PART 430-GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Subpart A-Introduction; Definitions

Sec.

430.0 Introduction to Subchapter C. 430.1 Definitions.

Subpart A-Introduction; Definitions

§ 430.0 Introduction to Subchapter C.

(a) Program description. Title XIX of the Social Security Act, enacted in 1965, authorizes Federal grants to States for medical assistance to lowincome persons who are age 65 or over, blind, disabled, or members of families with dependent children. The program is jointly financed by the Federal and State governments and administered by States. Within broad Federal rules, each State decides eligible groups, types and range of services, payment levels for services, and administrative and operating procedures. Payments for services are made directly by the State to the individuals or entities that furnish the services.

(b) Federal regulations. (1) The regulations in Subchapter C set forth State plan requirements, standards, procedures, and conditions for obtaining Federal matching. Each part (or subpart or section) in the subchapter describes the specific statutory basis for the regulation. However, where the basis is the Secretary's general authority to issue regulations for any program under the Act (sec. 1102 of the Act), or his general authority to prescribe State plan requirements needed for proper and efficient administration of the plan (sec. 1902(a)(4)), those statutory provisions are simply cited without further description.

(2) Related HEW regulations applicable to State medicaid programs include the following in 45 CFR Subtitle A:

Part 16-Department Grant Appeals Proc

ess.

Part 19-Limitations on Payment or Reimbursement for Drugs.

Part 70-Standards for a Merit System of Personnel Administration.

Part 74-Administration of Grants.

Part

80-Nondiscrimination Under Programs Receiving Federal Assistance Through the Department of Health, Education, and Welfare: Effectuation of Title VI of the Civil Rights Act of 1964. Part 81-Practice and Procedure for Hearings Under 45 CFR Part 80.

Part 84-Nondiscrimination on the Basis of Handicap in Programs and Activities Receiving or Benefiting From Federal Financial Assistance.

(3) Regulations in 45 CFR Parts 201 and 213 also apply to the Medicaid program, to the extent specified.

(Sec. 1102 of the Social Security Act, 49 Stat. 647 (42 U.S.C. 1302))

[43 FR 45187, Sept. 29, 1978, as amended at 44 FR 17929, Mar. 23, 1979]

In this subchapter, unless the context indicates otherwise

"Act" means the Social Security Act, and titles referred to are titles of that Act;

"Administrator" means the Administrator, Health Care Financing Administration;

"Applicant" means an individual whose written application for medicaid has been submitted to the agency determining medicaid eligibility, but has not received final action. This includes an individual (who need not be alive at the time of application) whose application is submitted through a representative or a person acting responsibly for the individual;

"Bureau Director" means the Director of the Federal medicaid program with HCFA;

"Central office" means the headquarters office of HCFA;

"Federal financial participation” (FFP) means the Federal Government's share of a State's expenditures under the medicaid program;

"FMAP" means the Federal medical assistance percentage, which is used to calculate the amount of the Federal share of State expenditures for services;

"HEW" means the Dep.rtment of Health, Education, and Welfare;

"HCFA" means the Health Care Financing Administration;

"Medicaid" means medical assistance provided under a State plan approved under title XIX of the Act;

"Medicaid agency" or "the agency" means the single State agency administering or supervising the administration of a State medicaid plan;

"Medicare" means the health insurance program for the aged and disabled under title XVIII of the Act;

"Provider" means any individual or entity furnishing medicaid services under a provider agreement with the medicaid agency; "Recipient"

means an individual who has been determined eligible for medicaid;

"Regional Administrator" means the Regional Administrator of HCFA;

"Regional Medicaid Director" means the Regional Medicaid Director of the Federal medicaid program;

"Regional office" means one of the regional offices of HCFA;

"Secretary" means the Secretary of Health, Education, and Welfare;

"Services" means the types of medical assistance specified in sec. 1905(a) (1) through (17) of the Act;

"State" means the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, and Guam;

"State plan" or "the plan" means a comprehensive written commitment by a medicaid agency, submitted under sec. 1902(a) of the Act, to administer or supervise the administration of a medicaid program in accordance with Federal requirements.

The masculine gender includes the feminine.

(Sec. 1102 of the Social Security Act, 49 Stat. 647 (42 U.S.C. 1302))

[43 FR 45187, Sept. 29, 1978]

PART 431-STATE ORGANIZATION AND GENERAL ADMINISTRATION

Sec.

431.1 Purpose.

Subpart A-Single State Agency

431.10 Single State agency. 431.11 Organization for administration. 431.12 Medical care advisory committee. 431.15 Methods of administration.

Sec.

431.241 Matters to be considered at the

hearing.

431.242 Procedural rights of the applicant or recipient.

431.243 Parties in cases involving an eligi

bility determination.

431.244 Hearing decisions.

431.245 Notifying the applicant or recipient of a State agency decision.

431.246 Corrective action.

FEDERAL FINANCIAL PARTICIPATION 431.250 Federal financial participation. Subpart F-Safeguarding Information on Applicants and Recipients

431.300 Basis and purpose. 431.301 State plan requirements. 431.302 Purposes directly related to State plan administration.

431.303 State authority for safeguarding information.

431.304 Publicizing safeguarding requirements.

431.305 Types of information to be safeguarded.

431.306 Release of information. 431.307

als.

Distribution of information materi

Sec.

431.527 Coverage and enrollment. 431.528 Population.

431.529 Duration of enrollment period. 431.530 Termination of enrollment.

431.531 Choice of health professional. 431.532 Emergency medical services. 431.533 Grievance procedure. 431.534 Quality assurance system. 431.535 Marketing.

431.536 Health care information. 431.537 Medical recordkeeping system.

HMO: STATE Agency REQUIREMENTS 431.540 Proof of HMO capability. 431.541 Enrollment.

431.542

Provision of required services. 431.543 System of periodic medical audits. 431.544 Approval of marketing plans, procedures, and materials for enrollment. 431.545 Distribution of general information.

431.546 Payment to contractors. 431.547 Continued service to formerly enrolled recipients.

431.548 Computation of premium rates and subscription charges.

431.549 Monitoring procedures. 431.550 Contracts that provide fewer or more services than are available under the plan.

Sec. 431.714 Waivers. 431.715 Federal financial participation.

Subpart O [Reserved]

Subpart P-Quality Control

431.800 Medicaid quality control (MQC) system.

431.801 Disallowance of Federal financial participation for erroneous State pay

ments.

AUTHORITY: Sec. 1102 of the Social Security Act, 49 Stat. 647 (42 U.S.C. 1302), unless otherwise noted.

SOURCE: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

§ 431.1 Purpose.

This part establishes State plan requirements for the designation, organization, and general administrative activities of a State agency responsible for operating the State medicaid program, directly or through supervision of local administering agencies.

Subpart A-Single State Agency

§ 431.10 Single State agency.

(a) Basis and purpose. This section implements section 1902(a)(5) of the Act, which provides for designation of a single State agency for the Medicaid program.

(b) Designation and certification. A State plan must

(1) Specify a single State agency established or designated to administer or supervise the administration of the plan; and

(2) Include a certification by the State Attorney General, citing the legal authority for the single State agency to

(i) Administer or supervise the administration of the plan; and

(ii) Make rules and regulations that it follows in administering the plan or that are binding upon local agencies that administer the plan.

(c) Determination of eligibility. (1) The plan must specify whether the agency that determines eligibility for families and for individuals under 21 is

(i) The Medicaid agency; or

(ii) The single State agency for the financial assistance program under

title IV-A (in the 50 States or the District of Columbia), or under title I or XVI (AABD), in Guam, Puerto Rico, or the Virgin Islands.

(2) The plan must specify whether the agency that determines eligibility for the aged, blind, or disabled is

(i) The Medicaid agency;

(ii) The single State agency for the financial assistance program under title IV-A (in the 50 States or the District of Columbia) or under title I or XVI (AABD), in Guam, Puerto Rico, or the Virgin Islands; or

(iii) The Federal agency administering the supplemental security income program under title XVI (SSI). In this case, the plan must also specify whether the Medicaid agency or the title IV-A agency determines eligibility for any groups whose eligibility is not determined by the Federal agency.

(d) Agreement with Federal or State agencies. The plan must provide for written agreements between the Medicaid agency and the Federal or other State agencies that determine eligibility for Medicaid, stating the relationships and respective responsibilities of the agencies.

(e) Authority of the single State agency. In order for an agency to qualify as the Medicaid agency

(1) The agency must not delegate, to other than its own officials, authority to

(i) Exercise administrative discretion in the administration or supervision of the plan, or

(ii) Issue policies, rules, and regulations on program matters.

(2) The authority of the agency must not be impaired if any of its rules, regulations, or decisions are subject to review, clearance, or similar action by other offices or agencies of the State.

(3) If other State or local agencies or offices perform services for the Medicaid agency, they must not have the authority to change or disapprove any administrative decision of that agency, or otherwise substitute their judgment for that of the Medicaid agency with respect to the application of policies, rules, and regulations issued by the Medicaid agency.

[44 FR 17930, Mar. 23, 1979]

§ 431.11 Organization for administration. (a) Basis and purpose. This section, based on section 1902(a)(4) of the Act, prescribes the general organization and staffing requirements for the Medicaid agency and the State plan.

(b) Medical assistance unit. A State plan must provide for a medical assistance unit within the Medicaid agency. staffed with a program director and other appropriate personnel who participate in the development, analysis, and evaluation of the Medicaid program.

(c) Description of organization. (1) The plan must include

(i) A description of the organization and functions of the Medicaid agency and an organization chart;

(ii) A description of the organization and functions of the medical assistance unit and an organization chart; and

(iii) A description of the kinds and number of professional medical personnel and supporting staff used in the administration of the plan and their responsibilities.

(d) Eligibility determined by other agencies. If eligibility is determined by State agencies other than the Medicaid agency or by local agencies under the supervision of other State agencies, the plan must include a description of the staff designated by those other agencies and the functions they perform in carrying out their responsibility.

[44 FR 17931, Mar. 23, 1979]

§ 431.12 Medical care advisory committee. (a) Basis and purpose. This section, based on sec. 1902(a)(4) of the Act, prescribes State plan requirements for establishment of a committee to advise the medicaid agency about health and medical care services.

(b) State plan requirement. A State plan must provide for a medical care advisory committee meeting the requirements of this section to advise the medicaid agency director about health and medical care services.

(c) Appointment of members. The agency director, or a higher State authority, must appoint members to the advisory committee on a rotating and continuous basis.