,,ii  #aadth ,,congress  #b;d ,session  
,s4 #bgja  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,march #ag1    
#bjaf ,mr4 ,heinrich 7for himself and   
,mr4 ,udall7 introduced the following   
bill2 which was read twice and referred 
to the ,committee on ,finance  ,a ,,bill
  ,to require consideration of the      
impact on beneficiary access to care and
 to enhance due process protections in  
procedures for suspending payments to   
,medicaid providers4  #a4 ,short title  
,this ,act may be cited as the ,medicaid
 ,program ,integrity ,enhancement ,act  
of #bjaf4  #b4 ,revision of regulations 
7a7 ,in general ,not later than #ahj    
days after the date of enactment of this
 section1 the ,secretary shall revise   
part #dee of title #db1 ,code of        
,federal ,regulations relating ,medicaid
 program integrity as follows3  7#a7    
,section #dee4b relating to the         
definition of credible allegation of    
fraud to comply with the requirements   
described in subsection 7b74  7#b7      

,section #dee4bc relating to the        
suspension of ,medicaid payments to a   
provider by a ,state ,medicaid agency to
 comply with the requirements described 
in subsection 7c74  7b7 ,requirement ,to
 consider impact on beneficiary access  
to care in determining a credible       
allegation of fraud ,the revised section
 #dee4b shall provide that an allegation
 shall be considered to be a credible   
allegation of fraud only if-- 7#a7 the  
allegation has indicia of reliability2  
7#b7 the ,state ,medicaid agency has    
reviewed all allegations1 facts1 and    
evidence carefully and acts judiciously 
on a case-by-case basis2 and  7#c7 the  
,state ,medicaid agency has taken into  
consideration the potential impact a    
payment suspension may have on          
beneficiary access to care4  7c7 ,due   
process requirements for payment        
suspension based on credible allegation 
of fraud  7#a7 ,process required before 
suspension ,a ,state ,medicaid agency   
that has received an allegation of fraud

 against a provider shall not suspend   
payments to such provider until the     
agency takes the following actions3 7,a7
 ,the ,state ,medicaid agency consults  
with the ,medicaid fraud control unit   
for the ,state or1 if the ,state has no 
,medicaid fraud control unit1 the ,state
 attorney general1 before suspending    
payments and receives a written         
verification from the ,medicaid fraud   
control unit or attorney general1 in    
such form as the ,secretary may require1
 confirming that such consultation took 
place4  7,b7 ,the ,state ,medicaid      
agency certifies to the ,secretary that 
it has considered whether-- 7i7         
beneficiary access to items or services 
would be jeopardized by a payment       
suspension2  7ii7 a good cause not to   
suspend payments exists under section   
#dee4bc7;e7 of title #db1 ,code of      
,federal ,regulations 7as revised after 
the application of this ,act72 and      
7iii7 a good cause to suspend payments  
only in part exists under section       

#dee4bc7;f7 of such title of such ,code 
7as so revised74  7,c7 ,the ,state      
,medicaid agency furnishes the provider 
with the agency's reasons for finding   
that there is no good cause to refrain  
from suspending payments in whole or    
part4  7#b7 ,process required after     
suspension ,after a ,state ,medicaid    
agency suspends payments 7in whole or   
part7 to a provider on the basis that   
the agency has determined that there is 
a credible allegation of fraud against a
 provider for which an investigation is 
pending under the ,medicaid program1 the
 agency shall take the following        
actions3  7,a7 ,at the beginning of each
 fiscal quarter that begins after       
payments to the provider have been      
suspended1 the ,state ,medicaid agency  
shall-- 7i7 certify to the ,secretary   
that it has considered whether the      
suspension of payments should be        
terminated or modified because--  7,i7 a
 good cause not to suspend payments     
exists under section #dee4bc7;e7 of     

title #db1 ,code of ,federal            
,regulations 7as revised after the      
application of this ,act72 or  7,,ii7 a 
good cause to suspend payments only in  
part exists under section #dee4bc7;f7 of
 such title 7as so revised72 and  7ii7  
if the agency finds that there is no    
good cause to terminate or modify the   
suspension of payments1 furnish to the  
provider the agency's reasons for such  
finding4  7,b7 ,if the investigation is 
not resolved in a reasonable amount of  
time 7as determined by the ,secretary71 
the ,state ,medicaid agency shall       
disclose to the provider the specific   
allegations of fraud that formed the    
basis for the agency's determination    
that there is a credible allegation of  
fraud against the provider4  7,c7 ,every
 #ahj days after the initiation of a    
suspension of payments based on credible
 allegations of fraud1 a ,state         
,medicaid ,agency shall-- 7i7 evaluate  
whether there is good cause to not      
continue such suspension2 and  7ii7     

request a certification from the        
,medicaid fraud control unit for the    
,state or1 if the ,state has no         
,medicaid fraud control unit1 the ,state
 attorney general1 or other law         
enforcement agency that the matter      
continues to be under investigation     
warranting continuation of the          
suspension4  7,d7 ,good cause not to    
continue to suspend payments to an      
individual or entity against which there
 are credible allegations of fraud shall
 be deemed to exist if a payment        
suspension has been in effect for #ah   
months and there has not been a         
resolution of the investigation1 except 
a ,state ,medicaid ,agency may extend a 
payment suspension beyond such period if
 --  7i7 the case has been referred to1 
and is being considered by1 the         
,medicaid fraud control unit for the    
,state or1 if the ,state has no         
,medicaid fraud control unit1 the ,state
 attorney general1 for administrative   
action or such administrative action is 

pending2 or  7ii7 the ,medicaid fraud   
control unit for the ,state or1 if the  
,state has no ,medicaid fraud control   
unit1 the ,state attorney general1      
submits a written request to the ,state 
,medicaid ,agency that the suspension of
 payments be continued based on the     
ongoing investigation and anticipated   
filing of criminal or civil action or   
both or based on a pending criminal or  
civil action or both4 ,at a minimum1 the
 request shall include the following3   
7,i7 ,identification of the entity under
 suspension4  7,,ii7 ,the amount of time
 needed for continued suspension in     
order to conclude the criminal or civil 
proceeding or both4  7,,iii7 ,a         
statement of why or how criminal or     
civil action or both may be affected if 
the requested extension is not granted4 
7d7 ,definitions ,for purposes of this  
section3  7#a7 ,the term ,medicaid fraud
 control unit means a ,state ,medicaid  
fraud control unit as defined in section
 #aijc7q7 of the ,social ,security ,act 

7#db ,u4,s4,c4 #acif;b7q774  7#b7 ,the  
term ,secretary means the ,secretary of 
,health and ,human ,services4  7#c7 ,the
 term ,state ,medicaid agency means the 
agency responsible for administering a  
,state plan under title ,,xix of the    
,social ,security ,act 7#db ,u4,s4,c4   
#acif et seq474  #c4 ,appeals process   
7a7 ,in general ,section #aijb7;a77#ci7 
of the ,social ,security ,act 7#db      
,u4,s4,c4 #acif;a7a77#ci77 is amended-- 
7#a7 by striking shall exclude and      
inserting 8shall--  7,a7 exclude  2     
7#b7 by adding and after the semicolon  
at the end2 and  7#c7 by adding at the  
end the following new subparagraph3     
7,b7 establish and codify a process     
whereby a provider to whom payments have
 been suspended1 in whole or part1 on   
the basis of credible allegations of    
fraud against such provider may appeal  
any decision 7including a decision not  
to terminate or modify a payment        
suspension that is already in place7 by 
the ,state agency that no good cause    

exists under the regulations of the     
,secretary to terminate1 modify1 or     
refrain from imposing such suspension of
 payment2  4  7b7 ,effective date  7#a7 
,in general ,subject to paragraph 7#b71 
the amendments made by this section     
shall take effect on the date that is #a
 year after the date of the enactment of
 this ,act4  7#b7 ,delay permitted if   
,state legislation required ,in the case
 of a ,state plan approved under title  
,,xix of the ,social ,security ,act     
which the ,secretary of ,health and     
,human ,services determines requires    
,state legislation 7other than          
legislation appropriating funds7 in     
order for the plan to meet the          
additional requirements imposed by this 
section1 the ,state plan shall not be   
regarded as failing to comply with the  
requirements of such title solely on the
 basis of the failure of the plan to    
meet such additional requirements before
 the first day of the first calendar    
quarter beginning after the close of the

 first regular session of the ,state    
legislature that ends after the #a-year 
period beginning with the date of the   
enactment of this section4 ,for purposes
 of the preceding sentence1 in the case 
of a ,state that has a #b-year          
legislative session1 each year of the   
session is deemed to be a separate      
regular session of the ,state           
legislature4