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1993.08.06 :  Regulatory Guidelines for Physician Standards

Contact: Anne Verano  202-690-6145
August 6, 1993

     HHS Secretary Donna E. Shalala announced today the release of new
regulatory guidelines which will require physicians to meet certain minimum
standards in order to bill Medicaid for services to children under 21 years of
age and to pregnant women.
     "We are attempting to improve the quality of medical services and
assistance under state Medicaid programs while retaining access to needed
medical care," said Secretary Shalala.  "The minimum qualifications for billing
of certain physician services, required by statute, takes the quality of
treatment another step forward-"
     Prior to the mandate of the omnibus Budget Reconciliation Act of iggo, any
physician who was a qualified provider under the state plan could bill Medicaid
for services rendered to Medicaid beneficiaries.  The states, in turn, would be
eligible for federal matching funds for these services.  Effective Jan. 1, 1992,
physicians who provide services to a child or to a pregnant woman or in the
60-day post-partum period must meet at least one of five specific criteria. 
They must:
    o Be certified in family practice, pediatrics or obstetrics; 
    o Be employed by or affiliated with a federally qualified health center;
    o  Hold admitting privileges at a Medicaid-participating
hospital;
    The federal government makes matching funds available to
states for payments to qualified physicians and other providers for services
provided to eligible Medicaid beneficiaries.
     The effective date of the law is Jan. 1, 1992, in all states, the District of
Columbia, the Northern Mariana Islands, American Samoa, Guam, Puerto Rico
and the Virgin Islands.  Physicians will have up to three years from this date to
meet at least one of the specified criteria.
     Physicians who are not board certified and do not hold admitting privileges
at a Medicaid approved hospital may be considered qualified if they have a
current written consultation and referral arrangement with a pediatrician,
obstetrician or family practitioner who is board certified for the purpose of
specialized treatment and admission to a hospital.  The regulation includes a
suggested format for such documentation.
     Because this regulation must balance requirements for qualified
practitioners with assurance that such criteria do not exacerbate a shortage of
participating physicians, the secretary is interested in receiving comments
regarding the impact of this rule on access to services.
     Comments on the proposed rule will be considered if submitted within 60
days of publication in the Federal Register.  Mail comments to the Health Care
Financing Administration, Attention: MB59-P, P.O. Box 26676, Baltimore, Md.
21207.


Editor's Note: HCFA, an agency of the U.S. Department of Health and Human
Services, directs the Medicare and Medicaid programs, which help pay the
medical bills of more than 67 million Americans.  HCFA's estimated fiscal year
1993 expenditures are almost $230 billion.