44038 Federal Register / Vol. 79, No. 145 / Tuesday, July 29, 2014 / Notices 

amendments only based on a 

determination that the amendments 

comply the requirements of relevant 

federal statutes and regulations and can 

serve as a basis for FFP. 

• Whether Louisiana SPAs 13–23, 

13–25 and 13–28 comply with the 

requirements of 1902(a)(2) and 

1902(a)(4) of the Act which requires that 

the state plan provide for the nonfederal share of expenditures under the 

state plan, from either state or local 

funding. Because the SPAs at issue 

propose to claim for FFP without 

adjustment to reflect unallowable 

expenditures resulting from the 

provider related donation and hold 

harmless arrangement discussed above, 

they would result in a non-federal share 

that would be insufficient to meet the 

requirements of section 1902(a)(2). 

Moreover, section 1902(a)(4) of the Act 

requires that the state plan comply with 

methods of administration as are found 

necessary by the Secretary for the 

proper and efficient operation of the 

plan. Among the implementing 

regulations for section 1902(a)(4) of the 

Act is the requirement at 42 CFR 430.10 

that a state plan contain all information 

necessary for CMS to determine that the 

plan can be approved to serve as a basis 

for FFP in the state program. Because 

the state has not established that the 

supplemental payments are not part of 

a hold harmless arrangement that would 

result in a reduction in FFP, t the state 

has not established that the SPAs are 

consistent with section 1902(a)(4) and 

the implementing regulations at 42 CFR 

430.10. 

• Whether the state has established 

that the supplemental payments set 

forth in Louisiana SPAs 13–23, 13–25, 

and 13–28 are consistent with the 

statutory requirement at section 

1902(a)(30)(A) of the Act that payments 

must be ‘‘consistent with efficiency, 

economy, and quality of care’’. 

• Whether Louisiana SPAs 13–23, 

13–25 and 13–28 comport with the 

broad principles of the federal-state 

partnership embodied in section 1903(a) 

of the Act, because they indicate 

circumstances in which the federal 

government would pay more than its 

share of the net expenditures, after 

accounting for claimed expenditures 

that are effectively repaid by the 

provider-related donations. 

If the hearing date is not acceptable, 

I would be glad to set another date that 

is mutually agreeable to the parties. The 

hearing will be governed by the 

procedures prescribed by federal 

regulations at 42 CFR Part 430. 

I am designating Mr. Benjamin R. 

Cohen as the presiding officer. If these 

arrangements present any problems, 

please contact Mr. Cohen at (410) 786 

3169. In order to facilitate any 

communication that may be necessary 

between the parties prior to the hearing, 

please notify the presiding officer to 

indicate acceptability of the hearing 

date that has been scheduled and 

provide names of the individuals who 

will represent the state at the hearing. 

Sincerely, 

Marilyn Tavenner 

cc: Benjamin R. Cohen 

Section 1116 of the Social Security 

Act (42 U.S.C. section 1316; 42 CFR 

section 430.18) 

(Catalog of Federal Domestic Assistance 

program No. 13.714, Medicaid 

Assistance Program.) 

Dated: July 23, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–17871 Filed 7–28–14; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–6057–N] 

Medicare Program; Expanded 

Medicare Prior Authorization for Power 

Mobility Devices (PMDs) 

Demonstration 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice announces the 

expansion of the Medicare Prior 

Authorization for Power Mobility 

Devices (PMDs) Demonstration to 12 

additional states. 

DATES: This expanded demonstration 

begins on October 1, 2014. 

FOR FURTHER INFORMATION CONTACT: 

Doris M. Jackson, (410) 786–4459. 

Questions regarding the Medicare 

Prior Authorization for Power Mobility 

Device Demonstration should be sent to 

pademo@cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Section 402(a)(1)(J) of the Social 

Security Amendments of 1967 (42 

U.S.C. 1395b–1(a)(1)(J)), authorizes the 

Secretary to conduct demonstrations 

designed to develop or demonstrate 

improved methods for the investigation 

and prosecution of fraud in the 

provision of care or services provided 

under the Medicare program. On 

September 1, 2012, we implemented the 

Medicare Prior Authorization for Power 

Mobility Devices (PMDs) Demonstration 

that would operate for a period of 3 

years (September 1, 2012 through 

August 31, 2015). The demonstration 

was initially implemented in California, 

Florida, Illinois, Michigan, New York, 

North Carolina, and Texas. These states 

were selected for the demonstrations 

based upon their history of having high 

levels of improper payments and 

incidents of fraud related to PMDs. The 

objective of the demonstration is to 

develop improved methods for the 

investigation and prosecution of fraud 

in order to protect the Medicare Trust 

Fund from fraudulent actions and any 

resulting improper payments. This 

demonstration is providing the agency 

with valuable data through which the 

agency, working with its partners, can 

develop new avenues for combating the 

submission of fraudulent claims to the 

Medicare program for PMDs and 

improving methods for the investigation 

and prosecution of PMD fraud. We will 

share demonstration data within the 

agency, with our contractors, and with 

law enforcement partners for further 

analysis and investigation. We believe 

that data evidencing changes in 

physician ordering and supplier billing 

practices that coincide with this 

demonstration could provide 

investigators and law enforcement with 

important information for determining 

how and where to focus their 

investigations concerning fraud in the 

provision of PMDs. For instance, results 

from this demonstration could 

potentially indicate collaboration 

between ordering physicians and 

suppliers in submitting fraudulent 

claims for PMDs. This data could assist 

investigators and law enforcement in 

targeting their investigations in this 

area. Additionally, changes in billing 

practices that result from this 

demonstration could provide specific 

leads for investigators and law 

enforcement personnel. For instance, 

where a supplier that frequently 

submitted claims prior to the 

demonstration stops submitting claims 

during the demonstration, law 

enforcement may determine it prudent 

to investigate that supplier. 

Data we will analyze will include the 

following: 

• Suppliers who no longer bill or 

have a significant decrease in billing. 

• Physicians/treating practitioners 

with a high volume of submissions. 

• Codes that show a dramatic 

increase in use. 

Based on preliminary data collected, 

spending per month on PMDs in the 


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Federal Register / Vol. 79, No. 145 / Tuesday, July 29, 2014 / Notices 44039 

seven demonstration states decreased 

after September 2012, indicating that 

physicians ordering and supplier billing 

practices have changed as a result of the 

demonstration. In addition, spending 

per month on PMDs decreased in the 

non-demonstration states. National 

suppliers have adjusted their billing 

practices nationwide and appear to have 

increased compliance with our policies 

in all locations, not just their offices in 

the demonstration states. 

II. Provisions of the Notice 

Because of the initial success of the 

demonstration in reducing spending on 

PMDs, we are expanding the 

demonstration to 12 additional states 

(Pennsylvania, Ohio, Louisiana, 

Missouri, Washington, New Jersey, 

Maryland, Indiana, Kentucky, Georgia, 

Tennessee, and Arizona) which have 

high expenditures and improper 

payments for PMDs based on 2012 

billing data. The 19 states selected for 

the demonstration, which include the 7 

current and 12 additional states account 

for 71 percent of expenditures for PMDs 

in 2012. The remaining states and 

territories would be the control group 

for the demonstration. 

Prior to the start of the expanded 

demonstration, contractors and the 

public will be notified about the 

expansion. This notice will serve as 

notification in addition to Web site 

postings and tweets. 

CMS or its agents will continue to 

conduct outreach and education 

including webinars, in-state meetings, 

and other educational sessions in the 

additional states as appropriate. 

Updated information will be posted to 

the CMS Web site (http://go.cms.gov/

PADemo). We will also work to limit the 

impact on Medicare beneficiaries by 

educating the Medicare beneficiaries 

about their protections. In addition, 

physicians, treating practitioners, and 

suppliers who have recently ordered a 

PMD for a beneficiary residing in a 

demonstration state will be notified via 

letter about the expanded demonstration 

prior to the start date of the 

demonstration. 

Under the expanded demonstration, 

we will continue to follow the policies 

and procedures that are currently in 

place for the demonstration. In 

accordance with current demonstration 

policy, a request for prior authorization 

and all relevant documentation to 

support the medical necessity along 

with the written order for the covered 

item must be submitted when one of the 

following Healthcare Common 

Procedures Coding System (HCPCS) 

codes for a PMD is ordered: 

• Group 1 Power Operated Vehicles 

(K0800 through K0802 and K0812). 

• All standard power wheelchairs 

(K0813 through K0829). 

• All Group 2 complex rehabilitative 

power wheelchairs (K0835 through 

K0843). 

• All Group 3 complex rehabilitative 

power wheelchairs without power 

options (K0848 through K0855). 

• Pediatric power wheelchairs (K0890 

and K0891). 

• Miscellaneous power wheelchairs 

(K0898). 

Under this demonstration, a physician, 

treating practitioner or supplier may 

submit the prior authorization request 

and all relevant documentation to 

support Medicare coverage of the PMD 

item along with the written order for the 

covered item to their Durable Medical 

Equipment (DME) Medicare 

Administrative Contractor (MAC). The 

physician, treating practitioner or 

supplier who submits the request is 

referred to as the ‘‘submitter.’’ 

In order to be affirmed, the request for 

prior authorization must meet all 

applicable rules, policies, and National 

Coverage Determination (NCD)/Local 

Coverage Determination (LCD) 

requirements for PMD claims. The LCD 

documentation requirement mandates 

that the physician or treating 

practitioner shall complete the seven 

element order, face-to-face encounter, 

and whatever other clinical 

documentation that is necessary to 

determine medical necessity regardless 

of which entity is functioning as the 

submitter. The supplier completes the 

detailed product description (DPD) 

regardless of which entity is functioning 

as the submitter. 

After receipt of all relevant 

documentation, CMS or its agents will 

make every effort to conduct a complex 

medical review and postmark the 

notification of their decision with the 

prior authorization number within 10 

business days. Notification is provided 

to the physician/treating practitioner, 

supplier, and the Medicare beneficiary 

for the initial submission. If a 

subsequent prior authorization request 

is submitted after a non-affirmative 

decision on a prior authorization 

request, CMS or its agents will make 

every effort to conduct a review and 

postmark the notification of decision 

with the prior authorization number 

within 20 business days. 

If the prior authorization request is 

not affirmed, and the claim is submitted 

by the supplier, the claim will be 

denied. Medicare beneficiaries may use 

existing appeal rights to contest claim 

denials. Suppliers must issue an 

Advance Beneficiary Notice to the 

beneficiary per CMS policy, prior to 

delivery of the item for the beneficiary 

to be held financially liable when a 

Medicare payment denial is expected 

for a PMD. 

Submitters may also request 

expedited reviews in emergency 

situations where a practitioner indicates 

clearly, with supporting rationale, that 

the standard (routine) timeframe for a 

prior authorization decision (10 days) 

could seriously jeopardize the 

beneficiary’s life or health. The 

expedited request must be accompanied 

by the required supporting 

documentation for this request to be 

considered complete thus commencing 

the 48-hour review. Inappropriate 

expedited requests may be downgraded 

to standard requests. After conducting 

an expedited review, CMS or its agents 

will communicate a decision for the 

prior authorization request to the 

submitter within 48 hours of the 

complete submission. 

The following explains the various 

prior authorization scenarios: 

• Scenario 1: A submitter sends a 

prior authorization request to the DME 

MAC with appropriate documentation 

and all relevant Medicare coverage and 

documentation requirements are met for 

the PMD. The DME MAC then sends an 

affirmative prior authorization decision 

to the physician or treating practitioner, 

supplier, and Medicare beneficiary. The 

supplier submits the claim to the DME 

MAC and the claim is linked to the prior 

authorization via the claims processing 

system. Provided all requirements in the 

applicable NCD/LCD are met, the claim 

is paid. 

• Scenario 2: A submitter sends a 

prior authorization request, but all 

relevant Medicare coverage and 

documentation requirements are not 

met for the PMD. The DME MAC sends 

a non-affirmative prior authorization 

decision to the physician or treating 

practitioner, supplier, and Medicare 

beneficiary advising them that Medicare 

will not pay for the item. If the supplier 

delivers the PMD and submits a claim 

with a non-affirmative prior 

authorization decision, the DME MAC 

would deny the claim. The supplier 

and/or the Medicare beneficiary would 

then have the Medicare denial for 

secondary insurance purposes and 

would have full appeal rights. Existing 

liability provisions with respect to 

delivery of a valid Advance Beneficiary 

Notice of Noncoverage (ABN) apply. 

If an applicable PMD claim is 

submitted without a prior authorization 

decision it will be stopped and 

documentation will be requested to 

conduct medical review. As with the 


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initial states in the demonstration, after 

the first 3 months of the expanded 

demonstration, we will assess a 

payment reduction in the new states for 

claims that, after review, are deemed 

payable, but did not first receive a prior 

authorization decision. As evidence of 

compliance, the supplier must submit 

the prior authorization number on the 

claim in order to not be subject to the 

25-percent payment reduction. The 25- 

percent payment reduction is nontransferrable to the Medicare beneficiary 

and not subject to appeal. In the case of 

capped rental items, the payment 

reduction will be applied to all claims 

in the series. 

The 25-percent reduction in the 

Medicare payment is for each payable 

base claim not preceded by a prior 

authorization request except in 

competitive bidding areas. If a 

competitive bid contract supplier 

submits a payable claim for a Medicare 

beneficiary with a permanent residence 

in a competitive bidding area that is 

included in the supplier’s contract, 

without first receiving a prior 

authorization decision, that competitive 

bid contract supplier would receive the 

applicable single payment amount 

under the competitive bid program, and 

would not be subject to the 25 percent 

reduction. These suppliers must still 

adhere to all other requirements of the 

demonstration. 

• Scenario 3: A submitter sends a 

prior authorization request where 

documentation is incomplete. The DME 

MAC sends back the prior authorization 

request to the submitter with an 

explanation about what information is 

missing and notifies the physician or 

treating practitioner, supplier, and 

Medicare beneficiary. The submitter 

may resubmit the prior authorization 

request. 

• Scenario 4: The DME supplier fails 

to submit a prior authorization request, 

but nonetheless delivers the item to the 

Medicare beneficiary and submits the 

claim to the DME MAC for payment. 

The PMD claim is reviewed under 

normal medical review processing 

timeframes and if approved the 25- 

percent payment reduction would 

apply. 

++ If the claim is determined to be 

not medically necessary, or 

insufficiently documented the claim 

will be denied. The supplier or 

Medicare beneficiary can appeal the 

claim denial. If the claim, after review, 

is deemed not payable, then all current 

Medicare beneficiary/supplier liability 

policies and procedures and appeal 

rights remain in effect. 

++ If the claim is determined to be 

payable, it will be paid. However, the 

25-percent reduction in the Medicare 

payment will be applied for failure to 

receive a prior authorization decision 

before the submission of a claim. This 

payment reduction will not be applied 

to competitive bidding program contract 

suppliers submitting claims for 

Medicare beneficiaries who maintain a 

permanent residence in a Competitive 

Bidding Area (CBA) according to the 

Common Working File (CWF). These 

contract suppliers will continue to 

receive the applicable single payment 

amount as determined in their contract. 

The 25-percent payment reduction is 

non-transferrable to the Medicare 

beneficiary for claims that are deemed 

payable. This payment reduction 

amount will begin 3 months after the 

start of the expanded demonstration and 

is not subject to appeal. In the case of 

capped rental items the payment 

reduction will be applied to all claims 

in the series. After a claim is submitted 

and processed, appeal rights are 

available if necessary. 

If the prior authorization request is 

not affirmed, and the claim is submitted 

by the supplier, the claim will be 

denied. Medicare beneficiaries may use 

existing appeal rights to contest claim 

denials. Suppliers must issue an ABN to 

the beneficiary per CMS policy, prior to 

delivery of the item in order for the 

beneficiary to be held financially liable 

when a Medicare payment denial is 

expected for a PMD. 

Additional information is available on 

the CMS Web site (http://go.cms.gov/

PADemo). 

III. Collection of Information 

Requirements 

In the February 7, 2012 Federal 

Register (77 FR 6124) and the May 29, 

2012 Federal Register (77 FR 31616), we 

published a 60-day and a 30-day notice, 

respectively, announcing and soliciting 

comments concerning the information 

collection requirements associated with 

the Medicare Prior Authorization for 

PMDs Demonstration implemented on 

September 1, 2012. The information 

collection request for the demonstration 

was approved under OMB control 

number 0938–1169. Subsequent to the 

initial approval, we published an 

additional Federal Register notice (79 

FR 18913) announcing that we were 

seeking emergency review and approval 

from OMB regarding the expansion of 

the demonstration; specifically, we 

revised the information collection 

request to account for the addition of 12 

new states to the program. The 

emergency revised information 

collection request was approved on June 

13, 2014, and is still approved under 

OMB control number 0938–1169 with 

an expiration date of December 31, 

2014. 

Dated: June 27, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–17805 Filed 7–28–14; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Proposed Information Collection 

Activity; Comment Request 

Proposed Projects: Evaluation of the 

Transitional Living Program (TLP) 

Title: Evaluation of the Transitional 

Living Program (TLP) 

OMB No.: 0970–0383 

Description: The Runaway and 

Homeless Youth Act (RHYA), as 

amended by Public Law 106–71 (42 

U.S.C. 5701 et seq.), provides for the 

Transitional Living Program (TLP), a 

residential program lasting up to 18 

months designed to prepare older 

homeless youth ages 16–21 for a healthy 

and self-sufficient adulthood. Section 

119 of RHYA requires a study on the 

long-term housing outcomes of youth 

after exiting the program. 

The proposed collection is being 

carried out in two steps: 

1. Interviews with TLP grantee 

administrators and front line staff about 

program structure, implementation, and 

approaches to service delivery. 

2. A set of surveys to be administered 

to run away and homeless youth to 

measure their short-term and longerterm outcomes such as demographic 

characteristics, receipt of TLP or ‘‘TLPlike’’ services, housing, employment, 

education, social connections (e.g., 

social relationships, civic engagement), 

psychosocial well-being (e.g., depressive 

symptoms, traumatic stress, risky 

behavior, history of abuse), and other 

measures related to self-sufficiency and 

well-being (exposure to violence, 

financial competence). 

This information will be used to 

better understand the most effective 

practices that improve the long-term 

outcomes for runaway and homeless 

youth and reduce future episodes of 

homelessness. 

Respondents: (1) Youth ages 16–21 

participating in Transitional Living 

Programs and (2) the Executive Director 

and front line staff representing TLP 

grantees. 


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