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Electronic Code of Federal Regulations

e-CFR Data is current as of September 12, 2014

Title 42Chapter IVSubchapter CPart 456 → Subpart H


Title 42: Public Health
PART 456—UTILIZATION CONTROL


Subpart H—Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental Hospitals


Contents
§456.500   Purpose.
§456.501   UR plans as a condition for FFP.

UR Plan: Waiver of Requirements

§456.505   Applicability of waiver.
§456.506   Waiver options for Medicaid agency.
§456.507   Review and granting of waiver requests.
§456.508   Withdrawal of waiver.

UR Plan: Remote Facility Variances from Time Requirements

§456.520   Definitions.
§456.521   Conditions for granting variance requests.
§456.522   Content of request for variance.
§456.523   Revised UR plan.
§456.524   Notification of Administrator's action and duration of variance.
§456.525   Request for renewal of variance.

§456.500   Purpose.

For hospitals and mental hospitals, this subpart—

(a) Prescribes conditions for the availability of FFP relating to UR plans;

(b) Prescribes conditions for granting a waiver of UR plan requirements; and

(c) Prescribes conditions for granting a variance in UR plan requirements for remote facilities.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

§456.501   UR plans as a condition for FFP.

(a) Except when waived under §§456.505 through 456.508, FFP is not available in expenditures for Medicaid services furnished by a hospital or mental hospital unless the facility has in effect a UR plan that meets the utilization review requirements for Medicare under section 1861(k) of the Act.

(b) A facility that participates in Medicare and Medicaid must use the same UR standards and procedures and review committee for Medicaid as it uses for Medicare.

(c) A facility that does not participate in Medicare must meet the UR plan requirements in subpart C or D of this part, which are equivalent to the Medicare UR plan requirements in §§405.1137, 482.30, and 482.60 of this chapter.

[43 FR 45266, Sept. 29, 1978, as amended at 51 FR 22042, June 17, 1986; 61 FR 38399, July 24, 1996]

UR Plan: Waiver of Requirements

§456.505   Applicability of waiver.

The Administrator may waive the UR plan requirements of subparts C or D of this part, except for provisions relating to disqualification of UR committee members under §456.106 of subpart C, and §456.206 of subpart D, if the Medicaid agency—

(a) Applies for a waiver; and

(b) Demonstrates to the Administrator's satisfaction that it has in operation specific UR procedures that are superior in their effectiveness to the UR plan requirements under subpart C or D of this part.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

§456.506   Waiver options for Medicaid agency.

(a) The agency may apply for a waiver at any time it has the procedures referred to under §456.505(b) in operation at least—

(1) On a demonstration basis; or

(2) In any part of the State.

(b) Any hospital or mental hospital participating under the plan that is not covered by a waiver must continue to meet all the UR plan requirements under subpart C or D of this part.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

§456.507   Review and granting of waiver requests.

(a) When the agency applies for a waiver, the Administrator will assess the agency's UR procedures and grant the waiver if he determines that the procedures meet criteria he establishes.

(b) The Administrator will review and evaluate each waiver between 1 and 2 years after he has granted it and between 1 and 2 years periodically thereafter.

§456.508   Withdrawal of waiver.

(a) The Administrator will withdraw a waiver if he determines that State procedures are no longer superior in their effectiveness to the procedures required for UR plans under subpart C or D of this part.

(b) If a waiver is withdrawn by the Administrator, each hospital or mental hospital covered by the waiver must meet all the UR plan requirements under subpart C or D of this part.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

UR Plan: Remote Facility Variances from Time Requirements

§456.520   Definitions.

As used in §§456.521 through 456.525 of this subpart:

Available physician or other professional personnel means an individual who—

(a) Is professionally qualified;

(b) Is not precluded from participating in UR under §456.107 of subpart C; or §456.207 of subpart D; and

(c) Is not precluded from effective participation in UR because he requires more than approximately 1 hour to travel between the remote facility and his place of work.

Remote facility means a facility located in an area that does not have enough available physicians or other professional personnel to perform UR as required under subparts C or D of this part, and for which the State requests a variance.

Variance means permission granted by the Administrator to the Medicaid agency for a specific remote facility to use time periods different from those specified for the start and completion of reviews of all cases under the following sections: §§456.125, 456.126, 456.136, and 456.137 of subpart C; and §456.238 of subpart D.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

§456.521   Conditions for granting variance requests.

(a) Except as described under paragraph (b) of this section, the administrator may grant a variance for a specific remote facility if the agency submits concurrently—

(1) A request for the variance that documents to his satisfaction that the facility is unable to meet the time requirements for which the variance is requested; and

(2) A revised UR plan for the facility.

(b) The Administrator will not grant a variance if the remote facility is operating under a UR plan waiver that the Secretary has granted or is considering under §§456.505 through 456.508.

§456.522   Content of request for variance.

The agency's request for a variance must include—

(a) The name, location, and type of the remote facility;

(b) The number of total patient admissions and the average daily patient census at the facility in the 6 months preceding the request;

(c) The number of Medicare and Medicaid patient admissions and the average daily Medicare and Medicaid patient census at the facility in the 6 months preceding the request;

(d) The name and location of each hospital, mental hospital, and ICF located within a 50-mile radius of the facility;

(e) The distance and average travel time between the remote facility and each facility listed in paragraph (e) of this section;

(f) Documentation by the facility of its attempts to obtain the services of available physicians or other professional personnel, or both;

(g) The names of all physicians on the active staff, and the names of all other professional personnel on the staff whose availability is relevant to the request;

(h) The practice locations of available physicians and the estimated number of available professional personnel whose availability is relevant to the request;

(i) Documentation by the facility of its inability to perform UR within the time requirements for which the variance is requested and its good faith efforts to comply with the UR plan requirements of subpart C or D of this part;

(j) An assurance by the facility that it will continue its good faith efforts to meet the UR plan requirements of subpart C or D of this part; and

(k) A statement of whether a planning or conditional PSRO exists in the area where the facility is located.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]

§456.523   Revised UR plan.

(a) The revised UR plan for the remote facility must specify the methods and procedures that the facility will use if a variance is granted to insure that it—

(1) Maintains effective and timely control over the utilization of services; and

(2) Conducts reviews in a way that improves the quality of care provided to patients.

(b) The revised UR plan for the remote facility is the basis for validation of UR under sec. 1903(g)(2) of the Act for the period when a variance is in effect.

§456.524   Notification of Administrator's action and duration of variance.

(a) The Administrator—

(1) Will notify the agency of the action he takes on its request for a variance; and

(2) Will specify the period of time, not to exceed 1 year, for which the variance may be granted.

(b) When it receives the Administrator's notification, the agency must promptly notify the remote facility of his action.

§456.525   Request for renewal of variance.

(a) The agency must submit a request for renewal of a variance to the Administrator at least 30 days before the variance expires.

(b) The renewal request must contain the information required under §456.522.

(c) The renewal request must show, to the Administrator's satisfaction, that the remote facility continues to meet the requirements of §§456.521 through 456.523.



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