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Department of Health and Social Services

Division of Medicaid and Medical Assistance

Statutory Authority: 31 Delaware Code, Section 512 (31 Del.C. §512)

PROPOSED

PUBLIC NOTICE

Medicaid Provider Screening and Enrollment

In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid and Medical Assistance (DMMA) is proposing to amend the Title XIX Medicaid State Plan regarding Medicaid Provider Screening and Enrollment.

Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Planning & Policy Development Unit, Division of Medicaid and Medical Assistance, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 or by fax to 302-255-4425 by March 31, 2012.

The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.

SUMMARY OF PROPOSAL

The proposed provides notice to the public that the Division of Medicaid and Medical Assistance (DMMA) intends to amend the Title XIX Medicaid State Plan regarding Medicaid Provider Screening and Enrollment.

Statutory Authority

Patient Protection and Affordable Care Act (Pub. L. No. 111-148 as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152)), together known as the Affordable Care Act. Specifically, Section 6401, Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid, and CHIP;
42 CFR Part 455 Subpart E

Background

Section 6401(a) of the Affordable Care Act, as amended by section 10603 of the Affordable Care Act, establishes procedures under which screening is conducted with respect to providers of medical or other items or services and suppliers under Medicare, Medicaid, and CHIP. Section 1866(j)(2)(B) of the Act requires the Secretary to determine the level of screening to be conducted according to the risk of fraud, waste, and abuse with respect to the category of provider or supplier. Section 1866(j)(2)(C) of the Act requires the Secretary to impose a fee on each institutional provider of medical or other items or services or supplier, to be used by the Secretary for program integrity efforts. Section 6401(b) of the Affordable Care Act includes requirements for States to comply with the process of screening providers and suppliers and imposing temporary enrollment moratoria for the Medicaid program as established by the Secretary. The Centers for Medicare and Medicaid Services (CMS) implemented these requirements with Federal regulations at 42 CFR Part 455 Subpart E. These regulations were published in the Federal Register, Volume 76, February 2, 2011, and were effective March 25, 2011.

Summary of Proposal

CMS recently issued a State plan preprint to assure compliance with and implementation of Section 6401.

The Division of Medicaid and Medical Assistance (DMMA) intends to make the appropriate changes to the Medicaid State Plan pertaining to the federally required changes in Medicaid provider enrollment processes pursuant to the Affordable Care Act of 2010. As such, the Medicaid state plan will be amended at General Program Administration, 4.46 - Provider Screening and Enrollment.

Initiated to combat fraud and abuse, these directives apply to newly enrolling providers and currently enrolled providers. As implementation of this mandate moves forward, DMMA will notify providers via provider alerts, provider newsletters, remittance advice banners and the Delaware Medical Assistance Program (DMAP) website.

The provisions of this state plan amendment are subject to approval by the Centers for Medicare and Medicaid Services (CMS).

Fiscal Impact Statement

These revisions impose no increase in cost on the General Fund.

The costs for system changes are already budgeted in the General Fund.

There will be additional costs for some providers associated with the enrollment/revalidation fee, criminal background checks and fingerprinting.

DMMA PROPOSED REGULATION #12-04

REVISION:

79aa

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: DELAWARE

 
4.46 Provider Screening and Enrollment
 
 
Citation
The State Medicaid agency gives the following assurances:
1902(a)(77)
1902(a)(39) of
the Act adds 1902(kk);
P.L. 111-148 and
P.L. 111-152
 
 
 
42 CFR 455
PROVIDER SCREENING
Subpart E
__X__ Assures that the State Medicaid agency complies
 
with the process for screening providers under section
 
1902(a)(39), 1902(a)(77) and 1902(kk) of the Act.
 
 
42 CFR 455.410
ENROLLMENT AND SCREENING OF PROVIDERS
 
__X__ Assures enrolled providers will be screened in
 
accordance with 42 CFR 455.400 et seq.
 
 
 
__X__ Assures that the State Medicaid agency requires all
 
ordering or referring physicians or other professionals, who
 
are not enrolled in Medicare, to be enrolled under the State
 
plan or under a waiver of the Plan as participating
 
providers.
 
 
42 CFR 455.412
VERIFICATION OF PROVIDER LICENSES
 
__X__ Assures that the State Medicaid agency has a
 
method for verifying providers licensed by a State and that
 
such providers’ licenses have not expired or have no
 
current limitations at the time of enrollment or
 
recertification.
 
 
42 CFR 455.414
REVALIDATION OF ENROLLMENT
 
__X__ Assures that providers will be revalidated regardless
 
of provider type at least every 5 years.

79ab

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: DELAWARE

 
4.46 Provider Screening and Enrollment Continued
 
 
42 CFR 455.416
TERMINATION OR DENIAL OF ENROLLMENT
 
__X__ Assures that the State Medicaid agency will comply
 
with 1902(a)(39) of the Act and with the requirements
 
outlined in 42 CFR 455.416 for all terminations or denials
 
of provider enrollment.
 
 
42 CFR 455.420
REACTIVATION OF PROVIDER ENROLLMENT
 
__X__ Assures that any reactivation of a provider will
 
include re-screening and payment of application fees as
 
required by 42 CFR 455.460.
 
 
42 CFR 455.422
APPEAL RIGHTS
 
__X__ Assures that all terminated providers and providers
 
denied enrollment as a result of the requirements of 42
 
CFR 455.416 will have appeal rights available under
 
procedures established by State law or regulation.
 
 
42 CFR 455.432
SITE VISITS
 
__X__ Assures that pre-enrollment and post enrollment site
 
visits of providers who are in “moderate” or “high risk”
 
categories will occur
 
 
42 CFR 455.434
CRIMINAL BACKGROUND CHECKS
 
__X__ Assures that providers as a condition of enrollment
 
will be required to consent to criminal background checks
 
including fingerprints if required to do so under State law or
 
by the level of screening based on risk of fraud, waste or
 
abuse for that category of provider.
 
 
42 CFR 455.436
FEDERAL DATABASE CHECKS
 
__X__ Assures that the State Medicaid agency will perform
 
Federal database checks on all providers or any person
 
with an ownership or controlling interest or who is an agent
 
or managing employee of the provider.
 
 
42 CFR 455.440
NATIONAL PROVIDER IDENTIFIER
 
__X__ Assures that the State Medicaid agency requires the
 
National Provider Identifier of any ordering or referring
 
physician or other professional to be specified on any claim
 
for payment that is based on an order or referral of the
 
physician or other professional.

79ac

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: DELAWARE

 
4.46 Provider Screening and Enrollment Continued
 
 
42 CFR 455.450
SCREENING LEVELS FOR MEDICAID PROVIDERS
 
__X__ Assures that the State Medicaid agency complies
 
with 1902(a)(77) and 1902(kk) of the Act and with the
 
requirements outlined in 42 CFR 455.450 for screening
 
levels based upon the categorical risk level determined for
 
a provider.
 
 
42 CFR 455.470
TEMPORARY MORATORIUM ON ENROLLMENT OF
 
NEW PROVIDERS OR SUPPLIERS
 
__X__ Assures that the State Medicaid agency complies
 
with any temporary moratorium on the enrollment of new
 
providers or provider types imposed by the Secretary
 
under section 1866(j)(7) and 1902(kk)(4) of the Act, subject
 
to any determination by the State and written notice to the
 
Secretary that such a temporary moratorium would not
 
adversely impact beneficiaries’ access to medical
 
assistance.
15 DE Reg. 1273 (03/01/12) (Prop.)
 
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