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Medicare and Medicaid Research

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

Statutes

Generally, the relevant law will be the Social Security Act (SSA). Certain parts of the SSA of special interest (Sometimes you will see references to “Title IV-E” foster children. It’s Title IV-E of the SSA being referenced.)

The Medicare and Medicaid statutes are mainly codified in the United States Code (U.S.C.) in Title 42, Chapter 7. There are several versions of the U.S.C. available:

If legislative history exists, you also may also want to look at it. (A full discussion of how to research legislative history is beyond the scope of this Guide. Please see the UCLA Law Library LibGuide: Federal Legislative History.)

Regulations

Most of the Medicare and Medicaid regulations are in Part 42 or Part 45 of the Code of Federal Regulations (C.F.R.)

Whenever you look at a regulation, it is a good idea to look at its associated regulatory history for any legal question, but it is critical when researching Medicare and Medicaid regulations. CMS (and HCFA before it) often puts a lot of gloss on its regulations with long, highly detailed explanations, and sets out policies in Federal Register issuances.

You can follow pending regulations and view regulatory dockets (including public submissions) at Regulations.gov.

Case Law

A full discussion of how to research case law is beyond the scope of this Guide. Please see these UCLA Law Library LibGuides:

Note: You may also need to check administrative decisions made by the Departmental Appeals Board (DAB). When a party appeals a CMS determination, they generally have to exhaust this appeal process before they can turn to the courts.

Sub-regulatory Guidance

National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs): These are determinations that CMS has made about specific services which will or won’t be covered

Private Health Care Facility Accrediting Organizations

Many health care entities choose to be accredited by a private organization, usually The Joint Commission (TJC), or the Healthcare Facilities Accreditation Program (HFAP), to gain “deemed” status for meeting the Medicare Conditions of Coverage, even though the rules of these organizations are sometimes stricter than those of CMS.

These are private entities, and so, unlike government materials, the manuals for TJC and HFAP are not available in digital form free on the internet. However, there is still valuable information in the form of FAQs, newsletters, and press releases available on the websites of these entities.

Two of the more commonly used accrediting bodies