(a) In generalThe Secretary, in consultation with the State agencies administering the State programs under parts B and E of subchapter IV, shall promulgate regulations for the review of such programs to determine whether such programs are in substantial conformity with—(1) State plan requirements under such parts B and E,
(2) implementing regulations promulgated by the Secretary, and
(3) the relevant approved State plans.
(b) Elements of review systemThe regulations referred to in subsection (a) shall—(1) specify the timetable for conformity reviews of State programs, including—(A) an initial review of each State program;
(B) a timely review of a State program following a review in which such program was found not to be in substantial conformity; and
(C) less frequent reviews of State programs which have been found to be in substantial conformity, but such regulations shall permit the Secretary to reinstate more frequent reviews based on information which indicates that a State program may not be in conformity;
(2) specify the requirements subject to review (which shall include determining whether the State program is in conformity with the requirement of section 671(a)(27) of this title), and the criteria to be used to measure conformity with such requirements and to determine whether there is a substantial failure to so conform;
(3) specify the method to be used to determine the amount of any Federal matching funds to be withheld (subject to paragraph (4)) due to the State program’s failure to so conform, which ensures that—(A) such funds will not be withheld with respect to a program, unless it is determined that the program fails substantially to so conform;
(B) such funds will not be withheld for a failure to so conform resulting from the State’s reliance upon and correct use of formal written statements of Federal law or policy provided to the State by the Secretary; and
(C) the amount of such funds withheld is related to the extent of the failure to so conform; and
(4) require the Secretary, with respect to any State program found to have failed substantially to so conform—(A) to afford the State an opportunity to adopt and implement a corrective action plan, approved by the Secretary, designed to end the failure to so conform;
(B) to make technical assistance available to the State to the extent feasible to enable the State to develop and implement such a corrective action plan;
(C) to suspend the withholding of any Federal matching funds under this section while such a corrective action plan is in effect; and
(D) to rescind any such withholding if the failure to so conform is ended by successful completion of such a corrective action plan.
(c) Provisions for administrative and judicial reviewThe regulations referred to in subsection (a) shall—(1) require the Secretary, not later than 10 days after a final determination that a program of the State is not in conformity, to notify the State of—(A) the basis for the determination; and
(B) the amount of the Federal matching funds (if any) to be withheld from the State;
(2) afford the State an opportunity to appeal the determination to the Departmental Appeals Board within 60 days after receipt of the notice described in paragraph (1) (or, if later, after failure to continue or to complete a corrective action plan); and
(3) afford the State an opportunity to obtain judicial review of an adverse decision of the Board, within 60 days after the State receives notice of the decision of the Board, by appeal to the district court of the United States for the judicial district in which the principal or headquarters office of the agency responsible for administering the program is located.
Structure US Code
Title 42— THE PUBLIC HEALTH AND WELFARE
SUBCHAPTER XI— GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION
§ 1304. Reservation of right to amend or repeal
§ 1305. Short title of chapter
§ 1306a. Public access to State disbursement records
§ 1306c. Restriction on access to the Death Master File
§ 1310. Cooperative research or demonstration projects
§ 1311. Public assistance payments to legal representatives
§ 1312. Medical care guides and reports for public assistance and medical assistance
§ 1313. Assistance for United States citizens returned from foreign countries
§ 1314. Public advisory groups
§ 1314a. Measurement and reporting of welfare receipt
§ 1315. Demonstration projects
§ 1315a. Center for Medicare and Medicaid Innovation
§ 1315b. Providing Federal coverage and payment coordination for dual eligible beneficiaries
§ 1316. Administrative and judicial review of public assistance determinations
§ 1318. Alternative Federal payment with respect to public assistance expenditures
§ 1320. Approval of certain projects
§ 1320a. Uniform reporting systems for health services facilities and organizations
§ 1320a–1. Limitation on use of Federal funds for capital expenditures
§ 1320a–2. Effect of failure to carry out State plan
§ 1320a–3a. Disclosure requirements for other providers under part B of Medicare
§ 1320a–4. Issuance of subpenas by Comptroller General
§ 1320a–6. Adjustments in SSI benefits on account of retroactive benefits under subchapter II
§ 1320a–6a. Interagency coordination to improve program administration
§ 1320a–7a. Civil monetary penalties
§ 1320a–7b. Criminal penalties for acts involving Federal health care programs
§ 1320a–7c. Fraud and abuse control program
§ 1320a–7d. Guidance regarding application of health care fraud and abuse sanctions
§ 1320a–7e. Health care fraud and abuse data collection program
§ 1320a–7f. Coordination of medicare and medicaid surety bond provisions
§ 1320a–7g. Funds to reduce medicaid fraud and abuse
§ 1320a–7h. Transparency reports and reporting of physician ownership or investment interests
§ 1320a–7i. Reporting of information relating to drug samples
§ 1320a–7j. Accountability requirements for facilities
§ 1320a–7k. Medicare and Medicaid program integrity provisions
§ 1320a–8. Civil monetary penalties and assessments for subchapters II, VIII and XVI
§ 1320a–8a. Administrative procedure for imposing penalties for false or misleading statements
§ 1320a–8b. Attempts to interfere with administration of this chapter
§ 1320a–9. Demonstration projects
§ 1320a–10. Effect of failure to carry out State plan
§ 1320b–1. Notification of Social Security claimant with respect to deferred vested benefits
§ 1320b–2. Period within which certain claims must be filed
§ 1320b–4. Nonprofit hospital or critical access hospital philanthropy
§ 1320b–5. Authority to waive requirements during national emergencies
§ 1320b–7. Income and eligibility verification system
§ 1320b–8. Hospital protocols for organ procurement and standards for organ procurement agencies
§ 1320b–9a. Child health quality measures
§ 1320b–9b. Adult health quality measures
§ 1320b–10. Prohibitions relating to references to Social Security or Medicare
§ 1320b–11. Blood donor locator service
§ 1320b–12. Research on outcomes of health care services and procedures
§ 1320b–13. Social security account statements
§ 1320b–15. Protection of social security and medicare trust funds
§ 1320b–17. Cross-program recovery of overpayments from benefits
§ 1320b–19. The Ticket to Work and Self-Sufficiency Program
§ 1320b–20. Work incentives outreach program
§ 1320b–21. State grants for work incentives assistance to disabled beneficiaries
§ 1320b–23. Pharmacy benefit managers transparency requirements
§ 1320b–24. Consultation with Tribal Technical Advisory Group