Under an agreement between the Secretary, CMS and each State, a State agency (usually
a component of the State Health Department) surveys and recommends to the Secretary
whether or not providers and suppliers are eligible to participate in the Medicare
program. The State agency’s principal activities in this area are:
Identifying an institution or facility that might qualify as a provider or supplier
for title XVIII and XIX programs, using guidelines provided by the Secretary;
Inspecting and certifying (recommending) to the Secretary whether or not the provider
or supplier qualifies as a participating provider or supplier;
Giving consultation to providers and suppliers to help them sustain their compliance
with quality standards to participate in the program;
For title XIX purposes, determining whether or not an institution can be paid for
treating Medicaid beneficiaries.
For certification purposes, a State agency must establish and maintain methods and
criteria for identifying situations in which a question of fraud in obtaining certification
may exist. Any such situations are reported to the CMS Bureau of Quality Control RO
having responsibility for investigating Medicare fraud in the area in which the offending
facility is located.
State agencies designated to carry out Health Insurance program functions may engage
in, and cooperate with, a variety of planning and coordination efforts which have
goals similar to those of the Health Insurance Program. These activities include health
facility planning, providing for the treatment of mental and chronic diseases, and
providing for sufficient community facilities for patient care at appropriate levels
of intensity. The Health Insurance Program encourages this coordination and reimburses
the State agencies for a fair share of the costs attributable to these activities.