[Federal Register: September 28, 2007 (Volume 72, Number 188)]
[Notices]
[Page 55221-55222]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr28se07-99]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Notice of Hearing: Reconsideration of Disapproval of Pennsylvania
State Plan Amendment (SPA) 06-007
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice of Hearing.
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SUMMARY: This notice announces an administrative hearing to be held on
November 16, 2007, at Suite 216, The Public Ledger Building, 150 S.
Independence Mall West, Conference Room 241, the Pennsylvania Room,
Philadelphia, PA 19106, to reconsider CMS's decision to disapprove
Pennsylvania SPA 06-007.
Closing Date: Requests to participate in the hearing as a party
must be received by the presiding officer by October 15, 2007.
FOR FURTHER INFORMATION CONTACT: Kathleen Scully-Hayes, Presiding
Officer, CMS, Lord Baltimore Drive, Mail Stop LB-23-20, Baltimore, MD
21244. Telephone: (410) 786-2055
SUPPLEMENTARY INFORMATION: This notice announces an administrative
hearing to reconsider CMS's decision to disapprove Pennsylvania State
plan amendment (SPA) 06-007 which was submitted on September 27, 2006.
This SPA was disapproved on June 29, 2007.
Under this SPA, the State requested the addition of targeted case
management services to low-income, first-time expectant mothers who
have, or are at risk of having, a high incidence of medical or social
problems. The new targeted case management services were to be provided
through the Nurse Family Partnership Program. CMS made a Request for
Additional Information on December 22, 2006, to which the State
responded on April 2, 2007. The information provided confirmed that the
targeted case management services proposed in SPA 06-007 are currently
provided to all individuals without charge.
The amendment was disapproved because CMS found that the amendment
violated the statute for reasons set forth in the disapproval letter.
CMS consulted with the Secretary as required by Federal regulations at
42 CFR 430.15(c)(2).
Section 1902(a)(10) of the Social Security Act (the Act) requires
that States make available medical assistance which is defined at
section 1905(a) of the Act, and is limited to payment of medical costs
for ``individuals whose income and resources are insufficient to meet
all of such costs.'' The term ``medical assistance'' fundamentally
excludes payment for medical services that are free to the general
public, since where a service is provided without charge the individual
is not in the circumstance of having insufficient income or resources
to meet the cost of care. Hence, such services do not meet the
definition of ``medical assistance.''
In addition, section 1902(a)(30) of the Act requires States to have
methods and procedures in place to assure that payments are consistent
with efficiency, economy, and quality of care. CMS did not find that
Medicaid payments for case management for first-time expectant mothers
were consistent with this requirement when these same services are
available to non-Medicaid enrollees without charge. Furthermore, the
State failed to provide documentation requested by CMS demonstrating
that the rate methodology used to determine payments to service
providers was consistent with section 1902(a)(30). The State also
failed to provide documentation of the various cost elements used to
determine a fee-schedule amount or to submit provider surveys conducted
by the State to determine whether its proposed indirect cost rate
should be applied to direct costs to calculate the final fee paid to
providers.
Based on the above, and after consultation with the Secretary of
the Department of Health and Human Services as required under Federal
regulations at 42 CFR 430.15(c)(2), CMS disapproved Pennsylvania
Medicaid SPA 06-007.
The issues to be decided at the hearing are:
Whether Pennsylvania has demonstrated that its SPA 06-007
[[Page 55222]]
complies with sections 1902(a)(10) and 1902(a)(30) of the Act by
limiting payment of medical assistance to payment of medical costs for
individuals who lack sufficient income and resources to meet the cost
of care; and
Whether the State has provided adequate documentation to
demonstrate that the State's rate methodology is consistent with the
requirements of section 1902(a)(30) of the Act; specifically whether
the rates paid to service providers are consistent with efficiency,
economy, and quality of care.
Section 1116 of the Act and Federal regulations at 42 CFR Part 430,
establish Department procedures that provide an administrative hearing
for reconsideration of a disapproval of a State plan or plan amendment.
CMS is required to publish a copy of the notice to a State Medicaid
agency that informs the agency of the time and place of the hearing,
and the issues to be considered. If we subsequently notify the agency
of additional issues that will be considered at the hearing, we will
also publish that notice.
Any individual or group that wants to participate in the hearing as
a party must petition the presiding officer within 15 days after
publication of this notice, in accordance with the requirements
contained at 42 CFR 430.76(b)(2). Any interested person or organization
that wants to participate as amicus curiae must petition the presiding
officer before the hearing begins in accordance with the requirements
contained at 42 CFR 430.76(c). If the hearing is later rescheduled, the
presiding officer will notify all participants.
The notice to Pennsylvania announcing an administrative hearing to
reconsider the disapproval of its SPA reads as follows:
Ms. Estelle B. Richman,
Secretary of Public Welfare, Commonwealth of Pennsylvania,
Department of Public Welfare, Office of Medical Assistance Programs,
Bureau of Policy, Budget and Planning,
P.O. Box 8046,
Harrisburg, PA 17105.
Dear Ms. Richman:
I am responding to your request for reconsideration of the
decision to disapprove Pennsylvania State plan amendment (SPA) 06-
007, which was submitted on September 27, 2006, and disapproved on
June 29, 2007.
Under this SPA, the State requested the addition of targeted
case management services for first-time, low-income expectant
mothers who have, or are at risk of having, a high incidence of
medical or social problems. The Centers for Medicare & Medicaid
Services (CMS) disapproved the SPA because CMS found that it
violated the statute for reasons set forth in the disapproval
letter.
The CMS made a Request for Additional Information on December
22, 2006, to which the State responded on April 2, 2007. The
information provided confirmed that the targeted case management
services proposed in SPA 06-007 are currently provided to first-time
expectant mothers without charge through State grant funding and
private funds.
Section 1902(a)(10) of the Social Security Act (the Act)
requires that States make available medical assistance, which is
defined at section 1905(a) of the Act, and is limited to payment of
medical costs for ``individuals whose income and resources are
insufficient to meet all of such costs.'' The term ``medical
assistance'' fundamentally excludes payment for medical services
that are free to the general public, since where a service is
provided without charge the individual is not in the circumstance of
having insufficient income or resources to meet the cost of care.
Hence, such services do not meet the definition of ``medical
assistance.''
In addition, section 1902(a)(30) of the Act requires States to
have methods and procedures in place to assure that payments are
consistent with efficiency, economy, and quality of care. CMS did
not find that Medicaid payments for case management for first-time
expectant mothers were consistent with this requirement when these
same services are available to non-Medicaid enrollees without
charge. Furthermore, the State failed to provide documentation
requested by CMS demonstrating that the rate methodology used to
determine payments to service providers was consistent with section
1902(a)(30). The State failed to provide documentation of the
various cost elements used to determine a fee-schedule amount or to
submit provider surveys conducted by the State to determine whether
its proposed indirect cost rate should be applied to direct costs to
calculate the final fee paid to providers.
Based on the above, and after consultation with the Secretary of
the Department of Health and Human Services as required under
Federal regulations at 42 CFR 430.15(c)(2), CMS disapproved
Pennsylvania Medicaid SPA 06-007.
The issues to be decided at the hearing are
Whether Pennsylvania has demonstrated that its SPA 06-
007 complies with sections 1902(a)(10) and 1902(a)(30) of the Act by
limiting payment of medical assistance to payment of medical costs
for individuals who lack sufficient income and resources to meet the
cost of care; and
Whether the State has provided adequate documentation
to demonstrate that the State's rate methodology is consistent with
the requirements of section 1902(a)(30) of the Act; specifically
whether the rates paid to service providers are consistent with
efficiency, economy, and quality of care.
I am scheduling a hearing on your request for reconsideration to
be held on November 16, 2007, at Suite 216, The Public Ledger
Building, 150 S. Independence Mall West, Conference Room 241, the
Pennsylvania Room, Philadelphia, PA 19106, to reconsider the
decision to disapprove SPA 06-007. If this date is not acceptable,
we would be glad to set another date that is mutually agreeable to
the parties. The hearing will be governed by the procedures
prescribed by Federal regulations at 42 CFR Part 430.
I am designating Ms. Kathleen Scully-Hayes as the presiding
officer. If these arrangements present any problems, please contact
the presiding officer at (410) 786-2055. In order to facilitate any
communication which may be necessary between the parties to the
hearing, please notify the presiding officer to indicate
acceptability of the hearing date that has been scheduled and
provide names of the individuals who will represent the State at the
hearing.
Sincerely,
Kerry Weems,
Acting Administrator.
Section 1116 of the Social Security Act (42 U.S.C. 1316; 42 CFR
430.18)
(Catalog of Federal Domestic Assistance Program No. 13.714, Medicaid
Assistance Program.)
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E7-19141 Filed 9-27-07; 8:45 am]
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