Section 6501 of the Affordable Care Act requires each State Medicaid program to terminate any provider who has been terminated under Medicare or by another State Medicaid program.
The Centers for Medicare & Medicaid Services (CMS) has defined “termination” as occurring when a State Medicaid program, CHIP, or the Medicare program has taken action to revoke a Medicaid or CHIP provider’s or Medicare provider or supplier’s billing privileges and the provider, supplier, or eligible professional has exhausted all applicable appeal rights or the timeline for appeal has expired.
The requirement to terminate only applies in cases where providers, suppliers, or eligible professionals have been terminated or had their billing privileges revoked “for cause.”
What does “for cause” mean for Medicaid or CHIP providers?
For cause may include, but is not limited to, termination for reasons based upon fraud, integrity, or quality. For cause does not include cases where a State terminates a Medicaid or CHIP provider due to a failure to submit claims due to inactivity.
In addition, for cause does not include any voluntary action the provider takes to end its participation in the program, except where that “voluntary” action is taken to avoid sanction. For example, suppose a provider submits a request to the State to “voluntarily” terminate its provider agreement to avoid sanctions due to non-compliance. In that case, this does not qualify as voluntary action.
Are States expected to report information on providers who HHS-OIG excludes from participation in the Medicaid and/or CHIP program?
States should report information on providers they have terminated from participation in their respective Medicaid programs and CHIP regardless of any action taken against such providers by any other entity, including exclusion by HHS-OIG.
What are the timeframes for States reporting provider terminations?
There is no specified timeframe for reporting terminations. However, States should report terminations monthly to assist other States in protecting themselves from providers who pose an increased risk to government healthcare programs.
What is the duration of State provider terminations and enrollment denials in other State Medicaid programs or CHIP resulting from a termination?
The duration of a termination should be consistent with the terminating State’s law.
For example, when State A terminates a provider’s participation for three years, this action triggers a termination in State B concerning the same provider. In State B, the length of termination is one year. Therefore, the provider is prohibited from re-enrolling in State B’s Medicaid program for one year, while State A imposes a three-year ban on re-enrollment.
The State should adhere to its laws concerning the duration of the enrollment denial period for providers who wish to enroll in a State Medicaid program or CHIP after being previously terminated by other State programs or having their billing privileges revoked under Medicare.
What is the scope of appeals for terminating programs?
The scope of appeals for the original terminating program, i.e., Medicare, Medicaid, or CHIP, should include a full appeal on the merits regarding the basis of the termination.
When subsequent states terminate based on that initial termination, the scope of their appeals should only examine whether the initiating program indeed terminated the provider.
The appeals process that follows should not reconsider the reasons for the initial termination. The appeal process in subsequent states does not serve as a new opportunity to contest the basis of termination set by another state’s Medicaid program, Medicare, or CHIP.
When is a Medicaid or CHIP termination triggered under section 6501?
A Medicaid or CHIP termination occurs when a provider is terminated by Medicare or by Medicaid or CHIP for cause, and the provider has either exhausted all applicable appeal rights or the timeframe for appeal has expired.
Are there any exceptions to the requirement to terminate a provider that Medicare or another State Medicaid program or CHIP terminated?
Yes. The statute provides for the same limitations on termination that apply to exclusion under 1128(c)(3)(B) and 1128(d)(3)(B) of the Social Security Act.
Thus, a State may request a waiver of the requirement to terminate a particular provider’s participation. State agencies may submit such waiver requests to their respective CMS Regional Offices.