42 C.F.R. PART 1002—PROGRAM INTEGRITY—STATE-INITIATED EXCLUSIONS FROM MEDICAID
Title 42 - Public Health
Authority: 42 U.S.C. 1302, 1320a–3, 1320a–5, 1320a–7, 1396(a)(4)(A), 1396(p)(1), 1396a(30), 1396a(39), 1396b(a)(6), 1396b(b)(3), 1396b(i)(2) and 1396b(q).
Source: 57 FR 3343, Jan. 29, 1992, unless otherwise noted.
The regulations in this part specify certain bases upon which individuals and entities may, or in some cases must, be excluded from participation in the Medicaid program. These regulations specifically address the authority of State agencies to exclude on their own initiative, regardless of whether the OIG has excluded an individual or entity under part 1001 of this chapter. These regulations also delineate the States' obligation to inform the OIG of certain Medicaid-related convictions. (a) In addition to any other authority it may have, a State may exclude an individual or entity from participation in the Medicaid program for any reason for which the Secretary could exclude that individual or entity from participation in the Medicare, Medicaid and other Federal health care programs under sections 1128, 1128A or 1866(b)(2) of the Social Security Act. (b) Nothing contained in this part should be construed to limit a State's own authority to exclude an individual or entity from Medicaid for any reason or period authorized by State law. [57 FR 3343, Jan. 29, 1992, as amended at 64 FR 39428, July 22, 1999] (a) Information that must be disclosed. Before the Medicaid agency enters into or renews a provider agreement, or at any time upon written request by the Medicaid agency, the provider must disclose to the Medicaid agency the identity of any person described in §1001.1001(a)(1) of this chapter. (b) Notification to Inspector General. (1) The Medicaid agency must notify the Inspector General of any disclosures made under paragraph (a) of this section within 20 working days from the date it receives the information. (2) The agency must promptly notify the Inspector General of any action it takes on the provider's application for participation in the program. (3) The agency must also promptly notify the Inspector General of any action it takes to limit the ability of an individual or entity to participate in its program, regardless of what such an action is called. This includes, but is not limited to, suspension actions, settlement agreements and situations where an individual or entity voluntarily withdraws from the program to avoid a formal sanction. (c) Denial or termination of provider participation. (1) The Medicaid agency may refuse to enter into or renew an agreement with a provider if any person who has ownership or control interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person's involvement in any program established under Medicare, Medicaid or the title XX Services program. (2) The Medicaid agency may refuse to enter into, or terminate, a provider agreement if it determines that the provider did not fully and accurately make any disclosure required under paragraph (a) of this section. [57 FR 3343, Jan. 29, 1992, as amended at 63 FR 46691, Sept. 2, 1998] The plan must provide that the requirements of this subpart are met. However, the provisions of these regulations are minimum requirements. The agency may impose broader sanctions if it has the authority to do so under State law. (a) The State agency, in order to receive Federal financial participation (FFP), must provide that it will exclude from participation any HMO, or entity furnishing services under a waiver approved under section 1915(b)(1) of the Act, if such organization or entity— (1) Could be excluded under §1001.1001 or §1001.1051 of this chapter, or (2) Has, directly or indirectly, a substantial contractual relationship with an individual or entity that could be excluded under §1001.1001 or §1001.1051 of this chapter. (b) As used in this section, the term— Exclude includes the refusal to enter into or renew a participation agreement or the termination of such an agreement. Substantial contractual relationship is one in which the sanctioned individual described in §1001.1001 of this chapter has direct or indirect business transactions with the organization or entity that, in any fiscal year, amount to more than $25,000 or 5 percent of the organization's or entity's total operating expenses, whichever is less. Business transactions include, but are not limited to, contracts, agreements, purchase orders, or leases to obtain services, supplies, equipment, space or salaried employment. [57 FR 3343, Jan. 29, 1992, as amended at 63 FR 46691, Sept. 2, 1998] The State agency must have administrative procedures in place that enable it to exclude an individual or entity for any reason for which the Secretary could exclude such individual or entity under parts 1001 or 1003 of this chapter. The period of such exclusion is at the discretion of the State agency. (a) Denial of payment. Except as provided for in §1001.1901(c)(3), (c)(4) and (c)(5)(i) of this chapter, no payment may be made by the State agency for any item or service furnished on or after the effective date specified in the notice by an excluded individual or entity, or at the medical direction or on the prescription of a physician who is excluded when a person furnishing such item or service knew, or had reason to know, of the exclusion. (b) Denial of FFP. FFP is not available where the State agency is required to deny payment under paragraph (a) of this section. FFP will be reinstated at such time as the excluded individual or entity is reinstated in the Medicaid program. [57 FR 3343, Jan. 29, 1992, as amended at 63 FR 46691, Sept. 2, 1998] When the State agency initiates an exclusion under §1002.210, it must provide to the individual or entity subject to the exclusion notification consistent with that required in subpart E of part 1001 of this chapter, and must notify other State agencies, the State medical licensing board (where applicable), the public, beneficiaries, and others as provided in §§1001.2005 and 1001.2006 of this chapter. Before imposing an exclusion under §1002.210, the State agency must give the individual or entity the opportunity to submit documents and written argument against the exclusion. The individual or entity must also be given any additional appeals rights that would otherwise be available under procedures established by the State. (a) The provisions of this section and §1002.215 apply to the reinstatement in the Medicaid program of all individuals or entities excluded in accordance with §1002.210, if a State affords reinstatement opportunity to those excluded parties. (b) An individual or entity who has been excluded from Medicaid may be reinstated only by the Medicaid agency that imposed the exclusion. (c) An individual or entity may submit to the State agency a request for reinstatement at any time after the date specified in the notice of exclusion. (a) The State agency may grant reinstatement only if it is reasonably certain that the types of actions that formed the basis for the original exclusion have not recurred and will not recur. In making this determination, the agency will consider, in addition to any factors set forth in State law— (1) The conduct of the individual or entity occurring prior to the date of the notice of exclusion, if not known to the agency at the time of the exclusion; (2) The conduct of the individual or entity after the date of the notice of exclusion; and (3) Whether all fines, and all debts due and owing (including overpayments) to any Federal, State or local government that relate to Medicare or any of the State health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations. (b) Notice of action on request for reinstatement. (1) If the State agency approves the request for reinstatement, it must give written notice to the excluded party, and to all others who were informed of the exclusion in accordance with §1002.212, specifying the date on which Medicaid program participation may resume. (2) If the State agency does not approve the request for reinstatement, it will notify the excluded party of its decision. Any appeal of a denial of reinstatement will be in accordance with State procedures and need not be subject to administrative or judicial review, unless required by State law. (a) The State agency must notify the OIG whenever a State or local court has convicted an individual who is receiving reimbursement under Medicaid of a criminal offense related to participation in the delivery of health care items or services under the Medicaid program, except where the State Medicaid Fraud Control Unit (MFCU) has so notified the OIG. (b) If the State agency was involved in the investigation or prosecution of the case, it must send notice within 15 days after the conviction. (c) If the State agency was not so involved, it must give notice within 15 days after it learns of the conviction.
Title 42: Public Health
PART 1002—PROGRAM INTEGRITY—STATE-INITIATED EXCLUSIONS FROM MEDICAID
Section Contents
§ 1002.1 Scope and purpose.
§ 1002.2 General authority.
§ 1002.3 Disclosure by providers and State Medicaid agencies.
§ 1002.100 State plan requirement.
§ 1002.203 Mandatory exclusion.
§ 1002.210 Permissive exclusions; general authority.
§ 1002.211 Effect of exclusion.
§ 1002.212 State agency notifications.
§ 1002.213 Appeals of exclusions.
§ 1002.214 Basis for reinstatement after State agency-initiated exclusion.
§ 1002.215 Action on request for reinstatement.
§ 1002.230 Notification of State or local convictions of crimes against Medicaid.
Subpart A—General Provisions
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§ 1002.1 Scope and purpose.
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§ 1002.2 General authority.
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§ 1002.3 Disclosure by providers and State Medicaid agencies.
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§ 1002.100 State plan requirement.
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Subpart B—Mandatory Exclusion
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§ 1002.203 Mandatory exclusion.
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Subpart C—Permissive Exclusions
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§ 1002.210 Permissive exclusions; general authority.
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§ 1002.211 Effect of exclusion.
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§ 1002.212 State agency notifications.
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§ 1002.213 Appeals of exclusions.
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§ 1002.214 Basis for reinstatement after State agency-initiated exclusion.
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§ 1002.215 Action on request for reinstatement.
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Subpart D—Notification to OIG of State or Local Convictions of Crimes Against Medicaid
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§ 1002.230 Notification of State or local convictions of crimes against Medicaid.
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