# Groundfish of the Bering Sea and Aleutian Islands Area

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URL: https://www.frixlaw.com/law-library/documents/fr%3A94-23279

## Record

- **Collection:** Federal Register
- **Document type:** Uncategorized Document
- **Published:** September 26, 1994

## Text

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 435 and 436

[MB-52-IFC]
RIN 0938-AF69

Medicaid Program: Outstation Intake Locations for Certain Low-
Income Pregnant Women, Infants, and Children Under Age 19

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Interim final rule with comment period.

-----------------------------------------------------------------------

SUMMARY: This interim final rule interprets the statutory requirement
that State Medicaid agencies must provide for receiving and initially
processing Medicaid applications by certain low-income pregnant women,
infants, and children under age 19 at locations other than those used
for the receipt and processing of applications for Aid to Families with
Dependent Children (AFDC). The statutory requirement also provides that
the application form for these individuals must be different from the
application form used for AFDC.
The basis for the rule is section 1902(a)(55) of the Social
Security Act, as added by section 4602(a)(3) of the Omnibus Budget
Reconciliation Act of 1990.

DATES: Effective Date. This interim final rule is effective on October
24, 1994.
Comment Date. Comments will be considered if received at the
appropriate address, as provided in the ``ADDRESSES'' section below, no
later than 5:00 p.m. on November 22, 1994.

ADDRESSES: Mail comments (original and three copies) to the following
address: Health Care Financing Administration, Department of Health and
Human Services, Attention: MB-52-IFC, P.O. Box 7518, Baltimore, Md.
21207-0518.
Please address a copy of comments on information collection
requirements to: Office of Information and Regulatory Affairs,
Attention: Laura Oliven, Office of Management and Budget, Room 3002,
New Executive Office Building, Washington, DC 20503.
If you prefer, you may deliver your comments (original and three
copies) to one of the following addresses: Room 309-G, Hubert H.
Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201,
or Room 132, East High Rise Building, 6325 Security Boulevard,
Baltimore, Maryland 21207.
Because of staffing and resource limitations, we cannot accept
comments of facsimile (FAX) transmission.
In commenting, please refer to file code MB-52-IFC. Timely comments
will be available for public inspection as they are received, beginning
approximately three weeks after publication of this document, in room
309-G of the Department's offices at 200 Independence Avenue, SW.,
Washington, DC, on Monday through Friday of each week from 8:30 a.m. to
5:00 p.m. (telephone: (202) 690-7890).

FOR FURTHER INFORMATION CONTACT: Robert Tomlinson, (410) 966-4463.

SUPPLEMENTARY INFORMATION:

I. Background

Generally, sections 1902(a)(10)(A) and (C) of the Social Security
Act (the Act) specify the groups of individuals who may be eligible for
Medicaid. Among these groups are low-income pregnant women, infants,
and children under age 19 who have incomes that are a specified
percentage of the Federal poverty level. Because Medicaid eligibility
for many of the eligibility groups specified under section
1902(a)(10)(A) is associated with eligibility for or receipt of Aid to
Families With Dependent Children (AFDC), many State Medicaid agencies
provide for the receipt and processing of Medicaid applications at
welfare offices, either concurrent with or separate from application
for AFDC or other cash assistance. In most cases in which an individual
is determined to be eligible for AFDC on the basis of an AFDC
application, Medicaid eligibility is automatic without a separate
Medicaid application. For other eligibility groups, such as low-income
pregnant women, infants, and children under age 19 with incomes related
to the Federal poverty level, eligibility for Medicaid is not
associated with AFDC eligibility.
In an effort to make the Medicaid application process more
accessible to low-income pregnant women, infants, and children under
age 19, Congress enacted section 4602 of the Omnibus Budget
Reconciliation Act of 1990 (OBRA '90), Public Law 101-508, on November
5, 1990. Section 4602(a)(3) amended the Social Security Act to add a
new Medicaid State plan requirement under section 1902(a)(55) relating
to the application process for these eligibility groups. The new
section 1902(a)(55) requires that a State Medicaid plan provide for
receipt and initial processing of Medicaid applications from the
following groups of individuals at locations other than those used for
processing applications for AFDC and for using at these locations an
application form for Medicaid that is not the AFDC application form:
Individuals specified under section 1902(a)(10)(A)(i)(IV)
of the Act (the mandatory eligibility group of pregnant women or
infants with incomes up to 133 percent of the Federal poverty level);
Individuals specified under section 1902(a)(10)(A)(i)(VI)
of the Act (the mandatory eligibility group of children age 1 up to age
6 with incomes at 133 percent of the Federal poverty level);
Individuals specified under section 1902(a)(10)(A)(i)(VII)
of the Act (the mandatory eligibility group of children age 6 up to age
19 born after September 30, 1983, with incomes up to 100 percent of the
Federal poverty level);
Individuals specified under section 1902(a)(10)(A)(ii)(IX)
of the Act (the optional eligibility groups of pregnant women or
infants, children age 1 up to age 6, and children age 6 up to age 19,
who are not eligible as a mandatory group, with incomes up to 185
percent of the Federal poverty level).
Section 1902(a)(55) provides that the outstation locations for
receipt and initial processing of applications for these individuals
must include facilities defined as disproportionate share hospitals
under section 1923(a)(1)(A) of the Act and Federally-qualified health
centers described in section 1905(1)(2)(B) of the Act.
The provisions of section 1902(a)(55) apply to Medicaid payments
for calendar quarters beginning on or after July 1, 1991, without
regard to whether final regulations to carry out the provisions have
been promulgated by that date.

II. Provisions of the Regulations

We are amending the Medicaid regulations under 42 CFR parts 435 and
436 to incorporate the provisions of section 1902(a)(55) of the Act.
Specifically--
1. Outstation Locations
We have added a new Sec. 435.904 to require that the State Medicaid
agency provide an opportunity for the designated groups of low-income
pregnant women, infants, and children under age 19 to apply for
Medicaid and have their application initially processed at locations
other than those at which AFDC applications are received and processed.
The statutory language of section 1902(a)(55) of the Act, as added by
section 4602 of OBRA '90, requires that States provide an opportunity
to apply for Medicaid at locations other than welfare offices,
including Federally-qualified health centers and disproportionate share
hospitals. By specifying that certain types of facilities be among the
outstation locations, Congress clearly intended that, at a minimum,
Federally qualified health centers and disproportionate share hospitals
would be among the outstation locations.
We consulted extensively with States and related organizations and
agencies before developing these interim final regulations. During this
consultation, we considered the option of requiring States to
outstation staff at every site operated by each Federally-qualified
health center and disproportionate share hospital. However, we rejected
this requirement because we believe that it would be burdensome on the
States. Therefore, to provide States with as much flexibility as
possible, especially in this era of restricted resources, we have
chosen to offer States two choices for implementing the outstationing
requirement. A State may establish outstation locations at each
Federally-qualified health center and each disproportionate share
hospital participating in the State's Medicaid program and providing
services to Medicaid-eligible pregnant women and to children, but not
at every site operated by these entities. As an alternative, a State
may submit a plan that provides for outstation locations which include
at least some Federally-qualified health centers and disproportionate
share hospitals, but not all such entities that provide services to the
target populations. For the alternative plan to be approved by HCFA,
the State must demonstrate that it is equally or more effective in
outreach than a plan that would meet the general requirement, including
the same level of staffing and funding by the State as the State would
be required to commit to implement outstationing under the general
requirement.
We are requiring that the outstations include Indian health clinics
operated by a tribe or tribal organization, as these clinics are
specifically included in the definition of Federally-qualified health
centers under section 1905(1)(2)(B) of the Act, and included in the
definition of rural health clinics under 42 CFR part 491, subpart A. If
a Federally-qualified health center or disproportionate share hospital
has more than one site, the State must ensure that applications for
Medicaid can be taken at an outstation location.
In addition to placing outstationed eligibility workers at
Federally-qualified health centers and disproportionate share hospitals
(or locations under an approved alternative plan) that provide services
to Medicaid-eligible pregnant women and to children, States may
consider other locations that are frequently visited by the targeted
populations. For example, States may consider family support centers or
school-linked service centers in addition to other sites operated by
Federally-qualified health centers as suitable outstation locations.
To permit additional flexibility, we are allowing a State, at its
option, to enter into reciprocal agreements with adjoining States to
ensure that the population living in border areas of a State have the
opportunity to apply for Medicaid at the health care locations they
normally frequent when those facilities are in another State
(Sec. 435.904(c)(4)).
2. Initial Processing
Section 1902(a)(55) provides for ``initial processing'' of
applications for the designated low-income pregnant women, infant, and
children groups. However, the phrase ``initial processing'' is
ambiguous and is not defined in the statute. The House Report
accompanying OBRA '90 states that the ``entire application process
would be conducted at [an outstation],'' and that the final eligibility
determination could also be made there. The language of the House
Report goes further to state that ``even if the eligibility worker were
an employee of the hospital or clinic, the pregnant woman or child
would not be required to go to the welfare office for a face-to-face
interview in order to complete the eligibility determination process.
Instead, the simplified application form, along with necessary
documentation, would then be forwarded to the welfare office for final
determination.'' (H. Rept. No. 881, 101st Cong., 2d Sess. 105 (1990)).
We are, therefore, defining ``initial processing'' to mean taking
applications, assisting applicants in completing the application,
providing information and referrals, obtaining required documentation
to complete processing of the application, assuring that the
information contained on the application form is complete, and
conducting any necessary interviews. Initial processing does not
include evaluating the information contained on the application and the
supporting documentation nor making a determination of eligibility or
ineligibility Sec. 435.904(d)(2). Even though the phrase ``initial
processing'' is not defined to include determinations of eligibility or
ineligibility, State eligibility workers who are assigned to outstation
locations may perform these tasks if they are authorized to do so in
the regular Medicaid agency intake office, as discussed in detail
below. If we were to define initial processing to include making a
determination of eligibility, the definition would conflict with the
requirement of section 1902(a)(5) of the Act. Under section 1902(a)(5),
the plan must be administered by a single State agency and
determination of eligibility is restricted by this section to the
Medicaid agency, the title IV-A agency, or SSA when administering the
SSI program.
3. Staffing
The State must assure HCFA that staff are available at each
outstation location to accept applications and assist applicants with
the application process during the hours that the regular State
Medicaid offices are normally open (Sec. 435.904(e)). In addition, we
are providing an exception to this requirement for staffing, and hours
when staff are available, at locations that are infrequently used by
the designated groups of low-income pregnant women, infants, and
children. To fulfill the spirit of this legislation, we also encourage
States to make outstation workers available at additional hours in the
evening or on weekends beyond the minimum staffing requirement set
forth in these regulations, thereby making access and the opportunity
to apply for Medicaid as easy as possible for the designated groups.
In order to provide the States with as much flexibility as
possible, we are allowing States to target and conserve their resources
while complying with the requirement on availability of staff. We are
not requiring outstation intake workers to be employees of the State
Medicaid agency, which is consistent with our regulations under 42 CFR
Part 432. However, all staff that perform this function must be trained
to assist applicants in filing applications and to accurately answer
questions that applicants may have or to refer such questions to the
State agency's regular office for answers. At a minimum, staff must be
available at all Federally-qualified health centers and
disproportionate share hospitals that provide services to Medicaid-
eligible pregnant women and to children. Proper application forms must
be on hand at all locations.
We are permitting States to staff outstation locations with State
employees, provider or contractor employees, or volunteers under
certain conditions and limitations. When a State places staff at
outstation locations, the State may schedule persons to either work at
a specific location or rotate among several locations. State employees
who are placed at outstation locations may perform any tasks in
connection with the receipt of, and processing of, an application for
Medicaid at the outstation location that the employee would be
authorized to perform at the State agency office, including the
eligibility determination. Provider or contractor employees at these
locations may only perform initial processing. This includes taking all
actions in receiving and processing applications and excludes
evaluating information provided on applications and supporting
documentation and making eligibility determinations. If contractor or
provider employees, including provider contractors, are used, the State
must ensure, whether by contract or other means, that these employees
adhere to State and Federal confidentiality of information provisions
concerning applicant and recipient information as specified in 42 CFR
431.300 through 431.307, to the prohibition on reassignment of provider
claims, as specified in 42 CFR 447.10, and to all State and Federal
laws concerning conflicts of interest. Volunteers may be used in the
same manner as provider or contractor employees, with the same
requirements for adherence to confidentiality of information and
conflict of interest prohibitions. These provisions are consistent with
our regulations at 42 CFR 431.10 (c) and (e) which specify the entities
authorized to make determinations of eligibility for Medicaid and the
authority of the single State agency.
At locations that are infrequently used by low-income pregnant
women, infants, and children under 19, States may use volunteers,
provider or contractor employees, or State agency staff, or telephone
assistance. At these locations, the State must display a notice in a
prominent place advising potential applicants about when outstation
intake staff will be available. The notification methods must take into
account the needs and characteristics of the population served. The
notice must provide a telephone number that applicants may call for
assistance with initial processing of an application when staff are not
available. The notice also must comply with Federal and State laws and
regulations concerning the provision of adequate notice to persons who
are blind or deaf or who cannot read or understand the English
language. The notice must adequately inform these people of the
opportunity to apply for Medicaid at locations other than the welfare
office.
4. Application Forms
Section 1902(a)(55)(B) specifies that the application form that is
to be used by the designated groups of low-income pregnant women,
infants, and children under 19 at the Medicaid outstation locations
must be an application other than that used to apply for AFDC. The
legislative history for OBRA '90 states that the House Committee bill
would require States to provide for the use of applications for
Medicaid-only coverage at outreach locations. It also states that
``States would develop application forms for use at designated
hospitals, health centers, and other outreach locations. These
simplified forms would contain only those information requirements
necessary to determine eligibility for Medicaid.'' (Emphasis added.) H.
Rept. No. 881, 101st Cong., 2d. Sess. 105 (1990). The legislative
history language further lists the items which should appear on the
application form.
To permit as much flexibility as possible within the scope of the
statutory language, we are specifying in Sec. 435.907(c) that the
application form, including any computerized application form, used at
outstation locations be an application designed for the designated
groups of low-income pregnant women, infants, and children under age
19, an application already used by Medicaid for applicants seeking
Medicaid only, or a multiple-program application form in which only
that information appropriate for the Medicaid program is obtained from
the designated low-income eligibility groups. The application form used
may not be the application form used to apply for AFDC. In response to
expressed concerns, we are permitting States to continue to use an
application form that is designed to accommodate all assistance
programs under certain circumstances. States may continue to use a
multiple-program application form if the form contains Medicaid-only
application sections or parts and it is clear to Medicaid applicants
that they can choose to complete only those sections or parts of the
application relating to Medicaid information requirements. The person
assisting the applicant at the outstation location must make it clear
to the applicant before the application is completed that only the
information pertinent to Medicaid eligibility for the groups described
in section 1902(a)(55) needs to be completed.

III. Federal Financial Participation

Federal financial participation (FFP) is available for costs
associated with the outstation locations, regardless of who provides
the services. However, effective October l, 1992, under the provisions
of section l903(w) (as added by section 2(a) of the Medicaid Voluntary
Contribution and Provider Specific Tax Amendments of 1991, Public Law
102-234, December 12, 1991), FFP is limited if a State receives
donations for outstationed eligibility workers made by a hospital,
clinic, or similar entity for the direct costs of State or local agency
personnel who are stationed at a facility to determine Medicaid
eligibility or to provide outreach services to eligible (or potentially
eligible) individuals. Direct costs include salaries and fringe
benefits for outstationed workers and the cost of pamphlets and
materials distributed by outstationed eligibility workers at the site.
These donations may not exceed 10 percent of the State's total Medicaid
administrative costs, excluding costs for family planning services.
Donations in excess of this 10-percent limit will be deducted from the
State's medical assistance expenditures prior to calculation of FFP.
Outstationed worker donations are also included in an overall
limitation (computed in accordance with a formula specified in section
1903(w) of the Act) on permissible donations that a State may receive.
The administrative functions of taking and processing applications
are reimbursed at the 50 percent rate under the provisions of section
1903(a)(7) of the Act as costs found necessary by the Secretary for the
proper and efficient administration of the State plan. Subject to the
limitations for outstationed eligibility worker donations discussed
above, this rate includes costs incurred by the State to implement and
provide outstationing of intake workers who are State employees,
provider employees, volunteers, or provider contractors. FFP is
available for necessary administrative costs such as salaries, fringe
benefits, travel, training, equipment, and space directly attributable
to the outstationing of intake workers.
Existing regulations under Secs. 432.50, 433.15, and 435.1001
already contain provisions for FFP for staffing and training costs and
for administrative costs that States incur in determining and
redetermining Medicaid eligibility.

IV. Application of Rules in Territories

The requirements of section 1902(a)(55) are applicable in Guam,
Puerto Rico, and the Virgin Islands. Our existing regulations on
eligibility determinations in the Territories cross-refer to the
regulations under Part 435. Therefore, no further major changes in the
regulations are necessary to make these interim final regulations
applicable in the Territories. We have made a minor conforming change
to Sec. 436.2.

V. Waiver of Proposed Rulemaking

The statutory effective date of section 1902(a)(55) of the Act (as
added by section 4602(a)(3) of OBRA '90) is July 1, 1991, without
regard to whether regulations have been promulgated. Section 4207(k) of
OBRA '90 gives the Secretary authority to issue regulations on an
interim or other basis as may be necessary to implement the amendments
made by the provisions of OBRA '90. Thus, we are utilizing the
authority given by section 4207(k) and publishing this rule as an
interim final rule. As stated earlier in this preamble, we have had
extensive consultation with States and related organizations and
agencies in developing the regulations. We are also providing a 60-day
comment period for public comments on this interim final rule.

VI. Response to Public Comments

Because of the large number of items of correspondence we normally
receive on a rule, we are not able to acknowledge or respond to them
individually. However, we will consider all comments that we receive by
the date specified in the ``Comment Period'' section of this preamble
and respond to them in the preamble to any subsequent rule that we
issue.

VII. Paperwork Burden

Section 435.907(c) of these interim final regulations with comment
period contains a revised information collection requirement that is
subject to review by the Office of Management and Budget under the
Paperwork Reduction Act of 1980 (44 U.S.C. Chapter 35). State agencies
may be required to develop a separate Medicaid-only application form
for the designated groups of low-income pregnant women, infants, and
children who may apply for Medicaid at outstation locations if a
Medicaid-only application is not currently available, or to amend their
existing multiple-program application form to conform it to the
requirement that there must be a clearly identified Medicaid-only
application section. We estimate that the burden hours for States to
develop or revise this application format will be 20 hours.
We do not anticipate any additional reporting burden hours on
applicants in the designated groups, as they are required under
currently approved reporting requirements to complete a Medicaid
application form for a determination of eligibility for Medicaid.
We do, however, anticipate an increased reporting burden for those
States that choose the option of submitting an alternate plan for the
establishment of outstation location sites under Sec. 435.904(c). These
States will have to demonstrate that the alternate plan compares
favorably to a plan to establish outstation locations at each
disproportionate share hospital and each Federally-qualified health
center. The State must demonstrate that the alternative plan, at a
minimum, is equally effective and commits an equal amount of staffing
and funding. We estimate that it will require a minimum of 40
additional hours to develop an alternative plan.
We will publish a notice in the Federal Register when the approval
of the information collection requirements is obtained.

VIII. Regulatory Impact Statement

We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612), unless the Secretary certifies that a final regulation
will not have a significant economic impact on a substantial number of
small entities. For purposes of the RFA, individuals and States are not
included in the definition of a small entity.
We do not believe that this interim final rule will have a
significant effect on a substantial number of small entities. The
statutory changes increase Medicaid program expenditures independently
of the promulgation of this rule and are effective on the statutory
established date, regardless of whether we have issued final
regulations. Costs associated with the interim final rule are the
result of legislation or due to interpretation of statutory changes
already in effect. We estimate that the Federal Medicaid costs
associated with implementation of the legislative changes will be
approximately $40 million per fiscal year, and the State costs to be
approximately $30 million per fiscal year.
This interim final rule incorporates, and, in some cases,
interprets in regulations statutory changes that are already in effect.
In cases where it was necessary to provide interpretations, we have
relied on the available legislative history of the statutory provisions
to reach the best reading of the provision. Therefore, we have not
prepared a regulatory flexibility analysis under the RFA.
Section 1102(b) of the Act requires the Secretary to prepare a
regulatory impact analysis if a final rule will have a significant
impact on the operations of a substantial number of small rural
hospitals. Such an analysis must conform to the provisions of section
604 of the RFA. For purposes of section 1102(b) of the Act, we define a
small rural hospital as a hospital that has fewer than 50 beds and is
located outside a Metropolitan Statistical Area.
We have determined, and the Secretary certifies, that this interim
final rule with comment period will not have a significant economic
impact on the operations of a substantial number of small rural
hospitals, and, therefore, have not prepared a rural hospital impact
statement.
The statute requires that all State Medicaid agencies must provide
an opportunity for the designated groups of low-income pregnant women,
infants, and children under age 19 to apply for Medicaid and to have
their applications initially processed at locations other than welfare
offices, including locations at Federally-qualified health centers and
disproportionate share hospitals. Although this provision appears to be
prescriptive, a majority of the States consider this to be a worthwhile
option and have provided outstation locations in their respective
States. Not only do we consider these provisions to be cost effective
for potential Medicaid recipients through savings from travel, we
expect State costs to be limited as a result of the availability of
FFP. However, to the extent that these requirements may be burdensome,
we request comments on any alternative approaches.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 435

Aid to Families with Dependent Children, Grant programs--health,
Medicaid, Reporting and recordkeeping requirements, Supplemental
Security Income (SSI), Wages.

42 CFR Part 436

Aid to Families with Dependent Children, Grant programs--health,
Guam, Medicaid, Puerto Rico, Supplemental Security Income (SSI), Virgin
Islands.

42 CFR Chapter IV, Subchapter C is amended as follows:

PART 435--ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE
NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA

A. Part 435 is amended as follows:
1. The authority citation for part 435 continues to read as
follows:

Authority: Sec. 1102 of the Social Security Act, 42 U.S.C. 1302.

2. Section 435.3 is amended by republishing the introductory text
of paragraph (a) and adding a new citation in numerical order to read
as follows:

Sec. 435.3 Basis.

(a) This part implements the following sections of the Act and
public laws that state eligibility requirements and standards:
* * * * *
1902(a)(55) Mandatory use of outstation locations other than welfare
offices to receive and initially process applications of certain low-
income pregnant women, infants, and children under age 19.
* * * * *

Sec. 435.902 [Redesignated as Sec. 435.901]

Sec. 435.903 [Redesignated as Sec. 435.902]

Sec. 435.904 [Redesignated as Sec. 435.903]

3. Sections 435.902, 435.903, and 435.904 are redesignated as
Secs. 435.901, 435.902, and 435.903, respectively.
4. A new Sec. 435.904 is added to read as follows:

Sec. 435.904 Establishment of outstation locations to process
applications for certain low-income eligibility groups.

(a) State plan requirements. The Medicaid State plan must specify
that the requirements of this section are met.
(b) Opportunity to apply. The agency must provide an opportunity
for the following groups of low-income pregnant women, infants, and
children under age 19 to apply for Medicaid at outstation locations
other than AFDC offices:
(1) The groups of pregnant women or infants with incomes up to 133
percent of the Federal poverty level as specified under section
1902(a)(10)(A)(i)(IV) of the Act;
(2) The group of children age 1 up to age 6 with incomes at 133
percent of the Federal poverty level as specified under section
1902(a)(10)(A)(i)(VI) of the Act;
(3) The group of children age 6 up to age 19 born after September
30, 1983, with incomes up to 100 percent of the Federal poverty level
as specified under section 1902(a)(10)(A)(i)(VII) of the Act; and
(4) The groups of pregnant women or infants, children age 1 up to
age 6, and children age 6 up to age 19, who are not eligible as a
mandatory group, with incomes up to 185 percent of the Federal poverty
level as specified under section 1902(a)(10)(A)(ii)(IX) of the Act.
(c) Outstation locations: general requirements.
(1) The agency must establish either--
(i) Outstation locations at each disproportionate share hospital,
as defined in section 1923(a)(1)(A) of the Act, and each Federally-
qualified health center, as defined in section 1905(1)(2)(B) of the
Act, participating in the Medicaid program and providing services to
Medicaid-eligible pregnant women and children; or
(ii) Other outstation locations, which include at least some,
disproportionate share hospitals and federally-qualified health
centers, as specified under an alternative State plan that is submitted
to and approved by HCFA if the following conditions are met:
(A) The State must demonstrate that the alternative plan for
outstationing is equally effective as, or more effective than, a plan
that would meet the requirements of paragraph (c)(1)(i) of this section
in enabling the individuals described in paragraph (b) of this section
to apply for and receive Medicaid; and
(B) The State must provide assurances that the level of staffing
and funding committed by the State under the alternative plan equals or
exceeds the level of staffing and funding under a plan that would meet
the requirements of establishing the outstation locations at the sites
specified in paragraph (c)(1)(i) of this section.
(2) The agency must establish outstation locations at Indian health
clinics operated by a tribe or tribal organization as these clinics are
specifically included in the definition of Federally-qualified health
centers under section 1905(l)(2)(B) of the Act and are also included in
the definition of rural health clinics under part 491, subpart A of
this chapter.
(3) The agency may establish additional outstation locations at any
other site where potentially eligible pregnant women or children
receive services--for example, at school-linked service centers and
family support centers. These additional sites may also include sites
other than the main outstation location of those Federally-qualified
health centers or disproportionate share hospitals providing services
to Medicaid-eligible pregnant women and to children and that operate
more than one site.
(4) The agency may, at its option, enter into reciprocal agreements
with neighboring States to ensure that the groups described in
paragraph (b) of this section who customarily receive services in a
neighboring State have the opportunity to apply at outstation locations
specified in paragraphs (c)(l) and (2) of this section.
(d) Outstation functions. (1) The agency must provide for the
receipt and initial processing of Medicaid applications from the
designated eligibility groups at each outstation location.
(2) ``Initial processing'' means taking applications, assisting
applicants in completing the application, providing information and
referrals, obtaining required documentation to complete processing of
the application, assuring that the information contained on the
application form is complete, and conducting any necessary interviews.
It does not include evaluating the information contained on the
application and the supporting documentation nor making a determination
of eligibility or ineligibility.
(3) The agency may, at its option, allow appropriate State
eligibility workers assigned to outstation locations to evaluate the
information contained on the application and the supporting
documentation and make a determination of eligibility if the workers
are authorized to determine eligibility for the agency which determines
Medicaid eligibility under Sec. 431.10 of this subchapter.
(e) Staffing. (1) Except for outstation locations that are
infrequently used by the low-income eligibility groups, the State
agency must have staff available at each outstation location during the
regular office operating hours of the State Medicaid agency to accept
applications and to assist applicants with the application process.
(2) The agency may station staff at one outstation location or
rotate staff among several locations as workload and staffing
availability dictate.
(3) The agency may use State employees, provider or contractor
employees, or volunteers who have been properly trained to staff
outstation locations under the following conditions:
(i) State outstation intake staff may perform all eligibility
processing functions, including the eligibility determination, if the
staff is authorized to do so at the regular Medicaid intake office.
(ii) Provider or contractor employees and volunteers may perform
only initial processing functions as defined in paragraph (d)(2) of
this section.
(4) Provider and contractor employees and volunteers are subject to
the confidentiality of information rules specified in part 431, subpart
F, of this subchapter, to the prohibition against reassignment of
provider claims specified in Sec. 447.10 of this subchapter, and to all
other State or Federal laws concerning conflicts of interest.
(5) At locations that are infrequently used by the designated low-
income eligibility groups, the State agency may use volunteers,
provider or contractor employees, or its own eligibility staff, or
telephone assistance.
(i) The agency must display a notice in a prominent place at the
outstation location advising potential applicants of when outstation
intake workers will be available.
(ii) The notice must include a telephone number that applicants may
call for assistance.
(iii) The agency must comply with Federal and State laws and
regulations governing the provision of adequate notice to persons who
are blind or deaf or who are unable to read or understand the English
language.
3. Section 435.907 is revised to read as follows:

Sec. 435.907 Written application.

(a) The agency must require a written application from the
applicant, an authorized representative, or, if the applicant is
incompetent or incapacitated, someone acting responsibly for the
applicant.
(b) Subject to the conditions specified in paragraph (c) of this
section, the application must be on a form prescribed by the agency and
signed under a penalty of perjury.
(c) The application form used at outstation locations for low-
income pregnant women, infants, and children specified in Sec. 435.904
must not be the application form used to apply for AFDC. The
application form (including any computerized application form) for
these designated eligibility groups may be--
(1) A Medicaid-only form prescribed by the agency specifically for
the designated eligibility groups;
(2) An existing Medicaid-only application; or
(3) A multiple-program application that contains clearly
identifiable Medicaid-only sections or parts.

PART 436--ELIGIBILITY IN GUAM, PUERTO RICO AND THE VIRGIN ISLANDS

B. Part 436 is amended as follows:
1. The authority citation for part 436 continues to read as
follows:

Authority: Sec. 1102 of the Social Security Act (42 U.S.C.
1302).

2. Section 436.2 is amended by revising the introductory text and
adding a new entry in numerical order to read as follows:

Sec. 436.2 Basis.

This part implements the following sections of the Act and public
laws that state requirements and standards for eligibility:
* * * * *
1902(a)(55) Mandatory use of outstation locations other than
welfare offices to receive and initially process applications of
certain low-income pregnant women, infants, and children under age 19.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.778--Medical
Assistance Programs)

Dated: July 15, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: July 28, 1994.
Donna E. Shalala,
Secretary.
[FR Doc. 94-23279 Filed 9-22-94; 8:45 am]
BILLING CODE 4120-01-P

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A94-23279. Public record. Not legal advice.