42 U.S.C. § 1396u–6: Medicaid Integrity Program

Summary

Creates the Medicaid Integrity Program to stop fraud, waste, and abuse in Medicaid. The Secretary must hire qualified contractors to do four main jobs: review providers and actions that could cause improper Medicaid payments, audit claims and related contracts (including cost reports, consulting contracts, and risk contracts), find overpayments, and give education and training to officials, providers, managed care plans, beneficiaries, and others. Contractors must show they can do the work, agree to cooperate with the HHS Inspector General, the Attorney General, and other law enforcement, follow federal conflict-of-interest rules, and give performance data when asked (for example, number and amount of overpayments recovered, number of fraud referrals, and return on investment). Contracting must follow competitive and conflict-of-interest procedures, allow renewals if performance is met, and include limits on contractor liability. The Secretary must make a new 5-fiscal-year plan starting with fiscal year 2006 and consult with the Attorney General, FBI Director, Comptroller General, HHS Inspector General, and state fraud officials. Funding is provided: $5,000,000 for FY2006; $50,000,000 for each of FY2007 and FY2008; $75,000,000 for each of FY2009 and FY2010; and each year after FY2010 the prior year’s amount increased by the annual CPI-U percent. These funds remain available until spent. The Secretary may pay travel and per diem for training attendees and must post on the CMS website total conference costs and travel costs. The Secretary must add 100 full-time staff (or more if needed) focused on Medicaid integrity, evaluate contractors at least every 3 years, and send Congress an annual report within 180 days after each fiscal year showing how funds were used and how effective they were.

Title 42, §1396u–6

The Public Health and Welfare, Source: USLM XML via OLRC

(a)In general

There is hereby established the Medicaid Integrity Program (in this section referred to as the “Program”) under which the Secretary shall promote the integrity of the program under this subchapter by entering into contracts in accordance with this section with eligible entities, or otherwise, to carry out the activities described in subsection (b).

(b)Activities described

Activities described in this subsection are as follows:

(1)Review of the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk, or other basis) for which payment may be made under a State plan approved under this subchapter (or under any waiver of such plan approved under section 1315 of this title) to determine whether fraud, waste, or abuse has occurred, is likely to occur, or whether such actions have any potential for resulting in an expenditure of funds under this subchapter in a manner which is not intended under the provisions of this subchapter.

(2)Audit of claims for payment for items or services furnished, or administrative services rendered, under a State plan under this subchapter, including—

(A)cost reports;

(B)consulting contracts; and

(C)risk contracts under section 1396b(m) of this title.

(3)Identification of overpayments to individuals or entities receiving Federal funds under this subchapter.

(4)Education or training, including at such national, State, or regional conferences as the Secretary may establish, of State or local officers, employees, or independent contractors responsible for the administration or the supervision of the administration of the State plan under this subchapter, providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care.

(c)Eligible entity and contracting requirements

(1)In general

An entity is eligible to enter into a contract under the Program to carry out any of the activities described in subsection (b) if the entity satisfies the requirements of paragraphs (2) and (3).

(2)Eligibility requirements

The requirements of this paragraph are the following:

(A)The entity has demonstrated capability to carry out the activities described in subsection (b).

(B)In carrying out such activities, the entity agrees to cooperate with the Inspector General of the Department of Health and Human Services, the Attorney General, and other law enforcement agencies, as appropriate, in the investigation and deterrence of fraud and abuse in relation to this subchapter and in other cases arising out of such activities.

(C)The entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement.

(D)The entity agrees to provide the Secretary and the Inspector General of the Department of Health and Human Services with such performance statistics (including the number and amount of overpayments recovered, the number of fraud referrals, and the return on investment of such activities by the entity) as the Secretary or the Inspector General may request.

(E)The entity meets such other requirements as the Secretary may impose.

(3)Contracting requirements

The entity has contracted with the Secretary in accordance with such procedures as the Secretary shall by regulation establish, except that such procedures shall include the following:

(A)Procedures for identifying, evaluating, and resolving organizational conflicts of interest that are generally applicable to Federal acquisition and procurement.

(B)Competitive procedures to be used—

(i)when entering into new contracts under this section;

(ii)when entering into contracts that may result in the elimination of responsibilities under section 202(b) of the Health Insurance Portability and Accountability Act of 1996; and

(iii)at any other time considered appropriate by the Secretary.

(C)Procedures under which a contract under this section may be renewed without regard to any provision of law requiring competition if the contractor has met or exceeded the performance requirements established in the current contract.

The Secretary may enter into such contracts without regard to final rules having been promulgated.

(4)Limitation on contractor liability

The Secretary shall by regulation provide for the limitation of a contractor’s liability for actions taken to carry out a contract under the Program, and such regulation shall, to the extent the Secretary finds appropriate, employ the same or comparable standards and other substantive and procedural provisions as are contained in section 1320c–6 of this title.

(d)Comprehensive plan for program integrity

(1)5-year plan

With respect to the 5-fiscal year period beginning with fiscal year 2006, and each such 5-fiscal year period that begins thereafter, the Secretary shall establish a comprehensive plan for ensuring the integrity of the program established under this subchapter by combatting fraud, waste, and abuse.

(2)Consultation

Each 5-fiscal year plan established under paragraph (1) shall be developed by the Secretary in consultation with the Attorney General, the Director of the Federal Bureau of Investigation, the Comptroller General of the United States, the Inspector General of the Department of Health and Human Services, and State officials with responsibility for controlling provider fraud and abuse under State plans under this subchapter.

(e)Appropriation

(1)In general

Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to carry out the Medicaid Integrity Program under this section (including the costs of equipment, salaries and benefits, and travel and training), without further appropriation—

(A)for fiscal year 2006, $5,000,000;

(B)for each of fiscal years 2007 and 2008, $50,000,000;

(C)for each of fiscal years 2009 and 2010, $75,000,000; and

(D)for each fiscal year after fiscal year 2010, the amount appropriated under this paragraph for the previous fiscal year, increased by the percentage increase in the consumer price index for all urban consumers (all items; United States city average) over the previous year.

(2)Availability; authority for use of funds

(A)Availability

Amounts appropriated pursuant to paragraph (1) shall remain available until expended.

(B)Authority for use of funds for transportation and travel expenses for attendees at education, training, or consultative activities

(i)In general

The Secretary may use amounts appropriated pursuant to paragraph (1) to pay for transportation and the travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5 while away from their homes or regular places of business, of individuals described in subsection (b)(4) who attend education, training, or consultative activities conducted under the authority of that subsection.

(ii)Public disclosure

The Secretary shall make available on a website of the Centers for Medicare & Medicaid Services that is accessible to the public—

(I)the total amount of funds expended for each conference conducted under the authority of subsection (b)(4); and

(II)the amount of funds expended for each such conference that were for transportation and for travel expenses.

(3)Increase in CMS staffing devoted to protecting Medicaid program integrity

From the amounts appropriated under paragraph (1), the Secretary shall increase by 100, or such number as determined necessary by the Secretary to carry out the Program, the number of full-time equivalent employees whose duties consist solely of protecting the integrity of the Medicaid program established under this section by providing effective support and assistance to States to combat provider fraud and abuse.

(4)Evaluations

The Secretary shall conduct evaluations of eligible entities which the Secretary contracts with under the Program not less frequently than every 3 years.

(5)Annual report

Not later than 180 days after the end of each fiscal year (beginning with fiscal year 2006), the Secretary shall submit a report to Congress which identifies—

(A)the use of funds appropriated pursuant to paragraph (1); and

(B)the effectiveness of the use of such funds.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 202(b) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (c)(3)(B)(ii), is section 202(b) of title II of Pub. L. 104–191, Aug. 21, 1996, 110 Stat. 1998, which amended section 1395h and 1395u of this title.

Prior Provisions

A prior section 1936 of act Aug. 14, 1935, was renumbered section 1939 and is classified to section 1396v of this title.

Amendments

2015—Subsec. (a). Pub. L. 114–115, § 6(1), inserted “, or otherwise,” after “entities”. Subsec. (e)(1). Pub. L. 114–115, § 6(2)(A), inserted “(including the costs of equipment, salaries and benefits, and travel and training)” after “Program under this section” in introductory provisions. Subsec. (e)(3). Pub. L. 114–115, § 6(2)(B), substituted “by 100, or such number as determined necessary by the Secretary to carry out the Program,” for “by 100”. 2010—Subsec. (c)(2)(D), (E). Pub. L. 111–148, § 6402(j)(2)(A), added subpar. (D) and redesignated former subpar. (D) as (E). Subsec. (e)(1)(C). Pub. L. 111–152, § 1303(b)(2)(A), substituted “for each of fiscal years 2009 and 2010” for “for each fiscal year thereafter”. Subsec. (e)(1)(D). Pub. L. 111–152, § 1303(b)(1), (2)(B), (3), added subpar. (D). Subsec. (e)(4), (5). Pub. L. 111–148, § 6402(j)(2)(B), added par. (4) and redesignated former par. (4) as (5). 2008—Subsec. (b)(4). Pub. L. 110–379, § 5(a)(1)(A), substituted “Education or training, including at such national, State, or regional conferences as the Secretary may establish, of State or local officers, employees, or independent contractors responsible for the administration or the supervision of the administration of the State plan under this subchapter,” for “Education of”. Subsec. (e)(2). Pub. L. 110–379, § 5(a)(1)(B), added par. (2) and struck out former par. (2). Prior to amendment, text read as follows: “Amounts appropriated pursuant to paragraph (1) shall remain available until expended.” Subsec. (e)(2)(B)(ii). Pub. L. 110–379, § 5(b)(1), added cl. (ii).

Statutory Notes and Related Subsidiaries

Effective Date

of 2008 Amendment Pub. L. 110–379, § 5(a)(2), Oct. 8, 2008, 122 Stat. 4078, provided that: “The

Amendments

made by paragraph (1) [amending this section] shall take effect as if included in the enactment of section 1936 of the Social Security Act [42 U.S.C. 1396u–6], as added by section 6034(a) of the Deficit Reduction Act of 2005 (Public Law 109–171).” Pub. L. 110–379, § 5(b)(2), Oct. 8, 2008, 122 Stat. 4079, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to conferences conducted under the authority of section 1936(b)(4) of the Social Security Act (42 U.S.C. 1396u–6(b)(4)) after the date of enactment of this Act [Oct. 8, 2008].”

§1396u–6 Medicaid Integrity Program

Summary

Title 42, §1396u–6

Notes & Related Subsidiaries

Editorial Notes

References in Text

Prior Provisions

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Amendments

Citations & Metadata