Medicaid program and State Children's Health Insurance Program (SCHIP) payment error rate measurement. Interim final rule with comment period.
This interim final rule sets forth the State requirements to provide information to us for purposes of estimating improper payments in Medicaid and the State Children's Health Insurance Program (SCHIP), as required under the Improper Payments Information Act (IPIA) of 2002. The IPIA requires heads of Federal agencies to annually estimate and report to the Congress these estimates of improper payments for the programs they oversee and, submit a report on actions the agency is taking to reduce erroneous payments. We published a proposed rule on August 27, 2004 to propose that States measure improper payments in Medicaid and SCHIP and report the State-specific error rates to us for purposes of computing the improper payment estimates for these programs. After extensive analysis of the issues related to having States measure improper payments in Medicaid and SCHIP, including public comments on the provisions in the proposed rule, we are revising our proposed approach. Our new approach incorporates commenters' suggestions to engage a Federal contractor by contracting with that entity to complete the data processing and medical reviews and calculate the State-specific error rates. Based on the States' error rates, the contractor also will calculate the improper payment estimates for these programs which will be reported by the Department of Health and Human Services as required by the IPIA. This interim final rule sets out the types of information that States would need to submit to allow CMS to conduct medical and data processing reviews on claims made in the fee-for-service (FFS) setting. CMS will address estimating improper payments for Medicaid managed care and eligibility and SCHIP FFS, managed care and eligibility at a later time. This rule responds to the public comments on the proposed rule, sets forth the requirements for States to assist us and the contractor to produce State-specific error rates in Medicaid and SCHIP which will be used as the basis for a national error rate, and outlines future plans for measuring eligibility, which may include greater State involvement than the level required for the medical and data processing reviews.
D002648:Child; D002662:Child Health Services / Q000191:economics / Q000331:legislation & jurisprudence*; D003284:Contract Services; D017598:Efficiency, Organizational / Q000331:legislation & jurisprudence*; D004608:Eligibility Determination / Q000331:legislation & jurisprudence; D035082:Federal Government; D006078:Government Programs / Q000331:legislation & jurisprudence; D006801:Humans; D007345:Insurance Claim Review / Q000191:economics / Q000331:legislation & jurisprudence*; D007349:Insurance, Health, Reimbursement / Q000191:economics / Q000331:legislation & jurisprudence; D008484:Medicaid / Q000191:economics / Q000331:legislation & jurisprudence*; D011632:Public Assistance / Q000191:economics / Q000331:legislation & jurisprudence*; D013219:State Government; D014481:United States