The State Medicaid Manual (SMM) is published by the United States Department of Health & Human Services (HHS) Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
As explained in its Foreward, at p. i,
"This manual makes available to all State Medicaid agencies, in a form suitable for ready reference, informational and procedural material needed by the States to administer the Medicaid program. It is an official medium by which the Health Care Financing Administration (HCFA) issues mandatory, advisory, and optional Medicaid policies and procedures to the Medicaid State agencies."
SMM § 2902.8, which addresses a Medical Assistance (MA) "Claimant's Right to a Different Medical Assessment" during a Fair Hearing, pursuant to 42 CFR § 431.240(b), explains that
"An appeal on medical issues may involve a challenge to the Medical Review Team’s decision regarding disability; or there may be disagreement about the content of reports concerning the appellant’s physical or mental condition or the individual’s need for medical care requiring prior authorization. When the assessment by a medical authority, other than the one involved in the decision under question, is requested by the claimant and considered necessary by the hearing officer, obtain it at agency expense. The medical source should be one satisfactory to the claimant. The assessment by such medical authority shall be given in writing or by personal testimony as an expert witness and shall be incorporated into the record."
See also 18 NYCRR § 358-5.6(b)(4), which applies to all Fair Hearings and which authorizes "where the hearing officer considers independent medical assessment necessary, require that an independent medical assessment be made part of the record when the fair hearing involves medical issues such as a diagnosis, an examining physician's report, or a medical review team's decision[.]"
Note: By operation of the opening provision of New York's Medical Assistance (MA) State Plan, "the New York State Department of Health hereby agrees to administer the program in accordance with the provisions of this State plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department."
See State Plan Submittal Statement, effective October 1, 1996, available at:
http://onlineresources.wnylc.net/FairHearingResources/docs/new_york_medicaid_state_plan_-_submittal_statement__10-01-87_.pdf
Note: The complete State Medicaid Manual is available from CMS at:
http://http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021927&intNumPerPage=2000
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