§1397ee. Payments to States
(a) In general
Subject to the succeeding provisions of this section, the Secretary shall pay to each State with a plan approved under this subchapter, from its allotment under section 1397dd of this title (taking into account any adjustment under section 1397dd(d) of this title), an amount for each quarter equal to the enhanced FMAP of expenditures in the quarter-
(1) for child health assistance under the plan for targeted low-income children in the form of providing health benefits coverage that meets the requirements of section 1397cc of this title; and
(2) only to the extent permitted consistent with subsection (c) of this section-
(A) for payment for other child health assistance for targeted low-income children;
(B) for expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children);
(C) for expenditures for outreach activities as provided in section 1397bb(c)(1) of this title under the plan; and
(D) for other reasonable costs incurred by the State to administer the plan.
(b) Enhanced FMAP
For purposes of subsection (a) of this section, the "enhanced FMAP", for a State for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the first sentence of section 1396d(b) of this title) for the State increased by a number of percentage points equal to 30 percent of the number of percentage points by which (1) such Federal medical assistance percentage for the State, is less than (2) 100 percent; but in no case shall the enhanced FMAP for a State exceed 85 percent.
(c) Limitation on certain payments for certain expenditures
(1) General limitations
Funds provided to a State under this subchapter shall only be used to carry out the purposes of this subchapter (as described in section 1397aa of this title), and any health insurance coverage provided with such funds may include coverage of abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(2) Limitation on expenditures not used for medicaid or health insurance assistance
(A) In general
Except as provided in this paragraph, payment shall not be made under subsection (a) of this section for expenditures for items described in subsection (a) of this section (other than paragraph (1)) for a fiscal year to the extent the total of such expenditures (for which payment is made under such subsection) exceeds 10 percent of the sum of-
(i) the total of such expenditures for such fiscal year, and
(ii) the total expenditures for medical assistance by the State under subchapter XIX of this chapter for which Federal payments made under section 1396b(a)(1) of this title are based on an enhanced FMAP described in subsection (b) of this section for such fiscal year.
(B) Waiver authorized for cost-effective alternative
The limitation under subparagraph (A) on expenditures for items described in subsection (a)(2) of this section shall not apply to the extent that a State establishes to the satisfaction of the Secretary that-
(i) coverage provided to targeted low-income children through such expenditures meets the requirements of section 1397cc of this title;
(ii) the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under section 1397cc of this title; and
(iii) such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 254b of this title or with hospitals such as those that receive disproportionate share payment adjustments under section 1395ww(d)(5)(F) or 1396r–4 of this title.
(3) Waiver for purchase of family coverage
Payment may be made to a State under subsection (a)(1) of this section for the purchase of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children only if the State establishes to the satisfaction of the Secretary that-
(A) purchase of such coverage is cost-effective relative to the amounts that the State would have paid to obtain comparable coverage only of the targeted low-income children involved, and
(B) such coverage shall not be provided if it would otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage.
(4) Use of non-Federal funds for State matching requirement
Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of non-Federal contributions required under subsection (a) of this section.
(5) Offset of receipts attributable to premiums and other cost-sharing
For purposes of subsection (a) of this section, the amount of the expenditures under the plan shall be reduced by the amount of any premiums and other cost-sharing received by the State.
(6) Prevention of duplicative payments
(A) Other health plans
No payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that a private insurer (as defined by the Secretary by regulation and including a group health plan (as defined in section 1167(1) of title 29), a service benefit plan, and a health maintenance organization) would have been obligated to provide such assistance but for a provision of its insurance contract which has the effect of limiting or excluding such obligation because the individual is eligible for or is provided child health assistance under the plan.
(B) Other Federal governmental programs
Except as otherwise provided by law, no payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that payment has been made or can reasonably be expected to be made promptly (as determined in accordance with regulations) under any other federally operated or financed health care insurance program, other than an insurance program operated or financed by the Indian Health Service, as identified by the Secretary. For purposes of this paragraph, rules similar to the rules for overpayments under section 1396b(d)(2) of this title shall apply.
(7) Limitation on payment for abortions
(A) In general
Payment shall not be made to a State under this section for any amount expended under the State plan to pay for any abortion or to assist in the purchase, in whole or in part, of health benefit coverage that includes coverage of abortion.
(B) Exception
Subparagraph (A) shall not apply to an abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(C) Rule of construction
Nothing in this section shall be construed as affecting the expenditure by a State, locality, or private person or entity of State, local, or private funds (other than funds expended under the State plan) for any abortion or for health benefits coverage that includes coverage of abortion.
(d) Maintenance of effort
(1) In medicaid eligibility standards
No payment may be made under subsection (a) of this section with respect to child health assistance provided under a State child health plan if the State adopts income and resource standards and methodologies for purposes of determining a child's eligibility for medical assistance under the State plan under subchapter XIX of this chapter that are more restrictive than those applied as of June 1, 1997.
(2) In amounts of payment expended for certain State-funded health insurance programs for children
(A) In general
The amount of the allotment for a State in a fiscal year (beginning with fiscal year 1999) shall be reduced by the amount by which-
(i) the total of the State children's health insurance expenditures in the preceding fiscal year, is less than
(ii) the total of such expenditures in fiscal year 1996.
(B) State children's health insurance expenditures
The term "State children's health insurance expenditures" means the following:
(i) The State share of expenditures under this subchapter.
(ii) The State share of expenditures under subchapter XIX of this chapter that are attributable to an enhanced FMAP under section 1396d(u) of this title.
(iii) State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 1397cc(d) of this title.
(e) Advance payment; retrospective adjustment
The Secretary may make payments under this section for each quarter on the basis of advance estimates of expenditures submitted by the State and such other investigation as the Secretary may find necessary, and may reduce or increase the payments as necessary to adjust for any overpayment or underpayment for prior quarters.
(f) Flexibility in submittal of claims
Nothing in this section or subsections (e) and (f) of section 1397dd of this title shall be construed as preventing a State from claiming as expenditures in the quarter expenditures that were incurred in a previous quarter.
(Aug. 14, 1935, ch. 531, title XXI, §2105, as added
Amendments
1999-Subsec. (d)(2)(B)(iii).
1997-Subsec. (c)(2)(A).
"(i) the total Federal payments made under subsection (a) of this section for such quarter in the fiscal year, and
"(ii) the total Federal payments made under section 1396b(a)(1) of this title based on an enhanced FMAP described in section 1396d(u)(2) of this title for such quarter."
Subsec. (f).
Effective Date of 1997 Amendment
Section 162 of
Section Referred to in Other Sections
This section is referred to in sections 1396d, 1397aa, 1397ff, 1397ii, 1397jj of this title.