C.F.R. » Title 42 » CHAPTER V—OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—OIG AUTHORITIES › PART 1002—PROGRAM INTEGRITY—STATE-INITIATED EXCLUSIONS FROM MEDICAID › Subpart A—General Provisions

42 C.F.R. § 1002.1

Basis and scope

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(a) Statutory basis. This part implements sections 1902(a)(4), 1902(a)(39), 1902(a)(41), 1902(p), 1903(i)(2), 1124, 1126, and 1128 of the Act.

(1) Under authority of section 1902(a)(4) of the Act, this part sets forth methods of administration and procedures the State agency must follow to exclude a provider from participation in the State Medicaid program. State-initiated exclusion from Medicaid may lead to OIG exclusion from all Federal health care programs.

(2) Under authority of sections 1124 and 1126 of the Act, this part requires the Medicaid agency to obtain and disclose to the OIG certain provider ownership and control information, along with actions taken on a provider's application to participate in the program.

(3) Under authority of sections 1902(a)(41) and 1128 of the Act, this part requires the State agency to notify the OIG of sanctions and other actions the State takes to limit a provider's participation in Medicaid.

(4) Section 1902(p) of the Act permits the State to exclude an individual or entity from Medicaid for any reason the Secretary can exclude and requires the State to exclude certain managed care entities that could be excluded by the OIG.

(5) Sections 1902(a)(39) and 1903(i)(2) of the Act prohibit State payments to providers and deny Federal financial participation (FFP) in State expenditures for items or services furnished by an individual or entity that has been excluded by the OIG from participation in Federal health care programs.

(b) Scope. This part specifies certain bases upon which the State may or, in some cases, must exclude an individual or entity from participation in the Medicaid program and the administrative procedures the State must follow to do so. These regulations specifically address the authority of State agencies to exclude on their own initiative, regardless of whether the OIG has excluded an individual or entity under part 1001 of this chapter. In addition, this part delineates the States' obligation to obtain certain information from Medicaid providers and to inform the OIG of information received and actions taken.

[82 FR 4117, Jan. 12, 2017]
Notes of Decisions
Cited in 5 cases, 1996–2013 · leading case: Eduardo Guzman v. Sandra Shewry, 552 F.3d 941 (9th Cir. 2009).
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Eduardo Guzman v. Sandra Shewry, 552 F.3d 941 (9th Cir. 2009). “B Second, Guzman points to the federal regulations that set forth the requirements for “State-Initiated Exclusions from Medicaid,” 42 C.F.R. §§ 1002.1 -.230. One such regulation requires the relevant state agency to “have administrative procedures in place that enable it to…”
Planned Parenthood Arizona Inc v. Tom Betlach, 727 F.3d 960 (9th Cir. 2013). “See 42 C.F.R. § 1002.1 (listing statutory provisions providing authority for the regulations in Part 1002).”
Levin v. Childers, 101 F.3d 44 (6th Cir. 1996). “The latter regulations are codified at 42 C.F.R. §§ 1002.1 et seq., in a part of Title 42 separate and distinct from the part in which § 455.”
Guzman v. Shewry, 544 F.3d 1073 (9th Cir. 2008). “B Second, Guzman points to the federal regulations that set forth the requirements for “State-Initiated Exclusions from Medicaid,” 42 C.F.R. §§ 1002.1 -.230. One such regulation requires the relevant state agency to “have administrative procedures in place that enable it to…”
Guzman v. Shewry (9th Cir. 2008). “B Second, Guzman points to the federal regulations that set forth the requirements for “State-Initiated Exclusions from Medicaid,” 42 C.F.R. §§ 1002.1 -.230. One such regulation requires the relevant state agency to “have administrative pro- cedures in place that enable it to…”
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