State Medicaid Fraud Control Units

To eliminate fraud and patient abuse in the State Medicaid Programs.


Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Website Address

http://www.dhhs.gov



Program Accomplishments

Forty-nine States and the District of Columbia are certified under this program.

Uses and Use Restrictions

The statute authorizes 90 percent matching funds for 12 quarters, and 75 percent matching funds thereafter for investigation and prosecution of fraud and patient abuse in the State Medicaid Programs.

A unit must be separate and distinct from the single State Medicaid agency.

A unit must also employ sufficient professional, administrative and support staff to carry out its duties and responsibilities in an effective and efficient manner.



Eligibility Requirements

Applicant Eligibility

An established State Medicaid Fraud Control Unit must be a single identifiable entity of the State government which the Secretary certifies (and the Office of Inspector General annually re-certifies) as complying with the requirements of 1903(q) of the Social Security Act (42 CFR 1007) regarding location, function and procedure.

Applicants must also comply with section 1902 (a)(61) of the Act as amended by the Omnibus Budget Reconciliation Act of 1993.

Tribes (American Indian/Alaskan Native/Native American) are not eligible to apply.

Beneficiary Eligibility

The State governments will benefit from this program.

Credentials/Documentation

Units must submit applications containing proposed organization, administration, agreements, detailed budgets and procedures for certification of eligibility (see 42 CFR 1007). Costs will be determined in accordance with OMB Circular No. A-87 and 45 CFR 92. Governors in States applying for Federal assistance must approve the application pursuant to 42 CFR 1007.15(a).

Aplication and Award Process

Preapplication Coordination

The standard application forms, as furnished by DHHS and required by OMB Circular No.

A-102 for State and local governments, must be used for the preapplication coordination.

The Inspector General's staff is available to assist with technical development of programs, plans, budget amendments and revisions.

This program is excluded from coverage under E.O.

12372.

Application Procedures

Application is made in the format prescribed by the Inspector General. This program is excluded from coverage under OMB Circular No. A-110.

Award Procedures

States are awarded funds based on a detailed description of estimated expenditures needed to support the program.

Deadlines

State expenditure reports are due 30 days following each quarter. A final financial report is due 90 days after the close of the grant year, as required by 45 CFR 92. The annual report and application for re-certification are due 60 days before the end of each 1-year certification period, as required by 42 CFR 1007.

Authorization

Social Security Act (The Act), as amended, Title XIX, Section 1903, Public Law 95-142; Public Law 96-499.

Range of Approval/Disapproval Time

The time required to process an application may take up to 90 days.

Appeals

If the application is not approved, the State may submit an amended application at any time.

Renewals

The application for the annual re-certification must be submitted 60 days prior to the end of each certification period.

Assistance Considerations

Formula and Matching Requirements

States are awarded, through the issuance of a grant award, for 90 percent of their costs for the first 12 quarters, and 75 percent thereafter, computed against a quarterly maximum allowable of the higher of $125,000, or one-fourth of 1 percent of the sums expended by the Federal, State, or local government in carrying out the State plan under Title XIX of the Social Security Act.

Length and Time Phasing of Assistance

Funds are awarded quarterly based on an approved annual budget and limitations on entitlement. An Electronic Funds Transfer System will be used.

Post Assistance Requirements

Reports

Quarterly program and financial reports are required.

Audits

HHS/OIG/Office of Audit Services performs periodic audits of the State program as appropriate; the OIG/Office of Evaluation and Inspections performs an annual re-certification review of each SMFCU.

Records

All records are to be retained for 3 years, in accordance with 45 CFR 92.

Financial Information

Account Identification

75-0512-0-1-551.

Obigations

(Grants) FY 07 $174,800,000; FY 08 est $186,000,000; and FY 09 est $195,300,000.

Range and Average of Financial Assistance

$293,000 to $39,269,000; $3,701,580.

Regulations, Guidelines, and Literature

42 CFR 1007, 45 CFR 92, OMB Circular No. A-87, and Performance Standards issued September 1994.

Information Contacts

Regional or Local Office

None.

Headquarters Office

Sharon L. Colby, Director, Medicaid Fraud Unit Oversight Division, Office of Evaluation and Inspections, Office of Inspector General, Office of the Secretary, Department of Health and Human Services, Room 5656, Cohen Building, 330 Independence Avenue, S.W., Washington, DC 20201. Telephone: (202) 260-3711. E-mail: Sharon.Colby@oig.hhs.gov.

Criteria for Selecting Proposals

None.



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