):
A. ICRs Regarding Review Procedure (Sec. 431.812)
Section 431.812(a)(1) states that except as provided in paragraph
(a)(2) of this section, the agency must review all active cases
selected from the State agency's lists of cases authorized eligible for
the review month, to determine if the cases were eligible for services
during all or part of the month under review, and, if appropriate,
whether the proper amount of recipient liability was computed. In Sec.
431.812, proposed paragraph (g) states that a State in its PERM year
may elect to substitute the random sample of selected cases,
eligibility review findings, and payment review findings obtained
through PERM reviews conducted in accordance with Sec. 431.980 of the
regulations for data required in this section, where the only
exclusions are those set forth in Sec. 431.978(d)(1) of this
regulation. The burden associated with this requirement is the time and
effort necessary to complete the review of active cases. The burden
associated with this requirement is currently approved under OMB
control number 0938-0147 with an October 31, 2009, expiration date.
States in their PERM year that elect to substitute PERM data to
meet the requirements of Sec. 431.812 would significantly reduce the
burden associated with reviewing active cases for MEQC. The burden
associated with the information collection requirements contained in
proposed Sec. 431.812(g) is the time and effort necessary for a State
to substitute the random sample of selected cases, eligibility review
findings, and payment review findings obtained through PERM reviews
conducted in accordance with Sec. 431.980. Currently, we believe 19
States (12 Medicaid States and 7 CHIP States) can elect the data
substitution and comply with this requirement. We estimate that it
would take each agency 10,055 hours to comply with the information
collection requirements. In subsequent years, we expect that more
States will elect to substitute data from section Sec. 431.980 to meet
this requirement so we are estimating the maximum burden for 34 States
(17 Medicaid States and 17 CHIP States). The total burden associated
with the requirements in proposed Sec. 431.812(g) is 341,870 hours.
Although the review burden would be significantly reduced, States
would still be required to report PERM and MEQC findings separately.
The additional burden is explained in the section below for Sec.
431.980. We will submit a revised information collection request for
0938-0147 to account for the increased burden as a result of the
requirements proposed in Sec. 431.812(g).
B. ICRs Regarding MEQC Sampling Plan and Procedures (Sec. 431.814)
Section 431.814 states that an agency must submit a basic MEQC
sampling plan (or revisions to a current plan) that meets the
requirements of this section to the appropriate CMS Regional Office for
approval at least 60 days before the beginning of the review period in
which it is to be implemented. The burden associated with this
requirement is the time and effort necessary to draft and submit a new
sampling plan or to draft and submit a revised sampling plan to the
appropriate CMS Regional Office. While this requirement is subject to
the PRA, it is currently approved under OMB control number 0938-0146
with an October 31, 2009, expiration date.
C. ICRs Regarding PERM Eligibility Sampling Plan and Procedures (Sec.
431.978)
In Sec. 431.978, the proposed revisions to paragraph (a) discuss
the requirements for sampling plan approval. Specifically, the proposed
revision to Sec. 431.978(a)(1) states that for each review year, the
agency must submit a State-specific Medicaid or CHIP sampling plan (or
revisions to a current plan) for both active and negative cases to CMS
for approval by the August 1 before the review year and must receive
approval of the plan before implementation. The proposed revision to
Sec. 431.978(a)(2) further explains that the agency must notify CMS
that it
[[Page 34479]]
would be using the same plan from the previous review year if the plan
is unchanged.
The burden associated with the information collection requirements
contained in Sec. 431.978(a) is the time and effort necessary for
State agencies to draft and submit the aforementioned information to
CMS. While this requirement is subject to the PRA, the associated
burden is approved under OMB control number 0938-1012 with a January
31, 2010, expiration date.
D. ICRs Regarding Eligibility Review Procedures (Sec. 431.980)
Proposed Sec. 431.980(d) states that unless the State has elected
to substitute MEQC data for PERM data under paragraph (f) of this
section, the agency must complete the following. Specifically, proposed
Sec. 431.980(d)(iii) requires a State to examine the evidence in the
case file that supports categorical and financial eligibility for the
category of coverage in which the case is assigned, and independently
verify information that is missing, older than 12 months and likely to
change, or otherwise as needed, to verify eligibility. Section
431.980(d)(vi) states that the elements of eligibility in which State
policy allows for self declaration can be verified with a new self-
declaration statement. Proposed Sec. 431.980(vii) contains the
requirements for a self-declaration statement.
The burden associated with the requirements contained in proposed
Sec. 431.980 is the time and effort necessary for a State agency to
complete the aforementioned requirements. While this requirement is
subject to the PRA, the associated burden is currently approved under
OMB control number 0938-1012.
Proposed Sec. 431.980(f)(1) allows for a State in its PERM year to
elect to substitute the random sample of selected cases, eligibility
review findings, and payment reviews findings obtained through MEQC
reviews conducted in accordance with section 1903(u) of the Act to meet
its PERM eligibility review requirement. The substitution of the MEQC
data is allowed as long as the State MEQC reviews are based on a broad,
representative sample of Medicaid applicants or enrollees in the State.
In addition, as stated in proposed Sec. 431.980(f)(2), the MEQC
samples must also meet PERM confidence and precision requirements.
The burden associated with the information collection requirements
contained in proposed Sec. 431.980(f) is the time and effort necessary
for a State to collect, review, and submit the MEQC data as part of
meeting its PERM eligibility review requirement. States that elect to
substitute MEQC data to complete the requirements of Sec. 431.980
would significantly reduce the burden associated with reviewing active
cases for PERM. Although the review burden would be eliminated, States
would still be required to report PERM and MEQC findings separately.
Currently we believe 19 States (12 Medicaid States and 7 CHIP States)
can elect the data substitution and comply with this requirement. We
estimate that it would take each agency 10,500 hours to comply with the
information collection requirements. In subsequent years, we expect
that more States will elect to substitute data from section Sec.
431.812 to meet this requirement so we are estimating the maximum
burden for 34 States (17 Medicaid States and 17 CHIP States). The total
burden associated with the requirements in proposed Sec. 431.980(f) is
357,000 hours.
We also propose adding additional burden as stated above. States
must report PERM and MEQC findings separately and will use an estimated
2 hours per required form to reformat PERM or MEQC data into the
appropriate forms. We are adding an additional 98 hours for each State
to reformat MEQC data into the appropriate PERM eligibility forms and
98 hours for each State to compile PERM eligibility data to submit on
the appropriate MEQC forms. We will submit a revised information
collection request for 0938-1012 to account for the increased burden as
a result of the requirements proposed in Sec. 431.980(f).
E. ICRs Regarding Corrective Action Plan (Sec. 431.992)
The proposed revisions to Sec. 431.992(a) specify that State
agencies must submit to CMS a corrective action plan to reduce improper
payments in its Medicaid and CHIP programs based on its analysis of the
error causes in the FFS, managed care, and eligibility components. In
Sec. 431.992(b), we are proposing to revise this section to require
States to submit a corrective action plan to CMS for the fiscal year it
was reviewed no later than 60 days from the date the State's error rate
is posted to the CMS Contractor's Web site. As proposed in Sec.
431.992(c), States will be required to implement corrective actions in
accordance with their corrective action plans as submitted to CMS.
Proposed Sec. 431.992(d) details the required components of a
corrective action plan.
The burden associated with the information collection requirements
in proposed revisions to Sec. 431.992 is the time and effort necessary
for States to develop corrective action plans, submit the plans to CMS,
and implement corrective actions as dictated by their corrective plans.
While these requirements are subject to the PRA, the burden is approved
under the OMB control numbers shown in Table 1.
Table 1--OMB Control Numbers
------------------------------------------------------------------------
Program component OMB control No. Expiration date
------------------------------------------------------------------------
Fee-for-Service................ 0938-0974.......... 02/29/2012
Managed Care................... 0938-0994.......... 09/30/2009
Eligibility.................... 0938-1012.......... 01/31/2010
------------------------------------------------------------------------
F. ICRs Regarding Difference Resolution and Appeal Process (Sec.
431.998)
As proposed in Sec. 431.998(a), a State may file, in writing, a
request with the Federal contractor to resolve differences in the
Federal contractor's findings based on medical or data processing
reviews on FFS and managed care claims in Medicaid and CHIP within 10
business days after the disposition report of claims review findings is
posted on the contractor's Web site. The written request must include a
factual basis for filing the difference and it must provide the Federal
contractor with valid evidence directly related to the error finding to
support the State's position that the claim was properly paid.
Proposed Sec. 431.998(b) states that for a claim in which the
State and the Federal contractor cannot resolve the difference in
findings, the State may appeal to CMS for final resolution within 5
business days from the date the contractor's finding as a result of the
[[Page 34480]]
difference resolution is posted on its Web site.
Proposed Sec. 431.998(c) states that for eligibility error
determinations made by agencies or personnel functionally and
physically separate from the State agencies and personnel that are
responsible for Medicaid and CHIP policy and operations, the State may
appeal error determinations by filing a request with the appropriate
State agencies. If no appeals process is in place at the State level,
differences in findings must be documented in writing for the
independent State agency to consider. Any unresolved differences may be
addressed by CMS between the final month of payment data submission and
error rate calculation. CMS may facilitate documentation exchange to
assist in resolving difference at the State level. Any changes in error
findings must be reported to CMS by the deadline for submitting final
eligibility review findings. Any appeals of determinations based on
interpretations of Federal policy may be referred to CMS.
The burden associated with the information collection requirements
contained in proposed Sec. 431.998(a) through (c) is the time and
effort necessary to draft and submit requests for difference resolution
proceedings and determination appeals. We believe the burden associated
with these requirements are exempt from the PRA under 5 CFR 1320.4.
Information collected subsequent to an administrative action is not
subject to the PRA.
G. OMB Control Number(s) for Reporting and Recordkeeping Burden
The burden is approved under the OMB control numbers stated in
Table 2.
Table 2--Estimated Annual Reporting and Recordkeeping Burden
----------------------------------------------------------------------------------------------------------------
Burden per
Regulation section(s) OMB control Respondents Responses response Total annual
No. (hours) burden (hours)
----------------------------------------------------------------------------------------------------------------
Sec. 431.812.................. 0938-0147 10 120 8 \1\ 960
Sec. 431.814.................. 0938-0146 10 20 24 480
Sec. 431.978.................. 0938-1012 34 1,360 393.875 535,670
Sec. 431.980.................. 0938-1012 34 1,360 393.875 \1\ 535,670
Sec. 431.992.................. 0938-0974 34 34 840 28,560
0938-0994 36 \2\ 18,000 1 23,400
0938-1012 34 1,360 393.875 \3\ 535,670
Total....................... .............. .............. .............. .............. 589,070
----------------------------------------------------------------------------------------------------------------
\1\ We are submitting a revision of the currently approved ICR for the proposed information collection
requirements in this section of the regulation.
\2\ The currently approved number of responses is 23,400; however, the value is incorrect due to an arithmetic
error. We have already submitted an 83-C Change Worksheet to OMB to correct the error.
\3\ For the purpose of totaling the burden associated with the ICRs in this regulation, the annual burden
associated with OMB control number 0938-1012 is counted only once.
If you comment on these information collection and recordkeeping
requirements, please do either of the following:
1. Submit your comments electronically as specified in the
ADDRESSES section of this proposed rule; or
2. Submit your comments to the Office of Information and Regulatory
Affairs, Office of Management and Budget,
Attention: CMS Desk Officer, [CMS-6150-P].
Fax: (202) 395-6974; or
E-mail: [email protected].
V. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
VI. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993, as
further amended), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-
4), Executive Order 13132 on Federalism (August 4, 1999), and the
Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866 (as amended by Executive Order 13258) directs
agencies to assess all costs and benefits of available regulatory
alternatives and, if regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, distributive impacts,
and equity). A regulatory impact analysis (RIA) must be prepared for
major rules with economically significant effects ($100 million or more
in any 1 year). For the reasons discussed below, we have determined
that this proposed rule is not a major rule.
1. Federal Contracting Cost Estimate
We have estimated that it will cost $14.7 million annually for
engaging Federal contractors to review FFS and managed care claims and
calculate error rates in 34 State programs (17 States for Medicaid and
17 States for CHIP). We estimated these costs as follows:
In the August 31, 2007 final rule, we estimated the Federal cost
for use of Federal contractors conducting the FFS and managed care
measurements to be $19.8 million annually. Due to more recent data
acquired through our experience with Federal contractors in the FY
2007, FY 2008, and FY 2009 PERM cycles, we were able to produce a more
accurate estimate by taking the average of Federal contracting costs
for the three cycles and including anticipated future PERM cycle costs.
The error rate measurements for 34 State programs (17 States for
Medicaid and 17 States for CHIP) would cost approximately $14,682,777
in Federal funds for the Federal contracting cost.
2. State Cost Estimate for Fee-for-Service and Managed Care Reviews
We estimated that total State cost for FFS and managed care reviews
for 34 State programs is $6.2 million
[[Page 34481]]
($4,309,490 in Federal cost and $1,846,924 in State cost). This cost
estimate is based on the cost for States to prepare and submit claims
universe information for both FFS and managed care payments, prepare
and submit claims details and provider information for sampled records,
submit State program policies and updates on a quarterly basis,
cooperate with Federal contractors during data processing review,
participate in the difference resolution and appeals process, and
prepare and submit a corrective action plan for claims errors. These
costs are estimated as follows:
We estimated that the annualized number of hours required to
respond to requests for required claims information for FFS and managed
care review for 34 State programs will be 112,200 hours (3,300 hours
per State per program). At the 2009 general schedule GS-12-01 rate of
pay that includes fringe and overhead costs ($54.87/hour), we
calculated a cost of $6,156,414 ($4,309,490 in Federal cost and
$1,846,924 in State cost). This cost estimate includes the following
estimated annualized hours: (1) Up to 1,800 hours required for States
to develop and submit required claims and capitation payments
information; (2) up to 500 hours for the collection and submission of
policies; and (3) up to 1,000 hours for States to cooperate with CMS
and the Federal contractors on other aspects of the claims review and
corrective action process.
Therefore, the total annual estimate of the State cost for 34 State
programs to submit information for FFS and managed care reviews and
participate with CMS and Federal contractors is $6,156,414 ($4,309,490
in Federal cost and $1,846,924 in State cost).
3. Cost Estimate for Eligibility Reviews
Beginning in FY 2007, States review eligibility in the same year
they are selected for FFS and managed care reviews in Medicaid and
CHIP. We estimated that total cost for eligibility review for 34 State
programs is $24,588,344 ($17,211,841 in Federal cost and $7,376,503 in
State cost). This cost estimate is based on the cost for States to
submit information to CMS and the cost for States to conduct
eligibility reviews and report rates to CMS. These costs are estimated
as follows:
We estimated in the information collection section, that the
annualized number of hours required to respond to requests for
information for the eligibility review (for example, sampling plan,
monthly sample lists, the eligibility corrective action report) for 34
State programs will be 108,800 hours (3,200 hours per State per
program). At the 2009 general schedule GS-12-01 rate of pay that
includes fringe and overhead costs ($54.87/hour), we calculated a cost
of $5,969,856 ($4,178,899 in Federal cost and $1,790,957 in State
cost). This cost estimate includes the following estimated annualized
hours: (1) Up to 1,000 hours required for States to develop and submit
a sampling plan; (2) up to 1,200 hours for States to submit 12 monthly
sample lists detailing the cases selected for review; and (3) up to
1,000 hours for States to submit a corrective action plan for purposes
of reducing the eligibility payment error rate. For the eligibility
review and reporting of the findings, we estimated that each State
would need to review an annual sample size of 504 active cases to
achieve a 3 percent margin of error at a 95 percent confidence interval
level in the State-specific error rates. We also estimated that States
would need to review 204 negative cases to produce a case error rate
that met similar standards for statistical significance. We estimated
that for 34 State programs the annualized number of hours required to
complete the eligibility case reviews and report the eligibility-based
error data to CMS would be 339,320 hours (9,980 hours per State, per
program). At the 2009 general schedule GS-12-01 rate of pay that
includes fringe and overhead costs ($54.87/hour), we calculated a cost
of $18,618,488 ($13,032,942 in Federal cost and $5,585,547 in State
cost).
Therefore, the total annual estimate of the cost for 34 State
programs to submit information and to conduct the eligibility reviews
and report the error rate to CMS is $24,588,344 ($17,211,841 in Federal
cost and $7,376,503 in State cost).
The CHIPRA requires CMS to provide States in their PERM year the
option to use PERM data to meet the MEQC requirements described in
section 1903(u) of the Act, and the option to use MEQC data described
in Sec. 431.812 to meet the PERM eligibility review requirement. While
the intent is to reduce redundancies and cost burden between the two
programs and their review requirements, States that substitute findings
may incur more costs to implement changes to their PERM or MEQC
sampling and review procedures.
4. Cost Estimate for Total PERM Costs
Based on our estimates of the costs for the FFS, managed care and
eligibility reviews for both the Medicaid and CHIP programs at
approximately $45.4 million ($36,204,108 in Federal cost and $9,223,428
in State cost), this rule does not exceed the $100 million or more in
any 1 year criterion for a major rule, and a regulatory impact analysis
is not required.
The RFA requires agencies to analyze options for regulatory relief
of small businesses, if a rule has a significant impact on a
substantial number of small entities. The great majority of hospitals
and most other health care providers and suppliers are small entities,
either by being nonprofit organizations or by meeting the SBA
definition of a small business (having revenues of less than $7.0
million to $34.5 million in any 1 year). Individuals and States are not
included in the definition of a small entity.
Providers could be required to supply medical records or other
similar documentation that verified the provision of Medicaid or CHIP
services to beneficiaries as part of the PERM reviews, but we
anticipate this action would not have a significant cost impact on
providers. Providers would only need to provide medical records for the
FFS component of this program. A request for medical documentation to
substantiate a claim for payment would not be a burden to providers nor
would it be outside the customary and usual business practices of
Medicaid or CHIP providers. Not all States would be reviewed every year
and medical records would only be requested for FFS claims, so it is
unlikely for a provider to be selected more than once per program per
measurement cycle to provide supporting documentation, particularly in
States with a large Medicaid or CHIP managed care population. If a
provider is, in fact, selected more than once per program to provide
supporting documentation it would not be outside customary and usual
business practices.
In addition, the information should be readily available and the
response should take minimal time and cost since the response would
merely require gathering the documents and either copying and mailing
them or sending them by facsimile. The request for medical
documentation from providers is within the customary and usual business
practice of a provider who accepts payment from an insurance provider,
whether it is a private organization, Medicare, Medicaid, or CHIP and
should not have a significant impact on the provider's operations.
Therefore, the Secretary has determined that this proposed rule will
not have a significant economic impact on a substantial number of small
entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory
[[Page 34482]]
impact analysis if a rule may have a significant impact on the
operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a metropolitan
statistical area and has fewer than 100 beds.
These entities may incur costs due to collecting and submitting
medical records to the contractor to support medical reviews; but, like
any other Medicaid or CHIP provider, we estimate these costs would not
be outside the limit of usual and customary business practices. Also,
since the sample is randomly selected and only FFS claims are subject
to medical review, we do not anticipate that a great number of small
rural hospitals would be asked for an unreasonable number of medical
records. As stated before, a State will be reviewed only once, per
program, every 3 years and it is unlikely for a provider to be selected
more than once per program to provide supporting documentation.
Therefore, the Secretary has determined that this proposed rule would
not have a significant impact on the operations of a substantial number
of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2009, that
threshold is approximately $133 million. This proposed rule does not
impose costs on States to produce the error rates for FFS and managed
care payments, but requires States and providers to submit claims
information and medical records and cooperate with Federal contractors
during the review so that error rates can be calculated.
Based on our estimates of State participation burden for both
Medicaid and CHIP, for 34 States (17 States per Medicaid and 17 States
for CHIP), we calculated that the annual burden for these States for
the PERM program is approximately $9,223,428 in State costs for both
Medicaid and CHIP. The combined costs of both programs total
approximately $542,555 for each of the 17 States. Thus, we do not
anticipate State costs to exceed $133 million. Executive Order 13132
establishes certain requirements that an agency must meet when it
promulgates a proposed rule (and subsequent final rule) that imposes
substantial direct requirement costs on State and local governments,
preempts State law, or otherwise has Federalism implications. This
proposed rule requires States to prepare and submit claims universe
information for both FFS and managed care payments, prepare and submit
claims details and provider information for sampled records, submit
State program policies and updates on a quarterly basis, cooperate with
Federal contractors during data processing reviews, participate in the
difference resolution and appeals process, and prepare and submit a
corrective action plan for claims errors. We estimated that the burden
to respond to requests for claims information for the FFS and managed
care measurement for Medicaid and CHIP for 34 State programs (17 States
for Medicaid and 17 States for CHIP) will be $6,156,414 ($4,309,490 in
Federal cost and $1,846,924 in State cost).
This proposed rule also require States selected for review to
submit an eligibility sampling plan, monthly sample selection
information, summary review findings, State error rate data, and other
information in order for CMS to calculate the eligibility State-
specific and national error rates. We estimated that the burden to
conduct the eligibility measurement for Medicaid and CHIP for 34 State
programs (17 States for Medicaid and 17 States for CHIP) will be
approximately $24,588,344 ($17,211,841 in Federal cost and $7,376,503
in State cost). As a result, we assert that this regulation will not
have a substantial impact on State or local governments.
B. Anticipated Effects
This proposed rule is intended to measure improper payments in
Medicaid and CHIP. States would implement corrective actions to reduce
the error rate, thereby producing savings over time. These savings
cannot be estimated until after the corrective actions have been
monitored and determined to be effective, which can take several years.
C. Alternatives Considered
This proposed rule reflects changes required by the CHIPRA.
Therefore, we considered only applying additional changes to the CHIP
component of PERM (except in instances where CHIPRA specifically
requires the provision to apply to Medicaid and CHIP). However, in
order to maintain a consistent measurement process for the Medicaid and
CHIP programs, we did not choose this alternative. No other
alternatives were considered since the modifications were required by
Federal statute.
D. Conclusion
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects
42 CFR Part 431
Grant programs--health, Health facilities, Medicaid, Privacy,
Reporting and recordkeeping requirements.
42 CFR Part 447
Accounting, Administrative practice and procedure, Drugs, Grant
programs--health, Health facilities, Health professions, Medicaid,
Reporting and recordkeeping requirements, Rural areas.
42 CFR Part 457
Administrative practice and procedure, Grant programs--health,
Health insurance, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR chapter IV as set forth
below:
PART 431--STATE ORGANIZATION AND GENERAL ADMINISTRATION
1. The authority for part 431 continues to read as follows:
Authority: Sec. 1102 of the Social Security Act, (42 U.S.C.
1302).
Subpart P--Quality Control
2. In 42 CFR part 431, revise all references to ``SCHIP'' to read
``CHIP''.
3. Amend Sec. 431.636 by revising all references to ``State
Children's Health Insurance Program'' to read ``Children's Health
Insurance Program.''
4. Section 431.806 is amended by--
A. Redesignating paragraph (b) as paragraph (c).
B. Adding new paragraph (b).
C. Revising redesignated paragraph (c).
The addition and revision read as follows:
Sec. 431.806 State plan requirements.
* * * * *
(b) Use of PERM data. A State plan must provide for operating a
Medicaid eligibility quality control program that is in accordance with
Sec. 431.978 through Sec. 431.980 of this part to meet the
requirements of Sec. 431.810 through Sec. 431.822 of this subpart
when a State is in their PERM year.
(c) Claims processing assessment system. Except in a State that has
an approved Medicaid Management Information System (MMIS) under
[[Page 34483]]
subpart C of part 433 of this subchapter, a State Plan must provide for
operating a Medicaid quality control claims processing assessment
system that meets the requirements of Sec. 431.836 of this subpart.
5. Section 431.812 is amended by adding new paragraphs (f) and (g)
to read as follows:
Sec. 431.812 Review procedures.
* * * * *
(f) MEQC pilot reviews and waivers. (1) A State may elect to
conduct MEQC pilot reviews using an alternative methodology or a
focused Medicaid population with CMS approval.
(2) States must submit a pilot proposal at least 60 days before
planned implementation of the pilot reviews.
(3) The State must receive CMS approval of its plan before it is
implemented.
(g) Substitution of PERM data. A State in its Payment Error Rate
Measurement (PERM) year may elect to substitute the random sample of
selected cases, eligibility review findings, and payment review
findings obtained through PERM reviews conducted in accordance with
Sec. 431.980 of this part for data required in this section, if the
only exclusions are those set forth in Sec. 431.978(d)(1) of this
part.
6. Section 431.814 is amended by revising paragraph (c)(4) to read
as follows:
Sec. 431.814 Sampling plan and procedures.
* * * * *
(c) * * *
(4) States must exclude from the MEQC universe all of the
following:
(i) SSI beneficiaries whose eligibility determinations were made
exclusively by the Social Security Administration under an agreement
under section 1634 of the Act.
(ii) Individuals in foster care or receiving adoption assistance
whose eligibility is determined under Title IV-E of the Act.
(iii) Individuals receiving Medicaid under programs that are 100
percent Federally-funded.
(iv) Individuals whose eligibility was determined under a State's
option under section 1902(e)(13) of the Act.
* * * * *
Subpart Q--Requirements for Estimating Improper Payments in
Medicaid and CHIP
7. Amend Sec. 431.950 by revising the reference to ``State
Children's Health Insurance Program'' to read ``Children's Health
Insurance Program.''
8. Section Sec. 431.954 is amended by adding a sentence to the end
of paragraph (a) to read as follows:
Sec. 431.954 Basis and scope.
(a) * * * This subpart also implements the provisions of section
601 of the Children's Health Insurance Program Reauthorization Act of
2009 (CHIPRA) (Pub. L. 111-3) which requires that the new PERM
regulations include the following: Clearly defined criteria for errors
for both States and providers; clearly defined processes for appealing
error determinations; clearly defined responsibilities and deadlines
for States in implementing any corrective action plans; requirements
for State verification of an applicant's self-declaration or self-
certification of eligibility for, and correct amount of, medical
assistance under Medicaid or child health assistance under CHIP; and
State-specific sample sizes for application of the PERM requirements.
* * * * *
9. Section 431.958 is amended by--
A. Adding definitions for the terms ``Annual sample size,''
``Children's Health Insurance Program,'' ``Provider error,'' and
``State error'' in alphabetical order.
B. Removing the definition of ``State Children's Health Insurance
Program.''
C. Revising the definition of ``Case''.
The additions and revision read as follows:
Sec. 431.958 Definitions and use of terms.
* * * * *
Annual sample size means the number of fee-for-service claims,
managed care payments or eligibility cases necessary to meet precision
requirements in a given PERM cycle.
* * * * *
Case means an individual beneficiary or family enrolled in Medicaid
or CHIP or who has been denied enrollment or has been terminated from
Medicaid or CHIP.
* * * * *
Children's Health Insurance Program (CHIP) means the program
authorized and funded under Title XXI of the Act.
* * * * *
Provider error includes, but is not limited to one of the
following:
(1) An improper payment made due to lack of or insufficient
documentation.
(2) Incorrect coding.
(3) Improper billing (for example, unbundling, incorrect number of
units).
(4) A payment that is in error due to lack of medical necessity.
(5) Evidence that the service was not provided in compliance with
documented State or Federal policy.
* * * * *
State error includes, but is not limited to one of the following:
(1) A payment that is in error due to incorrect processing (for
example, duplicate of an earlier payment, payment for a non-covered
service, payment for an ineligible beneficiary).
(2) Incorrect payment amount (for example, incorrect fee schedule
or capitation rate applied, incorrect third party liability applied).
(3) A payment error resulting from services being provided to an
individual who--
(i) Was ineligible when authorized or when he or she received
services;
(ii) Was eligible for the program but was ineligible for certain
services he or she received; or
(iii) Had not met applicable beneficiary liability requirements
when authorized eligible or paid too much toward actual liability.
* * * * *
10. Section 431.960 is added to read as follows:
Sec. 431.960 Types of payment errors.
(a) General rule. State or provider errors identified for the
Medicaid and CHIP improper payments measurement under the Improper
Payments Information Act of 2002 must affect payment under applicable
Federal policy and State policy.
(b) Data processing errors. (1) A processing error is an error
resulting in an overpayment or underpayment that is determined from a
review of the claim and other information available in the State's
Medicaid Management Information System, related systems, or outside
sources of provider verification.
(2) The difference in payment between what the State paid (as
adjusted within improper payment measurement guidelines) and what the
State should have paid is the dollar measure of the payment error.
(c) Medical review errors. (1) A medical review error is an error
resulting in an overpayment or underpayment that is determined from a
review of the provider's documentation, the State's written policies,
and a comparison with the information presented on the claim.
(2) The difference in payment between what the State paid (as
adjusted within improper payment measurement guidelines) and what the
State should have paid is the dollar measure of the payment error.
(d) Eligibility errors. (1) An eligibility error is an error
resulting from services being provided to an individual who--
(i) Was ineligible when authorized or when he or she received
services;
[[Page 34484]]
(ii) Was eligible for the program but was ineligible for certain
services he or she received;
(iii) Had not met applicable beneficiary liability requirements
when authorized as eligible or paid too much toward actual liability;
or
(iv) Had a lack of or insufficient documentation in the case record
to make a definitive determination of eligibility or ineligibility.
(2) The dollars paid in error due to the eligibility error is the
measure of the payment error.
(3) A State eligibility error does not result from the State's
verification of an applicant's self-declaration or self-certification
of eligibility for, and the correct amount of, medical assistance or
child health assistance, if the State process for verifying an
applicant's self-declaration or self-certification satisfies the
requirements for such process applicable under regulations at Sec.
457.380 of this chapter, in CMS approved State plans, or otherwise
approved by the Secretary. Requirements for acceptable self-declaration
for eligibility reviews are described at Sec. 431.980(d)(1) and
(d)(2).
(4) Negative case errors are errors resulting from either of the
following:
(i) Applications for Medicaid or CHIP that are improperly denied by
the State.
(ii) Existing cases that are improperly terminated from Medicaid or
CHIP by the State.
(5) No payment errors are associated with negative cases.
(e) Errors for purposes of determining the national error rates.
The Medicaid and CHIP national error rates include but are not limited
to the errors described in paragraphs (b) through (d)(1) of this
section.
(f) Errors for purposes of determining the State error rates. (1)
The Medicaid and CHIP State error rates include but are not limited to,
the errors described in paragraphs (b) through (d)(1)(iii) of this
section.
(2) Undetermined cases, as described in paragraph (d)(1)(iv) of
this section, cited in the eligibility reviews are excluded from State-
specific payment error rates if the errors satisfy the criteria in
paragraph (d)(3) of this section.
(g) Error codes. CMS may define different types of errors within
the above categories for analysis and reporting purposes. Only dollars
in error will factor into a State's PERM error rate.
11. Section 431.970 is amended by revising paragraph (a)(1) to read
as follows:
Sec. 431.970 Information submission requirements.
(a) * * *
(1) Adjudicated fee-for-service (FFS) or managed care claims
information or both, on a quarterly basis, from the review year;
* * * * *
12. Section 431.972 is added to read as follows:
Sec. 431.972 Claims sampling procedures.
(a) Claims universe. The PERM claims universe includes payments
that were originally paid (paid claims) and for which payment was
requested but denied (denied claims) during the Federal fiscal year,
and for which there is Federal financial participation (FFP) (or would
have been if the claim had not been denied) through Title XIX
(Medicaid) or Title XXI (CHIP).
(b) Sample size. CMS estimates a State's annual sample size for
claims review at the beginning of the PERM cycle.
(1) Precision and confidence levels. The annual sample size must be
estimated to achieve a State-level error rate within a 3 percent
precision level at 95 percent confidence interval for the claims
component of the PERM program, unless the precision requirement is
waived by CMS on its own initiative.
(2) Base year sample size. The annual sample size in a State's
first PERM cycle (the ``base year'') is--
(i) Five hundred fee-for-service claims and 250 managed care
payments drawn from the claims universe; or
(ii) If the claims universe of fee-for-service claims or managed
care capitation payments from which the annual sample is drawn is less
than 10,000, the State may request to reduce its sample size by the
finite population correction factor for the relevant PERM cycle.
(3) Subsequent year sample size. In PERM cycles following the base
year:
(i) CMS considers the error rate from the State's previous PERM
cycle to determine the State's annual sample size for the current PERM
cycle.
(ii) The maximum sample size is 1,000 fee-for-service or managed
care payments, respectively.
(iii) If a State measured in the FY 2007 or FY 2008 cycle elects to
reject its State-specific CHIP PERM rate determined during those
cycles, information from those cycles will not be used to calculate its
annual sample size in subsequent PERM cycles and the State's annual
sample size in FY 2010 or FY 2011 is 500 fee-for-service and 250
managed care payments.
13. Section 431.978 is amended by--
A. Revising paragraphs (a) through (c).
B. Revising paragraphs (d)(1)(i) and (ii).
The revisions read as follows:
Sec. 431.978 Eligibility sampling plan and procedures.
(a) Plan approval. For each review year, the State must--
(1) Submit its Medicaid or CHIP sampling plan (or revisions to a
current plan) for both active and negative cases to CMS for approval by
the August 1 before the review year; and
(2) Have its sampling plan approved by CMS before the plan is
implemented.
(b) Maintain current plan. The State must do the both of the
following:
(1) Keep its plan current, for example, by making adjustments to
the plan when necessary due to fluctuations in the universe.
(2) Review its plan each review year. If it is determined that the
approved plan is--
(i) Unchanged from the previous review year, the State must notify
CMS that it is using the plan from the previous review year; or
(ii) Changed from the previous review year, the State must submit a
revised plan for CMS approval.
(c) Sample size. (1) Precision and confidence levels. Annual sample
size for eligibility reviews must be estimated to achieve within a 3
percent precision level at 95 percent confidence interval for the
eligibility component of the program.
(2) Base year sample size. Annual sample size for each State's base
year of PERM is--
(i) Five hundred and four active cases and 204 negative cases drawn
from the active and negative universes; or
(ii) If the active case universe or negative case universe of
Medicaid or CHIP beneficiaries from which the annual sample is drawn is
less than 10,000, the sample size may be reduced by the finite
population correction factor for the relevant PERM cycle.
(3) Subsequent year sample size. In PERM cycles following the base
year the annual sample size may increase or decrease based on the
State's prior results of the previous cycle PERM error rate
information. The State may provide information to CMS in the
eligibility sampling plan due to CMS by the August 1 prior to the start
of the fiscal year to support the calculation of a reduced annual
sample size for the next PERM cycle.
(i) CMS considers the error rate from the State's previous PERM
cycle to determine the State's annual sample size for the current PERM
cycle.
[[Page 34485]]
(ii) The maximum sample size is 1,000 for the active cases and
negative cases, respectively.
(iii) If the active case universe or negative case universe of
Medicaid or CHIP beneficiaries from which the annual sample is drawn is
less than 10,000, the sample size may be reduced by the finite
population correction factor for the relevant PERM cycle.
(iv) If a State measured in the FY 2007 or FY 2008 cycle elects to
reject its PERM CHIP rate as determined during those cycles,
information from those cycles is not used to calculate the State's
sample size in subsequent PERM cycles and the State's sample size in FY
2010 or FY 2011 is 504 active cases and 204 negative cases.
(d) * * *
(1) * * *
(i) Medicaid. (A) The Medicaid active universe consists of all
active Medicaid cases funded through Title XIX for the sample month.
(B) The following types of cases are excluded from the Medicaid
active universe:
(1) Cases for which the Social Security Administration, under a
section 1634 agreement with a State, determines Medicaid eligibility
for Supplemental Security Income recipients.
(2) All foster care and adoption assistance cases under Title IV-E
of the Act are excluded from the universe in all States.
(3) Cases under active fraud investigations.
(4) Cases in which eligibility was determined under section
1902(e)(13) of the Act for States' express lane option.
(C) If the State cannot identify cases under active fraud
investigations for exclusion from the universe previous to the sample
selection, the State shall drop these cases from review if they are
selected in the sample and are later determined to be under active
fraud investigation at the time of selection.
(ii) CHIP. (A) The CHIP active universe consists of all active case
CHIP and Title XXI Medicaid expansion cases that are funded through
Title XXI for the sample month.
(B) The following types of cases are excluded from the CHIP active
universe:
(1) Cases under active fraud investigation.
(2) Cases in which eligibility was determined under section
1902(e)(13) of the Act for States' express lane option.
(C) If the State cannot identify cases that meet the exclusion
criteria specified in paragraph (d)(1)(ii)(B) of this section before
sample selection, the State must drop these cases from review if is
later determined that the cases meet the exclusion criteria specified
in paragraph (d)(1)(ii)(B) of this section.
* * * * *
14. Section 431.980 is amended by--
A. Revising the introductory text of paragraph (d)(1).
B. In paragraph (d)(1)(i) and (ii), removing the ``;'' at the end
of the paragraph and adding in its place a ``.''.
C. Revising paragraph (d)(1)(iii).
D. Redesignating paragraph (d)(1)(vi) as (d)(1)(x).
D. Adding new paragraphs (d)(1)(vi) through (d)(1)(ix).
E. Revising the introductory text of newly redesignated paragraph
(d)(1)(x).
F. Revising the introductory text of paragraph (d)(2).
G. Adding paragraph (f).
The revisions and additions read as follows:
Sec. 431.980 Eligibility review procedures.
* * * * *
(d) * * *
(1) Active cases--Medicaid. Unless the State has selected to
substitute MEQC data for PERM data under paragraph (f) of this section,
the agency must complete all of the following:
* * * * *
(iii) Examine the evidence in the case file that supports
categorical and financial eligibility for the category of coverage in
which the case is assigned, and independently verify information that
is missing, older than 12 months and likely to change, or otherwise as
needed, to verify eligibility.
* * * * *
(vi) Elements of eligibility in which State policy allows for self-
declaration can be verified with a new self-declaration statement.
(vii) The self-declaration must be--
(A) Present in the record;
(B) Not outdated (more than 12 months old);
(C) In a valid, State-approved format; and
(D) Consistent with other facts in the case record.
(viii) If a self-declaration statement in the case record is more
than 12 months old, eligibility may be verified through a new self-
declaration statement or other third party sources.
(ix) If eligibility or ineligibility cannot be verified, cite a
case as undetermined as specified in paragraph (d)(1)(x)(B) or
(d)(2)(ii) of this section.
(x) As a result of paragraphs (d)(1)(i) through (d)(1)(ix) of this
section--
* * * * *
(2) Active cases--CHIP. In addition to the procedures for active
cases as set forth in paragraphs (d)(1)(i) through (d)(1)(ix) of this
section, once the agency establishes CHIP eligibility, the agency must
verify that the case is not eligible for Medicaid by determining that
the child has income above the Medicaid levels in accordance with the
requirements in Sec. 457.350 of this chapter. Upon verification, the
agency must--
* * * * *
(f) Substitution of MEQC data. (1) A State in their PERM year may
elect to substitute the random sample of selected cases, eligibility
review findings, and payment reviews findings obtained through MEQC
reviews conducted in accordance with section 1903(u) of the Act for
data required in this section, as long as the State MEQC reviews are
based on a broad, representative sample of Medicaid applicants or
enrollees in the State, if the only exclusions are those set forth in
section 1902(e)(13) of the Act, Sec. 431.814(c)(4), and Sec.
431.978(d)(1) of this part.
(2) MEQC samples must also meet PERM confidence and precision
requirements.
15. Section 431.988 is amended by revising paragraphs (b)(1) and
(2) to read as follows:
Sec. 431.988 Eligibility case review completion deadlines and
submittal of reports.
* * * * *
(b) * * *
(1) Case and payment error data for active cases.
(2) Case error data for negative cases.
* * * * *
16. Section 431.992 is revised to read as follows:
Sec. 431.992 Corrective action plan.
(a) The State agency must develop a corrective action plan designed
to reduce improper payments in its Medicaid and CHIP programs based on
its analysis of the error causes in the FFS, managed care, and
eligibility components.
(b) In developing a corrective action plan, the State must take the
following actions:
(1) Data analysis. (i) States must conduct data analysis such as
reviewing clusters of errors, general error causes, characteristics,
and frequency of errors that are associated with improper payments as
well as error causes associated with number of errors.
(ii) Data analysis may sort the predominant payment errors and
number of errors by the following:
(A) Type: General classification (for example, FFS, managed care,
eligibility).
(B) Element: Specific type of classification (for example, no
[[Page 34486]]
documentation errors, duplicate claims, ineligible cases due to excess
income).
(C) Nature: Cause of error (for example, providers not submitting
medical records, lack of systems edits, unreported changes in income
that caused ineligibility).
(iii) States must analyze active and negative case errors and
causes for undetermined case findings under the eligibility component.
(2) Program analysis. (i) States must review the findings of the
data analysis to determine the specific programmatic causes to which
errors are attributed (for example, provider lack of understanding of
the PERM requirement to provide documentation) and to identify root
error causes.
(ii) The States may need to analyze the agency's operational
policies and procedures and identify those policies or procedures, or
both that are prone to contribute to errors, for example, unclear
policies or lack of operational oversight at the local level.
(3) Corrective action planning. States must determine the
corrective actions to be implemented that address the root error
causes.
(4) Implementation and monitoring. (i) States must develop an
implementation schedule for each corrective action initiative and
implement those actions in accordance with the schedule.
(ii) The implementation schedule must identify the following:
(A) Major tasks;
(B) Key personnel responsible for each activity; and
(C) A timeline for each action including target implementation
dates, milestones, and monitoring.
(5) Evaluation. States must evaluate the effectiveness of the
corrective action by assessing the following:
(i) Improvements in operations;
(ii) Efficiencies;
(iii) Number of errors; and
(iv) Improper payments.
(c) The State agency must submit to CMS and implement the
corrective action plan for the fiscal year it was reviewed no later
than 60 calendar days after the date on which the State's Medicaid or
CHIP error rates are posted on the CMS contractor's Web site.
(d) The State must submit a new corrective action plan for each
subsequent error rate measurement that contains an update on the status
of a previous corrective action plan. Items to address in the new
corrective action plan include, but are not limited to the following:
(1) Effectiveness of implemented corrective actions, as assessed
using concrete data.
(2) Discontinued or ineffective actions, actions not implemented,
and those actions, if any, that were substituted for such discontinued,
ineffective, or abandoned actions.
(3) Findings on short-term corrective actions.
(4) The status of the long-term corrective actions.
17. Section 431.998 is amended by--
A. Revising the section heading as set forth below.
B. Revising paragraphs (a) and (b).
C. Redesignating paragraph (c) as (d).
D. Adding new paragraph (c).
The revisions and addition read as follows:
Sec. 431.998 Difference resolution and appeal process.
(a) The State may file, in writing, a request with the Federal
contractor to resolve differences in the Federal contractor's findings
based on medical or data processing reviews on FFS and managed care
claims in Medicaid or CHIP within 10 business days after the
disposition report of claims review findings is posted on the
contractor's Web site. The State must complete all of the following:
(1) Have a factual basis for filing the difference.
(2) Provide the Federal contractor with valid evidence directly
related to the error finding to support the State's position that the
claim was properly paid.
(b) For a claim in which the State and the Federal contractor
cannot resolve the difference in findings, the State may appeal to CMS
for final resolution within 5 business days from the date of the
contractor's finding as a result of the difference resolution is posted
on the contractor's Web site. There is no minimum dollar threshold
required to appeal a difference in findings.
(c) For eligibility error determinations made by agencies or
personnel functionally and physically separate from the State agencies
and personnel that are responsible for Medicaid and CHIP policy and
operations, the State may appeal error determinations by filing an
appeal request.
(1) Filing an appeal request. The State may--
(i) File its appeal request with the appropriate State agency; or
(ii) If no appeals process is in place at the State level,
differences in findings--
(A) Must be documented in writing for the independent State agency
to consider; or
(B) May be resolved at the State level through document exchange
facilitated by CMS.
(2) After the filing of an appeals request. (i) Any changes in
error findings must be reported to CMS by the deadline for submitting
final eligibility review findings.
(ii) Any unresolved differences may be addressed by CMS not less
than 60 days and no more than 90 days after the State submits its
eligibility error data.
(iii) Any appeals of determinations based on interpretations of
Federal policy may be referred to CMS.
(iv) If CMS's decision causes an erroneous payment finding to be
made, any resulting recoveries are governed by Sec. 431.1002 of this
subchapter.
* * * * *
PART 447--PAYMENTS FOR SERVICES
18. The authority citation for part 447 continues to read as
follows:
Authority: Sec. 1102 of the Social Security Act (42 U.S.C.
1302).
19. In 42 CFR part 447, revise all references to ``SCHIP'' to read
``CHIP''.
20. In Sec. 447.504 amend paragraph (g)(15) by revising the
reference to ``State Children's Health Insurance Program'' to read
``Children's Health Insurance Program.''
PART 457--ALLOTMENTS AND GRANTS TO STATES
21. The authority citation for part 457 continues to read as
follows:
Authority: Section 1102 of the Social Security Act (42 U.S.C.
1302).
22. In 42 CFR part 457, revise all references to ``SCHIP'' to read
``CHIP''.
23. Section 457.10 is amended by--
A. Adding the definition of ``Children's Health Insurance Program''
in alphabetical order.
B. Removing the definition of ``State Children's Health Insurance
Program.''
The addition reads as follows:
Sec. 457.10 Definitions and use of terms.
* * * * *
Children's Health Insurance Program (CHIP) means a program
established and administered by a State, jointly funded with the
Federal government, to provide child health assistance to uninsured,
low-income children through a separate child health program, a Medicaid
expansion program, or a combination program.
* * * * *
24. In 42 CFR part 457, revise all references to ``State Children's
Health Insurance Program'' to read ``Children's Health Insurance
Program.''
Authority: (Catalog of Federal Domestic Assistance Program No.
93.778, Medical Assistance Program).
[[Page 34487]]
Dated: April 14, 2009.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: May 7, 2009.
Kathleen Sebelius,
Secretary.
[FR Doc. E9-16538 Filed 7-14-09; 8:45 am]
BILLING CODE 4120-01-P