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Medicare and Medicaid Research

URL: https://libguides.law.ucla.edu/medicaremedicaid

Research Strategy

Whenever you’re thinking about a Medicare or Medicaid related question, you often need to look to at a number of sources to thoroughly answer the question. You may not need to look at all of these sources, but generally you will need to cross reference at least a couple of them. First, there are the ones you’re probably already familiar with in any form of legal research:

  • Statutes
  • Regulations
  • Case law

Then, there are some that you may not know about, but matter a lot in practical terms:

  • Sub-regulatory guidance through CMS Manuals
  • National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
  • Sub-regulatory guidance through CMS Forms and their accompanying explanations
  • Sub-regulatory guidance through the CMS website
  • Sub-regulatory guidance through questions answered on the CMS website
  • Any materials you can find from the contractor acting as the Fiscal Intermediary/Medicare Administrative Contractor in your region.
  • Manuals and other information from private health care facility accrediting organizations
  • Medical procedure coding information.

If you are researching Medicaid, rather than Medicare, there is also the extra layer of whatever going on in the state you’re concerned with; so, you need to think about:

  • State statutes and implementing regulations for the state Medicaid program
  • The state’s Medicaid State Plan
  • Any Medicaid waivers or demonstration programs going on in the state
  • Sub-regulatory guidance from CMS in the form of Medicaid State Director Letters and State Health Official Letters
  • Sub-regulatory guidance from the state agency or agencies involved in administering the state’s Medicaid program

Specific Scenarios: State Law and Medicare

To give some insight into how complicated this research can be, note that even for some Medicare issues, state law does come into play. While the full complexity of this is outside the scope of this guide, a couple of examples are included here:

As part of the Medicare Conditions of Participation, certain entities receiving Medicare funds must comply with state laws, including:

  • Licensing laws (e.g., for Ambulatory Surgical Centers 42 C.F.R. § 416.40, for Home Health Agencies 42 C.F.R. § 484.12, etc.)
    • Many of California’s health care facility licensure regulations are in Title 22 of the California Code of Regulations (CCR) (See Primary Sources: State, this Guide).
  • Laws relating to advance directives (SSA § 1866(f); 42 C.F.R. Part 489, Subpart I)
    • California advance directives statue: Probate Code Sec. 4670 et seq.

 

CMS defers to state health care professional licensing laws in some cases to help determine who can perform and be paid for certain tasks. (42 C.F.R. § 489.20(d), see also e.g., SSA § 1861(s)(2)(K), (gg), (hh), (ii), (ll).)

In California, most statutes relating to the health care professions are in the Business and Professions Code, and most regulations are in Title 16 of the CCR. Additional information about licensure is available at the licensing boards of the various health care professions. For example:

For other licensing boards, see the ALA's Healthcare practitioners databases in State Agency Database