DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
 
 
 
CPI  CMCS INFORMATIONAL BULLETIN       
 
 
DATE:  May 31, 2011               CPI-B 11-05 
 
 
FROM:  Peter Budetti         
    Director 
    Center for Program Integrity (CPI)           
 
    Cindy Mann 
    Director 
    Center for Medicaid, CHIP and Survey & Certification (CMCS) 
 
SUBJECT:  Affordable Care Act Program Integrity Provisions - Guidance to States --  
Section 6501 - Termination of Provider Participation under Medicaid if 
Terminated under Medicare or other State Plan  
 
This Informational Bulletin is part of a series of bulletins intended to provide guidance regarding 
implementation of certain provisions of the Patient Protection and Affordable Care Act, Pub. L. 
111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-
152, together called the Affordable Care Act.  Specifically, this bulletin provides guidance on 
the following program integrity provision in the Affordable Care Act that was included in the 
final rule CMS-6028-FC, published in the Federal Register on February 2, 2011: 
 
  Section 6501 regarding termination of participation in Medicaid and the Childrens 
Health Insurance Program (CHIP) upon termination from Medicare or another States 
Medicaid program or CHIP.    
 
Termination of Provider Participation Under Medicaid and CHIP 
 
Section 6501 of the Affordable Care Act, Termination of Provider Participation Under 
Medicaid if Terminated Under Medicare or Other State Plan amends section 1902(a)(39) of the 
Social Security Act and requires States to terminate the participation of any individual or entity if  
such individual or entity is terminated under Medicare or any other Medicaid State plan.1   On 
February 2, 2011, the Centers for Medicare & Medicaid Services (CMS) published the final rule 
implementing this provision, applicable to terminations occurring on or after the statutory 
effective date of January 1, 2011.  See http://edocket.access.gpo.gov/2011/pdf/2011-1686.pdf.  
                                                 
1 Although Section 6501 of the Affordable Care Act does not specifically include terminations from CHIP, CMS has 
required CHIP, through Federal regulations, to take similar action regarding termination of a provider that is also 
terminated or had its billing privileges terminated under Medicare or any Medicaid State plan. 
 
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244  Page 2  CPI-CMCS Informational Bulletin 
 
Termination  
 
Termination occurs when the Medicare program, a State Medicaid program, or CHIP has taken 
an action to revoke a provider's billing privileges, a provider has exhausted all applicable appeal 
rights or the timeline for appeal has expired, and there is no expectation on the part of a provider 
or supplier or the Medicare program, State Medicaid program, or CHIP that the revocation is 
temporary.  The requirement for termination based upon a termination in another program 
applies in cases where providers, suppliers, or eligible professionals were terminated or had their 
billing privileges revoked for cause which may include reasons based on fraud, integrity, or 
quality.   
 
Reporting of Terminations 
 
As discussed above, States are required to terminate the participation of any individual or entity 
if such individual or entity is terminated under Medicare, or any other States Medicaid program, 
or CHIP on or after January 1, 2011.  In order to help States identify those providers whose 
billing privileges have been revoked by Medicare or who have been terminated by other State 
Medicaid programs or CHIP, CMS has established a secure web-based portal that allows States 
to share information regarding terminated providers.  Using this web-based portal, a State is able 
to download information regarding terminated providers in other States and Medicare and to 
upload information regarding its own terminations.  States are not required to report information 
on those providers who were terminated prior to January 1, 2011.  The web-based portal, 
however, is designed to accept information regarding terminations that have occurred as early as 
January 1, 2010.   Access to the information-sharing portal is limited to users approved by CMS.  
CMS has already provided guidance and training regarding the web-based portal to States.     
 
To assist States, we are in the process of developing a Medicaid State plan preprint that may be 
used when submitting a State plan amendment (SPA) to implement this and other program 
integrity provisions and anticipate distributing the preprint to States in the near future.   
 
The provisions of section 1902(a)(39), as amended by Section 6501 of the Affordable Care Act, 
are effective January 1, 2011. 
 
Questions and Answers 
 
Attached to this Informational Bulletin is operational guidance in the form of Frequently Asked 
Questions regarding Section 6501 of the Affordable Care Act.   
 
Thank you for your continued commitment to combating fraud, waste and abuse in the Medicaid 
program and CHIP.  We look forward to our continuing work together as we implement this 
important legislation.  Questions regarding this information can be directed to Angela Brice-
Smith at 410-786-4340 or via email at Angela.Brice-Smith@cms.hhs.gov. 
 
 
Enclosure 
 
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244  Frequently Asked Questions 
Section 6501 of the Affordable Care Act 
May 2011 
 
Section 6501 of the Affordable Care Act requires each State Medicaid program to terminate any 
provider who has been terminated under Medicare or by another State Medicaid program.  On 
February 2, 2011, CMS issued final Federal regulations implementing this provision, including 
defining termination and extending the requirements of this provision to include providers 
participating in the Childrens Health Insurance Program (CHIP) as well.   See 
http://edocket.access.gpo.gov/2011/pdf/2011-1686.pdf . CMS has defined termination as 
occurring when a State Medicaid program, CHIP, or the Medicare program has taken action to 
revoke a Medicaid or CHIP providers or Medicare provider or suppliers billing privileges and 
the provider, supplier or eligible professional has exhausted all applicable appeal rights or the 
timeline for appeal has expired.  The requirement to terminate only applies in cases where 
providers, suppliers or eligible professionals have been terminated or had their billing privileges 
revoked for cause.  CMS will facilitate the sharing of information to States through a secure 
web-based portal about terminated Medicaid and CHIP providers as well as Medicare providers 
who have had their billing privileges revoked.  The information contained in the portal about 
Medicaid and CHIP providers who were terminated for cause will be provided by the States 
reporting such information.  Information reported by States will not be independently verified by 
CMS.    
 
Q.  What does for cause mean for Medicaid or CHIP providers? 
 
A.  For cause may include, but is not limited to, termination for reasons based upon fraud, 
integrity, or quality.  For cause does not include cases where a State terminates a 
Medicaid or CHIP provider as a result of a failure to submit claims due to inactivity.   
 
In addition, for cause does not include any voluntary action taken by the provider to end 
its participation in the program, except where that voluntary action is taken to avoid 
sanction.  For example, if a provider submits a request to the State to voluntarily 
terminate its provider agreement in an effort to avoid sanctions due to non-compliance, 
then this does not qualify as voluntary action. 
 
Q.  How will States know of terminations by other State Medicaid programs? 
 
A.  CMS has established a secure web-based portal to facilitate the sharing of information by 
States regarding terminated Medicaid and CHIP providers.  Using this web-based portal, 
States are able to upload their own information as well as view information regarding 
terminated providers that is reported by Medicare and other States and use this 
information to help protect their respective programs from potential fraud, waste, and 
abuse.  CMS has already provided guidance and training regarding the web-based portal 
to States.  Access to the information-sharing portal is limited to users approved by CMS. 
 
 
 
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244   
Frequently Asked Questions  
Section 6501 of the Affordable Care Act 
May 2011 
 
 
Q.  Do the terms termination and exclusion mean the same thing?  
 
A.  No.  For purposes of section 6501, a termination occurs when the State terminates the 
participation of a Medicaid or CHIP provider from the program or the Medicare program 
has revoked a Medicare provider or suppliers billing privileges, and the provider has 
exhausted its appeal rights or the timeline for appeal has expired.  Generally, exclusion 
from participation in a federal health care program, including Medicare, Medicaid, and 
CHIP is a penalty imposed on providers and suppliers by the Departments Office of 
Inspector General (HHS-OIG).  Individuals and entities may be excluded from 
participating in federal health care programs for misconduct ranging from fraud 
convictions to patient abuse to defaulting on health education loans.  We recognize, 
however, that certain States give the same meaning to the terms exclusion and 
termination and these actions; therefore, ultimately result in the providers involuntary 
departure from the Medicaid program or CHIP.  
 
Q.  Are States expected to report information on providers who are excluded by HHS-
OIG from participation in the Medicaid and/or CHIP program? 
 
A.  States should report information on providers they have terminated from participation in 
their respective Medicaid programs and CHIP regardless of any action taken against such 
providers by any other entity including exclusion by HHS-OIG.   
   
Q.  When will States be expected to start reporting terminations? 
 
A.  States are expected to report those providers who were terminated on or after         
January 1, 2011.  In addition, reporting of terminations must not occur until after the 
timeline for appeal has expired or the provider has exhausted all applicable appeal rights.  
States are not required to report those providers who were terminated prior to January 1, 
2011.   
 
Q.  What are the timeframes for States reporting provider terminations? 
 
A.  There is no specified timeframe for reporting terminations.  However, at a minimum, 
States should report terminations on a monthly basis in order to assist other States with 
protecting themselves from providers who pose an increased risk to government health 
care programs. 
 
Q.  If a State notifies the HHS-OIG under 42 C.F.R.  1002.3(b)(3) of actions the State 
takes to limit a providers participation in the program, must the State also report 
terminations to the portal under section 6501? 
 
A.  Yes.  A State should still report terminations under section 6501.   
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244   
Frequently Asked Questions 
Section 6501 of the Affordable Care Act 
May 2011 
 
Q.  What is the duration of State provider terminations and denials of enrollment in 
other State Medicaid programs or CHIP as a result of a termination? 
 
A.  The duration of a termination should be consistent with the terminating States law.  For 
example, State A terminates a provider and the length of termination is 3 years.  A 
termination action is triggered in State B with regard to that same provider as a result of 
the State A termination action.  State Bs length of termination is 1 year.  The provider is 
not allowed to re-enroll in State Bs Medicaid program for a 1-year period as opposed to 
State As 3-year bar to re-enrollment.  Similarly, the State should follow its own State 
law with regard to the length of the denial of enrollment period for providers who are 
seeking to enroll in a State Medicaid program or CHIP that were previously terminated 
by other State programs or had their billing privileges revoked under Medicare.  
 
Q.  What is the scope of appeals by terminating programs? 
 
A.  The scope of appeals for the original terminating program, i.e., Medicare, Medicaid, or 
CHIP, should include a full appeal on the merits with regard to the basis of the 
termination.  When subsequent States terminate based upon that initial termination, the 
scope of their appeals should only review whether the provider was, in fact, terminated 
by the initiating program.  The subsequent appeals process should not review the 
underlying reasons for the initiating termination.  The appeal process in subsequent States 
does not provide a new forum in which to litigate the basis of termination by another 
State Medicaid program, Medicare or CHIP.    
 
Q.  Will managed care organizations be able to access provider termination 
information?  
 
A.  CMS will not provide managed care entities with direct access to the web-based portal 
reflecting provider termination information.   
 
Q.  When is a Medicaid or CHIP termination triggered under section 6501?     
 
A.  A Medicaid or CHIP termination is triggered when a provider is terminated by Medicare 
or terminated by Medicaid or CHIP for cause and the provider has either exhausted all 
applicable appeal rights or the timeline for appeal has expired.  
 
Q.  What if existing State law is inconsistent with the requirements of section 6501? 
 
A.  A State may delay implementation of the requirements of section 6501 if the Secretary 
determines that State legislation is required.  Accordingly, CMS will work with those 
States that require statutory, regulatory, or administrative changes.  If this applies to your 
State, send an email to providerterms@cms.hhs.gov with the word Termination in the 
subject line. 
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244   
Frequently Asked Questions  
Section 6501 of the Affordable Care Act 
May 2011 
 
Q.  Are there any exceptions to the requirement to terminate a provider that was 
terminated by Medicare or another State Medicaid program or CHIP?  
 
A.  Yes.  The statute provides for the same limitations on termination that apply to exclusion 
under  1128(c)(3)(B) and 1128(d)(3)(B) of the Social Security Act.  Thus, a State may 
request a waiver of the requirement to terminate a particular providers participation.  
State agencies may submit such waiver requests to their respective CMS Regional 
Offices. 
 
Q.  When is the web-based portal going to be available for use by the States? 
 
A.  The web-based portal is currently available for use by States.  Several State users have 
already been trained on how to use the portal.  For additional information regarding 
access to the web-based portal please provide your name, email address, agency, and 
telephone number via email to providerterms@cms.hhs.gov.  
   
 
 
 
 
7500 Security Boulevard 
Mailstop: B2-15-24 
Baltimore, MD 21244