 |
This Web site is a component of the SAMHSA Health Information Network. |
|
Screening for Mental Illness in Nursing Facility Applicants:
Understanding Federal Requirements
IV. Understanding Medicaid Policy
Medicaid policy is a complex framework of State and Federal laws, regulation, guidance, and court decisions that begins with the laws passed by Congress under Title XIX of the Social Security Act. Congress delegates some of its lawmaking powers to the Secretary of the Department of Health and Human Services (HHS), who promulgates Medicaid regulations that carry the weight of law. CMS issues guidance to States through the State Medicaid Manual, letters to State Medicaid agencies, and other communications. CMS guidance translates Federal requirements in statute and regulations, providing practical direction for State Medicaid program operations. Since States are given wide latitude in Medicaid program design, State statutes and regulations further spell out how individual State Medicaid programs work. State laws and regulations are reflected in State Medicaid plans, submitted to CMS to ensure they fulfill Federal requirements. Courts, at the Federal and State level, also make decisions about how Medicaid laws and regulations should be interpreted, potentially affecting how they are carried out. Over time, Congress changes statutes, HHS publishes new regulations, and CMS and courts reinterpret the meaning of laws and regulation. Thus, Medicaid policy is best characterized as a patchwork of laws, rules, and interpretations rather than as a seamless monolithic policy authorized by law, elaborated by regulations, interpreted by guidance, and executed by States.
Likewise, Medicaid policy regarding PASRR is fragmented and complex. Congress established PASRR in 1987. PASRR regulations were not published initially by HHS. Instead, CMS helped States implement PASRR statutory requirements by issuing interim guidance in the State Medicaid Manual. In 1990, Congress made several changes to PASRR law.5
Though these changes made the guidance in the interim State Medicaid Manual moot, CMS still plans to revise and update the State Medicaid Manual sections concerning PASRR. In 1992, HHS published final PASRR regulations that reflected the 1990 statutory changes (CMS, Federal Register, 1992). In 1996, Congress revisited the PASRR program and removed the requirement for annual resident review, replacing it with a requirement to conduct reviews when a resident's physical or mental status changes. Neither Federal regulations nor State Medicaid Manual sections have been changed to reflect the 1996 statutory amendments. Regulations and the State Medicaid Manual offer no guidance on how to implement the 1996 amendments.
Title XIX provisions concerning PASRR must be examined to understand what Federal policy requires of State Medicaid agencies, Mental Health Authorities, and nursing facilities. PASRR regulations also have the force of law, but regulations concerning the annual frequency of resident reviews were superseded by 1996 statutory changes and may be ignored. The State Medicaid Manual does not carry the force of law and can be consulted only to interpret PASRR provisions not superseded by the statutory changes in 1990 and 1996 and by regulations published in 1992. The following analysis of PASRR policy is based on a review of current law, regulations, and guidance. It is not a legal analysis and does not examine congressional intent or statutory construction. Thus, it does not necessarily reflect how a court may interpret the law and regulations.
5 For an overview of the 1990 legislative changes, see Mental Health Law Project, 1991.
Table of Contents | Previous | Next
|
|
