Statement of Organization, Functions, and Delegations of Authority; Substructure Reorganization of the Health Care Financing Administration

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

Statement of Organization, Functions, and Delegations of

Authority; Substructure Reorganization of the Health Care Financing

Administration

Part F of the Statement of Organization, Functions, and Delegations

of Authority for the Department of Health and Human Services, Health

Care Financing Administration (HCFA) is amended to reflect the

establishment of the subordinate organizational structure for HCFA

which was recently approved. Although the Bureaus/Offices have recently

been published, the entire set of HCFA's functional statements are

being republished to facilitate the amendment of Part F of the

Department statement. Included in this document are the new functional

statements for the subcomponents of HCFA.

The specific amendments to Part F are:

Section F.10., Health Care Financing Administration

(Organization) is amended to read as follows:

Section F.10., Health Care Financing Administration (Organization)

The Health Care Financing Administration (HCFA) is an Operating

Division of the Department. It is headed by an Administrator, HCFA, who

is appointed by the President and reports to the Secretary. It consists

of the following organizational elements:

A. Office of the Administrator (FA).

1. Provider Reimbursement Review Board (FA-1).

2. Equal Employment Opportunity Staff (FA-3).

3. Executive Secretariat (FA-4).

4. Office of Legislative and Inter-Governmental Affairs (FAA).

a. Division of Congressional Affairs (FAA1).

b. Division of Hearings & Policy Presentation (FAA2).

c. Division of Medicare Part A Analysis (FAA3).

d. Division of Medicare Part B Analysis (FAA4).

e. Division of Medicaid Analysis (FAA5).

f. Division of Intergovernmental Affairs (FAA6).

5. Medicaid Bureau (FAB).

a. Executive Operations Staff (FAB-1).

b. Medicaid Special Program Initiatives Staff (FAB-2).

c. Office of Medicaid Management (FAB1).

(1). Division of Financial Management (FAB11).

(2). Division of Program Performance (FAB12).

(3). Division of Payment Systems (FAB13).

d. Office of Medicaid Policy (FAB2).

(1). Division of Payment Policy (FAB21).

(2). Division of Coverage Policy (FAB22).

(3). Division of Eligibility Policy (FAB23).

6. Office of Managed Care (FAC).

a. Operational Analysis Staff (FAC-1).

b. Office of Managed Care Policy and Planning (FAC1).

(1). Division of Managed Care Policy and Evaluation (FAC11).

(2). Division of Planning and Promotion for Managed Care

(FAC12).

c. Medicaid Managed Care Office (FAC2).

d. Office of Managed Care Operations (FAC3).

(1). Division of Payment and Operations Support (FAC31).

(2). Division of Operations (FAC32).

(3). Division of Finance (FAC33).

B. Associate Administrator for Customer Relations and Communications

(FF).

1. Office of Beneficiary Services (FFA).

2. Office of Public Affairs (FFB).

a. Freedom of Information Division (FFB1).

b. Division of Public Appearances (FFB2).

3. Office of Public Liaison (FFC).

a. Division of Professional and Business Affairs (FFC1).

b. Division of Media Relations (FFC2).

C. Associate Administrator for Policy (FK).

1. Special Analysis Staff (FK-1).

2. Bureau of Policy Development (FKA).

a. Regulations Staff (FKA-1).

b. Office Of Regulations Management (FKA-2).

c. Office of Program Support (FKA-3).

(1) Executive Secretariat (FKA-31).

(2) Inquiries Staff (FKA-32).

(3) Program Liaison Staff (FKA-33).

d. Office of Payment Policy (FKA1).

(1) Division of Medical Services Payment (FKA11).

(2) Division of Hospital Payment Policy (FKA12).

(3) Division of Payment and Reporting Policy (FKA13).

(4) Division of Special Payment Programs (FKA14).

e. Office of Coverage and Eligibility Policy (FKA2).

(1) Division of Provider Services Coverage Policy (FKA21).

(2) Division of Medical Services Coverage Policy (FKA22).

(3) Division of Medicare Eligibility Policy (FKA23).

3. Office of Research and Demonstrations (FKB).

a. Office of Demonstrations and Evaluations (FKB1).

(1) Division of Long-Term Care Experimentation (FKB11).

(2) Division of Hospital Experimentation (FKB12).

(3) Division of Health Systems and Special Studies (FKB13).

b. Office of Research (FKB2).

(1) Division of Beneficiary Studies (FKB21).

(2) Division of Payment and Economic Studies (FKB22).

(3) Division of Program Studies (FKB23).

c. Office of Operations Support (FKB3).

(1) Division of Research and Demonstrations Systems Support

(FKB31).

(2) Division of Program Support (FKB32).

4. Office of the Actuary (FKC).

a. Office of Medicare and Medicaid Cost Estimates (FKC1).

(1) Division of Hospital Insurance (FKC11).

(2) Division of Supplementary Medical Insurance (FKC12).

(3) Division of Medicaid Cost Estimates (FKC13).

b. Office of National Health Statistics (FKC2).

(1) Division of Health Cost Analysis (FKC21).

(2) Division of Survey Analysis (FKC22).

D. Associate Administrator for Operations and Resource Management

(FL).

1. Office of the Attorney Advisor (FL-1).

2. Office of Planning and Support (FL-2).

3. Office of Financial and Human Resources (FLA).

a. Management Planning and Analysis Staff (FLA-1).

b. Office of Financial Management (FLA1).

(1) Division of Accounting (FLA11).

(2) Division of Budget (FLA12).

c. Office of Human Resources (FLA2).

(1) Division of Information and Organizational Management

(FLA21).

(2) Division of Performance Management and Development (FLA22).

(3) Division of Staffing and Employee Services (FLA23).

d. Office of Acquisitions and Grants (FLA3).

(1) Division of Health Standards Contracts (FLA31).

(2) Division of Contracts and Grants (FLA32).

e. Office of Administrative Services (FLA4).

(1) Division of Facilities Management (FLA41).

(2) Division of Safety and Property Management (FLA42).

(3) Division of Telecommunications and Graphics Services

(FLA43).

(4) Division of Printing and Distribution Services (FLA44).

4. Bureau of Program Operations (FLB).

a. Executive Secretariat (FLB-1).

b. Issuances Staff (FLB-3).

c. Office of Contracting and Financial Management (FLB1).

(1) Division of Acquisitions and Contracts (FLB11).

(2) Division of Financial Management (FLB12).

(3) Division of Contractor Planning and Management (FLB13).

(4) Division of Account Management and Collection (FLB14).

d. Office of Medicare Benefits Administration (FLB2).

(1) Division of Utilization Analysis (FLB21).

(2) Division of Entitlement and Benefit Coordination (FLB22).

(3) Division of Audit and Payment Management (FLB23).

(4) Division of Medigap Operations (FLB24).

e. Office of Program Operations Procedures (FLB3).

(1) Division of Claims Processing Procedures (FLB31).

(2) Division of Claims Processing Requirements (FLB32).

(3) Division of Appeals and Communications (FLB33).

(4) Division of Operational Systems Development (FLB34).

f. Office of Quality and Evaluation (FLB4).

(1) Division of Quality Programs (FLB41).

(2) Division of Standards (FLB42).

(3) Division of Program Evaluation (FLB43).

(4) Division of Reports and Information Management (FLB44).

5. Bureau of Data Management and Strategy (FLC).

a. Office of Information Resources Management (FLC1).

(1) Division of Information Systems Management (FLC11).

(2) Division of ADP Planning and Resources Management (FLC12).

b. Office of Statistics and Data Management (FLC2).

(1) Division of Payment Policy Support (FLC21).

(2) Decision Support Division (FLC22).

(3) Division of Special Programs (FLC23).

c. Office of Program Systems (FLC3).

(1) Division of Program Management Systems (FLC31).

(2) National Claims History Division (FLC32).

(3) Division of Medicaid Statistics (FLC33).

d. Office of Enrollment Systems (FLC4).

(1) Division of Enrollment Applications (FLC41).

(2) Division of Capitation and Collection Systems (FLC42).

(3) Division of Medicare Operations Support (FLC43).

e. Office of Information Technology (FLC5).

(1) Division of Administrative Systems (FLC51).

(2) Division of Office Automation Systems (FLC52).

f. Office of Computer Operations (FLC6).

(1) Division of Data Center Services (FLC61).

(2) Division of Data Communications and Distributed Services

(FLC62).

6. Office of the Regional Administrators (FLD(I-X)).

a. Division of Health Standards and Quality (FLD(I-X)A).

b. Division of Medicaid (FLD(I-X)B).

c. Division of Medicare (FLD(I-X)C).

7. Health Standards and Quality Bureau (FLE).

a. Management Resources Staff (FLE-1).

b. Office of Peer Review (FLE1).

(1) Division of Program Operations (FLE11).

(2) Division of Review Programs (FLE12).

(3) Division of Systems Management (FLE13).

(4) Division of Program Assessment and Information (FLE14).

c. Office of Survey and Certification (FLE2).

(1) Division of Long-Term Care Services (FLE21).

(2) Division of Systems Management and Data Analysis (FLE22).

(3) Division of Program Operations (FLE23).

(4) Division of Laboratory Standards and Performance (FLE24).

(5) Division of Hospitals, Home Health, and Ambulatory Services

(FLE25).

Section F.20., Health Care Financing Administration

(Functions) is amended by deleting the statement in its entirety and

replacing it with the following statements. The following statements

provide the overall organizational structure of the Health Care

Financing Administration. The new HCFA organizational structure is

described as follows:

A. Office of the Administrator (FA)

The Administrator directs the planning, coordination, and

implementation of the programs under Titles XI, XVIII, and XIX of the

Social Security Act and related statutes, as amended, and directs the

development of effective relationships between these programs and

private and federally supported health-related programs.

Within broad Department of Health and Human Services

policy and guidelines, the Administrator oversees the establishment of

program goals and objectives and the development of policies, standards

and guidelines; evaluates progress in the administration of HCFA

programs; and ensures that required actions are taken to direct or

redirect efforts to achieve program objectives.

The Administrator works with the States, other Federal

agencies and other concerned nongovernmental organizations in

administering health care financing programs.

The Administrator is assisted by a general deputy, who

functions with full authority during the Administrator's absence.

1. Provider Reimbursement Review Board (FA-1)

The Provider Reimbursement Review Board (Board) is

organizationally assigned to the HCFA for administrative support.

The Board, after determining that it has jurisdiction,

conducts hearings to resolve disputes on cost and prospective payment

submitted by Medicare providers under Section 1878 of the Social

Security Act.

Upon the completion of these hearings, the Board renders

impartial decisions on these appeals. This is the initial step in the

judicial review process.

Provides staff support to the Medicare Geographic

Classification Review Board (MGCRB) and conducts Medicare and Medicaid

hearings on behalf of the Secretary or the Administrator that are not

within the jurisdiction of the Department Appeals Board, the Social

Security Administration's Office of Hearings and Appeals, or the

States.

2. Equal Employment Opportunity Staff (FA-3)

Provides principal advisory services to the Administrator

concerning equal employment opportunity (EEO) and civil rights policies

and programs.

Develops EEO and voluntary civil rights compliance policy

for HCFA and assesses the Agency's compliance with applicable equal

opportunity statutes, executive orders, regulations and policies.

Identifies policy and operational issues and proposes

solutions for resolving these issues.

Serves as the central liaison point with the Department on

EEO and civil rights issues.

Coordinates the development of HCFA affirmative EEO plans

and evaluates their implementation by HCFA components.

Promotes EEO special emphasis programs and activities

affecting the concerns of minority groups, women, and individuals with

disabilities.

Provides for conciliation and adjudication of informal and

formal discrimination complaints by means of EEO counseling, formal

hearings, issuance of final decisions, etc.

Manages, coordinates and monitors HCFA's equal employment

opportunity activities working directly with bureau and office

personnel.

3. Executive Secretariat (FA-4)

Assists the HCFA Administrator in the resolution of agency

program and administrative policy matters through memoranda, action

documents, or correspondence.

Monitors HCFA performance in developing necessary

documents for the Administrator's review.

Manages the clearance system and reviews documents for

consistency with the Administrator's and Secretary's assignments,

previous decisions on related matters, and editorial standards.

Facilitates the resolution of issues connected with

matters forwarded to the Administrator.

Operates the agency-wide correspondence tracking and

control system, and provides guidance and technical assistance on

standards for content of correspondence and memoranda.

Serves as a primary focal point for liaison with the

Executive Secretariat in the Office of the Secretary on HCFA

correspondence and special administrative matters.

4. Office of Legislative and Inter-Governmental Affairs (FAA)

The Office of Legislative and Inter-Governmental Affairs

provides leadership and executive direction within HCFA for legislative

planning and congressional and intergovernmental affairs.

Develops and evaluates recommendations concerning

legislative proposals for changes in health care financing.

Develops the long-range HCFA legislative plans.

Coordinates activities with the Office of the Assistant

Secretary for Legislation (ASL) and serves as the ASL's principal

contact point on legislative and congressional relations, and

intergovernmental affairs.

Manages HCFA involvement in congressional hearings.

Provides technical, analytical, and advisory services to

HCFA components, to the Department, to other elements of the Executive

Branch, and other government agencies interested in health care

financing legislation, congressional relations, and intergovernmental

affairs.

In conjunction with the ASL, provides information services

to congressional committees, individual Congressmen, and private

organizations on health care financing legislation.

Provides leadership for HCFA in the area of

intergovernmental affairs.

Advises the Administrator on program matters which affect

other units and levels of government.

In coordination with the Department's Inter-Governmental

Affairs office, the Regional Directors, and other HCFA offices, meets

with key State and local officials in order to strengthen HCFA's

relationships with other governmental jurisdictions and to resolve

sensitive intergovernmental problems and issues. Reviews and consults

with State and local officials regarding proposed HCFA policy and

operational issuances. Assists States and localities in requesting and

obtaining technical materials, assistance, and support from appropriate

HCFA components. Upon State requests, coordinates the exchange of HCFA

staff with State and local agencies.

Develops and provides briefings on intergovernmental

affairs issues for HCFA staff.

Briefs State and local agencies on HCFA's mission,

organization, and functions.

a. Division of Congressional Affairs (FAA1)

Serves as the HCFA focal point for all congressional

liaison activities. Coordinates HCFA's congressional liaison activities

with the Office of the Assistant Secretary for Legislation (ASL).

Responds to congressional inquiries and constituent

concerns related to Medicare, Medicaid, and other health care financing

issues. Organizes briefings for Congressmen, congressional staff and

the public on specific issues and prepares reports on these issues for

higher level management.

Notifies Congress of specific HCFA activities of interest

to Members.

Provides advice to the Director, Office of Legislative &

Inter-Governmental Affairs (OLIGA), the Administrator, and other HHS

policy officials on the resolution of sensitive congressional issues.

Prepares legislative histories and congressional profiles

used by HCFA senior staff in preparation for congressional hearings.

Prepares a variety of summary reports on congressional

legislative activities and inquiries for use by the Director, OLIGA,

the Administrator, and other HHS policy officials.

Maintains the HCFA legislative reference library. Provides

legislative reference and research services to HCFA, the Department,

and the general public.

b. Division of Hearings & Policy Presentation (FAA2)

In preparation for congressional hearings, drafts

testimony to be used by the Administrator, the Secretary, and other HHS

policy officials.

Serves as the principle HCFA contact point with the Office

of the Assistant Secretary for Legislation on congressional hearings

and coordinates the preparation for such hearings, working with other

Office of Legislative & Inter-Governmental Affairs and HCFA components.

Clears other departmental and Administration testimony

that has a bearing on Medicare, Medicaid, or other health care

financing programs.

Reviews other written products such as bill reports,

studies, policy statements, etc., for clarity, presentation, and

consistency with overall HCFA policy.

Develops policy presentations for the general media in

consultation with the Office of the Associate Administrator for

Customer Relations & Communications.

c. Division of Medicare Part A Analysis (FAA3)

Conducts legislative, economic, and policy analyses

related to Medicare Part A issues. Substantive areas include Medicare

Part A benefits, eligibility, payment, and financing, and other cross-

cutting parts of Medicare and the health delivery system that have an

effect on Medicare Part A.

Coordinates the development of Medicare Part A legislative

proposals and develops the technical specifications for such

legislation.

Plans, develops, and directs the strategy to enhance the

enactment of the Administration's Medicare Part A legislative program.

Analyzes and reviews Medicare Part A regulations, issue

papers, Office of the Inspector General reports, reports to Congress,

and other policy documents for the Director, Office of Legislative &

Inter-Governmental Affairs (OLIGA).

Designs and conducts long-range Medicare Part A policy

studies as well as other special projects, such as representing HCFA or

OLIGA on task forces, outside commissions or policy panels in assigned

areas.

Working with the Office of the Assistant Secretary for

Legislation (ASL), provides (or coordinates) technical consultative

services to congressional members, their staff and the public on

Medicare Part A legislation and related HCFA activities.

Recommends the HCFA and HHS position on Medicare Part A

legislation likely to be considered by Congress. Develops bill reports

and coordinates comments from other HCFA and HHS components. Clears

enrolled bill reports and recommends Presidential veto or signature.

Prepares legislative summaries of newly enacted legislation and

selected congressional bills.

Monitors all Medicare Part A congressional legislative

activity, with an emphasis on Budget Reconciliation and other major

legislation.

Assists in the preparation of Medicare Part A briefing

materials, background, and testimony for HCFA and HHS policy officials'

appearances at congressional hearings.

Provides assistance to other offices within OLIGA to

ensure consistent, coordinated analyses and responses. Provides input

to cross-cutting projects.

d. Division of Medicare Part B Analysis (FAA4)

Conducts legislative, economic, and policy analyses

related to Medicare Part B issues. Substantive areas include Medicare

Part B benefits, eligibility, payment, and financing, and other cross-

cutting parts of Medicare and the health delivery system that have an

effect on Medicare Part B.

Coordinates the development of Medicare Part B legislative

proposals and develops the technical specifications for such

legislation.

Plans, develops, and directs the strategy to enhance the

enactment of the Administration's Medicare Part B legislative program.

Analyzes and reviews Medicare Part B regulations, issue

papers, Office of the Inspector General reports, reports to Congress,

and other policy documents for the Director, Office of Legislative &

Inter-Governmental Affairs (OLIGA).

Designs and conducts long-range Medicare Part B policy

studies as well as other special projects, such as representing HCFA or

OLIGA on task forces, outside commissions or policy panels in assigned

areas.

Working with the Office of the Assistant Secretary for

Legislation, provides (or coordinates) technical consultative services

to congressional members, their staff and the public on Medicare Part B

legislation and related HCFA activities.

Recommends the HCFA and HHS position on Medicare Part B

legislation likely to be considered by Congress. Develops bill reports

and coordinates comments from other HCFA and HHS components. Clears

enrolled bill reports and recommends Presidential veto or signature.

Prepares legislative summaries of newly enacted legislation and

selected congressional bills.

Monitors all Medicare Part B congressional legislative

activity, with an emphasis on Budget Reconciliation and other major

legislation.

Assists in the preparation of Medicare Part B briefing

materials, background, and testimony for HCFA and HHS policy officials'

appearances at congressional hearings.

Provides assistance to other offices within OLIGA to

ensure consistent, coordinated analyses and responses. Provides input

to cross-cutting projects.

e. Division of Medicaid Analysis (FAA5)

Conducts legislative, economic, and policy analyses

related to the Medicaid program. Substantive areas include Medicaid

eligibility, payment, coverage, financing, the impact on Medicaid of

changes to Public Health Service, and welfare programs, and the health

care of low income individuals.

Coordinates the development of Medicaid legislative

proposals and develops the technical specifications for such

legislation. Plans, develops, and directs legislative strategy to

enhance the enactment of the Administration's legislative program for

the Medicaid program.

Analyzes and reviews Medicaid regulations, issue papers,

Office of the Inspector General reports, reports to Congress, and other

policy documents for the Director, Office of Legislative & Inter-

Governmental Affairs (OLIGA).

Designs and conducts long-range Medicaid policy studies as

well as special projects, such as representing HCFA or OLIGA on task

forces, outside commissions or policy panels in assigned areas.

Working with the Office of the Assistant Secretary for

Legislation, provides (or coordinates) technical consultative services

to congressional members, their staff and the public on Medicaid

legislation and related HCFA activities.

Recommends the HCFA and HHS position on Medicaid

legislation likely to be considered by Congress. Develops bill reports

and coordinates comments from other HCFA and HHS components. Clears

enrolled bill reports and recommends Presidential veto or signature.

Prepares legislative summaries of newly enacted legislation and

selected congressional bills.

Monitors all Medicaid congressional legislative

activities, with an emphasis on Budget Reconciliation and other major

legislation.

Prepares Medicaid briefing materials, background, and

testimony for HCFA and HHS policy officials' appearances at

congressional hearings.

Provides assistance to other offices within OLIGA to

ensure consistent, coordinated analyses and responses. Provides input

to cross-cutting projects.

f. Division of Intergovernmental Affairs (FAA6)

Provides leadership for HCFA in the area of

intergovernmental affairs.

Advises the Director, Office of Legislative & Inter-

Governmental Affairs, on all policy and program matters which affect

other units and levels of government.

In coordination with the Department's Intergovernmental

Affairs office, the Principal Regional Directors, and other HCFA

offices, meets with key State and local officials in order to

strengthen HCFA's relationships with other governmental jurisdictions

and to resolve sensitive intergovernmental problems and issues.

Reviews and consults with State and local officials

regarding proposed HCFA policy and operational issuances.

Assesses the impact on State and localities of HCFA

actions involving penalties, disallowances, compliance actions, or new

performance standards.

Assists States and localities in requesting and obtaining

technical materials, assistance, and support from appropriate HCFA

components.

Upon State requests, arranges for the exchange of HCFA

staff with State and local agencies.

Develops and provides briefings on intergovernmental

affairs issues for HCFA staff.

Briefs State and local agencies on HCFA's mission,

organization, and functions.

5. Medicaid Bureau (FAB)

Directs the planning, coordination, and implementation of

the Medicaid program under Title XIX of the Social Security Act and

related statutes, as amended, except for Medicaid managed health care.

Formulates, evaluates, and prepares policies,

specifications for regulations, instructions, preprints and procedures

related to Medicaid eligibility, coverage, and payment activities;

makes recommendations for legislative changes; and, reviews State plan

amendments and makes recommendations on approvals/disapprovals.

Oversees, coordinates, processes and assesses the

operation of State Medicaid Home and Community-Based Services Waivers.

Administers the State grants process for administrative

and program payments, including budget preparation by States.

Provides Medicaid payment policy for administrative costs,

availability of Federal Financial Participation (FFP) and designation

of appropriate FFP rates.

Develops and monitors planning, development and

implementation of Medicaid program operations in regional offices and

State Medicaid agencies.

Develops and promulgates policies and procedures for the

proper maintenance, review, and approval of State plans and their

amendments.

Monitors State compliance with State plan and oversees the

compliance process.

Develops requirements, standards, procedures, guidelines,

and methodologies pertaining to the review and evaluation of State

agencies' automated systems.

Develops, operates, and manages a program for the

performance evaluation of Medicaid State agencies and fiscal agents.

Implements Medicaid maternal and infant health initiative

and the Early and Periodic Screening, Diagnostic, and Treatment program

through coordination of HCFA resources and activities with those of the

Public Health Service and other national organizations, monitoring

program performance, effective interagency and interprogram liaison,

guidance, and technical assistance.

Provides technical assistance to States, regional offices,

and other interested groups in all special Medicaid initiatives.

Coordinates with HCFA's Office of Legislative and Inter-Governmental

Affairs on all issues that affect States.

Coordinates with the Office of Research and Demonstrations

HCFA review and management of State waiver requests and projects.

a. Executive Operations Staff (FAB-1)

Advises the Medicaid Bureau (MB) managers on

organizational design and implementation; requests to establish

positions; and delegations of management and program administration

authorities.

Establishes and implements integrated and coordinated MB

work planning. Plans and monitors the execution of major Bureau program

initiatives through the administration of the Bureau's work planning to

ensure fairness and equity among components and to assure that

measurable and verifiable outputs are provided.

Interprets administrative budgetary policies and

limitations and develops and issues guidelines and instructions to MB

managers for budget formulation and execution. Executes the budget for

the bureau through the issuance of staff and dollar controls, budget

allowances for administrative expenditures, and employment ceilings to

bureau components.

Provides services and liaison with the Office of Financial

& Human Resources related to procurement; space acquisition,

utilization and management; telephone systems; records; publications;

forms printing; and reprographics.

Directs a bureau-wide tracking and control system for

legislation, regulations, instructions and correspondence; and provides

training and technical assistance on standards for content of written

documents.

Serves as the focal point for the General Accounting

Office and the Office of the Inspector General reports relating to MB;

and coordinates other operational reviews of, and within, MB (e.g.,

internal control reviews).

Provides bureau support and represents MB on issues

related to microcomputer systems.

b. Medicaid Special Program Initiatives Staff (FAB-2)

Implements Medicaid maternal and infant health initiative

and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

program through coordination of HCFA resources and activities with

those of the Public Health Service and other national organizations,

monitoring program performance, effective interagency and interprogram

liaison, guidance, and technical assistance.

Serves as HCFA liaison and manager of the Medicaid

Maternal and Child Health Technical Advisory Group.

Assists in developing Medicaid participation in

alternative service and delivery methods (e.g., collaboration and

pluralistic funding of health care for varied Human Immuno Virus/

Acquired Immune Deficiency Syndrome (AIDS)-infected Medicaid

Recipients) and conducts reconnaissance and analyses to identify

emerging and potential problem areas (e.g., financing community

substance abuse programs).

Provides technical assistance to States, regional offices,

and other interested groups in all special Medicaid initiatives.

Evaluates the effect of proposed legislation on sensitive

and special Medicaid issues (i.e., EPSDT and AIDS) and recommends new

or amended legislation in regard to these special areas.

c. Office of Medicaid Management (FAB1)

Provides oversight, coordinates, and formulates the

national Medicaid medical assistance and administrative costs budgets

and justifications. Develops and maintains budget preparation and

execution policies and procedures used by States and regional offices.

Administers the State grants process for administrative

and program payments including regional office disallowances.

Develops and monitors Medicaid automated systems

requirements, standards, procedures, guidelines, and methodologies.

Directs review, evaluation, and assessment of the operation,

development, and funding of Medicaid State agency automated systems,

including the claims processing and information retrieval and

integrated eligibility systems, and coordinates systems requirements

for Federal programs such as Child Health Assurance, Child Support

Enforcement, food stamps, and Aid to Families with Dependent Children.

Provides oversight and coordinates the Medicaid State plan

preprint process. Assists components in the development, publication,

timely issuance to States, and maintenance of the master copy of State

plan preprints.

Provides oversight of planning, development,

implementation, and monitors Medicaid program operations in regional

offices and State Medicaid agencies including drug rebate program,

Systematic Alien Verification for Entitlement System, national Medicaid

eligibility quality control program, Medicaid Drug Use Review program,

State claims processing and payment operations, and third party

liability activities.

(1) Division of Financial Management (FAB11)

Provides oversight and coordinates the national Medicaid

medical assistance and administrative costs budgets and justifications.

Develops and maintains budget preparation and execution policies and

procedures used by States and regional offices.

Establishes policies and procedures by which Medicaid

State agencies and regional offices submit quarterly budget estimates

and reports and administers the State grants process for administrative

and program payments.

Reviews all State claims for Federal payment under Title

XIX of the Social Security Act including regional office disallowances

of State claims.

Serves as the focal point for the defense of disallowance

decisions before the Department Appeals Board.

Provides oversight and manages the national State

Performance Evaluation and Comprehensive Test of Reimbursement Under

Medicaid review process.

Provides the definitive HCFA interpretation of Medicaid

payment policy for administrative costs. Responsible for operational

policies regarding availability of Federal Financial Participation

(FFP), designation of appropriate FFP rates, and for issuing

interpretations to regional offices regarding operational FFP issues.

Directs regional office financial reviews and audits of

State agencies and oversees the Medicaid claims processing review

activity.

Provides oversight, administration, and maintenance of the

Medicaid Budget and Expenditure System.

(2) Division of Program Performance (FAB12)

Develops, implements, and operates the national Medicaid

eligibility quality control program to determine the effectiveness of

Medicaid State agencies' performance in the area of eligibility

determinations.

Provides documentation and analysis necessary to initiate

and support actions on disallowances, penalties, and corrective action

requirements, and adjudication of appeals of disallowances and

penalties.

Develops, implements, and coordinates a system for

reviewing the States' performance of the Income Eligibility

Verification System (IEVS) requirements. Develops and interprets

regulations and policies for States to establish IEVS.

Develops, coordinates, and promulgates operational policy

for utilizing the Systematic Alien Verification for Entitlement system.

Provides expertise on sampling, precision, universe

identification, and other technical statistical issues in support of

the Medicaid quality control and assessment programs.

Develops and promulgates policies and procedures for the

proper maintenance, review, and approval of State plans and their

amendments. Monitors State compliance to State plan and oversees the

compliance process.

Ensures adherence to all Automated Data Processing (ADP)

security measures, policies, and procedures; assists with the

development, modification, and review of HCFA ADP policies as they

apply to Medicaid.

Directs the bureau's ADP activities relating to

development, implementation, and administration of mainframe ADP

systems programs.

Provides oversight and coordinates the Medicaid State plan

preprint process. Assists components in the development, publication,

timely issuance to States, and maintenance of the master copy of State

plan preprints.

Develops procedures with the Social Security

Administration concerning Medicaid eligibility operational issues such

as transfer of resources, deemed Supplemental Security Income

recipients and the State Data Exchange.

(3) Division of Payment Systems (FAB13)

Provides bureau support in the development and

implementation of new systems that interface with other HCFA components

or involve mainframe computers.

Develops the requirements, standards, procedures,

guidelines, methodologies, and test criteria pertaining to the review,

evaluation, and assessment of operations, development, and funding of

State agency automation, claims processing and information retrieval

and integrated eligibility systems to determine their compliance with

published Federal requirements.

Reviews State agency requests for Federal Financial

Participation (FFP) in the costs of operating Medicaid claims

processing, information retrieval systems, and development and

operations of the integrated eligibility systems.

Reviews State agency FFP requests for Medicaid Management

Information Systems and interdepartmental integrated eligibility

systems for approval.

Plans, develops, and monitors systems requirements for

Medicaid and coordinates systems requirements for related Federal

programs such as Child Health Assurance, Child Support Enforcement,

Food Stamps, and Aid to Families with Dependent Children.

Provides operational and systems support for

implementation of the Medicaid drug rebate program. Maintains liaison

with and provides technical assistance to drug manufacturers, Medicaid

State agencies, pharmaceutical associations, private sector vendors and

other parties regarding the drug rebate program. Prepares an annual

report to Congress regarding drug product and expenditure information.

Serves as the focal point for Medicaid third party

liability, qualified Medicare beneficiary, and Drug Use Review

operating instructions and policy guidance to Medicaid State agencies

and regional offices.

Coordinates with all State Medicaid agencies, in

conjunction with HCFA regional offices, implementation of system coding

and other changes related to the Medicare program's Physician Payment

Reform initiative and other data initiatives such as common coding,

uniform billing, and electronic media claims formats.

d. Office of Medicaid Policy (FAB2)

Formulates, evaluates and prepares policies,

specifications for regulations, instructions, preprints, and procedures

related to Medicaid eligibility, coverage, and payment activities.

Makes recommendations for legislative changes to improve

program policy and ease of administration.

Reviews State plan amendments and makes recommendations on

approvals/disapprovals.

Oversees, coordinates, processes, and assesses the

operation of State Medicaid Home and Community-Based Services Waivers.

(1) Division of Payment Policy (FAB21)

Formulates and evaluates policies, regulations,

instructions, and procedures related to Medicaid coverage activities.

Prepares regulations, manuals, program guidelines, State plan

preprints, and general instructions related to Medicaid institutional

and non-institutional payment policy.

Provides interpretations of Medicaid payment policies to

regional offices, congressional staffs, other Departments of the

Federal government, interest groups and State agencies.

Develops, evaluates, and reviews Medicaid policies,

regulations, guidelines, and instructions pertaining to provider and

other facility payment under the Medicaid program including, for

example, Medicaid institutional payment plans, Medicaid community

provider rates, Medicaid payment of such entities as rural health

clinics and federally qualified health centers and capitated rates for

Medicaid managed care organizations.

Formulates and evaluates policies and procedures related

to Medicaid payment for long-term care, physician services,

practitioner services, case management, obstetrical and pediatric

services, pharmaceuticals, supplies and equipment such as hearing aids,

eyeglasses, durable medical equipment, laboratory, and other medical

services.

Participates in the development and evaluation of proposed

legislation in the area of Medicaid payment.

Reviews State plan amendment requests under Medicaid.

Analyzes and recommends legislative or other remedies to

improve the effectiveness of Medicaid payment policies.

Reviews, with the Office of Research and Demonstrations,

research and demonstration agendas in the area of Medicaid payment.

(2) Division of Coverage Policy (FAB22)

Formulates and evaluates policies, regulations,

instructions, and procedures related to Medicaid coverage activities.

Prepares specifications for regulations, manuals, program guidelines,

State plan preprints, and general instructions related to these areas.

Provides interpretations of Medicaid coverage policies to

regional offices, congressional staffs, other departmental offices,

other Departments of the Federal government, interest groups and State

agencies.

Develops, evaluates, and reviews all Medicaid coverage

policies, regulations, and procedures.

Develops, evaluates, and reviews policies, regulations,

and procedures pertaining to States' requests for approval of waivers

of Medicaid requirements to provide home and community-based services

and makes recommendations whether the waivers should be approved or

disapproved.

Develops, evaluates, and reviews national coverage

policies concerning Medicaid medical service contracts, interagency

agreements, and prior authorizations.

Reviews coverage related Medicaid State plan amendment

requests.

Identifies, studies, and makes recommendations for

modifying Medicaid coverage policies to reflect changes in recipient

health care needs, program objectives, and the health care delivery

system.

(3) Division of Eligibility Policy (FAB23)

Develops, interprets, and evaluates policies pertaining to

all conditions under which recipients are eligible to have their health

care services covered under Medicaid, the rights and responsibilities

of recipients and applicants, and other special eligibility and

technical issues.

Evaluates the effect of proposed legislation on current

eligibility policies and recommends specifications for new or proposed

legislation on eligibility.

Provides consultation regarding State plan amendments and

waiver requests and prepares State plan disapproval actions.

Prepares specifications for regulations, preprints, and

manual instructions pertaining to Medicaid eligibility policy.

6. Office of Managed Care (FAC)

Provides national direction and executive leadership for

managed health care operations, including health maintenance

organizations (HMOs), prepaid health plans (PHPs), primary care case

management programs, competitive medical plans (CMPs), and other

capitated health organizations.

Serves as the departmental focal point in the areas of

managed health care plan qualification, including quality assurance,

ongoing regulation, State and employer compliance efforts, Medicare and

Medicaid HMO, Medicare CMP contracting and Medicaid freedom of choice

waivers.

Develops national managed care policies and objectives for

the development, qualification, and ongoing compliance of HMOs and

CMPs.

Plans, coordinates, and directs the development and

preparation of related legislative proposals, regulatory proposals, and

policy documents. Formulates, evaluates, and prepares policies,

specifications for regulations, instructions, preprints, and procedures

related to managed health care. Makes recommendations for legislative

changes to improve managed health care program policy.

a. Operational Analysis Staff (FAC-1)

Identifies and analyzes issues, problems, and trends

related to the Office of Managed Care (OMC) operations.

Develops OMC operational policy manuals, standard

operating procedures, and other instructions and issuances. Assists the

Office of Managed Care Policy & Planning (OMCPP) in the development of

policy and regulatory proposals.

Performs special studies and projects for OMC in the areas

of payment, operations, and finance.

Responds to operational policy questions generated by OMC

staff, regional offices, contractors, and other HCFA or departmental

components.

Establishes and maintains liaison with trade associations,

State regulatory agencies, OMCPP, and departmental components, such as

the Office of the General Counsel.

b. Office of Managed Care Policy and Planning (FAC1)

Develops national policies and objectives for the

development, qualification, and ongoing compliance of Health

Maintenance Organizations (HMOs) and Comprehensive Medical Plans

(CMPs). Plans, coordinates, and directs the development and preparation

of related legislative proposals, regulatory proposals, and policy

documents.

Acts as the focal point for all managed health care

research, demonstration, and evaluation study activity within and

external to the Department.

Develops and implements programs to encourage greater

access of Federal Medicare beneficiaries to HMOs and other prepaid

health plans.

Monitors and analyzes Federal activities and policies

regarding Federal beneficiaries in Medicare, CHAMPUS, and the Federal

Employees Health Benefits' programs. Coordinates the development and

implementation of health education and health promotion programs in

managed health care plans.

Coordinates the Department's efforts to move toward a

pluralistic health care delivery system.

Conducts special studies of managed health care plans

operations and operating data and identifies trends and develops

performance measures which can be used by the Office of Managed Care

Operations and by the industry to assess the development and operation

of managed health care plans.

Develops and issues technical guidance documents for use

by the industry in the development of managed health care plans and the

improvement of operations in existing managed health care plans.

Develops and maintains close relationships with national

organizations representing the managed health care plans industry to

enhance technical assistance capability and to establish appropriate

performance measures.

Plans, coordinates, and directs the development and

preparation of managed care legislative proposals, regulatory

proposals, and policy documents and performs strategic policy and

planning functions and other special tasks as required by the

Administrator.

Provides liaison staff for activities with other Federal

programs and agencies, health care professional associations, and trade

associations.

(1) Division of Managed Care Policy and Evaluation (FAC11)

Develops and coordinates legislative proposals, regulatory

specifications, and other policy documents to establish managed health

care national policies and to address the Agency objectives for the

development, qualification, contracting, and ongoing compliance of

health maintenance organizations (HMOs), comprehensive medical plans

(CMPs), preferred provider organizations (PPOs), and other managed

systems of health care.

Analyzes the manner in which the Agency objectives and

policies are tied into pending or existing managed health care

legislation and regulations. Evaluates national trends and their

possible effect on Agency-wide activities.

Reviews and analyzes policies regarding Federal

beneficiaries in Medicare, CHAMPUS, and the Federal Employees Health

Benefits' programs for coordination with managed health care programs.

Reviews and analyzes coordinated internal and external

health care research, demonstration, and evaluation study activities.

Develops presentation material for use with congressional

committees and with the Office of Management and Budget related to the

program and appropriation legislation affecting the managed health care

objectives of the Administration.

(2) Division of Planning and Promotion for Managed Care (FAC12)

Develops and implements activities to promote managed

health care programs to Health Maintenance Organizations (HMOs),

Comprehensive Medical Plans (CMPs), preferred provider organizations

(PPOs), employers, insurance companies, managed health care

associations/organizations, and other professional medical and private

groups, including Federal beneficiary and consumer groups.

Develops and coordinates managed health care education and

promotional programs within the Agency/Department to encourage greater

access of Federal Medicare beneficiaries to HMOs, CMPs, PPOs, and other

managed health care organizations. Supports the Agency/Department's

efforts to move toward a pluralistic health care delivery system.

Develops and supports the maintenance of close working

relationships with national organizations representing the managed

health care industry to enhance technical assistance options and to

promote appropriate managed health care performance measurement

standards.

Develops, coordinates, and supports strategic planning

activities for the managed health care program in the Agency and any

other specific managed health care planning initiatives.

Establishes and maintains a system to monitor the planning

schedule to assure appropriate coordination and completion of managed

health care activities within the Agency.

Supports the liaison activities for the Agency for managed

health care programs with other Federal/State programs and agencies,

health care professional organizations/associations, trade

associations, and consumer groups.

c. Medicaid Managed Care Office (FAC2)

Serves as the operational focal point for all Medicaid

managed care activities.

Formulates, evaluates, and prepares policies,

specifications for regulations, instructions, preprints, and procedures

related to Medicaid managed health care, including waivers.

Makes recommendations for legislative changes to improve

managed health care program policy.

Provides oversight of, and assistance to, State Medicaid

agencies on all managed health care issues, including Medicaid managed

health care contracting activities. Provides technical assistance to

State regulators.

Serves as the focal point and repository for State laws

and regulations dealing with Health Maintenance Organizations (HMOs),

group medical practice, insurance, licensing, foundations, service

corporations, certificate of need, and reserve requirement statutes.

Develops guidelines, policies, and procedures for use by

the regional offices when reviewing and approving/disapproving State

Medicaid agency contracts with managed health care plans.

Formulates and evaluates policies and procedures related

to HMOs and other managed health care contracts and freedom of choice

waiver programs including the preparation of recommendations for

waivers of freedom of choice and other State plan exception

requirements; monitoring of approved HMOs and other managed health care

contracts and freedom of choice waivers and recommendations for the

removal of waivers; State plan/waiver processing policy; and other

related issues.

Evaluates and assures the cost-effectiveness of approved

Medicaid freedom of choice waivers through review of State program and

cost reports, independent assessments, and regional compliance/

validation reviews.

d. Office of Managed Care Operations (FAC3)

Provides national direction and executive leadership for

managed health care operations, including health maintenance

organizations (HMOs), comprehensive medical plans (CMPs), and other

capitated health organizations.

Develops national operations objectives for the

qualification and ongoing compliance of managed health care plans.

Develops long- and short-range program operational goals

and objectives.

Serves as the departmental focal point in the areas of

managed health care plan qualification, ongoing regulation, employer

compliance efforts, and Medicare HMO and CMP risk contracting.

Administers Medicare managed care contracts, the

capitation formula, and payment policies.

Oversees the operation of the managed health care

information system.

Determines the amounts of payments to be made to managed

health care plans and the amounts, methods, and frequency of

retroactive adjustments.

Incorporates a prospective payment system for managed

health care through the implementation of the Tax Equity and Fiscal

Responsibility Act risk contracts.

Evaluates cost reporting methodologies and conducts a

continuing audit program to determine the final program liability for

cost contracts.

Administers beneficiary enrollment and disenrollment

including coordination with beneficiary groups and other HCFA and HHS

components.

(1) Division of Payment and Operations Support (FAC31)

Manages the national Medicare beneficiary enrollment and

disenrollment operations.

Ensures timely and accurate payment to managed health care

plans.

Plans, develops, operates, and evaluates the operational

and management information systems supporting the Medicare managed

health care program.

Conducts special analyses of specific managed health care

plans and management information systems to identify problems and

determine the need for new or enhanced systems design.

Establishes national operational policy, procedures, and

instructions for system specifications and data exchange methods which

define and automate the managed health care plans' enrollment,

disenrollment, and other systems operations.

Serves as liaison with the Bureau of Data Management and

Strategy and other HCFA Central Office and regional office components

in their implementation and evaluation of the management information

systems.

(2) Division of Operations (FAC32)

Directs the qualification applications process for Health

Maintenance Organizations (HMOs) under the requirements of section 1301

of the Public Health Service Act (PHS Act).

Coordinates with and provides technical assistance to the

regional offices on the monitoring of Medicare HMOs and Comprehensive

Medical Plans.

Manages and monitors the processing of Medicare managed

health care contract reconsiderations.

Investigates and evaluates applicants' conformance with

legal and financial requirements for qualification for Medicare

contracts under section 1301 of the PHS Act, section 1833 and section

1876 of the Social Security Act, and related regulations.

Coordinates Program Advisory Council activities, including

obtaining regional office reports and recommendations, incorporating

information from Central Office reviewers, and issuing approval of

initial applications and renewals. Coordinates and makes

recommendations on nonrenewals, terminations, and revocations based on

information and analysis provided by regional offices.

Implements new legislation and regulations regarding

managed health care operations.

Assures compliance with section 1310 of the PHS Act by

employers with the mandatory offering of a managed health care plan

alternative in employer health benefit plans.

In consultation with the regional offices, establishes

performance standards and evaluates the plans' performance.

Provides training for and guidance of regional offices in

activities related to managed health care. Also provides training and

workshops for HMOs.

Establishes and maintains liaison with appropriate State

and Federal regulatory agencies for coordination of qualification,

contract, and monitoring issues.

(3) Division of Finance (FAC33)

Establishes interim payment rates, retroactively adjusts

payments, and performs end-of-year settlements for all cost-based

contracting plans.

Reviews initial Adjusted Community Rate proposals.

Trains and guides the audit contractor who performs the

desk review of the Health Maintenance Organization (HMO) and

Comprehensive Medical Plan (CMP) cost reports.

Provides operational input for legislative and regulatory

proposals and standard operating procedures related to cost methodology

and fiscal responsibility.

Establishes national financial standards for federally

qualified HMOs and CMPs and assures that these entities comply with

these requirements.

Establishes national standards for the protection of

enrolles in the event of HMO or CMP insolvency. Assures that HMOs and

CMPs comply with these standards.

Develops procedures to improve or revise the payment

methodologies and processes of Medicare contractors and financial

reviews of HMOs and CMPs.

Manages the plan qualification fiscal soundness and

insolvency protection reviews process.

B. Associate Administrator for Customer Relations and Communications

(FF)

The Associate Administrator for Customer Relations and

Communications is responsible for the effective direction and

implementation of HCFA policies, rules, and procedures in the areas of:

customer relations and program communication.

Advises HCFA components concerning the services,

requirements, and initiatives relating to HCFA beneficiaries; liaison

with external medical, dental, and allied health practitioners,

institutional providers of health services, and academic institutions

responsible for the education of health care professionals; and

directing the public affairs activities of HCFA.

1. Office of Beneficiary Services (FFA)

Provides advisory services to the Associate Administrator

for Customer Relations and Communications and HCFA components

concerning the services for, needs of, and initiatives relating to HCFA

beneficiaries.

Promotes an awareness of the concerns of children, the

elderly, and needy among the HCFA components responsible for developing

program policies, regulations, and legislative proposals. Analyzes the

impact of proposed HCFA policies, regulations, and instructions on

beneficiaries. Maintains close working relationships with HCFA central

and regional components, the Social Security Administration District

Offices, the Public Health Service, other Federal agencies, State

agencies, and beneficiary consumer groups to identify and assess the

need for information, benefits and services; the impact of proposed

HCFA actions; and the effects that operating systems and programs have

on the health care system programs and current and future

beneficiaries.

Presents the overall HCFA mission and promotes its

acceptance by beneficiaries and representatives of their constituent

organizations.

Participates with other HCFA components in the development

and implementation of program objectives and strategies pertaining to

beneficiary services.

Through direct contact with children, the elderly, the

needy and/or their representative groups determines their understanding

of HCFA's programs and services and conveys this information to HCFA

components.

Responds to beneficiary referrals concerning accessing and

utilizing the Agency's health care financing programs.

Plans, directs, and coordinates the production of radio,

television, and film products, and the preparation of general-purpose

publications.

Reviews and clears all print, audiovisual, and exhibit

plans and material intended for external dissemination and serves as

clearance liaison with the Office of the Secretary, Office of the

Assistant Secretary for Public Affairs.

2. Office of Public Affairs (FFB)

Plans, directs and coordinates the public affairs

activities of HCFA including: speech writing, public appearances,

Administrator's meetings, special AACRC projects as well as conducting

evaluations and analysis.

Provides advice and counsel from a public affairs

perspective to the AACRC and all HCFA components.

Administers the Freedom of Information Act and Privacy Act

responsibilities for HCFA.

a. Freedom of Information Division (FFB1)

Conducts activities necessary to the receipt, management,

response, and reporting requirements of the Department under the

Freedom of Information Act (FOIA) regarding all correspondence received

by HCFA.

Maintains an orderly log of all FOIA requests received by

the Agency, refers requests to the proper components within

headquarters, the regions, or among carriers and intermediaries for the

collection of the documents requested, prepares replies to requesters

including denials of information as permitted under FOIA, and drafts

briefing materials and responses in connection with appeals of denial

decisions.

Consults with the Office of the General Counsel and the

Department of Health and Human Services' Freedom of Information Officer

regarding denials, releases, and appeals.

Provides guidance for FOIA coordinators in HCFA central

and regional office components and maintains up-to-date knowledge of

Federal Court decisions interpreting FOIA.

Prepares guidelines and Medicare and Medicaid manual

changes regarding FOIA program, keeps track of any charges levied for

FOIA research activities, and assures prompt payment.

b. Division of Public Appearances (FFB2)

Responsible for the efficient handling of speaking

requests received by top HCFA management.

Logs requests, recommends acceptance or denial of

invitations and coordinates correspondence for all invitations.

Arranges the scheduling of speaking appearances, compiles

briefing information, ensures that talking points or speeches are

prepared as necessary, and conducts follow-up activities such as

arranging for transcripts, courtesy correspondence, reprint

permissions, photographs, and biographies.

Recommends speaking opportunities and forums consistent

with Agency goals and objectives and overall public affairs plans.

Advises the Division of Media Relations on potential news

opportunities stemming from public appearances and speaking

engagements.

3. Office of Public Liaison (FFC)

Directs and implements HCFA policies, rules, and

procedures in the areas of liaison with external medical, dental, and

allied health practitioners, institutional providers of health

services, and business and academic institutions responsible for the

education of health care professionals.

Plans, directs and coordinates media relations.

a. Division of Professional and Business Affairs (FFC1)

Maintains liaison with external medical, dental, and

allied health practitioners, institutional providers of health

services, representatives of the business and insurance community, and

academic institutions responsible for the education of health care

professionals.

Provides professional knowledge and makes recommendations

to the Director, Office of Public Liaison (OPL) and manages the

development of policies, regulations, procedures, and legislative

proposals which affect the health care field.

Serves as the focal point in HCFA for external health care

groups to gain an understanding of HCFA objectives.

Evaluates and transmits suggestions and criticisms from

the health care field to the Director.

OPL promotes an exchange of viewpoints between the health

care field and HCFA components.

b. Division of Media Relations (FFC2)

Maintains relations with the nation's news media including

nationwide press, radio, television, wire services, and individual

reporters, writers, editors, and individual publications and

broadcasters.

Provides writing and editing services necessary in

conducting the public affairs activities of the Agency.

Develops and carries out a general plan for providing

information to the public through the news media and for promoting and

disseminating information on specific HCFA-related topics, issues, and

activities.

Responds to inquiries from the news media through

correspondence, telephone, and direct interviews and arranges for

interviews and similar response from senior Agency staff.

Prepares drafts and obtains clearances for press releases

and statements for the news media.

Drafts publications, fact sheets, reports, leaflets,

pamphlets, white papers, scripts, articles, and other background

materials for distribution to the general public on HCFA programs and

related topics.

Prepares and edits articles for submission to external

periodicals and publications on HCFA programs and prepares materials as

needed for internal employee communications such as the HCFA

Newsletter.

C. Associate Administrator for Policy (FK)

The Associate Administrator for Policy is responsible for

the effective direction and implementation of the development and

review of policies and regulations pertaining to all HCFA programs

including HCFA's research and demonstrations activities.

Conducts research and develops legislative proposals

designed to reform and make improvements in the health care delivery

system and develops the technical specifications for such legislation.

Performs actuarial, economic and demographic studies to

predict HCFA program expenditures under current law and under proposed

modifications to current law.

1. Special Analysis Staff (FK-1)

Conducts legislative, economic and policy analyses related

to the private health insurance industry and the overall structure of

health care financing and reform.

Analyzes and reviews current literature regarding the

state of the nation's health policy in order to develop national trend

analyses for future HCFA program directions.

Plans and develops future HCFA program policy in order to

assist in the development of legislative strategies that will enhance

the Department's legislative program.

Coordinates policy development and research relating to

legislative proposals designed to reform and make improvements in the

health care delivery system including the technical specifications for

such legislation.

2. Bureau of Policy Development (FKA)

Establishes national program policy on all issues of

Medicare payment including provider payment policy, provider accounting

and audit policy, and physician and medical services payment policy.

Develops, evaluates, and reviews national policies and

standards concerning the coverage and utilization effectiveness of

items and services under the Medicare program provided by hospitals,

long-term care facilities, hospices, End Stage Renal Disease

facilities, home health agencies, alternative health care

organizations, comprehensive outpatient rehabilitation facilities,

physicians, health practitioners, clinics, laboratories, and other

health care providers and suppliers.

Serves as the principal organization within HCFA for

evaluating the medical aspects of Medicare coverage issues and for

developing provider conditions of participation.

Develops, evaluates, and reviews national Medicare

coverage issues concerning reasonableness and necessity for medical and

related services.

Develops, interprets, and evaluates program policies

pertaining to Medicare eligibility, Medicare secondary payer policies

and other technical issues.

Develops regulations for the Medicare and Medicaid

programs.

Manages the HCFA system for developing regulations,

setting regulation priorities, and corresponding work agenda.

In cooperation with the Office of the General Counsel,

coordinates litigation affecting the Medicare program.

a. Regulations Staff (FKA-1)

Drafts all HCFA regulations and related clearance

documents and HCFA rulings.

Establishes and assures compliance with editorial

standards for clarity and uniformity of HCFA regulations and with the

requirements of the Office of the Federal Register.

Recommends schedules for the development of regulations,

tracks progress against these schedules, and develops routine and

special reports on HCFA's regulatory activities.

Negotiates resolution of policy issues with originating

component to meet regulations schedules. Obtains clearances of draft

regulations from initiating bureaus.

Coordinates the Bureau of Policy Development's (BPD)

review of regulations received for concurrence from other HCFA

components and prepares BPD's response.

Reviews draft regulations and completes needed studies to

assure compliance with the requirements for regulatory impact analysis

of Executive Order 12612, the Regulatory Flexibility Act, and small

rural hospital impact.

Maintains specialized word processing systems to assure

efficient preparation of regulations documents.

Maintains official agency regulations files. Maintains

current compilation of 42 Code of Federal Regulations, Part 400-End.

b. Office Of Regulations Management (FKA-2)

Manages the HCFA process for developing regulations,

setting regulation priorities, and corresponding work agendas.

Coordinates for the Administrator the development of all

policy documents associated with specific regulations under

development.

Negotiates work plans with major HCFA operating components

for the development of each regulation and monitors performance through

a computerized tracking system.

Works jointly with HCFA and the Office of the General

Counsel to identify and resolve all issues associated with each

regulation.

Manages the HCFA process for substantive review and

clearance of regulations within HCFA, and with the Office of the

General Counsel.

Establishes editorial and technical standards for writing

regulations.

Reviews each regulation to ensure consistency with Federal

Register technical requirements, editorial standards, and policy

agreements reached during the development of the regulation.

Serves as liaison on regulation issues to the Office of

the Secretary, the Office of the General Counsel, other Department and

Federal agencies, and the Federal Register. Provides training to HCFA

regulation writers and clerical staff.

c. Office of Program Support (FKA-3)

Directs the planning, development, and coordination of a

comprehensive program of management activities including: financial

management, management analysis and information, field liaison, Freedom

of Information operations, and an executive secretariat for the Bureau.

Prepares responses to all Medicare public inquiries

addressed to or referred to the Bureau.

Serves as principal advisor to the Director, as well as

the Bureau's executive staff, on the full range of management and

related administrative issues.

Responsible for handling highly sensitive and complex

assignments requiring the Director's and Deputy Director's personal

attention often involving inter-Bureau and office coordination and

direction.

(1) Executive Secretariat (FKA-31)

Assigns, controls, tracks, and coordinates all work

assigned to, or generated within the bureau, except regulations.

Prepares regular reports on bureau and component

performance on significant bureau activities and accomplishments and

long-range calendar events.

Reviews all action documents submitted to the Office of

Program Support to assure accuracy and completeness of staff work and

general readiness for the action requested.

Coordinates bureau responses to: (1) Requests for

background and briefing materials, (2) requests for comments on

experimentation and demonstration proposals, and (3) Audit and Service

Delivery Assessment reports.

Prepares or coordinates the preparation of responses to

Secretary and Administrator correspondence.

Handles bureau Freedom of Information requests,

determining what information may and may not be released to the public,

and ensuring that bureau replies are fully responsive.

Coordinates the development, implementation, and

maintenance of the bureau's work planning system.

Manages bureau-wide internal control systems.

(2) Inquiries Staff (FKA-32)

Plans, directs, and coordinates an inquiries program for

the bureau.

Receives controls, analyzes, and prepares responses to

inquiries from beneficiaries and their representatives, the White

House, members of Congress, State and local agencies, officials of

professional organizations, and the mass media.

Analyzes trends in public thinking and reports possible

policy implications to management.

Provides technical assistance upon request to components

and field offices.

(3) Program Liaison Staff (FKA-33)

Evaluates the impact of policy development and issuance

processes on regional operations, and determines whether policies and

instructions are being adequately and consistently carried out by the

regional offices.

Responds promptly to requests from the regional offices

for specific policy guidance and provides general policy

interpretations.

Develops, coordinates, and directs a management program

for the management analysis functions, internal financial management,

manpower selection and placement, training and employee development,

position control and manpower utilization.

Develops and issues Bureau-wide problem area reporting,

coordination of Bureau operational planning activities, and a variety

of administrative support services, including property and space

management.

Designs and evaluates Bureau management information

systems, conducts management information and project management

monitoring studies, and administers the Bureau's reports management

program.

Responsible for the Bureau's Automatic Data Processing,

Telecommunications and Word Processing systems including identifying

needs, procurement, evaluation, and maintaining liaison with the Bureau

of Data Management and Strategy, Office of Computer Operations.

d. Office of Payment Policy (FKA1)

Establishes national Medicare policy on all payment issues

including provider and other facility payment, reporting and accounting

policy, and physician and medical services payment policy, and assists

in the development and evaluation of related legislation.

Develops, evaluates, and maintains regulations, policies,

and standards for payments to hospitals for inpatient services under

the prospective payment system.

Coordinates with and reviews recommendations from the

Prospective Payment Assessment Commission and the Physician Payment

Review Commission.

Develops policies for physician fee schedules and

reasonable charges for physician and medical services payment.

Develops and maintains fee schedules for independent

laboratory and ambulatory surgical centers.

Develops payment policy for special forms of health care

delivery such as hospital outpatient departments, health maintenance

organizations, rural health clinics, hospices, health care prepayment

plans, and comprehensive health centers.

Establishes payment policies as they apply to the End-

Stage Renal Disease (ESRD) Program.

Establishes policy for implementing payment controls and

cost containment programs.

Reviews requests for exceptions to payment limitations and

recommends approval or disapproval.

(1) Division of Medical Services Payment (FKA11)

Formulates and evaluates national policies and standards

for Medicare payment and fiscal standards for physician services,

practitioner services, pharmaceuticals, supplies and equipment such as

hearing aids, eyeglasses, durable medical equipment, and other medical

services.

Develops policies for reasonable charges for physician and

medical services payment.

Drafts program regulations, manuals, guidelines, and other

general instructions related to medical services payment.

Coordinates with other HCFA bureaus, divisions, and

offices, the Social Security Administration, and other Departmental

components in the development of payment policies for medical services.

Coordinates with and reviews recommendations from the

Physician Payment Review Commission.

Participates in the development and evaluation of proposed

legislation in the area of medical services payment and recommends

alternatives to current methods of payment.

Provides interpretations of established policies and

technical assistance to Departmental and HCFA components, regional

offices, fiscal intermediaries, and carriers.

(2) Division of Hospital Payment Policy (FKA12)

Develops, evaluates, and maintains regulations, policies

and standards for payments to hospitals for inpatient services under

the prospective payment system (PPS).

Develops, evaluates, and maintains policies pertaining to

the determination of appropriate amounts of prospective payments to

hospitals for services furnished to inpatients.

Works with the Prospective Payment Assessment Commission

of PPS and reviews the Commission's recommendations on and basis for

rates of payments.

Develops, evaluates, and maintains policies pertaining to

the appropriate methods for determining the amount of payments for cost

items associated with inpatient hospital services but not yet within

the prospective payment rates and develops policies for bringing such

excepted cost items under PPS.

Develops, evaluates, and maintains policies for

determining and applying rates of increase and limitations to the costs

of hospitals for services furnished to inpatients.

Develops, evaluates, and maintains methods for classifying

hospitals and hospital services to inpatients, including sole community

hospitals, for the purpose of applying rates of increase and

limitations on hospitals' costs and for determining prospective

payments to hospitals.

Develops, evaluates, and maintains criteria for exceptions

to the established rates of increase and limitations on hospitals' cost

for inpatient services and reviews fiscal intermediaries'

recommendations on requests for exceptions.

Prepares regulations, program guidelines, and instructions

related to PPS and those excepted items or adjustments to the system

that are paid on a cost-payment basis to hospitals for inpatient

services.

Works with other offices in the bureau, HCFA, the

Department, and the Prospective Payment Assessment Commission to

improve hospital efficiency and reduce Medicare expenditures.

Review policies and operational guidelines and

instructions developed by other components for their impact on the

policies governing PPS and limitations on payment for hospital services

to inpatients.

Participates in the development and evaluation of proposed

legislation pertaining to PPS and cost containment for hospital

services to inpatients.

Provides interpretations of established policies and other

policy and technical assistance to regional offices, State agencies,

Medicare contractors, hospitals, hospital associations, congressional

staff, departmental offices, and others on policy issues relating to

PPS and cost containment policies for hospital inpatient services.

Assists in the Administration's professional relations and

public information activities to foster understanding and acceptance of

the PPS.

(3) Division of Payment and Reporting Policy (FKA13)

Develops and evaluates national policies, regulations, and

standards for payment of the costs incurred by providers of services

and other classes of facilities under the health insurance program.

Initiates and collaborates in the development and review

of legislative proposals on general Medicare payment policies,

interprets law (considering intent), and develops policy directives and

basic payment policy decision statements which derive from such

applicable law and which are reflective of the minimum requirements of

such law (i.e., the broad parameters).

Develops and issues implementing instructions consistent

with overall Medicare payment policy, directives, and specifications.

Reviews alternative payment and rate-setting systems for

potential adaptation to the health insurance program.

Establishes policies, principles, and guidelines related

to circumstances requiring atypical payment practices.

Plans, develops, and maintains a continuing program of

surveillance and evaluation of HCFA general payment policies, and

billing procedures at Central Office, regional offices, intermediary,

and carrier levels which impact on Office functions in order to

identify emerging problems and to develop and promulgate corrective

policies and procedures.

Formulates and evaluates national policies for all

Medicare program provider financial filing and reporting requirements.

Develops policies pertaining to the use of all cost

reporting forms, schedules, and related instructions necessary for

paying health care institutions.

Develops policies pertaining to the validity of accounting

policies and procedures.

Develops and maintains a system of internal controls for

the validation of policy decisions.

Formulates the basic principles and policies for

developing and applying limitations to the costs of health care.

Develops and evaluates the criteria for exceptions to the

limitations and reviews and makes decisions on the intermediary

recommendations on providers' requests for exceptions.

(4) Division of Special Payment Programs (FKA14)

Formulates and evaluates payment policies for services

under the End-Stage Renal Disease (ESRD) program, ambulatory surgical

centers and other special delivery systems, including capitation

organizations, non-provider based comprehensive health centers,

hospices and rural health clinics.

Prepares regulations, manuals, program guidelines, and

other general instructions in these policy areas.

Establishes payment policies and procedures for ESRD

services, transplantation, physician payment, kidney acquisition

including payments, organ procurement, histocompatibility services,

home and self-dialysis training, and other medical items and services

related to the ESRD program.

Establishes policies, procedures, and criteria for payment

exceptions for ESRD facilities.

Processes such requests and determines which ESRD

facilities should be granted exceptions to national payment rates.

Analyzes payment data, develops payment rates for ESRD

services and other special payment delivery systems, and updates rates.

Maintains continuing liaison with ESRD provider groups,

industry associations, patient organizations, medical associations, and

other parties that relate to special delivery systems.

Participates in the development and evaluation of proposed

legislation pertaining to the ESRD program and organ transplant issues.

Formulates and evaluates national policies for the payment

of special methods of health service delivery.

Develops policies pertaining to determining the payment

basis, including reasonable costs and charges, where appropriate, for

the services of these facilities.

Formulates the basic principles and policies for

developing and applying limitations to the costs of health care.

e. Office of Coverage and Eligibility Policy (FKA2)

Develops, evaluates, and reviews national policies and

standards concerning the coverage and utilization effectiveness of

items and services under the Medicare program provided by hospitals,

skilled nursing facilities, hospices, End-Stage Renal Disease

facilities, home health agencies, alternative health care

organizations, comprehensive outpatient rehabilitation facilities,

physicians, health practitioners, clinics, laboratories, and other

health care providers and suppliers.

Serves as the principal organization within HCFA for

evaluating the medical aspects of Medicare coverage issues and for

health quality and safety standards.

Develops, evaluates, and reviews national Medicare

coverage issues concerning the reasonableness and necessity for medical

and related services.

Develops, evaluates, and reviews health and safety

standards for providers and suppliers of health services under

Medicare.

Develops common medical coding standards and policy.

Participates in the formulation and use of medical codes

including: International Classification of Diseases--Ninth Revision--

Clinical Modification, HCFA Common Procedure Coding System, and

Diagnosis Related Groups.

Develops, evaluates, and reviews national Medicare

policies concerning the coverage of new and unusual items and services

and those medical items and services which are excluded from coverage.

Develops, interprets, and evaluates policies relating to

the conditions under which aged and disabled individuals and End-Stage

Renal Disease patients are eligible to have their health care covered

under the Medicare program and the rights available to these

beneficiaries.

Develops, evaluates, and reviews regulations, guidelines,

and instructions required for the dissemination of Medicare coverage

and eligibility policies to program contractors and the health care

field.

Identifies, studies, and makes recommendations for

modifying Medicare coverage and eligibility policies and health and

safety standards to reflect changes in beneficiary health care needs,

program objectives, and the health care delivery system.

Conducts ongoing analyses of innovative treatment

patterns, referral patterns, and activity that improve health care

outcomes.

Analyses and recommends legislative or other remedies to

improve coverage, eligibility, health and safety standards, and

utilization effectiveness.

(1) Division of Provider Services Coverage Policy (FKA21)

Develops, evaluates, and reviews national Medicare

policies and standards concerning the coverage of services and the

conditions of participation for hospitals, skilled nursing facilities,

home health agencies, hospices, and other providers of services.

Develops, evaluates, and reviews national Medicare

policies concerning the coverage of mental health, alcoholism and drug

treatment, utilization review, and physician certification, and prior

authorization requirements.

Coordinates Medicare coverage policies and Peer Review

Organization requirements.

Develops, evaluates, and reviews regulations, guidelines,

and instructions required for the dissemination of program policies to

program contractors and the health care field.

Identifies, studies, and makes recommendations for

modifying Medicare coverage policies and providers' health and safety

standards to reflect changes in beneficiary health care needs, program

objectives, and the health care delivery system.

Analyzes and recommends legislative or other remedies to

improve coverage, health and safety, and utilization effectiveness.

(2) Division of Medical Services Coverage Policy (FKA22)

Develops, evaluates, and reviews national Medicare

policies and health and safety standards concerning the coverage of

items and services which are provided by physicians, nonphysician

practitioners, ambulatory surgical centers, health maintenance

organizations, comprehensive medical plans, rural health clinics,

comprehensive outpatient rehabilitation facilities, outpatient physical

therapy/occupational therapy/speech pathology providers and other

alternative health care organizations.

Develops, evaluates, and reviews national Medicare

policies and health and safety standards concerning the coverage of

medical and other health services including supplies, drugs,

rehabilitative services, eyeglasses, laboratory services, x-ray

services, ambulance services, second opinions, new and unusual items

and services, dialysis and transplant services for Medicare

beneficiaries with End-Stage Renal Disease, and those medical items and

services which are excluded from coverage.

Develops, evaluates, and reviews national Medicare

policies concerning reasonableness and necessity for services.

Develops, evaluates, and reviews regulations, guidelines,

and instructions required for the dissemination of program policies to

program contractors and the health care field.

Identifies, studies, and makes recommendations for

modifying Medicare coverage policies to reflect changes in beneficiary

health care needs, program objectives, and the health care delivery

system.

Recommends legislative or other remedies to improve

coverage, health and safety, and utilization effectiveness.

Coordinates with other components responsible for the

Medicaid program, health and safety standards, program operations,

quality control, and other parties and individuals, as appropriate.

(3) Division of Medicare Eligibility Policy (FKA23)

Develops, interprets, and evaluates policies relating to

the conditions under which aged and disabled individuals and End-Stage

Renal Disease patients are eligible to have their health care covered

under the Medicare program and the rights available to these

beneficiaries.

Prepares policy materials for issuance in program manuals

and instructional materials, and for the development of regulations.

Reviews eligibility aspects of special research and

demonstration projects as needed.

Participates in assessing the needs for legislation and

makes recommendations accordingly.

Develops and interprets policy related to entitlement

aspects of part A and part B buy-in.

3. Office of Research and Demonstrations (FKB)

Provides leadership and executive direction within HCFA

for a wide range of health care financing research and demonstration

activities.

Develops, tests and evaluates new payment methods,

coverage policies and delivery mechanisms in Medicare, Medicaid and

other health care programs.

Has primary responsibility for managing HCFA's Medicare

and Medicaid demonstration waiver authorities including the Federal

review, approval, and oversight of State health reform waivers.

Develops new and innovative ways to reform the quality,

efficiency, and cost effectiveness of Federal, State and private health

care financing programs.

Works closely with the Associate Administrator for Policy,

other Bureau/Office Directors, and high level staff outside HCFA to

insure that the Agency's objectives and long range planning in these

areas are accomplished.

Participates with departmental components in a wide range

of experimental health care delivery projects.

Performs claims adjudication, payment, and data collection

for demonstration projects.

Undertakes research to facilitate informed program and

policy decisions designed to make improvements in the health care

delivery system.

a. Office of Demonstrations and Evaluations (FKB1)

Plans and directs the development, implementation,

monitoring and evaluation of demonstration projects designed to test

the costs and effectiveness of alternative payment methods, delivery

systems, benefit packages, or provider status in the Medicare and

Medicaid programs.

Develops and reviews innovative approaches to the delivery

of HCFA health care programs; coordinates with State and local

governments, providers, beneficiaries, researchers and program staff in

the implementation of projects; and assesses and synthesizes the

results of projects to determine their impact on the programs and

participants.

Recommends modifications to existing program policy and

legislation.

Provides technical advice and consultation to other

Federal and external organizations on potential experimental projects

and publishes results and analyses of experimental findings.

(1) Division of Long-Term Care Experimentation (FKB11)

Directs and manages the development, implementation,

monitoring, and evaluation of demonstrations and experiments which test

innovative long-term care financing arrangements, delivery systems, and

combinations of services provided to Medicare beneficiaries and

Medicaid recipients.

Conducts demonstrations involving health maintenance

organizations, prospective payment of home health agencies, competitive

bidding for home health agencies, and capitation experiments.

Conducts and evaluates demonstrations which test

alternative delivery systems and whether the coordination and

management of an appropriate mix of health and social services directed

at individual client needs will reduce institutionalization and costs

without sacrificing quality of care.

Provides technical support and advice to HCFA and

departmental components in regard to long-term care issues.

Makes available research findings to assist in policy

formulation and program initiatives, and publishes analyses of findings

resulting from demonstration projects.

(2) Division of Hospital Experimentation (FKB12)

Directs and manages the development, implementation,

monitoring, and evaluation of intramural and extramural hospital

financing and payment studies and experiments such as prospective and

incentive payment experimentation for hospitals.

Directs and manages the study, development, testing, and

evaluation of hospital alternative payment systems such as refinement

in diagnosis-specific payment and capitated payment rates.

Conducts studies and demonstrations on entire facilities

or specific areas such as out-patient departments and hospital capital

investment.

Directs studies and demonstrations which focus on

hospital-based and hospital-related activities including physician,

home health, skilled nursing, independent laboratories, and other

services that result in greater costs effectiveness.

(3) Division of Health Systems and Special Studies (FKB13)

Directs and manages the development, implementation,

monitoring, and evaluation of intramural and extramural financing and

payment, organization, and operational studies related to health care

delivery systems.

Directs the development, testing, and evaluation of cost-

effective alternatives to existing institutional and ambulatory care

patterns.

Directs the development and evaluation of cross-cutting

special studies in such areas as combining long-term care and acute

care financing, providing of durable medical equipment, managing end-

stage renal disease, and minimizing fraud and abuse.

6. Office of Research (FKB2)

Directs the development and conduct of research and

evaluation studies concerning the impact of Federal financing programs

on the health care industry, program beneficiaries, and health care

providers, including physicians.

Directs and designs analytical studies to be undertaken by

internal staff and outside contractors/grantees in a wide variety of

economic and financial aspects of health care delivery in the United

States, including the structure of the drug, medical supplies and

health insurance industries and the financing of capital investment.

Provides technical support to HCFA and departmental

components in research design, sampling design, mathematical and

statistical analysis, and the application of economic analysis.

Makes available research findings to assist in the

formulation of payment and other policy questions and publishes results

and analyses of these findings.

(1) Division of Beneficiary Studies (FKB21)

Designs and conducts intramural and extramural research

studies and surveys to test hypotheses relating to beneficiary

utilization and to determine factors underlying patterns and trends in

utilization of HCFA programs.

Develops and conducts evaluations of HCFA programs to

enable the Administrator, the Department and Congress to determine how

well HCFA policies and actions affect the attainment of HCFA's goals to

ensure that quality medical care is delivered to its beneficiary

population in the most cost effective manner.

Assesses the impact of HCFA programs on health care costs,

programs expenditures, HCFA beneficiaries, providers of services and

the total health care system.

Designs and directs the development of special data bases

and tabulations to support research and policy activities.

Provides analyses on complex beneficiary data sets for the

Medicaid program, health care planners and other users external to

HCFA.

(2) Division of Payment and Economic Studies (FKB22)

Conducts research to determine the influences which

current and alternative payment methods have on the economic, financial

and behavioral characteristics of providers (e.g., the effects on

physician productivity under alternative methods of payment).

Conducts research directed toward the development and

application of new, improved methods, quantitative models and other

technical tools for determining the costs and benefits to providers,

patients, and financing programs associated with alternative payment

schemes.

Participates in monitoring grants and the grants award

process in those areas related to hospital costs and physician payment.

Provides technical assistance and makes findings from

research available to assist in policy formulation, recommendations and

program initiatives.

Conducts research on factors which affect the demand for

and supply of services including supplies of staffpower and the

structure and future of the health care delivery systems.

Undertakes research to further the understanding of the

organization of the health industry, including the drug industry, the

insurance industry and the equipment producers.

Assesses the likely implications of trends in these

industries as they affect health care coverage either in benefits or

beneficiary population.

Examines the role of capital in the expansion and

replacement of plant and equipment in the health care sector and the

effects of alternative sources and costs of capital in this regard.

Provides analysis of payment alternatives for major

provider groups and makes recommendations for policy changes in payment

activities.

Assists in the implementation of payment changes.

(3) Division of Program Studies (FKB23)

Directs the design and development of the Medicare and

Medicaid statistical systems to provide ongoing data for the research

and evaluation program.

Consults with and provides technical direction to

professional staff and management in the development of research data

bases as a by-product of the administrative record system.

Designs and develops the production of periodic

statistical tabulations to assess the characteristics of the

beneficiaries and the utilization and costs of program benefits.

Designs and writes periodic analytical reports to

disseminate data and to describe patterns and trends for program

evaluation and policy direction.

c. Office of Operations Support (FKB3)

Directs the research and demonstrations project grant,

cooperative agreement and procurement programs.

Directs and plans ongoing research publications and

information resources programs.

Performs claims adjudication, payment, and data collection

for demonstration projects.

Participates with departmental components in a wide range

of experimental health care delivery projects.

Provides a setting for testing proposed policies and

procedures which impact on fiscal intermediary operations and provides

the capacity for serving specialized providers.

Directs the Office of Research & Demonstrations'

correspondence, tracking, and control system and responds to ORDs'

Freedom of Information requests.

Coordinates the development of, and responses to,

regulations related to ORD.

(1) Division of Research and Demonstrations Systems Support (FKB31)

Serves as fiscal intermediary for experiments and

demonstrations conducted under legislative authorities in the Social

Security Act, Public Health Service Act, and related legislation.

Also serves as fiscal intermediary for former direct-

dealing providers who were terminated from the Medicare program and

have final cost reports and bills yet to be processed.

Performs a wide range of duties related to the

development, implementation, and ongoing operation of the

demonstrations.

Provides technical advice and assistance prior to the

start of the demonstrations and throughout the period of the

experiment, to other bureaus and agencies in developing service

definitions, payments protocols, contracts, and reporting mechanisms.

Assists in the design and establishment of information

systems for compiling demonstration payment and service data for

evaluator use.

Develops cost reporting and billing systems.

Acts as liaison between governmental agencies, service

contractors, and Medicare carriers and intermediaries participating in

demonstration activities.

Provides systems support to other components of the Office

of Research & Demonstration (ORD). Performs other support duties as

requested.

Carries out project management; by directing project teams

in the analysis, design, and implementation of management information

systems which are ORD program-oriented.

(2) Division of Program Support (FKB32)

Plans, organizes, and administers the extramural ORD

research and demonstration (grants, cooperative agreements, and

contracts) program assuring that both technical and administrative

requirements are met.

Plans and directs an ongoing publications dissemination

and information resources program.

Provides assistance in the coordination and production of

major written documents, plans, and reports.

4. Office of the Actuary (FKC)

Conducts and directs the actuarial program for HCFA and

directs the development of and methodologies for macroeconomic analysis

of health care financing issues.

Performs actuarial, economic and demographic studies to

predict HCFA program expenditures under current law and under proposed

modifications to current law.

Provides program estimates for use in the President's

budget and for reports required by Congress.

Studies questions concerned with financing present and

future health programs, evaluates operations of the Federal Hospital

Insurance Trust Fund and Supplementary Medical Insurance Trust Fund and

performs microanalyses for the purpose of assessing the impact of

various health care financing factors upon the costs of Federal

programs.

Develops and conducts studies to estimate and project

national and area health expenditures.

Analyzes trend data sources such as the Consumer Price

Index to develop projections of health care costs.

Analyzes data on physicians' costs and charges to develop

payment indices and monitors expansion of service and inflation of

costs in the health care sector.

Publishes cost projections and economic analyses, and

provides actuarial, technical advice and consultation to HCFA

components, governmental components, Congress and outside

organizations.

a. Office of Medicare and Medicaid Cost Estimates (FKC1)

Prepares cost estimates for the Hospital Insurance (HI)

program, the Supplementary Medical Insurance (SMI) program, and the

Medicaid program for use in the President's budget.

Evaluates the operations of the Medicare trust funds

particularly relating to outlays and program solvency.

Develops such variables as the Part B premium rates, the

inpatient hospital deductible, the Part A premium rate for voluntary

enrolles, and the physicians' economic index applicable to prevailing

fees.

Develops the payment rates for the annual update of the

adjusted average per capita cost (AAPCC) ratebook, which is used to pay

health maintenance organizations that enter into a risk contract with

HCFA to provide benefits to Medicare enrolles.

Provides cost estimates for the Medicaid program,

including the development of cost estimates for proposed changes in

Medicaid or in programs affecting Medicaid, and overall Medicaid

program costs for years after the current budget year.

Serves as technical consultant throughout the Government

on Medicare and Medicaid cost estimate issues.

(1) Division of Hospital Insurance (FKC11)

Prepares cost estimates for the Hospital Insurance (HI)

program for use in the President's budget.

Evaluates operations of the Medicare HI trust fund

concerning income and outgo, and the necessary tax rates for program

solvency.

Develops such variables as Part A inpatient hospital

deductible and the Part A premium rate for voluntary enrolles.

Computes estimates of the impact of modifications in

program benefits and financing.

Serves as technical consultant throughout the Government

on Medicare HI cost estimate issues.

(2) Division of Supplementary Medical Insurance (FKC12)

Prepares cost estimates for the Supplementary Medical

Insurance (SMI) program for use in the President's budget.

Evaluates operations of the Medicare SMI trust fund

concerning income and outgo, the necessary premium, and actuarial rates

for program solvency.

Develops such variables as the Part B premium rate and the

physicians' economic index applicable to prevailing fees.

Computes estimates of the impact of modifications in

program benefits and financing.

Serves as technical consultant throughout the Government

on Medicare SMI cost estimate issues.

(3) Division of Medicaid Cost Estimates (FKC13)

Provides cost estimates for the Medicaid program,

including the development of cost estimates for proposed changes in

Medicaid or in programs affecting Medicaid, and overall Medicaid

program costs for years after the current budget year.

Develops forecasts of Medicaid expenditures for

incorporation into the HCFA budget development process.

Provides actuarial consultation to other components of

HCFA concerning various proposals and programs affecting the future of

the Medicaid program.

Studies actuarial approaches and techniques, and develops

data to assist in the development of program forecasts.

Serves as technical consultant throughout the Government

on Medicaid cost estimate issues.

b. Office of National Health Statistics (FKC2)

Develops, maintains and makes analytical use of the

National Health Accounts (NHA) which include annual estimates and

publication of National Health Expenditures (NHE) and periodic

estimates and publication of NHE by age groupings or by region.

Provides technical support for HCFA regulatory processes,

especially those related to payment systems or reform.

Develops, analyzes and publishes, health sector models and

associated estimates which allow assessments of historical

relationships and projections of current law or evaluation of the

impact of proposed changes to the current system.

Conducts and evaluates surveys containing information

relevant to the health care system.

(1) Division of Health Cost Analysis (FKC21)

Maintains the National Health Accounts. Provides an

interdisciplinary approach to data collection, manipulation and

analysis, and interpretation of national, and regional health use,

costs and payment sources, both public and private.

Estimates and disseminates annual national health

expenditures estimates, periodic estimates of health expenditures by

region or State, and produces quarterly ``health indicators'' measures.

Provides technical support for HCFA regulatory processes,

especially those related to payment systems or reform.

Provides technical analysis and data for Agency,

Department, or Administration initiatives.

Responds to requests for information and analysis on the

health sector and its relationship to the general economy.

(2) Division of Survey Analysis (FKC22)

Plans and manages the Medicare Current Beneficiary Survey.

Provides all the in-house activities needed for survey management, data

analysis, and coordination and information dissemination.

Conducts and evaluates surveys containing information

relevant to the health care system.

Develops, maintains, and analyses the statistical

reliability and representation of the Medicare Current Beneficiary

Survey. Assures that sample replenishment reflects population and sub-

group profiles.

Develops and provides analysis of the survey methodology

and techniques in conjunction with the survey contractor. Establishes

an interdisciplinary approach to data collection, manipulation and

analysis and interpretation.

Provides technical analysis and data for Agency,

Department, or Administration initiatives.

Responds to requests for information and analysis on the

health sector as it relates to survey data.

D. Associate Administrator for Operations and Resource Management

(FL)

The Associate Administrator for Operations and Resource

Management (AAORM) is responsible for the effective direction,

coordination and implementation of all aspects of Headquarters and

regional program operations and resource management activities.

The program operational functions include the Medicare

financial management systems; the development, negotiation, execution

and management of contracts with Medicare contractors; enforcement of

health quality and safety standards for providers and suppliers of

health care services; the administration of professional review and

other medical review programs; the evaluation of contractors and State

agencies against performance standards; and the statistically based

quality control programs which measure the financial integrity of

Medicare.

The 10 Regional Administrators report to the AAORM through

the Deputy Associate Administrator for Operations and Resource

Management.

The resource management responsibilities include

developing and implementing HCFA's policies, rules and procedures in

the areas of financial, personnel and contracts management, project

grant administration, management evaluation and analysis and

administrative services; the nationwide operation of a centralized

Automated Data Processing (ADP) and telecommunications facility;

establishing and maintaining computerized records supporting HCFA

programs; developing and coordinating information and statistical plans

and policies; and maintaining a statistical data system which will

provide program accountability data to the Administrator, HCFA,

Congress, and the public.

1. Office of the Attorney Advisor (FL-1)

The Office of the Attorney Advisor is attached to AAORM

for administrative issues but continues to report to the Administrator,

HCFA, for substantive issues.

The Attorney Advisor recommends initiation of ``own motion

review'' of Provider Reimbursement Review Board decisions and of

Medicare Geographical Classification Review Board (MGCRB) decisions.

Evaluates cases under ``own motion review'' and recommends

the disposition of such cases by the Administrator.

Evaluates and makes recommendations for disposition of

MGCRB decisions appealed to the Administrator.

2. Office of Planning and Support (FL-2)

Develops and manages systems for integrating and focusing

all Operations and Resource Management's efforts and capabilities

toward achieving initiatives of the HCFA Administrator and the

Associate Administrator for Operations and Resource Management (AAORM).

Establishes and implements the integrated and coordinated

AAORM-wide management planning, workplanning, and performance

monitoring processes.

Formulates policies and positions on management programs

having AAORM-wide impact, including financial management; budget

preparation and execution; resource utilization; and management and

organizational analysis. Coordinates the preparation and execution of

the AAORM-wide budget. Furnishes financial management advice to AAORM

and provides liaison on AAORM fiscal matters with HCFA's Office of

Financial and Human Resources.

Coordinates and monitors the development of AAORM-wide

automated data processing plans and information strategies. Designs,

develops, and manages Operations and Resource Management-wide

information systems.

Develops and implements AAORM program and administrative

delegations of authority.

Ensures regional office input to the development, review

and clearance of program policies, procedures, and instructions.

3. Office of Financial and Human Resources (FLA)

Provides HCFA-wide policy direction, coordination and control in

the areas of budget, financial and accounting operations, personnel,

management evaluation and analysis, administrative services, project

grants, contracting and procurement, audit resolution, and

workplanning. Develops and promulgates HCFA policy in these areas and

executes these policies throughout HCFA; also assures consistency with

departmental policy. Designs systems support for personnel management,

financial management, procurement, and facilities management programs

within HCFA. The Director serves as the Chief Financial Officer and the

Deputy Ethics Counselor for the Agency.

a. Management Planning and Analysis Staff (FLA-1)

Provides Agency-wide services, policy, direction, and

coordination with respect to HCFA's management analysis, planning, and

control programs including: workplanning, management analysis,

productivity improvement, Privacy Act, internal controls, Office of

Inspector General audit resolutions functions, advisory and assistance

services certification, contracting of commercial and industrial

activities, the administrative issuances system, memoranda of

understanding and interagency agreements, delegations of authority, and

reduction of paperwork programs.

Conducts special studies and analyses concerning Agency-

wide and cross-cutting OFHR issues and other broad-based administrative

issues.

Advises the OFHR Director in management analysis

activities.

Develops, reviews, analyzes, and maintains existing or

proposed Agency-wide delegations of authority.

Provides services, policy direction, and coordination

regarding the HCFA paperwork reduction activities.

b. Office of Financial Management (FLA1)

Provides financial and accounting services, leadership,

and policy direction for HCFA's financial management program. Operates

the Agency's accounting and financial reporting activities and

processes all obligations and expenditure documents including employee

payroll and travel costs.

Prepares, justifies, and executes the HCFA program and

administrative budget. Coordinates with officials at the Department and

at the Office of Management and Budget to resolve budget issues.

Provides advice and assistance to HCFA components in the development

and justification of their annual budgets.

Manages the HCFA financial and manpower resource

allocation activities. Prepares reports and other resource allocation

control mechanisms for the Director, OFHR, and other HCFA Senior Staff.

(1) Division of Accounting (FLA11)

Plans, directs and operates the HCFA accounting, fiscal

and financial reporting functions.

Administers and operates the HCFA accounting system.

Establishes policy for the allocation of costs among appropriations.

Develops methodologies to determine costs by program, organization and

source of funds.

Performs accounting functions for all appropriations, fund

warrants, apportionments, allotments and allowances. Processes all

obligations and expenditure documents, including verification of

entitlement for all commercial and intergovernmental financial

transactions for the compensation and related cost of personnel

(payroll), and for employee travel and transportation (domestic and

foreign).

Reviews time and attendance reports prior to transmittal

to the Central Payroll Office, resolves employee leave and payroll

problems, and conducts a time and attendance report preparation

training program.

Performs accounting for all grants issued to fund

programs, and schedules payments by check to those grantees not funded

through Departmental Federal Assistance Financing System (DFAFS).

Reviews and reconciles grantees' advance accounts on the

basis of verified expenditures.

Monitors and reconciles data generated in Agency

appropriations as a result of entries made in the Regional Accounting

System.

Provides cashier services, processes collections, and

maintains accounts receivable control records.

Develops accounting policy and procedures for HCFA.

(2) Division of Budget (FLA12)

Consolidates, prepares, and executes HCFA's budget and

operates HCFA's budget system. Serves as the central information point

for all budgetary matters including interagency agreements impacting on

HCFA's funding and transfer of funds to and from other agencies.

Provides advice on the reporting of program and financial data

necessary for the presentation and defense of budget requests.

Provides advice, guidance, and assistance to HCFA

components in the development of budget justification materials and

analysis including current services budgeting and other budgetary

principles required by the Office of the Secretary, HHS, the Office of

Management and Budget, and Congress. Provides technical direction to

HCFA regional components on all budgetary matters.

Develops budget control systems necessary to insure that

appropriate measures are in place to prevent violations of the Anti-

Deficiency Act.

Maintains and monitors an allotment and allowance system

sufficient to pinpoint responsibility and accountability for Federal

funds.

Provides staff expertise in the review and analysis of

budgetary, operational, legislative, or regulatory proposals by HCFA

operating components. Reviews these proposals to determine the fiscal

impact on, and consistency with, HCFA and departmental management and

programmatic objectives.

Develops financial management policy as it relates to

HCFA's programmatic objectives. Certifies the cost impact of all

proposed program and demonstration waivers.

Reviews financial data and makes recommendations as to the

effectiveness of the waiver and potential termination or nonrenewal

actions.

Directs the allocation of HCFA's staffing resources among

HCFA components, issues employment ceilings, and directs HCFA's

manpower management system. Assures the validity of cost allocation

data and monitors adherence to financial management policies among HCFA

components.

c. Office of Human Resources (FLA2)

Provides services, leadership, direction, and control with

respect to personnel and related services within HCFA.

Serves as the principle advisor to the Director of the

Office of Financial and Human Resources on the operation of HCFA's

personnel system, including recruitment and placement, position

classification, personnel management evaluation, performance appraisal,

employee development and training, employee relations, ethics

functions, and labor relations.

Administers the Agency special emphasis placement and

executive personnel programs.

Serves in a leadership role in providing authoritative

advice and assistance to management officials in carrying out their

position management responsibilities.

Provides for an employee counseling service for employees

in HCFA Central Office.

Provides services, policy direction, and coordination with

respect to the organizational analysis activities.

Provides direct service and establishes policy for other

HCFA components with respect to health and activities related to health

matters.

(1) Division of Information and Organizational Management (FLA21)

Coordinates all personnel information management

activities for the Office of Human Resources. Administers and operates

the Department's automated personnel/payroll system, Improved

Management of Personnel Administration through Computer Technology

(IMPACT), as it applies to HCFA components.

Develops human resource functional requirements for and

access to HCFA's Comprehensive Personnel System. Provides systems

support and technical assistance on all other automated data processing

and office automation activities that relate to human resources

functions.

Plans, directs, and implements a comprehensive HCFA

position classification and position management program for all

positions GS-15 and below in the Central and Regional Offices. Inputs

data into the automated personnel system and prepares statistical

information and reports relating to the position management and

classification program.

Conducts the HCFA-wide organizational analysis program.

Studies HCFA's organizational and functional arrangements and develops

plans for assimilating new or modified functions into the HCFA

organization.

Conducts in-depth analyses of new legislation affecting

HCFA for the purposes of determining the affect on HCFA's

organizational structure. Develops recommendations for organizational

changes, and submits proposals to upper management's consideration.

(2) Division of Performance Management and Development (FLA22)

Provides leadership, direction, and control with respect

to HCFA's employee training and career development activities,

performance management, and awards programs in both headquarters and

the regions.

Provides management advisory service concerning the

regulatory and procedural aspects of implementing the assigned

programs.

Serves as an Agency representative in dealing with

employee/management/union organizations, the Department of Health and

Human Services, and other Federal agencies on the issues concerning the

Division's programs.

Plans, coordinates, and executes a wide range of major

studies and projects involving performance management, employee

development, and awards issues of Agency-wide magnitude.

(3) Division of Staffing and Employee Services (FLA23)

Provides service to all central office HCFA components in

the areas of recruitment, in-service staffing, selective placement, and

pre-employment investigations, and personnel security clearances for

all types of appointments and all occupational classes and levels of

work (except Senior Executive Service, Schedule C, and related

appointments).

Provides advice, guidance, and consultation to HCFA

supervisory and management officials on such issues as optimal staffing

mixes, recruitment sources, and qualification factors.

Interprets regulations, guides, directives, and bulletins

related to staffing and personnel services.

Establishes and maintains the employment data base for

routine and special reports and statistical studies related to the

employee population.

Plans and controls the central system for all personnel

and payroll employee transaction processes, (except U.S. Savings

Bonds), serves as the official custodian for all personnel folder

clearances, confidential reports, employment agreements and other

related areas.

Plans, administers, and evaluates HCFA-wide employee

benefits, health, and wellness program activities.

Provides general employee counseling on such matters as

retirement, life insurance, health plans, workers' compensation claims,

and unemployment compensation claims.

Serves as the central HCFA reference point for inquiries,

guidance, and interpretation on employee benefits, health, and wellness

matters.

Processes insurance claims and annuity applications for

retirees and survivors of deceased employees. Processes the full range

of employee benefit and payroll transaction documents, with the

exception of U.S. Savings Bonds.

Directs programs for occupational health services,

employee health enhancement, physical fitness, and blood assurance

programs. Plans and administers the Agency's contract for the Employee

Assistance Program.

Directs and administers HCFA's child care initiative.

Directs the Agency's Voluntary Leave Transfer and Video Display

Terminal Eye Care Programs.

Under direction of the HCFA Deputy Ethics Officer, plans

and administers the entire ethics program for both central and regional

offices. Reviews financial disclosure reports prior to departmental

submittal and coordinates outside activity requests and approvals.

Directs and coordinates all Agency medical determinations

related to employability issues, such as fitness for duty and

reasonable accommodation.

d. Office of Acquisitions and Grants (FLA3)

Provides procurement services for other HCFA components

including project grant, contract, and small purchase solicitation,

award, and administration; cost and advisory function; and procurement-

related training. Monitors the annual HCFA contract plan and prepares

and submits required reports.

Solicits, negotiates, analyzes, and coordinates proposal

evaluation and prepares and awards contracts. Provides HCFA cost

advisory and audit services on pre-award and post-award grant and

procurement actions to ensure conformance to legal and regulatory

requirements.

Performs all HCFA cost/price analysis and evaluation

required for the review, negotiation, award administration, and close-

out of grants and contracts. Provides field audit capability during the

pre-award and close-out phases of contract and grant activities.

Coordinates and acts as liaison with the Defense Contract

Audit Agency, Department of Health and Human Services (HHS) Audit

Agency, Office of the General Counsel, and other HHS agencies to obtain

required audit support and resolution.

Coordinates and/or conducts training for contracts and

grant personnel and project officers in HCFA components. Provides

services, policy direction, and coordination with respect to HCFA's

advisory and assistance services contracting.

(1) Division of Health Standards Contracts (FLA31)

Provides acquisition services in support of HCFA's Peer

Review Organization (PRO) and End-Stage Renal Disease (ESRD) contracts,

including guidance and assistance to the Health Standards and Quality

Bureau.

Solicits, negotiates, analyzes, and coordinates proposal

evaluations and prepares awards documents.

Conducts post-award coordination, administration

(including progress report and voucher monitoring), modifications, and

all contract closeout functions.

Provides guidance and assistance to incumbent and

prospective contractors.

Assists in the direction of related procurement preference

programs wherever applicable.

Participates in monitoring PRO/ESRD annual contract plans

and prepares and submits required reports.

As required, on specific PRO/ESRD contract actions, serves

as liaison and provides information and documentation to the

Department, Congress, and other Government agencies.

Develops PRO/ESRD specific policies and procedures and

provides guidance to PRO/ESRD program offices.

(2) Division of Contracts and Grants (FLA32)

Provides contracting support, guidance, and assistance to

all HCFA components and prospective contractors. Issues policy and

procedural guidance to program staff in contracts and grants areas.

Assists in the direction of related small, disadvantaged,

8(a), (minority contracts), labor surplus area, and women-owned

business contracting efforts. Provides HCFA project (discretionary)

grants and cooperative agreements services.

Solicits, analyzes, and coordinates proposal evaluations

and negotiates, prepares, and awards contracts. Directs the post-award

coordination, administration and modification, and participates in the

close-out of contracts.

Serves as the HCFA liaison with the Department's Office of

Procurement, Assistance and Logistics, the Office of the General

Counsel, other Department of Health and Human Services' components,

Congress, other Government agencies, and private parties in contract,

grant, and cooperative agreement matters.

Monitors the annual contract plans and assists in the

preparation and submittal of required reports. Provides HCFA project

(discretionary) grants and cooperative agreements services.

Receives applications, operates the application referral

system, reviews the system for compliance with law, policies, and cost

principles, performs site visits, obtains clearances, negotiates and

issues grant awards, maintains funds control records and master grant

files.

Provides HCFA small purchasing services, guidance, and

assistance to all HCFA components.

e. Office of Administrative Services (FLA4)

Provides services, policy direction, coordination, and

broad operational control of HCFA's voice telecommunication services,

administrative services, single-site planning, printing and

distribution services, conference management, records and mail

services, facilities management, space management, property management,

real property management, and related support services.

Conducts extensive analyses in the areas of facilities

management, property management, real property management,

environmental safety and security, and space planning for HCFA's single

site.

Determines the overall impact, budget and administrative,

of changes in the areas of facilities management, property management,

real property management, environmental safety and security, and space

planning.

Coordinates and handles graphics services for the Agency.

(1) Division of Facilities Management (FLA41)

Provides direct services and establishes policy for other

HCFA components with respect to facilities management, real property

management, space management, supplies, space acquisition, management

and maintenance, conference facilities, and parking.

Develops comprehensive budget estimates for and management

of centralized facilities management funds.

Conducts extensive analyses in the areas of facilities

management, space management, real property management, property

management, environmental safety and security, printing and

distribution management for HCFA's single site.

Analyzes and determines the budget and administrative

impact of changes in the areas of facilities management, space

management, real property management, property management,

environmental safety and security, printing and distribution

management.

Coordinates all Information Resources Center activities.

(2) Division of Safety and Property Management (FLA42)

Provides direct service and establishes/implements

policies and procedures for the HCFA personal property and supply

management programs.

Maintains and operates the warehouse and the computerized

property management and accountability system.

Provides direct service and establishes/implements

policies and procedures for environmental safety nationwide, emergency

preparedness, civil defense, tort claims, and accident and fire

prevention.

Conducts special studies and analyses in the areas of

personal property and supply management, and environmental safety and

security.

(3) Division of Telecommunications and Graphics Services (FLA43)

Manages all activities associated with the operation of

HCFA's nationwide voice telecommunications system.

Conducts extensive research, studies, and analyses

associated with voice telecommunications activities in HCFA.

Develops policies and procedures for nationwide

implementation and operation of various voice telecommunications

systems in HCFA.

Develops policies, standards, and procedures for HCFA's

graphics management program.

Provides graphics services to the Agency.

Serves as the Agency's liaison on all matters concerning

graphics policy and the acquisition of graphics supplies and services.

(4) Division of Printing and Distribution Services (FLA44)

Provides printing, reprographic, distribution, and forms

management services for HCFA.

Conducts research, planning, and analyses to determine

Agency needs for photocopying equipment and printing services.

Develops policies, standards, and procedures for HCFA's

printing, reprographics, forms, and distribution programs.

Obtains printing, binding, and distribution services from

private vendors under contracts negotiated and entered into by the

Government Printing Office (GPO).

Manages and maintains centralized program (except for

research and demonstrations) for the distribution, printing, and

reproduction of forms and other printed materials.

Manages HCFA's acquisition, leasing and utilization of

copying equipment.

Provides HCFA liaison on all forms, distribution, and

printing matters with the HHS, the Government Printing Office and the

Congressional Joint Committee on Printing.

4. Bureau of Program Operations (FLB)

Provides direction and technical guidance for the

nationwide administration of the Medicare health care financing

programs.

Develops, negotiates, executes, and manages contracts with

Medicare contractors.

Manages the Medicare financial management system and

national budgets for Medicare contractors.

Establishes national policies and procedures for the

procurement of claims processing and related services from the private

sector.

Defines the relative responsibilities of all parties in

the health care financing operations and designs the operational

systems which link these parties.

Directs the establishment of standards of performance for

contractors. Compiles operational and performance data for recurring

and special reports to reflect status and trends in program operations

effectiveness.

Prepares recommendations regarding terminations, awards,

penalties, non-renewals, or other appropriate contract actions.

Establishes national policy and procedures for the

recovery of overpayments.

Directs the processing of Part A beneficiary appeals and

issues instructions and guidance for resolving beneficiary

overpayments.

Following coordination with pertinent HCFA components,

notifies carriers and fiscal intermediaries of findings resulting from

quality control programs.

Makes recommendations to the Associate Administrator for

Operations and Resource Management regarding financial penalties

authorized and determined appropriate under regulations.

Assists Medicare contractors in improving the management

of Federally required quality control programs.

Identifies significant trends and priority problems

through comprehensive analyses of program operations and performance

and evaluates findings surfaced through various assessment programs.

Develops and conducts comprehensive analyses and studies

of selected areas of policy and operations to evaluate the

appropriateness, cost effectiveness, or other impact resulting from the

implementation of law, regulations, policies, or operational procedures

and systems.

Develops recommendations for specific policy or

operational improvements based on assessment findings.

Coordinates, monitors, and evaluates all corrective action

initiatives resulting from program assessment findings.

Develops program-wide policies, regulations, procedures,

guidelines, and studies dealing with program oversight and improvement.

Coordinates the preparation of manuals and other policy

issuances required to meet the instructional and informational needs of

providers, contractors, State Agencies, Regional Offices, Peer Review

Organizations, the Social Security Administration, and other audiences

directly involved in the administration of HCFA programs.

a. Executive Secretariat (FLB-1)

Coordinates, for the Bureau Director, matters concerning

bureau policy in the administration of the Medicare program.

Directs studies to identify problems in such areas as

inconsistencies of interpretation and application of Medicare

legislation, regulations and policy. Recommends solutions to such

problems and initiates necessary corrective action.

Directs the management of the bureau's assignment control

system including the receipt, review, coordination, and control of all

correspondence, assignments, written congressional and public

inquiries, and the preparation of responsive replies for the signature

of the Secretary of Health and Human Services, Administrator of HCFA,

the Bureau Director, and other high level management officials.

Serves as the primary focal point for the bureau on

operational as well as administrative inquiries, including telephone

inquiries from Presidential Staffs, congressional offices, other

Government agencies, private institutions, and individuals seeking

information concerning the various regulations and policies of the

bureau.

Establishes and maintains contact with HCFA's Executive

Secretariat in the Office of Executive Operations, the Congressional

Liaison Office, the Office of the General Counsel, and with other HCFA

components and Federal departments and agencies, to obtain or provide

information and coordinate correspondence replies.

Provides bureau-wide guidance and technical assistance on

related procedures and standards for content of memoranda and

correspondence.

b. Issuances Staff (FLB-3)

The Director, Issuances Staff assures the exchange of

important information among HCFA components and the Office of the

Secretary.

Prepares or coordinates the preparation of written

documents in order to assist the Director, Bureau of Program Operations

in resolving HCFA program and administrative policy issues.

Coordinates the preparation of manuals and other policy

issuances required to meet the instructional and informational needs of

providers, contractors, State agencies, regional offices, Peer Review

Organizations, the Social Security Administration, and other audiences

directly involved in the administration of HCFA programs.

Manages the HCFA system for developing regulations,

setting regulation priorities, and corresponding work agendas.

Serves as the HCFA Federal Register contact point.

c. Office of Contracting and Financial Management (FLB1)

Administers contracts with private organizations to

perform various aspects of Medicare program operations falling under

the bureau's area of responsibility.

Develops, negotiates, maintains, and modifies primary

contracts and agreements with intermediaries, carrier, and other

organizations authorized under Title XVIII of the Social Security Act.

Provides direction and guidance to Central Office and

Regional Office staff on Medicare intermediary and carrier contracts

and contracting activities under the bureau's area of responsibility.

Establishes policies and procedures to be used by all

Medicare intermediary and carrier contractors in the procurement of

equipment, facilities management, software, and other services.

Establishes the policies and procedure by which Medicare

intermediary and carrier contractors and regional offices prepare and

submit periodic budget estimates.

In consultation with other HCFA and bureau components,

develops and negotiates the national budget for Medicare contractors,

including workload estimates.

Controls and manages the Medicare cash flow and related

banking activities.

Reviews periodic contractor expenditure reports to

evaluate Medicare intermediary and carrier budget execution and

determines the allowability of costs.

Prepares analysis of Medicare intermediary and carrier

expenditure trends and patterns.

Reviews regional office and contractor performance in

determining the correct amount of provider, physician, and supplier

overpayments, and assists contractors in negotiations related to the

acceptability of techniques for determining the amount of an

overpayment and the methods of recovery.

Prepares cases when compromises are not appropriate and

overpayments are collectable and assists the HCFA Claims Collection

Officer in preparing such cases for disposition.

Prepares manual instructions concerning the procedures for

the recovery of provider, physician and supplier overpayments.

Designs, implements, and maintains a Medicare overpayment

tracking system.

Plans, directs, and coordinates operational policy and

procedures for the establishment and maintenance of premium billing and

collection.

Develops plans for possible transitions between new and

current contractors, and manages transition activities in coordination

with the regional offices.

Plans, develops, and directs Medicare intermediary and

carrier operating contracting experiments.

(1) Division of Acquisitions and Contracts (FLB11)

Develops, maintains, negotiates, and modifies all

agreements with intermediaries, and contracts with carriers as

authorized under Title XVIII of the Social Security Act.

Develops procedures for the award, non-renewal,

termination, extension, and amendment of Medicare contracts.

Represents the bureau in processing contractor claims

resulting from changes in contract requirements or other disputes

involving the selection or non-selection of contractors.

Directs contract-related surveys requested by both the

Executive and Legislative Branches of the Federal Government.

Directs and guides Central Office and Regional Office

staff on contracts and contract procurement and maintains an oversight

role on regional activity in the areas of Title XVIII contracting.

Coordinates Fiscal Intermediary Group and Carrier

Representative Group activities.

Serves as a HCFA resource in regard to technical Medicare

contracting issues concerning matters.

Reviews the Bureau's contractors' requests for change

orders and adjustments in price, determines where liquidated damages

should be assessed against contractor and takes proper action.

Develops and directs policy regarding regional

intermediary concept such as for Home Health Agencies.

Develops necessary regulations and other issuances dealing

with Medicare contract administration.

Provides liaison with contractor management.

Provides leadership in litigation activities related to

contract disputes.

(2) Division of Financial Management (FLB12)

Provides leadership in developing, implementing, and

evaluating policies and procedures for the Medicare contractor budget

process.

Formulates and approves the national budget for Medicare

contractor administrative costs.

Develops, implements, and monitors cash management letter-

of-credit procedures for contractors and servicing banks.

Develops, implements, and monitors fund control for the

Medicare contractor administrative costs.

Sets requirements and procedures for contractors and

regional offices to prepare and submit periodic budget estimates and

reports.

Participates in negotiations and approval of all related

price adjustments and reviews periodic contractor expenditure reports

to evaluate budget execution and determination of the allowability of

costs.

Designs, maintains, and as necessary, prepares

specifications to revise the Medicare financial administration and

benefit payment systems.

Analyzes contractor administrative cost data and trends.

Directs and prepares instructions to guide regional office

performance to assure consistency in implementation of financial

policy.

(3) Division of Contractor Planning and Management (FLB13)

Plans, develops, and directs contracting experiments that

involve HCFA contractors, agencies, and separate contracts with

commercial organizations.

Develops plans for possible transitions between new and

current contractors and provides oversight of these transition

activities in coordination with the regional offices.

Assists, manages, monitors, and provides oversight of

contractor transition activities in coordination with the regional

offices, and carries out plans for transition between new and old

contractors.

Evaluates implementation proposals associated with

Medicare electronic data processing (EDP) facility management

procurement, software acquisitions, and major systems changes and

testing.

Provides technical assistance to regional offices with

respect to Medicare EDP procurements and reviews, proposed hardware and

software modifications, and equipment upgrades.

Incorporates current procurement and operating policy as

well as lessons learned from prior transitions into the implementation

sections of Request for Proposals and subsequent transitions.

Evaluates Medicare claims processing contracting

arrangements, formulates plans for improvement, and carries out these

improvement plans.

(4) Division of Account Management and Collection (FLB14)

Directs the nationwide administration of the institutional

and physician and supplier recovery activity.

Develops regulations, policies, procedures, guidelines,

and recommendations for regional offices and HCFA contractors to assure

timely and accurate provider overpayment identification, interest

assessment, collection, and reduction of incidence of overpayment.

Assures that the accounting practices, recovery

procedures, and collection activities of regional offices and

contractors properly and sufficiently implement the providers

overpayment recovery policies, procedures, and regulations of HCFA, the

Department of Health and Human Services, the General Accounting Office,

the Department of Justice, and all applicable Federal statutes.

Plans, develops, and issues operational policy,

specifications, requirements, procedures, and instructional material to

administer Third Party agreements for enrollment and premium payments

for States, Office of Personnel Management (OPM), third party groups,

professional organizations, carriers and intermediaries, and Social

Security Administration, the Medicare Lock-Box premium collection for

Medicare beneficiaries, and the direct billed beneficiaries.

Assists in the negotiation and modification of agreements

for third party and direct billing premium collection operations.

Manages lock-box contracts for collection of State buy-in and third

party group premiums, and for collection of direct billed beneficiary

premiums.

Resolves premium collection problems for States, OPM,

third party groups and beneficiaries.

Develops procedures and provides training and assistance

to regional offices for the review and evaluation of the institutional

provider, physician, supplier, and beneficiary overpayment recovery,

and third party systems.

Serves as the Agency systems manager for premium

collection requirements.

d. Office of Medicare Benefits Administration (FLB2)

Oversees the operations and administration of various

Medicare program areas including Medigap, Medicare Secondary Payer

(MSP), audit and payment management, benefit integrity, entitlement,

medical review, and utilization analysis.

Develops, implements, and administers MSP and Medigap

operational policy. Analyzes and evaluates specific operating policy

and procedures in the MSP and Medigap programs and initiates proposals

to better achieve program objectives.

Reviews, analyzes, and prepares recommendations regarding

approval or disapproval of State regulatory programs for Medicare

supplemental health insurance to ensure compliance with the Social

Security Act. Conducts the mandatory Certification Program in those

States not having an approved regulatory program.

Develops, implements, and monitors the Medicare SELECT

direct contracting option for medical necessity determinations.

Reviews State regulatory programs for Medicare

supplemental insurance and Medicare supplemental health insurance

policies for compliance with the Social Security Act.

Develops national MSP budget and annual savings goals,

enforces MSP provisions and supports MSP litigation and post pay

activities.

Plans and develops methods to improve and enhance the

audit and payment management functions and makes recommendations for

improvements in the management of the audit program. Analyzes

regulations, executive orders, policies, and legislative proposals and

assesses their financial impact on the audit budget.

Develops, implements, and maintains programs and systems

to ensure that Medicare benefits are paid within the meaning of

applicable law, regulations, and program policy and to ensure that

internal or external allegations of fraudulent or abusive behavior are

promptly acknowledged, developed, and disposed of including referral to

the Office of Inspector General.

Directs the development and issuance of specifications,

requirements, procedures, forms, and instructional material to

implement and maintain operational systems for Part A and Part B

medical review and utilization analysis.

Develops the national budget for intermediary and carrier

medical review activities, linking programmatic expectations with

funding requirements and available resources.

Implements new legislation impacting on the medical review

processes and/or Medicare covered services.

Serves as the Agency systems manager for entitlement

requirements.

(1) Division of Utilization Analysis (FLB21)

Directs the development of analytical studies, tools, and

methodologies, for assessing health care utilization, beneficiary

episodes of care, quality of care, patterns, and trends to improve the

effectiveness of the medical review program.

Directs the development and issuance of specifications,

requirements, procedures, forms, and instructional material to

implement and maintain operational systems for Part A and Part B

medical review and utilization analysis.

Designs edits and specifications for contractor medical

review screens, systems and reports, including nationally mandated

screens and reports, and conducts ongoing analysis of the effectiveness

of national requirements.

Utilizes the National Claims History Database to analyze

and compare utilization patterns and to assess national trends in the

provision of care to the Medicare population.

Develops the national budget for intermediary and carrier

medical review activities linking programmatic expectations with

funding requirements.

Reviews proposed policy, payment, and legislative

proposals to evaluate the operational impact on the Medical Review and

Utilization Review (MR/UR) program. Implements new legislation

affecting MR/UR and develops program safeguards for new and revised

procedures.

Provides contractors with analytical techniques for

analysis of provider specific data, development of cost effective

review methodologies, and clarification of Medicare policies. Monitors

development and use of contractor MR/UR policies and implementation of

MR directives and provides training and technical support to

contractors.

Directs contractor workgroups to develop, enhance, and

maintain the most effective MR/UR program.

Assists with the development of contractor performance

standards to assess the effectiveness of the contractor's MR/UR

program.

Provides technical support and assistance to the bureau,

other HCFA and non-HCFA components on contractor MR/UR programs.

Serves as liaison with representatives of the health care

industry on MR/UR issues to obtain expert input into policy

development, to promote understanding of the MR/UR program, and to

ensure that HCFA's MR/UR processes are compatible with health

practices.

(2) Division of Entitlement and Benefit Coordination (FLB22)

Develops, implements, and administers Medicare Secondary

Payer (MSP) operational policy for coordinating Medicare benefits with

other health insurance benefits. Analyzes and evaluates specific

operating policy and procedural problems in the benefit coordination

program and initiates proposals to better achieve program objectives.

Plans and directs operational liaison and outreach

activities, including public relations, publications, conferences, and

presentations.

Develops national MSP budget and annual performance

objectives and priorities. Analyzes contractors' MSP expenditures and

goal performance.

Participates in the design, performance, and analysis of

evaluations of contractor MSP performance assessment.

Enforces MSP provisions and supports MSP litigation and

post pay activities.

Monitors regional office and contractor operations on

negotiation, waiver, and compromise of liability settlements where

Medicare has a claim for recovery of prior conditional payments.

Designs and conducts special projects to improve national

coordination of Medicare benefits with other health coverage.

Develops and monitors the ongoing operations of a data

match of the Internal Revenue Service and Social Security

Administration data to identify MSP cases. Coordinates MSP operations

with HCFA and non-HCFA governmental components and with other payers

and their representative organizations, particularly State insurance

departments and the National Association of Insurance Commissioners and

like organizations.

Develops operational policy and instructional material for

the establishment and maintenance of Medicare entitlement.

Conducts studies and demonstrations to improve the

systems, methods, and procedures for establishing and maintaining

entitlement information. Develops and recommends entitlement related

legislative and policy proposals.

Develops procedures for issuing and reissuing health

insurance cards, monitoring records maintenance and correction, and

processing voluntary and other identification problems from the

Medicare claim process.

Serves as the Agency systems manager for entitlement

requirements.

(3) Division of Audit and Payment Management (FLB23)

Analyzes regulations, executive orders, policies, and

legislative proposals and assesses their financial impact on the audit

budget. Develops the plan, necessary audit programs, guidelines and

instructions for the implementation of current and future legislation,

regulations, and court orders.

Plans and develops methods to improve and enhance the

audit function and makes recommendations for improvements in management

of the audit program, including the identification and implementation

of automated data processing programs in the desk review, audit, and

settlement activities.

Develops rationale for the audit and payment management

portion of the current and future national contractor budgets.

Establishes and monitors return ratio requirements for provider audits

to assure maximum return on investment expenditures.

Reviews and analyzes Contractor Auditing and Settlement

Reports to determine the effectiveness of contractor audit and payment

performance and compliance with established audit guidelines,

priorities, funding limitations, and workload objectives.

Researches and responds to all Office of Inspector General

and General Accounting Office payment and financial audit reports and

studies. Prepares position papers and reports offering alternative

methods of resolution.

(4) Division of Medigap Operations (FLB24)

Develops, implements, and administers Medigap operational

policy.

Analyzes State laws and regulations for Medicare

supplemental health insurance to ensure compliance with the Social

Security Act.

Conducts the mandatory Certification Program in those

States not having an approved regulatory program. Reviews and analyzes

Medicare supplemental health insurance policies for compliance with the

Social Security Act and recommends that certification be granted or

denied.

Develops, implements, and monitors the Medicare SELECT

direct contracting option for medical necessity determinations.

Conducts periodic operational reviews of State regulatory

programs for continued operational compliance the Social Security Act.

Monitors States' application and enforcement of standards; i.e.,

simplification standards, anti-duplication standards, loss ratios and

premium standards, pre-existing conditions and medical underwriting

limitation standards.

Provides liaison with governmental entities (both Federal

and State) regulating other payers for health care and their

representative organizations, particularly State insurance departments

and the National Association of Insurance Commissioners and like

organizations. Serves as liaison with internal HCFA and departmental

components, the General Accounting Office, and the Office of Inspector

General on Medigap issues.

Provides service, advice, guidance, and consultation

directly, and through joint efforts with other HCFA components and

Medicare contractors, to States, other Government entities, employers,

insurers, providers, physicians, beneficiaries, and their

representative organizations, to insure the Medigap program is

understood.

Prepares and assists in preparation of various reports to

Congress on Medigap related issues.

Coordinates the Medigap Federal penalty provisions

referenced in the Social Security Act.

e. Office of Program Operations Procedures (FLB3)

Develops and administers the specification, requirements,

methods, systems, standards, procedures, and budget guidelines to

implement and maintain the operational systems for the Medicare program

including detailed definitions of the relative responsibilities of

providers, contractors, HCFA, and the beneficiaries of the Medicare

program.

Reviews and evaluates systems, systems plans and

proposals, and Automated Data Processing acquisition and modifications

involving carriers and intermediaries.

Develops and promulgates specification and requirements

for contractor processing of beneficiary and provider appeals.

Develops specifications and recommends budget necessary

for more effective methods to process Medicare claims.

Reviews proposed policy, payment, and legislative

proposals to evaluate the operational impact on claims processing and

appeals activities including the development of cost estimates for the

implementation of such proposals.

Develops and maintains forms and electronic formats used

by intermediaries and carriers to process claims.

Develops, maintains, and disperses a quarterly task

management plan which reviews contractor budget workload and

initiatives.

(1) Division of Claims Processing Procedures (FLB31)

Directs the development and issuance of specifications,

requirements, procedures, and instructional material to implement and

maintain operational systems for processing Medicare claims and

defining their applications to Medicare carriers, Medicare

intermediaries, providers, physicians, other independent medical

professionals, suppliers of service, beneficiaries, and HCFA.

Maintains the intermediary and carrier instructional

manuals including the Common Working File (CWF) interface instructions

for processing claims from Medicare providers, physicians, other

independent medical professionals, and suppliers of services.

Reviews proposed policy, payment, and legislative

proposals to evaluate the operational impact on Medicare claims

processing operations.

Implements new legislation impacting on Medicare claims

processing operations.

Develops the discharge data set specifying required

information to be provided by intermediaries to Peer Review

Organizations (PRO) in support of PRO medical review activities.

Maintains liaison with representatives of the health care

industry to ensure the HCFA processes are compatible with the

industry's administration practices.

Develops bill processing edits for intermediaries,

carriers, and the CWF processing of Medicare claims.

Develops instructions for and maintains and monitors

supplier numbering clearinghouse.

(2) Division of Claims Processing Requirements (FLB32)

Prepares general systems plans and develops requirements

for the detailed design and programming for claims processing modules

to be used by Medicare contractors.

Plans, conducts, and evaluates studies aimed at long-range

improvements in electronic claims processing systems, methods, and

procedures as they relate to the administration of the Medicare program

and integration of operations within the framework of HCFA policies,

goals, and objectives to promote efficiency and cost effectiveness.

Develops programs to promote acceptance and usage of

electronic claims processing, electronic funds transfer, and electronic

remittance advice

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