This is not intended to be a completely comprehensive guide, and does not fully capture the complexity of researching even seemingly simple Medicare or Medicaid questions. Also, Medicaid is a joint federal/state program; every state has its own state sources, but this guide only discusses California state sources.
Most of the sources cited in this guide are available free on the internet, mostly through federal or state government websites, but much of the material is also available through paid database services like LexisNexis, Westlaw, Bloomberg Law, Loislaw, CCH Health Care Compliance and Reimbursement, or Mediregs. Use of those resources is highly recommended at some point in your research process, because when there are updates they may be more transparent in one of those databases than on the government websites. BUT, don’t rely entirely on those sources to do the work for you; check CMS transmittals, the Federal Register, etc., for updates on your topic. And always feel free to ask a reference librarian if you need help.
Also, if you find this area of law difficult to work through, don’t worry—you’re in good company:
As program after program has evolved, there has developed a degree of complexity in the Social Security Act and particularly the regulations which makes them almost unintelligible to the uninitiated.” -- Friedman v. Berger, 547 F.2d 724, 727 n.7 (2d Cir. 1976)
There can be no doubt but that the statutes and provisions… involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity…with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase.” --Rehab. Ass'n of Virginia v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir. 1994).
Hopefully we can at least make it easier for you to find the sources.
In this guide, “agency guidance” or “guidance” refers to the collection of materials produced by a government agency which explain the agency’s positions, policies, and its views of what it thinks its governing statutes and regulations mean.
A federal law which prohibits any kind of direct or indirect remuneration for: 1. patient referrals; or 2. recommending, ordering, leasing, or purchasing of goods, services, or facilities, if federal health care program monies are used for any part of the payment for the patient care, goods, services, or facilities. Social Security Act (SSA) § 1128B(b) (Codified at 42 U.S.C. § 1320a–7b(b)), regulations at 42 C.F.R. §§ 1001.951-1001.952 (See also 42 C.F.R. Part 1001 generally for discussions of sanctions for convictions based on offenses against Medicare or state health care programs.)
|CMS||The Centers for Medicare and Medicaid Services. This is the federal agency which administers the Medicare and Medicaid programs.
Note: CMS was called the Health Care Financing Administration (HCFA) until mid-2001. All literature before mid-2001 will be about “HCFA” rather than “CMS” rules, and you will still find some forms with HCFA numbers. Be careful with this in searching.
The government publication which publishes proposed and final regulations promulgated by federal agencies (which become incorporated into the Code of Federal Regulations once finalized), notices from various federal agencies, and some presidential documents.
The Department of Health and Human Services. The parent agency which oversees CMS and a number of other health-related agencies, including the Food and Drug Administration, the National Institutes of Health, the Indian Health Service, and the Centers for Disease Control. It also has its own Office of Inspector General (OIG).
The federal/state program which provides health insurance to qualifying low-income persons. Eligibility varies by state. In California, the Medicaid program is called Medi-Cal. General information on Medicaid eligibility
California’s Medicaid program. Administered by the California Department of Health Care Services.
The federal program which provides health insurance to qualifying persons who are over 65, disabled, or have end stage renal (kidney) disease (ESRD). Medicare is generally described as being composed of 4 parts:
General information about Medicare
Website for beneficiaries and the general public
|OIG or HHS OIG||
The Office of the Inspector General for the Department of Health and Human Services. The agency within HHS which, as one of its tasks, enforces penalties against persons or entities which violate certain parts of the Social Security Act. Note that while the OIG offers opinions on laws that impact federal health care programs, and has the same parent agency as CMS, it is a separate agency from CMS.
|CHIP or S-CHIP||
(State) Children's Health Insurance Program. A federal/state program to provide health insurance to children and pregnant women who are low-income, but have incomes too high to qualify for Medicaid.
A federal law, named after United States Congress Representative Pete Stark (D-Cal. 13th), and also sometimes called the “self-referral” law, which prohibits physicians from referring patients to a health care entity in which the physician has a financial interest in most circumstances. SSA § 1877 (Codified at 42 U.S.C. § 1395), regulations at 42 C.F.R. Part 411, Subpart J (§§ 411.350-411.389).