42 C.F.R. Subpart A—Single State Agency
Title 42 - Public Health
(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] (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] (a) Basis and purpose. This section, based on section 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. (d) Committee membership. The committee must include— (1) Board-certified physicians and other representatives of the health professions who are familiar with the medical needs of low-income population groups and with the resources available and required for their care; (2) Members of consumers' groups, including Medicaid recipients, and consumer organizations such as labor unions, cooperatives, consumer-sponsored prepaid group practice plans, and others; and (3) The director of the public welfare department or the public health department, whichever does not head the Medicaid agency. (e) Committee participation. The committee must have opportunity for participation in policy development and program administration, including furthering the participation of recipient members in the agency program. (f) Committee staff assistance and financial help. The agency must provide the committee with— (1) Staff assistance from the agency and independent technical assistance as needed to enable it to make effective recommendations; and (2) Financial arrangements, if necessary, to make possible the participation of recipient members. (g) Federal financial participation. FFP is available at 50 percent in expenditures for the committee's activities. A State plan must provide for methods of administration that are found by the Secretary to be necessary for the proper and efficient operation of the plan. (Sec. 1902(a)(4) of the Act) [44 FR 17931, Mar. 23, 1979] A State plan must provide that the Medicaid agency will— (a) Submit all reports required by the Secretary; (b) Follow the Secretary's instructions with regard to the form and content of those reports; and (c) Comply with any provisions that the Secretary finds necessary to verify and assure the correctness of the reports. [44 FR 17931, Mar. 23, 1979] (a) Basis and purpose. This section, based on section 1902(a)(4) of the Act, prescribes the kinds of records a Medicaid agency must maintain, the retention period, and the conditions under which microfilm copies may be substituted for original records. (b) Content of records. A State plan must provide that the Medicaid agency will maintain or supervise the maintenance of the records necessary for the proper and efficient operation of the plan. The records must include— (1) Individual records on each applicant and recipient that contain information on— (i) Date of application; (ii) Date of and basis for disposition; (iii) Facts essential to determination of initial and continuing eligibility; (iv) Provision of medical assistance; (v) Basis for discontinuing assistance; (vi) The disposition of income and eligibility verification information received under §§435.940 through 435.960 of this subchapter; and (2) Statistical, fiscal, and other records necessary for reporting and accountability as required by the Secretary. (c) Retention of records. The plan must provide that the records required under paragraph (b) of this section will be retained for the periods required by the Secretary. (d) Conditions for optional use of microfilm copies. The agency may substitute certified microfilm copies for the originals of substantiating documents required for Federal audit and review, if the conditions in paragraphs (d)(1) through (4) of this section are met. (1) The agency must make a study of its record storage and must show that the use of microfilm is efficient and economical. (2) The microfilm system must not hinder the agency's supervision and control of the Medicaid program. (3) The microfilm system must— (i) Enable the State to audit the propriety of expenditures for which FFP is claimed; and (ii) Enable the HHS Audit Agency and CMS to properly discharge their respective responsibilities for reviewing the manner in which the Medicaid program is being administered. (4) The agency must obtain approval from the CMS regional office indicating— (i) The system meets the conditions of paragraphs (d)(2) and (3) of this section; and (ii) The microfilming procedures are reliable and are supported by an adequate retrieval system. [44 FR 17931, Mar. 23, 1979, as amended at 51 FR 7210, Feb. 28, 1986] (a) Basis and purpose. This section, based on section 1902(a)(4) of the Act, prescribes State plan requirements for facilitating access to Medicaid rules and policies by individuals outside the State Medicaid agency. (b) State plan requirements. A State plan must provide that the Medicaid agency meets the requirements of paragraphs (c) through (g) of this section. (c) Availability in agency offices. (1) The agency must maintain, in all its offices, copies of its current rules and policies that affect the public, including those that govern eligibility, provision of medical assistance, covered services, and recipient rights and responsibilities. (2) These documents must be available upon request for review, study, and reproduction by individuals during regular working hours of the agency. (d) Availability through other entities. The agency must provide copies of its current rules and policies to— (1) Public and university libraries; (2) The local or district offices of the Bureau of Indian Affairs; (3) Welfare and legal services offices; and (4) Other entities that— (i) Request the material in order to make it accessible to the public; (ii) Are centrally located and accessible to a substantial number of the recipient population they serve; and (iii) Agree to accept responsibility for filing all amendments or changes forwarded by the agency. (e) Availability in relation to fair hearings. The agency must make available to an applicant or recipient, or his representative, a copy of the specific policy materials necessary— (1) To determine whether to request a fair hearing; or (2) To prepare for a fair hearing. (f) Availability for other purposes. The agency must establish rules for making program policy materials available to individuals who request them for other purposes. (g) Charges for reproduction. The agency must make copies of its program policy materials available without charge or at a charge related to the cost of reproduction. [44 FR 17931, Mar. 23, 1979] (a) Basis and purpose. This section, based on section 1902(a) (57) and (58) of the Act, prescribes State plan requirements for the development and distribution of a written description of State law concerning advance directives. (b) A State Plan must provide that the State, acting through a State agency, association, or other private nonprofit entity, develop a written description of the State law (whether statutory or as recognized by the courts of the State) concerning advance directives, as defined in §489.100 of this chapter, to be distributed by Medicaid providers and health maintenance organizations (as specified in section 1903(m)(1)(A) of the Act) in accordance with the requirements under part 489, subpart I of this chapter. Revisions to the written descriptions as a result of changes in State law must be incorporated in such descriptions and distributed as soon as possible, but no later than 60 days from the effective date of the change in State law, to Medicaid providers and health maintenance organizations. [57 FR 8202, Mar. 6, 1992, as amended at 60 FR 33293, June 27, 1995]
Title 42: Public Health
PART 431—STATE ORGANIZATION AND GENERAL ADMINISTRATION
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.
§ 431.16 Reports.
§ 431.17 Maintenance of records.
§ 431.18 Availability of agency program manuals.
§ 431.20 Advance directives.
