42 C.F.R. Subpart A—General Provisions
Title 42 - Public Health
(a) This part prescribes requirements concerning control of the utilization of Medicaid services including— (1) A statewide program of control of the utilization of all Medicaid services; and (2) Specific requirements for the control of the utilization of Medicaid services in institutions. (3) Specific requirements for an outpatient drug use review program. (b) The requirements in this part are based on the following sections of the Act. Table 1 shows the relationship between these sections of the Act and the requirements in this part. (1) Methods and procedures to safeguard against unnecessary utilization of care and services. Section 1902(a)(30) requires that the State plan provide methods and procedures to safeguard against unnecessary utilization of care and services. (2) Penalty for failure to have an effective program to control utilization of institutional services. Section 1903(g)(1) provides for a reduction in the amount of Federal Medicaid funds paid to a State for long-stay inpatient services if the State does not make a showing satisfactory to the Secretary that it has an effective program of control over utilization of those services. This penalty provision applies to inpatient services in hospitals, mental hospitals, and intermediate care facilities (ICF's). Specific requirements are: (i) Under section 1903(g)(1)(A), a physician must certify at admission, and a physician (or physician assistant or nurse practitioner under the supervision of a physician) must periodically recertify, the individual's need for inpatient care. (ii) Under section 1903(g)(1)(B), services must be furnished under a plan established and periodically evaluated by a physician. (iii) Under section 1903(g)(1)(C), the State must have in effect a continuous program of review of utilization of care and services under section 1902(a)(30) whereby each admission is reviewed or screened in accordance with criteria established by medical and other professional personnel. (iv) Under section 1903(g)(1)(D), the State must have an effective program under sections 1902(a) (26) and (31) of review of care in intermediate care facilities and mental hospitals. This must include evaluation at least annually of the professional management of each case. (3) Medical review in mental hospitals. Section 1902(a)(26)(A) requires that the plan provide for a program of medical review that includes a medical evaluation of each individual's need for care in a mental hospital, a plan of care, and, where applicable, a plan of rehabilitation. (4) Independent professional review in intermediate care facilities. Section 1902(a)(31)(A) requires that the plan provide for a program of independent professional review that includes a medical evaluation of each individual's need for intermediate care and a written plan of service. (5) Inspection of care and services in institutions. Sections 1902(a)(26) (B) and (C) and 1902(a)(31) (B) and (C) require that the plan provide for periodic inspections and reports, by a team of professional persons, of the care being provided to each recipient in institutions for mental diseases (IMD's), and ICF's participating in Medicaid. (6) Denial of FFP for failure to have specified utilization review procedures. Section 1903(i)(4) provides that FFP is not available in a State's expenditures for hospital or mental hospital services unless the institution has in effect a utilization review plan that meets Medicare requirements. However, the Secretary may waive this requirement if the Medicaid agency demonstrates to his satisfaction that it has utilization review procedures superior in effectiveness to the Medicare procedures. (7) State health agency guidance on quality and appropriateness of care and services. Section 1902(a)(33)(A) requires that the plan provide that the State health or other appropriate medical agency establish a plan for review, by professional health personnel, of the appropriateness and quality of Medicaid services to provide guidance to the Medicaid agency and the State licensing agency in administering the Medicaid program. (8) Drug use review program. Section 1927(g) of the Act provides that, for payment to be made under section 1903 of the Act for covered outpatient drugs, the State must have in operation, by not later than January 1, 1993, a drug use review (DUR) program. It also requires that each State provide, either directly or through a contract with a private organization, for the establishment of a DUR Board. [43 FR 45266, Sept. 29, 1978, as amended at 46 FR 48561, Oct. 1, 1981; 57 FR 49408, Nov. 2, 1992; 61 FR 38398, July 24, 1996] (a) A State plan must provide that the requirements of this part are met. (b) These requirements may be met by the agency by: (1) Assuming direct responsibility for assuring that the requirements of this part are met; or (2) Deeming of medical and utilization review requirements if the agency contracts with a QIO to perform that review, which in the case of inpatient acute care review will also serve as the initial determination for QIO medical necessity and appropriateness review for patients who are dually entitled to benefits under Medicare and Medicaid. (c) In accordance with §431.15 of this subchapter, FFP will be available for expenses incurred in meeting the requirements of this part. [46 FR 48566, Oct. 1, 1981, as amended at 50 FR 15327, Apr. 17, 1985; 51 FR 43198, Dec. 1, 1986] The Medicaid agency must implement a statewide surveillance and utilization control program that— (a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments; (b) Assesses the quality of those services; (c) Provides for the control of the utilization of all services provided under the plan in accordance with subpart B of this part; and (d) Provides for the control of the utilization of inpatient services in accordance with subparts C through I of this part. (a) The agency must— (1) Monitor the statewide utilization control program; (2) Take all necessary corrective action to ensure the effectiveness of the program; (3) Establish methods and procedures to implement this section; (4) Keep copies of these methods and procedures on file; and (5) Give copies of these methods and procedures to all staff involved in carrying out the utilization control program. The agency must establish and use written criteria for evaluating the appropriateness and quality of Medicaid services. This section does not apply to services in hospitals and mental hospitals. For these facilities, see the following sections: §§456.122 and 456.132 of subpart C; and §456.232 of subpart D. [43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996] (a) The Medicaid agency must have an agreement with the State health agency or other appropriate State medical agency, under which the health or medical agency is responsible for establishing a plan for the review by professional health personnel of the appropriateness and quality of Medicaid services. (b) The purpose of this review plan is to provide guidance to the Medicaid agency in the administration of the State plan and, where applicable, to the State licensing agency described in §431.610.
Title 42: Public Health
PART 456—UTILIZATION CONTROL
Subpart A—General Provisions
§ 456.1 Basis and purpose of part.
Table 1 [This table relates the regulations in this part to the sections of the Act on which they are based.] ---------------------------------------------------Subpart 1902(a)(30) A_General 1902(a)(33)(A)Subpart 1902(a)(30) B_Utilization Control: All Medicaid ServicesSubpart C_Utilization Control: Hospitals Certification 1903(g)(1)(A) of need for care. Plan of care. 1903(g)(1)(B) Utilization 1902(a)(30) review plan 1903(g)(1)(C) (including admission review). 1903(i)(4)Subpart D_Utilization Control: Mental Hospitals Certification 1903(g)(1)(A) of need for care. Medical 1902(a)(26)(A) evaluation 1903(g)(1)(C) and admission review. Plan of care. 1902(a)(26)(A) 1903(g)(1)(B) Admission and 1902(a)(26)(A) plan of care 1903(g)(1) (B), (C) requirements for individuals under 21. Utilization 1902(a)(30) review plan. 1903(g)(1)(C) 1903(i)(4)Subpart F_Utilization Control: Intermediate Care Facilities Certification 1903(g)(1)(A) of need for care. Medical 1902(a)(31)(A) evaluation 1903(g)(1)(C) and admission review. Plan of care. 1902(a)(31)(A) 1903(g)(1)(B) Utilization 1902(a)(30) review plan. 1903(g)(1)(C) 1903(i)(4)Subpart 1905 (a)(16) and (h) G_Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care RequirementsSubpart .................................. H_Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental HospitalsSubpart .................................. I_Inspections of Care in Intermediate Care Facilities and Institutions for Mental DiseasesSubpart 1903(g) J_Penalty for Failure To Make a Satisfactory Showing of An Effective Institutional Utilization Control ProgramSubpart K_Drug 1927(g) and (h) Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims------------------------------------------------------------------------
§ 456.2 State plan requirements.
§ 456.3 Statewide surveillance and utilization control program.
§ 456.4 Responsibility for monitoring the utilization control program.
§ 456.5 Evaluation criteria.
§ 456.6 Review by State medical agency of appropriateness and quality of services.
