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1 sonnel of administrative entities known as of January 1, 1977 2 as the 'Bureau of Health Insurance', the 'Medical Services 3 Administration', the 'Bureau of Quality Assurance' (includ4 ing the National Professional Standards Review Council), 5 and the Office of Long-Term Care' and related research 6 and statistical units (including the Division of Health In7surance Studies of the Social Security Administration) 8 which shall be under the direction of the Assistant Secre9 tary for Health Care Financing, who shall report directly 10 to the Secretary and who shall have policy and adminis11 trative responsibility (including policy and administrative 12 responsibility with respect to health care standards and certi13 fication requirements as they apply to practitioners and in14 stitutions) for the programs established by titles XVIII 15 and XIX, part B of title XI, for the renal disease program 16 established by section 226 and any other health care financ17 ing programs as may be established under this Act. The 18 Assistant Secretary may not have any other duties or func19 tions assigned to him which would prevent him from carrying 20 out the duties required under the preceding sentence on a full21 time basis.

22 (b) (1) There shall be in the Department of Health, 28 Education, and Welfare an Assistant Secretary for Health 24 Care Financing, who shall be appointed by the President, 25 by and with the, advice and consent of the Senate.

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1 (2) Section 5315 of title 5, United States Code, is

2 amended in paragraph (17) by striking out "(5)" and

3 inserting in lieu thereof " (6) ".

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STATE MEDICAID ADMINISTRATION

SEC. 31. (a) Section 1902 (a) is amended by adding at

6 the end the following:

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“(37) provide

"(A) for making eligibility determinations on the basis of applications for coverage, within fortyfive days of the date of application for all individ

uals: (i) receiving aid or assistance (or who ex

cept for income and resources would be eligible for

aid or assistance) under a plan of the State ap

proved under title IV, part A, (ii) receiving aid or assistance (or who except for income and resources would be eligible for assistance) under any plan of the State approved under title I, X, or XVI (for the aged and the blind), or (ii) with respect to whom supplemental security income benefits are being paid (or who would except for income and resources be eligible to have paid with respect to them supplemental security income benefits) under title XVI on the basis of age or blindness; and

"(B) for making eligibility determina

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tions based upon applications for coverage, within sixty days of application for all individuals: (i) receiving aid or assistance (or who except for income and resources would be eligible for aid or

assistance) on the basis of disability under any plan of the State approved under title XIV or XVI, or (ii) for whom supplemental security income benefits are being paid (or who would except for income and resources be eligible to have paid to them supplemental security income benefits) under title XVI based upon disability;

"(C) for making redeterminations of eligibility for persons specified in subparagraphs

(A) and (B): (i) when required based upon information the agency has previously obtained on anticipated changes in the individual's situation, (ii) within thirty days after receiving information on

changes in an individual's circumstances which may affect his eligibility, and (iii) periodically but not less often than every six months for persons specified in subparagraph (A) (i), and not less often than annually for persons specified in subparagraph (A) (ii) and (A) (iii);

"(38) establish procedures to assure accurate

determinations of eligibility and provide that the error

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1 rate for eligibility determinations made on or after

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October 1, 1977, shall not exceed the rate specified in

section 1911 (b); and

"(39) establish payment procedures to assure that

(A) 95 percent of claims for which no further written information or substantiation is required to make payment, be paid within thirty days of receipt of the claim from a provider, and that 99 percent of such claims be paid within ninety days, and (B) both prepayment and postpayment claims review procedures are performed, including

“(i) review, on a reasonable sample or more extensive basis, to determine the accuracy of data submitted and processed;

"(ii) review to determine that the provider is a participating provider;

"(iii) review to determine whether the service is covered under the State's plan;

"(iv) review to determine whether the recip⚫ient is eligible;

"(v) review of care and services provided

where such review has not been assumed by an

organization designated by the Secretary under

part B of title XI of this Act;

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'(vi) review to determine that payments made

do not exceed those allowable;

"(vii) review to determine and recover any third party liability;

"(viii) review which reasonably safeguards against duplicate billing.".

(b) Section 1902 (a) (6) is amended by adding the 8 following at the end: "the reports are to be accurate and 9 filed within sixty days following the close of the reporting 10 period for monthly and quarterly reports, and within one 11 hundred and five days following the close of reporting 12 periods for yearly reports;".

13 (c) Amend section 1903 by adding at the end the 14 following subsection:

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"(n) (1) Effective with each calendar quarter beginning 16 October 1, 1978 the amount paid to each State under para17 graphs (a) (2), (a) (3), and (a) (6) shall be reduced or 18 terminated unless the State demonstrates to the Secretary 19 that

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"(A) 95 percent of eligibility determinations are made within the time periods specified under section

22 1902 (a) (37) (A) and (B), except that in determin

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ing whether a State has met the requirements of this paragraph there shall not be included eligibility deter

minations for persons whose eligibility is determined

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