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B-164031(3).154 1 (1980-03-04)

handle is hein.gao/gaobadibc0001 and id is 1 raw text is: __THE COMPTROLLER GENE -AL DEC~IDN 22~~-4OF THE UNITED SAE W AAS HINGT N. 0.C. 20548 FILE: B-16403103) .154 DATE: March 4, 1980 MATTER OF: Medicaid-Utilization Control DIGEST: Department of Health, Education, and Welfare (HEW) is required to reduce Medicaid payments to State under section 1903(g) of Social Security Act, 42 U.S.C. 1396b(g) as amended, unless State makes sat- isfactory and valid showing that it has program of control over utilization of long term institutional services. In order to make valid showing, State must comply with criteria listed in statute includ- ing physician certification of need and plan for care in case of each long term patient. Fact that State may have satisfied most of requirements of statute does not permit HEW to find showing valid where any long term patients are found not to have certification of need or plan of care. This decision is in response to a request from the former Sec- retary of the Department of Health, Ediation, and Welfare (HEW) for our o'nion concerning the Secretary's authority with.-eapect to t-h-e- reduc9eo- Medicaid payments>made to the States of Hawaii, Tennessee, Colorado and Missouri. The Secretary had determined that the payments must be reduced as a result of the failure of these States to satisfy, for the quarter ending March 31, 1978, the utilization control provi- sions of the Medicaid program set forth in section 1903(g) of the Social Security Act, as amended, 42 U.S.C. § 1396b(g) (1976 and Supp. I, 1977). Because these States have satisfied the requirements with respect to all but a few recipients of long term medical assistance, HEW feels that a full reduction in payments in accordance with the statutory for- mula is too harsh in light of the limited defects found. If this situation should occur again, HEW would like to know if it is authorized to find that a State has satisfied the utilization control provision of the act if the State has met the requirements in all except one or two instances. For the reasons stated below, there is no authority for the Secretary of HEW to make a finding of compliance under these circum- stances. Section 1903(g) of the Social Security Act requires HEW to reduce a State's Federal Medicaid payment unless the State has made a showing satisfactory to the Secretary of HEW that it had an adequate program of control over the utilization of institutional long term care for the -k CEe+~it 40 --- 1

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