42 CFR Part 447 — Payments for Services

PART 447—PAYMENTS FOR SERVICES Authority: 42 U.S.C. 1302, and 1396r-8, and Pub. L. 111-148. Source: 43 FR 45253, Sept. 29, 1978, unless otherwise noted. Subpart A—Payments: General Provisions § 447.1 Purpose. This subpart prescribes State plan requirements, FFP limitations and procedures concerning payments made by State Medicaid agencies for Medicaid services. § 447.10 Prohibition against reassignment of provider claims. (a) Basis and purpose. (b) Definitions. Facility Factor Organized health care delivery system (c) State plan requirements. (d) Who may receive payment. (1) To the provider; or (2) To the beneficiary if he is a noncash beneficiary eligible to receive the payment under § 447.25; or (3) In accordance with paragraphs (e), (f), and (g) of this section. (e) Reassignments. (f) Business agents. (1) Related to the cost of processing the billing; (2) Not related on a percentage or other basis to the amount that is billed or collected; and (3) Not dependent upon the collection of the payment. (g) Individual practitioners. (1) The employer of the practitioner, if the practitioner is required as a condition of employment to turn over his fees to the employer; (2) The facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim; or (3) A foundation, plan, or similar organization operating an organized health care delivery system, if the practitioner has a contract under which the organization submits the claim. (h) Prohibition of payment to factors. (i) The payment prohibition in section 1902(a)(32) of the Act and paragraph (d) of this section does not apply to payments to a third party on behalf of an individual practitioner for benefits such as health insurance, skills training, and other benefits customary for employees, in the case of a class of practitioners for which the Medicaid program is the primary source of revenue, if the practitioner voluntarily consents to such payments to third parties on the practitioner's behalf. [43 FR 45253, Sept. 29, 1978, as amended at 46 FR 42672, Aug. 24, 1981; 61 FR 38398, July 24, 1996; 79 FR 3039, Jan. 16, 2014; 84 FR 19728, May 6, 2019; 87 FR 29690, May 16, 2022] § 447.15 Acceptance of State payment as payment in full. A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual. The provider may only deny services to any eligible individual on account of the individual's inability to pay the cost sharing amount imposed by the plan in accordance with § 447.52(e). The previous sentence does not apply to an individual who is able to pay. An individual's inability to pay does not eliminate his or her liability for the cost sharing charge. [78 FR 42307, July 15, 2013] § 447.20 Provider restrictions: State plan requirements. A State plan must provide for the following: (a) In the case of an individual who is eligible for medical assistance under the plan for service(s) for which a third party or parties is liable for payment, if the total amount of the established liability of the third party or parties for the service is— (1) Equal to or greater than the amount payable under the State plan (which includes, when applicable, cost-sharing payments provided for in §§ 447.52 through 447.54), the provider furnishing the service to the individual may not seek to collect from the individual (or any financially responsible relative or representative of that individual) any payment amount for that service; or (2) Less than the amount payable under the State plan (including cost sharing payments set forth in §§ 447.52 through 447.54), the provider furnishing the service to that individual may collect from the individual (or any financially responsible relative or representative of the individual) an amount which is the lesser of— (i) Any cost-sharing payment amount imposed upon the individual under §§ 447.52 through 447.54; or (ii) An amount which represents the difference between the amount payable under the State plan (which includes, where applicable, cost-sharing payments provided for in §§ 447.52 through 447.54) and the total of the established third party liability for the services. (b) A provider may not refuse to furnish services covered under the plan to an individual who is eligible for medical assistance under the plan on account of a third party's potential liability for the service(s). [55 FR 1433, Jan. 16, 1990, as amended at 78 FR 42307, July 15, 2013] § 447.21 Reduction of payments to providers. If a provider seeks to collect from an individual (or any financially responsible relative or representative of that individual) an amount that exceeds an amount specified under § 447.20(a)— (a) The Medicaid agency may provide for a reduction of any payment amount otherwise due to the provider in addition to any other sanction available to the agency; and (b) The reduction may be equal to up to three times the amount that the provider sought to collect in violation of § 447.20(a). [55 FR 1433, Jan. 16, 1990] § 447.25 Direct payments to certain beneficiaries for physicians' or dentists' services. (a) Basis and purpose. (b) State plan requirements. (1) Provide for direct payments; and (2) Specify the conditions under which payments are made. (c) Federal financial participation. (1) Who is receiving assistance under the State's approved plan under title I, IV-A, X, XIV or XVI (AABD) of the Act; or (2) To whom supplemental security benefits are being paid under title XVI of the Act; or (3) Who is receiving or eligible for a State supplementary payment or would be eligible if he were not in a medical institution, and who is eligible for Medicaid as a categorically needy beneficiary. (d) Federal requirements. (2) Direct payments must be supported by providers' bills for services. § 447.26 Prohibition on payment for provider-preventable conditions. (a) Basis and purpose. (1) Section 2702 of the Affordable Care Act requires that the Secretary exercise authority to prohibit Federal payment for certain provider preventable conditions (PPCs) and health care-acquired conditions (HCACs). (2) Section 1902(a)(19) of the Act requires that States provide care and services consistent with the best interests of the beneficiaries. (3) Section 1902(a)(30) of the Act requires that State payment methods must be consistent with efficiency, economy, and quality of care. (b) Definitions. Health care-acquired condition Other provider-preventable condition (i) Is identified in the State plan. (ii) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iii) Has a negative consequence for the beneficiary. (iv) Is auditable. (v) Includes, at a minimum, wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient. Provider-preventable condition (c) General rules. (2) No reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment for that patient by that provider. (3) Reductions in provider payment may be limited to the extent that the following apply: (i) The identified provider-preventable conditions would otherwise result in an increase in payment. (ii) The State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the provider-preventable conditions. (4) FFP will not be available for any State expenditure for provider-preventable conditions. (5) A State plan must ensure that non-payment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries. (d) Reporting. [76 FR 32837, June 6, 2011] § 447.30 Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. (b) When withholding occurs. (1) The provider has not made arrangements satisfactory to CMS to repay the Medicare overpayment; or (2) CMS has been unable to collect information from the provider to determine the existence or amount of Medicare overpayment. (c) The Federal share of Medicaid payments may be withheld with respect to the following providers: (1) An institutional provider that has or previously had in effect a Medicare provider agreement under section 1866 of the Act; and (2) A Medicaid provider who has previously accepted Medicare payment on the basis of an assignment under section 1842(b)(3)(B)(ii) of the Act; and during the 12 month period preceding the quarter in which the Federal share is to be withheld for a Medicare overpayment, submitted no claims under Medicare or submitted claims which total less than the amount of overpayment. (d) Order to reduce State payment. (2) The order to reduce payment to the provider will remain in effect until— (i) The Medicaid agency determines that the overpayment has been completely recovered; or (ii) CMS terminates the order. (3) CMS may withhold FFP from any State that does not comply with the order specified in paragraph (d)(1) of this section to reduce payment to the provider and claims FFP for the expenditure on its quarterly expenditure report. (e) Notice of withholding. (2) The notice will include the instruction to reduce State payments, as provided under paragraph (d) of this section. (3) CMS will send the notice referred to in paragraph (e)(1) by certified mail, return receipt requested. (4) Each Medicaid agency must identify the amount of payment due the provider under Medicaid and give that information to CMS in the next quarterly expenditure report. (5) The Medicaid agency may appeal any disallowance of FFP resulting from the withholding decision to the Grant Appeals Board, in accordance with 45 CFR part 16. (f) Amount to be withheld. CMS may require the Medicaid agency to reduce the Federal share of its payment to the provider by the lesser of the following amounts. (1) The Federal matching share of payments to the provider, or (2) The total Medicare overpayment to the provider. (g) Effective date of withholding. (h) Duration of withholding. (i) Termination of withholding. (i) The Medicare overpayment is completely recovered: (ii) The institution or person makes an agreement satisfactory to CMS to repay the overpayment; or (iii) CMS determines that there is no overpayment based on newly acquired evidence or a subsequent audit. (2) CMS will notify each State that previously received a notice ordering the withholding that the withholding has been terminated. (j) Procedures for restoring excess withholding. (k) Recovery of funds from Medicaid agency. [50 FR 19688, May 10, 1985; 50 FR 23307, June 3, 1985] § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. (b) Agency notice to providers. (i) Notice that— (A) There has been an overpayment; (B) Repayment is required; and (C) The overpayment determination is subject to agency appeal procedures, but we may withhold Medicare payments while an appeal is in progress. (ii) Notice that— (A) Information is needed to determine the amount of overpayment if any; and (B) The provider has at least 30 days in which to supply the information to the agency. (2) Notice that, 30 days or later from the date of the notice, the agency intends to refer the case to CMS for withholding of Medicare payments. (3) The agency must send all notices to providers by certified mail, return receipt requested. (c) Documentation to be submitted to CMS. (1) A statement of the reason that withholding is requested. (2) The amount of overpayment, type of overpayment, date the overpayment was determined, and the closing date of the pertinent cost reporting period (if applicable). (3) The quarter in which the overpayment was reported on the quarterly expenditure report (Form CMS 64). (4) As needed, and upon request from CMS, the names and addresses of the provider's officers and owners for each period that there is an outstanding overpayment. (5) A statement of assurance that the State agency has met the notice requirements under paragraph (b) of this section. (6) As needed, and upon request for CMS, copies of notices (under paragraph (b) of this section), and reports of contact or attempted contact with the provider concerning the overpayment, including any reduction or suspension of Medicaid payments made with respect to that overpayment. (7) A copy of the provider's agreement with the agency under § 431.107 of this chapter. (d) Notification to terminate withholding. (i) The Medicaid provider makes an agreement satisfactory to the agency to repay the overpayment; (ii) The Medicaid overpayment is completely recovered; or (iii) The agency determines that there is no overpayment, based on newly acquired evidence or subsequent audit. (2) Upon receipt of notification from the State agency, CMS will terminate withholding. (e) Accounting for returned overpayment. (f) Procedures for restoring excess withholding. [50 FR 19689, May 10, 1985, as amended at 61 FR 63749, Dec. 2, 1996] § 447.40 Payments for reserving beds in institutions. (a) The Medicaid agency may make payments to reserve a bed during a beneficiary's temporary absence from an inpatient facility, if— (1) The State plan provides for such payments and specifies any limitations on the policy; and (2) Absences for purposes other than required hospitalization (which cannot be anticipated and planned) are included in the patient's plan of care. (b) An agency that pays for reserved beds in an inpatient facility may pay less for a reserved bed than an occupied bed if there is a cost differential between the two beds. (Section 1102 of the Act.) [43 FR 45253, Sept. 29, 1978, as amended at 51 FR 24491, July 3, 1986] § 447.45 Timely claims payment. (a) Basis and purpose. (1) State plan requirements for— (i) Timely processing of claims for payment; (ii) Prepayment and postpayment claims reviews; and (2) Conditions under which the Administrator may grant waivers of the time requirements. (b) Definitions. Claim Clean claim A shared health facility (1) Two or more health care practitioners practice their professions at a common physical location; (2) The practitioners share common waiting areas, examining rooms, treatment rooms, or other space, the services of supporting staff, or equipment; (3) The practitioners have a person (who may himself be a practitioner)— (i) Who is in charge of, controls, manages, or supervises substantial aspects of the arrangement or operation for the delivery of health or medical services at the common physical location other than the direct furnishing of professional health care services by the practitioners to their patients; or (ii) Who makes available to the practitioners the services of supporting staff who are not employees of the practitioners; and (iii) Who is compensated in whole or in part, for the use of the common physical location or related support services, on a basis related to amounts charged or collected for the services rendered or ordered at the location or on any basis clearly unrelated to the value of the services provided by the person; and (4) At least one of the practitioners received payments on a fee-for-service basis under titles V, XVIII, and XIX in an amount exceeding $5,000 for any one month during the preceding 12 months or in an aggregate amount exceeding $40,000 during the preceding 12 months. The term does not include a provider of services (as specified in § 489.2(b) of this chapter), a health maintenance organization (as defined in section 1301(a) of the Public Health Service Act), a hospital cooperative shared services organization meeting the requirements of section 501(e) of the Internal Revenue Code of 1954, or any public entity. Third party (c) State plan requirements. (2) Specify the definition of a claim, as provided in paragraph (b) of this section, to be used in meeting the requirements for timely claims payment. The definition may vary by type of service (e.g., physician service, hospital service). (d) Timely processing of claims. (2) The agency must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt. (3) The agency must pay 99 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 90 days of the date of receipt. (4) The agency must pay all other claims within 12 months of the date of receipt, except in the following circumstances: (i) This time limitation does not apply to retroactive adjustments paid to providers who are reimbursed under a retrospective payment system, as defined in § 447.272 of this part. (ii) If a claim for payment under Medicare has been filed in a timely manner, the agency may pay a Medicaid claim relating to the same services within 6 months after the agency or the provider receives notice of the disposition of the Medicare claim. (iii) The time limitation does not apply to claims from providers under investigation for fraud or abuse. (iv) The agency may make payments at any time in accordance with a court order, to carry out hearing decisions or agency corrective actions taken to resolve a dispute, or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it. (5) The date of receipt is the date the agency receives the claim, as indicated by its date stamp on the claim. (6) The date of payment is the date of the check or other form of payment. (e) Waivers. (2) The agency's request for a waiver must contain a written plan of correction specifying all steps it will take to meet the requirements of this section. (3) The Administrator will review each case and if he approves a waiver, will specify its expiration date, based on the State's capability and efforts to meet the requirements of this section. (f) Prepayment and postpayment claims review. (i) Verification that the beneficiary was included in the eligibility file and that the provider was authorized to furnish the service at the time the service was furnished; (ii) Checks that the number of visits and services delivered are logically consistent with the beneficiary's characteristics and circumstances, such as type of illness, age, sex, service location; (iii) Verification that the claim does not duplicate or conflict with one reviewed previously or currently being reviewed; (iv) Verification that a payment does not exceed any reimbursement rates or limits in the State plan; and (v) Checks for third party liability within the requirements of § 433.137 of this chapter. (2) The agency must conduct post-payment claims review that meets the requirements of parts 455 and 456 of this chapter, dealing with fraud and utilization control. (g) Reports. (Secs. 1102 and 1902(a)(37) of the Social Security Act (42 U.S.C. 1302, 1396a(a)(37))) [44 FR 30344, May 25, 1979, as amended at 55 FR 1434, Jan. 16, 1990] § 447.46 Timely claims payment by MCOs. (a) Basis and scope. (b) Definitions. (c) Contract requirements Basic rule. (2) Exception. (3) Alternative schedule. [67 FR 41115, June 14, 2002] Medicaid Premiums and Cost Sharing Source: 78 FR 42307, July 15, 2013, unless otherwise noted. § 447.50 Premiums and cost sharing: Basis and purpose. Sections 1902(a)(14), 1916 and 1916A of the Act permit states to require certain beneficiaries to share in the costs of providing medical assistance through premiums and cost sharing. Sections 447.52 through 447.56 specify the standards and conditions under which states may impose such premiums and or cost sharing. § 447.51 Definitions. As used in this part— Alternative non-emergency services provider Contract health service means any health service that is: (1) Delivered based on a referral by, or at the expense of, an Indian health program; and (2) Provided by a public or private medical provider or hospital that is not a provider or hospital of the IHS or any other Indian health program Cost sharing Emergency services Federal poverty level (FPL) Federal Register Indian (1) Is a member of a Federally-recognized Indian tribe; (2) Resides in an urban center and meets one or more of the following four criteria: (i) Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; (ii) Is an Eskimo or Aleut or other Alaska Native; (iii) Is considered by the Secretary of the Interior to be an Indian for any purpose; or (iv) Is determined to be an Indian under regulations promulgated by the Secretary; (3) Is considered by the Secretary of the Interior to be an Indian for any purpose; or (4) Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. Indian health care provider Inpatient stay Non-emergency services Outpatient services Preferred drugs Premium § 447.52 Cost sharing. (a) Applicability. (b) Maximum Allowable Cost Sharing. Services Maximum allowable cost sharing Individuals with family income Individuals with family income Individuals with family income Outpatient Services ( physician visit, physical therapy, etc. $4 10% of cost the agency pays 20% of cost the agency pays. Inpatient Stay 75 10% of total cost the agency pays for the entire stay 20% of total cost the agency pays for the entire stay. (2) States with cost sharing for an inpatient stay that exceeds $75, as of July 15, 2013, must submit a plan to CMS that provides for reducing inpatient cost sharing to $75 on or before July 1, 2017. (3) In states that do not have fee-for-service payment rates, any cost sharing imposed on individuals at any income level may not exceed the maximum amount established, for individuals with income at or below 100 percent of the FPL described in paragraph (b)(1) of this section. (c) Maximum cost sharing. (d) Targeted cost sharing. (2) For cost sharing imposed for non-preferred drugs under § 447.53 and for non-emergency services provided in a hospital emergency department under § 447.54, the agency may target cost sharing to specified groups of individuals regardless of income. (e) Denial of service for nonpayment. (i) The individual has family income above 100 percent of the FPL, (ii) The individual is not part of an exempted group under § 447.56(a), and (iii) For cost sharing imposed for non-emergency services furnished in an emergency department, the conditions under § 447.54(d) of this part have been satisfied. (2) Except as provided under paragraph (e)(1) of this section, the state plan must specify that no provider may deny services to an eligible individual on account of the individual's inability to pay the cost sharing. (3) Nothing in this section shall be construed as prohibiting a provider from choosing to reduce or waive such cost sharing on a case-by-case basis. (f) Prohibition against multiple charges. (g) Income-related charges. (h) Services furnished by a managed care organization (MCO). (i) State Plan Specifications. (1) The service for which the charge is made; (2) The group or groups of individuals that may be subject to the charge; (3) The amount of the charge; (4) The process used by the state to— (i) Ensure individuals exempt from cost sharing are not charged, (ii) Identify for providers whether cost sharing for a specific item or service may be imposed on an individual and whether the provider may require the individual, as a condition for receiving the item or service, to pay the cost sharing charge; and (5) If the agency imposes cost sharing under § 447.54, the process by which hospital emergency room services are identified as non-emergency service. § 447.53 Cost sharing for drugs. (a) The agency may establish differential cost sharing for preferred and non-preferred drugs. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (d) of this section. All drugs will be considered preferred drugs if so identified or if the agency does not differentiate between preferred and non-preferred drugs. (b) At state option, cost sharing for drugs may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment. Such increase shall not be applied to any cost sharing that is based on the amount the agency pays for the service): Services Maximum allowable cost sharing Individuals with family income ≤150% of the FPL Individuals with family income >150% of the FPL Preferred Drugs $4 $4. Non-Preferred Drugs 8 20% of the cost the agency pays. (c) In states that do not have fee-for-service payment rates, cost sharing for prescription drugs imposed on individuals at any income level may not exceed the maximum amount established for individuals with income at or below 150 percent of the FPL in paragraph (b) of this section. (d) For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-preferred drugs, not to exceed the maximum amount established in paragraph (b) of this section. (e) In the case of a drug that is identified by the agency as a non-preferred drug within a therapeutically equivalent or therapeutically similar class of drugs, the agency must have a timely process in place so that cost sharing is limited to the amount imposed for a preferred drug if the individual's prescribing provider determines that a preferred drug for treatment of the same condition either will be less effective for the individual, will have adverse effects for the individual, or both. In such cases the agency must ensure that reimbursement to the pharmacy is based on the appropriate cost sharing amount. § 447.54 Cost sharing for services furnished in a hospital emergency department. (a) The agency may impose cost sharing for non-emergency services provided in a hospital emergency department. The provisions in § 447.56(a) shall apply except as the agency exercises the option under paragraph (c) of this section. (b) At state option, cost sharing for non-emergency services provided in an emergency department may be established at or below the amounts shown in the following table (except that the maximum allowable cost sharing identified for individuals with family income at or below 150 percent of the FPL shall be increased each year, beginning October 1, 2015, by the percentage increase in the medical care component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next higher 5-cent increment): Services Maximum allowable cost sharing Individuals with family income ≤150% of the FPL Individuals with family income >150% of the FPL Non-emergency Use of the Emergency Department $8 No Limit. (c) For individuals otherwise exempt from cost sharing under § 447.56(a), the agency may impose cost sharing for non-emergency use of the emergency department, not to exceed the maximum amount established in paragraph (b) of this section for individuals with income at or below 150 percent of the FPL. (d) For the agency to impose cost sharing under paragraph (a) or (c) of this section for non-emergency use of the emergency department, the hospital providing the care must— (1) Conduct an appropriate medical screening under § 489.24 subpart G to determine that the individual does not need emergency services. (2) Before providing non-emergency services and imposing cost sharing for such services: (i) Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department; (ii) Provide the individual with the name and location of an available and accessible alternative non-emergency services provider; (iii) Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and (iv) Provide a referral to coordinate scheduling for treatment by the alternative provider. (e) Nothing in this section shall be construed to: (1) Limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or (2) Modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization. § 447.55 Premiums. (a) The agency may impose premiums upon individuals whose income exceeds 150 percent of the FPL, subject to the exemptions set forth in § 447.56(a) and the aggregate limitations set forth in § 447.56(f) of this part, except that: (1) Pregnant women described in described in paragraph (a)(1)(ii) of this section may be charged premiums that do not exceed 10 percent of the amount by which their family income exceeds 150 percent of the FPL after deducting expenses for care of a dependent child. (i) The agency may use state or local funds available under other programs for payment of a premium for such pregnant women. Such funds shall not be counted as income to the individual for whom such payment is made. (ii) Pregnant women described in this clause include pregnant women eligible for Medicaid under § 435.116 of this chapter whose income exceeds the higher of - (A) 150 percent FPL; and (B) If applicable, the percent FPL described in section 1902(l)(2)(A)(iv) of the Act up to 185 percent FPL. (2) Individuals provided medical assistance only under sections 1902(a)(10)(A)(ii)(XV) or 1902(a)(10)(A)(ii)(XVI) of the Act and the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), may be charged premiums on a sliding scale based on income. (3) Disabled children provided medical assistance under section 1902(a)(10)(A)(ii)(XIX) of the Act in accordance with the Family Opportunity Act, may be charged premiums on a sliding scale based on income. The aggregate amount of the child's premium imposed under this paragraph and any premium that the parent is required to pay for family coverage under section 1902(cc)(2)(A)(i) of the Act, and other cost sharing charges may not exceed: (i) 5 percent of the family's income if the family's income is no more than 200 percent of the FPL. (ii) 7.5 percent of the family's income if the family's income exceeds 200 percent of the FPL but does not exceed 300 percent of the FPL. (4) Qualified disabled and working individuals described in section 1905(s) of the Act, whose income exceeds 150 percent of the FPL, may be charged premiums on a sliding scale based on income, expressed as a percentage of Medicare cost sharing described at section 1905(p)(3)(A)(i) of the Act. (5) Medically needy individuals, as defined in §§ 435.4 and 436.3 of this chapter, may be charged on a sliding scale. The agency must impose an appropriately higher charge for each higher level of family income, not to exceed $20 per month for the highest level of family income. (b) Consequences for non-payment. (2) Except for premiums imposed under paragraph (a)(5) of this section, the agency may terminate an individual from medical assistance on the basis of failure to pay for 60 days or more. (3) For premiums imposed under paragraph (a)(2) of this section— (i) For individuals with annual income exceeding 250 percent of the FPL, the agency may require payment of 100 percent of the premiums imposed under this paragraph for a year, such that payment is only required up to 7.5 percent of annual income for individuals whose annual income does not exceed 450 percent of the FPL. (ii) For individuals whose annual adjusted gross income (as defined in section 62 of the Internal Revenue Code of 1986) exceeds $75,000, increased by inflation each calendar year after 2000, the agency must require payment of 100 percent of the premiums for a year, except that the agency may choose to subsidize the premiums using state funds which may not be federally matched by Medicaid. (4) For any premiums imposed under this section, the agency may waive payment of a premium in any case where the agency determines that requiring the payment will create an undue hardship for the individual or family. (5) The agency may not apply further consequences or penalties for non-payment other than those listed in this section. (c) State plan specifications. (1) The group or groups of individuals that may be subject to the charge; (2) The amount and frequency of the charge; (3) The process used by the state to identify which beneficiaries are subject to premiums and to ensure individuals exempt from premiums are not charged; and (4) The consequences for an individual or family who does not pay. § 447.56 Limitations on premiums and cost sharing. (a) Exemptions. (i) Individuals ages 1 and older and under age 18 eligible under § 435.118 of this chapter. (ii) Infants under age 1 eligible under § 435.118 of this chapter whose income does not exceed the higher of— (A) 150 percent FPL (for premiums) or 133 percent FPL (for cost sharing); and (B) If applicable, the percent FPL described in section 1902(l)(2)(A)(iv) of the Act up to 185 percent FPL. (iii) Individuals under age 18 eligible under §§ 435.120-435.122 or § 435.130 of this chapter. (iv) Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age. (v) At State option, individuals under age 19, 20 or age 21, eligible under § 435.222 or § 435.223 of this chapter. (vi) Disabled children, except as provided at § 447.55(a)(4) (premiums), who are receiving medical assistance by virtue of the application of the Family Opportunity Act in accordance with sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act. (vii) Pregnant women, except for premiums allowed under § 447.55(a)(1) and cost sharing for services specified in the state plan as not pregnancy-related, during the pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends. (viii) Any individual whose medical assistance for services furnished in an institution, or at state option in a home and community-based setting, is reduced by amounts reflecting available income other than required for personal needs. (ix) An individual receiving hospice care, as defined in section 1905(o) of the Act. (x) An Indian who is eligible to receive or has received an item or service furnished by an Indian health care provider or through referral under contract health services is exempt from premiums. Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services are exempt from all cost sharing. (xi) Individuals who are receiving Medicaid because of the state's election to extend coverage as authorized by § 435.213 of this chapter (Breast and Cervical Cancer). (2) The agency may not impose cost sharing for the following services: (i) Emergency services as defined at section 1932(b)(2) of the Act and § 438.114(a) of this chapter; (ii) Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and pharmaceuticals for which the State claims or could claim Federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies; (iii) Preventive services, at a minimum the services specified at § 457.520 of chapter D, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics; and (iv) Pregnancy-related services, including those defined at §§ 440.210(a)(2) and 440.250(p) of this chapter, and counseling and drugs for cessation of tobacco use All services provided to pregnant women will be considered as pregnancy-related, except those services specifically identified in the state plan as not being related to the pregnancy. (v) Provider-preventable services as defined in § 447.26(b). (b) Applicability. (c) Payments to providers. (2) For items and services provided to Indians who are exempt from cost sharing under paragraph (a)(1)(x) of this section, the agency may not reduce the payment it makes to a provider, including an Indian health care provider, by the amount of cost sharing that will otherwise be due from the Indian. (3) For those providers that the agency reimburses under Medicare reasonable cost reimbursement principles, in accordance with subpart B of this part, an agency may increase its payment to offset uncollected cost sharing charges that are bad debts of providers. (d) Payments to managed care organizations. (e) Payments to states. (1) Any premiums or cost sharing amounts that recipients should have paid under §§ 447.52 through 447.55 (except for amounts that the agency pays as bad debts of providers under paragraph (c)(3) of this section; and (2) Any amounts paid by the agency on behalf of ineligible individuals, whether or not the individual had paid any required premium, except for amounts for premium assistance to obtain coverage for eligible individuals through family coverage that may include ineligible individuals when authorized in the approved state plan. (f) Aggregate limits. (2) If the state adopts premiums or cost sharing rules that could place beneficiaries at risk of reaching the aggregate family limit, the state plan must indicate a process to track each family's incurred premiums and cost sharing through an effective mechanism that does not rely on beneficiary documentation. (3) The agency must inform beneficiaries and providers of the beneficiaries aggregate limit and notify beneficiaries and providers when a beneficiary has incurred out-of-pocket expenses up to the aggregate family limit and individual family members are no longer subject to cost sharing for the remainder of the family's current monthly or quarterly cap period. (4) The agency must have a process in place for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium. (5) Nothing in paragraph (f) shall preclude the agency from establishing additional aggregate limits, including but not limited to a monthly limit on cost sharing charges for a particular service. [78 FR 42307, July 15, 2013, as amended at 89 FR 22873, Apr. 2, 2024] § 447.57 Beneficiary and public notice requirements. (a) The agency must make available a public schedule describing current premiums and cost sharing requirements containing the following information: (1) The group or groups of individuals who are subject to premiums and/or cost sharing and the current amounts; (2) Mechanisms for making payments for required premiums and cost sharing charges; (3) The consequences for an applicant or recipient who does not pay a premium or cost sharing charge; (4) A list of hospitals charging cost sharing for non-emergency use of the emergency department; and (5) A list of preferred drugs or a mechanism to access such a list, including the agency Web site. (b) The agency must make the public schedule available to the following in a manner that ensures that affected applicants, beneficiaries, and providers are likely to have access to the notice: (1) Beneficiaries, at the time of their enrollment and reenrollment after a redetermination of eligibility, and when premiums, cost sharing charges, or aggregate limits are revised, notice to beneficiaries must be in accordance with § 435.905(b) of this chapter; (2) Applicants, at the time of application; (3) All participating providers; and (4) The general public. (c) Prior to submitting to the Centers for Medicare & Medicaid Services for approval a state plan amendment (SPA) to establish or substantially modify existing premiums or cost sharing, or change the consequences for non-payment, the agency must provide the public with advance notice of the SPA, specifying the amount of premiums or cost sharing and who is subject to the charges. The agency must provide a reasonable opportunity to comment on such SPAs. The agency must submit documentation with the SPA to demonstrate that these requirements were met. If premiums or cost sharing is substantially modified during the SPA approval process, the agency must provide additional public notice. § 447.88 Options for claiming FFP payment for section 1920A presumptive eligibility medical assistance payments. (a) The FMAP rate for medical assistance payments made available to a child during a presumptive eligibility period under section 1920A of the Act is the regular FMAP under title XIX, based on the category of medical assistance; that is, the enhanced FMAP is not available for section 1920A presumptive eligibility expenditures. (b) States have the following 3 options for identifying Medicaid section 1920A presumptive eligibility expenditures and the application of payments for those expenditures: (1) A State may identify Medicaid section 1920A presumptive eligibility expenditures in the quarter expended with no further adjustment based on the results of a subsequent actual eligibility determination (if any). (2) A State may identify Medicaid section 1920A presumptive eligibility expenditures in the quarter expended but may adjust reported expenditures based on results of the actual eligibility determination (if any) to reflect the actual eligibility status of the individual, if other than presumptively eligible. (3) A State may elect to delay submission of claims for payments of section 1920A presumptive eligibility expenditures until after the actual eligibility determination (if any) is made and, at that time identify such expenditures based on the actual eligibility status of individuals if other than presumptively eligible. At that time, the State would, as appropriate, recategorize the medical assistance expenditures made during the section 1920A presumptive eligibility period based on the results of the actual eligibility determination, and claim them appropriately. [65 FR 33622, May 24, 2000] § 447.90 FFP: Conditions related to pending investigations of credible allegations of fraud against the Medicaid program. (a) Basis and purpose. (b) Denial of FFP. (1) The item or service is furnished as an emergency item or service, but not including items or services furnished in an emergency room of a hospital; or (2) The State determines and documents that good cause as specified at § 455.23(e) or (f) of this chapter exists not to suspend such payments, to suspend payments only in part, or to discontinue a previously imposed payment suspension. [76 FR 5965, Feb. 2, 2011] Subpart B—Payment Methods: General Provisions § 447.200 Basis and purpose. This subpart prescribes State plan requirements for setting payment rates to implement, in part, section 1902(a)(30) of the Act, which requires that payments for services be consistent with efficiency, economy, and quality of care. [46 FR 48560, Oct. 1, 1981] § 447.201 State plan requirements. (a) A State plan must provide that the requirements in this subpart are met. (b) The plan must describe the policy and the methods to be used in setting payment rates for each type of service included in the State's Medicaid program. § 447.202 Audits. The Medicaid agency must assure appropriate audit of records if payment is based on costs of services or on a fee plus cost of materials. § 447.203 Documentation of access to care and service payment rates. (a) The agency must maintain documentation of payment rates and make it available to HHS upon request. (b)(1) Payment rate transparency. (i) For purposes of this paragraph (b)(1), the payment rates that the State agency is required to publish are Medicaid fee-for-service fee schedule payment rates made to providers delivering Medicaid services to Medicaid beneficiaries through a fee-for-service delivery system. (ii) The website where the State agency publishes its Medicaid fee-for-service payment rates must be easily reached from a hyperlink on the State Medicaid agency's website. (iii) Medicaid fee-for-service payment rates must be organized in such a way that a member of the public can readily determine the amount that Medicaid would pay for a given service. (iv) In the case of a bundled payment methodology, the State must publish the Medicaid fee-for-service bundled payment rate and, where the bundled payment rate is based on fee schedule payment rates for each constituent service, must identify each constituent service included within the rate and how much of the bundled payment is allocated to each constituent service under the State's methodology. (v) If the rates vary, the State must separately identify the Medicaid fee-for-service payment rates by population (pediatric and adult), provider type, and geographical location, as applicable. (vi) The initial publication of the Medicaid fee-for-service payment rates shall occur no later than July 1, 2026 and include approved Medicaid fee-for-service payment rates in effect as of July 1, 2026. The agency is required to include the date the payment rates were last updated on the State Medicaid agency's website and to ensure these data are kept current where any necessary update must be made no later than 1 month following the latter of the date of CMS approval of the State plan amendment, section 1915(c) HCBS waiver amendment, or similar amendment revising the provider payment rate or methodology, or the effective date of the approved amendment. In the event of a payment rate change that occurs in accordance with a previously approved rate methodology, the State will ensure that its payment rate transparency publication is updated no later than 1 month after the effective date of the most recent update to the payment rate. (2) Comparative payment rate analysis and payment rate disclosure. (i) Primary care services. (ii) Obstetrical and gynecological services. (iii) Outpatient mental health and substance use disorder services. (iv) Personal care, home health aide, homemaker, and habilitation services, as specified in § 440.180(b)(2) through (4) and (6), provided by individual providers and provider agencies. (3) Comparative payment rate analysis and payment rate disclosure requirements. (i) For the categories of services described in paragraph (b)(2)(i) through (iii) of this section, the comparative payment rate analysis must compare the State agency's Medicaid fee-for-service fee schedule payment rates to the most recently published Medicare payment rates effective for the same time period for the evaluation and management (E/M) codes applicable to the category of service. The State must conduct the comparative payment rate analysis at the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code level, as applicable, using the most current set of codes published by CMS, and the analysis must meet the following requirements: (A) The State must organize the analysis by category of service as described in paragraphs (b)(2)(i) through (iii) of this section. (B) The analysis must clearly identify the base Medicaid fee-for-service fee schedule payment rates for each E/M CPT/HCPCS code identified by CMS under the applicable category of service, including, if the rates vary, separate identification of the payment rates by population (pediatric and adult), provider type, and geographical location, as applicable. (C) The analysis must clearly identify the Medicare non-facility payment rates as established in the annual Medicare Physician Fee Schedule final rule effective for the same time period for the same set of E/M CPT/HCPCS codes, and for the same geographical location as the base Medicaid fee-for-service fee schedule payment rates, that correspond to the base Medicaid fee-for-service fee schedule payment rates identified under paragraph (b)(3)(i)(B) of this section, including separate identification of the payment rates by provider type. (D) The analysis must specify the base Medicaid fee-for-service fee schedule payment rate identified under paragraph (b)(3)(i)(B) of this section as a percentage of the Medicare non-facility payment rate as established in the annual Medicare Physician Fee Schedule final rule identified under paragraph (b)(3)(i)(C) of this section for each of the services for which the base Medicaid fee-for-service fee schedule payment rate is published pursuant to paragraph (b)(3)(i)(B) of this section. (E) The analysis must specify the number of Medicaid-paid claims and the number of Medicaid enrolled beneficiaries who received a service within a calendar year for each of the services for which the base Medicaid fee-for-service fee schedule payment rate is published pursuant to paragraph (b)(3)(i)(B) of this section. (ii) For each category of services specified in paragraph (b)(2)(iv) of this section, the State agency is required to publish a payment rate disclosure that expresses the State's payment rates as the average hourly Medicaid fee-for-service fee schedule payment rates, separately identified for payments made to individual providers and provider agencies, if the rates vary. The payment rate disclosure must meet the following requirements: (A) The State must organize the payment rate disclosure by category of service as specified in paragraph (b)(2)(iv) of this section. (B) The disclosure must identify the average hourly Medicaid fee-for-service fee schedule payment rates by applicable category of service, including, if the rates vary, separate identification of the average hourly Medicaid fee-for-service fee schedule payment rates for payments made to individual providers and provider agencies, by population (pediatric and adult), provider type, geographical location, and whether the payment rate includes facility-related costs, as applicable. (C) The disclosure must identify the number of Medicaid-paid claims and the number of Medicaid enrolled beneficiaries who received a service within a calendar year for each of the services for which the average hourly Medicaid fee-for-service fee schedule payment rates are published pursuant to paragraph (b)(3)(ii)(B) of this section. (4) Comparative payment rate analysis and payment rate disclosure timeframe. (5) Compliance with payment rate transparency, comparative payment rate analysis, and payment rate disclosure requirements. (6) Interested parties advisory group for rates paid for certain services. (ii) The interested parties advisory group must include, at a minimum, direct care workers, beneficiaries, beneficiaries' authorized representatives, and other interested parties impacted by the services rates in question, as determined by the State. (iii) The interested parties advisory group will advise and consult with the Medicaid agency on current and proposed payment rates, HCBS payment adequacy data as required at § 441.311(e), and access to care metrics described in § 441.311(d)(2), associated with services found at § 440.180(b)(2) through (4) and (6), to ensure the relevant Medicaid payment rates are sufficient to ensure access to personal care, home health aide, homemaker, and habilitation services for Medicaid beneficiaries at least as great as available to the general population in the geographic area and to ensure an adequate number of qualified direct care workers to provide self-directed personal assistance services. (iv) The interested parties advisory group shall meet at least every 2 years and make recommendations to the Medicaid agency on the sufficiency of State plan, 1915(c) waiver, and demonstration direct care worker payment rates, as applicable. The State agency will ensure the group has access to current and proposed payment rates, HCBS provider payment adequacy reporting information as described in § 441.311(e), and applicable access to care metrics as described in § 441.311(d)(2) for HCBS in order to produce these recommendations. The process by which the State selects interested party advisory group members and convenes its meetings must be made publicly available. (v) The Medicaid agency must publish the recommendations produced under paragraph (b)(6)(iv) of the interested parties advisory group consistent with the publication requirements described in paragraph (b)(1) through (b)(1)(ii) of this section, within 1 month of when the group provides the recommendation to the agency. (c)(1) Initial State analysis for rate reduction or restructuring. (i) Medicaid payment rates in the aggregate (including base and supplemental payments) following the proposed reduction or restructuring for each benefit category affected by the proposed reduction or restructuring would be at or above 80 percent of the most recently published Medicare payment rates for the same or a comparable set of Medicare-covered services. (ii) The proposed reduction or restructuring, including the cumulative effect of all reductions or restructurings taken throughout the current State fiscal year, would be likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a State fiscal year. (iii) The public processes described in paragraph (c)(4) of this section and § 447.204 yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, or if such processes did yield concerns, the State can reasonably respond to or mitigate the concerns, as appropriate, as documented in the analysis provided by the State pursuant to § 447.204(b)(3). (2) Additional State rate analysis. (i) A summary of the proposed payment change, including the State's reason for the proposal and a description of any policy purpose for the proposed change, including the cumulative effect of all reductions or restructurings taken throughout the current State fiscal year in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a State fiscal year. (ii) Medicaid payment rates in the aggregate (including base and supplemental payments) before and after the proposed reduction or restructuring for each benefit category affected by proposed reduction or restructuring, and a comparison of each (aggregate Medicaid payment before and after the reduction or restructuring) to the most recently published Medicare payment rates for the same or a comparable set of Medicare-covered services and, as reasonably feasible, to the most recently available payment rates of other health care payers in the State or the geographic area for the same or a comparable set of covered services. (iii) Information about the number of actively participating providers of services in each benefit category affected by the proposed reduction or restructuring. For this purpose, an actively participating provider is a provider that is participating in the Medicaid program and actively seeing and providing services to Medicaid beneficiaries or accepting Medicaid beneficiaries as new patients. The State must provide the number of actively participating providers of services in each affected benefit category for each of the 3 years immediately preceding the State plan amendment submission date, by State-specified geographic area (for example, by county or parish), provider type, and site of service. The State must document observed trends in the number of actively participating providers in each geographic area over this period. The State may provide estimates of the anticipated effect on the number of actively participating providers of services in each benefit category affected by the proposed reduction or restructuring, by geographic area. (iv) Information about the number of Medicaid beneficiaries receiving services through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring. The State must provide the number of beneficiaries receiving services in each affected benefit category for each of the 3 years immediately preceding the State plan amendment submission date, by State-specified geographic area (for example, by county or parish). The State must document observed trends in the number of Medicaid beneficiaries receiving services in each affected benefit category in each geographic area over this period. The State must provide quantitative and qualitative information about the beneficiary populations receiving services in the affected benefit categories over this period, including the number and proportion of beneficiaries who are adults and children and who are living with disabilities, and a description of the State's consideration of the how the proposed payment changes may affect access to care and service delivery for beneficiaries in various populations. The State must provide estimates of the anticipated effect on the number of Medicaid beneficiaries receiving services through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring, by geographic area. (v) Information about the number of Medicaid services furnished through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring. The State must provide the number of Medicaid services furnished in each affected benefit category for each of the 3 years immediately preceding the State plan amendment submission date, by State-specified geographic area (for example, by county or parish), provider type, and site of service. The State must document observed trends in the number of Medicaid services furnished in each affected benefit category in each geographic area over this period. The State must provide quantitative and qualitative information about the Medicaid services furnished in the affected benefit categories over this period, including the number and proportion of Medicaid services furnished to adults and children and who are living with disabilities, and a description of the State's consideration of the how the proposed payment changes may affect access to care and service delivery. The State must provide estimates of the anticipated effect on the number of Medicaid services furnished through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring, by geographic area. (vi) A summary of, and the State's response to, any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the service(s) for which the payment rate reduction or restructuring is proposed as required under § 447.204(a)(2). (3) Compliance with requirements for State analysis for rate reduction or restructuring. (4) Mechanisms for ongoing beneficiary and provider input. (ii) States should promptly respond to public input through these mechanisms citing specific access problems, with an appropriate investigation, analysis, and response. (iii) States must maintain a record of data on public input and how the State responded to this input. This record will be made available to CMS upon request. (5) Addressing access questions and remediation of inadequate access to care. (i) The State's corrective actions may address the access deficiencies through a variety of approaches, including, but not limited to: Increasing payment rates, improving outreach to providers, reducing barriers to provider enrollment, providing additional transportation to services, providing for telemedicine delivery and telehealth, or improving care coordination. (ii) The resulting improvements in access must be measured and sustainable. (6) Compliance actions for access deficiencies. [43 FR 45253, Sept. 29, 1978, as amended at 80 FR 67611, Nov. 2, 2015; 81 FR 21480, Apr. 12, 2016; 89 FR 40871, May 10, 2024] § 447.204 Medicaid provider participation and public process to inform access to care. (a) The agency's payments must be consistent with efficiency, economy, and quality of care and sufficient to enlist enough providers so that services under the plan are available to beneficiaries at least to the extent that those services are available to the general population. In reviewing payment sufficiency, states are required to consider, prior to the submission of any state plan amendment that proposes to reduce or restructure Medicaid service payment rates: (1) The data collected, and the State analysis performed, under § 447.203(c). (2) Input from beneficiaries, providers and other affected stakeholders on beneficiary access to the affected services and the impact that the proposed rate change will have, if any, on continued service access. The state should maintain a record of the public input and how it responded to such input. (b) The State must submit to CMS with any such proposed State plan amendment affecting payment rates documentation of the information and analysis required under § 447.203(c) of this chapter. (c) CMS may disapprove a proposed state plan amendment affecting payment rates if the state does not include in its submission the supporting documentation described in paragraph (b) of this section, for failure to document compliance with statutory access requirements. Any such disapproval would follow the procedures described at part 430 Subpart B of this title. [80 FR 67612, Nov. 2, 2015, as amended at 89 FR 40874, May 10, 2024] § 447.205 Public notice of changes in Statewide methods and standards for setting payment rates. (a) When notice is required. (b) When notice is not required. (1) The change is being made to conform to Medicare methods or levels of reimbursement; (2) The change is required by court order; or (3) The change is based on changes in wholesalers' or manufacturers' prices of drugs or materials, if the agency's reimbursement system is based on material cost plus a professional fee. (c) Content of notice. (1) Describe the proposed change in methods and standards; (2) Give an estimate of any expected increase or decrease in annual aggregate expenditures; (3) Explain why the agency is changing its methods and standards; (4) Identify a local agency in each county (such as the social services agency or health department) where copies of the proposed changes are available for public review; (5) Give an address where written comments may be sent and reviewed by the public; and (6) If there are public hearings, give the location, date and time for hearings or tell how this information may be obtained. (d) Publication of notice. (1) Be published before the proposed effective date of the change; and (2) Appear as a public announcement in one of the following publications: (i) A State register similar to the Federal Register. (ii) The newspaper of widest circulation in each city with a population of 50,000 or more. (iii) The newspaper of widest circulation in the State, if there is no city with a population of 50,000 or more. (iv) A Web site developed and maintained by the single State agency or other responsible State agency that is accessible to the general public, provided that the Web site: (A) Is clearly titled and can be easily reached from a hyperlink included on Web sites that provide general information to beneficiaries and providers, and included on the State-specific page on the Federal Medicaid Web site. (B) Is updated for bulletins on a regular and known basis (for example, the first day of each month), and the public notice is issued as part of the regular update; (C) Includes the actual date it was released to the public on the Web site; or (D) Complies with national standards to ensure access to individuals with disabilities; and (E) Includes protections to ensure that the content of the issued notice is not modified after the initial publication and is maintained on the Web site for no less than a 3-year period. [46 FR 58680, Dec. 3, 1981; 47 FR 8567, Mar. 1, 1982, as amended at 48 FR 56057, Dec. 19, 1983; 80 FR 67612, Nov. 2, 2015] Subpart C—Payment for Inpatient Hospital and Long-Term Care Facility Services Source: 46 FR 47971, Sept. 30, 1981, unless otherwise noted. § 447.250 Basis and purpose. (a) This subpart implements section 1902(a)(13)(A) of the Act, which requires that the State plan provide for payment for hospital and long-term care facility services through the use of rates that the State finds, and makes assurances satisfactory to the Secretary, are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities to provide services in conformity with State and Federal laws, regulations, and quality and safety standards. (b) Section 447.253(a)(2) implements section 1902(a)(30) of the Act, which requires that payments be consistent with efficiency, economy, and quality of care; (c) Sections 447.253 (c) and (d) implement sections 1902(a)(13)(B) and 1902(a)(13)(C) of the Act, which require a State Medicaid agency to make certain assurances to the Secretary regarding increases in payments resulting solely from changes in ownerships of hospitals, NFs, and ICFs/IID. (d) Section 447.271 implements section 1903(i)(3) of the Act, which requires that payments for inpatient hospital services not exceed the hospital's customary charges. (e) Section 447.280 implements section 1913(b) of the Act, which concerns reimbursement for long-term care services furnished by swing-bed hospitals. [48 FR 56057, Dec. 19, 1983, as amended at 57 FR 43921, Sept. 23, 1992] Payment Rates § 447.251 Definitions. For the purposes of this subpart— Long-term care facility services Provider [46 FR 47971, Sept. 30, 1981, as amended at 54 FR 5359, Feb. 2, 1989; 56 FR 48867, Sept. 26, 1991] § 447.252 State plan requirements. (a) The plan must provide that the requirements of this subpart are met. (b) The plan must specify comprehensively the methods and standards used by the agency to set payment rates in a manner consistent with § 430.10 of this chapter. (c) If the agency chooses to apply the cost limits established under Medicare (see § 413.30 of this chapter) on an individual provider basis, the plan must specify this requirement. (Approved by the Office of Management and Budget under control number 0938-0193) [48 FR 56058, Dec. 19, 1983, as amended at 51 FR 34833, Sept. 30, 1986] § 447.253 Other requirements. (a) State assurances. (b) Findings. (1) Payment rates. (ii) With respect to inpatient hospital services— (A) The methods and standards used to determine payment rates take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs; (B) If a State elects in its State plan to cover inappropriate level of care services (that is, services furnished to hospital inpatients who require a lower covered level of care such as skilled nursing or intermediate care services) under conditions similar to those described in section 1861(v)(1)(G) of the Act, the methods and standards used to determine payment rates must specify that the payments for this type of care must be made at rates lower than those for inpatient hospital level of care services, reflecting the level of care actually received, in a manner consistent with section 1861(v)(1)(G) of the Act; and (C) The payment rates are adequate to assure that beneficiaries have reasonable access, taking into account geographic location and reasonable travel time, to inpatient hospital services of adequate quality. (iii) With respect to nursing facility services— (A) Except for preadmission screening for individuals with mental illness and Intellectual Disability under § 483.20(f) of this Chapter, the methods and standards used to determine payment rates take into account the costs of complying with the requirements of part 483 subpart B of this chapter; (B) The methods and standards used to determine payment rates provide for an appropriate reduction to take into account the lower costs (if any) of the facility for nursing care under a waiver of the requirement in § 483.35(e) of this Chapter to provide licensed nurses on a 24-hour basis; (C) The State establishes procedures under which the data and methodology used in establishing payment rates are made available to the public. (2) Upper payment limits. (c) Changes in ownership of hospitals. (d) Changes in ownership of NFs and ICFs/IID. (1) For transfers on or after July 18, 1984 but before October 1, 1985, the State's methods and standards must provide that payment rates can reasonably be expected not to increase in the aggregate, solely as the result of a change in ownership, more than payments would increase under Medicare under §§ 413.130, 413.134, 413.153 and 413.157 of this chapter, insofar as these sections affect payment for depreciation, interest on capital indebtedness, return on equity capital (if applicable), acquisition costs for which payments were previously made to prior owners, and the recapture of depreciation. (2) For transfers on or after October 1, 1985, the State's methods and standards must provide that the valuation of capital assets for purposes of determining payment rates for NFs and ICFs/IID is not to increase (as measured from the date of acquisition by the seller to the date of the change of ownership) solely as a result of a change of ownership, by more than the lesser of— (i) One-half of the percentage increase (as measured from the date of acquisition by the seller to the date of the change of ownership, or, if necessary, as extrapolated retrospectively by the Secretary) in the Dodge construction index applied in the aggregate with respect to those facilities that have undergone a change of ownership during the fiscal year; or (ii) One-half of the percentage increase (as measured from the date of acquisition by the seller to the date of the change of ownership) in the Consumer Price Index for All Urban Consumers (CPI-U) (United States city average) applied in the aggregate with respect to those facilities that have undergone a change of ownership during the fiscal year. (e) Provider appeals. (f) Uniform cost reporting. (g) Audit requirements. (h) Public notice. (i) Rates paid. [48 FR 56057, Dec. 19, 1983, as amended at 52 FR 28147, July 28, 1987; 54 FR 5359, Feb. 2, 1989; 57 FR 43921, Sept. 23, 1992; 81 FR 68847, Oct. 4, 2016] § 447.255 Related information. The Medicaid agency must submit, with the assurances described in § 447.253(a), the following information: (a) The amount of the estimated average proposed payment rate for each type of provider (hospital, ICF/IID, or nursing facility), and the amount by which that estimated average rate increased or decreased relative to the average payment rate in effect for each type or provider for the immediately preceding rate period; (b) An estimate of the short-term and, to the extent feasible, long-term effect the change in the estimated average rate will have on— (1) The availability of services on a Statewide and geographic area basis; (2) The type of care furnished; (3) The extent of provider participation; and (4) The degree to which costs are covered in hospitals that serve a disproportionate number of low income patients with special needs. [48 FR 56058, Dec. 19, 1983, as amended at 54 FR 5359, Feb. 2, 1989; 56 FR 48867, Sept. 26, 1991; 57 FR 43924, Sept. 23, 1992; 57 FR 46431, Oct. 8, 1992] § 447.256 Procedures for CMS action on assurances and State plan amendments. (a) Criteria for approval. (2) In the case of State plan and plan amendment changes in payment methods and standards, CMS bases its approval on the acceptability of the Medicaid agency's assurances that the requirements of § 447.253 have been met, and the State's compliance with the other requirements of this subpart. (b) Time limit. (c) Effective date. [48 FR 56058, Dec. 19, 1983, as amended at 52 FR 28147, July 28, 1987] Federal Financial Participation § 447.257 FFP: Conditions relating to institutional reimbursement. FFP is not available for a State's expenditures for hospital inpatient or long-term care facility services that are in excess of the amounts allowable under this subpart. [52 FR 28147, July 28, 1987] Upper Limits § 447.271 Upper limits based on customary charges. (a) Except as provided in paragraph (b) of this section, the agency may not pay a provider more for inpatient hospital services under Medicaid than the provider's customary charges to the general public for the services. (b) The agency may pay a public provider that provides services free or at a nominal charge at the same rate that would be used if the provider charges were equal to or greater than its costs. [75 FR 73975, Nov. 30, 2010] § 447.272 Inpatient services: Application of upper payment limits. (a) Scope. (1) State government-owned or operated facilities (that is, all facilities that are either owned or operated by the State). (2) Non-State government-owned or operated facilities (that is, all government facilities that are neither owned nor operated by the State). (3) Privately-owned and operated facilities. (b) General rules. (2) Except as provided for in paragraph (c) of this section, aggregate Medicaid payments to a group of facilities within one of the categories described in paragraph (a) of this section may not exceed the upper payment limit described in paragraph (b)(1) of this section. (c) Exceptions Indian Health Services and tribal facilities. (2) Disproportionate share hospitals. (i) The aggregate DSH limit using the Federal share of the DSH limit under section 1923(f) of the Act. (ii) The hospital-specific DSH limit in section 1923(g) of the Act. (iii) The aggregate DSH limit for institutions for mental disease (IMDs) under section 1923(h) of the Act. (d) Compliance dates. (1) For non-State government owned or operated hospitals,—March 19, 2002. (2) For all other facilities—March 13, 2001. [66 FR 3175, Jan. 12, 2001, as amended at 66 FR 46399, Sept. 5, 2001; 67 FR 2610, Jan. 18, 2002; 72 FR 29834, May 29, 2007; 75 FR 73975, Nov. 30, 2010; 77 FR 31512, May 29, 2012] Swing-Bed Hospitals § 447.280 Hospital providers of NF services (swing-bed hospitals). (a) General rule. (1) Provide for payment at the average rate per patient day paid to NFs, as applicable, for routine services furnished during the previous calendar year; or (2) Meet the State plan and payment requirements described in this subpart, as applicable. (b) Application of the rule. [59 FR 56237, Nov. 10, 1994] Subpart D [Reserved] Subpart E—Payment Adjustments for Hospitals That Serve a Disproportionate Number of Low-Income Patients Source: 57 FR 55143, Nov. 24, 1992, unless otherwise noted. § 447.294 Medicaid disproportionate share hospital (DSH) allotment reductions. (a) Basis and purpose. (b) Definitions. Aggregate DSH allotment reductions Budget neutrality factor (BNF) DSH payment Effective DSH allotment High level of uncompensated care factor (HUF) High Medicaid volume hospital High uncompensated care hospital High volume of Medicaid inpatients factor (HMF) Hospital with high volumes of Medicaid inpatients Low DSH adjustment factor (LDF) Low DSH State Mean HUF reduction percentage Medicaid inpatient utilization rate (MIUR) Non-high Medicaid volume hospital State group State-specific DSH allotment reduction Total hospital cost Total Medicaid cost Total population Total uninsured cost Uncompensated care cost Uncompensated care level Unreduced DSH allotment Uninsured percentage factor (UPF) Uninsured population (c) Aggregate DSH allotment reduction amounts. (d) State data submission requirements. (e) DHRM methodology. (1) Establishing State groups. (2) Aggregate DSH allotment reduction allocation. (i) Dividing the sum of each State group's preliminary unreduced DSH allotments by the sum of both State groups' preliminary unreduced DSH allotment amounts to determine a percentage. (ii) Multiplying the value of paragraph (e)(2)(i) of this section by the aggregate DSH allotment reduction amount under paragraph (c) of this section for the applicable fiscal year. (iii) Applying the low DSH adjustment factor under paragraph (e)(3) of this section. (3) Low DSH adjustment factor (LDF) calculation. (i) Dividing each State's preliminary unreduced DSH allotment by their respective total estimated Medicaid service expenditures for the applicable fiscal year. (ii) Calculating for each State group the mean of all values determined in paragraph (e)(3)(i) of this section. (iii) Dividing the value of paragraph (e)(3)(ii) of this section for the low-DSH State group by the value of paragraph (e)(3)(ii) for the non-low DSH state group. (4) LDF application. (i) Multiplying the LDF by the aggregate DSH allotment reduction for the low DSH State group. (ii) Utilizing the value of paragraph (e)(4)(i) of this section as the aggregate DSH allotment reduction allocated to the low DSH State group. (iii) Subtracting the value of paragraph (e)(4)(ii) of this section from the value of paragraph (e)(2)(ii) of this section for the low DSH State group; and (iv) Adding the value of paragraph (e)(4)(iii) of this section to the value of paragraph (e)(2)(ii) of this section for the non-low DSH State group. (5) Reduction factor allocation. (i) UPF—50 percent. (ii) HMF—25 percent. (iii) HUF—25 percent. (6) Uninsured percentage factor (UPF) calculation. (i) Dividing the total State population by the uninsured in State for each State. (ii) Determining the uninsured reduction allocation component for each State as a percentage by dividing each State's value of paragraph (e)(6)(i) of this section by the sum of the values of paragraph (e)(6)(i) of this section for the respective State group (the sum of the values of all States in the State group should total 100 percent). (iii) Determine a weighting factor by dividing each State's unreduced DSH allotment by the sum of all preliminary unreduced DSH allotments for the respective State group. (iv) Multiply the weighting factor calculated in (e)(6)(iii) of this section by the value of each State's uninsured reduction allocation component from paragraph (e)(6)(ii) of this section. (v) Determine the UPF as a percentage by dividing the product of paragraph (e)(6)(iv) of this section for each State by the sum of the values of paragraph (e)(6)(iv) of this section for the respective State group (the sum of the values of all States in the State group should total 100 percent). (7) UPF application and reduction amount. (8) High volume of Medicaid inpatients factor (HMF) calculation. (9) HMF application and reduction amount. (10) High level of uncompensated care factor (HUF) calculation. (11) HUF application and reduction amount. (12) Section 1115 budget neutrality factor (BNF) calculation. (i) For States in which the State's DSH allotment was included in the budget neutrality calculation for a coverage expansion that was approved under section 1115 as of July 31, 2009, determining the amount of the State's DSH allotment included in the budget neutrality calculation for coverage expansion. This amount is not subject to reductions under the HMF and HUF calculations. DSH allotment amounts included in the budget neutrality calculation for purposes other than coverage expansion for a demonstration project under section 1115 that was approved as of July 31, 2009, are subject to reduction as specified in paragraphs (e)(12)(ii) through (iv) of this section. For States whose DSH allotment was included in the budget neutrality calculation for a demonstration project that was approved under section 1115 after July 31, 2009, whether for coverage expansion or otherwise, the entire DSH allotment amount that was included in the budget neutrality calculation is subject to reduction as specified in paragraphs (e)(12)(ii) through (iv) of this section. (ii) Determining the amount of the State's DSH allotment included in the budget neutrality calculation subject to reduction. The amount to be assigned reductions under paragraphs (e)(12)(iii) and (iv) of this section is the total of each State's DSH allotment diverted under an approved 1115 demonstration during the period that aligns with the associated State plan rate year DSH audit utilized in the DSH allotment reductions. (iii) Multiplying each qualifying State's value of paragraph (e)(12)(ii) of this section by the mean HMF reduction percentage for the respective State group. (iv) Multiplying each qualifying State's value of paragraph (e)(12)(ii) of this section by the mean HUF reduction percentage for the respective State group. (v) For each State, calculating the sum of the value of paragraphs (e)(12)(iii) and of (e)(12)(iv) of this section. (13) Section 1115 budget neutrality factor (BNF) application. (14) State-specific DSH allotment reduction calculation. (i) Taking the sum of the value of paragraphs (e)(7), (e)(9), and (e)(11) of this section for each State. (ii) For States qualifying under paragraph (e)(12) of this section, adding the value of paragraph (e)(12)(v) of this section. (iii) Reducing the amount of paragraph (e)(14)(i) of this section for each State that does not qualify under paragraph (e)(12)(v) of this section based on the proportion of each State's preliminary unreduced DSH allotment compared to the national total of preliminary unreduced DSH allotments so that the sum of paragraph (e)(14)(iii) of this section equals the sum of paragraph (e)(12)(v) of this section. (iv) No state will receive a reduction as calculated in paragraph (e)(14) of this section in excess of 90 percent of its preliminary unreduced DSH allotment for the respective fiscal year. For any state assigned a reduction amount determined under paragraph (e)(14) of this section in excess of 90 percent of its unreduced DSH allotment, the reduction amount that exceeds 90 percent of that state's unreduced DSH allotment will be distributed among the remaining states in the state group that do not exceed the 90 percent reduction cap, based on the proportion of each of these remaining states' allotment reduction amount before any distribution is performed pursuant to this paragraph (e)(14)(iv) to the aggregate allotment reduction amount for the state group. This operation will be performed until all reduction amounts in excess of the 90 percent reduction cap for all states are allocated within each respective state group. (f) Annual DSH allotment reduction application. [78 FR 57311, Sept. 18, 2013, as amended at 84 FR 50332, Sept. 25, 2019; 89 FR 13945, Feb. 23, 2024] § 447.295 Hospital-specific disproportionate share hospital payment limit: Determination of individuals without health insurance or other third party coverage. (a) Basis and purpose. (b) Definitions. Health insurance coverage limit Individuals who have no health insurance (or other source of third party coverage) for the services furnished during the year 97th percentile hospital (i) CMS will identify the 97th percentile hospitals, for each Medicaid State plan rate year beginning on or after October 1, 2021, using Medicare cost reporting and claims data sources, as well as supplemental security income eligibility data provided by the Social Security Administration. (ii) CMS will publish lists identifying each 97th percentile hospital annually in advance of October 1 of each year. CMS will revise a published list only to correct a mathematical or other similar technical error that is identified to CMS during the one-year period beginning on the date the list is published. No source of third party coverage for a specific inpatient hospital or outpatient hospital service (c) Determination of an individual's third party coverage status. (1) The determination of an individual's status as having a source of third party coverage must be a service-specific coverage determination. The service-specific coverage determination can occur only once per individual per service provided and applies to the entire service, including all elements as that service, or similar services, would be defined in Medicaid. (2) Individuals who are inmates in a public institution or are otherwise involuntarily in secure custody as a result of criminal charges are considered to have a source of third party coverage. (d) Hospital-specific DSH limit calculation. (2) For each State's first Medicaid State plan rate year beginning on or after October 1, 2021, and thereafter, subject to paragraph (d)(3) of this section, only costs incurred in providing inpatient hospital and outpatient hospital services to Medicaid individuals when Medicaid is the primary payer for such services, and revenues received with respect to those services, and costs incurred in providing inpatient hospital and outpatient hospital services, and revenues received with respect to those services, for which a determination has been made in accordance with paragraph (c) of this section that the services were furnished to individuals who have no source of third-party coverage for the specific inpatient hospital or outpatient hospital service are included when calculating the costs and revenues for Medicaid individuals and individuals who have no health insurance or other source of third-party coverage for purposes of section 1923(g)(1) of the Act. (3) Effective for each State's first Medicaid State plan rate year beginning on or after October 1, 2021, and thereafter, the hospital-specific DSH limit for a 97th percentile hospital defined in paragraph (b) of this section is the higher of the values from the calculations described in paragraphs (d)(1) and (2) of this section. [79 FR 71694, Dec. 3, 2014, as amended at 89 FR 13945, Feb. 23, 2024] § 447.296 Limitations on aggregate payments for disproportionate share hospitals for the period January 1, 1992 through September 30, 1992. (a) The provisions of this section apply to the 50 States and the District of Columbia, but not to any State whose entire Medicaid program is operated under a waiver granted under section 1115 of the Act. (b) For the period January 1, 1992 through September 30, 1992, FFP is available for aggregate payments to hospitals that serve a disproprotionate number of low-income patients with special needs only if the payments are made in accordance with sections 1902(a)(13)(A) and 1923 of the Act, and with one of the following: (1) An approved State plan in effect as of September 30, 1991. (2) A State plan amendment submitted to CMS by September 30, 1991. (3) A State plan amendment, or modification thereof, submitted to CMS between October 1, 1991 and November 26, 1991, if the amendment, or modification thereof, was intended to limit the State's definition of disproportionate share hospitals to those hospitals with Medicaid inpatient utilization rates or low-income utilization rates (as defined in section 1923 (b) of the Act) at or above the statewide arithmetic mean. (4) A methodology for disproportionate share hospital payments that was established and in effect as of September 30, 1991, or in accordance with a State law enacted or State regulation adopted as of September 30, 1991. (5) A State plan amendment submitted to CMS by September 30, 1992 that increases aggregate disproportionate share hospitals payments in order to meet the minimum payment adjustments required by section 1923(c)(1) of the Act. The minimum payment adjustment is the amount required by the Medicare methodology described in section 1923(c)(1) of the Act for those hospitals that satisfy the minimum Federal definition of a disproportionate share hospital in section 1923(b) of the Act. (6) A State plan amendment submitted to CMS by September 30, 1992 that provides for a redistribution of disproportionate share hospital payments within the State without raising total payments compared to the previously approved State plan. CMS will approve the amendment only if the State submits written documentation that demonstrates to CMS that the aggregate payments that will be made after the redistribution are no greater than those payments made before the redistribution. (7) A State plan amendment submitted to CMS by September 30, 1992 that provides for a reduction in disproportionate share hospital payments. § 447.297 Limitations on aggregate payments for disproportionate share hospitals beginning October 1, 1992. (a) Applicability. (b) National payment target. (c) State disproportionate share hospital allotments. (d) Final national disproportionate share hospitals expenditure target and State disproportionate share hospitals allotments. (2) If CMS determines that at any time a State has exceeded its final DSH allotment for a Federal fiscal year, FFP attributable to the excess DSH expenditures will be disallowed. (3) If a State's actual DSH expenditures applicable to a Federal fiscal year are less than its final State DSH allotment for that Federal fiscal year, the State is permitted, to the extent allowed by its approved State plan, to make additional DSH expenditures applicable to that Federal fiscal year up to the amount of its final DSH allotment for that Federal fiscal year. [57 FR 55143, Nov. 24, 1992, as amended at 58 FR 43182, Aug. 13, 1993; 89 FR 13946, Feb. 23, 2024] § 447.298 State disproportionate share hospital allotments. (a) Calculation of State's base allotment for Federal fiscal year 1993. (i) The total amount of the State's projected DSH payments for Federal fiscal year 1992 under the State plan applicable to Federal fiscal year 1992, calculated in accordance with paragraph (a)(2) of this section; or (ii) $1,000,000. (2) In calculating the State's DSH payments applicable to Federal fiscal year 1992, CMS will derive amounts from payments applicable to the period of October 1, 1991, through September 30, 1992, under State plans or plan amendments that meet the requirements specified in § 447.296(b). The calculation will not include— (i) DSH payment adjustments made by the State applicable to the period October 1, 1991 through December 31, 1991 under State plans or plan amendments that do not meet the criteria described in § 447.296; and (ii) Retroactive DSH payments made in 1992 that are not applicable to Federal fiscal year 1992. (3) CMS will calculate a percentage for each State by dividing the DSH base allotment by the total unadjusted medical assistance expenditures, excluding administrative costs, made during Federal fiscal year 1992. On the basis of this percentage, CMS will classify each State as a “high-DSH” or “low-DSH” State. (i) If the State's base allotment exceeded 12 percent of its total unadjusted medical assistance expenditures made under the State plan in Federal fiscal year 1992, CMS will classify the State as a “high-DSH” State. (ii) If the State's base allotment was 12 percent or less of its total unadjusted medical assistance expenditures made under the State plan in Federal fiscal year 1992, CMS will classify the State as a “low-DSH” State. (b) State disproportionate share hospital allotments for Federal fiscal year 1993. (2) For high-DSH States, the dollar amount of DSH payments in Federal fiscal year 1993 may not exceed the dollar amount of DSH payments applicable to Federal fiscal year 1992 (that is, the State base allotment). (c) State disproportionate share hospital allotment for Federal fiscal years 1994 and after. (1) For low-DSH States, CMS will calculate the DSH allotment for each Federal fiscal year by increasing the prior year's State DSHs allotment by— (i) State growth, as specified in paragraph (d) of this section; and (ii) A supplemental amount, if applicable, as described in paragraph (e) of this section. (2) For high-DSH States, the dollar amount of DSH payments applicable to any Federal fiscal year may not exceed the dollar amount of payments applicable to Federal fiscal year 1992 (that is, the State base allotment). This payment limitation will apply until the Federal fiscal year in which the State's DSH payments applicable to that Federal fiscal year, expressed as a percentage of the State's total unadjusted medical assistance expenditures in that Federal fiscal year, equal 12 percent or less. When a high-DSH State's percentage equals 12 percent or less, the State will be reclassified as a low-DSH State. (d) State growth. (i) The growth factor that is CMS's projected percentage increase in the State's total unadjusted medical assistance expenditures (including administrative costs) relative to the corresponding amount in the previous year; and (ii) The State's prior year DSH allotment. (2) If the growth factor is zero or is negative, the State growth is zero. (3) If a low-DSH State experiences a level of negative growth to the extent that its previous Federal fiscal year's DSH allotment would be more than 12 percent of its current Federal fiscal year's total unadjusted medical assistance expenditures (excluding administrative costs), the low-DSH State's previous year's DSH allotment will be reduced to the extent necessary to maintain the individual low-DSH State's 12-percent limit and that amount will become the low-DSH State's DSH allotment for the current Federal fiscal year. In no Federal fiscal year will a low-DSH State's DSH allotment be allowed to exceed its individual State 12-percent limit. (e) Supplemental amount available for low-DSH States. (2) CMS will calculate the redistribution pool for the appropriate Federal fiscal year by subtracting from the projected national DSH expenditure target the following: (i) The total of the State DSH base allotments for all high-DSH States; (ii) The total of the previous year's State DSH allotments for all low-DSH States; (iii) The State growth amount for all low-DSH States; and (iv) The total amount of additional DSH payment adjustments made in order to meet the minimum payment adjustments required under section 1923(c)(l) of the Act, which are made in accordance with § 447.296(b)(5). (3) CMS will determine the percent of the redistribution pool for each low-DSH State on the basis of each State's relative share of the total unadjusted medical assistance expenditures for the Federal fiscal year compared to the total unadjusted medical assistance expenditures for the Federal fiscal year projected to be made by all low-DSH States. The percent of the redistribution pool that each State will receive is equal to the State's total unadjusted medical assistance expenditures divided by the total unadjusted medical assistance expenditures for all low-DSH States. (4) CMS will not provide any low-DSH State a supplemental amount that would result in the State's total DSH allotment exceeding 12 percent of its projected total unadjusted medical assistance expenditures. CMS will reallocate any supplemental amounts not allocated to States because of this 12-percent limitation to other low-DSH States in accordance with the percentage determined in paragraph (e)(3) of this section. (5) CMS will not reallocate to low-DSH States the difference between any State's actual DSH expenditures applicable to a Federal fiscal year and its State DSH allotment applicable to that Federal fiscal year. Thus, any unspent DSH allotment may not be reallocated. (f) Special provision. [57 FR 55143, Nov. 24, 1992, as amended at 58 FR 43182, Aug. 13, 1993] § 447.299 Reporting requirements. (a) Beginning with the first quarter of Federal fiscal year 1993, each State must submit to CMS the quarterly aggregate amount of its disproportionate share hospital payments made to each individual public and private provider or facility. States' reports must present a complete, accurate, and full disclosure of all of their DSH programs and expenditures. (b) Each State must report the aggregate information specified under paragraph (a) of this section on a quarterly basis in accordance with procedures established by CMS. (c) Beginning with each State's Medicaid State plan rate year 2005, for each Medicaid State plan rate year, the State must submit to CMS, at the same time as it submits the completed audit required under § 455.304 of this chapter, the following information for each DSH hospital to which the State made a DSH payment in order to permit verification of the appropriateness of such payments: (1) Hospital name. (2) Estimate of hospital-specific DSH limit. (3) Medicaid inpatient utilization rate. (4) Low income utilization rate. (5) State defined DSH qualification criteria. (6) IP/OP Medicaid fee-for-service (FFS) basic rate payments. (7) IP/OP Medicaid managed care organization payments. (8) Supplemental/enhanced Medicaid IP/OP payments. (9) Total Medicaid IP/OP Payments. (10) Total cost of care for Medicaid IP/OP services. (i) Are defined as costs net of third-party payments, including, but not limited to, payments by Medicare and private insurance. (ii) Must capture the total burden on the hospital of treating Medicaid patients as determined in accordance with § 447.295(d), not including payment by Medicaid. Thus, costs must be determined in the aggregate and not by estimating the cost of individual patients. For example, if a hospital treats two Medicaid patients at a cost of $2,000 and receives a $500 payment from a third party for each individual, the total cost to the hospital for purposes of this section is $1,000, regardless of whether the third-party payment received for one patient exceeds the cost of providing the service to that individual. (11) Total Medicaid Uncompensated Care. (12) Uninsured IP/OP revenue. (13) Total Applicable Section 1011 Payments. (14) Total cost of IP/OP care for the uninsured. (15) Total uninsured IP/OP uncompensated care costs. (i) The amount should be the result of subtracting paragraphs (c)(12) and (c)(13), from paragraph (c)(14) of this section. (ii) The uncompensated care costs of providing physician services to the uninsured cannot be included in this amount. (iii) The uninsured uncompensated amount also cannot include amounts associated with unpaid co-pays or deductibles for individuals with third party coverage for the inpatient and/or outpatient hospital services they receive or any other unreimbursed costs associated with inpatient and/or outpatient hospital services provided to individuals with those services in their third party coverage benefit package. (iv) The uncompensated care costs do not include bad debt or payer discounts related to services furnished to individuals who have health insurance or other third party payer. (16) Total annual uncompensated care costs. (17) Disproportionate share hospital payments. (18) Medicaid provider number. (19) Medicare provider number. (20) Total hospital cost. (21) Financial impact of audit findings. (22) Reporting. (d) Each State must maintain, in readily reviewable form, supporting documentation that provides a detailed description of each DSH program, the legal basis of each DSH program, and the amount of DSH payments made to each individual public and private provider or facility each quarter. This information must be made available to Federal reviewers upon request. (e) If a State fails to comply with the reporting requirements contained in this section, future grant awards will be reduced by the amount of FFP CMS estimates is attributable to the expenditures made to the disproportionate share hospitals as to which the State has not reported properly, until such time as the State complies with the reporting requirements. Deferrals and/or disallowances of equivalent amounts may also be imposed with respect to quarters for which the State has failed to report properly. Unless otherwise prohibited by law, FFP for those expenditures will be released when the State complies with all reporting requirements. (f) DSH payments found in the independent certified audit process under part 455, subpart D, of this chapter to exceed hospital-specific cost limits are provider overpayments which must be returned to the Federal Government in accordance with the requirements in part 433, subpart F, or redistributed by the State to other qualifying hospitals, if redistribution is provided for under the approved State plan. Overpayment amounts returned to the Federal Government must be separately reported on the Form CMS-64 as a decreasing adjustment which corresponds to the fiscal year DSH allotment and Medicaid State plan rate year of the original DSH expenditure claimed by the State. (g) As applicable, States must report any overpayment redistribution amounts on the Form CMS-64 within 2 years from the date of discovery that a hospital-specific limit has been exceeded, as determined under § 433.316(f) of this chapter in accordance with a redistribution methodology in the approved Medicaid State plan. The State must report redistribution of DSH overpayments on the Form CMS-64 as separately identifiable decreasing adjustments reflecting the return of the overpayment as specified in paragraph (f) of this section and increasing adjustments representing the redistribution by the State. Both adjustments must correspond to the fiscal year DSH allotment and Medicaid State plan rate year of the related original DSH expenditure claimed by the State. [46 FR 47971, Sept. 30, 1981, as amended at 73 FR 77950, Dec. 19, 2008; 74 FR 18657, Apr. 24, 2009; 77 FR 31512, May 29, 2012; 78 FR 57313, Sept. 18, 2013; 82 FR 16122, Apr. 3, 2017; 85 FR 72909, Nov. 16, 2020; 89 FR 13946, Feb. 23, 2024] Subpart F—Payment Methods for Other Institutional and Noninstitutional Services Source: 43 FR 45253, Sept. 29, 1978, unless otherwise noted. Redesignated at 46 FR 47973, Sept. 30, 1981, and further redesignated at 58 FR 6095, Jan. 26, 1993. § 447.300 Basis and purpose. In this subpart, §§ 447.302 through 447.325 and 447.361 implement section 1902(a)(30) of the Act, which requires that payments be consistent with efficiency, economy and quality of care. Section 447.371 implements section 1902(a)(15) of the Act, which requires that the State plan provide for payment for rural health clinic services in accordance with regulations prescribed by the Secretary. [72 FR 39239, July 17, 2007] § 447.302 State plan requirements. A State plan must provide that the requirements of this subpart are met. [46 FR 48560, Oct. 1, 1981] § 447.304 Adherence to upper limits; FFP. (a) The Medicaid agency must not pay more than the upper limits described in this subpart. (b) In the case of payments made under the plan for deductibles and coinsurance payable on an assigned Medicare claim for noninstitutional services, those payments may be made only up to the reasonable charge under Medicare. (c) FFP is not available for a State's expenditures for services that are in excess of the amounts allowable under this subpart. Note: The Secretary may waive any limitation on reimbursement imposed by subpart F of this part for experiments conducted under section 402 of Pub. L. 90-428, Incentives for Economy Experimentation, as amended by section 222(b) of Pub. L. 92-603, and under section 222(a) of Pub. L. 92-603. [46 FR 48560, Oct. 1, 1981; 46 FR 54744, Nov. 4, 1981, as amended at 66 FR 3176, Jan. 12, 2001] Outpatient Hospital and Clinic Services § 447.321 Outpatient hospital and clinic services: Application of upper payment limits. (a) Scope. (1) State government-owned or operated facilities (that is, all facilities that are owned or operated by the State.) (2) Non-State government owned or operated facilities (that is, all government operated facilities that are neither owned nor operated by the State). (3) Privately-owned and operated facilities. (b) General rules. (2) Except as provided in paragraph (c) of this section, aggregate Medicaid payments to a group of facilities within one of the categories described in paragraph (a) of this section may not exceed the upper payment limit described in paragraph (b)(1) of this section. (c) Exceptions. (d) Compliance dates. (1) For non-State government-owned or operated hospitals—March 19, 2002. (2) For all other facilities—March 13, 2001. [66 FR 3176, Jan. 12, 2001, as amended at 66 FR 46399, Sept. 5, 2001; 67 FR 2611, Jan. 18, 2002; 72 FR 29835, May 29, 2007; 75 FR 73975, Nov. 30, 2010; 77 FR 31513, May 29, 2012] Other Inpatient and Outpatient Facilities § 447.325 Other inpatient and outpatient facility services: Upper limits of payment. The agency may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances. § 447.342 [Reserved] Prepaid Capitation Plans § 447.362 Upper limits of payment: Nonrisk contract. Under a nonrisk contract, Medicaid payments to the contractor may not exceed— (a) What Medicaid would have paid, on a fee-for-service basis, for the services actually furnished to beneficiaries: plus (b) The net savings of administrative costs the Medicaid agency achieves by contracting with the plan instead of purchasing the services on a fee-for-service basis. [48 FR 54025, Nov. 30, 1983] Rural Health Clinic Services § 447.371 Services furnished by rural health clinics. The agency must pay for rural health clinic services, as defined in § 440.20(b) of this subchapter, and for other ambulatory services furnished by a rural health clinic, as defined in § 440.20(c) of this subchapter, as follows: (a) For provider clinics, the agency must pay the reasonable cost of rural health clinic services and other ambulatory services on the basis of the cost reimbursement principles in part 413 of this chapter. For purposes of this section, a provider clinic is an integral part of a hospital, skilled nursing facility, or home health agency that is participating in Medicare and is licensed, governed, and supervised with other departments of the facility. (b) For clinics other than provider clinics that do not offer any ambulatory services other than rural health clinic services, the agency must pay for rural health clinic services at the reasonable cost rate per visit determined by a Medicare carrier under §§ 405.2426 through 405.2429 of this chapter. (c) For clinics other than provider clinics that do offer ambulatory services other than rural health clinic services, the agency must pay for the other ambulatory services by one of the following methods: (1) The agency may pay for other ambulatory services and rural health clinic services at a single rate per visit that is based on the cost of all services furnished by the clinic. The rate must be determined by a Medicare carrier under §§ 405.2426 through 405.2429 of this chapter. (2) The agency may pay for other ambulatory services at a rate set for each service by the agency. The rate must not exceed the upper limits in this subpart. The agency must pay for rural health clinic services at the Medicare reimbursement rate per visit, as specified in § 405.2426 of this chapter. (3) The agency may pay for dental services at a rate per visit that is based on the cost of dental services furnished by the clinic. The rate must be determined by a Medicare carrier under §§ 405.2426 through 405.2429 of this chapter. The agency must pay for ambulatory services other than dental services under paragraph (c) (1) or (2) of this section. (d) For purposes of paragraph (c) (1) and (3) of this section, “visit” means a face-to-face encounter between a clinic patient and any health professional whose services are reimbursed under the State plan. Encounters with more than one health professional, and multiple encounters with the same health professional, that take place on the same day and at a single location constitute a single visit, except when the patient, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. [43 FR 45253, Sept. 29, 1978, as amended at 51 FR 34833, Sept. 30, 1986] Subpart G—Payments for Primary Care Services Furnished by Physicians Source: 77 FR 66700, Nov. 6, 2012, unless otherwise noted. § 447.400 Primary care services furnished by physicians with a specified specialty or subspecialty. (a) States pay for services furnished by a physician as defined in § 440.50 of this chapter, or under the personal supervision of a physician who self-attests to a specialty designation of family medicine, general internal medicine or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). Such physician then attests that he/she: (1) Is Board certified with such a specialty or subspecialty and/or (2) Has furnished evaluation and management services and vaccine administration services under codes described in paragraph (b) of this section that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed CY or, for newly eligible physicians, the prior month. (b) At the end of CY 2013 and 2014 the Medicaid agency must review a statistically valid sample of physicians who received higher payments to verify that they meet the requirements of paragraph (a)(1) or (2) of this section. (c) Primary care services designated in the Healthcare Common Procedure Coding System (HCPCS) are as follows: (1) Evaluation and Management (E&M) codes 99201 through 99499. (2) Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474, or their successor codes. (d)(1) The state must submit to CMS, in such form and at such time as CMS specifies, information relating to participation by physicians described in paragraph (a) of this section and the utilization of E&M codes described in paragraph (c) of this section (whether furnished by or under the supervision of a physician described in paragraph (a)) of this section for the following peri—s— (i) As of July 1, 2009, and (ii) CY 2013 (2) As soon as practicable after receipt, CMS will post this information on www.Medicaid.gov. [77 FR 66700, Nov. 6, 2012, as amended at 77 FR 74382, Dec. 14, 2012] § 447.405 Amount of required minimum payments. (a) For CYs 2013 and 2014, a state must pay for physician services described in § 447.400 based on the lower of: (1) The Medicare Part B fee schedule rate that is applicable to the specific site of service or, at the state's option, the office setting and is also adjusted for either the specific geographic location of the service or reflects the mean over all counties of the rate for each E&M code. If there is no applicable rate, the rate specified in a fee schedule established and announced by CMS (that is, the product of multiplying the Medicare CF in effect at the beginning of CYs 2013 or 2014 (or the CY 2009 CF, if higher) and the CY 2013 and 2014 relative value units (RVUs). (2) The provider's actual billed charge for the service. (b) For vaccines provided under the Vaccines for Children Program in CYs 2013 and 2014, a State must pay the lesser of: (1) The Regional Maximum Administration Fee; or, (2) The Medicare fee schedule rate in CY 2013 or 2014 (or, if higher, the rate using the 2009 conversion factor and the 2013 and 2014 RVUs) for code 90460. [77 FR 66700, Nov. 6, 2012, as amended at 77 FR 74382, Dec. 14, 2012] § 447.410 State plan requirements. The state must amend its state plan to reflect the increase in fee schedule payments in CYs 2013 and 2014 unless, for each of the billing codes eligible for payment, the state currently reimburses at least as much as the higher of the CY 2013 and CY 2014 Medicare rate or the rate that would be derived using the CY 2009 conversion factor and the CY 2013 and 2014 Medicare relative value units (RVUs). The amendment must: (a) Identify all eligible codes that the state will reimburse at the Medicare rate in CYs 2013 and 2014. (b) Identify all codes that were not reimbursed under the Medicaid program as of July 1, 2009. (c) Specify either that the state will make all adjustments applicable to the specific site of service or, at the state's option, the office setting and will also either adjust for the specific geographic location of the service or pay rates that reflect the mean over all counties of the rate for each E&M code. The state must specify the formula that the state will use to determine the mean rate for each E&M code. § 447.415 Availability of Federal financial participation (FFP). (a) For primary care services furnished by physicians specified in § 447.400, FFP will be available at the rate of 100 percent for the amount by which the payment required to comply with § 447.405 exceeds the Medicaid payment that would have been made under the approved state plan in effect on July 1, 2009. (b) For purposes of calculating the payment that would have been made under the approved State plan in effect on July 1, 2009, the state must exclude incentive, bonus, and performance-based payments but must include supplemental payments for which the approved methodology is linked to volume and payment for specific codes. (c) For vaccine administration, the state must impute the payment that would have been made for code 90460 under the approved Medicaid state plan. The imputed rate for July 1, 2009, for code 90460 equals the payment rates for codes 90465 and 90471 weighted by service volume. (d) For any payment made under a bundled rate methodology, including bundled rates for vaccines and vaccine administration, the amount directly attributable to the applicable primary care service must be isolated for purposes of determining the availability of the 100 percent FFP rate. Bundled rates, for purposes of this provision, do not include encounter and per diem rates. Subpart H [Reserved] Subpart I—Payment for Drugs Source: 81 FR 5347, Feb. 1, 2016, unless otherwise noted. § 447.500 Basis and purpose. (a) Basis. (1) Interprets those provisions of section 1927 of the Act that set forth requirements for drug manufacturers' calculating and reporting average manufacturer prices (AMPs) and best prices and that set upper payment limits for covered outpatient drugs. (2) Implements section 1903(i)(10) of the Act with regard to the denial of Federal financial participation (FFP) in expenditures for certain physician-administered drugs. (3) Implements section 1902(a)(54) of the Act with regard to a State plan that provides covered outpatient drugs. (4) Implements section 1903(m)(2)(A)(xiii) of the Act, in part, and section 1927(b) of the Act with regard to rebates for covered outpatient drugs dispensed to individuals eligible for medical assistance who are enrolled in Medicaid managed care organizations (MCOs). (5) Implements section 1902(a)(30)(A) of the Act with regard to the efficiency, economy, and quality of care in the context of payments for covered outpatient drugs. (b) Purpose. § 447.502 Definitions. For the purpose of this subpart, the following definitions apply: Actual acquisition cost (AAC) Authorized generic drug Bona fide service fee Brand name drug Bundled sale (1) The discounts in a bundled sale, including those discounts resulting from a contingent arrangement, are allocated proportionally to the total dollar value of the units of all drugs or products sold under the bundled arrangement. (2) For bundled sales where multiple drugs are discounted, the aggregate value of all the discounts in the bundled arrangement must be proportionally allocated across all the drugs or products in the bundle. (3) Value-based purchasing (VBP) arrangements may qualify as a bundled sale. Clotting factor CMS-authorized supplemental rebate agreement Consumer Price Index—Urban (CPI-U) Covered outpatient drug (COD) (1) A drug can only be considered a covered outpatient drug if it: (i) Is approved for safety and effectiveness as a prescription drug by the FDA under section 505 or 507 of the FFDCA or under section 505(j) of the FFDCA; (ii) Was commercially used or sold in the United States before the enactment of the Drug Amendments of 1962 or which is identical, similar, or related (within the meaning described in FDA regulations at 21 CFR 310.6(b)(1)) to such a drug, and which has not been the subject of a final determination by the Secretary that it is a “new drug” (within the meaning of section 201(p) of the FFDCA) or an action brought by the Secretary under sections 301, 302(a), or 304(a) of FFDCA to enforce section 502(f) or 505(a) of the FFDCA; (iii) Is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the Secretary has determined there is a compelling justification for its medical need or is identical, similar, or related (within the meaning described in FDA regulations at 21 CFR 310.6(b)(1)) to such a drug or for which the Secretary has not issued a notice for an opportunity for a hearing under section 505(e) of the FFDCA on a proposed order of the Secretary to withdraw approval of an application for such drug under section 505(e) of the FFDCA because the Secretary has determined that the drug is less than effective for some or all conditions of use prescribed, recommended, or suggested in its labeling; (iv) Is a biological product other than a vaccine that may only be dispensed upon a prescription and is licensed under section 351 of the Public Health Service Act (PHSA) and is produced at an establishment licensed under section 351 of the PHSA to produce such product; or (v) Is insulin certified under section 506 of the FFDCA. (2) A covered outpatient drug does not include any drug, biological product, or insulin provided as part of or incident to and in the same setting as any of the services in paragraphs (2)(i) through (viii) of this definition (and for which payment may be made as part of payment for that service and not as direct reimbursement for the drug, as described in paragraph (4) of this definition). (i) Inpatient Services; (ii) Hospice Services; (iii) Dental Services, except that drugs for which the State plan authorizes direct reimbursement to the dispensing dentist are covered outpatient drugs; (iv) Physician services; (v) Outpatient hospital services; (vi) Nursing facility and services provided by an intermediate care facility for individuals with intellectual disabilities; (vii) Other laboratory and x-ray services; or (viii) Renal dialysis. (3) A covered outpatient drug does not include: (i) Any drug product, prescription or over-the-counter (OTC), for which an NDC number is not required by the FDA; (ii) Any drug product for which a manufacturer has not submitted to CMS evidence to demonstrate that the drug product satisfies the criteria in paragraph (1) of this definition; (iii) Any drug product or biological used for a medical indication which is not a medically accepted indication; or (iv) Over-the-counter products that are not drugs. (4) Direct reimbursement for a drug may include both: (i) Reimbursement for a drug alone, or (ii) Reimbursement for a drug plus the service, in a single inclusive payment if: (A) The drug, charge for the drug, and number of units of the drug are separately identified on the claim, and; (B) The inclusive payment includes an amount directly attributable to the drug, and, (C) The amount paid that is attributable to the drug is based on a reimbursement methodology that is included in the applicable section of the State plan. Customary prompt pay discount Drug product information Innovator multiple source drug Internal investigation Lagged price concession Line extension Manufacturer (1) Is engaged in the production, preparation, propagation, compounding, conversion, or processing of covered outpatient drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis; or (2) Is engaged in the packaging, repackaging, labeling, relabeling, or distribution of covered outpatient drug products and is not a wholesale distributor of drugs or a retail pharmacy licensed under State law. (3) For authorized generic products, the term “manufacturer” will also include the original holder of the NDA. (4) For drugs subject to private labeling arrangements, the term “manufacturer” will also include the entity under whose own label or trade name the product will be distributed. Market date, Multiple source drug (1) Is rated as therapeutically equivalent (under the FDA's most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations” which is available at http://www.accessdata.fda.gov/scripts/cder/ob/ (2) Except as provided at section 1927(k)(7)(B) of the Act, is pharmaceutically equivalent and bioequivalent, as defined at section 1927(k)(7)(C) of the Act and as determined by FDA. (3) Is sold or marketed in the United States during the period. National drug code (NDC) National rebate agreement New formulation Nominal price Noninnovator multiple source drug (1) A multiple source drug that is not an innovator multiple source drug or a single source drug; (2) A multiple source drug that is marketed under an ANDA or an abbreviated antibiotic drug application; (3) A covered outpatient drug that entered the market before 1962 that is not marketed under an NDA; (4) Any drug that has not gone through an FDA approval process, but otherwise meets the definition of covered outpatient drug; or (5) If any of the drug products listed in this definition of a noninnovator multiple source drug subsequently receives an NDA or ANDA approval from FDA, the product's drug category changes to correlate with the new product application type. Oral solid dosage form Over-the-counter (OTC) drug Pediatric indication Professional dispensing fee (1) Is incurred at the point of sale or service and pays for costs in excess of the ingredient cost of a covered outpatient drug each time a covered outpatient drug is dispensed; (2) Includes only pharmacy costs associated with ensuring that possession of the appropriate covered outpatient drug is transferred to a Medicaid beneficiary. Pharmacy costs include, but are not limited to, reasonable costs associated with a pharmacist's time in checking the computer for information about an individual's coverage, performing drug utilization review and preferred drug list review activities, measurement or mixing of the covered outpatient drug, filling the container, beneficiary counseling, physically providing the completed prescription to the Medicaid beneficiary, delivery, special packaging, and overhead associated with maintaining the facility and equipment necessary to operate the pharmacy; and (3) Does not include administrative costs incurred by the State in the operation of the covered outpatient drug benefit including systems costs for interfacing with pharmacies. Rebate period Single source drug States United States Value-based purchasing (VBP) arrangement (1) Evidence-based measures, which substantially link the cost of a covered outpatient drug to existing evidence of effectiveness and potential value for specific uses of that product; and/or (2) Outcomes-based measures, which substantially link payment for the covered outpatient drug to that of the drug's actual performance in patient or a population, or a reduction in other medical expenses. Wholesaler [81 FR 5347, Feb. 1, 2016, as amended at 81 FR 80005, Nov. 15, 2016; 84 FR 64786, Nov. 25, 2019; 85 FR 87101, Dec. 31, 2020; 86 FR 64825, Nov. 19, 2021; 89 FR 79081, Sept. 26, 2024] § 447.504 Determination of average manufacturer price. (a) Definitions. Average manufacturer price (AMP) Average unit price Charitable and not-for profit pharmacies Insurers Net sales Retail community pharmacy (b) Sales, nominal price sales, and associated discounts, rebates, payments, or other financial transactions included in AMP. (1) Sales to wholesalers for drugs distributed to retail community pharmacies. (2) Sales to retail community pharmacies (including those sales, nominal price sales, and associated discounts, rebates (other than rebates under section 1927 of the Act or as specified in regulations), payments, or other financial transactions that are received by, paid by, or passed through to retail community pharmacies). (c) Sales, nominal price sales, and associated discounts, rebates, payments, or other financial transactions excluded from AMP. (1) Any prices on or after October 1, 1992, to the Indian Health Service (IHS), the Department of Veterans Affairs (DVA), a State home receiving funds under 38 U.S.C. 1741, the Department of Defense (DoD), the Public Health Service (PHS), or a covered entity described in section 1927(a)(5)(B) of the Act (including inpatient prices charged to hospitals described in section 340B(a)(4)(L) of the PHSA). (2) Any prices charged under the Federal Supply Schedule (FSS) of the General Services Administration (GSA). (3) Any depot prices (including TRICARE) and single award contract prices, as defined by the Secretary, of any agency of the Federal government. (4) Sales outside the United States. (5) Sales to hospitals. (6) Sales to health maintenance organizations (HMOs) (including managed care organizations (MCOs)), including HMO or MCO operated pharmacies. (7) Sales to long-term care providers, including nursing facility pharmacies, nursing home pharmacies, long-term care facilities, contract pharmacies for the nursing facility where these sales can be identified with adequate documentation, and other entities where the drugs are dispensed through a nursing facility pharmacy, such as assisted living facilities. (8) Sales to mail order pharmacies. (9) Sales to clinics and outpatient facilities (for example, surgical centers, ambulatory care centers, dialysis centers, and mental health centers). (10) Sales to government pharmacies (for example, a Federal, State, county, or municipal-owned pharmacy). (11) Sales to charitable pharmacies. (12) Sales to not-for-profit pharmacies. (13) Sales, associated rebates, discounts, or other price concessions paid directly to insurers. (14) Bona fide service fees, as defined in § 447.502, paid by manufacturers to wholesalers or retail community pharmacies. (15) Customary prompt pay discounts extended to wholesalers. (16) Reimbursement by the manufacturer for recalled, damaged, expired, or otherwise unsalable returned goods, including (but not limited to) reimbursement for the cost of the goods and any reimbursement of costs associated with return goods handling and processing, reverse logistics, and drug destruction, but only to the extent that such payment covers only those costs. (17) Associated discounts, rebates, or other price concessions provided under the Medicare Coverage Gap Discount Program under section 1860D-14A of the Act. (18) Payments received from and rebates and discounts provided to pharmacy benefit manufacturers (PBMs). (19) Rebates under the national rebate agreement or a CMS-authorized State supplemental rebate agreement paid to State Medicaid Agencies under section 1927 of the Act. (20) Sales to hospices (inpatient and outpatient). (21) Sales to prisons. (22) Sales to physicians. (23) Direct sales to patients. (24) Free goods, not contingent upon any purchase requirement. (25) Manufacturer coupons to a consumer redeemed by the manufacturer, agent, pharmacy or another entity acting on behalf of the manufacturer, but only to the extent that the full value of the coupon is passed on to the consumer and the pharmacy, agent, or other AMP-eligible entity does not receive any price concession. (26) Manufacturer-sponsored programs that provide free goods, including but not limited to vouchers and patient assistance programs, but only to the extent that: The voucher or benefit of such a program is not contingent on any other purchase requirement; the full value of the voucher or benefit of such a program is passed on to the consumer; and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (27) Manufacturer-sponsored drug discount card programs, but only to the extent that the full value of the discount is passed on to the consumer and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (28) Manufacturer-sponsored patient refund/rebate programs, to the extent that the manufacturer provides a full or partial refund or rebate to the patient for out-of-pocket costs and the pharmacy, agent, or other AMP eligible entity does not receive any price concessions. (29) Manufacturer copayment assistance programs, to the extent that the program benefits are provided entirely to the patient and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (30) Any rebates, discounts, or price concessions provided to a designated State Pharmacy Assistance Program (SPAP). (d) Sales, nominal price sales, and associated discounts, rebates, payments, or other financial transactions included in AMP for 5i drugs that are not generally dispensed through retail community pharmacies. (1) Sales to physicians. (2) Sales to pharmacy benefit managers. (3) Sales to health maintenance organizations (HMOs), including managed care organizations (MCOs). (4) Sales to insurers (except for rebates under section 1927 of the Act and this subpart). (5) Sales to hospitals. (6) Sales to clinics and outpatient facilities (for example, surgical centers, ambulatory care centers, dialysis centers, mental health centers). (7) Sales to mail order pharmacies. (8) Sales to long-term care providers, including nursing facility pharmacies, nursing home pharmacies, long-term care facilities, contract pharmacies for the nursing facility where these sales can be identified with adequate documentation, and other entities where the drugs are dispensed through a nursing facility pharmacy, such as assisted living facilities. (9) Sales to hospices (inpatient and outpatient). (10) Sales to manufacturers, or any other entity that does not conduct business as a wholesaler or retail community pharmacy. (e) Sales, nominal price sales, and associated discounts, rebates, payments, or other transactions excluded from AMP for 5i drugs that are not generally dispensed through retail community pharmacies. (1) Any prices on or after October 1, 1992, to the Indian Health Service (IHS), the Department of Veterans Affairs (DVA), a State home receiving funds under 38 U.S.C. 1741, the Department of Defense (DoD), the Public Health Service (PHS), or a covered entity described in section 1927(a)(5)(B) of the Act (including inpatient prices charged to hospitals described in section 340B(a)(4)(L) of the PHSA). (2) Any prices charged under the Federal Supply Schedule (FSS) of the General Services Administration (GSA). (3) Any depot prices (including TRICARE) and single award contract prices, as defined by the Secretary, of any agency of the Federal government. (4) Sales outside the United States. (5) Bona fide service fees as defined in § 447.502 paid by manufacturers to wholesalers or retail community pharmacies. (6) Customary prompt pay discounts extended to wholesalers. (7) Reimbursement by the manufacturer for recalled, damaged, expired, or otherwise unsalable returned goods, including (but not limited to) reimbursement for the cost of the goods and any reimbursement of costs associated with return goods handling and processing, reverse logistics, and drug destruction, but only to the extent that such payment covers only these costs. (8) Any prices charged which are negotiated by a prescription drug plan under Part D of title XVIII, by any MA-PD plan under Part C of such title for covered Part D drugs, or by a Qualified Retiree Prescription Drug Plan (as defined in section 1860D-22(a)(2) of the Act) for such drugs on behalf of individuals entitled to benefits under Part A or enrolled under Part B of Medicare, or any discounts provided by manufacturers under the Medicare coverage gap discount program under section 1860D-14A of the Act. (9) Rebates under the national rebate agreement or a CMS-authorized State supplemental rebate agreement paid to State Medicaid Agencies under section 1927 of the Act. (10) Any rebates, discounts, or price concessions provided to a designated State Pharmacy Assistance Program (SPAP). (11) Sales to patients. (12) Free goods, not contingent upon any purchase requirement. (13) Manufacturer coupons to a consumer redeemed by the manufacturer, agent, pharmacy or another entity acting on behalf of the manufacturer, but only to the extent that the full value of the coupon is passed on to the consumer and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (14) Manufacturer-sponsored programs that provide free goods, including, but not limited to vouchers and patient assistance programs, but only to the extent that the voucher or benefit of such a program is not contingent on any other purchase requirement; the full value of the voucher or benefit of such a program is passed on to the consumer; and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (15) Manufacturer-sponsored drug discount card programs, but only to the extent that the full value of the discount is passed on to the consumer and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (16) Manufacturer-sponsored patient refund/rebate programs, to the extent that the manufacturer provides a full or partial refund or rebate to the patient for out-of-pocket costs and the pharmacy, agent, or other AMP eligible entity does not receive any price concessions. (17) Manufacturer copayment assistance programs, to the extent that the program benefits are provided entirely to the patient and the pharmacy, agent, or other AMP eligible entity does not receive any price concession. (18) Sales to government pharmacies (for example, a Federal, State, county, or municipal-owned pharmacy). (19) Sales to charitable pharmacies. (20) Sales to not-for-profit pharmacies. (f) Further clarification of AMP calculation. (2) Quarterly AMP is calculated as a weighted average of monthly AMPs in that quarter. (3) The manufacturer must adjust the AMP for a rebate period if cumulative discounts, rebates, or other arrangements subsequently adjust the prices actually realized, to the extent that such cumulative discounts, rebates, or other arrangements are not excluded from the determination of AMP by statute or regulation. [81 FR 5347, Feb. 1, 2016, as amended at 85 FR 87102, Dec. 31, 2020; 89 FR 79082, Sept. 26, 2024] § 447.505 Determination of best price. (a) Definitions. Best price Provider (b) Prices included in best price. (c) Prices excluded from best price. (1) Any prices on or after October 1, 1992, charged to the IHS, the DVA, a State home receiving funds under 38 U.S.C. 1741, the DoD, or the PHS. (2) Any prices charged to a covered entity described in section 1927(a)(5)(B) of the Act (including inpatient prices charged to hospitals described in section 340B(a)(4)(L) of the PHSA). (3) Any prices charged under the FSS of the GSA. (4) Any prices, rebates, or discounts provided to a designated State Pharmacy Assistance Program (SPAP). (5) Any depot prices (including TRICARE) and single award contract prices, as defined by the Secretary, of any agency of the Federal government. (6) Any prices charged which are negotiated by a prescription drug plan under Part D of title XVIII, by any MA-PD plan under Part C of such title for covered Part D drugs, or by a Qualified Retiree Prescription Drug Plan (as defined in section 1860D-22(a)(2) of the Act) for such drugs on behalf of individuals entitled to benefits under Part A or enrolled under Part B of Medicare, or any discounts provided by manufacturers under the Medicare coverage gap discount program under section 1860D-14A of the Act. (7) Rebates under the national rebate agreement or a CMS-authorized supplemental rebate agreement paid to State Medicaid Agencies under section 1927 of the Act. (8) Manufacturer-sponsored drug discount card programs, but only to the extent that the full value of the discount is passed on to the consumer and the pharmacy, agent, or other entity does not receive any price concession. (9) Manufacturer coupons to a consumer redeemed by a consumer, agent, pharmacy, or another entity acting on behalf of the manufacturer; but only to the extent that the full value of the coupon is passed on to the consumer, and the pharmacy, agent, or other entity does not receive any price concession. (10) Manufacturer copayment assistance programs, to the extent that the program benefits are provided entirely to the patient and the pharmacy, agent, or other entity does not receive any price concession. (11) Manufacturer-sponsored patient refund or rebate programs, to the extent that the manufacturer provides a full or partial refund or rebate to the patient for out-of-pocket costs and the pharmacy, agent, or other entity does not receive any price concession. (12) Manufacturer-sponsored programs that provide free goods, including but not limited to vouchers and patient assistance programs, but only to the extent that the voucher or benefit of such a program is not contingent on any other purchase requirement; the full value of the voucher or benefit of such a program is passed on to the consumer; and the pharmacy, agent, or other entity does not receive any price concession. (13) Free goods, not contingent upon any purchase requirement. (14) Reimbursement by the manufacturer for recalled, damaged, expired, or otherwise unsalable returned goods, including, but not limited to, reimbursement for the cost of the goods and any reimbursement of costs associated with return goods handling and processing, reverse logistics, and drug destruction but only to the extent that such payment covers only these costs. (15) Nominal prices to certain entities as set forth in § 447.508. (16) Bona fide service fees as defined in § 447.502. (17) PBM rebates, discounts, or other financial transactions except their mail order pharmacy's purchases or where such rebates, discounts, or other financial transactions are designed to adjust prices at the retail or provider level. (18) Sales outside the United States. (19) Direct sales to patients. (d) Further clarification of best price. (2) Best price must be determined on a unit basis without regard to package size, special packaging, labeling, or identifiers on the dosage form or product or package. (3) The manufacturer must adjust the best price for a rebate period if cumulative discounts, rebates, or other arrangements subsequently adjust the prices available, to the extent that such cumulative discounts, rebates, or other arrangements are not excluded from the determination of best price by statute or regulation. [81 FR 5347, Feb. 1, 2016, as amended at 85 FR 87102, Dec. 31, 2020; 89 FR 79082, Sept. 26, 2024] § 447.506 Authorized generic drugs. (a) Definitions. Primary manufacturer Secondary manufacturer of an authorized generic drug (b) Exclusion of authorized generic drugs from AMP by a primary manufacturer. (c) Inclusion of authorized generic drugs in best price by a primary manufacturer. (d) Inclusion of authorized generic in AMP and best price by a secondary manufacturer. [81 FR 5347, Feb. 1, 2016, as amended at 85 FR 87102, Dec. 31, 2020] § 447.507 Identification of inhalation, infusion, instilled, implanted, or injectable drugs (5i drugs). (a) Identification of a 5i drug. (b) Not generally dispensed through a retail community pharmacy. (1) A 5i drug is not generally dispensed through a retail community pharmacy if 70 percent or more of the sales (based on units at the NDC-9 level) of the 5i drug, were to entities other than retail community pharmacies or wholesalers for drugs distributed to retail community pharmacies. (2) A manufacturer is responsible for determining and reporting to CMS whether a 5i drug is not generally dispensed through a retail community pharmacy on a monthly basis. § 447.508 Exclusion from best price of certain sales at a nominal price. (a) Exclusion from best price. (1) A covered entity as described in section 340B(a)(4) of the PHSA. (2) An ICF/IID providing services as set forth in § 440.150 of this chapter. (3) A State-owned or operated nursing facility providing services as set forth in § 440.155 of this chapter. (4) A public or non-profit entity, or an entity based at an institution of higher learning whose primary purpose is to provide health care services to students of that institution, that provides family planning services described under section of 1001(a) of PHSA, 42 U.S.C. 300. (5) An entity that: (i) Is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of that Act or is State-owned or operated; and (ii) Is providing the same services to the same type of population as a covered entity described in section 340B(a)(4) of the PHSA but does not receive funding under a provision of law referred to in such section. (b) Nonapplication. (c) Rule of construction. § 447.509 Medicaid drug rebates (MDR). (a) Determination of rebate amount Basic rebate for single source drugs and innovator multiple source drugs. (i) The total number of units of each dosage form and strength paid for under the State plan in the rebate period (as reported by the State); and (ii) The greater of: (A) The difference between the AMP and the best price for the dosage form and strength of the drug; or (B) The AMP for the dosage form and strength of the drug multiplied by one of the following percentages: ( 1 ( 2 ( 3 (2) Additional rebate for single source and innovator multiple source drugs. (i) The total number of units of such dosage form and strength paid for under the State plan in the rebate period. (ii) The amount, if any, by which: (A) The AMP for the dosage form and strength of the drug for the period exceeds: (B) The base date AMP for such dosage form and strength, increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index associated with the base date AMP of the drug. (3) Total rebate. (4) Treatment of new formulations. (A) The AMP of the line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form. (B) The highest additional rebate (calculated as a percentage of AMP) under this section for any strength of the original single source drug or innovator multiple source drug. (C) The total number of units of each dosage form and strength of the line extension product paid for under the State plan in the rebate period (as reported by the State). (ii) In the case of a drug that is a line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form, the rebate obligation for the rebate periods beginning on October 1, 2018 through December 31, 2021 is the amount computed under paragraphs (a)(1) through (3) of this section for such new drug or, if greater, the amount computed under paragraph (a)(1) of this section plus the product of all of the following: (A) The AMP of the line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form. (B) The highest additional rebate (calculated as a percentage of AMP) under this section for any strength of the original single source drug or innovator multiple source drug. (C) The total number of units of each dosage form and strength of the line extension product paid for under the State plan in the rebate period (as reported by the State). (iii) In the case of a drug that is a line extension of a single source drug or an innovator multiple source drug, provided that the initial single source drug or innovator multiple source drug is an oral solid dosage form, the rebate obligation for the rebate periods beginning on and after January 1, 2022 is the amount computed under paragraphs (a)(1) through (3) of this section for such new drug or, if greater, the amount computed under paragraph (a)(1) of this section plus the product of all of the following: (A) The AMP of the line extension of a single source drug or an innovator multiple source drug. (B) The highest additional rebate (calculated as a percentage of AMP) under this section for any strength of the original single source drug or innovator multiple source drug. (C) The total number of units of each dosage form and strength of the line extension product paid for under the State plan in the rebate period (as reported by the State). (iv) The alternative rebate is required to be calculated if the manufacturer of the line extension drug also manufactures the initial brand name listed drug or has a corporate relationship with the manufacturer of the initial brand name listed drug. (5) Limit on rebate. (6) Rebate for drugs other than a single source drug or innovator multiple source drug. (i) The total number of units of such dosage form and strength for which payment was made under the State plan for the rebate period; and (ii) The AMP for the dosage form and strength for the rebate period multiplied by 13 percent. (7) Additional rebate for drugs other than a single source drug or innovator multiple source drug. (i) The total number of units of such dosage form and strength paid for under the State plan in the rebate period. (ii) The amount, if any, by which: (A) The AMP for the dosage form and strength of the drug for the period exceeds the base date AMP for such dosage form and strength, increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index associated with the base date AMP of the drug. (B) The base date AMP has the meaning of AMP set forth in sections 1927(c)(2)(A)(ii)(II), 1927(c)(2)(B) and 1927(c)(3)(C) of the Act. (8) Total rebate. (9) Limit on rebate. (b) Rebates for drugs dispensed through Medicaid managed care organizations (MCOs). (2) Manufacturers are exempt from the requirement in paragraph (b)(1) of this section if such drugs are the following: (i) Dispensed by health maintenance organizations including MCOs that contract under section 1903(m) of the Act; and (ii) Discounted under section 340B of the PHSA. (c) Federal offset of rebates. (1) For single source or innovator multiple source drugs other than blood clotting factors and drugs approved by FDA exclusively for pediatric indications: (i) If AMP minus best price is less than or equal to AMP times 15.1 percent, then the offset amount is the full 8.0 percent of AMP (the difference between 23.1 percent of AMP and 15.1 percent of AMP). (ii) If AMP minus best price is greater than AMP times 15.1 percent but less than AMP times 23.1 percent, then the offset amount is the difference between AMP times 23.1 percent and AMP minus best price. (iii) If AMP minus best price is equal to or greater than AMP times 23.1 percent, then there is no offset amount. (2) For single source or innovator multiple source drugs that are clotting factors and drugs approved by FDA exclusively for pediatric indications that are subject to a rebate percentage of 17.1 percent of AMP: (i) If AMP minus best price is less than or equal to AMP times 15.1 percent, then the offset amount is the full 2.0 percent of AMP (the difference between 17.1 percent of AMP and 15.1 percent of AMP). (ii) If AMP minus best price is greater than AMP times 15.1 percent but less than AMP times 17.1 percent, then the offset amount is the difference between AMP times 17.1 percent and AMP minus best price. (iii) If AMP minus best price is equal to or greater than AMP times 17.1 percent, then there is no offset amount. (3) For a drug that is a line extension of a single source or innovator multiple source drug that is an oral solid dosage form, the offset amount is the difference between the unit rebate amount (URA) calculation for the drug calculated based on the applicable rebate percentage in section 1927 of the Act prior to the Affordable Care Act and the calculation of the URA for the line extension drug, if greater, in accordance with the Affordable Care Act. (4) For a drug other than a single source drug or innovator multiple source drug, the offset amount is equal to 2.0 percent of the AMP (the difference between 13.0 percent of AMP and 11.0 percent of AMP). (d) Manufacturer misclassification of a covered outpatient drug and recovery of unpaid rebate amounts due to the misclassification and other penalties (1) Definition of misclassification. (i) Reported and certified to the agency its drug category or drug product information related to a covered outpatient drug that is not supported by the statute and applicable regulations; or, (ii) Reported and certified to the agency its drug category or drug product information that is supported by the statute and applicable regulations, but pays rebates to States at a level other than that associated with that classification. (2) Manufacturer notification by the agency of drug misclassification. (i) Provide the agency such drug product and drug pricing information needed to correct the misclassification of the covered outpatient drug and calculate rebate obligations due, if any, pursuant to paragraph (d)(3) of this section. The required pricing data submitted by the manufacturer to the agency shall include the best price information for the covered outpatient drug, if applicable, for the rebate periods for which the manufacturer misclassified the covered outpatient drug; and, (ii) Certify applicable price and drug product data after entered into the system by the agency. (3) Manufacturer payment of unpaid rebates due to misclassification determined by agency. (i) When the agency has determined that a manufacturer has misclassified a covered outpatient drug as described in paragraph (d)(1) of this section, such that rebates are owed to the States, and notification has been provided to the manufacturer as provided under paragraph (d)(2) of this section, a manufacturer must pay to each State an amount equal to the sum of the products of: (A) The difference between: ( 1 ( 2 (B) The total units of the drug paid for under the State plan in each period. (ii) Manufacturers must pay such rebates to the States for the period or periods of time that such covered outpatient drug was misclassified, based on the formula described in this section, within 60 calendar days of notification by the agency to the manufacturer of the misclassification, and provide documentation to the agency that the States were contacted by the manufacturer, and that such payments were made to the States within the 60 calendar days. (4) Agency authority to correct misclassifications and additional penalties for drug misclassification. (i) Correct the misclassification of the drug in the system on behalf of the manufacturer, using any pricing and drug product information that may have been provided by the manufacturer. In such case, the manufacturer must certify the applicable correction within 30 calendar days. (ii) Suspend the misclassified drug and the drug's status as a covered outpatient drug under the manufacturer's rebate agreement from the MDRP, and exclude the misclassified drug from FFP in accordance with section 1903(i)(10)(E) of the Act. (iii) Impose a civil monetary penalty (CMP) for each rebate period during which the drug is misclassified, not to exceed an amount equal to the product of: (A) The total number of units of each dosage form and strength of such misclassified drug paid for under any State plan during such a rebate period; and (B) 23.1 percent of the AMP for the dosage form and strength of such misclassified drug for that period. (iv) Other actions and penalties available under section 1927 of the Act (or any other provision of law), including referral to the HHS Office of the Inspector General and termination from the MDRP. (5) Transparency of manufacturers' drug misclassifications. [81 FR 5347, Feb. 1, 2016, as amended at 84 FR 12136, Apr. 1, 2019; 85 FR 87103, Dec. 31, 2020; 89 FR 79082, Sept. 26, 2024] § 447.510 Requirement and penalties for manufacturers. (a) Quarterly reports. (1) AMP, calculated in accordance with § 447.504. (2) Best price, calculated in accordance with § 447.505. (3) Customary prompt pay discounts, which are reported as an aggregate dollar amount for each covered outpatient drug at the nine-digit NDC level, provided to all wholesalers in the rebate period. (4) Prices that fall within the nominal price exclusion, which are reported as an aggregate dollar amount and include all sales of single source and innovator multiple source drugs to the entities listed in § 447.508(a) for the rebate period. (b) Reporting revised quarterly AMP, best price, customary prompt pay discounts, or nominal prices. (i) The change is a result of the drug category change or a market date change. (ii) The change is an initial submission for a product. (iii) The change is due to termination of a manufacturer from the MDR program for failure to submit pricing data and must submit pricing data to reenter the program. (iv) The change is due to a technical correction; that is, not based on any changes in sales transactions or pricing adjustments from such transactions. (v) The change is to address specific rebate adjustments to States by manufacturers, as required by CMS or court order, or under an internal investigation as defined at § 447.502, or an Office of Inspector General (OIG) or Department of Justice investigation. (vi) The change is a result of a VBP arrangement, as defined in § 447.502, requiring the manufacturer to make changes outside of the 12-quarter rule in this paragraph (b), when the outcome must be evaluated outside of the 12-quarter period. (2) A manufacturer must report revised AMP within the 12-quarter time period, except when the revision would be solely as a result of data pertaining to lagged price concessions. (c) Base date AMP report Reporting period. (2) Recalculation of the DRA base date AMP. (ii) A manufacturer may choose to recalculate the DRA base date AMP on a product-by-product basis. (iii) A manufacturer must use actual and verifiable pricing records in recalculating the DRA base date AMP. (3) Reporting a revised Affordable Care Act base date AMP. (4) Recalculation of the Affordable Care Act base date AMP. (ii) A manufacturer may choose to recalculate the Affordable Care Act base date AMP on a product-by-product basis. (iii) A manufacturer must use actual and verifiable pricing records in recalculating the Affordable Care Act base date AMP. (d) Monthly AMP Definition. (2) Calculation of monthly AMP. (i) The monthly AMP is calculated based on the weighted average of prices for all the manufacturer's package sizes of each covered outpatient drug sold by the manufacturer during a month. (ii) It is calculated as net sales divided by number of units sold, excluding goods or any other items specifically excluded in the statute or regulations. Monthly AMP is calculated based on the best data available to the manufacturer at the time of submission. (iii) In calculating monthly AMP, a manufacturer must estimate the impact of its lagged AMP-eligible price concessions using a 12-month rolling percentage in accordance with the methodology described in this paragraph (d)(2). (A) For each NDC-9 with at least 12 months of AMP-eligible sales, after adjusting for sales excluded from AMP, the manufacturer calculates a percentage equal to the sum of the price concessions for the most recent 12-month period (inclusive of the current reporting period) available associated with sales subject to the AMP reporting requirement divided by the total in dollars for the sales subject to the AMP reporting requirement for the same 12-month period. (B) For each NDC-9 with less than 12 months of AMP-eligible sales, the calculation described in paragraph (d)(2)(iii)(A) of this section is performed for the time period equaling the total number of months of AMP-eligible sales. (iv) The manufacturer multiplies the applicable percentage described in paragraph (d)(2)(iii)(A) or (B) of this section by the total in dollars for the sales subject to the AMP reporting requirement (after adjusting for sales excluded from AMP) for the month being submitted. The result of this multiplication is then subtracted from the total in dollars for the sales subject to the AMP reporting requirement (after adjusting for sales excluded from AMP) for the month being submitted. (v) The manufacturer uses the result of the calculation described in paragraph (d)(2)(iv) of this section as the numerator and the number of units sold in the month (after adjusting for sales excluded from AMP) as the denominator to calculate the manufacturer's AMP for the NDC for the month being submitted. (vi) Example. (3) Timeframe for reporting revised monthly AMP. (4) Exception. (5) Terminated products. (6) Monthly AMP units. (e) Certification of pricing reports. (1) The manufacturer's chief executive officer (CEO). (2) The manufacturer's chief financial officer (CFO). (3) An individual other than a CEO or CFO, who has authority equivalent to a CEO or a CFO; or (4) An individual with the directly delegated authority to perform the certification on behalf of an individual described in paragraphs (e)(1) through (3) of this section. (f) Recordkeeping requirements. (i) The records must include these data and any other materials from which the calculations of the AMP, the best price, customary prompt pay discounts, and nominal prices are derived, including a record of any assumptions made in the calculations. (ii) The 10-year timeframe applies to a manufacturer's quarterly and monthly submissions of pricing data, as well as any revised pricing data subsequently submitted to CMS. (2) A manufacturer must retain records beyond the 10-year period if all of the following circumstances exist: (i) The records are the subject of an audit, or of a government investigation related to pricing data that are used in AMP, best price, customary prompt pay discounts, or nominal prices of which the manufacturer is aware. (ii) The audit findings or investigation related to the AMP, best price, customary prompt pay discounts, or nominal price have not been resolved. (g) Data reporting format. (h) Suspension of manufacturer's NDRA for late reporting of drug pricing and drug product information. (1) If a manufacturer fails to timely provide information required to be reported to the agency under section 1927(b)(3)(A) of the Act, and paragraphs (a) and (d) of this section, the agency will provide written notice to the manufacturer of failure to provide timely information. If such information is not reported within 90 calendar days of the date of the notice communicated to the manufacturer electronically and in writing by the agency, such failure by the manufacturer to report such information in a timely manner shall result in suspension of the manufacturer's rebate agreement for all covered outpatient drugs furnished after the end of the 90-day calendar period. The rebate agreement will remain suspended until the date the information is reported to the agency in full and certified, and the agency reviews for completeness, but not for a period of fewer than 30 calendar days. Continued suspension of the rebate agreement could result in termination for cause. Suspension of a manufacturer's rebate agreement under this section applies for Medicaid purposes only and does not affect manufacturer obligations and responsibilities under the 340B Program or reimbursement under Medicare Part B during the period of the suspension. (2) During the period of the suspension, the covered outpatient drugs of the manufacturer are not eligible for FFP. The agency will notify the States 30 calendar days before the beginning of the suspension period for the manufacturer's rebate agreement and any applicable associated labeler rebate agreements. (i) Manufacturer audits of State-provided information. [81 FR 5347, Feb. 1, 2016, as amended at 85 FR 87103, Dec. 31, 2020; 89 FR 79084, Sept. 26, 2024] § 447.511 Requirements for States. (a) Invoices submitted to participating drug manufacturers. (1) The State code. (2) National Drug Code. (3) Period covered. (4) Product FDA list name. (5) Unit rebate amount. (6) Units reimbursed. (7) Rebate amount claimed. (8) Number of prescriptions. (9) Medicaid amount reimbursed. (10) Non-Medicaid amount reimbursed. (11) Total amount reimbursed. (b) Data submitted to CMS. (c) State that has participating Medicaid Managed care organizations (MCO). (d) State data certification. (1) The State Medicaid Director (SMD); (2) The Deputy State Medicaid Director (DSMD); (3) An individual other than the SMD or DSMD, who has authority equivalent to an SMD or DSMD; or (4) An individual with the directly delegated authority to perform the certification on behalf of an individual described in paragraphs (d)(1) through (3) of this section. (e) State data certification language. [43 FR 45253, Sept. 29, 1978, as amended at 85 FR 87103, Dec. 31, 2020] § 447.512 Drugs: Aggregate upper limits of payment. (a) Multiple source drugs. (b) Other drugs. (1) AAC plus a professional dispensing fee established by the agency; or (2) Providers' usual and customary charges to the general public. (c) Certification of brand name drugs. (2) The agency must decide what certification form and procedure are used. (3) A check off box on a form is not acceptable but a notation like “brand necessary” is allowable. (4) The agency may allow providers to keep the certification forms if the forms will be available for inspection by the agency or HHS. § 447.514 Upper limits for multiple source drugs. (a) Establishment and issuance of a listing. http://www.accessdata.fda.gov/scripts/cder/ob/. (2) CMS publishes the list of multiple source drugs for which upper limits have been established and any revisions to the list in Medicaid Program issuances. (b) Specific upper limits. (2) Exception. (c) Ensuring a drug is for sale nationally. (1) The AMP of a terminated NDC will not be used to set the Federal upper limit (FUL) beginning with the first day of the month after the termination date reported by the manufacturer to CMS. (2) The monthly AMP units data will be used to calculate the weighted average of monthly AMPs for all multiple source drugs to establish the FUL. (d) The FUL will be applied as an aggregate upper limit. § 447.516 Upper limits for drugs furnished as part of services. The upper limits for payment for prescribed drugs in this subpart also apply to payment for drugs provided as part of skilled nursing facility services and intermediate care facility services and under prepaid capitation arrangements. § 447.518 State plan requirements, findings, and assurances. (a) State plan. (i) A covered entity described in section 1927(a)(5)(B) of the Act. (ii) A contract pharmacy under contract with a covered entity described in section 1927(a)(5)(B) of the Act. (iii) An Indian Health Service, tribal and urban Indian pharmacy. (2) The agency's payment methodology in paragraph (a)(1) of this section must be in accordance with the definition of AAC in § 447.502. (b) Findings and assurances. (1) Findings. (i) In the aggregate, its Medicaid expenditures for multiple source drugs, identified and listed in accordance with § 447.514(a), are in accordance with the upper limits specified in § 447.514(b). (ii) In the aggregate, its Medicaid expenditures for all other drugs are in accordance with § 447.512. (2) Assurances. (c) Recordkeeping. (d) Data requirements. (2) A State participating in VBP arrangements approved under a CMS-authorized supplemental rebate agreement (SRA) must report data described in paragraph (d)(3) of this section on an annual basis. (3) Within 60 days of the end of each year, the State must submit all of the following data, including cumulative data to date: (i) State. (ii) National drug code(s) (for drugs covered under the CMS-authorized VBP SRA). (iii) Product's FDA list name. (iv) Number of prescriptions. (v) Cost to the State to administer the CMS-authorized VBP SRA (for example, systems changes, tracking outcomes, etc.). (vi) Total savings generated by the supplemental rebate due to the CMS-authorized VBP SRA. [81 FR 5347, Feb. 16, 2016, as amended at 86 FR 87104, Dec. 31, 2020; 89 FR 79084, Sept. 26, 2024] § 447.520 Federal Financial Participation (FFP): Conditions relating to physician-administered drugs. (a) Availability of FFP. 40 40 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-430. (1) Single source drugs. (2) Multiple source drugs. (3) States are required to invoice for rebates consistent with this section for multiple source physician-administered drugs that are CODs and that are not on the top 20 multiple source physician-administered drug list published under paragraph (c) of this section, or may be subject to a withhold of FFP as provided under 42 CFR 430.35. 41 41 (b) Required coding. (c) Top 20 multiple source physician-administered drug list. (d) Hardship waiver. [89 FR 79084, Sept. 26, 2024] § 447.522 Optional coverage of investigational drugs and other drugs not subject to rebate. (a) Medicaid coverage of investigational drugs may be provided at State option under section 1905(a)(12) of the Act when such drug is the subject of an investigational new drug application (IND) that has been allowed by FDA to proceed. (b) A State agency electing to provide coverage of an investigational drug must include in its State plan a description of the coverage and payment for such drug. (c) The State plan must indicate that any reimbursement for investigational drugs by the State are consistent with FDA regulations at 21 CFR part 312 if they are to be eligible to receive FFP for these drugs. (d) Medicaid coverage of other drugs may be provided at State option under section 1905(a)(12) of the Act provided that they are not eligible to be covered as covered outpatient drugs in the Medicaid Drug Rebate program. (e) Investigational drugs and other drugs are not subject to the rebate requirements of section 1927 of the Act provided they do not meet the definition of a covered outpatient drug as set forth in section 1927(k) of the Act.

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