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e-CFR data is current as of January 19, 2021

Title 42Chapter VSubchapter BPart 1002 → Subpart C


Title 42: Public Health
PART 1002—PROGRAM INTEGRITY—STATE-INITIATED EXCLUSIONS FROM MEDICAID


Subpart C—Procedures for State-Initiated Exclusions


Contents
§1002.210   General authority.
§1002.211   [Reserved]
§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.

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§1002.210   General authority.

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.

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§1002.211   [Reserved]

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§1002.212   State agency notifications.

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.

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§1002.213   Appeals of exclusions.

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.

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§1002.214   Basis for reinstatement after State agency-initiated exclusion.

(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.

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§1002.215   Action on request for reinstatement.

(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.

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