C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 456—UTILIZATION CONTROL › Subpart J—Penalty for Failure To Make a Satisfactory Showing of an Effective Institutional Utilization Control Program

42 C.F.R. § 456.657

Computation of reductions in FFP

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(a) For each level of care specified in a provider agreement, and for each quarter for which a satisfactory showing is not made, the amount of the reduction in FFP is computed as follows:

(1) For each level of care, the number of beneficiaries who received services in facilities that did not meet the requirements of this subpart is divided by the total number of beneficiaries who received services in facilities for which a showing was required under this subpart. If any of the requirements specified in § 456.652(a)(1) through (4) were not met for any beneficiary in a facility, the reduction will be computed on the total number of beneficiaries in that facility at the level of care in question.

(2) The fraction obtained in paragraph (a)(1) of this section is multiplied by one-third.

(3) The product obtained in paragraph (a)(2) of this section is multiplied by the Federal Medical Assistance Percentage (FMAP).

(4) The product obtained in paragraph (a)(3) of this section is multiplied by the agency payments for longstay services furnished during the quarter at that level of care.

(b) If any of the data required to compute the amount of the reduction in FFP are unavailable, the Administrator will substitute an estimate. If the agency determines the exact data to the satisfaction of the Administrator, the estimate may later be adjusted. If the number of beneficiaries in individual facilities is not available, the fraction specified in paragraph (a)(1) of this section will be estimated, for each level of care, by dividing the number of facilities in which the requirements were not met by the total number of facilities for which a showing is required under this subpart.

Notes of Decisions
Cited in 5 cases, 1987–1991 · leading case: Delaware Div. of Health & Soc. Servs. v. United States Dep't of Health & Human Servs., 665 F. Supp. 1104 (D. Del. 1987).
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Delaware Div. of Health & Soc. Servs. v. United States Dep't of Health & Human Servs., 665 F. Supp. 1104 (D. Del. 1987). · cites it 2× “653 (1986); 42 C.F.R. 456.657 (1986) (assessing a penalty based on the “facility”); 42 C.”
Johnson v. Sullivan, 758 F. Supp. 1496 (N.D. Ga. 1991). “42 C.F.R. § 456.657 (a)(1) (emphasis' supplied).”
Virginia ex rel. Virginia Dep't of Med. Assistance Servs. v. Bowen, 683 F. Supp. 148 (W.D. Va. 1988). “First, the regulations require the HCFA to reduce FFP “[f]or each level of care specified in a provider agreement, *153 and for each quarter for which a satisfactory showing is not made_” 42 C.F.R. § 456.657 (a) (1987). See 42 C.”
Com. of Va. Ex Rel. Dept. of Med. Assis. v. Bowen, 683 F. Supp. 148 (W.D. Va. 1988). “" 42 C.F.R. § 456.657 (a) (1987). See 42 C.”
Virginia ex rel. Virginia Dep't of Med. Assistance Servs. v. Bowen, 680 F. Supp. 228 (W.D. Va. 1988). “See also 42 C.F.R. § 456.657 (b)(1986). Section 1396b(g)(5) imposes penalties for a state’s failure to satisfy § 1396b(g)(l).”
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