medicaid program puerto rico department of health · 2020-05-15 · medicare racs, as published in...

PUERTO RICO MEDICAID STATE PLAN

MEDICAID PROGRAM PUERTO RICO DEPARTMENT OF HEALTH

MAY 2019

r

PUERTO RICO MEDICAID STATE PLAN SECTION 4

GENERAL PROGRAM ADMINISTRATION

MEDICAID PROGRAM PUERTO RICO DEPARTMENT OF HEALTH

MAYO 2019

Effective Date ~/ig--· HCFA ID: 1002P/0010P

Approval Date TN No. ;rg;_- I Supersedes TN No.· _

/fr r:?o~38"

• 57

54

. 53

• • • • 52

• • • • • • . • • 51

46

45

• • • . 44

42

41

• 40

• 39 . 38 . 37

• 36

• 35

• 34

• I • e e • • 33

• 32

. 32

PAGE NUMBERS

OMB No. 0938-0193

iv 4.19 Payment for Services 4.18 Cost Sharing and Similar Charges 4.17 Liens and Recoveries

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

4.15 Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases

4.14 Utilization control 4 .·13 Requit·ed Provider Agreement 4.12 Consultation to Medical Facilities

4.11 Relations with Standard-Setting and Survey Agencies ••.•••

4.10 Free Choice of Providers

4.9 Reporting Provider Payments to the Internal Revenue Service

4.8 Availability of Agency Program Manuals 4.7 Maintenance of Records 4 .6 Reports ..

4.5 Medicaid Agency Fraud Detection and Investigation Program ••.••

4.4 Medicaid Quality Control

4.3 Safeguarding Information on Applicants and Recipients . . . • • • • •••

4.2 Hearings for Applicants and Recipients 4.1 Methods of Administration.

SECTION 4 - GENERAL PROGRAM ADMINISTRATION. SECTION

(BERG) Revision: HCFA-PM-87-4 MARCH 1987

l -c .....

. . •!

· .. (·-· e::.J: I

'-~~\1;~1),<; :.:.( ..

~( .... \

. l1

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. TN No. qo-1-··-· · supei:-sedes · - · · ·,. · ···

TN No·. '3'5-l C·.-~ r ':

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:: .. ; - - .... : ... ·-~ v -~

l

- ···-:.·;.:· - -.- . ( ·-~- ~ ..... ,._.. ~- - .. . . .... - - -·-

79c Requirements of Participation

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet

•. 79b 4.34 Systematic Alien V~rification for Entitlements I

:• :: .•.

. ~ ·~· .

. . :~~:;rt1~~,t~:;rt~;~~~:~~;~;~;~;;:;~~~~~;#.~~~~q:r~;,~~"r~~~~~ ~ : ~2 __ ,t_.n<;:ome an,~ .JUig~bi1i. ~y_··~~';tf.ication~':~jl~~~·;· .. ~f/.~'{~?~~D·:~.;:~'.· ·. .; -~'.:~,f~· .: "=:,~~)·.:~/---·· :··. · · ·

~:zf .ii~::!6;·,~~~~:.:~-~~~~~~M~!·I~~~~1{~Ji~~*i~;;i#i(~~~~~t4£i&Ii1*~Eg'*;~

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-.·~·~.:.---~- .... ·r~~'·=~=- .'-: ':!'1i..:~ '1.."';::f--.U. ;";;:Jj~·~':W· :' :.-:-;·:::· .:""!".', ~ ;- . • .

. ,'·78 4.30 Exclusion of Providers and Suspension of

Pt"actitioners Convicted. and Other· Individuals

• • • • 7 7 · 4. 29 Conflict of Interest Provisions : .•. r : .

76

.:. ...... ,.- · .. --::• .... · .. ~. ~· ... · ... 4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities

.• 75 • • • ' • I I• • •

4.27 Disclosure of Survey Infot'1!\ation and Provider or Contractor Evaluation

74 4.26 RESERVED

73 _ 4. 25 Program for Licensing Administrators·

of Nursing Homes ••.•• , ....••.•

72 4. 24 Standat"ds for Payments for Skilled Nut"~ing · ·

and Intermediate Care Facility Services .•

• • I • 1J 71 .. ' .. 4.23 Use of Contracts

69 4.22 Third Party Liability

. 68 .4.21 Prohibition Against_ Reassignment of Provider Claims •• • •

67 4.20 Direct Payments to Certain Recipients for

Physicians' Ot' Dentists• Services . • •••• ~ I !

. ::.I ;:.; .... : ..... :--:-:..

.• ·····Revision:

.·:,.· .. \··

i .. :h

HCFA ID: 1010P/0012P Effective Date

TN No. ---=._/ Supe.raedeo TY No. _:7:i::I

+w.!Pg~)~:~ 1s~~~i~1W~~~t$-t1.~i*fa~-. s , t . . .

The Medicaid agency employs methods of administration found by the Secretary of Health and Human Set"Vices to be necessary for the proper and efficient operation of the plan.

0938-0193

4.1 Methods of Administration Citation 42 CFR 431.15 AT-79-29

.·I' SECTION 4 - GENERAL PROGRAM ADMINISTRATION

Puerto Rico State/Territory:

HCFA-PK-87-4 KARCH 1987 (BERC) ·Rtlvblon: (

o~. "OMB Uo.:

3·2

.r.

Approval Date "'~ffeL Effective Date 'if//,/';z.. ~ 'IN # fj'- -I Supersedes ' 'IN# -

4.2 Bearings for Acolicants and Re::ioients The Medicaid agency has a system of hearings that meets all the requirements of 42 CF.R Part 431, Subpart E.

Citaticn 42 cm. 431. 202 Nr-79-29 AT-80-34

Commonwealth of Puerto Rico

~evisicn: ~-AT-80-38 {BPP) May 22, 1980

33

HCFA ID: 1010P/0012P

Rffectlve Date ;t,,

Approva1 D.at.e' _·._. __ _,,_-i;;

Off.lC·IAL ·

All other requirements of 42 CFR Part 431, Subpart F are met.

4. 3 ~afeguarding Information on Applicants and Re~ipients

Under State statute which imposes legal sanctions, safeguards are provided that .restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan.


OKB No.: 0938-0193 (BERG)

TN No. Supersedes TN N'o. '2.!:f.:_/

52 FR 5967

Citation 42 CFR 431. 301 AT-79-29

Revision: HCFA-AT-87-9 AUGUST1987

34

l

. \

(-

(

I.

('

Effective Date JUL l 1985 Approval Date OCT g 1985

TN lio . fl~ - LJ Sup"r1:1edeE1 . Tll llo • 7 8-c.~


L_I Hot applicable. The agency bas a Medicaid Management Information System (MMIS) approved under 42 CFR Part 433, Subpart c.

LP Yes.

Cb) The agency operates a claims processing assessment system that meets the requirements of 5431.SOO(e), (g), (h), (j) and (k).

(a) A system of eligibility quality control is implemented that meets the requirements of 42 CFR 431. BOO(d), (f), (h), (i) and (lt).

4.4 Medicaid Quality Control 42 CFR 431.SOO(c) 50 FR 21839

Citation(s) Puerto Rico State/Terr'itory:

OKB HO.: 0938-0193 (BERC) Revision: HCFA-PH-85-7 JULY 1985

35

MAR S 1 mt Ap_p.rqvaJ. Date: ------ Emxstive Date: January 1, 2Q 11

11-001 TN No. Supersedes TN No.

(~ t

X - The State !!hall not provide any ~yments for items or services provided under the State plan or under a waiver to au,y ti11aneial instlt~on or entity I~ out.side oftbe !)nited States.

Section 1902(a)(80).ofthe Soeiel Security Act, P~L. 111-148 (Section 650.5)

Citation

4.44 Medicaid. Prohibition on Payment to Institutions or Entities.Located Outs~de of the United States

Stateirerritpry;:.pumro ruco .PROPOSED SECTION 4-GENERALPROGRAM ADMINISTRATION

Medicaid State Plan Preprint

ENCLOSURE A

(

/~ i_

,,,.....


19.89 Effective DaJlll 1 ----- . !11·6 1 5 1989 Approval Dill~

TN No. tt) supersed.~ 1 TN so. ~v

·- (.; .

The Medicaid agency has established and will maintain methods, criteria, and procedures that meet all requirements of 42 CFR 455.13 through 455.21 and 455.23 for prevention and control of program fraud and abuse.

4. 5 Medicaid Agency Fraud Detection and Investigation i/ Program

Citation 42 CFR 455.12 AT-78-90 48 FR 3742 52 FR 48817


OMB No.: 0938-0193 Revision: HCFA-PM-88-10 (BERC) SEPTEMBER 1988

36

Effective Date: DfC 2 2 2010 Approval Date: FEB 0 9 2011 TN No. _ Supersedes TN No. _

The State attests that the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate.

The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register.

The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (e.g., the percentage of the contingency fee):

__ The State will make payments to the RAC(s) on a contingent Basis for collecting overpayments.

__ The State will make payments to the RAC(s) only from amounts recovered.

Place a check mark to provide assurance of the following:

__ The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute.

__ The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver ofthe State plan.

XX The State is seeking an exception to establishing such program for the following reasons:

The Medicaid Program in Puerto Rico is administered by private Managed Care Organizations {MCOs) through a managed care system. We understand that the RAC requirements should not apply to the Puerto Rico MEDICAID Program. See attached letter dated December 22, 2010.

Section 1902 (a)(42)(B)(ii)(ll){aa) of the Act

Sectfon 1902(a)(42)(B)(ii)(I) of the Act

Section 1902(a)(42)(B)(i) of the Social Security Act

Citation

4.5 Medicaid Recovery Audit Contractor Program

PROPOSED SECTION 4- GENERAL PROGRAM ADMINISTRATION

OFFJ&JAL Revision:

Effective Date: --- DEC 2 2 ~01,0 FEB 0. 9 ZOU

Approval Date: ----

Efforts of the Medicaid RAC(s) will be coordinated with other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program.

___ The State assures that the recovered amounts will be subject to a State's quarterly expenditure estimates and funding of

the State's share.

The State assures that the amounts expended by the State to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State plan or a waiver of the plan.

The State has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RAC(s).

__ The following payment methodology shall be used to determine State payments to Medicaid RACs for the identification of underpayments (e.g., amount of flat fee, the percentage of the contingency fee):

__ The contingency fee rate paid to the Medicaid RAC that will exceed the highest rate paid to Medicare RACs, as published in· the Federal Register. The State will submit a justification for that rate and will submit for FFP for the full amount of the contingency fee.

TN No.-----,-- Supersedes TN No. _

Section 1902 (a)(42)(B)(ii)(IV)(cc) Of the Act

Section 1902(a}(42}(B)(ii)(IV(bb) of the Act

Section 1902 (a}(42}(B)(ii)(IV)(aa) of the Act

Section 1902 (a)(42)(B}(ii)(lll) of the Act

Section 1902 (a)(42}(B)(ii)(ll)(bb) of the Act

(

Approval Date,9&¥~ .Effective Date ¢,/~1'-:-. 'IN # Z2:SiL:- / Supersedes ' LN"""'# _

The Me(licaid agency will submit all reports in the form an::1 with the content required by the Secretary, and will a:mply with an'f provisions that the Secretary finds necessary to verify and assure the correctness of the reports. All requirements of 42 c:rn 431.16 are met.

4.6 Reoorts Citaticn 42 CER 431.16 M-79-29


Revisicn: HCFA-AT-80-38(BPP) May 22, 1980

37

Approval Date~~ Effective Date c¢/.;z~ { \'IN# ?¥--/ Supersedes 'IN.!!.,# _

The Medicaid agency maintains or supervises tb: maintenance of records necessary for the proper and efficie.~t operation of t.~e plan, incl\rling records regarding aFPlications, determinaticn of eligibility, t.,e provision of medical assistance, an:J. administrative costs, and statistical, fiscal and other records necessary for reporting am accountability, and retains t.!Jese records in accordance with Federal requi rementa, All :e:;ruirements of 42 CFR 431.17 are ~et.

4.7 Maintenance of Records Citatio:i 42 cm 431.17 Al'-79-29

Commonwealth of Puert0 Rico

Revision: HCE'A-Al'-80-38{BPP) May 22, 1980

38 \

'"! # i'-'f-- -I -~upersedes / * -

4.8 Availabilitv of Aciencv Prcsram Manuals Program manuals and ether- pol.Ley Issuances t.."'lat affect the public, inclu.:Jing the Medicaid agency1s rules and regulatioos go11erning eligibility, need arrl amount of assistance, recipient rights and responsibilities, and services offered by the agency are maintained in the State off ice and in each lc:cal and district office for examination, upcn request, by individuals for review, study, or reprcdcct.i.on, All !'equir:ments of 42 ~ 431.18 are met.

Citation 42 CFR 431.18 (b) AT-79-29

Commonwealth of Puerto Rico .. State ~~~~~~~~~~~~~~~~~~~~~~~~-

HCFA-AT-80-38 (BPP) May 22, 1980

. Revision: ( \

39

'IN # 9S'-"=" I Supersedes 'IN# -

There are procedures implemented in accordance with 42 CPR 433.37 for identificaticn of providers of services by sccial security number or by employer identificaticn rn.miber and for re:porting the infocnaticn requi red py the Intern:µ Revenue Ccrle (26 U.S.C. 6041) with reS!)eet to payment for services under the plan.·

4.9 Reoortinc Provider Pavments to Internal Revenue Service

Citaticn 42 CFR 433.37 N!-78-90


Revisicn: BCFA-KI'-80-38 {BPP) May 22, 1980

40

Effective Date as 11 3 /a 3 Approval Date JtB 2 4 289ll

TN# 03-08 Supersedes TN #~-=-9=2~-1'"""0 _

x Freedom of Choice is not applicable to Puerto Rico

( c) Enrollment of an individual eligible for medical assistance in a primary care case management system described in section 1905(t), 1915(a), 1915(b) (I), or 1932(a); managed care organization, prepaid inpatient health plan, a prepaid ambulatory health plan, or a similar entity shall not restrict the choice of the qualified person from whom the individual may '" receive emergency services or services under section 1905 (a)(4)(c;).

(5) Under an exception allowed under 42 CFR 438.50 or 42 CFR 440.168, subject to the limitations in paragraph (c).

Section l932(a) (1) Section 1905(t)

( 4) By individuals or entities who have been convicted of a felony under Federal or State law and for which the State determines that the offense is inconsistent with the best interests of the individual eligible to obtain Medicaid services, or

Section I 902(a) (23) Of the Social Security Act P.L. 105-33

(3) By an individual or entity excluded from participation in accordance with section l 902(p) of the Act,

(1) Under an exception allowed under 42 CFR 431.54, subject to the limitations in paragraph (c), or

(2) Under a waiver approved under 42 CFR 431.55, subject to the limitations in paragraph ( c ), or

(b) Paragraph (a) does not apply to services furnished to an individual -

(a) Except as provided in paragraph (b), the Medicaid agency assures that an individual eligible under the plan may obtain Medicaid services from any institution, agency, pharmacy person, or organization that is qualified to perform the services, including of the Act an organization that provides these services or arranges for their availability on a prepayment basis.

AT78-90 46 FR48524 48 FR23212 l 902(a) (23) P.L. 100-93 (section 8(f)) P.L. 100-203 (Section 4113)

4.10 Free Choice of Providers Citation 42 CFR 431.51

State: ...... fP.::..u=e:.:rt~o'-'Rio.:::'c:o:co><-]1--- ~

New: HCF A-PM-99-3 JUNE 1999

41

{ ·; \. ..

~ # 9-Y"" -/ ·:>upersedes '#

(c) ATrnCHMENI' 4. ll-A descr ibes the standards specified in paragraphs (a) and (b) atove, that are kept en file and made available to the Health care Financing Administraticn en request.

(b) The State authority(ies) responsible for establishing and maintaining standards, other than those relating to health, for p.lblic or private instituticns t..~t provide services to Medicaid recipients is (are): Department of Health of

Puerto Rico.

(a) The State aqency utilized by the Secretary to determine qualifications of institutions and sucoliers of·· services to participate in Medicare ,is responsible for establishing and maintaining health standards for private or public instituticas {exclusive of Christian Science sanatoria) that provide services to Medicaid :::-eci?ien-:s. T::is agency is Department of Health of

Puerto Rico

4.11 Relations with Standard-Settino and Survev .A.oencies

Citaticn 42.CFR 431.610 Kr-78-90 AT-80-34

State Commonwealth of Puerto Rico --~~~~~~~.;.;......;;..;;..--.;-.=;..;:;;.;;;""'"""""""" ........ ~~~~~~~~~

~ ~·rision: HCFA-AT-80-38 (BPP) M::..'"'Y 22, 1980

42

'

. , i'4t -I ;'-="crsedes :N {

':;.

Puerto Rico (agency) which is the State agency responsible for licensing health institutions, determines if institutions ard agencies meet the requirements for participaticn in the Medicaid program. The requirements in 42 CFR 431.610(e), (f) and (g) are met •

The Department of Health of 4.ll {d) itatioo 2 CF.R 431. 610 r-78-90 r-89-34


av~~icn: B:FA-AT-B0-38(BPP) May 22, 1980

43

A};proval Date .,..!$./...c;,s;z('~ Effective Date ~/.;z. "'°. 'IN t 9?'"-/ ~upersedes N# -

@Not applicable. Similar services are oot provided to other types of medical

.facilities.

U Yes, as listed t:elow:

(b) Similar services are provided to other types of facilities providing medical care to individuals receiving services UL~der the pro.;rams specified in 42 CFR 431.105 (b) .

(a) Consultative services are provided cy health an:::l other awropriate State agencies to hospitals, nursing facilities, heme health agencies, clinics and laboratories in accordance with 42 CFR 431.lOS(b).

4.12 Consultatiai to Medical Facilities Citaticn 42 CFR 431.lOS(b) 'AT-78-90

..

State~ c_o_nnn __ o_nw_e_a_l_t_h __ of __ P_.u_e_r_t_o_R_i_c_o~-------------------

ECE'1>i.-AT-80-38(BPP) May 22, 19.80

d.evisim: ,,-.'·.···.· c· \

44

HCFA ID: 7982E

JAN 1 - 1992 Effective Date

(

TN No • ~JZ - ;;;z: . l Supersedes 00 Approval Date MAY 1992 TN No. Q_Q.- {

All services are provided through Department of Health facilities.

For each provider that is eligible under the plan to furnish ambulatory prenatal care to pregnant women during a presumptive eligibility period, all the requirements of section 1920(b)(2) and (c) are met.

Lx/ Not applicable. Ambulatory prenatal care is not provided to pregnant women during a

.presumptive eligibility period.

For providers of !CF/MR services, the requirements of participation in 42 CFR Part 483, Subpart Dare also met.

For providers of NF services, the requirements of 42 CFR Part 483, Subpart B, and section 1919 of the Act are also met.

For all providers, the requirements of 42 CFR 431.107 and 42 CFR Part 442, Subparts A and B (if applicable) are met.

With respect to agreements between the Medicaid agency and each provider furnishing services under the plan:

(d) 1920 of the Act

( c) 42 CFR Part 483, Subpart D

(b) 42 CFR Part 483 1919.of the Act

(a) 42 CFR 431.107

4.13 Required Provider Agreement

Puerto Rico

OMB No.: 0938- (BPD)

45

Citation State/Territory:

Revision: HCFA-PM-91- 4 At.:Gt:ST 1991

(e) Ensure compliance with requirements of State Law (whether

(d) Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive;

Document in the individual's medical records whether or not the individual has executed an advance directive;

(c)

Effective Date 08/13/03 Approval Date FEB e 4 ..

TN# 03-02 Supersedes TN #~9'"""2=---<-.9 _

/ ~·

(b) Provide written information to all adult individuals on their policies concerning implementation of such rights;

(a) Maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the· provider or organization about their rights under State law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

( 1) · Hospitals, nursing facilities, providers of home health care or personal care services, hospice programs, managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans (unless the P AHP excludes providers in 42 CFR 489.102)) and health insuring organizations are required to do the following:

For each provider receiving funds under the plan, all the requirements for advance directives of section 1902(w) are met:

4.13 (e)

Citation 1902 (a)(58) l 902(w)

State/Territory. , -------------J[i.:.Pu-=ert=o:::...=Ri='c=o.._] ------------

OMBNo.: (MB) ]Revision: HCFA-PM-91-9 October 1991

45(a)

Effective Date 08 I l 3 / 0 3 Approval Date FEB I 4 2111

TN# 03-02 -~~'-"'"---- Supersedes TN #--'9'-=2'-'-9"-----

(3) Attachment 4.34A describes law of the State (whether statutory or as Recognized by the courts of the State) concerning advance directives.

Not applicable. No State law or court decision exist regarding advance directives.

( e) Managed care organizations, health insuring organizations, prepaid inpatient health plans, and prepaid ambulatory health plans (as applicable} at the time of ,:,. enrollment of the individual with' the organization.

( d) Hospice program at the time of initial receipt of hospice care by the individual from the program; and

(c) Providers of home health care or personal care services before the individual comes under the care of the provider;

(b) Nursing facilities when the individual is admitted as a resident.

(a) Hospitals at the time an individual is admitted as an inpatient.

{2) Providers will furnish the written information'described in paragraph (l)(a) to all adult individuals at the time specified below:

(f) Provide (individually or with others) for education for staff and the community on issues concerning advance directives.

statutory or recognized by the courts) concerning advance directives; and

State/Territory: __.[Pu~=ert .... o ............ Ri~·c~o .... l _

OMBNo.:

45(b)

(MB) .Kevision: HCF A-PM-9 I-9 October 1991

Effective Date MAR 2 !) 2004 Approval Date APR ~ O ZOM

,, TN # ()I.I .,, 00 I Supersedes TN# 'J¥ _. /

A qualified External Quality Review Organization performs an annual External Quality Review that meets the requirements of 42 CFR 438 Subpart E each managed care organization, prepaid inpatient health plan, and health insuring organizations under contract, except where exempted by the regulation

l 932(c)(2) and 1902(d) of the ACT, P.L. 99-509 (section 9431)

(5) Includes a description of the extent to which PRO determinations are considered conclusive for payment purposes.

(4) Ensures that PRO review activities are not inconsistent with the PRO review of Medicare services; and

·(3) Identifies the services and providers subject to PRO review;

(2) Includes a monitoring and evaluation plan to ensure satisfactory performance;

(1) Meets the requirements of §434.6(a):

By undertaking medical and utilization review requirements through a contract with a Utilization and Quality Control Peer Review Organization (PRO) designated under 42 CFR Part 462. The contract with the PRO-

x

~x~_Directly .... /

A Statewide program of surveillance and utilization control has been implemented that safeguards against unnecessary or inappropriate use of Medicaid services available under this plan and against excess payments, and that assesses the quality of services. The requirements of 42 CFR Part 456 are met:

(a) 42 CFR 431.60 42 CFR456.2 50 FR 15312 l 902(a)(30)(C) and 1902(d) of the Act, P .L. 99-509 (Section 94 31)

4.14 Utilizatiori/Quality Control Citation

HCFA-PM-91-10 (MB) DECEMBER 1991 QH\&\l\l

State/Territory: -----~[Pu~e=rt~o-'ru~·co-=...>.-1 _

Revision:

46

Approval Date OCT 1 7 '1985. · Effective Date JUL 1 1985 TN No. 'iSS d.$ Supersedes TN No • .!lS::Q.


IX/ No waivers have been granted. L_ _ _/ Those specified in the waiver.

!._/All hospitals (other than mental hospitals).

!._/Utilization review is performed in accordance with 42 CFR Part 456, Subpart H, that specifies the conditions of a waiver of the requirements of Subpart C for:

!._/Utilization and medical review are performed by a Utilization and Quality Control Peer Review Organization.designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Cb) The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart C, for control of the utilization of inpatient hospital services.

4.14 Citation 42 CFR 456.2 50 FR 15312

OMB NO. 0938-0193

(BERC)

Puerto Rico State: Revision: HCFA-PM-85-3 HAY 1985

47

Effective Date JUL l 1985 Approval DatQGT l 7 1985. TB IJo. ~ 8upereeden TH No. rJj--'Zf


IX! Not applicable. Inpatient services in mental hospitals are not provided under this plan.

L_/ No waivers have been granted.

L_I Those specified in the waiver.

L_/ All mental hospitals.

L_/ Utilization review is performed in accordance with 42 CFR Part 456• Subpart H, that specifies the conditions of a waiver of the requirements of Subpart D for:

L_/ Utilization and medical review are performed by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part.462 that has a contract with the agency to perform those reviews.

(c) The Medicaid agency meets the requirements of 42 CFR Part 456. Subpart D, for control of utilization of inpatient services in mental hospitals.

4.14 Citation 42 CFR 456.2 50 FR 15312

State/Territory: Puerto Rico ........._...._ .................... ........,..,.__~~~~~~~~~~~~~-

OMB HO.: 0938-0193 (BERC) Revleion: HCFA-PK-85-7 .JULY 1985

48


1985 Effective Date ~JUL 1 ----- OCT 1 '7 19~5 Approval Date------

TN No. M.2. Supersedes TN No. '15-8

IX/ No waivers have been granted. L_I Those specified in the waiver. L_I All skilled nursing facilities.

L_I Utilization review is performed in accordance with 42 CFR Part 456, Subpart H, that specifies ~he conditions of a waiver of the requirements of Subpart E for:

I I Utilization and medical review are performed by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

(d) The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart E, for the control of utilization of skilled nursing facility services.

4.14 Citation 42 CFR 456.2 50 FR 15312

OMB NO. 0938-0193

(BERC) Puerto Rico State:

HCFA-PM-85-3 Revision: KAY 1985

49

n'·•·, ,,. Effective Date~~l ~ ----- Approval Date TH No. fil3_ Supersedes TN No. 75-8

HCFA ID: 0048Pl0002P

/:i._l Not applicable. Intermediate care facility services are not pt"ovtded under this plan.

L_I Two or more of the above methods. ATTACHMENT 4.14-B describes the circumstances under which each method is used.

LI Another method as described in ATTACHMENT 4.14-A.

LI Utilization and Quality Control Peer Review Ot"ganizations.

LI Personnel under contract to the medical assistance unit of the State agency.

LI D~rect review by personnel of the medical assistance unit of the State agency.

LI Facility-based review.

The Medicaid agency meets the requirements of 42 CFR Pal"t 456. subpart F. for contro], of the utilization of intermediate cat"e facility services. Utilization review in facilities is provided through:

4.14 LICe> Citation 42 CFR 456.2 50 FR 15312

OMB NO. 0938-0193

(BERG)

Puerto Rtco State: Revision: HCFA-PM-85-3 KAY 1985

50

·I ' . •

Effective Date MAR 2 b 2004 Approval Date AM 2 ~ aM

™ # O'J- -01) I Supersedes rN 'fA/- /

Not applicable.

The State must ensure that an External Quality Review Organization and its subcontractors performing the External Quality Review or External Quality Review related activities meets the competence and independence requirements.

42 CFR 438.354 42 CFR 438.356(b) and (d)

For each contract, the State must follow an open, competitive procurement process that is in accordance with State law and regulations and consistent with 45 CFR part 74 as it applies to State procurement of Medicaid services.

42 CFR 438.356(e)

4.14 Utilization/Quality Control (Continued) Citation

State/Territory: -----~[P~u!!:::e~rt~o..c!oRi.!:!·~co~JL-. _

OFFICIAL (MB) HCFA-PM-91-10 December 1991

Revision:

SO a

BCFA ID: Effective DateJUL 1 •1,1Qgl Approval Date NOV 1 9 1992 TN No. !J...i::.S

Supersedes TN No • .:J..f::K°'

-r , -. :.

NOT APPLICABLE

Not applicable with respect to inpatient psychiatric services for indiv·iduals under age 21; such services are not provided under this plan.

Not applicable with respect to services for individuals age 65 or over in institutions for menteo • -, disease; such services are not provided under this plan.

Not applicable with respect to intermediate care facilities for the mentally retarded services; such services are not provided under this plan.

All applicable requirements of 42 CFR Part 456, Subpart I, are met with respect to periodic inspections of care and services.

42 CFR Part 456 Subpart A and 1902(a)(30) of the Act

Mental Hospitals.

Inpatient psychiatric facilities for recipients under age 21; and

ICFs/MR;

42·CFR Part 456 Subpart I, and 1902(a)(31) and 1903(g) of the Act

4.15 Inspection of Care in Intermediate care Facilities for the Mentally Retarded, Facilities Providing Inoatient Psychiatric Services for Individuals Under 21, and Mental Hospitals

The State has contracted with a Peer Review organization (PRO) to perform inspection of care for:

Citation ::·f. ·. :~: :~ffh~P~d;~~;:

Puerto Rico State/Territory=~~~~~~~~~~~~~~~~~~~~~~

(HSQB) Revision: HCFA-PM-92- 2 MARCH 1992

51 \

J

A;:proval Date~Effec::ive Date ¢.~!'- '!N * .;:r--1 ~upersedes

·rn # ------

A~ 4.16~ cesc=ibes the c::ot:erative arrancements with t.1ie hea.lt.11 an:i- vocational r=-h..abilitaticn agencies.

~Medicaid ager..cy has ~ative arrangene.'"lts with S~te healt., and vccatialal r""h.abili taticn age."lCies ar.d with title v grant._oes, that meet the requi.:ements of 42 CTR 431.615.

4.16 Relations wit.."l St.ate Fi~.-lt.a, and ilocational Rehabilit.:.ticn Aaencies and Tit.le V Grantees

Citatiai 42 CTR 431. 615 (c) AT-78-90


52

. Revisicn: a::::A-M-80-38 (3PP) l't'..ay 22., 1980

'IN f &.3 -- 2 ··~sedes

( ·'' ?<!--/ >

(b) Liens are placed against the real property of an irrlividual before his or her death because of Medicaid claims paid or to be paid for that individual in accordance with 42 CFR 433.36(~ -Md=- (g) (2).

D Item (b) is rot aR)llCBble. No such lien is in:p::JSed ..

Item (a) applies to both an iooividlal' s real and personal property.

D

Item (a) applies only to an irrliviooal's personal property; or D

Item (a) ai:plies only to an iooividual's real Pr-operty;

u

Item (a) is oot ai:plicable. No sldi lien is i.np)sed •

u

(a) Liens are imposed against an irrlividual "s property before his or her death because of Medicaid clains paid a: to be paid en behalf of that irrlividual following a court jlrlgement whidl determined that benefits were in:x:>rrectly paid for that irrlividual.

Liens are iJnI:osed against an iooividual • s property •

l!l No.

D Yes.

..

4.17 Liens an3 Recoveries Citatiat 42 cm 433.36(c) AT-78-90 47 FR 43644

Puerto Rico )

~-AT-82- 29 (BPP) Dec.ember 1982

53

~ ' t ' i { u f ! ~ ..

_-JI!_ ..:....__ ' --

. '.JW f £5-? ersedes mt Af.ew<-

(c) Specifies the criteria l:1j whidi a son or daughter can establish that he- or she has been ·providing care, as specified under 42 CFR 433.36(f) •

(b) Defires the ter:ms specified in 42 CFR 433.36(e).

(a) Specifies the process for determining that an in.stituticnalized irrlividual canrot reasorably be expected · to be discharged fran tre medical institutirn and return tx:me. The descriptiai of the process meets

· the requirements of 42 CFR 433.36(d).

( e) A 'I'rnCHMENI' 4 .1 7-A ~

(d) No rn::ney payments under enotber program are redu::::erl as a means of recovering Medicaid claims iricorrectly paid.

• '

4.17 (c) Adjustments cc recoveries for Medicaid cl aims rorrectly paid are Imposed cnly in accordance with sectiai 433.36(h).

Citatim 42 CFR 433.36(c) AT-78-90 47 FR 43644

r'"'-..visioo: HCF1\-AT-82-z.9 (BPP) I · December 1982

53a

L . L

TN# o 1- oo-a.. Supersedes TN # 03-05

(ii) Setvices to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

Effective Date OCT O 1 2001 Approval Date SEP 1 l 21Ml9'

Reasonable categories of individuals who are age 18 or older, butunder age 21, to whom charges apply is listed below, if applicable.

(i) · Services to individuals under age· 18, or under-, [] Age 19

[] Age 20

[] Age 21

(2} No deductible, coinsurance, co-payment, or similar charge is imposed under the plan for the following:

(1) No enrollment fee, premium, or similar charge is imposed under the plan.

(b) Except as specified in items 4.1 8{b)(4), (5), and (6) below, with_ respect to individuals covered as categorically needy or as qualified Medicare beneficiaries (as defined in section 1905(p)(I) of the Act) under the plan:

(a) Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and co-payments do not exceed the maximum allowable charges under 42 CFR 447.54.

1916(a) and (b) of the Act

Citation 42 CFR 447.51 through 447.58

4.18 Recipient Cost Shar,in·g and Similar Charges

Statefferritory: _......[P ...... u ..... e....,rt=-o ...... R ...... ic ...... o.,._] ---------

OMB No.: 0938.- Revision: HCFA-AT-91-4(BPD) AUGUST 1991

54

Effective Date Approval Date

[ ]

[XJ Managed care enrollees are charged deductibles, coinsurance rates, and co payments in an amount equal to.the State Plan service cost-sharing. Managed care enrollees are not charged deductibles, coinsurance rates, and copayments.

Services furnished to an individual receiving hospice care, as defined in section 190.5(0) of the Act.

(viii)

(vii) Services furnlshed by a managed.care organization, health insuring organization, prepaid inpatient health plan, or prepaid ambulatory health plan in which the individual· is enrolled, unless they meet the requirements of 42 CFR 447.60.

{vi) Family planning services and supplies furnished to individuals of childbearing age.

(v) Emergency services if the services meet the requirements in 42 CFR 447 .53(b}(4).

(iv) Services furnished to any individual who is an inpatient in a hospital, long"'.term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution to spend for medical care costs all but a minimal amount of his or her income required for personal needs.

[ ] Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy.

(iii) All services furnished to pregnant women.

(Continued)

1916 of the Act, P.L 99-272, (Section 9505)

TN# D 1- ll'D -a._ Supersedes TN ...... # ..... 0""""3 ....... -0"""'"5'---- _

42 CFR 438.108 .42 CFR 447 .60

42 CFR 447.51 through 447.58

4.1 8(b)(2} Citation

State/Territory: ---------=f P---=u=e=rto=-=-=R=ic=o..._l ------------

OMB No.: 0938-

55

Revision: HCFA-PM-91-4 (BPD) AUGUST 1991

( )

Effective Date ,OCT 0 1 2ao7 Approval Date .IEP 11~'

[ ] Charges apply to services furnished to the following reasonable categories of individuals fisted below who are 18 years of age or older but under age 21.

· (X) 18 or older ( ) 19 or older ( ) 20 or older ( } 21 or older

{ii) Charges apply to services furnished to the following age groups:

(i) For any service, no more than one type of charge is imposed

[ ] Not applicable. No such charges are imposed.

(Continued)

(3) Unless a waiver under the 42 CFR 431.55 (g) applies, nominal deductible; coinsurance, co-payments, or similar charges are imposed for services that are not excluded from such charges under item (b )(2) above.

TN# f). 7• 001. Supersedes TN # 92·02.

42 CFR 447.51 through 447.58

4.18(b} Citation

State/Territory: ___.[.._P=ue=rt=o~R=ic=ol..__ _

OMB No.: 0938-

56

Revision: HCFA-PM-91-4 AUGUST 1991

' l . I

; ' ;

OCT o 1 Zil01 Effective Date -----~~ Approval Date SEP 1 l 2009'.

TN# 0 7 .... 00-z. Supersedes TN # 92-02

(G} Cumulative maximum that applies to all deductible; coinsurance or co-payment charges imposed on a specified .time period.

(X) Not applicable. There is no maximum.

CJ

(F) Procedures for implementing and enforcing the exclusions from cost sharing contained in 4~ CFR 447 .53(b} and

(E) . Basis for determining whether an individual is unable to pay the charge and the means by which such an individual is identified to providers;

(C) Amount(s) and basis for detemiining the charge(s);

(D) Method used to collect the charge (s):

(B) Nature of the charge is imposed on each service;

(A) Service(s) for which a charge(s} is applied;

(iii) For the categorically needy and qualified Medicare beneficiaries, Attachme·nt 4.18.A specifies the:

42 CFR 447.51 447.58

4.18(b) (3) Citation

(BPD) . l\ftfH{ll» - l Ula 1l,dA

State!Territory:. ....if-'-P.:::u~ert~o~R~i~co~I:........... n _ (Continued)

(_. r•

56 a

OMB No.: 0938- · HCFA~PM-91-4 AUGUST 1991

Revision:

( ) A monthly premium, set on a sliding scale, imposed on qualified disabled and working individuals who are covered under section 1902 (a)( 1 O)(E) (ii) of the Act and whose income exceeds 150% (but does not exceed 200%} of the Federal Poverty Level applicable to a family of the size involved. The requirements of section 1916 (d) of the Act are met. Attachment 4.18-E specifies the method and standards the State uses for detennining the premium.

Effective Date ,OCT (} 1 2001 Approval Date~

TN# . ()1- dl)2-_ Supersedes TN # 92-02

( ) For families receiving extended benefits during a second 6 months period under section 1925 of the Act, a monthly premium is imposed in accordance with sections 1925(b )( 4) and (5) of the Act.

1902 (a)(52) 4.18 (b}(5) And 1925 (b) Of the Act

( ) 1916 (d) of 4.18 (b)(6) The Act

( ) A monthly premium is imposed on pregnant women and infants who are covered under Section 1902(a)(1 O)(A}(ii)(IX) of the Act and whose income equals or exceeds 150% percent of federal poverty level applicable to a family of the size involved. The requirements of section 1916(c) of the Act are met. Attachment 4.1 B~D specifies the method the States uses for determining the premium and the use

· criteria for determining what constitutes undue hardship for waiving payment of premiums by recipients.

1916 {c) of the 4.18(b)(4) Act

Citation

Stateff erritory: --------· _._[._P=ue=rt~o;:;....:....;R=ic~o ..... l _

OMB No.: 0938- (BPo) llfflC/A{ Revision: . HCFA-PM-91-4

AUGUST 1991

56 b

Effective Date OCT 0 1 2007 Approval Date SEP 1 1 2009~

Reasonable categories of individuals who are age 18, but under age 21 .to whom charges apply are listed below, if · applicable.

() age 19 () age 20 () age 21

Services to the individuals under age 18 or under:

(i)

(2) No· deductible, coinsurance, copayrnent, or similar charge is imposed under the plan for the following:

{ 1} ( ) An enrollment fee, premium or similar charge is imposed. Attachment 4.18-B specifies the amount of and liability period for such charges subject to the maximum allowable charges in the 42 CFR447.52 (b) and defines the State's policy regarding the effect on recipients of non-payment of the enrollment fee, premium, or similar charge.

(X) Individuals are covered as medically . needy under the plan


56c

TN# D 7.,, d7)Z... Supersedes TN # 92-02

42 CFR 447.51 Through 447.58

4.18 (c) Citation

Revision: HCFA-PM-91-4 AUGUST 1991 t\t\l

Stateff erritory: ..... [P-"u=e:.;..;rt=o_,_R=ic=o::.i.1-=;...;._I_· _

[ ] . Managed care enrollees are not charged deductibles, coinsurance rates and copayments.

Effective Date OCT 0 1 2001. Appr~val Date ~IJEP .11 •.

TN# o7-"1)1-- Supersedes TN # 92-02

(viii) Services furnished by a managed care organization, health insuring organization, or prepaid inpatient health plan, or prepaid ambulatory health plan in which the individual is enrolled, unless they meet the requirements of 42 CFR 447 .60.

[x] Managed care enrollees are charged deductibles, coinsurance rates, and copayments in an amount equal to the State Plan service cost-sharing.

42 CFR 43R 108 42 CFR 447.60

(vii) Services furnished to an individual receiving hospice care, as defined in section 1905( o) of the Act

1916 of the Act P.L. 99-272 P.I.,. 99-272 (Section 9505)"

(vi) · Family planning services and supplies furnished to individuals of childbearing age.

Emergency services if the services meet the requirements in section 42 CFR 447.53 (b) (4).

(v)

· (iv) Services furnished to any individual who is an inpatient in a hospital, long term care facility, or any other medical institution; if the individual is required, as a· condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs.

( ) Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy.

(iii) All services furnished to pregnant women.

Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy

(ii)

Continued

~3~~f~~~~{ (BPD) OMB No.: 0938- Off :?~H\~L '. j~~ti \

State/Territory: ------~[~P"""'u""'ert"'"'o""""R'--'1=·c-=o]'------------- Citation 4. 18 (c) (2) 42 CFR 447.51 Through 447.58

Revision:

56d

( )

( ..

Effective OCT 0 1 20D1 Approval Date 'SEP l 1 2009'

TN# () 7.-01)1- Supersedes TN# 92-02 ..

Reasonable categories· of individual who are 18 years of age, but not under 21, to whom charges apply are listed below, if applicable.

()

(X) 18 or older: ( ) 19 or older: ( ) 20 or older: ( ) 21 or older:

(ii) Charges apply to services furnished to the following age group:

(i) For any service, no more than one type of charge is imposed ..

() Not applicable. No such charges are imposed.

42 CFR 447.51 through 447.58

Citation

fl ti Al .State{ferritory: .; .....Jr ...... P-=u=ert=o::....;...:R=ic=ol,____ _

4.18 (c).(3) Unless a waiver under 42 CFR431.55 (g) applies, nominal deductible, coinsurance, co-payment, or similar charges are imposed on services that are not excluded from such charges under item (b) (2) above.

56e

OMB No.: 0938~ (BPD) HCFA-PM-91-4 AUGUST 1991

Revision:

Effective Date· t'lCT 0 l 2001 ·· Approval Date ·sep 11 2Dl

(X) Not applicable. There is no maximum.

(G) Cumulative maximum that applies to all deductible, coinsurance, or co-payment

· charges imposed on a family during a specified time period.

(F) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53 (b); and

(B) Nature of the charge is imposed on each service;

(C) Amount(s) of and basis for determining the charge(s);

(D) Met!'Jod used to collect the charge(s);

(E) Basis for determining whether an individual is unable to pay the charge(s); and the means by which such an individual is identified to providers;

(iii) For the medically needy, and other optional, Attachment 4.18 C specifies the:

. (A) Service(s) for the charge(s) is applied;

{Continued)


56f

TN# Supersedes TN !!.#~9=2~~0=2'-----

447.51 through 447.58

4.18 (c) (3) Citation

HCFA~PM-91-4 AUGUST 1991

Revision: [t@~l.l 1·1~1\ '

State!Territo'ry: --------'[1,.;..P"""'u=ert=o;;_o...;R=ic .... o,,,__] ------------

Effective Date 'JAN 1 - 1992 TN No· q;:z - 4 . MAY 1 1992 Supersede~ · Approval Date TN No. ~s=- J

HCFA ID: 7982E

.YI Inappropriate level of care days are not covered.

L_I Inappropriate level of care days are covered and are paid under the State plan at lower rates than other in~atient hospital services, reflecting the level of care actually received, in a manner consistent with section 186l(v)(1)(G) of the Act •

ATTACHMENT 4.19-A describes the methods and standards used to determine rates for payment for inpatient hospital services.

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart c, and sections 1902(a)(l3) and 1923 of the Act with respect to payment for inpatient hospital services.

(a) 42 CFR 447.252 1902(a)(l3) and 1923 of the Act

4.19 Payment for Services Citation


OMB No.: 0938- (BPD) Revision: HCFA-PM-91- 4 AUGUST 19 9 1

57

-u.s. c.r.o. :199>->112-239:eo1i:.'?

NO\I · 1 8 199( Effective Date JUL 1 - 1994 Approval Date

NOT APPLICABLE

SUPPL~MENT 1 to ATTACHMENT 4.19-B describes general methods and standards used for establishing payment .for Medicare Part A and E deductible/coinsurance.

1902(a) (10) and 1902(a)(30) of the Act

ATTACHMENT 4.19-B describes the methods and standards used for the payment of each of these services except for inpatient hospital, nursing facility services and services in intermediate care facilities for the mentally retarded that are described in other attachments.

(2) Sections 1902(a)(l3)(E) and 1926 of the Act, and 42 CFR Part 447, Subpart D, with respect ta payment for all other types of ambulatory services provided by rural health clinics under the plan.

(1) Section 1902(a)(l3)(E) of the Act regarding payment for services furnished by Federally qualified health centers {FQHCs) under section 1905(a) (2) (C) of the Act. T.he agency meets the requirements of section 6303 of the State Medicaid Manual (HCFA-Pub. 45-6) regarding payment for FQHC services. ATTACHMENT 4. 19-B describes the method of payment and how the agency determines the reasonable costs of the services (for example, cost-reports, cost or budget reviews, or sample surveys).

4.19(b) In addition to the services specified in paragraphs 4.19(a), (d), (k), (l), and (m),the Medicaid agency meets the following requirements:

Citation 42 CFR 447.201 42 CFR 447.302 52 FR 28648 1902(a) (13) (E) 1903(a) (1) and (n), 1920, and 1926 of the Act

P11erto Rico State/Territory:

OME No.: 0938- (MB) HCFA-PM-93- 6 1993

Revision: August

58

I I i. !

I

At=Proval Date ~~'il:p. Effective Date~~~ 'IN #9r-+. Supersedes 'IN *'i?:?--=?

( '·

il/ No.

4.19 (er Payment is made o reserve a bed during a recipient's te;rporary absence frcm an· inpatient facility.

D Yes. The State's policy is described in .a..TrACHMENT 4 .19~.

Citaticn 42 Cffi 447 • 40 xr-78-90

~-AT-80-38(BPP) zt..ay 22, 1980

. Revisic..'1: r: \

59

,.

Date Approval· Date 10.10P/0012P ID:

~· . T '\i . ·fi' ~~~-; rrfA Effective .... ,,fA.'\)' HCFA

TN No. t?r'.,3 Supet·sedes TN No. £°c/-/

Section 4.19(d){l) of this plan is not applicable with respect to intermediate care facility services; such services are not pr-ov i.ded under this Sta.te plan.

!.:ti ( 4)

IX/ Not applicable. The agency does not provide payment for ICF services to a swing-bed hospital.

!__I At a rate estab1ished by the State, which meets the requirements of 42 CFR Part 447, Subpart C, as applicable.

LI At the average rate per patient day paid to ICFs, other than ICFs for the mentally retarded, for routine services furnished during the previous calendar year.

(3) The Medicaid agency provides payment for routine intennediate care facility services furnished by a swing-bed hospital.

!).e.l Not applicable. The agency does not provide payment for SNF services to a swing-bed hospital.

!__I At a rate established by the State, which meets the requirements of 42 CFR Part 447, Subpart C, as applicable.

!__I At the average rate per patient day paid to SNFs for routine services furnished during the previous calendar year.

·c2) The Medicaid agency provides payment for routine skilled nursing facility services furnished by a swing-bed hospital.

ATTACHMENT 4.19-D describes the methods and standards used to detennine rates for payment for skilled nursing and intermediate care facility services.

f:/U (1) The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart c, with respect to payments for skilled nursing and intermediate care facility services.

4.19 (d) Citation 42 CFR 447.252 47 FR 47964 48 FR 56046 42 CFR 447.280 47 FR 31518 52 FR 28141

Puerto Rico . State/Territory:

OMB No. : .093.8:-.0193 (BERG) Revision: HCFA-PH-87- 9 AUGUST 1987

60

l .··

(

(

(

MTACEMENT 4.19-E specifies, for each type of service, the definition of a claim far purposes of meeting these requirements.

4.19 (e) The Medicaid agency meets all requirements of 42 ·cm 447. 45 far ti'llely payment of claims.

Citation. 42 CER 447.45(c} AT-79-50

State Commonwealth of Puerto Rico

:<.evisim: B:FA-AT-80-38 (BPP) May 22, 1980

61

TN No. 5i?-/ Supersedes TN No. z?3-j

Effective Date ¥M8!f


L

No provider participating under this plan may deny services to any individual eligible under the plan on account of the individual's inability to pay a cost sharing amount imposed by the plan in accordance with 42 CFR 431.SS(g) and 447.53. This service guarantee does not apply to an individual who is able to pay, nor does an individual's inability to pay eliminate his or her liability for the cost sharing change.

4.19 Cf) The Medicaid agency limits participation to providers who meet the requirements of 42 CFR 447.15.

Citation 42 CFR 447.15 AT-78-90 AT-80-34 48 FR 5730

.,I '!


OMB No.: 0938-0193 (BERC) Revision: HCFA-PM-87-4 MARCH 1987 (

62 OFFICIAL

Effective Date ~/;:z 7> Approval Date~~ 'IN #?Z~

: Supersedes 'IN # ;?£- -3

(

4.19(g) The Medicaid agency assures appropriate audit of records when payment is based en costs of services or en a fee plus cost of materials.

Citatic:n 42 cm 447.201 42 CFR 447.202 "fl.:X-78-90


Revision.: H:FA-AT-80-38(BPP) May 22 f l.980

63

. ---~. ~""·· · ..

Afproval Date~? Effective Date.-;;ij~ 'lN # 92~ Supersedes 'IN # 9.K--3 . {

'. .

4.19 (h) The Medicaid agency meets the requirements of 42 CFR 447.203 for documentation and availability of payment rates.

Citation 42 CFR 447.201 42 CFR 447.203 NJ;-78-90


Revision: HCFA-AT-80-60 (BPP) August 12, 1980 ·

/V C..., L~ /· /:" 64

4.19 (i) The Medicaid agency's payments are sufficient to enlist enough providers so that services under the plan are available to recipients at least to the exta11t that those services are available to the general f.OPU.lation.

Citatic:n 42 CTR 447 • 201 42 CFR 447 • 204 Kr-78-90

State Commonwealth of Puerto Rico ~~~~~~--";.;.;......;..m.....-...=.;;...;;.;;;;..~-=-~~~~~~~~~~

Revision: B:FA-AT-80-38(BPE>) May 22, 1980

65 /VC 7

Effective Date ,IAN 1 - 1992 HCFA ID: 79B4E

Approval Date MAY 1 1992

Not Applicable

The Medicaid agency meets the requirements of section 1903(v) of the Act with respect to paymen~ for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law. Payment is made only for care and services that are necessary for the treatment of an emergency medical condition, as defined in section 1903(v) bf the Act.

The Medicaid agency.meets the requirements of section 1920(d) of the Act with respect to payment for ambulatory prenatal care furnished to pregnant women during a presumptive eligibility period.

The Medicaid agency meets the requirements of 42 CFR 447.205 for public notice of any changes in Statewide method or standards for setting payment rates.

Puerto Rico


66

1903(v) of the (l) Act

1920 of the L___/(k) Act, P.L. 99-509 (Section 9407)

46 FR 58677

42 CFR 447.201 4.19(j) and 447.205

Citation

Territory:

Revision: HCFA-PM-91-4 Al:Gt;ST 1991

Effective Date JUL 1 - 1993 Approval Date JAN l 1 1994. TN No. 93-2 Supers el\] ' TN No·e'\41

~ill

NOT APPLICABLE

4.19(1) The Medicaid agency meets the requirements of section 1903(i)(14) of the Act with respect to payment for physician services furnished to children under 21 and pregnant women. Payment for physician services furnished by a physican to a child or a pregnant woman is made only to physicians who meet one of the requirements listed under this section of the Act.

PUERTO RICO

1903(i) (14) of the Act

Citation

state/Territory:

(MB) Revision: HCFA-PM~92-7 Oct~ber: · · 1992

66 (a)

SupersedesTNNo.: 95~2

Effective Date: April 1, 2015

.Approval Date: September 11, lOIS ~~~~~~~~~~~~~

Transmittal No.: 15-002

1923 of the Act

4.19 (m) Medicaid Reimbm·sement for Administration of Vaccines under the Pediatric Immunization Program (i) A provider may impose a charge for the administration of a

qualified pediatric vaccine as stated in 1928 (c) (2) (C) (ii) of the Act Within this overall provision, Medicaid reimbursement to providers will be administered as follows.

(ii) The State: D Sets a payment rate at the level of the regional

maximum established by the DHHS Secretary. rgj Is a Universal Purchase State and sets a payment rate at

the level of the regional maximum established in accordance with State law.

D Sets a payment rate below the level of the regional maximum established by the DHHS Secretary.

D Is a Universal Purchase State and sets a payment rate below the level of the regional maximum established by the Universal Purchase State.

·The State pays the following rate for the administration of a vaccine:

Not applicable, see note that follows. (iii) Medicaid beneficiary access to immunizations is ·assured

through the following methodology: The Puerto Rico Department of Health provides vaccines to children ages 0~18 through the Children's Immunization Program. The coverage benefits of the Puerto Rico Medicaid Program also include immunizations for Medicaid beneficiaries' ages 19-20. Each managed care organization (MCO), contracted by the State, will contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide the immunization services.

1928( c )(2)(C)(ii) of the Act

Citation

ST ATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO

Revision: HCF A-PM-94-8 (MB) October 1994

66 (b)

. ·.J." # 9~-Z: Supersedes 1r . z:r-r-

r, ~:.

Not applicable. No direct payments are made to recipients .

A'ITACEMENI' 4. 20-A SE)eci:ies the condi.t ions under which such payments are made.

Direct payments are made to certain recipients as speci.fie:l by, an:J in accordance with, the requirements of 42 CFR 447.25. U Yes, for ~ physicians' services

LJ dentists' services

4. 20/ Direct P'avments to Certain Recipients for Phvsicia.'1.S' or Dentists' Services

Citation 42 CFR 447 .25 (b) Al'-78-90


·ision: HCFA-Al'-80-38 (BPP) May 22, 1980

67

Approval Date ~;*~ Effective Date_;(-M-c?--

Payment for Medicaid services furnished by any provider under this plan is made only in accordance with the requirements of 42 CFR 447.10.

4.21 Prohibition Against Reassignment of Provider Claims

TN # £2- -/ Supersedes TN~---::_,$~-

42 CFR 447.lO(c) AT-78-90 46 FR 42699


Citation

10-81 Revision: HCFA-AT-81-34 (BPP) Off~C~AL 68

>'

Approval Date JUL 1 - 1994 'I f't' • 2. ~ 19g11 N\J V ' ''+ Effective Date

(4) Describes the methods the agency uses for following up on paid claims identified under §433.138(e) (methods include a procedure for periodically identifying those trauma codes that yield the highest third party collections and giving priority to following up on those codes) and specifies the time frames for incorporation into the eligibility case file and into its third party data, base and third party recovery unit of all information obtained through the followup that ~dentifies legally liable third party resources.

(3) Describes the methods the agency uses for following up on information obtained through the. State motor vehicle accident report file data exchange required under §433.138(d){4)(ii) and specifies the ti.roe frames for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the followup that identifies legally liable third party resources; and

(2) Describes the methods the agency uses for meeting the followup requirements contained in §433.138(g)(l)(i) and (g)(2){i);

(1) Specifies the frequency with which the data exchanges required in S433.138{d)(l), (d)(3) and {d)(4) and the diagnosis and trauma code edits required in S433.138(e} are conducted;

(b) ATTACHMENT 4.22-A --

(1) 42 CFR 433.138 and 433.139. (2) 42 CFR 433.145 through 433.148~ (3) 42 CFR 433.151 through 433.154. (4) Sections 1902(a)(25)(H) and (I) of the

4.22 Third Party Liability (a) · The M~dicaid agency. mee t s all .i;equirement s of:

.. Pue r t o .Rf.c o

(MB)

69

TN No. 9Lf q: Supersedes TN No. go-/

42 CFR 433.138(g)(4)(i) through ('iii)

42 CFR 433.138(g){3)(i) and (iii)

42 CFR 433.138(g)(l)(ii) and (2) (ii)

42 CFR 433.138(£)

1902(a)(25)(H) and (I) Act. of the Act

Citation . . ·!?ta te/Ter r i tory:

·Revision: HCFA-PM-94-1 . FEBRUARY 1994 ..-·

TN No. Supersedes TN No.

Effective Date JUL 1 - 1994 Approval Date NOV E a go-1

(e) The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20.

42 CFR 447 .20

(3) The dollar amount or time period the State uses to accumulate billings from a particular liable third party in making· the decision to seek recovery of reUnbursement.

42 CFR 433.139(£)(3)

(2) The threshold amount or other guideline used in determining whether to seek recovery of reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reUnbursement would not be cost effective.

42 CFR 433.139(f)(2)

(1) The method used in determining a provider's compliance with the third party billing requirements at S433.139(b) (3) (ii) {C).

42 CFR 433.139(b) (3) (ii) (C)

(d) ATTACHMENT 4.22-B specifies the following:

Providers are required to bill liable 'third parties when services covered unde r the plan are furnia.hed to an individual on whose behalf·· child support enforcement is bei~g c~rried out by the State IV-D agency.

( c) x 42 CFR 433.139(b)(3) (ii) (A)

Citation

P~eFto Rico State/Territory:

Revision: HCFA-PM-94-1 .. (MB) FEBRUARY 1994

69a

NOV 2 3 1994 Effective Due JUL 1 ~ 1994 TN No. 9 'f"-q> '. SupereaQea hpprov4l Date TN 1'0 • g.i.- g

The ~ecretary's met~od as provldad ln tba State Medicaid Manual, section 3910. Thg State providco ~ethodg to~ deterrr.ining CcGt erteet~venece on ~'!"l'ACHM?~T 4.22-C.

(h) ThG Medicaid agency specifies ::tie 9.ui.delincis uaed in determining tne ctnst cffoctiveneS5 of an employer-baseo 9roup ha~lth plan by aelectJ.n9 one of tbQ fallowinq.

1906 of the Act

(~) The Medicaid agency as:,,urGa that the S~ate has ir: etfec't thic ;.a.wa ral.atinq to. 1T1edi.cal child support Qnde~ •Qction J908 of the Act.

1902(a)(60) Qf ~he A~c

Courts and law enforcement offici.:alo.

O~her appropr1a'te ~g~ncy(a) of another Sta.ta-

Ct.her 6ppropria.te Sta'te aqeney(s)--

State title IV-D agency. The reC?Uireoents of 42 CFR 4J3.152(cJ arQ m~t.

Th• Medicaid aqancy has wrlt~cn ~oope&&~ive acreement~ tor thA entor~ament of ~iqhta to •nd co l Ieec Lon of tti1rd porty ben~fi.ts a&&l.qned t<:1 the State as 4 condiLion of eliglbili~y for meal.cal. coa:.1.!..s1:.anca with th~ follot.iing: (er.eek aa ~ppropri~te.)

{£) 42 CFR 43J.1Sl(a) 4. 22 (continue<1)

Cic.at1.on

Revhl.on1 HC::FA-PM-94-l (MB) FEBROAAY 199..:.

Puerto Rico Rtate/Terr1tor~1

70 . ·~·-·----------~..:..__·------·-··--

Effective Date 08/13/03 Approval Date l'£B I 4 2004

TN# 03-11 Supersedes TN # 94~ I --'"---'-=---- .......

Not applicable

a Prepaid Ambulatory Health Plan that meets the definition of 42 CFR438.2

_L a Prepaid Inpatient Health Plan that meets the definition of 42 CFR438.2

_L a Managed Care Organization that meets the definition of l 903(m) of the Act and 42 CFR 438.2

The Medicaid agency has contracts of the type(s) listed in 42 CFR Part 438. All contracts meet.the requirements of 42 CFR Part 438. Risk contracts are procured through an open, competitive procurement process that is consistent with 45 CFR Part 74. The risk contract is with (check all that apply):

42 CFR Part 438

U Not applicable. The State has no such .contracts.

The Medicaid agency has contracts of the type(s) listed in 42 CFR Part 434. All contracts meet the requirements of 42 CFR Part 434.

42 CFR434.4 48 FR 54013

4.23 Use of Contracts Citation

State/Territory: _.[Pu""'-"=ert=o:;;...Ri='c=o~J --------------

Revision: HCF A-AT-84-2 (BERC) 01~84

71 OMB No. 0938-0193

Effective Dat·;· JlJL ·1 - 1994 ND\/ 1 $ 1994 Approval Date TN No. q q:-s Supersedes TN No~ '6 / - ;),,

! { '·

X Not applicable to intermediate care facilities for the mentally retarded; such services are not provided under this plan.

With respect to nursing facilities and intermediate care facilities for the mentally retarded, all applicable requirements of 42 CFR Part 442, Subparts Band Care met.

Standards for Payments for Nursing Facility and Intermediate Care Facility for the .Mentally Retarded Services

4.24 Citation 42 CFR 442.10 and 442.100 AT-78-90 AT-79-18 AT-80-25 AT-80-34 52 FR 32544 P.L 100-203 {Sec. 4211) 54 FR 5316 56 FR 48826

( State/Territory: __,P;__:u!,!£.e.1..r..1.tJ.OL..1B:1.-11-'· co _

Revision: HCFA-PM-94-2 (BPD) APRIL 1994

72

™#r~-/ Supersedes 'IN--*----

(

t:::::;:::::

{ ' \

............ ............

[£f.t}f.;}

!;·~;~;·;·:;·;~:~ ··········· ·•········ -·····--

!:::::::::: :1\li" ff J{f,~(!i! ;:::::::::::

The State has a program that, except with respect to Christian Science sanatoria, meets the requirements of 42 CFR Part 431, Subpart N, for the licensing of nursing hane administrators.

4.25 Prcgram for Licensing Administrators of Nursing Hanes

Citation 42 c:m 431. 702 Nr-78-90


_.t:vision: ECFA-Kr-80-38 (BPP) May 22, 1980

73

Not Applicable

Date JU[ l - 1993 Effective 1 2 1994 TN No. £({-q3--'9 '"'"U\1 Supersedes Approval Date .!Jnll TN No. qi-s ------

-American·Hoepital Fobl!ulary Service Drug Information -United states Pharmacopeia-Drug Information

-American Medical Association Drug Evaluations

The DUR program shall assess data use against predetermined standards whose source materials for their development are consistent with peer-reviewed medical literature which has been critically reviewed by unbiased independent experts and the ·following compendia:

c. 1927(g) (1) (B) 42 CFR 456.703 (d)and(f)

-Potential and actual adverse drug reactions -Therapeutic appropriateness -Overutilization and underutilization -Appropriate use of generic products -Therapeutic duplication -Drug disease contraindications -Drug-drug interactions -Incorrect drug dosage or duration of drug treatment -Drug-allergy interactions -Clinical abuse/misuse

The DUR program is designed to educate physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and patients or associated with specific drugs as wel·l as:

B.

1927(g) (l) (a) 42 CFR 456.705(b) and 456.709(b)

-Appropriate -Medically necessary -Are not likely to result in adverse medical results

2. The DUR program assures that prescriptions for outpatient drugs are:

1927 (g) ( l) (A)

A.l. The Medicaid agency meets the requirements of Section 1927(g) of the Act for a drug use review (DUR) program for outpatient drug claims.

4.26 Drug Utilization Review. Program 1927(g) 42 CFR 456.700

Citation Puerto Rico State/Territory:

(MB) Revision: HCFA-PM- OFFICIAL 74

TN No. e\1 92:)-tj Supersedes TN No. 9'2.-£

-Patterns of fraud and abuse -Gross overuse -Inappropriate or medically unnecessary car~1·•

among physicians, pharmacists, Medicaid recipients, or associated with specific drugs or groups of drugs.

Effective Date·JU[ 1 ~ 1993 Not Applicable

F.1. The DUR program includes retrospective DUR through its mechanized drug claims processing and informat.ion retrieval system or otherwise which undertakes ongoing periodic examination of claims data and other records to identify:

1927(g) (2) (B) 42 CFR 456.709(a)

3. Prospective DUR includes counseling for Medicaid recipients based on standards established by State law and maintenance of patient profiles.

1927(g) (2) (A) (ii) 42 CFR 456.705 (c) and (d)

-Therapeutic duplication -Drug-disease contraindications -Drug-drug interactions -Drug-interactions with non-prescription or o.ver-the-counter drugs -Incorrect drug dosage or duration of drug treatment

-Drug allergy interactions -clinical abuse/misuse

2. Prospective DUR includes screening each prescription filled or delivered to an individual receiving benefits for potential drug therapy problems due to:

1927(g) (2) (A) (i) 42 CFR 456.705(b), (1)-(7))

E.l. The DUR program includes prospective review of drug therapy at the point of sale or point of distribution before each prescription is filled or delivered to the Medicaid recipient.

1927(g) (2) (A) 42 CFR 456.705(b)

Prospective DUR Retrospective DUR.

DUR is not required for drugs dispensed to residents of nursing facilities that are in compliance with drug regimen review procedures set forth in 42 CFR 483.60. The State has never-the-less chosen to include nursing home drugs in:

D. 1927 (g) ( l) (D) 42 CFR 456.703{b)

Citation

Puerto Ri co s.t.ate/Terr i to:i;y:

{MB) .OffJCIAl 74a . Revision: HCFA-P~-

1 - 19'J3 Effective Date JO( -------- Date JAN 1 2 1994

- Retrospective DUR, - Application of Standards as defined in

section l927(g)(2)(C), and - Ongoing interventions for physicians and

pharmacists targeted toward therapy problems or individuals identified in the course of retrospective DUR.

3. The activities of the DUR Board include:

- Clinically appropriate prescribing of covered outpatient drugs.

- Clinically appropriate dispensing and monitoring of covered outpatient drugs.

- Drug use review, evaluation and intervention.

- Medical quality assurance.

2. The DUR Board membership includes health professionals (one-third licensed actively practicing pharmacists and one-third but no more than 51 percent licensed and actively practicing physicians) with knowledge and experience in one or more of the following:

Directly, or Under contract with a private organization

G.l. The DUR program has established a State DUR Soard either:

3. The DUR program through its State DUR Board,. using data provided by the Board, provides for active and ongoing educational outreach programs to educate practitioners on conunon drug therapy problems to improve prescribing and dispensing practices.

-Therapeutic appropriateness -overutilization and underutilization -Appropriate use of generic products -Therapeutic duplication -Drug-disease contraindications -Drug-drug interactions -Incorrect drug dosage/duration of drug treatment

-Clinical abuse/misuse

F.2. The DUR program assesses data on drug use against explicit predetermined standards including but not limited to monitoring for:

Puerto R·ic.o _OFFICIAL 74b

(M,8 l

Supersedes Approval TN No • . 'j ;;J,_ - !)

Not Applicable TN No. pp; 92-9

927(g) (3) (C) 42 CFR 456.716(rl)

1927(g) (3) (B) 42 CFR 456.716 (A) AND (B)

1927(g) (3) (A) 42 CFR 456.716(a)

1927(g) (2) (D) 42 CFR 456. 711

927(g) (2) (C) 42 CFR 456.709(b)

Citation

. ~ : . . . · S.tate/Territory:

R~vision; ~CFA-PM-

TN No. rR q 3 if -JAN 1 2 1994 *U.S. G.P.0.:1993-342-239:80043

199'J JUL l Effective Date supers~W Approval Date TN No. l!f .. C ---~~~~-

Not Applicable

J. Hospitals which dispense covered outpatient drugs are exempted from the drug utilization review requirements of this section when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purchasing cost for such covered outpatient drugs.

1927(j)(2) 42 CFR 456.703(c)

2. Prospective DUR is performed using an electronic point of sale drug claims prqcessing system.

1927(9) (2) (A) (i) 42 CFR 456.705(b)

I.l. The State establishes, as its principal means of processing claims for covered 9utp~tient drugs under this title, a point-of-sale electronic claims management system to .perform on-line:

real time eligibility verification claims data capture ~djudication of claims assistance to pharmacists, etc. applying for and receiving payment.

1927(h)(l) 42 CFR 4!;i6.722

H. The State assures that it will prepare and submit an annual report to the secretary, which incorporates a report from the State DUR Board, and that the State will adhere to the plans, steps, procedures as described in the report.

1927 (g) (3) (D) 42 CFR 456.712 {A) and (B)

- Information dissemination - Written, oral, and electronic reminders - Face-to-Face discussions - Intensified monitoring/review of

prescribers/dispensers

The interventions include in appropriate instances:

G.4 1927(g) (3) (C) 42 CFR 456.711 (a)-(d}

Citation

Puerto." .Rico State/Territory:

(MB} OMB No. 740- _O.FFlCIAL

Revision: - HCFA-PM-

'IN i ;?-7 -/O ~ / ( upersedes · ~roval Date ~~~?o Effective Date "94 >/' 'il- '?'

.i.N # zt;; -//

The Medicaid agency has established procedures for disclosing pertinent firrlings obtained from surveys and provider and contractor evaluations that meet all the requirements in 42 CFR 431.115.

4.27 Disclosure of Survey In.fomticn and Provider or contractor Evaluaticn

Citatfr.:n 42 CFR 431.lJ.S(c) M-78-90 M-79-74

State Commonwealth of Puerto Rico ~~~~~--------~_....;.....;...;;..;.....;.;...;;..;..;..~~~~---~~~~~--

.,,,evision: HCFA-AT-80-38 (BPP) May 22, 1980

75

JUL 1 - 1993 Effective Date Date JAN --,------- Approval Supersedes· TN No. gq-1 TN No. PR 93-3

Not Appli cab] e

(b) The state provides an appeals system that meets the requirements of 42 CFR 431 Subpart E, 42 CFR 483.12, and 42 CFR.483 Subpart E for residents who wish to appeal a notice of intent to transfer or discharge from a NF and for individuals adversely affected by the preadmission and annual resident review requirements of 42 CFR 483 Subpart c.

{a) The Medicaid agency has established appeals procedures for NFs as specified in 42 CFR 431.153 and 431.154.

42 CFR 431.152; AT-79-18 52 FR 22444; Secs. 1902(a) (28) (D) (i) and 1919(e) (7) of the Act; P.L. 100-203 {Sec. 42ll(c)).

Appeals Process 4.28 Citation


(BPD). HCFA-PM-93- l January 1993

'.evision: 76

Effective Date 08/13/2003 Approval Date FD I 4 1l(M

The Medicaid agency meets the requirements of I 902(a)(4)lD) of the Act concerning the safeguards against conflicts of interest that are at least as stringent as the safeguards that apply under section 27 of the Office of Federal Procurement Policy Act (41u.s.c.423).

Tue Medicaid agency meets the requirements of Section l902(a)(4)(C) of the Act concerning the Prohibition against acts, with respect to any activity Under the plan, that is prohibited by section 207 or 208 of Title 18, United States Code.

4.29 Conflict of Interest Provisions

tN # 03-06 Supersedes TN #_7:....:9;.....-4_,__ _

i \..

1902(a)(4)(D) of the Social Security Act P.L. 105-33 1932(d)(3) 42 CFR 438.58

l 902(a)(4)(C) of the Social Security Act P.L. 105-33

Citation

State: .._.[P~u~e~rt=o~Ri~·'""co~J------

77

• New: HCFA-PM-99-3 JUNE 1999

•'

Date ·-- · · \~~~ Effective Date ¥/4rfi' HCFA ID: 1010P/0012P

. ;,,._

-001 i o~ Approval TN No. ~t/ Super-sedes TN No. ?°S--b

OFFICIAL-.

' '

L_I The agency, under the authority of State law, imposes broader sanctions.

(a) All requirements of 42 CFR Part 1002, Subpart Bare met.

4.30 Exclusion of Providers and Suspension of Practitioners and Other Individuals

Citation 42 CFR 1002.203 AT-79-54 48 FR 3742 51 FR 34772


OMB No.: 0938-0193 (BERC) Revision: HCFA-PM-87-14 . OCTOBER 1987 (

78 ....

Effective Date 08I13 I 03 Approval Date FEB I 4 Z8IM

TN# '03-07 Supersedes TN #--'8=8,._~_,_4 _

(2) An MCO, PIHP, P AHP, or PCCM may not have prohibited affiliations with individuals (as defined in 42 CPR 438.6 lO(b )) suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non procurement activities under regulations issued under · Executive Order No.12549 or under guidelines implementing Executive Order No. 12549. If the State finds that an MCO, PCCM, PIHP, or PAHP is not in compliance the State will comply with the requirements of 42 CFR 438.610(c)

1932(d)(l) 42 CFR 438.610

(ii) Has, directly or indirectly, a substantial contractual relationship (as defined by the Secretary) with an individual or entity that is described in section l 128(b) {8)(B) of the Act.

Could be excluded under section l 128(b)(8) relating to owners and managing employees who have been convicted of certain crimes or received other sanctions, or

(i)

(B) An MCO (as defined in section 1903(m) of the Act), or an entity furnishing services under a waiver approved under section 191 S(b )( 1) of the Act, that -

42 CFR 438.808

(A) At the State's discretion, any individual or entity for any reason for which the Secretary could exclude the individual or entity from participation in a program under title XVIII in accordance with sections 1128, l l 28A, or 1866(b )(2).

(1) Section 1902(p) of the Act by excluding from participation-

1902(p) of the Act

The Medicaid agency meets the requirements of - (b) Citation

State!Territory: {L"'Pu-=·,..ert..,.o~Ri~·co=-=-1--------------

OMB No.: 0938-0193 Revision: HCFA-AT-87-14 (BERC) OCTOBER 1987

78a

Effective Date · 08/ 13/03 Approval Date. RB 2 4 84

Section 1902(a)(49) of the Act with respect to providing information and access to information regarding sanctions taken against health care practitioners and providers by State licensing authorities in accordance with section 1921 of.the Act.

(2)

Section 1902(a)(41)ofthe Act with respect to prompt notification to CMS whenever a provider is terminated, suspended, sanctioned, or otherwise excluded from participating under this State Plan; and

TN# 03-07 Supersedes TN #_8~8_-4...._ _

l 902(a)(49) of the Act P.L. 100-93 (sec. 5(a)(4))

. (1) 1902(a)(41) of the Act P.L. 96-272 (sec. 308(c))

(c) The Medicaid agency meets the requirements of -

(B) Providing that no payment will be made with respect to any item or service furnished by an individual or entity during this period.

(A) Excluding an individual or entity from participation for the period specified by the Secretary, when required by the Secretary to do so in accordance with sections 1128 and l 128A of the Act; and

Section 1902(a}(39) of the Act by- (3) 1902(a)(39) of the Act P.L. 100-93 (section 8(t))

Citation

State/Territory: __ ._-AO[P:::...;u=e=rt=oo...::Ri=·=co><-· .J..l _

OMB No.: 0938-0193

78b

Revision: HCFA-AT-87-14 (BERC) · OCTOBER 1987

HCFA ID: . 1010P/0012P Effective Date

. .

Approval Date .0.CT. ~ 0 .~ .~~-~~(£~

Cb) ATTACHMENT 4.32-A describes. in accordance with 42 CFR 435.948(a)(6), the infonnation that will be requested in order to verify eligibility or the correct payment amount and the agencies and the State(s) from which that_infonnation will be requested.

(a) The Medicaid agency has established a system for income and eligibility verification in accordance with the requirements of 42 CFR 435.940 through 435.960.

4.32 In~ome and Eligibility Verification System

.. 4.31 Disclosure of Infonnatlon by Providers and Fiscal Agents

The Medicaid agency bas established procedures for the disclosure of information by providers and fiscal agents as specified in 42 CFR 455.104 through 455.106 and sections 1128(b)(9) and 1902(a)(38) of the Act.

TN No. (!T,JF- if' Supersedes

· TN !Jo • tr6 ~,,)..

435.940 through 435.960 52 FR 5967 S4 rt\ g"J~g

Citation 455.103 44 FR 41644 1902(a)(38) of the Act P.L. 100-93 (sec. 8(f))

State/Territory: Puerto Rico

OMB No.: 0938-0193 (BERC) Revision:· HCFA-PH--87-14 OCTOBER 1987

79

'tr U.S. GOVERNMENT' PRINTING OFFICE; 1ge7_ 2 0 ~ - 8 1 8 I 6 D 4 3 7

HCFA ID: 1010P/0012P (

Effective Date TU Mo. Supersedes TH llo. J(,I~

Approval

(b) ATTACHMENT 4.33-A specifies the method for issuance of Medicaid eligibility cards to homeless individuals.

'(a) The Medicaid agency has a method for making cards evidencing eligibility for medical assistance available to an individual eligible under the State•s approved plan who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

4.33 Medicaid Eligibility Cards for Homeless Individuals Citation 1902(a)(48) of the Act, P.L. 99-570 (Section 11005) P.L 100-93 (sec. 5(a)(3))

State/Territory: Puerto Rico

OMB Uo.: 0938-0193 (BERC) Revision: HCFA-PH-87-14 OCTOBER 1987

79a


Effective Dat~ 1 '------- Approval TN No • <trJ.- I Supersedes TN No:~

L ... .1 Partial implementation

L_I Alternative system

L_I Total waiver

L/ The State Medicaid agency has received the following type(s) of waiver from participation in SAVE.

[_/The State Medicaid agency has elected to participate in the option period of October 1, 1987 to September 30, 1988 to verify alien status through the INS designated system (SAVE).

P.L. 99-603 (sec. 121)

4.34 systematic Alien Verification for Entitlements The State Medicaid agency has established procedures for the verification of alien status through the Immigration & Naturalization Service (INS) designated system, Systematic Alien Verification for Entitlements (SAV~), effective October 1, 1988.

Citation 1137 of the Act

Puert~ Rico State/Territory:

OMB No.: 0938-0193 Revision: HCFA-PM-88-10 (BERC) SEPTEMBER 1988

79b

1010P/0012P HCFA ID:

ADP e ~ 199:; Effective Date~~~~~- AUG 2 2 1990 Approval Date~~~~~ TN No • .1Q..::l Supersedes TN No. NEuJ

I I (2) Incentive payments. 1 I

I

L_I (1) Public recognition.

The agency uses one of the following incentive programs to reward skilled nursing or intermediate care facilities that furnish the highest quality care to Medicaid residents:

The agency establishes alternative State remedies to the specified Federal remedies (except for termination of participation): ATTACHMENT 4.35-B describes these alternative remedies and specifies the basis for their use.

1919(h)(2)(B)(ii) LI (c) i of the Act 1

1 1919(h)(2)(F} I I (d) of the Act

(4) In emergency cases, closure of the facility and/or transfer of residents.

(3) Appointment of temporary management.

(2) Civil money penalty.

(1) Denial of payment for new admissions,

I I (b) The agency uses the following remedy(ies):

!...¥./Not applicable to intermediate care facilities; these services are not furnished under this plan.

(a) The Medicaid agency meets the requirements of section 1919(h)(2)(A) through (D) of the Act concerning remedies for skilled nursing and intermediate care facilities that do not meet one or.more requirements of participation. ATTACHMENT 4.35-A describes the criteria for applying the remedies specified in section 1919(h)(2)(A)(i) through (iv) of the Act.

1919(h) (1) and (2) of the Act, P.L. 100-203 (Sec, 4213(a))

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation

Citation

Puerto· ·Rico state/Territory:

0938-0193 OMB No.: 79c 6ff \t\~l HCFA-PM-90- 2 (BPD) JANUARY 1990

Revision:

·.·.; j ' ' ....

. j, I

~

~ e l .

.

I ·1

Effective. Date JAN 1 - 1992 HCFA ID: 7982E

1992 MAY -1 Date TN No. 1'J -"2: supersed~ ~proval TN No. e '.

The Medicaid agency provides for the coordination between the Medicaid program and the Special Supplemental Food Program for Women, Infants, and Children (WIC) and provides timely notice and referral to WIC in accordance with section 1902(a)(53) of the Act.

1902(a)(ll)(C) and 1902(a) (53) of the Act

4.36 Required Coordination Between the Medicaid and WIC Programs

Citation


OMB No.: 0938- (BPD) Revision: HCFA-PM-91- 4 AUGUST 1991

79d

Effective Dat.JU_'l_l __ 1_9_92 __ OCT 14 1992

(f) The State offers a nurse aide competency evaluation program that meets the requirements of 42 CFR 483.154.

{e) The State offers a nurse aide training and competency evaluation program that meet.s the requirements of 42 CFR 483.152.

(d) The State specifies any nurse aide training and competency evaluation programs it approves as meeting ~he requirements of 42 CFR 483.152 and competency evaluation programs it approves as meeting the requirements of 42 CFR 483.154.

(c) The State deems individuals who meet the·requirements of 42 CFR 483.150(b)(2) to have met the nurse aide training and competency evaluation requirements.

(b) The State waives the competency evaluation requirements for individuals who meet the requirements of 42 CFR 483. 150 ( b) ( 1) •

(a) The State assures that the requirements of 42 CFR 483.lSO(a), which relate to individuals deemed to meet the nurse aide training and competency evaluation requirements, are met.

Nurse Aide Training and Competency Evaluation for Nursing Facilities

Pllerto Bjco

(BPD)

79n

Approval Date TN No. CJ.J:.:Jo supersew1 _ TN No. a..ew

4.38 Citation 42 CFR 483.75; 42 CFR 483 Subpart D; Secs. 1902(a)(28), 1919(e)(l) and (2), and 1919 ( f }( 2 ) , P.L. 100-203 (Sec. 4211(a)(3)); P.L .. 101-239 (Secs. 6901 (b) ( 3) and (4)); P.L. 101-508 {Sec. 4801(a)).

Revision: HCFA-PM-91- 10 DECEMBER 1991

State/Territory:

'IPR-1 6 2010 - .: Approval Date':=----~~-- Effective [)ate:~~~ 0.1 2001

A governmental component providing Medicaid health care items or services for which Medicaid payments are made would

ualif as an "entit " c, ., a slate mental .---·-----~

If an entity furnishes items or services at more than a single location or under more than one contractual or other payment arrangement, the 'provisions of section 1902(a)(68) apply if the aggregate payments to that entity meet the $5,000,000 annual threshold. This applies whether the entity submits claims for payments using one or more provider identification or tax identification numbers.

(A) An "entity" includes a governmental agency, organlzatlon, unit, corporation. partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a State Pinn approved under title XIX or under any waiver of such plan, totaling at least $5,000,000 annually.

(I) Definitions.

(a) The Medicaid agency meets the requirements regarding establishment of policies and procedures for the education of employees of entities covered by section l 902(a)(68) of the Social Security Act (theAct) regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements.

Citation I 902(a)(68) of the Act, P.L 109-171 (section 6032}

4.42 Employee Educruion About False Claims Recoveries.

STATE PLAN UNDER TITLE XIX Of'"THE SOCIAL SECURITY ACT

S / 'P • c , h r r R' n1:r:1 f'.f r:l~ · tate , errttory: om1nonwca t o ue1to1co th 5·· K4~~ ~ti

'ection 6032 State Plan Preprint 3c I of3

•

;··· \ .

Approval • 1 6 2011 Effective nate: rJAN 0 1 2007

(2) The entity must establish and disseminate written policies which must also be adopted by its contractors or agents. Written policies may be on paper or in electronic form, but must be readily available to all employees, contractors, or agents. The entity need not create an employee handbook if none already exists.

(C) A "contractor" or "agent" includes any contractor, subcontractor, agent, or other person which or. who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid health care items or services, performs billing .or coding functions, or is involved in the monitoring of health care provided by the entity.

(B) An "employee" includes any officer or employee of the entity.

health facility or school distrlct .. pro'Vi<ling school-based health services). A government agency which merely administers the Medicaid program, in whole or part (e.g., managing the claims processing system or determining beneficiary eligibillty), is not, for these purposes, considered to be an entity. An entity will have met the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in Federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of section l 902(a)(68) will be made by January 1 of each subsequent year, based upon the amount of payments an entity either received or made under the State Plan during the preceding Federal fiscal year.

/ [\ •

(··-

State/Territory: Commonwealth of Puerto Rico

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT [

' Section 6032 State Plan Preprint Page 2 of J

~ \ ~ t\\\\\ Approval Date~~--~-----· Effective Date: JAN 0 1 2.007

----·-------r-------------,---.,..,.,.._,---,.-------------, (3) An entity shall establish written policies for all . employees (including management), and of any contractor or agent of the entity, that include detailed information about the False Claims Act and the other provisions named in section l 902(a)(68XA). The entity shall include in those written policies detailed information about the entity's policies and procedures for detecting and preventing waste, fraud, and abuse. The entity shall also include in any employee handbook a specific discussion of the laws described in the written policies, the rights of employees to be protected as whistleblowers and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste. and abuse.

(b) ATf ACHMENT4.42-A describes, in accordance with section 1902(a)(68) of the Act, the methodology of compliance oversight and the frequency with which the State wi 11 re-assess compliance on an ongoing basis.

(5) The Stale will implement this State Plan amendment on January 1, 2007.

(4) The requirements of this law should be incorporated 'into each State's provider enrollment agreements.

Statc/Tcrritory:_Commonw!!~1h.9f Puctto Rico

1N No.12_£:: (?, Supersedes TN No. _

STATE PLAN UNDER TITLE XIX OF TME SOCIAL SECURITY ACT

Section 6032 Stale Plan Preprint Page 3 of 3

•

/. t

1992 Effective Date'UL 1 ------- I

Approval Date OCT 14 1992

(1) The state does not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in certain facilities as described in 42 CFR 483.15l(b)(2) and (3).

(k) For program reviews ouher than the initial review, the State visits the entity providing the program.

(j) Before approving a nurse aide competency evaluation program, the State determines whether the requirements of 42 CFR 483.154 are met.

(i) Before approving a nurse aide training and competency evaluation program, the State determines whether the requirements of 42 CFR 483.152 are met.

The State survey agency determines,.during the course of all surveys, whether the requirements of 483.75(e) are met.

(h)

If the State does not choose to offer a nurse aide training and competency evaluation program or nurse aide competency evaluation program, the state reviews all nurse aide training and competency evaluation programs and competency evaluation programs upon request.

( g) Citation 42 CFR 483.75; 42 CFR 483 Subpart D; Secs. 1902(a)(28), 1919{e)(l) and (2), and 1919 ( f ) ( 2 ) , P.L. 100-203 (Sec. 42ll(a)(3)); P.L. 101-239 (Secs. 690l{b) (3) and (4)); P.L. 101-508 (Sec. 4801(a)).

Puerto Rico

790 (BPD) Revision: HCFA-.PM-91- 10

DECEMBER 1991 state/Territory:

Approval Date OCT 14 1992 Effective Dat~UL l 1992 TN No. Y.012.JD Supersectxi _ TN No. ffeW

1 (

(q) The state withdraws approval of nurse aide training and competency evaluation programs that cease to meet the requirements of 42 CFR 483.152- and competency evaluation programs that cease to meet the requirements of 42 CFR 48~.154.

(r) The State withdraws approval of nurse aide training and competency evaluation programs and competency evaluation programs that do not permit unannounced visits by the State.

x

(p) The State withdraws approval from nurse aide training and competency evaluation programs and competency evaluation programs when-the program is described in 42 CFR 483.15l(b)(2) or (3).

The State does not grant approval of a nurse aide training and competency evaluation program for a period longer than 2 years.

(o) The State reviews programs when notified of substantive changes (e.g., extensive curriculum modification).

(n)

The state, within 90 days of receiving a request for approval of a nurse aide training and competency evaluation program or competency evaluation program, either advises the requestor whether or not the program has been approved or requests additional information from the requester.

(m)

Puerto Rico

79p" (BPD)

Citation 42 CFR 483.75; 42 CFR 483 Subpart D; Secs. 1902(a)(28), 1919(e)(l) and (2), and l919(f~(2), P.L. 100-203 (Sec. 4211 (a) ( 3) ) ; P. L. 101-239 (Secs. - 6901 (b) ( 3) and (4)); P.L. 101-508 (Sec. 4801 (a) ) •

State/Territory:

Revision: HCFA-PM-91-10 DECEMBER 1991

Approval Date OCT 14 1992 Effective DateJUL 1 1992 ------- TN No. ~/O Superse~ .... TN No. ~w

. I

(y) The State has a standard for successful completion of competency evaluation programs.

(x) The State permits proctoring of the competency evaluation in accordance with 42 CFR 483.154(d).

(w) Competency evaluation programs are administered by the State or by a State-approved entity which is neither a skilled nursing facility participating in Medicare nor a nursing facility participating in Medicaid.

The State provides advance notice that a record of successful completion of competency evaluation will be included in the State's nurse aide registry.

(v)

(u) The State provides for the reimbur.sement of costs incurred in completing a nurse aide training and competency evaluation program or competency evaluation program for nurse aides who become employed by or who obtain an offer of employment from a facility within 12 months of completing such program.

The State permits students who have started a training and competency evaluation program from which approval is withdrawn to finish the program.

(t)

When the State withdraws approval from.a nurse afde training and competency ev~luation program or competency evaluation program, the State notifies the program in writing, indicating the reasons for withdrawal of approval.

{ s}

Puerto Rico

79q (BPD)

Citation 42 CFR 483.75; 42 CFR 483 Subpart D; secs. 1902(a)(28), 1919(e) (1) and (2), and 1919 { f ) { 2 ) , P.L. 100-203 (Sec. 4211(a) (3)); P.L. 101-239 (Secs. 6901{b)(3) and (4)); P.L. 101-508 (Sec. 4801(a)).

State/Territory:

Revision: HCFA-PM-91-IO DECEMBER 1991

Effective DatJUL 1 1992 Approval Date 0 CT 1 4 1992

I

(ff) ATTACHMENT 4.38-A contains the state's description of information included on the registry in addition to the information required by 42 CFR 483.156(c).

(ee) ATTACHMENT 4.38 contains the State's description of registry information to be disclosed in addition to that required in 42 CFR 483~156(c)(l)(iii) and (iv).

(dd) The state contracts the operation of the registry to a non State entity.

(cc) The state includes home health aides on the registry.

(bb) The state maintains a nurse aide registry that meets the requirements in 42 CFR 483.156.

(aa) The State imposes a maximum upon the number of times an individual may take a competency evaluation program (any maximum imposed is not less than 3).

(z) The State includes a record of successful completion of a competency evaluation within 30 days of the date an individual is found competent.

Puerto Rico

79r (BPD)

TN No. Yklo Superse<b1~,,_,~1 TN No. ~lHi'~

Citation 42 CFR 483.7Si 42 CFR 483 Subpart Di secs. 1902(a)(28), 1919(e}(l) and (2), and 1919(f)(2}, P.L. 100-203 (Sec. 4211(a}{3)); P.L. 101-239 (Secs. 6901(b) (3) and (4)); P.L. 101-508 (Sec. 4801{a)).

state/Territory:

Revision: HCFA-PM-91-10 DECEMBER 1991

( ;·:.

supersUeW TN No. · Effective Date JUL 1 - 1993 Approval Date JAN 1 2 1994 TN No. ft( 9c- 3

Not Applicable

(e) ATTACHMENT 4.39 specifies the State's definition of specialized services.

(d) With the exception of NF services furnished to certain NF residents defined in 42 CFR 483.118(c)(l), the State does not claim as "medical assistance under the State plan" the cost of NF services to individuals who'are found not to require NF services.

(c) The state does not claim as "medical assistance under the State Plan" the cost of services to individuals who should receive preadrnission screening or annual resident review until such individuals are screened or reviewed.

(b) The State operates a preadmission and annual resident review program that meets the requirements of 42 CFR 483.100-138.

(a) The Medicaid agency has in effect a written agreement with the State mental health and mental retardation authorities that meet the requirements of 42 {CFR) 431.62l(c).

4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities

Citation Secs. 1902(a) (28) (D) (i) and 1919(e)(7) of the Act; P.L. 100-203 (Sec . 4 211 ( o ) ) ; P.L. 101-508 (Sec. 4801(b)).

Puerto Rico State/Territory:· OfflCfAl (BPD) Revision: HCFA-PM-93~1

January 1993

79s

Approval 1 - 1993 Effective Date JUL ~~~~~~~~

Not Applicable

{g) The State describes any categorical determinations it applies in ATTACHMENT 4.39-A.

(£) Except for residents identified in 42 CFR 483.llS(c)(l), the State mental health or mental retardation authority makes categorical determinations that individuals with certain mental conditions or levels of severity of mental illness would normally require specialized services of such an intensity that a speci..alized services program could not be deli..vered by the State in most, if not all, NFs and that a more appropriate placement should be utilized.

4.39 (Conti..nued)

.Puerto Rico State/Territory:

(BPD) HCFA-PM-93- 1 January 1993

79t

TN No. Supers TN No. '(

Revision:

HCFA ID:

Approval DateOCT 14 1992 JUL 1 Effective Date TN No.~ Supersed~I W TN No. ___pa e (

The state notifies the appropriate licensure authority of any licensed individual found to have neglected or abused a resident or misappropriated resident property in a facility.

( f)

The State a aauz e s that a nurse aide, found to have neglected or abused a resident or misappropriated resident property in a facility, is notified of the finding. The name and finding is placed on the nurse aide registry.

The State agency responsible for surveys and certification of nursing facilities or an aqericy delegated by the State survey agency conducts the process for the receipt and timely review ~nd . investigation of allegations of neglect and abuse and misappropriation of resident property. If not the State survey agency, what agency?

(d)

The State provides for a process for the receipt and timely review and investigation of allegations of neg~ect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility or by another individual used by the facility. Attachment 4.40-B describes the State's process.

The State conducts periodic education programs for staff and residents (and their representatives). Attachment 4.40-A describes the survey and certification educational program.

Not Applicable

1919(g)(l) (C) of the Act

. ( e) 1919(g) (1) (C) of the Act

1919(g) (1) (C) of the Act

(c) 1919(g) (1) {C) of the Act

(b)

4.40 Survey & Certification Process (a) The State assures that the requirements of

1919(g)(l)(A) through (C) and section 1919(g)(2)(A) through (E)(iii) of the Act which relate to the survey and certification of non-State owned facilities based on the requirements of section 1919(b), (c) and (d) of the Act, are met.

Citation Sections l919(g)(l) thru (2) and 1919(g) (4) thru (5) of the Act P.L. 100-203 (Sec. 4212 (a))

1919(g)(l) (B) of the Act


OMB No.:

79u Revision: HCFA-PM-92-3 (HSQB)

APRIL 1992

HCFA ID:

'J- \ '1 , 1992 Effective Date ~~ • OCT 4 1992 Approval Date TN No. Superse TN No.

Not Applicable

(1) The State conducts standard and extended surveys based upon a protocol, i.e., survey forms, methods, procedures and guidelines developed by HCFA, using individuals in the survey team who meet minimum qualifications established by the secretary.

1919(g) (2) (C) of the Act

(k) The State conducts extended surveys immediately or, if not practicable, not later that 2 weeks following a completed standard survey in a _ nursing facility which is found to have provided substandard care or in any other facility at the Secretary's or State's discretion.

1919(g)(2) (B) of the Act

(j) The State may conduct a special standard or special abbreviated standard survey within 2 months of any change of ownership,

_ administration, management, or director of nursing of the nursing facility to determine whether the change has resulted in any decline in the quality of care furnished in the facility.

1919(g) (2) (A) (iii) (II) of the Act

( i) The State assures that the Statewide average interval between standard surveys of nursing facilities does not exceed 12 months.

1919(g) (2) (A)(iii)(I) of the Act

(h) The State assures that each facility shall have a standard survey which includes (for a case-mix stratified sample of residents) a survey of the quality of care furnished, as measured by indicators of medical, nursing and rehabilitative care, dietary and nutritional services, activities and social participation, and sanitation, infection control, and the physical environment, written plans of care and audit of resident's assessments, and a review of compliance with resident's rights, not later than 15 months after the date of the previous standard survey.

1919(g) (2) (A) (ii) of the Act

The State has procedures, as provided for at section 1919(g)(2)(A)(i), for the scheduling and conduct of standard surveys to assure that the State has taken all reasonable steps to avoid giving notice through the.scheduling procedures and the conduct of the surveys themselves. Attachment 4.40-C de aczLbe a the State's procedures.

( g) 1919(g) (2) (A) (i) of the Act

Puerto Rico state/Territory:

OMB No: (HSQB) Revision: HCFA-PM-92-3 APRIL 1992

79v

HCFA ID: Approval Date OCT l 4 1992 nn 1 1392 Effective Date>' !.. -----

The state provides the State Medicaid fraud and abuse agency access to all information concerning survey and certification actions.

(u)

If the State finds substandard quality of care in a facility, the State notifies the attending physician of each resident with respect to which such finding is made and the nursing facility administrator licensing board.

(t)

The State notifies the State long-term care ombudsman of the State's finding of non compliance with any of the requirements of subsection (b), (c), and (d) or of any adverse actions taken against a nursing facility.

(s)

The state makes available to the ~ublic information respecting surveys and certification of nursing facilities including statements of deficiencies, plans of correction, copies of cost reports, statements of ownership and the Lnf o rmat.Lon disclosed under. section 1126 of the Act.

( r)

The State maintains procedures and adequate staff to investigate complaints of violations of requirements by nursing facilities and onsite monitoring. Attachment 4.40-E describes the State's complaint procedures.

( q)

The State assures that no individual shall serve as a member of any survey team unless the individual has successfully completed a training and test program in survey and certification techniques approved by the Secretary.

(p)

The State assures that members of a survey team do not serve (or have not served within the previous two years) as a member of the staff or consultant to the nursing facility or has no personal or familial financial interest in the facility being surveyed.

The state uses a multidisciplinary team of professionals including a registered professional nurse.

The State provides for programs to measure and reduce inconsistency in the application of survey results among surveyors. Attachment 4.40-D describes the State's programs.

Puerto Rico

OMB No: (HSQB)

79w

NOT Applicable

1919(g) (5) (D) of the Act

1919(g) (5) {C) of the Act

1919(g)(5) (B) of the Act

1919(g)(S) (A) of the Act

1919(g){4) of the Act

1919(g)(2) (E) (iii) of the Act

( o ) 1919(g) (2) ( E) (ii) of the Act

(n) 1919(g)(2) (E)(i) of the Act

(m) 1919(g) (2) (D) of the Act

State/Territory:

Revision: HCFA-PM-92- 3 APRIL 1992

Effective Date ~L l- '993 HCFA ID: ----

NOV 1 9 1992 Date .,..N. No. o::rn=s 1persedes Approval

... fl No.New

NOT APPLICABLE

a resident assessment instrument that t.he Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines as specified by the Secretary (see Section 4470 of the State Medicaid Manual for the Secretary's approval criteria). [§1919(e) (5) (B)].

1919(e)(S) (B) of the Act

~hft!!:HH~~ ..... " .. >UU•t' ·~: : . ~·3:.:~·

the resident assessment instrument designated by the Health care Financing Administration (see Transmittal #241 of the State Operations Manual) [§1919(e)(S)(A)]; or

1::;~~11~: -~:~ ..

.;:··::·- (b) The State is using: 1919(e) (5)

(A) of the Act

Sections l919(b)(3) and 1919 ( e) ( 5) of the Act

Resident Assessment for Nursing Facilities (a) The State specifies the instrument to be used by

nursing facilities for conducting a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity as required in· §1919(b)(3)(A) of the Act.

4.41 Citation

PUERTO RICO

(HSQB) HCFA-PM-92- 2 MARCH 1992.

. ) Revision: ... ~P"~---·/

\

79x

.. '

medicaid program puerto rico department of health · 2020-05-15 · medicare racs, as published in...

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