Source: https://www.law.cornell.edu/cfr/text/42/402.308
Timestamp: 2018-10-17 06:04:58
Document Index: 300434988

Matched Legal Cases: ['art 402', '§ 402', '§ 402', '§ 402', '§ 1001', '§ 1001', 'art 402', 'art 402', 'arts 402']

42 CFR 402.308 - Waivers of exclusions. | US Law | LII / Legal Information Institute
CFR › Title 42 › Chapter IV › Subchapter A › Part 402 › Subpart C › Section 402.308
42 CFR 402.308 - Waivers of exclusions.
§ 402.308 Waivers of exclusions.
(a)Basis. Section 1128(c)(3)(B) of the Act specifies that in the case of an exclusion from participation in the Medicare program based upon section 1128(a)(1), (a)(3), or (a)(4) of the Act, the individual may request that CMS present, on his or her behalf, a request to the OIG for a waiver of the exclusion.
Excluded person has the same meaning as a “person” as defined in § 402.3 who meets for the purposes of this subpart, the definition of the term “exclusion” in § 402.3.
Hardship for purposes of this section means something that negatively affects Medicare beneficiaries and results from the imposition of an exclusion because the excluded person is the sole community physician or sole source of essential specialized services in the Medicare community.
Sole community physician has the same meaning as that term is defined § 1001.2 of this title.
Sole source of essential specialized services in the community has the same meaning as that term defined by the § 1001.2 of this title.
(c)General rule. If CMS determines that a hardship as defined in paragraph (b)(2) of this section results from exclusion of an affected person from the Medicare program, CMS may consider and may make a request to the Inspector General for waiver of the Medicare exclusion.
(d)Submission and content of a waiver of exclusion request. An excluded person must submit a request for waiver of exclusion in writing to CMS that includes the following:
(1) A copy of the exclusion notice from the OIG.
(2) A statement requesting that CMS present a waiver of exclusion request to the OIG on his or her behalf.
(3) A statement that he or she is the sole community physician or sole source of essential specialized services in the community.
(4) Documentation to support the statement in paragraph (d)(3) of this section.
(e)Processing of waiver of exclusion requests. CMS processes a request for a waiver of exclusion as follows:
(1) Notifies the submitter that the waiver of exclusion request has been received.
(2) Reviews and validates all submitted documents.
(3) During its analysis, CMS may require additional, specific information, and authorization to obtain information from private health insurers, peer review organizations (including, but not limited to, Quality Improvement Organizations), and others as necessary to determine validity.
(4) Makes a determination regarding whether or not to submit the waiver of exclusion request to the OIG based on review and validation of the submitted documents.
(5) If CMS elects to submit the waiver of exclusion request to the OIG, CMS copies the excluded person on the request.
(6) If CMS denies the request, then CMS notifies the excluded person of the decision and specifies the reason(s) for the decision.
(f)Administrative or judicial review. A determination rendered under paragraph (e)(4) of this section is not subject to administrative or judicial review.
The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 402 after this date.
81 FR 57554 - Request for Information: Inappropriate Steering of Individuals Eligible for or Receiving Medicare and Medicaid Benefits to Individual Market Plans
FR Doc. 2016-20034
RIN 0938-ZB31
CMS-6074-NC
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 22, 2016.
42 CFR Part 402, 420, and, 455
This request for information seeks public comment regarding concerns about health care providers and provider-affiliated organizations steering people eligible for or receiving Medicare and/or Medicaid benefits to an individual market plan for the purpose of obtaining higher payment rates. CMS is concerned about reports of this practice and is requesting comments on the frequency and impact of this issue from the public. We believe this practice not only could raise overall health system costs, but could potentially be harmful to patient care and service coordination because of changes to provider networks and drug formularies, result in higher out-of-pocket costs for enrollees, and have a negative impact on the individual market single risk pool (or the combined risk pool in states that have chosen to merge their risk pools). We are seeking input from stakeholders and the public regarding the frequency and impact of this practice, and options to limit this practice.
78 FR 9458 - Medicare, Medicaid, Children&apos;s Health Insurance Programs; Transparency Reports and Reporting of Physician Ownership or Investment Interests
FR Doc. 2013-02572
RIN 0938-AR33
CMS-5060-F
Effective date: These regulations are effective on April 9, 2013. Compliance date: Applicable manufacturers and applicable group purchasing organizations must begin to collect the required data on August 1, 2013 and report the data to CMS by March 31, 2014.
42 CFR Parts 402 and 403
This final rule will require applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children&apos;s Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers of value provided to physicians or teaching hospitals (“covered recipients”). In addition, applicable manufacturers and applicable group purchasing organizations (GPOs) are required to report annually certain physician ownership or investment interests. The Secretary is required to publish applicable manufacturers&apos; and applicable GPOs&apos; submitted payment and ownership information on a public Web site.