[Federal Register: January 8, 2008 (Volume 73, Number 5)]
[Notices]
[Page 1355-1357]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr08ja08-71]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Notice of hearing: Reconsideration of Disapproval of California's
State Plan Amendment (SPA) 06-019B
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice of hearing.
-----------------------------------------------------------------------
SUMMARY: This notice announces an administrative hearing to be held on
February 15, 2008, at the CMS San Francisco Regional Office, 90 7th
Street, 5th Floor, Room 5A, San Francisco, California 94103, to
reconsider CMS' decision to disapprove California's SPA 06-019B.
Closing Date: Requests to participate in the hearing as a party
must be received by the presiding officer by January 23, 2008.
[[Page 1356]]
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' decision to disapprove California's SPA
06-019B which was submitted on December 27, 2006.
Under this SPA, the State was seeking to provide direct
reimbursement effective October 1, 2006, to Medicaid recipients where
the recipient obtains and pays for Medicaid services after receiving a
Medicaid card.
The amendment was disapproved because it did not comport with the
requirements of sections 1902(a)(10), 1902(a)(32), and 1905(a) of the
Social Security Act (the Act) and Federal regulations at 42 CFR
431.246, 431.250, and 447.15.
The following are the issues to be considered at the hearing:
Would payments under the proposed SPA that would be made
directly to Medicaid recipients for services furnished after the
recipients have been determined to be eligible (and not during a
retroactive eligibility period) be within the scope of the definition
of ``medical assistance'' referenced in section 1902(a)(10) and set
forth in section 1905(a) of the Act? The definition at section 1905(a)
specifically limits medical assistance to payments made to providers of
covered services (the ``vendor payment principle''), and contains an
express statutory exception permitting direct payment to recipients
only for physician and dentist services; the proposed SPA does not
appear to be limited to payments for these service categories.
Would payments under the proposed SPA that are made
directly to Medicaid recipients for services furnished after the
recipients have been determined eligible (and not during a retroactive
eligibility period) be consistent with the requirement of section
1902(a)(32) of the Act? That section limits payment under the plan to
amounts paid directly to providers (or certain assignees of those
providers). This statutory requirement ensures that recipients obtain
covered services from participating providers who bill the Medicaid
program rather than the recipient, and accept the State's payment,
including a payment of zero dollars, as payment in full. (See 42 CFR
447.15.)
Would payments under the proposed SPA that are made
directly to Medicaid recipients for services furnished after the
recipients have been determined eligible (and not during a retroactive
eligibility period) be within the regulatory exception at 42 CFR
431.246 and 431.250(b) to the vendor payment principle? Those sections
provide for corrective payments based on a successful appeal by a
recipient who, pending the appeal decision, sought and paid for covered
services. Such a circumstance in the context of SPA 06-019B would exist
where a recipient appealed the State's determination of the amount of
the recipient's ``share of cost'' for covered services. But, SPA 06-
019B does not appear to limit such payment to these exceptions to the
vendor payment rule.
Is there any binding judicial decision that would permit
the Federal Government to participate in the payments contemplated in
the proposed SPA? The United States was not a party to a California
State Court case that apparently addressed the issues, and is not bound
by that decision. Moreover, under regulations at 42 CFR 431.250 that
provide for Federal participation in payments made under court order,
the services must be provided within the scope of the Medicaid program
under Federal law. Services that are billed directly to the recipient
(and not part of a retroactive eligibility period) are outside of the
Federal definition of medical assistance, and thus are not within the
scope of the Federal Medicaid program.
Is there any statutory or regulatory conflict providing a
basis to conclude that the express statutory provisions establishing
the vendor payment principle could not practically be applied? CMS has
recognized such a conflict as the basis for permitting an exception to
the vendor payment principle during a retroactive period, but such a
conflict does not appear to be present in this instance.
Are direct payments to recipients who have been determined
eligible consistent with accuracy, efficiency, and effectiveness of the
State Medicaid program in serving those recipients?
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 California announcing an administrative hearing to
reconsider the disapproval of its SPA reads as follows:
Mr. Stan Rosenstein, Chief Deputy Director, Health Care Program,
Health and Human Services Agency, 1501 Capitol Avenue, MS 4506, P.O.
Box 997413, Sacramento, CA 99859-7413.
Dear Mr. Rosenstein:
I am responding to your request for reconsideration of the
decision to disapprove California's State plan amendment (SPA) 06-
109B, which was submitted on December 27, 2006.
Under this SPA, the State was seeking to provide direct
reimbursement, effective October 1, 2006, to Medicaid recipients
where the recipient obtains and pays for Medicaid services after
receiving a Medicaid card.
The amendment was disapproved because it did not comport with
the requirements of sections 1902(a)(10), 1902(a)(32), and 1905(a)
of the Social Security Act (the Act) and Federal regulations at 42
CFR sections 431.246, 431.250, and 447.15.
The following are the issues to be considered at the hearing:
Would payments under the proposed SPA that would be
made directly to Medicaid recipients for services furnished after
the recipients have been determined to be eligible (and not during a
retroactive eligibility period) be within the scope of the
definition of ``medical assistance'' referenced in section
1902(a)(10) and set forth in section 1905(a) of the Act? The
definition at section 1905(a) specifically limits medical assistance
to payments made to providers of covered services (the ``vendor
payment principle''), and contains an express statutory exception
permitting direct payment to recipients only for physician and
dentist services; the proposed SPA does not appear to be limited to
payments for these service categories.
Would payments under the proposed SPA that are made
directly to Medicaid recipients for services furnished after the
recipients have been determined eligible (and not during a
retroactive eligibility period) be consistent with the requirement
of section 1902(a)(32) of the Act? That section limits payment under
the plan to amounts paid directly to providers (or certain assignees
of those providers). This statutory requirement ensures that
recipients obtain covered services from participating providers who
[[Page 1357]]
bill the Medicaid program rather than the recipient, and accept the
State's payment, including a payment of zero dollars, as payment in
full. (See 42 CFR 447.15.)
Would payments under the proposed SPA that are made
directly to Medicaid recipients for services furnished after the
recipients have been determined eligible (and not during a
retroactive eligibility period) be within the regulatory exception
at 42 CFR 431.246 and 431.250(b) to the vendor payment principle?
Those sections provide for corrective payments based on a successful
appeal by a recipient who, pending the appeal decision, sought and
paid for covered services. Such a circumstance in the context of SPA
06-019B would exist where a recipient appealed the State's
determination of the amount of the recipient's ``share of cost'' for
covered services. But, SPA 06-019B does not appear to limit such
payment to these exceptions to the vendor payment rule.
Is there any binding judicial decision that would
permit the Federal Government to participate in the payments
contemplated in the proposed SPA? The United States was not a party
to a California State Court case that apparently addressed the
issues and is not bound by that decision. Moreover, under
regulations at 42 CFR 431.250 that provide for Federal participation
in payments made under court order, the services must be provided
within the scope of the Medicaid program under Federal law. Services
that are billed directly to the recipient (and not part of a
retroactive eligibility period) are outside of the Federal
definition of medical assistance, and thus are not within the scope
of the Federal Medicaid program.
Is there any statutory or regulatory conflict providing
a basis to conclude that the express statutory provisions
establishing the vendor payment principle could not practically be
applied? CMS has recognized such a conflict as the basis for
permitting an exception to the vendor payment principle during a
retroactive period, but such a conflict does not appear to be
present in this instance.
Are direct payments to recipients who have been
determined eligible consistent with accuracy, efficiency, and
effectiveness of the State Medicaid program in serving those
recipients?
I am scheduling a hearing on your request for reconsideration to
be held on February 15, 2008, at the CMS San Francisco Regional
Office, 90 7th Street, 5th Floor, Room 5A, San Francisco, California
94103, to reconsider the decision to disapprove SPA 06-019B. 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.)
Dated: January 2, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E8-109 Filed 1-7-08; 8:45 am]
BILLING CODE 4120-01-P