SUBCHAPTER XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
Subchapter Referred to in Other Sections
This subchapter is referred to in
§1396. Appropriations
For the purpose of enabling each State, as far as practicable under the conditions in such State, to furnish (1) medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services, and (2) rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care, there is hereby authorized to be appropriated for each fiscal year a sum sufficient to carry out the purposes of this subchapter. The sums made available under this section shall be used for making payments to States which have submitted, and had approved by the Secretary, State plans for medical assistance.
(Aug. 14, 1935, ch. 531, title XIX, §1901, as added
Amendments
1984—
1973—
Effective Date of 1984 Amendment
Amendment by
Effective Date of 1973 Amendment
Amendment by
§1396a. State plans for medical assistance
(a) Contents
A State plan for medical assistance must—
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
(2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under
(3) provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness;
(4) provide (A) such methods of administration (including methods relating to the establishment and maintenance of personnel standards on a merit basis, except that the Secretary shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods, and including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan) as are found by the Secretary to be necessary for the proper and efficient operation of the plan, (B) for the training and effective use of paid subprofessional staff, with particular emphasis on the full-time or part-time employment of recipients and other persons of low income, as community service aides, in the administration of the plan and for the use of nonpaid or partially paid volunteers in a social service volunteer program in providing services to applicants and recipients and in assisting any advisory committees established by the State agency, (C) that each State or local officer, employee, or independent contractor who is responsible for the expenditure of substantial amounts of funds under the State plan, each individual who formerly was such an officer, employee, or contractor, and each partner of such an officer, employee, or contractor shall be prohibited from committing any act, in relation to any activity under the plan, the commission of which, in connection with any activity concerning the United States Government, by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee is prohibited by
(5) either provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan; or provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan, except that the determination of eligibility for medical assistance under the plan shall be made by the State or local agency administering the State plan approved under subchapter I or XVI of this chapter (insofar as it relates to the aged) if the State is eligible to participate in the State plan program established under subchapter XVI of this chapter, or by the agency or agencies administering the supplemental security income program established under subchapter XVI or the State plan approved under part A of subchapter IV of this chapter if the State is not eligible to participate in the State plan program established under subchapter XVI of this chapter;
(6) provide that the State agency will make such reports, in such form and containing such information, as the Secretary may from time to time require, and comply with such provisions as the Secretary may from time to time find necessary to assure the correctness and verification of such reports;
(7) provide safeguards which restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan;
(8) provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals;
(9) provide—
(A) that the State health agency, or other appropriate State medical agency (whichever is utilized by the Secretary for the purpose specified in the first sentence of
(B) for the establishment or designation of a State authority or authorities which shall be responsible for establishing and maintaining standards, other than those relating to health, for such institutions, and
(C) that any laboratory services paid for under such plan must be provided by a laboratory which meets the applicable requirements of
(10) provide—
(A) for making medical assistance available, including at least the care and services listed in paragraphs (1) through (5), (17) and (21) of
(i) all individuals—
(I) who are receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI of this chapter, or part A or part E of subchapter IV of this chapter (including individuals eligible under this subchapter by reason of section 602(a)(37),1 606(h),1 or 673(b) of this title, or considered by the State to be receiving such aid as authorized under section 682(e)(6)1 of this title),
(II) with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter (or were being paid as of the date of the enactment of section 211(a) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (
(III) who are qualified pregnant women or children as defined in
(IV) who are described in subparagraph (A) or (B) of subsection (l)(1) of this section and whose family income does not exceed the minimum income level the State is required to establish under subsection (l)(2)(A) of this section for such a family; 2
(V) who are qualified family members as defined in
(VI) who are described in subparagraph (C) of subsection (l)(1) of this section and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(B) of this section for such a family, or
(VII) who are described in subparagraph (D) of subsection (l)(1) of this section and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(C) of this section for such a family; 3
(ii) at the option of the State, to 4 any group or groups of individuals described in
(I) who meet the income and resources requirements of the appropriate State plan described in clause (i) or the supplemental security income program (as the case may be),
(II) who would meet the income and resources requirements of the appropriate State plan described in clause (i) if their work-related child care costs were paid from their earnings rather than by a State agency as a service expenditure,
(III) who would be eligible to receive aid under the appropriate State plan described in clause (i) if coverage under such plan was as broad as allowed under Federal law,
(IV) with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them, aid or assistance under the appropriate State plan described in clause (i), supplemental security income benefits under subchapter XVI of this chapter, or a State supplementary payment; 2
(V) who are in a medical institution for a period of not less than 30 consecutive days (with eligibility by reason of this subclause beginning on the first day of such period), who meet the resource requirements of the appropriate State plan described in clause (i) or the supplemental security income program, and whose income does not exceed a separate income standard established by the State which is consistent with the limit established under
(VI) who would be eligible under the State plan under this subchapter if they were in a medical institution, with respect to whom there has been a determination that but for the provision of home or community-based services described in subsection (c), (d), or (e) of
(VII) who would be eligible under the State plan under this subchapter if they were in a medical institution, who are terminally ill, and who will receive hospice care pursuant to a voluntary election described in
(VIII) who is a child described in
(aa) for whom there is in effect an adoption assistance agreement (other than an agreement under part E of subchapter IV of this chapter) between the State and an adoptive parent or parents,
(bb) who the State agency responsible for adoption assistance has determined cannot be placed with adoptive parents without medical assistance because such child has special needs for medical or rehabilitative care, and
(cc) who was eligible for medical assistance under the State plan prior to the adoption assistance agreement being entered into, or who would have been eligible for medical assistance at such time if the eligibility standards and methodologies of the State's foster care program under part E of subchapter IV of this chapter were applied rather than the eligibility standards and methodologies of the State's aid to families with dependent children program under part A of subchapter IV of this chapter; 5
(IX) who are described in subsection (l)(1) of this section and are not described in clause (i)(IV), clause (i)(VI), or clause (i)(VII); 5
(X) who are described in subsection (m)(1) of this section; 5
(XI) who receive only an optional State supplementary payment based on need and paid on a regular basis, equal to the difference between the individual's countable income and the income standard used to determine eligibility for such supplementary payment (with countable income being the income remaining after deductions as established by the State pursuant to standards that may be more restrictive than the standards for supplementary security income benefits under subchapter XVI of this chapter), which are available to all individuals in the State (but which may be based on different income standards by political subdivision according to cost of living differences), and which are paid by a State that does not have an agreement with the Commissioner of Social Security under
(XII) who are described in subsection (z)(1) of this section (relating to certain TB-infected individuals); 5
(XIII) who are in families whose income is less than 250 percent of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with
(XIV) who are optional targeted low-income children described in
(XV) who, but for earnings in excess of the limit established under
(XVI) who are employed individuals with a medically improved disability described in
(XVII) who are independent foster care adolescents (as defined in
(B) that the medical assistance made available to any individual described in subparagraph (A)—
(i) shall not be less in amount, duration, or scope than the medical assistance made available to any other such individual, and
(ii) shall not be less in amount, duration, or scope than the medical assistance made available to individuals not described in subparagraph (A);
(C) that if medical assistance is included for any group of individuals described in
(i) the plan must include a description of (I) the criteria for determining eligibility of individuals in the group for such medical assistance, (II) the amount, duration, and scope of medical assistance made available to individuals in the group, and (III) the single standard to be employed in determining income and resource eligibility for all such groups, and the methodology to be employed in determining such eligibility, which shall be no more restrictive than the methodology which would be employed under the supplemental security income program in the case of groups consisting of aged, blind, or disabled individuals in a State in which such program is in effect, and which shall be no more restrictive than the methodology which would be employed under the appropriate State plan (described in subparagraph (A)(i)) to which such group is most closely categorically related in the case of other groups;
(ii) the plan must make available medical assistance—
(I) to individuals under the age of 18 who (but for income and resources) would be eligible for medical assistance as an individual described in subparagraph (A)(i), and
(II) to pregnant women, during the course of their pregnancy, who (but for income and resources) would be eligible for medical assistance as an individual described in subparagraph (A);
(iii) such medical assistance must include (I) with respect to children under 18 and individuals entitled to institutional services, ambulatory services, and (II) with respect to pregnant women, prenatal care and delivery services; and
(iv) if such medical assistance includes services in institutions for mental diseases or in an intermediate care facility for the mentally retarded (or both) for any such group, it also must include for all groups covered at least the care and services listed in paragraphs (1) through (5) and (17) of
(D) for the inclusion of home health services for any individual who, under the State plan, is entitled to nursing facility services;
(E)(i) for making medical assistance available for medicare cost-sharing (as defined in
(ii) for making medical assistance available for payment of medicare cost-sharing described in
(iii) for making medical assistance available for medicare cost sharing described in
(iv) subject to
(I) for medicare cost-sharing described in
(II) for the portion of medicare cost-sharing described in
(F) at the option of a State, for making medical assistance available for COBRA premiums (as defined in subsection (u)(2) of this section) for qualified COBRA continuation beneficiaries described in subsection (u)(1) of this section; and
(G) that, in applying eligibility criteria of the supplemental security income program under subchapter XVI of this chapter for purposes of determining eligibility for medical assistance under the State plan of an individual who is not receiving supplemental security income, the State will disregard the provisions of subsections (c) and (e) of
except that (I) the making available of the services described in paragraph (4), (14), or (16) of
(11)(A) provide for entering into cooperative arrangements with the State agencies responsible for administering or supervising the administration of health services and vocational rehabilitation services in the State looking toward maximum utilization of such services in the provision of medical assistance under the plan, (B) provide, to the extent prescribed by the Secretary, for entering into agreements, with any agency, institution, or organization receiving payments under (or through an allotment under) subchapter V of this chapter, (i) providing for utilizing such agency, institution, or organization in furnishing care and services which are available under such subchapter or allotment and which are included in the State plan approved under this section 6 (ii) making such provision as may be appropriate for reimbursing such agency, institution, or organization for the cost of any such care and services furnished any individual for which payment would otherwise be made to the State with respect to the individual under
(12) provide that, in determining whether an individual is blind, there shall be an examination by a physician skilled in the diseases of the eye or by an optometrist, whichever the individual may select;
(13) provide—
(A) for a public process for determination of rates of payment under the plan for hospital services, nursing facility services, and services of intermediate care facilities for the mentally retarded under which—
(i) proposed rates, the methodologies underlying the establishment of such rates, and justifications for the proposed rates are published,
(ii) providers, beneficiaries and their representatives, and other concerned State residents are given a reasonable opportunity for review and comment on the proposed rates, methodologies, and justifications,
(iii) final rates, the methodologies underlying the establishment of such rates, and justifications for such final rates are published, and
(iv) in the case of hospitals, such rates take into account (in a manner consistent with
(B) for payment for hospice care in amounts no lower than the amounts, using the same methodology, used under part A of subchapter XVIII of this chapter and for payment of amounts under
(C)(i) for payment for services described in clause (B) or (C) of
(14) provide that enrollment fees, premiums, or similar charges, and deductions, cost sharing, or similar charges, may be imposed only as provided in
(15) Repealed.
(16) provide for inclusion, to the extent required by regulations prescribed by the Secretary, of provisions (conforming to such regulations) with respect to the furnishing of medical assistance under the plan to individuals who are residents of the State but are absent therefrom;
(17) except as provided in subsections (l)(3), (m)(3), and (m)(4) of this section, include reasonable standards (which shall be comparable for all groups and may, in accordance with standards prescribed by the Secretary, differ with respect to income levels, but only in the case of applicants or recipients of assistance under the plan who are not receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV of this chapter, and with respect to whom supplemental security income benefits are not being paid under subchapter XVI of this chapter, based on the variations between shelter costs in urban areas and in rural areas) for determining eligibility for and the extent of medical assistance under the plan which (A) are consistent with the objectives of this subchapter, (B) provide for taking into account only such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient and (in the case of any applicant or recipient who would, except for income and resources, be eligible for aid or assistance in the form of money payments under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, or to have paid with respect to him supplemental security income benefits under subchapter XVI of this chapter) as would not be disregarded (or set aside for future needs) in determining his eligibility for such aid, assistance, or benefits, (C) provide for reasonable evaluation of any such income or resources, and (D) do not take into account the financial responsibility of any individual for any applicant or recipient of assistance under the plan unless such applicant or recipient is such individual's spouse or such individual's child who is under age 21 or (with respect to States eligible to participate in the State program established under subchapter XVI of this chapter), is blind or permanently and totally disabled, or is blind or disabled as defined in
(18) comply with the provisions of
(19) provide such safeguards as may be necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided, in a manner consistent with simplicity of administration and the best interests of the recipients;
(20) if the State plan includes medical assistance in behalf of individuals 65 years of age or older who are patients in institutions for mental diseases—
(A) provide for having in effect such agreements or other arrangements with State authorities concerned with mental diseases, and, where appropriate, with such institutions, as may be necessary for carrying out the State plan, including arrangements for joint planning and for development of alternate methods of care, arrangements providing assurance of immediate readmittance to institutions where needed for individuals under alternate plans of care, and arrangements providing for access to patients and facilities, for furnishing information, and for making reports;
(B) provide for an individual plan for each such patient to assure that the institutional care provided to him is in his best interests, including, to that end, assurances that there will be initial and periodic review of his medical and other needs, that he will be given appropriate medical treatment within the institution, and that there will be a periodic determination of his need for continued treatment in the institution; and
(C) provide for the development of alternate plans of care, making maximum utilization of available resources, for recipients 65 years of age or older who would otherwise need care in such institutions, including appropriate medical treatment and other aid or assistance; for services referred to in section 303(a)(4)(A)(i) and (ii) 8 or section 1383(a)(4)(A)(i) and (ii) 8 of this title which are appropriate for such recipients and for such patients; and for methods of administration necessary to assure that the responsibilities of the State agency under the State plan with respect to such recipients and such patients will be effectively carried out;
(21) if the State plan includes medical assistance in behalf of individuals 65 years of age or older who are patients in public institutions for mental diseases, show that the State is making satisfactory progress toward developing and implementing a comprehensive mental health program, including provision for utilization of community mental health centers, nursing facilities, and other alternatives to care in public institutions for mental diseases;
(22) include descriptions of (A) the kinds and numbers of professional medical personnel and supporting staff that will be used in the administration of the plan and of the responsibilities they will have, (B) the standards, for private or public institutions in which recipients of medical assistance under the plan may receive care or services, that will be utilized by the State authority or authorities responsible for establishing and maintaining such standards, (C) the cooperative arrangements with State health agencies and State vocational rehabilitation agencies entered into with a view to maximum utilization of and coordination of the provision of medical assistance with the services administered or supervised by such agencies, and (D) other standards and methods that the State will use to assure that medical or remedial care and services provided to recipients of medical assistance are of high quality;
(23) provide that (A) any individual eligible for medical assistance (including drugs) may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required (including an organization which provides such services, or arranges for their availability, on a prepayment basis), who undertakes to provide him such services, and (B) an enrollment of an individual eligible for medical assistance in a primary care case-management system (described in
(24) effective July 1, 1969, provide for consultative services by health agencies and other appropriate agencies of the State to hospitals, nursing facilities, home health agencies, clinics, laboratories, and such other institutions as the Secretary may specify in order to assist them (A) to qualify for payments under this chapter, (B) to establish and maintain such fiscal records as may be necessary for the proper and efficient administration of this chapter, and (C) to provide information needed to determine payments due under this chapter on account of care and services furnished to individuals;
(25) provide—
(A) that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties (including health insurers, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 [
(i) the collection of sufficient information (as specified by the Secretary in regulations) to enable the State to pursue claims against such third parties, with such information being collected at the time of any determination or redetermination of eligibility for medical assistance, and
(ii) the submission to the Secretary of a plan (subject to approval by the Secretary) for pursuing claims against such third parties, which plan shall be integrated with, and be monitored as a part of the Secretary's review of, the State's mechanized claims processing and information retrieval systems required under
(B) that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual and where the amount of reimbursement the State can reasonably expect to recover exceeds the costs of such recovery, the State or local agency will seek reimbursement for such assistance to the extent of such legal liability;
(C) that in the case of an individual who is entitled to medical assistance under the State plan with respect to a service for which a third party is liable for payment, the person furnishing the service may not seek to collect from the individual (or any financially responsible relative or representative of that individual) payment of an amount for that service (i) if the total of the amount of the liabilities of third parties for that service is at least equal to the amount payable for that service under the plan (disregarding
(D) that a person who furnishes services and is participating under the plan may not refuse to furnish services to an individual (who is entitled to have payment made under the plan for the services the person furnishes) because of a third party's potential liability for payment for the service;
(E) that in the case of prenatal or preventive pediatric care (including early and periodic screening and diagnosis services under
(i) make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to the liability of a third party for payment for such services; and
(ii) seek reimbursement from such third party in accordance with subparagraph (B);
(F) that in the case of any services covered under such plan which are provided to an individual on whose behalf child support enforcement is being carried out by the State agency under part D of subchapter IV of this chapter, the State shall—
(i) make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to any third-party liability for payment for such services, if such third-party liability is derived (through insurance or otherwise) from the parent whose obligation to pay support is being enforced by such agency, if payment has not been made by such third party within 30 days after such services are furnished; and
(ii) seek reimbursement from such third party in accordance with subparagraph (B);
(G) that the State prohibits any health insurer (including a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 [
(H) that to the extent that payment has been made under the State plan for medical assistance in any case where a third party has a legal liability to make payment for such assistance, the State has in effect laws under which, to the extent that payment has been made under the State plan for medical assistance for health care items or services furnished to an individual, the State is considered to have acquired the rights of such individual to payment by any other party for such health care items or services;
(26) if the State plan includes medical assistance for inpatient mental hospital services, provide, with respect to each patient receiving such services, for a regular program of medical review (including medical evaluation) of his need for such services, and for a written plan of care;
(27) provide for agreements with every person or institution providing services under the State plan under which such person or institution agrees (A) to keep such records as are necessary fully to disclose the extent of the services provided to individuals receiving assistance under the State plan, and (B) to furnish the State agency or the Secretary with such information, regarding any payments claimed by such person or institution for providing services under the State plan, as the State agency or the Secretary may from time to time request;
(28) provide—
(A) that any nursing facility receiving payments under such plan must satisfy all the requirements of subsections (b) through (d) of
(B) for including in "nursing facility services" at least the items and services specified (or deemed to be specified) by the Secretary under
(C) for procedures to make available to the public the data and methodology used in establishing payment rates for nursing facilities under this subchapter; and
(D) for compliance (by the date specified in the respective sections) with the requirements of—
(i)
(ii)
(iii)
(29) include a State program which meets the requirements set forth in
(30)(A) provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan (including but not limited to utilization review plans as provided for in
(B) provide, under the program described in subparagraph (A), that—
(i) each admission to a hospital, intermediate care facility for the mentally retarded, or hospital for mental diseases is reviewed or screened in accordance with criteria established by medical and other professional personnel who are not themselves directly responsible for the care of the patient involved, and who do not have a significant financial interest in any such institution and are not, except in the case of a hospital, employed by the institution providing the care involved, and
(ii) the information developed from such review or screening, along with the data obtained from prior reviews of the necessity for admission and continued stay of patients by such professional personnel, shall be used as the basis for establishing the size and composition of the sample of admissions to be subject to review and evaluation by such personnel, and any such sample may be of any size up to 100 percent of all admissions and must be of sufficient size to serve the purpose of (I) identifying the patterns of care being provided and the changes occurring over time in such patterns so that the need for modification may be ascertained, and (II) subjecting admissions to early or more extensive review where information indicates that such consideration is warranted to a hospital, intermediate care facility for the mentally retarded, or hospital for mental diseases;
(31) with respect to services in an intermediate care facility for the mentally retarded (where the State plan includes medical assistance for such services) provide, with respect to each patient receiving such services, for a written plan of care, prior to admission to or authorization of benefits in such facility, in accordance with regulations of the Secretary, and for a regular program of independent professional review (including medical evaluation) which shall periodically review his need for such services;
(32) provide that no payment under the plan for any care or service provided to an individual shall be made to anyone other than such individual or the person or institution providing such care or service, under an assignment or power of attorney or otherwise; except that—
(A) in the case of any care or service provided by a physician, dentist, or other individual practitioner, such payment may be made (i) to the employer of such physician, dentist, or other practitioner if such physician, dentist, or practitioner is required as a condition of his employment to turn over his fee for such care or service to his employer, or (ii) (where the care or service was provided in a hospital, clinic, or other facility) to the facility in which the care or service was provided if there is a contractual arrangement between such physician, dentist, or practitioner and such facility under which such facility submits the bill for such care or service;
(B) nothing in this paragraph shall be construed (i) to prevent the making of such a payment in accordance with an assignment from the person or institution providing the care or service involved if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or (ii) to preclude an agent of such person or institution from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such person or institution under the plan is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment;
(C) in the case of services furnished (during a period that does not exceed 14 continuous days in the case of an informal reciprocal arrangement or 90 continuous days (or such longer period as the Secretary may provide) in the case of an arrangement involving per diem or other fee-for-time compensation) by, or incident to the services of, one physician to the patients of another physician who submits the claim for such services, payment shall be made to the physician submitting the claim (as if the services were furnished by, or incident to, the physician's services), but only if the claim identifies (in a manner specified by the Secretary) the physician who furnished the services; and
(D) in the case of payment for a childhood vaccine administered before October 1, 1994, to individuals entitled to medical assistance under the State plan, the State plan may make payment directly to the manufacturer of the vaccine under a voluntary replacement program agreed to by the State pursuant to which the manufacturer (i) supplies doses of the vaccine to providers administering the vaccine, (ii) periodically replaces the supply of the vaccine, and (iii) charges the State the manufacturer's price to the Centers for Disease Control and Prevention for the vaccine so administered (which price includes a reasonable amount to cover shipping and the handling of returns);
(33) provide—
(A) that the State health agency, or other appropriate State medical agency, shall be responsible for establishing a plan, consistent with regulations prescribed by the Secretary, for the review by appropriate professional health personnel of the appropriateness and quality of care and services furnished to recipients of medical assistance under the plan in order to provide guidance with respect thereto in the administration of the plan to the State agency established or designated pursuant to paragraph (5) and, where applicable, to the State agency described in the second sentence of this subsection; and
(B) that, except as provided in
(34) provide that in the case of any individual who has been determined to be eligible for medical assistance under the plan, such assistance will be made available to him for care and services included under the plan and furnished in or after the third month before the month in which he made application (or application was made on his behalf in the case of a deceased individual) for such assistance if such individual was (or upon application would have been) eligible for such assistance at the time such care and services were furnished;
(35) provide that any disclosing entity (as defined in
(36) provide that within 90 days following the completion of each survey of any health care facility, laboratory, agency, clinic, or organization, by the appropriate State agency described in paragraph (9), such agency shall (in accordance with regulations of the Secretary) make public in readily available form and place the pertinent findings of each such survey relating to the compliance of each such health care facility, laboratory, clinic, agency, or organization with (A) the statutory conditions of participation imposed under this subchapter, and (B) the major additional conditions which the Secretary finds necessary in the interest of health and safety of individuals who are furnished care or services by any such facility, laboratory, clinic, agency, or organization;
(37) provide for claims payment procedures which (A) ensure that 90 per centum of claims for payment (for which no further written information or substantiation is required in order to make payment) made for services covered under the plan and furnished by health care practitioners through individual or group practices or through shared health facilities are paid within 30 days of the date of receipt of such claims and that 99 per centum of such claims are paid within 90 days of the date of receipt of such claims, and (B) provide for procedures of prepayment and postpayment claims review, including review of appropriate data with respect to the recipient and provider of a service and the nature of the service for which payment is claimed, to ensure the proper and efficient payment of claims and management of the program;
(38) require that an entity (other than an individual practitioner or a group of practitioners) that furnishes, or arranges for the furnishing of, items or services under the plan, shall supply (within such period as may be specified in regulations by the Secretary or by the single State agency which administers or supervises the administration of the plan) upon request specifically addressed to such entity by the Secretary or such State agency, the information described in
(39) provide that the State agency shall exclude any specified individual or entity from participation in the program under the State plan for the period specified by the Secretary, when required by him to do so pursuant to
(40) require each health services facility or organization which receives payments under the plan and of a type for which a uniform reporting system has been established under
(41) provide that whenever a provider of services or any other person is terminated, suspended, or otherwise sanctioned or prohibited from participating under the State plan, the State agency shall promptly notify the Secretary and, in the case of a physician and notwithstanding paragraph (7), the State medical licensing board of such action;
(42) provide that the records of any entity participating in the plan and providing services reimbursable on a cost-related basis will be audited as the Secretary determines to be necessary to insure that proper payments are made under the plan;
(43) provide for—
(A) informing all persons in the State who are under the age of 21 and who have been determined to be eligible for medical assistance including services described in
(B) providing or arranging for the provision of such screening services in all cases where they are requested,
(C) arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services, and
(D) reporting to the Secretary (in a uniform form and manner established by the Secretary, by age group and by basis of eligibility for medical assistance, and by not later than April 1 after the end of each fiscal year, beginning with fiscal year 1990) the following information relating to early and periodic screening, diagnostic, and treatment services provided under the plan during each fiscal year:
(i) the number of children provided child health screening services,
(ii) the number of children referred for corrective treatment (the need for which is disclosed by such child health screening services),
(iii) the number of children receiving dental services, and
(iv) the State's results in attaining the participation goals set for the State under
(44) in each case for which payment for inpatient hospital services, services in an intermediate care facility for the mentally retarded, or inpatient mental hospital services is made under the State plan—
(A) a physician (or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician) certifies at the time of admission, or, if later, the time the individual applies for medical assistance under the State plan (and a physician, a physician assistant under the supervision of a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, recertifies, where such services are furnished over a period of time, in such cases, at least as often as required under
(B) such services were furnished under a plan established and periodically reviewed and evaluated by a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician;
(45) provide for mandatory assignment of rights of payment for medical support and other medical care owed to recipients, in accordance with
(46) provide that information is requested and exchanged for purposes of income and eligibility verification in accordance with a State system which meets the requirements of
(47) at the option of the State, provide for making ambulatory prenatal care available to pregnant women during a presumptive eligibility period in accordance with
(48) provide a method of making cards evidencing eligibility for medical assistance available to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address;
(49) provide that the State will provide information and access to certain information respecting sanctions taken against health care practitioners and providers by State licensing authorities in accordance with
(50) provide, in accordance with subsection (q) of this section, for a monthly personal needs allowance for certain institutionalized individuals and couples;
(51) meet the requirements of
(52) meet the requirements of
(53) provide—
(A) for notifying in a timely manner all individuals in the State who are determined to be eligible for medical assistance and who are pregnant women, breastfeeding or postpartum women (as defined in
(B) for referring any such individual to the State agency responsible for administering such program;
(54) in the case of a State plan that provides medical assistance for covered outpatient drugs (as defined in
(55) provide for receipt and initial processing of applications of individuals for medical assistance under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX) of this section—
(A) at locations which are other than those used for the receipt and processing of applications for aid under part A of subchapter IV of this chapter and which include facilities defined as disproportionate share hospitals under
(B) using applications which are other than those used for applications for aid under such part;
(56) provide, in accordance with subsection (s) of this section, for adjusted payments for certain inpatient hospital services;
(57) provide that each hospital, nursing facility, provider of home health care or personal care services, hospice program, or medicaid managed care organization (as defined in
(58) provide that the State, acting through a State agency, association, or other private nonprofit entity, develop a written description of the law of the State (whether statutory or as recognized by the courts of the State) concerning advance directives that would be distributed by providers or organizations under the requirements of subsection (w) of this section;
(59) maintain a list (updated not less often than monthly, and containing each physician's unique identifier provided under the system established under subsection (x) of this section) of all physicians who are certified to participate under the State plan;
(60) provide that the State agency shall provide assurances satisfactory to the Secretary that the State has in effect the laws relating to medical child support required under
(61) provide that the State must demonstrate that it operates a medicaid fraud and abuse control unit described in
(62) provide for a program for the distribution of pediatric vaccines to program-registered providers for the immunization of vaccine-eligible children in accordance with
(63) provide for administration and determinations of eligibility with respect to individuals who are (or seek to be) eligible for medical assistance based on the application of
(64) provide, not later than 1 year after August 5, 1997, a mechanism to receive reports from beneficiaries and others and compile data concerning alleged instances of waste, fraud, and abuse relating to the operation of this subchapter; and
(65) provide that the State shall issue provider numbers for all suppliers of medical assistance consisting of durable medical equipment, as defined in
(A)(i) full and complete information as to the identity of each person with an ownership or control interest (as defined in
(ii) to the extent determined to be feasible under regulations of the Secretary, the name of any disclosing entity (as defined in
(B) a surety bond in a form specified by the Secretary under
Notwithstanding paragraph (5), if on January 1, 1965, and on the date on which a State submits its plan for approval under this subchapter, the State agency which administered or supervised the administration of the plan of such State approved under subchapter X of this chapter (or subchapter XVI of this chapter, insofar as it relates to the blind) was different from the State agency which administered or supervised the administration of the State plan approved under subchapter I of this chapter (or subchapter XVI of this chapter, insofar as it relates to the aged), the State agency which administered or supervised the administration of such plan approved under subchapter X of this chapter (or subchapter XVI of this chapter, insofar as it relates to the blind) may be designated to administer or supervise the administration of the portion of the State plan for medical assistance which relates to blind individuals and a different State agency may be established or designated to administer or supervise the administration of the rest of the State plan for medical assistance; and in such case the part of the plan which each such agency administers, or the administration of which each such agency supervises, shall be regarded as a separate plan for purposes of this subchapter (except for purposes of paragraph (10)). The provisions of paragraphs (9)(A), (31), and (33) and of
For purposes of paragraph (10) any individual who, for the month of August 1972, was eligible for or receiving aid or assistance under a State plan approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter and who for such month was entitled to monthly insurance benefits under subchapter II of this chapter shall for purposes of this subchapter only be deemed to be eligible for financial aid or assistance for any month thereafter if such individual would have been eligible for financial aid or assistance for such month had the increase in monthly insurance benefits under subchapter II of this chapter resulting from enactment of
The requirement of clause (A) of paragraph (37) with respect to a State plan may be waived by the Secretary if he finds that the State has exercised good faith in trying to meet such requirement. For purposes of this subchapter, any child who meets the requirements of paragraph (1) or (2) of
(b) Approval by Secretary
The Secretary shall approve any plan which fulfills the conditions specified in subsection (a) of this section, except that he shall not approve any plan which imposes, as a condition of eligibility for medical assistance under the plan—
(1) an age requirement of more than 65 years; or
(2) any residence requirement which excludes any individual who resides in the State, regardless of whether or not the residence is maintained permanently or at a fixed address; or
(3) any citizenship requirement which excludes any citizen of the United States.
(c) Lower payment levels or applying for benefits as condition of applying for, or receiving, medical assistance
Notwithstanding subsection (b) of this section, the Secretary shall not approve any State plan for medical assistance if the State requires individuals described in subsection (l)(1) of this section to apply for assistance under the State program funded under part A of subchapter IV of this chapter as a condition of applying for or receiving medical assistance under this subchapter.
(d) Performance of medical or utilization review functions
If a State contracts with an entity which meets the requirements of
(e) Continued eligibility of families determined ineligible because of income and resources or hours of work limitations of plan; individuals enrolled with health maintenance organizations; persons deemed recipients of supplemental security income or State supplemental payments; entitlement for certain newborns; postpartum eligibility for pregnant women
(1)(A) Notwithstanding any other provision of this subchapter, effective January 1, 1974, subject to subparagraph (B) each State plan approved under this subchapter must provide that each family which was receiving aid pursuant to a plan of the State approved under part A of subchapter IV of this chapter in at least 3 of the 6 months immediately preceding the month in which such family became ineligible for such aid because of increased hours of, or increased income from, employment, shall, while a member of such family is employed, remain eligible for assistance under the plan approved under this subchapter (as though the family was receiving aid under the plan approved under part A of subchapter IV of this chapter) for 4 calendar months beginning with the month in which such family became ineligible for aid under the plan approved under part A of subchapter IV of this chapter because of income and resources or hours of work limitations contained in such plan.
(B) Subparagraph (A) shall not apply with respect to families that cease to be eligible for aid under part A of subchapter IV of this chapter during the period beginning on April 1, 1990, and ending on September 30, 2001. During such period, for provisions relating to extension of eligibility for medical assistance for certain families who have received aid pursuant to a State plan approved under part A of subchapter IV of this chapter and have earned income, see
(2)(A) In the case of an individual who is enrolled with a medicaid managed care organization (as defined in
(B) For purposes of subparagraph (A), the term "minimum enrollment period" means, with respect to an individual's enrollment with an organization or entity under a State plan, a period, established by the State, of not more than six months beginning on the date the individual's enrollment with the organization or entity becomes effective.
(3) At the option of the State, any individual who—
(A) is 18 years of age or younger and qualifies as a disabled individual under
(B) with respect to whom there has been a determination by the State that—
(i) the individual requires a level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded,
(ii) it is appropriate to provide such care for the individual outside such an institution, and
(iii) the estimated amount which would be expended for medical assistance for the individual for such care outside an institution is not greater than the estimated amount which would otherwise be expended for medical assistance for the individual within an appropriate institution; and
(C) if the individual were in a medical institution, would be eligible for medical assistance under the State plan under this subchapter,
shall be deemed, for purposes of this subchapter only, to be an individual with respect to whom a supplemental security income payment, or State supplemental payment, respectively, is being paid under subchapter XVI of this chapter.
(4) A child born to a woman eligible for and receiving medical assistance under a State plan on the date of the child's birth shall be deemed to have applied for medical assistance and to have been found eligible for such assistance under such plan on the date of such birth and to remain eligible for such assistance for a period of one year so long as the child is a member of the woman's household and the woman remains (or would remain if pregnant) eligible for such assistance. During the period in which a child is deemed under the preceding sentence to be eligible for medical assistance, the medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires).
(5) A woman who, while pregnant, is eligible for, has applied for, and has received medical assistance under the State plan, shall continue to be eligible under the plan, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan, through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends.
(6) In the case of a pregnant woman described in subsection (a)(10) of this section who, because of a change in income of the family of which she is a member, would not otherwise continue to be described in such subsection, the woman shall be deemed to continue to be an individual described in subsection (a)(10)(A)(i)(IV) of this section and subsection (l)(1)(A) of this section without regard to such change of income through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends. The preceding sentence shall not apply in the case of a woman who has been provided ambulatory prenatal care pursuant to
(7) In the case of an infant or child described in subparagraph (B), (C), or (D) of subsection (l)(1) of this section or paragraph (2) of
(A) who is receiving inpatient services for which medical assistance is provided on the date the infant or child attains the maximum age with respect to which coverage is provided under the State plan for such individuals, and
(B) who, but for attaining such age, would remain eligible for medical assistance under such subsection,
the infant or child shall continue to be treated as an individual described in such respective provision until the end of the stay for which the inpatient services are furnished.
(8) If an individual is determined to be a qualified medicare beneficiary (as defined in
(9)(A) At the option of the State, the plan may include as medical assistance respiratory care services for any individual who—
(i) is medically dependent on a ventilator for life support at least six hours per day;
(ii) has been so dependent for at least 30 consecutive days (or the maximum number of days authorized under the State plan, whichever is less) as an inpatient;
(iii) but for the availability of respiratory care services, would require respiratory care as an inpatient in a hospital, nursing facility, or intermediate care facility for the mentally retarded and would be eligible to have payment made for such inpatient care under the State plan;
(iv) has adequate social support services to be cared for at home; and
(v) wishes to be cared for at home.
(B) The requirements of subparagraph (A)(ii) may be satisfied by a continuous stay in one or more hospitals, nursing facilities, or intermediate care facilities for the mentally retarded.
(C) For purposes of this paragraph, respiratory care services means services provided on a part-time basis in the home of the individual by a respiratory therapist or other health care professional trained in respiratory therapy (as determined by the State), payment for which is not otherwise included within other items and services furnished to such individual as medical assistance under the plan.
(10)(A) The fact that an individual, child, or pregnant woman may be denied aid under part A of subchapter IV of this chapter pursuant to section 602(a)(43) 10 of this title shall not be construed as denying (or permitting a State to deny) medical assistance under this subchapter to such individual, child, or woman who is eligible for assistance under this subchapter on a basis other than the receipt of aid under such part.
(B) If an individual, child, or pregnant woman is receiving aid under part A of subchapter IV of this chapter and such aid is terminated pursuant to section 602(a)(43) 10 of this title, the State may not discontinue medical assistance under this subchapter for the individual, child, or woman until the State has determined that the individual, child, or woman is not eligible for assistance under this subchapter on a basis other than the receipt of aid under such part.
(11)(A) In the case of an individual who is enrolled with a group health plan under
(B) For purposes of subparagraph (A), the term "minimum enrollment period" means, with respect to an individual's enrollment with a group health plan, a period established by the State, of not more than 6 months beginning on the date the individual's enrollment under the plan becomes effective.
(12) At the option of the State, the plan may provide that an individual who is under an age specified by the State (not to exceed 19 years of age) and who is determined to be eligible for benefits under a State plan approved under this subchapter under subsection (a)(10)(A) of this section shall remain eligible for those benefits until the earlier of—
(A) the end of a period (not to exceed 12 months) following the determination; or
(B) the time that the individual exceeds that age.
(f) Effective date of State plan as determinative of duty of State to provide medical assistance to aged, blind, or disabled individuals
Notwithstanding any other provision of this subchapter, except as provided in subsection (e) of this section and
(g) Reduction of aid or assistance to providers of services attempting to collect from beneficiary in violation of third-party provisions
In addition to any other sanction available to a State, a State may provide for a reduction of any payment amount otherwise due with respect to a person who furnishes services under the plan in an amount equal to up to three times the amount of any payment sought to be collected by that person in violation of subsection (a)(25)(C) of this section.
(h) Payments for hospitals serving disproportionate number of low-income patients and for home and community care
Nothing in this subchapter (including subsections (a)(13) and (a)(30) of this section) shall be construed as authorizing the Secretary to limit the amount of payment that may be made under a plan under this subchapter for home and community care.
(i) Termination of certification for participation of and suspension of State payments to intermediate care facilities for the mentally retarded
(1) In addition to any other authority under State law, where a State determines that a 11 intermediate care facility for the mentally retarded which is certified for participation under its plan no longer substantially meets the requirements for such a facility under this subchapter and further determines that the facility's deficiencies—
(A) immediately jeopardize the health and safety of its patients, the State shall provide for the termination of the facility's certification for participation under the plan and may provide, or
(B) do not immediately jeopardize the health and safety of its patients, the State may, in lieu of providing for terminating the facility's certification for participation under the plan, establish alternative remedies if the State demonstrates to the Secretary's satisfaction that the alternative remedies are effective in deterring noncompliance and correcting deficiencies, and may provide
that no payment will be made under the State plan with respect to any individual admitted to such facility after a date specified by the State.
(2) The State shall not make such a decision with respect to a facility until the facility has had a reasonable opportunity, following the initial determination that it no longer substantially meets the requirements for such a facility under this subchapter, to correct its deficiencies, and, following this period, has been given reasonable notice and opportunity for a hearing.
(3) The State's decision to deny payment may be made effective only after such notice to the public and to the facility as may be provided for by the State, and its effectiveness shall terminate (A) when the State finds that the facility is in substantial compliance (or is making good faith efforts to achieve substantial compliance) with the requirements for such a facility under this subchapter, or (B) in the case described in paragraph (1)(B), with the end of the eleventh month following the month such decision is made effective, whichever occurs first. If a facility to which clause (B) of the previous sentence applies still fails to substantially meet the provisions of the respective section on the date specified in such clause, the State shall terminate such facility's certification for participation under the plan effective with the first day of the first month following the month specified in such clause.
(j) Waiver or modification of subchapter requirements with respect to medical assistance program in American Samoa
Notwithstanding any other requirement of this subchapter, the Secretary may waive or modify any requirement of this subchapter with respect to the medical assistance program in American Samoa and the Northern Mariana Islands, other than a waiver of the Federal medical assistance percentage, the limitation in
(k) Repealed. Pub. L. 103–66, title XIII, §13611(d)(1)(C), Aug. 10, 1993, 107 Stat. 627
(l) Description of group
(1) Individuals described in this paragraph are—
(A) women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy),
(B) infants under one year of age,
(C) children who have attained one year of age but have not attained 6 years of age, and
(D) children born after September 30, 1983 (or, at the option of a State, after any earlier date), who have attained 6 years of age but have not attained 19 years of age,
who are not described in any of subclauses (I) through (III) of subsection (a)(10)(A)(i) of this section and whose family income does not exceed the income level established by the State under paragraph (2) for a family size equal to the size of the family, including the woman, infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to individuals described in subparagraph (A) or (B) of that paragraph, the State shall establish an income level which is a percentage (not less than the percentage provided under clause (ii) and not more than 185 percent) of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with
(ii) The percentage provided under this clause, with respect to eligibility for medical assistance on or after—
(I) July 1, 1989, is 75 percent, or, if greater, the percentage provided under clause (iii), and
(II) April 1, 1990, 133 percent, or, if greater, the percentage provided under clause (iv).
(iii) In the case of a State which, as of July 1, 1988, has elected to provide, and provides, medical assistance to individuals described in this subsection or has enacted legislation authorizing, or appropriating funds, to provide such assistance to such individuals before July 1, 1989, the percentage provided under clause (ii)(I) shall not be less than—
(I) the percentage specified by the State in an amendment to its State plan (whether approved or not) as of July 1, 1988, or
(II) if no such percentage is specified as of July 1, 1988, the percentage established under the State's authorizing legislation or provided for under the State's appropriations;
but in no case shall this clause require the percentage provided under clause (ii)(I) to exceed 100 percent.
(iv) In the case of a State which, as of December 19, 1989, has established under clause (i), or has enacted legislation authorizing, or appropriating funds, to provide for, a percentage (of the income official poverty line) that is greater than 133 percent, the percentage provided under clause (ii) for medical assistance on or after April 1, 1990, shall not be less than—
(I) the percentage specified by the State in an amendment to its State plan (whether approved or not) as of December 19, 1989, or
(II) if no such percentage is specified as of December 19, 1989, the percentage established under the State's authorizing legislation or provided for under the State's appropriations.
(B) For purposes of paragraph (1) with respect to individuals described in subparagraph (C) of such paragraph, the State shall establish an income level which is equal to 133 percent of the income official poverty line described in subparagraph (A) applicable to a family of the size involved.
(C) For purposes of paragraph (1) with respect to individuals described in subparagraph (D) of that paragraph, the State shall establish an income level which is equal to 100 percent of the income official poverty line described in subparagraph (A) applicable to a family of the size involved.
(3) Notwithstanding subsection (a)(17) of this section, for individuals who are eligible for medical assistance because of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10) (A)(i)(VII), or (a)(10)(A)(ii)(IX) of this section—
(A) application of a resource standard shall be at the option of the State;
(B) any resource standard or methodology that is applied with respect to an individual described in subparagraph (A) of paragraph (1) may not be more restrictive than the resource standard or methodology that is applied under subchapter XVI of this chapter;
(C) any resource standard or methodology that is applied with respect to an individual described in subparagraph (B), (C), or (D) of paragraph (1) may not be more restrictive than the corresponding methodology that is applied under the State plan under part A of subchapter IV of this chapter;
(D) the income standard to be applied is the appropriate income standard established under paragraph (2); and
(E) family income shall be determined in accordance with the methodology employed under the State plan under part A or E of subchapter IV of this chapter (except to the extent such methodology is inconsistent with clause (D) of subsection (a)(17) of this section), and costs incurred for medical care or for any other type of remedial care shall not be taken into account.
Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(17) of this section, require or permit such treatment for other individuals.
(4)(A) In the case of any State which is providing medical assistance to its residents under a waiver granted under
(B) In the case of a State which is not one of the 50 States or the District of Columbia, the State need not meet the requirement of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), or (a)(10)(A)(i)(VII) of this section and, for purposes of paragraph (2)(A), the State may substitute for the percentage provided under clause (ii) of such paragraph any percentage.
(m) Description of individuals
(1) Individuals described in this paragraph are individuals—
(A) who are 65 years of age or older or are disabled individuals (as determined under
(B) whose income (as determined under
(C) whose resources (as determined under
(2)(A) The income level established under paragraph (1)(B) may not exceed a percentage (not more than 100 percent) of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with
(B) In the case of a State that provides medical assistance to individuals not described in subsection (a)(10)(A) of this section and at the State's option, the State may use under paragraph (1)(C) such resource level (which is higher than the level described in that paragraph) as may be applicable with respect to individuals described in paragraph (1)(A) who are not described in subsection (a)(10)(A) of this section.
(C) The provisions of
(3) Notwithstanding subsection (a)(17) of this section, for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(X) of this section—
(A) the income standard to be applied is the income standard described in paragraph (1)(B), and
(B) except as provided in
Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(17) of this section, require or permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17) of this section, for qualified medicare beneficiaries described in
(A) the income standard to be applied is the income standard described in
(B) except as provided in
Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(17) of this section, require or permit such treatment for other individuals.
(n) Payment amounts
(1) In the case of medical assistance furnished under this subchapter for medicare cost-sharing respecting the furnishing of a service or item to a qualified medicare beneficiary, the State plan may provide payment in an amount with respect to the service or item that results in the sum of such payment amount and any amount of payment made under subchapter XVIII of this chapter with respect to the service or item exceeding the amount that is otherwise payable under the State plan for the item or service for eligible individuals who are not qualified medicare beneficiaries.
(2) In carrying out paragraph (1), a State is not required to provide any payment for any expenses incurred relating to payment for deductibles, coinsurance, or copayments for medicare cost-sharing to the extent that payment under subchapter XVIII of this chapter for the service would exceed the payment amount that otherwise would be made under the State plan under this subchapter for such service if provided to an eligible recipient other than a medicare beneficiary.
(3) In the case in which a State's payment for medicare cost-sharing for a qualified medicare beneficiary with respect to an item or service is reduced or eliminated through the application of paragraph (2)—
(A) for purposes of applying any limitation under subchapter XVIII of this chapter on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under subchapter XVIII of this chapter plus the amount of payment (if any) under the State plan shall be considered to be payment in full for the service;
(B) the beneficiary shall not have any legal liability to make payment to a provider or to an organization described in
(C) any lawful sanction that may be imposed upon a provider or such an organization for excess charges under this subchapter or subchapter XVIII of this chapter shall apply to the imposition of any charge imposed upon the individual in such case.
This paragraph shall not be construed as preventing payment of any medicare cost-sharing by a medicare supplemental policy or an employer retiree health plan on behalf of an individual.
(o) Certain benefits disregarded for purposes of determining post-eligibility contributions
Notwithstanding any provision of subsection (a) of this section to the contrary, a State plan under this subchapter shall provide that any supplemental security income benefits paid by reason of subparagraph (E) or (G) of
(1) is eligible for medical assistance under the plan, and
(2) is in a hospital, skilled nursing facility, or intermediate care facility at the time such benefits are paid,
will be disregarded for purposes of determining the amount of any post-eligibility contribution by the individual to the cost of the care and services provided by the hospital, skilled nursing facility, or intermediate care facility.
(p) Exclusion power of State; exclusion as prerequisite for medical assistance payments; "exclude" defined
(1) In addition to any other authority, a State may exclude any individual or entity for purposes of participating under the State plan under this subchapter for any reason for which the Secretary could exclude the individual or entity from participation in a program under subchapter XVIII of this chapter under
(2) In order for a State to receive payments for medical assistance under
(A) could be excluded under
(B) has, directly or indirectly, a substantial contractual relationship (as defined by the Secretary) with an individual or entity that is described in
(C) employs or contracts with any individual or entity that is excluded from participation under this subchapter under
(3) As used in this subsection, the term "exclude" includes the refusal to enter into or renew a participation agreement or the termination of such an agreement.
(q) Minimum monthly personal needs allowance deduction; "institutionalized individual or couple" defined
(1)(A) In order to meet the requirement of subsection (a)(50) of this section, the State plan must provide that, in the case of an institutionalized individual or couple described in subparagraph (B), in determining the amount of the individual's or couple's income to be applied monthly to payment for the cost of care in an institution, there shall be deducted from the monthly income (in addition to other allowances otherwise provided under the State plan) a monthly personal needs allowance—
(i) which is reasonable in amount for clothing and other personal needs of the individual (or couple) while in an institution, and
(ii) which is not less (and may be greater) than the minimum monthly personal needs allowance described in paragraph (2).
(B) In this subsection, the term "institutionalized individual or couple" means an individual or married couple—
(i) who is an inpatient (or who are inpatients) in a medical institution or nursing facility for which payments are made under this subchapter throughout a month, and
(ii) who is or are determined to be eligible for medical assistance under the State plan.
(2) The minimum monthly personal needs allowance described in this paragraph 12 is $30 for an institutionalized individual and $60 for an institutionalized couple (if both are aged, blind, or disabled, and their incomes are considered available to each other in determining eligibility).
(r) Disregarding payments for certain medical expenses by institutionalized individuals
(1)(A) For purposes of
(i) medicare and other health insurance premiums, deductibles, or coinsurance, and
(ii) necessary medical or remedial care recognized under State law but not covered under the State plan under this subchapter, subject to reasonable limits the State may establish on the amount of these expenses.
(B)(i) In the case of a veteran who does not have a spouse or a child, if the veteran—
(I) receives, after the veteran has been determined to be eligible for medical assistance under the State plan under this subchapter, a veteran's pension in excess of $90 per month, and
(II) resides in a State veterans home with respect to which the Secretary of Veterans Affairs makes per diem payments for nursing home care pursuant to
any such pension payment, including any payment made due to the need for aid and attendance, or for unreimbursed medical expenses, that is in excess of $90 per month shall be counted as income only for the purpose of applying such excess payment to the State veterans home's cost of providing nursing home care to the veteran.
(ii) The provisions of clause (i) shall apply with respect to a surviving spouse of a veteran who does not have a child in the same manner as they apply to a veteran described in such clause.
(2)(A) The methodology to be employed in determining income and resource eligibility for individuals under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10) (A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) of this section or under
(i) in the case of groups consisting of aged, blind, or disabled individuals, under the supplemental security income program under subchapter XVI of this chapter, or
(ii) in the case of other groups, under the State plan most closely categorically related.
(B) For purposes of this subsection and subsection (a)(10) of this section, methodology is considered to be "no more restrictive" if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.
(s) Adjustment in payment for hospital services furnished to low-income children under age of 6 years
In order to meet the requirements of subsection (a)(55) 13 of this section, the State plan must provide that payments to hospitals under the plan for inpatient hospital services furnished to infants who have not attained the age of 1 year, and to children who have not attained the age of 6 years and who receive such services in a disproportionate share hospital described in
(1) if made on a prospective basis (whether per diem, per case, or otherwise) provide for an outlier adjustment in payment amounts for medically necessary inpatient hospital services involving exceptionally high costs or exceptionally long lengths of stay,
(2) not be limited by the imposition of day limits with respect to the delivery of such services to such individuals, and
(3) not be limited by the imposition of dollar limits (other than such limits resulting from prospective payments as adjusted pursuant to paragraph (1)) with respect to the delivery of such services to any such individual who has not attained their first birthday (or in the case of such an individual who is an inpatient on his first birthday until such individual is discharged).
(t) Limitation on payments to States for expenditures attributable to taxes
Nothing in this subchapter (including
(u) Qualified COBRA continuation beneficiaries
(1) Individuals described in this paragraph are individuals—
(A) who are entitled to elect COBRA continuation coverage (as defined in paragraph (3)),
(B) whose income (as determined under
(C) whose resources (as determined under
(D) with respect to whose enrollment for COBRA continuation coverage the State has determined that the savings in expenditures under this subchapter resulting from such enrollment is likely to exceed the amount of payments for COBRA premiums made.
(2) For purposes of subsection (a)(10)(F) of this section and this subsection, the term "COBRA premiums" means the applicable premium imposed with respect to COBRA continuation coverage.
(3) In this subsection, the term "COBRA continuation coverage" means coverage under a group health plan provided by an employer with 75 or more employees provided pursuant to title XXII of the Public Health Service Act [
(4) Notwithstanding subsection (a)(17) of this section, for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(XI) of this section—
(A) the income standard to be applied is the income standard described in paragraph (1)(B), and
(B) except as provided in
Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(10)(B) or (a)(17) of this section, require or permit such treatment for other individuals.
(v) State agency disability and blindness determinations for medical assistance eligibility
A State plan may provide for the making of determinations of disability or blindness for the purpose of determining eligibility for medical assistance under the State plan by the single State agency or its designee, and make medical assistance available to individuals whom it finds to be blind or disabled and who are determined otherwise eligible for such assistance during the period of time prior to which a final determination of disability or blindness is made by the Social Security Administration with respect to such an individual. In making such determinations, the State must apply the definitions of disability and blindness found in
(w) Maintenance of written policies and procedures respecting advance directives
(1) For purposes of subsection (a)(57) of this section and
(A) to provide written information to each such individual concerning—
(i) an individual's rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives (as defined in paragraph (3)), and
(ii) the provider's or organization's written policies respecting the implementation of such rights;
(B) to document in the individual's medical record whether or not the individual has executed an advance directive;
(C) not to condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive;
(D) to ensure compliance with requirements of State law (whether statutory or as recognized by the courts of the State) respecting advance directives; and
(E) to provide (individually or with others) for education for staff and the community on issues concerning advance directives.
Subparagraph (C) shall not be construed as requiring the provision of care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A) shall be provided to an adult individual—
(A) in the case of a hospital, at the time of the individual's admission as an inpatient,
(B) in the case of a nursing facility, at the time of the individual's admission as a resident,
(C) in the case of a provider of home health care or personal care services, in advance of the individual coming under the care of the provider,
(D) in the case of a hospice program, at the time of initial receipt of hospice care by the individual from the program, and
(E) in the case of a medicaid managed care organization, at the time of enrollment of the individual with the organization.
(3) Nothing in this section shall be construed to prohibit the application of a State law which allows for an objection on the basis of conscience for any health care provider or any agent of such provider which as a matter of conscience cannot implement an advance directive.
(4) In this subsection, the term "advance directive" means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provision of such care when the individual is incapacitated.
(5) For construction relating to this subsection, see
(x) Physician identifier system; establishment
The Secretary shall establish a system, for implementation by not later than July 1, 1991, which provides for a unique identifier for each physician who furnishes services for which payment may be made under a State plan approved under this subchapter.
(y) Intermediate sanctions for psychiatric hospitals
(1) In addition to any other authority under State law, where a State determines that a psychiatric hospital which is certified for participation under its plan no longer meets the requirements for a psychiatric hospital (referred to in
(A) immediately jeopardize the health and safety of its patients, the State shall terminate the hospital's participation under the State plan; or
(B) do not immediately jeopardize the health and safety of its patients, the State may terminate the hospital's participation under the State plan, or provide that no payment will be made under the State plan with respect to any individual admitted to such hospital after the effective date of the finding, or both.
(2) Except as provided in paragraph (3), if a psychiatric hospital described in paragraph (1)(B) has not complied with the requirements for a psychiatric hospital under this subchapter—
(A) within 3 months after the date the hospital is found to be out of compliance with such requirements, the State shall provide that no payment will be made under the State plan with respect to any individual admitted to such hospital after the end of such 3-month period, or
(B) within 6 months after the date the hospital is found to be out of compliance with such requirements, no Federal financial participation shall be provided under
(3) The Secretary may continue payments, over a period of not longer than 6 months from the date the hospital is found to be out of compliance with such requirements, if—
(A) the State finds that it is more appropriate to take alternative action to assure compliance of the hospital with the requirements than to terminate the certification of the hospital,
(B) the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and
(C) the State agrees to repay to the Federal Government payments received under this paragraph if the corrective action is not taken in accordance with the approved plan and timetable.
(z) Optional coverage of TB-related services
(1) Individuals described in this paragraph are individuals not described in subsection (a)(10)(A)(i) of this section—
(A) who are infected with tuberculosis;
(B) whose income (as determined under the State plan under this subchapter with respect to disabled individuals) does not exceed the maximum amount of income a disabled individual described in subsection (a)(10)(A)(i) of this section may have and obtain medical assistance under the plan; and
(C) whose resources (as determined under the State plan under this subchapter with respect to disabled individuals) do not exceed the maximum amount of resources a disabled individual described in subsection (a)(10)(A)(i) of this section may have and obtain medical assistance under the plan.
(2) For purposes of subsection (a)(10) of this section, the term "TB-related services" means each of the following services relating to treatment of infection with tuberculosis:
(A) Prescribed drugs.
(B) Physicians' services and services described in
(C) Laboratory and X-ray services (including services to confirm the presence of infection).
(D) Clinic services and Federally-qualified health center services.
(E) Case management services (as defined in
(F) Services (other than room and board) designed to encourage completion of regimens of prescribed drugs by outpatients, including services to observe directly the intake of prescribed drugs.
(Aug. 14, 1935, ch. 531, title XIX, §1902, as added
Amendment of Section
References in Text
Parts A, D, and E of subchapter IV of this chapter, referred to in subsecs. (a), (c), (e)(1), (10), and (l)(3), are classified to sections 601 et seq., 651 et seq., and 670 et seq., respectively, of this title.
Parts A and B of subchapter XVIII of this chapter, referred to in subsec. (a)(10), (13)(B), are classified to sections 1395c et seq. and 1395j et seq., respectively, of this title.
The date of the enactment of section 211(a) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, referred to in subsec. (a)(10)(A)(i)(II), is the date of enactment of
Section 4611 of the Balanced Budget Act of 1997, referred to in subsec. (a)(10)(E)(iv)(II), is section 4611 of
Section 1383(a)(4)(A)(i) and (ii) of this title, referred to in subsec. (a)(20)(C), is a reference to section 1383(a)(4)(A)(i) and (ii) existing prior to the general revision of subchapter XVI of this chapter by
Part B of subchapter XI of this chapter, referred to in subsec. (d), is classified to
The Public Health Service Act, referred to in subsec. (u)(3), is act July 1, 1944, ch. 373,
The Internal Revenue Code of 1986, referred to in subsec. (u)(3), is classified generally to Title 26.
The Employee Retirement Income Security Act of 1974, referred to in subsec. (u)(3), is
Amendments
1999—Subsec. (a)(10)(A)(ii)(XIV).
Subsec. (a)(10)(A)(ii)(XV).
Subsec. (a)(10)(A)(ii)(XVI).
Subsec. (a)(10)(A)(ii)(XVII).
Subsec. (a)(10)(G).
Subsec. (a)(13)(C)(i).
Subsec. (a)(30)(A).
Subsec. (a)(30)(B)(ii).
Subsec. (a)(30)(C).
Subsec. (a)(60).
Subsec. (a)(64).
Subsec. (d).
Subsec. (j).
Subsec. (l)(1)(C).
Subsec. (l)(3).
Subsec. (l)(4)(B).
Subsec. (v).
1997—Subsec. (a).
Subsec. (a)(4)(C), (D).
Subsec. (a)(9)(C).
Subsec. (a)(10)(A)(i)(II).
Subsec. (a)(10)(A)(ii)(XIII).
Subsec. (a)(10)(A)(ii)(XIV).
Subsec. (a)(10)(E)(iv).
Subsec. (a)(13)(A).
Subsec. (a)(13)(B).
Subsec. (a)(13)(C).
"(i) one-half of the percentage increase (as measured over the same period of time, or, if necessary, as extrapolated retrospectively by the Secretary) in the Dodge Construction Systems Costs for Nursing Homes, applied in the aggregate with respect to those facilities which have undergone a change of ownership during the fiscal year, or
"(ii) one-half of the percentage increase (as measured over the same period of time) in the Consumer Price Index for All Urban Consumers (United States city average);".
Subsec. (a)(13)(D), (E).
Subsec. (a)(13)(F).
Subsec. (a)(23).
Subsec. (a)(23)(B).
Subsec. (a)(25)(A)(ii).
"(I) be integrated with, and be monitored as a part of the Secretary's review of, the State's mechanized claims processing and information retrieval system under
"(II) be subject to the provisions of
Subsec. (a)(25)(G) to (I).
Subsec. (a)(26).
"(A) with respect to each patient"
and struck out subpars. (B) and (C) which read as follows:
"(B) for periodic inspections to be made in all mental institutions within the State by one or more medical review teams (composed of physicians and other appropriate health and social service personnel) of the care being provided to each person receiving medical assistance, including (i) the adequacy of the services available to meet his current health needs and promote his maximum physical well-being, (ii) the necessity and desirability of his continued placement in the institution, and (iii) the feasibility of meeting his health care needs through alternative institutional or noninstitutional services; and
"(C) for full reports to the State agency by each medical review team of the findings of each inspection under subparagraph (B), together with any recommendations;".
Subsec. (a)(31).
"(A) with respect to each patient"
and struck out subpars. (B) and (C) which read as follows:
"(B) with respect to each intermediate care facility for the mentally retarded within the State, for periodic onsite inspections of the care being provided to each person receiving medical assistance, by one or more independent professional review teams (composed of a physician or registered nurse and other appropriate health and social service personnel), including with respect to each such person (i) the adequacy of the services available to meet his current health needs and promote his maximum physical well-being, (ii) the necessity and desirability of his continued placement in the facility, and (iii) the feasibility of meeting his health care needs through alternative institutional or noninstitutional services; and
"(C) for full reports to the State agency by each independent professional review team of the findings of each inspection under subparagraph (B), together with any recommendations;".
Subsec. (a)(47).
Subsec. (a)(57).
Subsec. (a)(63).
Subsec. (a)(64).
Subsec. (a)(65).
Subsec. (e)(2)(A).
Subsec. (e)(12).
Subsec. (i)(1)(B).
Subsec. (j).
Subsec. (l)(1)(D).
Subsec. (n).
Subsec. (p)(2).
Subsec. (r)(1).
Subsec. (w)(2)(E).
Subsec. (w)(5).
1996—Subsec. (a).
Subsec. (a)(25)(A)(i).
Subsec. (a)(59).
Subsec. (a)(63).
Subsec. (c).
"(1) the State has in effect, under its plan established under part A of subchapter IV of this chapter, payment levels that are less than the payment levels in effect under such plan on May 1, 1988; or
"(2) the State requires individuals described in subsection (l)(1) of this section to apply for benefits under such part as a condition of applying for, or receiving, medical assistance under this subchapter."
Subsec. (e)(1)(B).
Subsec. (j).
1994—Subsec. (a)(10)(A)(ii)(XI).
Subsec. (a)(11)(C), (53)(A).
1993—Subsec. (a)(10).
Subsec. (a)(10)(A)(ii)(XII).
Subsec. (a)(1)(C)(iv).
Subsec. (a)(11).
Subsec. (a)(18).
Subsec. (a)(25)(A).
Subsec. (a)(25)(A)(i).
Subsec. (a)(25)(H).
Subsec. (a)(25)(I).
Subsec. (a)(32)(D).
Subsec. (a)(43)(A).
Subsec. (a)(51).
Subsec. (a)(54).
"(A) provide that, any formulary or similar restriction (except as provided in
"(B) comply with the reporting requirements of
Subsec. (a)(55).
Subsec. (a)(56).
Subsec. (a)(57).
Subsec. (a)(58).
Subsec. (a)(59).
Subsec. (a)(60).
Subsec. (a)(61).
Subsec. (a)(62).
Subsec. (j).
Subsec. (k).
"(k)(1) In the case of a medicaid qualifying trust (described in paragraph (2)), the amounts from the trust deemed available to a grantor, for purposes of subsection (a)(17) of this section, is the maximum amount of payments that may be permitted under the terms of the trust to be distributed to the grantor, assuming the full exercise of discretion by the trustee or trustees for the distribution of the maximum amount to the grantor. For purposes of the previous sentence, the term 'grantor' means the individual referred to in paragraph (2).
"(2) For purposes of this subsection, a 'medicaid qualifying trust' is a trust, or similar legal device, established (other than by will) by an individual (or an individual's spouse) under which the individual may be the beneficiary of all or part of the payments from the trust and the distribution of such payments is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the individual.
"(3) This subsection shall apply without regard to—
"(A) whether or not the medicaid qualifying trust is irrevocable or is established for purposes other than to enable a grantor to qualify for medical assistance under this subchapter; or
"(B) whether or not the discretion described in paragraph (2) is actually exercised.
"(4) The State may waive the application of this subsection with respect to an individual where the State determines that such application would work an undue hardship."
Subsec. (z).
1991—Subsec. (h).
Subsec. (t).
1990—Subsec. (a)(10).
Subsec. (a)(10)(A)(i)(VII).
Subsec. (a)(10)(A)(ii)(IX).
Subsec. (a)(10)(C)(iv).
Subsec. (a)(10)(E)(iii).
Subsec. (a)(10)(F).
Subsec. (a)(13)(A).
Subsec. (a)(13)(E).
Subsec. (a)(13)(F).
Subsec. (a)(17).
Subsec. (a)(25)(G).
Subsec. (a)(32)(C).
Subsec. (a)(41).
Subsec. (a)(54).
Subsec. (a)(55).
Subsec. (a)(57).
Subsec. (a)(58).
Subsec. (e)(2)(A).
Subsec. (e)(4).
Subsec. (e)(6).
Subsec. (e)(11).
Subsec. (h).
Subsec. (j).
Subsec. (l)(1)(C).
Subsec. (l)(1)(D).
Subsec. (l)(2)(C).
Subsec. (l)(3).
Subsec. (l)(4)(A).
Subsec. (l)(4)(B).
Subsec. (m)(1)(B).
Subsec. (m)(2)(C).
Subsec. (r)(1).
Subsec. (r)(2)(A).
Subsec. (s).
Subsec. (t).
Subsec. (u).
Subsec. (v).
Subsec. (w).
Subsec. (x).
Subsec. (y).
1989—Subsec. (a)(9)(C).
Subsec.(a)(10)(A).
Subsec. (a)(10)(A)(i)(VI).
Subsec. (a)(10)(A)(ii)(IX).
Subsec. (a)(10)(E).
Subsec. (a)(11)(C).
Subsec. (a)(13)(D).
Subsec. (a)(13)(E).
Subsec. (a)(30)(A).
Subsec. (a)(43)(A).
Subsec. (a)(43)(D).
Subsec. (a)(53).
Subsec. (e)(7).
Subsec. (f).
Subsec. (l)(1)(C), (D).
Subsec. (l)(2)(A)(ii)(II).
Subsec. (l)(2)(A)(iv).
Subsec. (l)(2)(B), (C).
Subsec. (l)(3).
Subsec. (l)(3)(C).
Subsec. (l)(4)(A).
Subsec. (l)(4)(B).
Subsec. (p)(2)(C).
Subsec. (r)(2)(A).
1988—Subsec. (a)(9)(C).
Subsec. (a)(10).
Subsec. (a)(10)(A)(i)(I).
Subsec. (a)(10)(A)(i)(IV).
Subsec. (a)(10)(A)(i)(V).
Subsec. (a)(10)(A)(ii)(VI).
Subsec. (a)(10)(A)(ii)(IX).
Subsec. (a)(10)(A)(ii)(X).
Subsec. (a)(10)(A)(ii)(XI).
Subsec. (a)(10)(C)(i)(III).
Subsec. (a)(10)(E).
Subsec. (a)(13)(A).
Subsec. (a)(13)(C).
Subsec. (a)(13)(D).
Subsec. (a)(15).
Subsec. (a)(17).
Subsec. (a)(28)(D)(i).
Subsec. (a)(33)(B).
Subsec. (a)(44)(A).
Subsec. (a)(50).
Subsec. (a)(51).
Subsec. (a)(52).
Subsec. (c).
Subsec. (d).
Subsec. (e)(1).
Subsec. (e)(2)(A).
Subsec. (e)(6).
Subsec. (e)(7).
Subsec. (e)(10).
Subsec. (f).
Subsec. (i).
Subsec. (l)(1).
Subsec. (l)(1)(C).
Subsec. (l)(2)(A).
Subsec. (l)(2)(A)(ii).
Subsec. (l)(2)(A)(iii).
Subsec. (l)(3).
Subsec. (l)(4).
"(A) A State plan may not elect the option of furnishing medical assistance to individuals described in subsection (a)(10)(A)(ii)(IX) of this section unless the State has in effect, under its plan established under part A of subchapter IV of this chapter, payment levels that are not less than the payment levels in effect under its plan on July 1, 1987.
"(B)(i) A State may not elect, under subsection (a)(10)(A)(ii)(IX) of this section, to cover only individuals described in paragraph (1)(A) or to cover only individuals described in paragraph (1)(B).
"(ii) A State may not elect, under subsection (a)(10)(A)(ii)(IX) of this section, to cover individuals described in subparagraph (C) of paragraph (1) unless the State has elected, under such subsection, to cover individuals described in the preceding subparagraphs of such paragraph.
"(C) A State plan may not provide, in its election of the option of furnishing medical assistance to individuals described in paragraph (1), that such individuals must apply for benefits under part A of subchapter IV of this chapter as a condition of applying for, or receiving, medical assistance under this subchapter."
Subsec. (m)(3).
Subsec. (m)(4).
Subsec. (m)(4)(A).
Subsec. (m)(5).
Subsec. (o).
Subsec. (q).
Subsec. (r).
Subsec. (r)(2)(A).
1987—Subsec. (a)(9)(C).
Subsec. (a)(10).
Subsec. (a)(10)(A)(ii)(VI).
Subsec. (a)(10)(A)(ii)(IX), (X).
Subsec. (a)(10)(A)(ii)(XI).
Subsec. (a)(10)(C)(iv).
Subsec. (a)(10)(D).
Subsec. (a)(13)(A).
Subsec. (a)(13)(C).
Subsec. (a)(13)(D).
Subsec. (a)(17).
Subsec. (a)(23).
Subsec. (a)(28).
Subsec. (a)(30)(B)(i), (ii).
Subsec. (a)(30)(C).
Subsec. (a)(31).
Subsec. (a)(33)(B).
Subsec. (a)(38).
Subsec. (a)(39).
Subsec. (a)(42).
Subsec. (a)(44).
Subsec. (a)(44)(A).
Subsec. (a)(44)(B).
Subsec. (a)(46).
Subsec. (a)(47).
Subsec. (a)(48).
Subsec. (a)(49).
Subsec. (a)(50).
Subsec. (d).
Subsec. (e)(2)(A).
Subsec. (e)(3)(B)(i).
Subsec. (e)(3)(C).
Subsec. (e)(4).
Subsec. (e)(5).
Subsec. (e)(7).
Subsec. (e)(9).
Subsec. (e)(9)(A)(iii).
Subsec. (e)(9)(B).
Subsec. (f).
Subsec. (i).
Subsec. (j).
Subsec. (l).
Subsec. (l)(1).
Subsec. (l)(1)(C).
Subsec. (l)(1)(D) to (F).
Subsec. (l)(2).
Subsec. (l)(3)(C).
Subsec. (l)(3)(D).
Subsec. (l)(3)(E).
Subsec. (l)(4)(A).
Subsec. (l)(4)(B)(ii).
Subsec. (l)(4)(C).
Subsec. (m)(2)(A).
Subsec. (o).
Subsec. (p).
Subsec. (q).
1986—Subsec. (a).
Subsec. (a)(9)(C).
Subsec. (a)(10).
Subsec. (a)(10)(A)(i)(I).
Subsec. (a)(10)(A)(i)(II).
Subsec. (a)(10)(A)(ii)(V).
Subsec. (a)(10)(A)(ii)(VII).
Subsec. (a)(10)(A)(ii)(VIII).
Subsec. (a)(10)(A)(ii)(IX).
Subsec. (a)(10)(A)(ii)(X).
Subsec. (a)(10)(C).
Subsec. (a)(10)(C)(iv).
Subsec. (a)(10)(E).
Subsec. (a)(13)(B).
Subsec. (a)(13)(C).
Subsec. (a)(13)(D).
Subsec. (a)(13)(E).
Subsec. (a)(15).
Subsec. (a)(17).
Subsec. (a)(25).
Subsec. (a)(30)(C).
Subsec. (a)(47).
Subsec. (b)(2).
Subsec. (d).
Subsec. (e)(2)(A).
Subsec. (e)(2)(B).
Subsec. (e)(5).
Subsec. (e)(6), (7).
Subsec. (e)(8).
Subsec. (e)(9).
Subsec. (f).
Subsec. (g).
Subsec. (h).
Subsec. (j).
Subsec. (k).
Subsec. (l).
Subsec. (m).
Subsec. (m)(3).
Subsec. (m)(5).
Subsec. (n).
1984—Subsec. (a)(9)(C).
Subsec. (a)(10)(A).
Subsec. (a)(10)(A)(i).
Subsec. (a)(10(A)(i)(I).
Subsec. (a)(13)(A).
Subsec. (a)(13)(B), (C).
Subsec. (a)(20)(B).
Subsec. (a)(20)(C).
Subsec. (a)(26).
Subsec. (a)(26)(B)(ii).
Subsec. (a)(26)(C).
Subsec. (a)(28).
Subsec. (a)(30).
Subsec. (a)(31).
Subsec. (a)(33)(A).
Subsec. (a)(42).
Subsec. (a)(43).
Subsec. (a)(44).
Subsec. (a)(45).
Subsec. (a)(46).
Subsec. (a), foll. par. (46).
Subsec. (e)(4).
Subsec. (f).
1982—Subsec. (a)(10)(A).
Subsec. (a)(10)(C), (D).
Subsec. (a)(10)(C)(i).
Subsec. (a)(10)(C)(ii)(I).
Subsec. (a)(10).
Subsec. (a)(14).
Subsec. (a)(18).
Subsec. (a).
Subsec. (b)(2) to (4).
Subsec. (d).
Subsec. (e)(3).
Subsec. (j).
1981—Subsec. (a)(9)(C).
Subsec. (a)(10)(A).
Subsec. (a)(10)(B).
Subsec. (a)(10)(C).
Subsec. (a)(10)(D).
Subsec. (a)(11).
Subsec. (a)(13)(A).
Subsec. (a)(13)(B).
Subsec. (a)(13)(C).
Subsec. (a)(13)(D).
Subsec. (a)(13)(E), (F).
Subsec. (a)(20)(D).
Subsec. (a)(23).
Subsec. (a)(25)(C).
Subsec. (a)(30).
Subsec. (a)(39).
Subsec. (a)(44).
Subsec. (b)(2).
Subsec. (d).
Subsec. (e).
Subsec. (h).
1980—Subsec. (a)(13)(B).
Subsec. (a)(13)(C)(i).
Subsec. (a)(13)(C)(ii).
Subsec. (a)(13)(D).
Subsec. (a)(13)(D)(i).
Subsec. (a)(13)(E).
Subsec. (a)(14)(A)(i).
Subsec. (a)(33)(B).
Subsec. (a)(35).
Subsec. (a)(39).
Subsec. (a)(41).
Subsec. (a)(42).
Subsec. (a)(43).
Subsec. (g).
Subsec. (h).
Subsec. (i).
Subsec. (j).
1978—Subsec. (a)(4)(C).
1977—Subsec. (a)(13)(F).
Subsec. (a)(23).
Subsec. (a)(26).
Subsec. (a)(27)(B).
Subsec. (a)(32).
Subsec. (a)(35).
Subsec. (a)(37).
Subsec. (a)(38).
Subsec. (a)(39).
Subsec. (a)(40).
Subsec. (a), foll. par. (40).
Subsec. (g).
1976—Subsec. (g).
1975—Subsec. (a).
Subsec. (a)(23).
Subsec. (g).
1974—Subsec. (a)(14)(B)(i).
1973—Subsec. (a)(5).
Subsec. (a)(10).
Subsec. (a)(13)(B).
Subsec. (a)(13)(C)(ii)(I).
Subsec. (a)(14)(A).
Subsec. (a)(14)(B).
Subsec. (a)(17).
Subsec. (a)(18).
Subsec. (a)(20)(C).
Subsec. (a)(21), (24).
Subsec. (a)(26)(B).
Subsec. (a)(33)(A).
Subsec. (a)(34).
Subsec. (a)(35)(A).
Subsec. (a)(35) to (37).
Subsec. (e).
Subsec. (f).
1972—Subsec. (a).
Subsec. (a)(9).
Subsec. (a)(13)(A)(ii), (C).
Subsec. (a)(13)(D).
Subsec. (a)(13)(E).
Subsec. (a)(14).
Subsec. (a)(23).
Subsec. (a)(26).
Subsec. (a)(28).
Subsec. (a)(30).
Subsec. (a)(31)(A).
Subsec. (a)(32).
Subsec. (a)(33).
Subsec. (a)(34).
Subsec. (a)(35).
Subsec. (a)(37).
Subsec. (d).
Subsec. (e).
Subsec. (f).
1971—Subsec. (a)(31).
1969—Subsec. (c).
Subsec. (d).
1968—Subsec. (a)(2).
Subsec. (a)(4).
Subsec. (a)(10).
Subsec. (a)(11).
Subsec. (a)(13).
Subsec. (a)(13)(A).
Subsec. (a)(14)(A).
Subsec. (a)(14)(B).
Subsec. (a)(15).
Subsec. (a)(17).
Subsec. (a)(23) to (30).
Subsec. (b)(2).
Subsec. (c).
Effective Date of 1999 Amendments
Amendment by section 205(c) of
Amendment by section 206(b) of
"(1) The amendment made by subsection (a)(1) [amending this section] applies to expenditures made on and after the date of the enactment of this Act [Nov. 29, 1999].
"(2) The amendments made by subsections (a)(2) and (b) [amending this section and
Effective Date of 1997 Amendments
Amendment by section 4106(c) of
Amendment by section 4454(b)(1) of
Amendment by section 4701(b)(2)(A)(i)–(iv), (d)(1) of
Amendment by section 4702(b)(2) of
Amendment by section 4709 of
Section 4711(d) of
Section 4712(b)(3) of
Section 4714(c) of
Section 4715(b) of
Section 4724(c)(2) of
Section 4724(g)(2) of
Section 4731(c) of
Section 4741(c) of
Section 4751(c) of
Section 4752(b) of
Section 4753(c) of
Section 4911(c) of
Section 4912(c) of
Section 4913(b) of
Amendment by
Effective Date of 1996 Amendments
Section 1(a)(2) of
Amendment by sections 108(k) and 114(b)–(d)(1), of
Section 913 of
Effective Date of 1994 Amendments
Amendment by
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13581(b)(2) of
Section 13601(c) of
Amendment by section 13602(c) of
Section 13603(f) of
Amendment by section 13611(d)(1) of
Section 13622(d) of
"(1) Except as provided in paragraph (2), the amendments made by subsections (a)(1), (b), and (c) [amending this section] shall apply to calendar quarters beginning on or after October 1, 1993, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by subsections (a) and (b) [amending this section and
"(3) The amendment made by subsection (a)(2) [amending
Amendment by section 13623(a) of
Section 13625(b) of
Section 13631(e)(2) of
Section 13631(f)(3) of
"(A) Except as provided in subparagraph (B), the amendments made by this subsection [amending this section and
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this subsection, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Aug. 10, 1993]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 13631(i) of
Effective Date of 1991 Amendment
Section 2(c)(1) of
Section 3(e)(1) of
Effective Date of 1990 Amendment
Section 4402(e) of
"(1) The amendments made by this section [enacting
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation authorizing or appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by subsection (a) [enacting
Section 4501(f) of
Section 4601(b) of
"(1) The amendments made by this subsection [probably should be "section", which amended this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation authorizing or appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this subsection [section], the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Nov. 5, 1990]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 4602(b) of
Section 4603(b) of
"(1)
"(2)
Section 4604(d) of
"(1) The amendments made by this subsection [probably should be "section", which amended this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation authorizing or appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this subsection [section], the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Nov. 5, 1990]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Amendment by section 4701(b)(1) of
Section 4704(f) of
Section 4708(b) of
Section 4711(e) of
"(1) Except as provided in this subsection, the amendments made by this section [enacting
"(2)(A) The amendments made by subsection (c)(1) [amending this section] shall apply to home and community care furnished on or after July 1, 1991, or, if later, 30 days after the date of publication of interim regulations under section 1929(k)(1) [
"(B) The amendment made by subsection (c)(2) [amending
Section 4713(c) of
Section 4715(b) of
Section 4732(e) of
Section 4751(c) of
Section 4752(c)(2) of
Section 4754(b) of
Section 4755(c)(1) of
Section 4801(e)(11) of
Section 4801(e)(19) of
Effective Date of 1989 Amendments
Amendment by section 6115(c) of
Section 6401(c) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Dec. 19, 1989]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 6402(c), formerly §6402(d), of
Section 6403(e) of
Section 6404(d) of
"(1) The amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Dec. 19, 1989]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 6405(c) of
Section 6406(b) of
Section 6408(c)(2) of
Section 6408(d)(5) of
"(A) The amendments made by this subsection [amending this section and
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this subsection, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Dec. 19, 1989]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 6411(a)(2) of
Amendment by section 6411(d)(3)(B) of
Section 6411(e)(4) of
"(A)
"(B)
Amendment by
Effective Date of 1988 Amendments
Section 8434(c) of
Amendment by section 202(c)(4) of
Section 303(f) of
"(1) The amendments made by this section [enacting
"(2) The amendment made by subsection (b)(3) [amending
"(3) The amendment made by subsection (d) [amending this section] shall become effective on the effective date of section 402(a)(43) of the Social Security Act, as inserted by section 403(a) of this Act [the first day of the first calendar quarter to begin one year or more after Oct. 13, 1988, see section 403(b) of
"(4) The amendment made by subsection (e) [amending provisions formerly set out as a note under
Section 401(g) of
"(1) Except as provided in paragraph (2), and in section 1905(m)(2) of the Social Security Act [
"(2) The amendments made by this section shall not become effective with respect to Puerto Rico, American Samoa, Guam, or the Virgin Islands, until the date of the repeal of the limitations contained in section 1108(a) of the Social Security Act [
[Section 234(b) of
Amendment by section 608(d)(14)(I), (15)(A), (B), (16)(C), (27)(F)–(H), (28) of
Amendment by section 204(d)(3) of
Amendment by section 301(e)(2) of
Section 301(h) of
"(1) The amendments made by this section [amending this section and
"(A) monthly premiums under title XVIII of such Act [subchapter XVIII of this chapter] for months beginning with January 1989, and
"(B) items and services furnished on and after January 1, 1989.
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first session of the State legislature that begins after the date of the enactment of this Act [July 1, 1988]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 302(f) of
"(1)
"(2)
"(3)
Amendment by section 303(d) of
Amendment by section 303(e)(1), (5) of
Subsec. (a)(51)(A), as enacted by section 303(e)(2)–(4) of
Subsec. (a)(51)(B), as enacted by section 303(e)(2)–(4) of
Except as specifically provided in section 411 of
Effective Date of 1987 Amendments
For effective date of amendment by section 4072(d) of
Section 4101(a)(3) of
Section 4101(b)(3) of
Amendment by section 4101(c)(2) of
Section 4101(e)(6) of
"(A) The amendment made by paragraph (1) [amending this section] shall become effective on the date of enactment of this Act [Dec. 22, 1987].
"(B) The amendments made by paragraphs (2) and (3) [amending this section] shall be effective as if they had been included in the enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985 [
"(C) The amendment made by paragraph (4) [amending this section] shall apply to elections made on or after the enactment of this Act.
"(D) The amendment made by paragraph (5) [amending this section] shall apply as if included in the enactment of section 9401 of the Omnibus Budget Reconciliation Act of 1986 [
Section 4113(c)(3) of
Section 4118(c)(2) of
Section 4118(h)(3), formerly §4118(h)(2), of
Section 4118(m)(2) of
Amendments by sections 4211(b)(1), (h)(1)–(5), 4212(d)(2), (3), (e)(1) of
Section 4212(d)(4) of
"(A) the State has specified the resident assessment instrument under section 1919(e)(5) of the Social Security Act [
"(B) the State has begun conducting surveys under section 1919(g)(2) of such Act."
Amendment by section 4213(b)(1) of
Section 4218(b) of
Amendment by section 9115(b) of
Section 9119(d)(2) of
Amendment by sections 5(a) and 8(f) of
Amendment by section 7 of
Effective Date of 1986 Amendments
Section 10(b) of
"(1) Except as provided in paragraph (2), the amendments made by sections 3, 4, 5, 6, and 7 [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the requirements imposed by the amendments made by section 3(b) [amending this section] and section 7 of this Act [amending this section and
Section 11005(c)(2) of
Amendment by
Amendment by section 9320(h)(3) of
Section 9401(f) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) Subparagraph (C) of section 1902(l)(1) of the Social Security Act [subsec. (l)(1)(C) of this section], as added by subsection (b) of this section, shall apply to medical assistance furnished in calendar quarters beginning on or after October 1, 1987.
"(3) An amendment made by this section shall become effective as provided in paragraph (1) or (2) without regard to whether or not final regulations to carry out such amendment have been promulgated by the applicable date."
Section 9402(c) of
Section 9403(h) of
Section 9404(c) of
"(1) The amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Oct. 21, 1986]."
Section 9406(c) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendment made in subsection (b) [amending this section], the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [Oct. 21, 1986]."
Section 9407(d) of
Section 9408(d) of
Section 9431(c) of
Section 9433(b) of
Section 9435(f) of
Section 9501(d)(2), (3) of
"(2)
"(3)
Section 9503(g) of
"(1) Except as otherwise provided, the amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act.
"(3) No penalty may be applied against any State for a violation of section 1902(a)(25) of the Social Security Act [subsec. (a)(25) of this section] occurring prior to the effective date of the amendments made by this section.
"(4) The amendment made by subsection (c) [enacting provisions set out below] shall become effective on the date of the enactment of this Act [Apr. 7, 1986]."
Section 9505(e) of
Section 9506(b), (c) of
"(b)
"(c)
Section 9509(b) of
"(1) Except as provided in paragraphs (2) and (3), the amendments made by this section [amending this section and enacting provisions set out below] shall apply to medical assistance furnished on or after October 1, 1985, but only with respect to changes of ownership occurring on or after such date.
"(2) The amendments made by this section shall not apply with respect to a change of ownership pursuant to an enforceable agreement entered into prior to October 1, 1985.
"(3) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet the requirements imposed by the amendments made by this section before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [Apr. 7, 1986]."
Section 9510(b) of
Section 9529(a)(2) of
Section 9529(b)(3) of
Amendment by section 12305(b)(3) of
Effective Date of 1984 Amendments
Amendment by
Amendment by section 2303(g)(1) of
Section 2314(c)(3) of
"(A) Except as provided in subparagraph (B), the amendments made by subsection (b) [amending this section] shall apply to medical assistance furnished on or after October 1, 1984.
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirement imposed by the amendments made by this section [amending this section and
Amendment by section 2335(e) of
Section 2361(d) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [July 18, 1984]."
Section 2362(b) of
Amendment by section 2363(a)(1) of
Section 2367(c) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [July 18, 1984]."
Section 2368(c) of
Amendment by section 2651(c) of
Effective Date of 1982 Amendment
Amendment by section 131(a), (c) of
Amendment by section 132(a), (c) of
Section 134(b) of
Amendment by section 136(d) of
Section 137(d) of
"(1) Except as otherwise provided in this section, any amendment to the Omnibus Budget Reconciliation Act of 1981 [
"(2) Except as otherwise provided in this section, any amendment to the Social Security Act [this chapter] made by the preceding provisions of this section [amending this section and
Amendment by section 146(a) of
Effective Date of 1981 Amendment
Section 2113(o) of
Section 2171(c) of
Section 2172(c) of
Section 2173(b)(2) of
Section 2174(c) of
Section 2175(d)(2) of
"(A) The amendments made by paragraph (1) [amending this section] shall (except as provided under subparagraph (B)) be effective with respect to payments under title XIX of the Social Security Act [this subchapter] for calendar quarters beginning on or after October 1, 1981.
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirement imposed by the amendment made by paragraph (1)(C), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar year beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [Aug. 13, 1981]."
Section 2178(c) of
Section 2181(b) of
For effective date, savings, and transitional provisions relating to amendment by section 2193(c)(9) of
Effective Date of 1980 Amendment
Amendment by section 902(b) of
Section 914(b)(2) of
"(A) The amendments made by paragraph (1) [amending this section] shall (except as provided under subparagraph (B)) apply to cost reporting periods, beginning on or after April 1, 1981, of an entity providing services under a State plan approved under title XIX of the Social Security Act [this subchapter]."
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by paragraph (1), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act."
Section 918(b)(2) of
"(A) The amendments made by paragraph (1) [enacting this section] shall (except as otherwise provided in subparagraph (B)) apply to medical assistance provided, under a State plan approved under title XIX of the Social Security Act [this subchapter], on and after the first day of the first calendar quarter that begins more than six months after the date of the enactment of this Act [Dec. 5, 1980].
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by paragraph (1), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act."
Section 962(b) of
Section 965(c) of
"(1) The amendments made by this section [amending this section and
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act."
Effective Date of 1978 Amendment
Section 14(a)(2) of
"(A) Except as provided in subparagraph (B), the amendments made by paragraph (1) [amending this section] shall take effect one hundred and eighty days after the date of the enactment of this Act [Nov. 1, 1978].
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary determines requires State legislation in order for the plan to meet the requirement added by the amendments made by paragraph (1), such amendments shall not apply with respect to such State plan before ninety days after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act."
Effective Date of 1977 Amendments
Amendment by
Amendment by section 2(a)(3) of
Section 2(b)(2) of
Amendment by section 3(c)(1) of
Section 7(e)(2) of
Section 19(c)(2) of
"(A) The amendments made by subsection (b) [amending this section and
"(B) The amendments made by subsection (b) [amending this section and
"(C) Except as provided in subparagraphs (A) and (B), the amendments made by subsection (b)(2) [amending this section] shall apply, with respect to State plans approved under title XIX of the Social Security Act [this subchapter], on and after October 1, 1977."
Amendment by section 20(b) of
Effective Date of 1976 Amendment
Section 2 of
Effective Date of 1975 Amendment
Section 111(c) of
Effective Date of 1974 Amendment
Section 9(b) of
Effective Date of 1973 Amendment
Section 13(d) of
Section 18(z–3)(4) of
Effective Date of 1972 Amendment
Section 208(b) of
Section 209(b)(2) of
Section 232(c) of
Amendment by section 236(b) of
Section 237(d)(2) of
Section 239(d) of
Amendment by section 246(a) of
Section 255(b) of
Section 268(c) of
Amendment by section 299D(b) of
Effective Date of 1971 Amendment
Section 4(d) of
Effective Date of 1968 Amendment
Amendment by section 210(a)(6) of
Section 223(b) of
Section 224(b) of
Section 224(c)(2) of
Section 227(b) of
Section 229(b) of
Section 234(b) of
Section 235(b) of
Enactment by section 236(a) of
Section 237 of
Section 238 of
Construction of 1999 Amendment
"(1) the amendments made by that Act [see Tables for classification] shall be executed as if this Act [see Short Title of 1999 Amendment note under
"(2) with respect to subsection (a)(1)(A) of this section [amending this section], any reference to subclause (XIII) is deemed a reference to subclause (XV);
"(3) with respect to subsection (a)(1)(B) of this section [amending this section], any reference to subclause (XIV) is deemed a reference to subclause (XVI);
"(4) [Amended this section.]
"(5) [Amended
Transfer of Functions
Functions, powers, and duties of Secretary of Health and Human Services under subsec. (a)(4)(A) of this section, insofar as relates to the prescription of personnel standards on a merit basis, transferred to Office of Personnel Management, see
GAO Reports
"(1) the extent to which higher health care costs for individuals with disabilities at higher income levels deter employment or progress in employment;
"(2) whether such individuals have health insurance coverage or could benefit from the State option established under such amendments to provide a medicaid buy-in; and
"(3) how the States are exercising such option, including—
"(A) how such States are exercising the flexibility afforded them with regard to income disregards;
"(B) what income and premium levels have been set;
"(C) the degree to which States are subsidizing premiums above the dollar amount specified in section 1916(g)(2) of the Social Security Act (
"(D) the extent to which there exists any crowd-out effect."
Demonstration of Coverage Under the Medicaid Program of Workers With Potentially Severe Disabilities
"(a)
"(1) that provided under section 1905(a) of the Social Security Act (
"(2) in the case of a State that has not elected to provide medical assistance under that section to such individuals, such medical assistance as the Secretary determines is an appropriate equivalent to the medical assistance described in paragraph (1).
"(b)
"(1)
"(A) is at least 16, but less than 65, years of age;
"(B) has a specific physical or mental impairment that, as defined by the State under the demonstration project, is reasonably expected, but for the receipt of items and services described in section 1905(a) of the Social Security Act (
"(C) is employed (as defined in paragraph (2)).
"(2)
"(A) is earning at least the applicable minimum wage requirement under section 6 of the Fair Labor Standards Act (
"(B) is engaged in a work effort that meets substantial and reasonable threshold criteria for hours of work, wages, or other measures, as defined under the demonstration project and approved by the Secretary.
"(c)
"(1)
"(2)
"(A)
"(B)
"(3)
"(A)
"(i)
"(I) $42,000,000 for each of fiscal years 2001 through 2004; and
"(II) $41,000,000 for each of fiscal years 2005 and 2006.
"(ii)
"(B)
"(i) the aggregate amount of payments made by the Secretary to States under this section exceed $250,000,000;
"(ii) the aggregate amount of payments made by the Secretary to States for administrative expenses relating to annual reports required under subsection (d) exceed $2,000,000 of such $250,000,000; or
"(iii) payments be provided by the Secretary for a fiscal year after fiscal year 2009.
"(C)
"(D)
"(E)
"(d)
"(1) the total population of workers with potentially severe disabilities served by the demonstration project; and
"(2) each population of such workers with a specific physical or mental impairment described in subsection (b)(1)(B) served by such project.
"(e)
"(f)
Medical Assistance Payments for Eligible PACE Program Enrollees
Study and Report by Secretary of Health and Human Services
Section 4711(b) of
"(1)
"(2)
Dual Eligibles; Monitoring Payments
Section 4724(e) of
Extension of Effective Date for State Law Amendment
Section 4759 of title IV of
References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996
For provisions that certain references to provisions of part A (§601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see
Demonstration Projects To Study Effect of Allowing States To Extend Medicaid Coverage to Certain Low-Income Families Not Otherwise Qualified To Receive Medicaid Benefits
Section 4745 of
"(a)
"(1)
"(B) In entering into agreements with States under this section the Secretary shall provide that at least 1 and no more than 2 of the projects are conducted on a substate basis.
"(2)
"(i) the project can reasonably be expected to improve access to health insurance coverage for the uninsured;
"(ii) with respect to projects for which the statewideness requirement has not been waived, the State provides, under its plan under title XIX of the Social Security Act [this subchapter], for eligibility for medical assistance for all individuals described in subparagraphs (A), (B), (C), and (D) of paragraph (1) of section 1902(l) of such Act [subsec. (l)(1)(A), (B), (C), (D) of this section] (based on the State's election of certain eligibility options the highest income standards and, based on the State's waiver of the application of any resource standard);
"(iii) eligibility for benefits under the project is limited to individuals in families with income below 150 percent of the income official poverty line and who are not individuals receiving benefits under title XIX of the Social Security Act;
"(iv) if the Secretary determines that it is cost-effective for the project to utilize employer coverage (as described in section 1925(b)(4)(D) of the Social Security Act [
"(v) the project provides for coverage of benefits consistent with subsection (b); and
"(vi) the project only imposes premiums, coinsurance, and other cost-sharing consistent with subsection (c).
"(B) The Secretary may waive the requirements of clause (ii) of this paragraph [probably means subparagraph (A)] with respect to those projects described in subparagraph (B) of paragraph (1).
"(3)
"(4)
"(5)
"(A)
"(B)
"(b)
"(1)
"(2)
"(A)
"(B)
"(3)
"(c)
"(1)
"(2)
"(3)
"(d)
"(e)
"(1)
"(B) Of the amounts appropriated under subparagraph (A), the Secretary shall provide that no more than one-third of such amounts shall be used to carry out the projects described in paragraph (1)(B) of subsection (a) (for which the statewideness requirement has been waived).
"(2)
"(3)
"(f)
"(1)
"(A) access to, and costs of, health care,
"(B) private health care insurance coverage, and
"(C) premiums and cost-sharing.
"(2)
"(g)
"(1) The term 'income official poverty line' means such line as defined by the Office of Management and Budget and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981 [
"(2) The term 'project' refers to a demonstration project under subsection (a)."
[Section 13643(a) of
Demonstration Project To Provide Medicaid Coverage for HIV-Positive Individuals
Section 4747 of
"(a)
"(b)
"(2) A demonstration project under subsection (a) shall provide services in addition to the services described in paragraph (1) which shall be limited only on the basis of medical necessity or the appropriateness of such services. To the extent not provided as described in paragraph (1), such additional services shall include—
"(A) general and preventative medical care services (including inpatient, outpatient, residential care, physician visits, clinic visits, and hospice care);
"(B) prescription drugs, including drugs for the purposes of preventative health care services;
"(C) counseling and social services;
"(D) substance abuse treatment services (including services for multiple substances abusers);
"(E) home care services (including assistance in carrying out activities of daily living);
"(F) case management;
"(G) health education services;
"(H) respite care for caregivers;
"(I) dental services; and
"(J) diagnostic and laboratory services[.]
"(c)
"(2) A demonstration project described in subsection (a) shall be limited to an enrollment of not more than 200 individuals.
"(3) A demonstration project conducted under subsection (a) shall commence not later than 9 months after the date of the enactment of this Act [Nov. 5, 1990] and shall terminate on the date that is 3 years after the date of commencement.
"(4)(A) The Secretary shall provide for an evaluation of the comparative costs of providing services to individuals who have tested positive for the presence of HIV virus at an early stage after detection of such virus and those that are treated at a later stage after such detection.
"(B) The Secretary shall report to Congress on the results of the evaluation conducted under subparagraph (A) no later than 6 months after the date of termination of the demonstration projects described in this section.
"(d)
"(e)
"(f)
Public Education Campaign
Section 4751(d) of
"(1)
"(2)
"(3)
"(4)
Physician Identifier System; Deadline and Considerations
Section 4752(a)(1)(B) of
Foreign Medical Graduate Certification
Section 4752(d) of
"(1)
"(A) has passed the FMGEMS examination (as defined in section 1886(h)(5)(E) of such Act);
"(B) has previously received certification from, or has previously passed the examination of, the Educational Commission for Foreign Medical Graduates; or
"(C) has held a license from 1 or more States continuously since 1958.
"(2)
Exclusions in Determination of Income and Resources Under This Subchapter
Section 11115(c) of
Development of Model Applications for Medicaid Program
Section 6506(b) of
"(1)
"(2)
Clarification of Federal Financial Participation for Case-Management Services
Section 8435 of
Treatment of States Operating Under Demonstration Projects
Section 301(g)(1) of
Adjustment in Medicaid Payment for Inpatient Hospital Services Furnished by Disproportionate Share Hospitals
Amendment to State Plan To Provide Adjustment for Services Furnished During Fiscal Year 1990
Section 4211(b)(2) of
Technical Assistance With Respect to Facilities That Take Into Account Case Mix of Residents
Section 4211(j) of
State Utilization Review Systems
Section 9432 of
"(a)
"(2) The Secretary may not, during the period beginning on the date of the enactment of the Omnibus Budget Reconciliation Act of 1990 [Nov. 5, 1990] and ending on the date that is 180 days after the date on which the report required by subsection (d) is submitted to the Congress, publish final or interim final regulations requiring a State plan approved under title XIX of the Social Security Act [this subchapter] to include a program for ambulatory surgery, preadmission testing, or same-day surgery.
"(b)
"(1) The Secretary shall report to Congress, by not later than October 1, 1988, for each State in a representative sample of States—
"(A) the identity of those procedures which are high volume or high cost procedures among patients who are covered under the State medicaid plan,
"(B) the payment rates under those plans for such procedures, and the aggregate annual payment amounts made under such plans for such procedures (including the Federal share of such payment amounts),
"(C) the rate at which each such procedure is performed on medicaid patients and (to the extent that data are available) comparisons to the rate at which such procedure is performed on patients of comparable age who are not medicaid patients,
"(D) with respect to each such procedure—
"(i) the number of board certified or board eligible physicians in the State who provide care and services to medicaid patients and who perform the procedure, and
"(ii) in the case of a State with a mandatory second surgical opinion program in operation, the number of physicians described in clause (i) who provide second opinions (of the type described in section 1164 of the Social Security Act [
"(E) in the case of a State with a mandatory second surgical opinion program or a program of inpatient hospital preadmission review in operation, a description of—
"(i) the extent to which such program impedes access to necessary care and services, and
"(ii) the measures that the State has taken to address such impediments, particularly in rural areas.
"(2) Such report shall also include a list of those surgical procedures which the Secretary believes meet the following criteria and for which a mandatory second opinion program under medicaid plans may be appropriate:
"(A) The procedure is one which generally can be postponed without undue risk to the patient.
"(B) The procedure is a high volume procedure among patients who are covered under State medicaid plans or is a high cost procedure.
"(C) The procedure has a comparatively high rate of nonconfirmation upon examination by another qualified physician, there is substantial geographic variation in the rates of performance of the procedure, or there are other reasons why requiring second opinions for 100 percent of such procedures would be cost effective.
"(3) The representative sample of States required to be included in the report shall include States with mandatory second surgical opinion programs in operation, States with programs of inpatient hospital preadmission review in operation, and States with neither such program in operation.
"(4) In this subsection and subsection (d), the term 'medicaid plan' means a State plan approved under title XIX of the Social Security Act [this subchapter].
"(c)
"(1) The Secretary shall conduct a study of the utilization of selected medical treatments and surgical procedures by medicaid beneficiaries in order to assess the appropriateness, necessity, and effectiveness of such treatments and procedures.
"(2) The study shall analyze the extent to which there is significant variation in the rate of utilization by medicaid beneficiaries of selected treatments and procedures for different geographic areas within States and among States.
"(3) The study shall also identify underutilized, medically necessary treatments and procedures for which—
"(A) a failure to furnish could have an adverse effect on health status, and
"(B) the rate of utilization by medicaid beneficiaries is significantly less than the rate for comparable, age-adjusted populations.
"(4) The study shall be coordinated, to the extent practicable, with the research program established pursuant to section 1875(c) of the Social Security Act [
"(5) The Secretary shall submit an interim report on the results of the study, including an analysis of the geographic variations under paragraph (2), to the Congress not later than January 1, 1990, and shall report the final results of the study to the Congress not later than January 1, 1992.
"(d)
"(1) an analysis of the procedures for which programs for ambulatory surgery, preadmission testing, and same-day surgery are appropriate for patients who are covered under the State medicaid plan, and
"(2) the effects of such programs on access of such patients to necessary care, quality of care, and costs of care.
In selecting such a sample of States, the Secretary shall include some States with medicaid plans that include such programs."
Promulgation of Regulations
Section 9503(c) of
Study by Comptroller General of Effect of Amendment to Subsection (a)(13)
Section 9509(c) of
Task Force on Technology-Dependent Children
Section 9520 of
Medicaid Coverage Relating to Adoption Assistance Agreements Entered Into Before April 7, 1986
Section 9529(b)(2) of
"(A) the requirements of subdivisions (aa) and (bb) of section 1902(a)(10)(A)(ii)(VIII) of the Social Security Act [subsec. (a)(10)(A)(ii)(VIII)(aa), (bb) of this section] shall be deemed to be met if the State agency responsible for adoption assistance agreements determines that—
"(i) at the time of adoptive placement the child had special needs for medical or rehabilitative care that made the child difficult to place; and
"(ii) there is in effect with respect to such child an adoption assistance agreement between the State and an adoptive parent or parents; and
"(B) the requirement of subdivision (cc) of such section shall be deemed to be met if the child was found by the State to be eligible for medical assistance prior to such agreement being entered into."
Payment for Psychiatric Hospital Services
Section 2366 of
Moratorium on Regulatory Actions by Secretary
Section 2373(c) of
"(1) The Secretary of Health and Human Services shall not take any compliance, disallowance, penalty, or other regulatory action against a State with respect to the moratorium period described in paragraph (2) by reason of such State's plan described in paragraph (5) under title XIX of the Social Security Act [this subchapter] (including any part of the plan operating pursuant to section 1902(f) of such Act [subsec. (f) of this section]), or the operation thereunder, being determined to be in violation of clause (IV), (V), or (VI) of section 1902(a)(10)(A)(ii) or section 1902(a)(10)(C)(i)(III) of such Act on account of such plan's (or its operation) having a standard or methodology which the Secretary interprets as being less restrictive than the standard or methodology required under such section, provided that such plan (or its operation) does not make ineligible any individual who would be eligible but for the provisions of this subsection.
"(2) The moratorium period is the period beginning on October 1, 1981, and ending 18 months after the date on which the Secretary submits the report required under paragraph (3).
"(3) The Secretary shall report to the Congress within 12 months after the date of the enactment of this Act [July 18, 1984] with respect to the appropriateness, and impact on States and recipients of medical assistance, of applying standards and methodologies utilized in cash assistance programs to those recipients of medical assistance who do not receive cash assistance, and any recommendations for changes in such requirements.
"(4) No provision of law shall repeal or suspend the moratorium imposed by this subsection unless such provision specifically amends or repeals this subsection.
"(5) In this subsection, a State plan is considered to include—
"(A) any amendment or other change in the plan which is submitted by a State, or
"(B) any policy or guideline delineated in the Medicaid operation or program manuals of the State which are submitted by the State to the Secretary,
whether before or after the date of enactment of this Act [July 18, 1984] and whether or not the amendment or change, or the operating or program manual was approved, disapproved, acted upon, or not acted upon by the Secretary.
"(6) During the moratorium period, the Secretary shall implement (and shall not change by any administrative action) the policy in effect at the beginning of such moratorium period with respect to—
"(A) the point in time at which an institutionalized individual must sell his home (in order that it not be counted as a resource); and
"(B) the time period allowed for sale of a home of any such individual,
who is an applicant for or recipient of medical assistance under the State plan as a medically needy individual (described in section 1902(a)(10)(C) of the Social Security Act [subsec. (a)(10)(C) of this section]) or as an optional categorically needy individual (described in section 1902(a)(10)(A)(ii) of such Act)."
[Amendment of section 2373(c) of
Evaluation and Study of Reasons for Termination by Medicaid Beneficiaries of Membership in Health Maintenance Organizations
Section 2178(d) of
Continuing Medicaid Eligibility for Certain Recipients of Veterans' Administration Pensions
Section 310(b)(1) of
"(A) For purposes of section 1902(a)(10)(A) of the Social Security Act [subsec. (a)(10)(A) of this section], any individual who, prior to the date of enactment of this Act [June 17, 1980] and for the month of December 1978, was eligible for and received aid or assistance under a State plan approved under title I, X, XIV, or XVI, or part A of title IV of such Act [subchapter I, X, XIV, or XVI, or part A of subchapter IV of this chapter], or was eligible for and received supplemental security income benefits under title XVI of such Act [subchapter XVI of this chapter] (or a supplementary payment described in section 13(c) of
"(B)(i) The provisions of subparagraph (A) shall take effect on January 1, 1979, and shall cease to be effective, in the case of any individual, for and after the first calendar month beginning more than 10 days after an 'informed election' (as defined in subdivision (ii) of this subparagraph) has been made by such individual (or, if such individual is not eligible to make such an election, by a member of such individual's family who is eligible to make such an election which affects such individual's eligibility for aid, assistance, or benefits under a plan or program referred to in subparagraph (A)).
"(ii) The term 'informed election' means an election made under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978 [section 306 of
Preservation of Medicaid Eligibility for Individuals Who Cease To Be Eligible for Supplemental Security Income Benefits on Account of Cost-of-Living Increases in Social Security Benefits
Medicaid Eligibility for Individuals Receiving Mandatory State Supplementary Payments; Effective Date
Section 13(c) of
"(1) for any month for which there (A) is payable with respect to such individual a supplementary payment pursuant to an agreement entered into between the State and the Secretary of Health, Education, and Welfare [now Health and Human Services] under section 212(a) of
"(2) in like manner, and subject to the same terms and conditions, as medical assistance is provided under such plan to individuals with respect to whom benefits are payable for such month under the supplementary security income program established by title XVI of the Social Security Act [subchapter XVI of this chapter].
Federal matching under title XIX of the Social Security Act [this subchapter] shall be available for the medical assistance furnished to individuals who are eligible for such assistance under this subsection."
Coverage of Essential Persons Under Medicaid
Section 230 of
"(1) the individual (referred to in the last sentence of section 1905(a) of such Act [
"(2) such person continues to have the relationship with such individual described in such sentence and meets the other criteria (referred to in such sentence) with respect to a State plan (so referred to) as such plan was in effect for December 1973.
Federal matching under title XIX of the Social Security Act [this subchapter] shall be available for the medical assistance furnished to individuals eligible for such assistance under this section."
Persons in Medical Institutions
Section 231 of
"(1) was an inpatient in an institution qualified for reimbursement under title XIX of the Social Security Act [this subchapter], and
"(2)(A) received or would (except for his being an inpatient in such institution) have been eligible to receive aid or assistance under a State plan approved under title I, X, XIV, or XVI of such Act [subchapter I, X, XIV, or XVI of this chapter], and
"(B), [sic] on the basis of his status as described in subparagraph (A), was included as an individual eligible for medical assistance under a State plan approved under title XIX of such Act [this subchapter] (whether or not such individual actually received aid or assistance under a State plan referred to in subparagraph (A)),
shall be deemed to be receiving such aid or assistance for such month and for each succeeding month in a continuous period of months if, for each month in such period—
"(3) such individual continues to be (for all of such month) an inpatient in such an institution and would (except for his being an inpatient in such institution) continue to meet the conditions of eligibility to receive aid or assistance under such plan (as such plan was in effect for December 1973), and
"(4) such individual is determined (under the utilization review and other professional audit procedures applicable to State plans approved under title XIX of the Social Security Act [this subchapter]) to be in need of care in such an institution.
Federal matching under title XIX of the Social Security Act [this subchapter] shall be available for the medical assistance furnished to individuals eligible for such assistance under this section."
Blind and Disabled Medically Indigent Persons
Section 232 of
Impact of 1972 Social Security Benefits Increase Under Pub. L. 92–336 Upon Eligibility for Assistance Under This Subchapter
Section 249E of
Nursing Homes Eligible for Matching Funds for Home Services When Meeting State Licensure Requirements After June 30, 1968
Section 234(c) of
District of Columbia; Plan for Medical Assistance
"(b)(1) Notwithstanding any other provision of law, the Commissioner may take such action as may be necessary to submit such plan to the Secretary and to establish and carry out such medical assistance program, except that in prescribing the standards for determining eligibility for and the extent of medical assistance under the District of Columbia's plan for medical assistance, the Commissioner may not (except to the extent required by title XIX of the Social Security Act [this subchapter])—
"(A) prescribe maximum income levels for recipients of medical assistance under such plan which exceed (i) the title XIX maximum income levels if such levels are in effect, or (ii) the Commissioner's maximum income levels for the local medical assistance program if there are no title XIX maximum income levels in effect; or
"(B) prescribe criteria which would permit an individual or family to be eligible for such assistance if such individual or family would be ineligible, solely by reason of his or its resources, for medical assistance both under the plan of the State of Maryland approved under title XIX of the Social Security Act [this subchapter] and under the plan of the State of Virginia approved under such title.
"(2) For purposes of subparagraph (A) of paragraph (1) of this subsection—
"(A) the term 'title XIX maximum income levels' means any maximum income levels which may be specified by title XIX of the Social Security Act [this subchapter] for recipients of medical assistance under State plans approved under that title;
"(B) the term 'the Commissioner's maximum income levels for the local medical assistance program' means the maximum income levels prescribed for recipients of medical assistance under the District of Columbia's medical assistance program in effect in the fiscal year ending June 30, 1967; and
"(C) during any of the first four calendar quarters in which medical assistance is provided under such plan there shall be deemed to be no title XIX maximum income levels in effect if the title XIX maximum income levels in effect during such quarter are higher than the Commissioner's maximum income levels for the local medical assistance program."
Section Referred to in Other Sections
This section is referred to in
1 See References in Text note below.
2 So in original. The semicolon probably should be a comma.
3 So in original. Probably should be followed by "and".
4 So in original. The word "to" probably should not appear.
5 So in original. The semicolon probably should be a comma.
6 So in original. Probably should be followed by a comma.
8 See References in Text note below.
9 So in original. Probably should be section "1396d(l)(2)(B)".
10 See References in Text note below.
11 So in original. Probably should be "an".
12 So in original. Probably should be "this subsection".
13 So in original. Probably should be subsection "(a)(56)".
14 See References in Text note below.
§1396b. Payment to States
(a) Computation of amount
From the sums appropriated therefor, the Secretary (except as otherwise provided in this section) shall pay to each State which has a plan approved under this subchapter, for each quarter, beginning with the quarter commencing January 1, 1966—
(1) an amount equal to the Federal medical assistance percentage (as defined in
(2)(A) an amount equal to 75 per centum of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the State agency or any other public agency; plus
(B) notwithstanding paragraph (1) or subparagraph (A), with respect to amounts expended for nursing aide training and competency evaluation programs, and competency evaluation programs, described in
(C) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to preadmission screening and resident review activities conducted by the State under
(D) for each calendar quarter during—
(i) fiscal year 1991, an amount equal to 90 percent,
(ii) fiscal year 1992, an amount equal to 85 percent,
(iii) fiscal year 1993, an amount equal to 80 percent, and
(iv) fiscal year 1994 and thereafter, an amount equal to 75 percent,
of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to State activities under
(3) an amount equal to—
(A)(i) 90 per centum of so much of the sums expended during such quarter as are attributable to the design, development, or installation of such mechanized claims processing and information retrieval systems as the Secretary determines are likely to provide more efficient, economical, and effective administration of the plan and to be compatible with the claims processing and information retrieval systems utilized in the administration of subchapter XVIII of this chapter, including the State's share of the cost of installing such a system to be used jointly in the administration of such State's plan and the plan of any other State approved under this chapter, and
(ii) 90 per centum of so much of the sums expended during any such quarter in the fiscal year ending June 30, 1972, or the fiscal year ending June 30, 1973, as are attributable to the design, development, or installation of cost determination systems for State-owned general hospitals (except that the total amount paid to all States under this clause for either such fiscal year shall not exceed $150,000), and
(B) 75 per centum of so much of the sums expended during such quarter as are attributable to the operation of systems (whether such systems are operated directly by the State or by another person under a contract with the State) of the type described in subparagraph (A)(i) (whether or not designed, developed, or installed with assistance under such subparagraph) which are approved by the Secretary and which include provision for prompt written notice to each individual who is furnished services covered by the plan, or to each individual in a sample group of individuals who are furnished such services, of the specific services (other than confidential services) so covered, the name of the person or persons furnishing the services, the date or dates on which the services were furnished, and the amount of the payment or payments made under the plan on account of the services; and
(C)(i) 75 per centum of the sums expended with respect to costs incurred during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to the performance of medical and utilization review by a utilization and quality control peer review organization or by an entity which meets the requirements of
(ii) 75 percent of the sums expended with respect to costs incurred during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to the performance of independent external reviews conducted under
(D) 75 percent of so much of the sums expended by the State plan during a quarter in 1991, 1992, or 1993, as the Secretary determines is attributable to the statewide adoption of a drug use review program which conforms to the requirements of
(4) an amount equal to 100 percent of the sums expended during the quarter which are attributable to the costs of the implementation and operation of the immigration status verification system described in
(5) an amount equal to 90 per centum of the sums expended during such quarter which are attributable to the offering, arranging, and furnishing (directly or on a contract basis) of family planning services and supplies;
(6) subject to subsection (b)(3) of this section, an amount equal to—
(A) 90 per centum of the sums expended during such a quarter within the twelve-quarter period beginning with the first quarter in which a payment is made to the State pursuant to this paragraph, and
(B) 75 per centum of the sums expended during each succeeding calendar quarter,
with respect to costs incurred during such quarter (as found necessary by the Secretary for the elimination of fraud in the provision and administration of medical assistance provided under the State plan) which are attributable to the establishment and operation of (including the training of personnel employed by) a State medicaid fraud control unit (described in subsection (q) of this section); plus
(7) subject to
(b) Quarterly expenditures beginning after December 31, 1969
(1) Notwithstanding the preceding provisions of this section, the amount determined under subsection (a)(1) of this section for any State for any quarter beginning after December 31, 1969, shall not take into account any amounts expended as medical assistance with respect to individuals aged 65 or over and disabled individuals entitled to hospital insurance benefits under subchapter XVIII of this chapter which would not have been so expended if the individuals involved had been enrolled in the insurance program established by part B of subchapter XVIII of this chapter, other than amounts expended under provisions of the plan of such State required by
(2) For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a State or areawide planning agency, see
(3) The amount of funds which the Secretary is otherwise obligated to pay a State during a quarter under subsection (a)(6) of this section may not exceed the higher of—
(A) $125,000, or
(B) one-quarter of 1 per centum of the sums expended by the Federal, State, and local governments during the previous quarter in carrying out the State's plan under this subchapter.
(4) Amounts expended by a State for the use of an enrollment broker in marketing medicaid managed care organizations and other managed care entities to eligible individuals under this subchapter shall be considered, for purposes of subsection (a)(7) of this section, to be necessary for the proper and efficient administration of the State plan but only if the following conditions are met with respect to the broker:
(A) The broker is independent of any such entity and of any health care providers (whether or not any such provider participates in the State plan under this subchapter) that provide coverage of services in the same State in which the broker is conducting enrollment activities.
(B) No person who is an owner, employee, consultant, or has a contract with the broker either has any direct or indirect financial interest with such an entity or health care provider or has been excluded from participation in the program under this subchapter or subchapter XVIII of this chapter or debarred by any Federal agency, or subject to a civil money penalty under this chapter.
(5) Notwithstanding the preceding provisions of this section, the amount determined under subsection (a)(1) of this section for any State shall be decreased in a quarter by the amount of any health care related taxes (described in subsection (w)(3)(A) of this section) 1 that are imposed on a hospital described in subsection (w)(3)(F) of this section in that quarter.
(c) Treatment of educationally-related services
Nothing in this subchapter shall be construed as prohibiting or restricting, or authorizing the Secretary to prohibit or restrict, payment under subsection (a) of this section for medical assistance for covered services furnished to a child with a disability because such services are included in the child's individualized education program established pursuant to part B of the Individuals with Disabilities Education Act [
(d) Estimates of State entitlement; installments; adjustments to reflect overpayments or underpayments; time for recovery or adjustment; uncollectable or discharged debts; obligated appropriations; disputed claims
(1) Prior to the beginning of each quarter, the Secretary shall estimate the amount to which a State will be entitled under subsections (a) and (b) of this section for such quarter, such estimates to be based on (A) a report filed by the State containing its estimate of the total sum to be expended in such quarter in accordance with the provisions of such subsections, and stating the amount appropriated or made available by the State and its political subdivisions for such expenditures in such quarter, and if such amount is less than the State's proportionate share of the total sum of such estimated expenditures, the source or sources from which the difference is expected to be derived, and (B) such other investigation as the Secretary may find necessary.
(2)(A) The Secretary shall then pay to the State, in such installments as he may determine, the amount so estimated, reduced or increased to the extent of any overpayment or underpayment which the Secretary determines was made under this section to such State for any prior quarter and with respect to which adjustment has not already been made under this subsection.
(B) Expenditures for which payments were made to the State under subsection (a) of this section shall be treated as an overpayment to the extent that the State or local agency administering such plan has been reimbursed for such expenditures by a third party pursuant to the provisions of its plan in compliance with
(C) For purposes of this subsection, when an overpayment is discovered, which was made by a State to a person or other entity, the State shall have a period of 60 days in which to recover or attempt to recover such overpayment before adjustment is made in the Federal payment to such State on account of such overpayment. Except as otherwise provided in subparagraph (D), the adjustment in the Federal payment shall be made at the end of the 60 days, whether or not recovery was made.
(D) In any case where the State is unable to recover a debt which represents an overpayment (or any portion thereof) made to a person or other entity on account of such debt having been discharged in bankruptcy or otherwise being uncollectable, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof).
(3)(A) The pro rata share to which the United States is equitably entitled, as determined by the Secretary, of the net amount recovered during any quarter by the State or any political subdivision thereof with respect to medical assistance furnished under the State plan shall be considered an overpayment to be adjusted under this subsection.
(B)(i) Subparagraph (A) and paragraph (2)(B) shall not apply to any amount recovered or paid to a State as part of the comprehensive settlement of November 1998 between manufacturers of tobacco products, as defined in section 5702(d) of the Internal Revenue Code of 1986, and State Attorneys General, or as part of any individual State settlement or judgment reached in litigation initiated or pursued by a State against one or more such manufacturers.
(ii) Except as provided in subsection (i)(19) of this section, a State may use amounts recovered or paid to the State as part of a comprehensive or individual settlement, or a judgment, described in clause (i) for any expenditures determined appropriate by the State.
(4) Upon the making of any estimate by the Secretary under this subsection, any appropriations available for payments under this section shall be deemed obligated.
(5) In any case in which the Secretary estimates that there has been an overpayment under this section to a State on the basis of a claim by such State that has been disallowed by the Secretary under
(6)(A) Each State (as defined in subsection (w)(7)(D) of this section) shall include, in the first report submitted under paragraph (1) after the end of each fiscal year, information related to—
(i) provider-related donations made to the State or units of local government during such fiscal year, and
(ii) health care related taxes collected by the State or such units during such fiscal year.
(B) Each State shall include, in the first report submitted under paragraph (1) after the end of each fiscal year, information related to the total amount of payment adjustments made, and the amount of payment adjustments made to individual providers (by provider), under
(e) Transition costs of closures or conversions permitted
A State plan approved under this subchapter may include, as a cost with respect to hospital services under the plan under this subchapter, periodic expenditures made to reflect transitional allowances established with respect to a hospital closure or conversion under
(f) Limitation on Federal participation in medical assistance
(1)(A) Except as provided in paragraph (4), payment under the preceding provisions of this section shall not be made with respect to any amount expended as medical assistance in a calendar quarter, in any State, for any member of a family the annual income of which exceeds the applicable income limitation determined under this paragraph.
(B)(i) Except as provided in clause (ii) of this subparagraph, the applicable income limitation with respect to any family is the amount determined, in accordance with standards prescribed by the Secretary, to be equivalent to 1331/3 percent of the highest amount which would ordinarily be paid to a family of the same size without any income or resources, in the form of money payments, under the plan of the State approved under part A of subchapter IV of this chapter.
(ii) If the Secretary finds that the operation of a uniform maximum limits payments to families of more than one size, he may adjust the amount otherwise determined under clause (i) to take account of families of different sizes.
(C) The total amount of any applicable income limitation determined under subparagraph (B) shall, if it is not a multiple of $100 or such other amount as the Secretary may prescribe, be rounded to the next higher multiple of $100 or such other amount, as the case may be.
(2)(A) In computing a family's income for purposes of paragraph (1), there shall be excluded any costs (whether in the form of insurance premiums or otherwise and regardless of whether such costs are reimbursed under another public program of the State or political subdivision thereof) incurred by such family for medical care or for any other type of remedial care recognized under State law or, (B) notwithstanding
(3) For purposes of paragraph (1)(B), in the case of a family consisting of only one individual, the "highest amount which would ordinarily be paid" to such family under the State's plan approved under part A of subchapter IV of this chapter shall be the amount determined by the State agency (on the basis of reasonable relationship to the amounts payable under such plan to families consisting of two or more persons) to be the amount of the aid which would ordinarily be payable under such plan to a family (without any income or resources) consisting of one person if such plan provided for aid to such a family.
(4) The limitations on payment imposed by the preceding provisions of this subsection shall not apply with respect to any amount expended by a State as medical assistance for any individual described in section 1396a(a)(10)(A)(i)(III), 1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V), 1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII), 1396a(a)(10)(A)(ii)(IX), 1396a(a)(10)(A)(ii)(X), 1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or 2 1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI), 1396d(p)(1) of this title or for any individual—
(A) who is receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV or XVI, or part A of subchapter IV, or with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter, or
(B) who is not receiving such aid or assistance, and with respect to whom such benefits are not being paid, but (i) is eligible to receive such aid or assistance, or to have such benefits paid with respect to him, or (ii) would be eligible to receive such aid or assistance, or to have such benefits paid with respect to him if he were not in a medical institution, or
(C) with respect to whom there is being paid, or who is eligible, or would be eligible if he were not in a medical institution, to have paid with respect to him, a State supplementary payment and is eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in
at the time of the provision of the medical assistance giving rise to such expenditure.
(g) Decrease in Federal medical assistance percentage of amounts paid for services furnished under State plan after June 30, 1973
(1) Subject to paragraph (3), with respect to amounts paid for the following services furnished under the State plan after June 30, 1973 (other than services furnished pursuant to a contract with a health maintenance organization as defined in
(2) The Secretary shall, as part of his validation procedures under this subsection, conduct timely sample onsite surveys of private and public institutions in which recipients of medical assistance may receive care and services under a State plan approved under this subchapter, and his findings with respect to such surveys (as well as the showings of the State agency required under this subsection) shall be made available for public inspection.
(3)(A) No reduction in the Federal medical assistance percentage of a State otherwise required to be imposed under this subsection shall take effect—
(i) if such reduction is due to the State's unsatisfactory or invalid showing made with respect to a calendar quarter beginning before January 1, 1977;
(ii) before January 1, 1978;
(iii) unless a notice of such reduction has been provided to the State at least 30 days before the date such reduction takes effect; or
(iv) due to the State's unsatisfactory or invalid showing made with respect to a calendar quarter beginning after September 30, 1977, unless notice of such reduction has been provided to the State no later than the first day of the fourth calendar quarter following the calendar quarter with respect to which such showing was made.
(B) The Secretary shall waive application of any reduction in the Federal medical assistance percentage of a State otherwise required to be imposed under paragraph (1) because a showing by the State, made under such paragraph with respect to a calendar quarter ending after January 1, 1977, and before January 1, 1978, is determined to be either unsatisfactory under such paragraph or invalid under paragraph (2), if the Secretary determines that the State's showing made under paragraph (1) with respect to any calendar quarter ending on or before December 31, 1978, is satisfactory under such paragraph and is valid under paragraph (2).
(4)(A) The Secretary may not find the showing of a State, with respect to a calendar quarter under paragraph (1), to be satisfactory if the showing is submitted to the Secretary later than the 30th day after the last day of the calendar quarter, unless the State demonstrates to the satisfaction of the Secretary good cause for not meeting such deadline.
(B) The Secretary shall find a showing of a State, with respect to a calendar quarter under paragraph (1), to be satisfactory under such paragraph with respect to the requirement that the State conduct annual onsite inspections in mental hospitals and intermediate care facilities for the mentally retarded under paragraphs (26) and (31) of
(i) in each of not less than 98 per centum of the number of such hospitals and facilities requiring such inspection, and
(ii) in every such hospital or facility which has 200 or more beds,
and that, with respect to such hospitals and facilities not inspected within such period, the State has exercised good faith and due diligence in attempting to conduct such inspection, or if the State demonstrates to the satisfaction of the Secretary that it would have made such a showing but for failings of a technical nature only.
(5) In the case of a State's unsatisfactory or invalid showing made with respect to a type of facility or institutional services in a calendar quarter, the per centum amount of the reduction of the State's Federal medical assistance percentage for that type of services under paragraph (1) is equal to 331/3 per centum multiplied by a fraction, the denominator of which is equal to the total number of patients receiving that type of services in that quarter under the State plan in facilities or institutions for which a showing was required to be made under this subsection, and the numerator of which is equal to the number of such patients receiving such type of services in that quarter in those facilities or institutions for which a satisfactory and valid showing was not made for that calendar quarter.
(6)(A) Recertifications required under
(B) Such recertifications in the case of services in an intermediate care facility for the mentally retarded shall be conducted at least—
(i) 60 days after the date of the initial certification,
(ii) 180 days after the date of the initial certification,
(iii) 12 months after the date of the initial certification,
(iv) 18 months after the date of the initial certification,
(v) 24 months after the date of the initial certification, and
(vi) every 12 months thereafter.
(C) For purposes of determining compliance with the schedule established by this paragraph, a recertification shall be considered to have been done on a timely basis if it was performed not later than 10 days after the date the recertification was otherwise required and the State establishes good cause why the physician or other person making such recertification did not meet such schedule.
(h) Repealed. Pub. L. 100–203, title IV, §4211(g)(1), Dec. 22, 1987, 101 Stat. 1330–205
(i) Payment for organ transplants; item or service furnished by excluded individual, entity, or physician; other restrictions
Payment under the preceding provisions of this section shall not be made—
(1) for organ transplant procedures unless the State plan provides for written standards respecting the coverage of such procedures and unless such standards provide that—
(A) similarly situated individuals are treated alike; and
(B) any restriction, on the facilities or practitioners which may provide such procedures, is consistent with the accessibility of high quality care to individuals eligible for the procedures under the State plan; or
(2) with respect to any amount expended for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished—
(A) under the plan by any individual or entity during any period when the individual or entity is excluded from participation under subchapter V, XVIII, or XX of this chapter or under this subchapter pursuant to
(B) at the medical direction or on the prescription of a physician, during the period when such physician is excluded from participation under subchapter V, XVIII, or XX of this chapter or under this subchapter pursuant to
(3) with respect to any amount expended for inpatient hospital services furnished under the plan (other than amounts attributable to the special situation of a hospital which serves a disproportionate number of low income patients with special needs) to the extent that such amount exceeds the hospital's customary charges with respect to such services or (if such services are furnished under the plan by a public institution free of charge or at nominal charges to the public) exceeds an amount determined on the basis of those items (specified in regulations prescribed by the Secretary) included in the determination of such payment which the Secretary finds will provide fair compensation to such institution for such services; or
(4) with respect to any amount expended for care or services furnished under the plan by a hospital unless such hospital has in effect a utilization review plan which meets the requirements imposed by
(5) with respect to any amount expended for any drug product for which payment may not be made under part B of subchapter XVIII of this chapter because of
(6) with respect to any amount expended for inpatient hospital tests (other than in emergency situations) not specifically ordered by the attending physician or other responsible practitioner; or
(7) with respect to any amount expended for clinical diagnostic laboratory tests performed by a physician, independent laboratory, or hospital, to the extent such amount exceeds the amount that would be recognized under
(8) with respect to any amount expended for medical assistance (A) for nursing facility services to reimburse (or otherwise compensate) a nursing facility for payment of a civil money penalty imposed under
(9) Repealed.
(10)(A) with respect to covered outpatient drugs unless there is a rebate agreement in effect under
(B) with respect to any amount expended for an innovator multiple source drug (as defined in
(11) with respect to any amount expended for physicians' services furnished on or after the first day of the first quarter beginning more than 60 days after the date of establishment of the physician identifier system under
(12) Repealed.
(13) with respect to any amount expended to reimburse (or otherwise compensate) a nursing facility for payment of legal expenses associated with any action initiated by the facility that is dismissed on the basis that no reasonable legal ground existed for the institution of such action; or
(14) with respect to any amount expended on administrative costs to carry out the program under
(15) with respect to any amount expended for a single-antigen vaccine and its administration in any case in which the administration of a combined-antigen vaccine was medically appropriate (as determined by the Secretary); or
(16) with respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997 [
(17) with respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under a State plan under this subchapter; or
(18) with respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State agency on a continuing basis a surety bond in a form specified by the Secretary under paragraph (7) of
(19) with respect to any amount expended on administrative costs to initiate or pursue litigation described in subsection (d)(3)(B) of this section; or
(20) with respect to amounts expended for medical assistance provided to an individual described in subclause (XV) or (XVI) of
Nothing in paragraph (1) shall be construed as permitting a State to provide services under its plan under this subchapter that are not reasonable in amount, duration, and scope to achieve their purpose. Paragraphs (1), (2), (16), (17), and (18) shall apply with respect to items or services furnished and amounts expended by or through a managed care entity (as defined in
(j) Adjustment of amount
Notwithstanding the preceding provisions of this section, the amount determined under subsection (a)(1) of this section for any State for any quarter shall be adjusted in accordance with
(k) Technical assistance to States
The Secretary is authorized to provide at the request of any State (and without cost to such State) such technical and actuarial assistance as may be necessary to assist such State to contract with any medicaid managed care organization which meets the requirements of subsection (m) of this section for the purpose of providing medical care and services to individuals who are entitled to medical assistance under this subchapter.
(l) Repealed. Pub. L. 94–552, §1, Oct. 18, 1976, 90 Stat. 2540
(m) "Medicaid managed care organization" defined; duties and functions of Secretary; payments to States; reporting requirements; remedies
(1)(A) The term "medicaid managed care organization" means a health maintenance organization, an eligible organization with a contract under
(i) makes services it provides to individuals eligible for benefits under this subchapter accessible to such individuals, within the area served by the organization, to the same extent as such services are made accessible to individuals (eligible for medical assistance under the State plan) not enrolled with the organization, and
(ii) has made adequate provision against the risk of insolvency, which provision is satisfactory to the State, meets the requirements of subparagraph (C)(i) (if applicable), and which assures that individuals eligible for benefits under this subchapter are in no case held liable for debts of the organization in case of the organization's insolvency.
An organization that is a qualified health maintenance organization (as defined in section 300e–9(d) 4 of this title) is deemed to meet the requirements of clauses (i) and (ii).
(B) The duties and functions of the Secretary, insofar as they involve making determinations as to whether an organization is a medicaid managed care organization within the meaning of subparagraph (A), shall be integrated with the administration of section 300e–11(a) and (b) of this title.
(C)(i) Subject to clause (ii), a provision meets the requirements of this subparagraph for an organization if the organization meets solvency standards established by the State for private health maintenance organizations or is licensed or certified by the State as a risk-bearing entity.
(ii) Clause (i) shall not apply to an organization if—
(I) the organization is not responsible for the provision (directly or through arrangements with providers of services) of inpatient hospital services and physicians' services;
(II) the organization is a public entity;
(III) the solvency of the organization is guaranteed by the State; or
(IV) the organization is (or is controlled by) one or more Federally-qualified 5 health centers and meets solvency standards established by the State for such an organization.
For purposes of subclause (IV), the term "control" means the possession, whether direct or indirect, of the power to direct or cause the direction of the management and policies of the organization through membership, board representation, or an ownership interest equal to or greater than 50.1 percent.
(2)(A) Except as provided in subparagraphs (B), (C), and (G), no payment shall be made under this subchapter to a State with respect to expenditures incurred by it for payment (determined under a prepaid capitation basis or under any other risk basis) for services provided by any entity (including a health insuring organization) which is responsible for the provision (directly or through arrangements with providers of services) of inpatient hospital services and any other service described in paragraph (2), (3), (4), (5), or (7) of
(i) the Secretary has determined that the entity is a medicaid managed care organization as defined in paragraph (1);
(ii) Repealed.
(iii) such services are provided for the benefit of individuals eligible for benefits under this subchapter in accordance with a contract between the State and the entity under which prepaid payments to the entity are made on an actuarially sound basis and under which the Secretary must provide prior approval for contracts providing for expenditures in excess of $1,000,000 for 1998 and, for a subsequent year, the amount established under this clause for the previous year increased by the percentage increase in the consumer price index for all urban consumers over the previous year;
(iv) such contract provides that the Secretary and the State (or any person or organization designated by either) shall have the right to audit and inspect any books and records of the entity (and of any subcontractor) that pertain (I) to the ability of the entity to bear the risk of potential financial losses, or (II) to services performed or determinations of amounts payable under the contract;
(v) such contract provides that in the entity's enrollment, reenrollment, or disenrollment of individuals who are eligible for benefits under this subchapter and eligible to enroll, reenroll, or disenroll with the entity pursuant to the contract, the entity will not discriminate among such individuals on the basis of their health status or requirements for health care services;
(vi) such contract (I) permits individuals who have elected under the plan to enroll with the entity for provision of such benefits to terminate such enrollment in accordance with
(vii) such contract provides that, in the case of medically necessary services which were provided (I) to an individual enrolled with the entity under the contract and entitled to benefits with respect to such services under the State's plan and (II) other than through the organization because the services were immediately required due to an unforeseen illness, injury, or condition, either the entity or the State provides for reimbursement with respect to those services,6
(viii) such contract provides for disclosure of information in accordance with
(ix) such contract provides, in the case of an entity that has entered into a contract for the provision of services with a Federally-qualified 5 health center or a rural health clinic, that the entity shall provide payment that is not less than the level and amount of payment which the entity would make for the services if the services were furnished by a provider which is not a Federally-qualified health center or a rural health clinic;
(x) any physician incentive plan that it operates meets the requirements described in
(xi) such contract provides for maintenance of sufficient patient encounter data to identify the physician who delivers services to patients; and
(xii) such contract, and the entity complies with the applicable requirements of
(B) Subparagraph (A) 7 except with respect to clause (ix) of subparagraph (A), does not apply with respect to payments under this subchapter to a State with respect to expenditures incurred by it for payment for services provided by an entity which—
(i)(I) received a grant of at least $100,000 in the fiscal year ending June 30, 1976, under
(II) provides to its enrollees, on a prepaid capitation risk basis or on any other risk basis, all of the services and benefits described in paragraphs (1), (2), (3), (4)(C), and (5) of
(ii) is a nonprofit primary health care entity located in a rural area (as defined by the Appalachian Regional Commission)—
(I) which received in the fiscal year ending June 30, 1976, at least $100,000 (by grant, subgrant, or subcontract) under the Appalachian Regional Development Act of 1965, and
(II) for the period beginning July 1, 1976, and ending on the expiration of the period for which payments are to be made under this subchapter either has been the recipient of a grant, subgrant, or subcontract under such Act or has provided services under a contract (initially entered into during a year in which the entity was the recipient of such a grant, subgrant, or subcontract) with a State agency under this subchapter on a prepaid capitation risk basis or on any other risk basis; or
(iii) which has contracted with the single State agency for the provision of services (but not including inpatient hospital services) to persons eligible under this subchapter on a prepaid risk basis prior to 1970.
(C) to (E) Repealed.
(F) Repealed.
(G) In the case of an entity which is receiving (and has received during the previous two years) a grant of at least $100,000 under
(H) In the case of an individual who—
(i) in a month is eligible for benefits under this subchapter and enrolled with a medicaid managed care organization with a contract under this paragraph or with a primary care case manager with a contract described in
(ii) in the next month (or in the next 2 months) is not eligible for such benefits, but
(iii) in the succeeding month is again eligible for such benefits,
the State plan, subject to subparagraph (A)(vi), may enroll the individual for that succeeding month with the organization described in clause (i) if the organization continues to have a contract under this paragraph with the State or with the manager described in such clause if the manager continues to have a contract described in
(3) Repealed.
(4)(A) Each medicaid managed care organization which is not a qualified health maintenance organization (as defined in section 300e–9(d) 8 of this title) must report to the State and, upon request, to the Secretary, the Inspector General of the Department of Health and Human Services, and the Comptroller General a description of transactions between the organization and a party in interest (as defined in
(i) Any sale or exchange, or leasing of any property between the organization and such a party.
(ii) Any furnishing for consideration of goods, services (including management services), or facilities between the organization and such a party, but not including salaries paid to employees for services provided in the normal course of their employment.
(iii) Any lending of money or other extension of credit between the organization and such a party.
The State or Secretary may require that information reported respecting an organization which controls, or is controlled by, or is under common control with, another entity be in the form of a consolidated financial statement for the organization and such entity.
(B) Each organization shall make the information reported pursuant to subparagraph (A) available to its enrollees upon reasonable request.
(5)(A) If the Secretary determines that an entity with a contract under this subsection—
(i) fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has substantial likelihood of adversely affecting) the individual;
(ii) imposes premiums on individuals enrolled under this subsection in excess of the premiums permitted under this subchapter;
(iii) acts to discriminate among individuals in violation of the provision of paragraph (2)(A)(v), including expulsion or refusal to re-enroll an individual or engaging in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this subsection) by eligible individuals with the organization whose medical condition or history indicates a need for substantial future medical services;
(iv) misrepresents or falsifies information that is furnished—
(I) to the Secretary or the State under this subsection, or
(II) to an individual or to any other entity under this subsection,9 or
(v) fails to comply with the requirements of
the Secretary may provide, in addition to any other remedies available under law, for any of the remedies described in subparagraph (B).
(B) The remedies described in this subparagraph are—
(i) civil money penalties of not more than $25,000 for each determination under subparagraph (A), or, with respect to a determination under clause (iii) or (iv)(I) of such subparagraph, of not more than $100,000 for each such determination, plus, with respect to a determination under subparagraph (A)(ii), double the excess amount charged in violation of such subparagraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under subparagraph (A)(iii), $15,000 for each individual not enrolled as a result of a practice described in such subparagraph, or
(ii) denial of payment to the State for medical assistance furnished under the contract under this subsection for individuals enrolled after the date the Secretary notifies the organization of a determination under subparagraph (A) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur.
The provisions of
(6)(A) For purposes of this subsection and
(B) The undertaking described in subparagraph (A) must provide—
(i) for the establishment of a separate entity responsible for the operation of a program meeting the requirements of this subsection, which entity may be a subdivision of the State agency administering the State plan under this subchapter;
(ii) for separate accounting for the funds used to operate such program; and
(iii) for setting the capitation rates and any other payment rates for services provided in accordance with this subsection using a methodology satisfactory to the Secretary designed to ensure that total Federal matching payments under this subchapter for such services will be lower than the matching payments that would be made for the same services, if provided under the State plan on a fee for service basis to an actuarially equivalent population.
(C) The undertaking described in subparagraph (A) shall be subject to approval (and annual re-approval) by the Secretary in the same manner as a contract under this subsection.
(D) The undertaking described in subparagraph (A) shall not be eligible for a waiver under
(n) Repealed. Pub. L. 100–93, §8(h)(1), Aug. 18, 1987, 101 Stat. 694
(o) Restrictions on authorized payments to States
Notwithstanding the preceding provisions of this section, no payment shall be made to a State under the preceding provisions of this section for expenditures for medical assistance provided for an individual under its State plan approved under this subchapter to the extent that a private insurer (as defined by the Secretary by regulation and including a group health plan (as defined in
(p) Assignment of rights of payment; incentive payments for enforcement and collection
(1) When a political subdivision of a State makes, for the State of which it is a political subdivision, or one State makes, for another State, the enforcement and collection of rights of support or payment assigned under
(2) Where more than one jurisdiction is involved in such enforcement or collection, the amount of the incentive payment determined under paragraph (1) shall be allocated among the jurisdictions in a manner to be prescribed by the Secretary.
(q) "State medicaid fraud control unit" defined
For the purposes of this section, the term "State medicaid fraud control unit" means a single identifiable entity of the State government which the Secretary certifies (and annually recertifies) as meeting the following requirements:
(1) The entity (A) is a unit of the office of the State Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal violations, (B) is in a State the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the Secretary, that (i) assure its referral of suspected criminal violations relating to the program under this subchapter to the appropriate authority or authorities in the State for prosecution and (ii) assure its assistance of, and coordination with, such authority or authorities in such prosecutions, or (C) has a formal working relationship with the office of the State Attorney General and has formal procedures (including procedures for its referral of suspected criminal violations to such office) which are approved by the Secretary and which provide effective coordination of activities between the entity and such office with respect to the detection, investigation, and prosecution of suspected criminal violations relating to the program under this subchapter.
(2) The entity is separate and distinct from the single State agency that administers or supervises the administration of the State plan under this subchapter.
(3) The entity's function is conducting a statewide program for the investigation and prosecution of violations of all applicable State laws regarding any and all aspects of fraud in connection with (A) any aspect of the provision of medical assistance and the activities of providers of such assistance under the State plan under this subchapter; and (B) upon the approval of the Inspector General of the relevant Federal agency, any aspect of the provision of health care services and activities of providers of such services under any Federal health care program (as defined in
(4)(A) The entity has—
(i) procedures for reviewing complaints of abuse or neglect of patients in health care facilities which receive payments under the State plan under this subchapter;
(ii) at the option of the entity, procedures for reviewing complaints of abuse or neglect of patients residing in board and care facilities; and
(iii) procedures for acting upon such complaints under the criminal laws of the State or for referring such complaints to other State agencies for action.
(B) For purposes of this paragraph, the term "board and care facility" means a residential setting which receives payment (regardless of whether such payment is made under the State plan under this subchapter) from or on behalf of two or more unrelated adults who reside in such facility, and for whom one or both of the following is provided:
(i) Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse, or licensed nursing assistant.
(ii) A substantial amount of personal care services that assist residents with the activities of daily living, including personal hygiene, dressing, bathing, eating, toileting, ambulation, transfer, positioning, self-medication, body care, travel to medical services, essential shopping, meal preparation, laundry, and housework.
(5) The entity provides for the collection, or referral for collection to a single State agency, of overpayments that are made under the State plan or under any Federal health care program (as so defined) to health care facilities and that are discovered by the entity in carrying out its activities. All funds collected in accordance with this paragraph shall be credited exclusively to, and available for expenditure under, the Federal health care program (including the State plan under this subchapter) that was subject to the activity that was the basis for the collection.
(6) The entity employs such auditors, attorneys, investigators, and other necessary personnel and is organized in such a manner as is necessary to promote the effective and efficient conduct of the entity's activities.
(7) The entity submits to the Secretary an application and annual reports containing such information as the Secretary determines, by regulation, to be necessary to determine whether the entity meets the other requirements of this subsection.
(r) Mechanized claims processing and information retrieval systems; operational, etc., requirements
(1) In order to receive payments under subsection (a) of this section for use of automated data systems in administration of the State plan under this subchapter, a State must have in operation mechanized claims processing and information retrieval systems that meet the requirements of this subsection and that the Secretary has found—
(A) are adequate to provide efficient, economical, and effective administration of such State plan;
(B) are compatible with the claims processing and information retrieval systems used in the administration of subchapter XVIII of this chapter, and for this purpose—
(i) have a uniform identification coding system for providers, other payees, and beneficiaries under this subchapter or subchapter XVIII of this chapter;
(ii) provide liaison between States and carriers and intermediaries with agreements under subchapter XVIII of this chapter to facilitate timely exchange of appropriate data; and
(iii) provide for exchange of data between the States and the Secretary with respect to persons sanctioned under this subchapter or subchapter XVIII of this chapter;
(C) are capable of providing accurate and timely data;
(D) are complying with the applicable provisions of part C of subchapter XI of this chapter;
(E) are designed to receive provider claims in standard formats to the extent specified by the Secretary; and
(F) effective for claims filed on or after January 1, 1999, provide for electronic transmission of claims data in the format specified by the Secretary and consistent with the Medicaid Statistical Information System (MSIS) (including detailed individual enrollee encounter data and other information that the Secretary may find necessary).
(2) In order to meet the requirements of this paragraph, mechanized claims processing and information retrieval systems must meet the following requirements:
(A) The systems must be capable of developing provider, physician, and patient profiles which are sufficient to provide specific information as to the use of covered types of services and items, including prescribed drugs.
(B) The State must provide that information on probable fraud or abuse which is obtained from, or developed by, the systems, is made available to the State's medicaid fraud control unit (if any) certified under subsection (q) of this section.
(C) The systems must meet all performance standards and other requirements for initial approval developed by the Secretary.
(s) Limitations on certain physician referrals
Notwithstanding the preceding provisions of this section, no payment shall be made to a State under this section for expenditures for medical assistance under the State plan consisting of a designated health service (as defined in subsection (h)(6) of
(t) Repealed. Pub. L. 97–35, title XXI, §2161(c)(2), Aug. 13, 1981, 95 Stat. 805 , as amended by Pub. L. 97–248, title I, §137(a)(2), Sept. 3, 1982, 96 Stat. 376
(u) Limitation of Federal financial participation in erroneous medical assistance expenditures
(1)(A) Notwithstanding subsection (a)(1) of this section, if the ratio of a State's erroneous excess payments for medical assistance (as defined in subparagraph (D)) to its total expenditures for medical assistance under the State plan approved under this subchapter exceeds 0.03, for the period consisting of the third and fourth quarters of fiscal year 1983, or for any full fiscal year thereafter, then the Secretary shall make no payment for such period or fiscal year with respect to so much of such erroneous excess payments as exceeds such allowable error rate of 0.03.
(B) The Secretary may waive, in certain limited cases, all or part of the reduction required under subparagraph (A) with respect to any State if such State is unable to reach the allowable error rate for a period or fiscal year despite a good faith effort by such State.
(C) In estimating the amount to be paid to a State under subsection (d) of this section, the Secretary shall take into consideration the limitation on Federal financial participation imposed by subparagraph (A) and shall reduce the estimate he makes under subsection (d)(1) of this section, for purposes of payment to the State under subsection (d)(3) of this section, in light of any expected erroneous excess payments for medical assistance (estimated in accordance with such criteria, including sampling procedures, as he may prescribe and subject to subsequent adjustment, if necessary, under subsection (d)(2) of this section).
(D)(i) For purposes of this subsection, the term "erroneous excess payments for medical assistance" means the total of—
(I) payments under the State plan with respect to ineligible individuals and families, and
(II) overpayments on behalf of eligible individuals and families by reason of error in determining the amount of expenditures for medical care required of an individual or family as a condition of eligibility.
(ii) In determining the amount of erroneous excess payments for medical assistance to an ineligible individual or family under clause (i)(I), if such ineligibility is the result of an error in determining the amount of the resources of such individual or family, the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment with respect to such individual or family, or (II) the difference between the actual amount of such resources and the allowable resource level established under the State plan.
(iii) In determining the amount of erroneous excess payments for medical assistance to an individual or family under clause (i)(II), the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment on behalf of the individual or family, or (II) the difference between the actual amount incurred for medical care by the individual or family and the amount which should have been incurred in order to establish eligibility for medical assistance.
(iv) In determining the amount of erroneous excess payments, there shall not be included any error resulting from a failure of an individual to cooperate or give correct information with respect to third-party liability as required under section 1396k(a)(1)(C) or 602(a)(26)(C) 10 of this title or with respect to payments made in violation of
(v) In determining the amount of erroneous excess payments, there shall not be included any erroneous payments made for ambulatory prenatal care provided during a presumptive eligibility period (as defined in
(E) For purposes of subparagraph (D), there shall be excluded, in determining both erroneous excess payments for medical assistance and total expenditures for medical assistance—
(i) payments with respect to any individual whose eligibility therefor was determined exclusively by the Secretary under an agreement pursuant to
(ii) payments made as the result of a technical error.
(2) The State agency administering the plan approved under this subchapter shall, at such times and in such form as the Secretary may specify, provide information on the rates of erroneous excess payments made (or expected, with respect to future periods specified by the Secretary) in connection with its administration of such plan, together with any other data he requests that are reasonably necessary for him to carry out the provisions of this subsection.
(3)(A) If a State fails to cooperate with the Secretary in providing information necessary to carry out this subsection, the Secretary, directly or through contractual or such other arrangements as he may find appropriate, shall establish the error rates for that State on the basis of the best data reasonably available to him and in accordance with such techniques for sampling and estimating as he finds appropriate.
(B) In any case in which it is necessary for the Secretary to exercise his authority under subparagraph (A) to determine a State's error rates for a fiscal year, the amount that would otherwise be payable to such State under this subchapter for quarters in such year shall be reduced by the costs incurred by the Secretary in making (directly or otherwise) such determination.
(4) This subsection shall not apply with respect to Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, or American Samoa.
(v) Medical assistance to aliens not lawfully admitted for permanent residence
(1) Notwithstanding the preceding provisions of this section, except as provided in paragraph (2), no payment may be made to a State under this section for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law.
(2) Payment shall be made under this section for care and services that are furnished to an alien described in paragraph (1) only if—
(A) such care and services are necessary for the treatment of an emergency medical condition of the alien,
(B) such alien otherwise meets the eligibility requirements for medical assistance under the State plan approved under this subchapter (other than the requirement of the receipt of aid or assistance under subchapter IV of this chapter, supplemental security income benefits under subchapter XVI of this chapter, or a State supplementary payment), and
(C) such care and services are not related to an organ transplant procedure.
(3) For purposes of this subsection, the term "emergency medical condition" means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—
(A) placing the patient's health in serious jeopardy,
(B) serious impairment to bodily functions, or
(C) serious dysfunction of any bodily organ or part.
(w) Prohibition on use of voluntary contributions, and limitation on use of provider-specific taxes to obtain Federal financial participation under medicaid
(1)(A) Notwithstanding the previous provisions of this section, for purposes of determining the amount to be paid to a State (as defined in paragraph (7)(D)) under subsection (a)(1) of this section for quarters in any fiscal year, the total amount expended during such fiscal year as medical assistance under the State plan (as determined without regard to this subsection) shall be reduced by the sum of any revenues received by the State (or by a unit of local government in the State) during the fiscal year—
(i) from provider-related donations (as defined in paragraph (2)(A)), other than—
(I) bona fide provider-related donations (as defined in paragraph (2)(B)), and
(II) donations described in paragraph (2)(C);
(ii) from health care related taxes (as defined in paragraph (3)(A)), other than broad-based health care related taxes (as defined in paragraph (3)(B));
(iii) from a broad-based health care related tax, if there is in effect a hold harmless provision (described in paragraph (4)) with respect to the tax; or
(iv) only with respect to State fiscal years (or portions thereof) occurring on or after January 1, 1992, and before October 1, 1995, from broad-based health care related taxes to the extent the amount of such taxes collected exceeds the limit established under paragraph (5).
(B) Notwithstanding the previous provisions of this section, for purposes of determining the amount to be paid to a State under subsection (a)(7) of this section for all quarters in a Federal fiscal year (beginning with fiscal year 1993), the total amount expended during the fiscal year for administrative expenditures under the State plan (as determined without regard to this subsection) shall be reduced by the sum of any revenues received by the State (or by a unit of local government in the State) during such quarters from donations described in paragraph (2)(C), to the extent the amount of such donations exceeds 10 percent of the amounts expended under the State plan under this subchapter during the fiscal year for purposes described in paragraphs (2), (3), (4), (6), and (7) of subsection (a) of this section.
(C)(i) Except as otherwise provided in clause (ii), subparagraph (A)(i) shall apply to donations received on or after January 1, 1992.
(ii) Subject to the limits described in clause (iii) and subparagraph (E), subparagraph (A)(i) shall not apply to donations received before the effective date specified in subparagraph (F) if such donations are received under programs in effect or as described in State plan amendments or related documents submitted to the Secretary by September 30, 1991, and applicable to State fiscal year 1992, as demonstrated by State plan amendments, written agreements, State budget documentation, or other documentary evidence in existence on that date.
(iii) In applying clause (ii) in the case of donations received in State fiscal year 1993, the maximum amount of such donations to which such clause may be applied may not exceed the total amount of such donations received in the corresponding period in State fiscal year 1992 (or not later than 5 days after the last day of the corresponding period).
(D)(i) Except as otherwise provided in clause (ii), subparagraphs (A)(ii) and (A)(iii) shall apply to taxes received on or after January 1, 1992.
(ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to impermissible taxes (as defined in clause (iii)) received before the effective date specified in subparagraph (F) to the extent the taxes (including the tax rate or base) were in effect, or the legislation or regulations imposing such taxes were enacted or adopted, as of November 22, 1991.
(iii) In this subparagraph and subparagraph (E), the term "impermissible tax" means a health care related tax for which a reduction may be made under clause (ii) or (iii) of subparagraph (A).
(E)(i) In no case may the total amount of donations and taxes permitted under the exception provided in subparagraphs (C)(ii) and (D)(ii) for the portion of State fiscal year 1992 occurring during calendar year 1992 exceed the limit under paragraph (5) minus the total amount of broad-based health care related taxes received in the portion of that fiscal year.
(ii) In no case may the total amount of donations and taxes permitted under the exception provided in subparagraphs (C)(ii) and (D)(ii) for State fiscal year 1993 exceed the limit under paragraph (5) minus the total amount of broad-based health care related taxes received in that fiscal year.
(F) In this paragraph in the case of a State—
(i) except as provided in clause (iii), with a State fiscal year beginning on or before July 1, the effective date is October 1, 1992,
(ii) except as provided in clause (iii), with a State fiscal year that begins after July 1, the effective date is January 1, 1993, or
(iii) with a State legislature which is not scheduled to have a regular legislative session in 1992, with a State legislature which is not scheduled to have a regular legislative session in 1993, or with a provider-specific tax enacted on November 4, 1991, the effective date is July 1, 1993.
(2)(A) In this subsection (except as provided in paragraph (6)), the term "provider-related donation" means any donation or other voluntary payment (whether in cash or in kind) made (directly or indirectly) to a State or unit of local government by—
(i) a health care provider (as defined in paragraph (7)(B)),
(ii) an entity related to a health care provider (as defined in paragraph (7)(C)), or
(iii) an entity providing goods or services under the State plan for which payment is made to the State under paragraph (2), (3), (4), (6), or (7) of subsection (a) of this section.
(B) For purposes of paragraph (1)(A)(i)(I), the term "bona fide provider-related donation" means a provider-related donation that has no direct or indirect relationship (as determined by the Secretary) to payments made under this subchapter to that provider, to providers furnishing the same class of items and services as that provider, or to any related entity, as established by the State to the satisfaction of the Secretary. The Secretary may by regulation specify types of provider-related donations described in the previous sentence that will be considered to be bona fide provider-related donations.
(C) For purposes of paragraph (1)(A)(i)(II), donations described in this subparagraph are funds expended by a hospital, clinic, or similar entity for the direct cost (including costs of training and of preparing and distributing outreach materials) of State or local agency personnel who are stationed at the hospital, clinic, or entity to determine the eligibility of individuals for medical assistance under this subchapter and to provide outreach services to eligible or potentially eligible individuals.
(3)(A) In this subsection (except as provided in paragraph (6)), the term "health care related tax" means a tax (as defined in paragraph (7)(F)) that—
(i) is related to health care items or services, or to the provision of, the authority to provide, or payment for, such items or services, or
(ii) is not limited to such items or services but provides for treatment of individuals or entities that are providing or paying for such items or services that is different from the treatment provided to other individuals or entities.
In applying clause (i), a tax is considered to relate to health care items or services if at least 85 percent of the burden of such tax falls on health care providers.
(B) In this subsection, the term "broad-based health care related tax" means a health care related tax which is imposed with respect to a class of health care items or services (as described in paragraph (7)(A)) or with respect to providers of such items or services and which, except as provided in subparagraphs (D), (E), and (F)—
(i) is imposed at least with respect to all items or services in the class furnished by all non-Federal, nonpublic providers in the State (or, in the case of a tax imposed by a unit of local government, the area over which the unit has jurisdiction) or is imposed with respect to all non-Federal, nonpublic providers in the class; and
(ii) is imposed uniformly (in accordance with subparagraph (C)).
(C)(i) Subject to clause (ii), for purposes of subparagraph (B)(ii), a tax is considered to be imposed uniformly if—
(I) in the case of a tax consisting of a licensing fee or similar tax on a class of health care items or services (or providers of such items or services), the amount of the tax imposed is the same for every provider providing items or services within the class;
(II) in the case of a tax consisting of a licensing fee or similar tax imposed on a class of health care items or services (or providers of such services) on the basis of the number of beds (licensed or otherwise) of the provider, the amount of the tax is the same for each bed of each provider of such items or services in the class;
(III) in the case of a tax based on revenues or receipts with respect to a class of items or services (or providers of items or services) the tax is imposed at a uniform rate for all items and services (or providers of such items or services) in the class on all the gross revenues or receipts, or net operating revenues, relating to the provision of all such items or services (or all such providers) in the State (or, in the case of a tax imposed by a unit of local government within the State, in the area over which the unit has jurisdiction); or
(IV) in the case of any other tax, the State establishes to the satisfaction of the Secretary that the tax is imposed uniformly.
(ii) Subject to subparagraphs (D) and (E), a tax imposed with respect to a class of health care items and services is not considered to be imposed uniformly if the tax provides for any credits, exclusions, or deductions which have as their purpose or effect the return to providers of all or a portion of the tax paid in a manner that is inconsistent with subclauses (I) and (II) of subparagraph (E)(ii) or provides for a hold harmless provision described in paragraph (4).
(D) A tax imposed with respect to a class of health care items and services is considered to be imposed uniformly—
(i) notwithstanding that the tax is not imposed with respect to items or services (or the providers thereof) for which payment is made under a State plan under this subchapter or subchapter XVIII of this chapter, or
(ii) in the case of a tax described in subparagraph (C)(i)(III), notwithstanding that the tax provides for exclusion (in whole or in part) of revenues or receipts from a State plan under this subchapter or subchapter XVIII of this chapter.
(E)(i) A State may submit an application to the Secretary requesting that the Secretary treat a tax as a broad-based health care related tax, notwithstanding that the tax does not apply to all health care items or services in class (or all providers of such items and services), provides for a credit, deduction, or exclusion, is not applied uniformly, or otherwise does not meet the requirements of subparagraph (B) or (C). Permissible waivers may include exemptions for rural or sole-community providers.
(ii) The Secretary shall approve such an application if the State establishes to the satisfaction of the Secretary that—
(I) the net impact of the tax and associated expenditures under this subchapter as proposed by the State is generally redistributive in nature, and
(II) the amount of the tax is not directly correlated to payments under this subchapter for items or services with respect to which the tax is imposed.
The Secretary shall by regulation specify types of credits, exclusions, and deductions that will be considered to meet the requirements of this subparagraph.
(F) In no case shall a tax not qualify as a broad-based health care related tax under this paragraph because it does not apply to a hospital that is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under section 501(a) of such Code and that does not accept payment under the State plan under this subchapter or under subchapter XVIII of this chapter.
(4) For purposes of paragraph (1)(A)(iii), there is in effect a hold harmless provision with respect to a broad-based health care related tax imposed with respect to a class of items or services if the Secretary determines that any of the following applies:
(A) The State or other unit of government imposing the tax provides (directly or indirectly) for a payment (other than under this subchapter) to taxpayers and the amount of such payment is positively correlated either to the amount of such tax or to the difference between the amount of the tax and the amount of payment under the State plan.
(B) All or any portion of the payment made under this subchapter to the taxpayer varies based only upon the amount of the total tax paid.
(C) The State or other unit of government imposing the tax provides (directly or indirectly) for any payment, offset, or waiver that guarantees to hold taxpayers harmless for any portion of the costs of the tax.
The provisions of this paragraph shall not prevent use of the tax to reimburse health care providers in a class for expenditures under this subchapter nor preclude States from relying on such reimbursement to justify or explain the tax in the legislative process.
(5)(A) For purposes of this subsection, the limit under this subparagraph with respect to a State is an amount equal to 25 percent (or, if greater, the State base percentage, as defined in subparagraph (B)) of the non-Federal share of the total amount expended under the State plan during a State fiscal year (or portion thereof), as it would be determined pursuant to paragraph (1)(A) without regard to paragraph (1)(A)(iv).
(B)(i) In subparagraph (A), the term "State base percentage" means, with respect to a State, an amount (expressed as a percentage) equal to—
(I) the total of the amount of health care related taxes (whether or not broad-based) and the amount of provider-related donations (whether or not bona fide) projected to be collected (in accordance with clause (ii)) during State fiscal year 1992, divided by
(II) the non-Federal share of the total amount estimated to be expended under the State plan during such State fiscal year.
(ii) For purposes of clause (i)(I), in the case of a tax that is not in effect throughout State fiscal year 1992 or the rate (or base) of which is increased during such fiscal year, the Secretary shall project the amount to be collected during such fiscal year as if the tax (or increase) were in effect during the entire State fiscal year.
(C)(i) The total amount of health care related taxes under subparagraph (B)(i)(I) shall be determined by the Secretary based on only those taxes (including the tax rate or base) which were in effect, or for which legislation or regulations imposing such taxes were enacted or adopted, as of November 22, 1991.
(ii) The amount of provider-related donations under subparagraph (B)(i)(I) shall be determined by the Secretary based on programs in effect on September 30, 1991, and applicable to State fiscal year 1992, as demonstrated by State plan amendments, written agreements, State budget documentation, or other documentary evidence in existence on that date.
(iii) The amount of expenditures described in subparagraph (B)(i)(II) shall be determined by the Secretary based on the best data available as of December 12, 1991.
(6)(A) Notwithstanding the provisions of this subsection, the Secretary may not restrict States' use of funds where such funds are derived from State or local taxes (or funds appropriated to State university teaching hospitals) transferred from or certified by units of government within a State as the non-Federal share of expenditures under this subchapter, regardless of whether the unit of government is also a health care provider, except as provided in
(B) For purposes of this subsection, funds the use of which the Secretary may not restrict under subparagraph (A) shall not be considered to be a provider-related donation or a health care related tax.
(7) For purposes of this subsection:
(A) Each of the following shall be considered a separate class of health care items and services:
(i) Inpatient hospital services.
(ii) Outpatient hospital services.
(iii) Nursing facility services (other than services of intermediate care facilities for the mentally retarded).
(iv) Services of intermediate care facilities for the mentally retarded.
(v) Physicians' services.
(vi) Home health care services.
(vii) Outpatient prescription drugs.
(viii) Services of a medicaid managed care organization with a contract under subsection (m) of this section.
(ix) Such other classification of health care items and services consistent with this subparagraph as the Secretary may establish by regulation.
(B) The term "health care provider" means an individual or person that receives payments for the provision of health care items or services.
(C) An entity is considered to be "related" to a health care provider if the entity—
(i) is an organization, association, corporation or partnership formed by or on behalf of health care providers;
(ii) is a person with an ownership or control interest (as defined in
(iii) is the employee, spouse, parent, child, or sibling of the provider (or of a person described in clause (ii)); or
(iv) has a similar, close relationship (as defined in regulations) to the provider.
(D) The term "State" means only the 50 States and the District of Columbia but does not include any State whose entire program under this subchapter is operated under a waiver granted under
(E) The "State fiscal year" means, with respect to a specified year, a State fiscal year ending in that specified year.
(F) The term "tax" includes any licensing fee, assessment, or other mandatory payment, but does not include payment of a criminal or civil fine or penalty (other than a fine or penalty imposed in lieu of or instead of a fee, assessment, or other mandatory payment).
(G) The term "unit of local government" means, with respect to a State, a city, county, special purpose district, or other governmental unit in the State.
(Aug. 14, 1935, ch. 531, title XIX, §1903, as added
Repeal of Subsection (m)(2)(A)(ix)
References in Text
Parts A and B of subchapter XVIII of this chapter, referred to in subsecs. (b) and (i), are classified to sections 1395c et seq. and 1395j et seq., respectively, of this title.
Subsection (w)(3)(A) of this section, referred to in subsec. (b)(5), was in the original "section 1902(w)(3)(A)", and was translated as reading "section 1903(w)(3)(A)", meaning section 1903(w)(3)(A) of the Social Security Act, to reflect the probable intent of Congress, because section 1902(w)(3), which is classified to
The Individuals with Disabilities Education Act, referred to in subsec. (c), is title VI of
Part A of subchapter IV of this chapter, referred to in subsec. (f), is classified to
The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (i)(16), is
Part C of subchapter XVIII of this chapter, referred to in subsec. (m)(1)(A), is classified to
The Appalachian Regional Development Act of 1965, referred to in subsec. (m)(2)(B)(ii), (G), is
Part C of subchapter XI of this chapter, referred to in subsec. (r)(1)(D), is classified to
The Internal Revenue Code of 1986, referred to in subsecs. (d)(3)(B)(i) and (w)(3)(F), is classified generally to Title 26, Internal Revenue Code.
Amendments
1999—Subsec. (a)(3)(C)(i).
Subsec. (b)(4).
Subsec. (d)(3).
Subsec. (d)(3)(B).
Subsec. (f)(2).
Subsec. (f)(4).
Subsec. (i)(14).
Subsec. (i)(19).
Subsec. (i)(20).
Subsec. (m)(2)(A)(vi).
Subsec. (m)(2)(A)(xi), (xii).
Subsec. (m)(6)(B)(ii).
Subsec. (m)(6)(B)(iii).
Subsec. (m)(6)(B)(iv).
Subsec. (o).
Subsec. (q)(3).
Subsec. (q)(4).
Subsec. (q)(5).
Subsec. (w)(1)(B).
Subsec. (w)(3)(B).
Subsec. (w)(7)(A)(viii).
1997—Subsec. (a)(3)(C).
Subsec. (b)(4).
Subsec. (b)(5).
Subsec. (f)(4).
Subsec. (f)(4)(C).
Subsec. (i).
Subsec. (i)(2).
Subsec. (i)(10)(B), (11).
Subsec. (i)(12).
Subsec. (i)(13).
Subsec. (i)(16).
Subsec. (i)(17).
Subsec. (i)(18).
Subsec. (k).
Subsec. (m)(1)(A).
Subsec. (m)(1)(A)(ii).
Subsec. (m)(1)(B).
Subsec. (m)(1)(C).
Subsec. (m)(2)(A)(i).
Subsec. (m)(2)(A)(ii).
Subsec. (m)(2)(A)(iii).
Subsec. (m)(2)(A)(vi).
Subsec. (m)(2)(A)(ix).
Subsec. (m)(2)(A)(xi).
Subsec. (m)(2)(C) to (E).
"(C) Subparagraph (A)(ii) shall not apply with respect to payments under this subchapter to a State with respect to expenditures incurred by it for payment for services by an entity during the three-year period beginning on October 8, 1976, or beginning on the date the entity qualifies as a health maintenance organization (as determined by the Secretary), whichever occurs later, but only if the entity demonstrates to the satisfaction of the Secretary by the submission of plans for each year of such three-year period that it is making continuous efforts and progress toward achieving compliance with subparagraph (A)(ii).
"(D) In the case of a health maintenance organization that is a public entity, the Secretary may modify or waive the requirement described in subparagraph (A)(ii) but only if the Secretary determines that the organization has taken and is taking reasonable efforts to enroll individuals who are not entitled to benefits under the State plan approved under this subchapter or under subchapter XVIII of this chapter.
"(E) In the case of a health maintenance organization that—
"(i) is a nonprofit organization with at least 25,000 members,
"(ii) is and has been a qualified health maintenance organization (as defined in
"(iii) provides basic health services through members of the staff of the organization,
"(iv) is located in an area designated as medically underserved under
"(v) previously received a waiver of the requirement described in subparagraph (A)(ii) under
the Secretary may modify or waive the requirement described in subparagraph (A)(ii) but only if the Secretary determines that special circumstances warrant such modification or waiver and that the organization has taken and is taking reasonable efforts to enroll individuals who are not entitled to benefits under the State plan approved under this subchapter or under subchapter XVIII of this chapter."
Subsec. (m)(2)(F).
"(i) a contract with an entity described in subparagraph (E) or (G), with a qualified health maintenance organization (as defined in
"(ii) a program pursuant to an undertaking described in paragraph (6) in which at least 25 percent of the membership enrolled on a prepaid basis are individuals who (I) are not insured for benefits under part B of subchapter XVIII of this chapter or eligible for benefits under this subchapter, and (II) (in the case of such individuals whose prepayments are made in whole or in part by any government entity) had the opportunity at the time of enrollment in the program to elect other coverage of health care costs that would have been paid in whole or in part by any governmental entity,
a State plan may restrict the period in which requests for termination of enrollment without cause under subparagraph (A)(vi)(I) are permitted to the first month of each period of enrollment, each such period of enrollment not to exceed six months in duration, but only if the State provides notification, at least twice per year, to individuals enrolled with such entity or organization of the right to terminate such enrollment and the restriction on the exercise of this right. Such restriction shall not apply to requests for termination of enrollment for cause."
Subsec. (m)(2)(G).
Subsec. (m)(2)(H).
Subsec. (m)(2)(H)(i).
Subsec. (m)(4)(A).
Subsec. (r)(1).
"(1)(A) In order to receive payments under paragraphs (2)(A) and (7) of subsection (a) of this section without being subject to per centum reductions set forth in subparagraph (C) of this paragraph, a State must provide that mechanized claims processing and information retrieval systems of the type described in subsection (a)(3)(B) of this section and detailed in an advance planning document approved by the Secretary are operational on or before the deadline established under subparagraph (B).
"(B) The deadline for operation of such systems for a State is September 30, 1985.
"(C) If a State fails to meet the deadline established under subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) of subsection (a) of this section with respect to that State shall each be reduced by 5 percentage points for the first two quarters beginning on or after such deadline, and shall be further reduced by an additional 5 percentage points after each period consisting of two quarters during which the Secretary determines the State fails to meet the requirements of subparagraph (A); except that—
"(i) neither such per centum may be reduced by more than 25 percentage points by reason of this paragraph; and
"(ii) no reduction shall be made under this paragraph for any quarter following the quarter during which such State meets the requirements of subparagraph (A)."
Subsec. (r)(2).
"(2)(A) In order to receive payments under paragraphs (2)(A) and (7) of subsection (a) of this section without being subject to the per centum reductions set forth in subparagraph (C) of this paragraph, a State must have its mechanized claims processing and information retrieval systems, of the type required to be operational under paragraph (1), initially approved by the Secretary in accordance with paragraph (5)(A) on or before the deadline established under subparagraph (B).
"(B) The deadline for approval of such systems for a State is the last day of the fourth quarter that begins after the date on which the Secretary determines that such systems became operational as required under paragraph (1).
"(C) If a State fails to meet the deadline established under subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) of subsection (a) of this section with respect to that State shall each be reduced by 5 percentage points for the first two quarters beginning after such deadline, and shall be further reduced by an additional 5 percentage points at the end of each period consisting of two quarters during which the State fails to meet the requirements of subparagraph (A); except that—
"(i) neither such per centum may be reduced by more than 25 percentage points by reason of this paragraph, and
"(ii) no reduction shall be made under this paragraph for any quarter following the quarter during which such State's systems are approved by the Secretary as provided in subparagraph (A).
"(D) Any State's systems which are approved by the Secretary for purposes of subsection (a)(3)(B) of this section on or before October 7, 1980, shall be deemed to be initially approved for purposes of this subsection."
Subsec. (r)(3), (4).
Subsec. (r)(5).
Subsec. (r)(6) to (8).
Subsec. (u)(1)(D)(v).
Subsec. (w)(3)(B).
Subsec. (w)(3)(F).
Subsec. (w)(7)(A)(viii).
1996—Subsec. (i)(9).
Subsec. (i)(12)(A)(i).
Subsec. (i)(12)(A)(vi).
Subsec. (i)(12)(A)(vii).
Subsec. (i)(12)(B)(i).
Subsec. (i)(12)(B)(vi).
Subsec. (i)(12)(B)(vii).
1993—Subsec. (i)(10).
Subsec. (i)(11).
Subsec. (i)(12).
Subsec. (i)(13).
Subsec. (i)(14).
Subsec. (i)(15).
Subsec. (o).
Subsec. (s).
Subsec. (v)(2)(C).
1991—Subsec. (a)(1).
Subsec. (c).
Subsec. (d)(6).
Subsec. (i)(10).
Subsec. (w).
1990—Subsec. (a)(1).
Subsec. (a)(2)(B).
Subsec. (a)(3)(C), (D).
Subsec. (f)(2).
Subsec. (f)(4).
Subsec. (i)(8).
Subsec. (i)(10).
Subsec. (i)(11).
Subsec. (i)(12).
Subsec. (i)(14).
Subsec. (m)(1)(A).
Subsec. (m)(2)(A)(i).
Subsec. (m)(2)(A)(ix).
Subsec. (m)(2)(A)(x).
Subsec. (m)(2)(A)(xi).
Subsec. (m)(2)(B).
Subsec. (m)(2)(D).
Subsec. (m)(2)(F)(i).
Subsec. (m)(2)(H).
Subsec. (m)(3).
Subsec. (m)(5)(A)(v).
Subsec. (u)(1)(D)(iv).
1989—Subsec. (a)(2)(B).
Subsec. (f)(4).
Subsec. (i)(2).
Subsec. (i)(5).
1988—Subsec. (a)(1).
Subsec. (c).
Subsec. (f)(2).
Subsec. (f)(4).
Subsec. (i)(2)(A).
Subsec. (i)(2)(B).
Subsec. (i)(3).
Subsec. (i)(5).
Subsec. (i)(9).
Subsec. (m)(2)(B)(i)(II).
Subsec. (m)(2)(F).
Subsec. (m)(5).
"(A) Any entity with a contract under this subsection that fails substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under such contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals, is subject to a civil money penalty of not more than $10,000 for each such failure.
"(B) The provisions of
1987—Subsec. (a)(1).
Subsec. (a)(2)(A) to (C).
Subsec. (a)(2)(D).
Subsec. (a)(3)(C).
Subsec. (a)(7).
Subsec. (f)(2).
Subsec. (f)(4).
Subsec. (g)(1).
Subsec. (g)(4)(B).
Subsec. (g)(6)(B) to (D).
"(i) 30 days after the date of the initial certification,
"(ii) 60 days after the date of the initial certification,
"(iii) 90 days after the date of the initial certification, and
"(iv) every 60 days thereafter."
Subsec. (g)(7).
Subsec. (h).
Subsec. (i).
Subsec. (i)(1).
Subsec. (i)(2).
Subsec. (i)(2)(A).
Subsec. (i)(2)(B).
Subsec. (i)(3).
Subsec. (i)(4).
Subsec. (i)(8).
Subsec. (m)(2)(F).
Subsec. (m)(6).
Subsec. (n).
Subsec. (r).
1986—Subsec. (a)(1).
Subsec. (a)(3)(C).
Subsec. (a)(4).
Subsec. (d)(2).
Subsec. (f)(4).
Subsec. (i)(1).
Subsec. (m)(2)(A).
Subsec. (m)(2)(A)(iii).
Subsec. (m)(2)(A)(viii).
Subsec. (m)(2)(F).
Subsec. (m)(2)(G).
Subsec. (m)(4).
Subsec. (m)(5).
Subsec. (r)(1)(B).
Subsec. (r)(4)(A).
Subsec. (r)(6)(J).
Subsec. (u)(1)(D)(iv).
Subsec. (u)(1)(D)(v).
Subsec. (v).
1984—Subsec. (g)(1).
Subsec. (g)(4)(B).
Subsec. (g)(6).
Subsec. (g)(7).
Subsec. (i)(7).
Subsec. (m)(2)(A)(vi).
Subsec. (m)(2)(B)(i)(I).
Subsec. (m)(2)(B)(i)(II).
Subsec. (m)(2)(C).
Subsec. (m)(2)(E), (F).
Subsec. (s)(3)(B).
1983—Subsec. (t)(3).
1982—Subsec. (a)(3)(C).
Subsec. (f)(3).
Subsec. (g)(1).
Subsec. (g)(1)(A).
Subsec. (k).
Subsec. (m)(2)(A).
Subsec. (s).
Subsec. (s)(1)(A).
Subsec. (s)(1)(C).
Subsec. (s)(3)(D).
Subsec. (s)(4)(B).
Subsec. (s)(5)(A)(i).
Subsec. (s)(5)(B).
Subsec. (t).
Subsec. (t)(1)(A).
Subsec. (t)(1)(B).
Subsec. (t)(1)(C).
Subsec. (t)(2)(A).
Subsec. (t)(3).
Subsec. (u).
1981—Subsec. (a)(3)(B).
Subsec. (d)(5).
Subsec. (e).
Subsec. (g)(1)(A).
Subsec. (i)(1).
Subsec. (i)(5).
Subsec. (i)(6).
Subsec. (m)(1)(A).
Subsec. (m)(2)(A).
Subsec. (m)(2)(D).
Subsec. (n).
Subsec. (s).
Subsec. (t).
1980—Subsec. (a)(1).
Subsec. (a)(6).
Subsec. (d)(5).
Subsec. (g)(3)(B).
Subsec. (j).
Subsec. (n).
Subsec. (r).
1979—Subsec. (m)(2)(C).
1978—Subsec. (m)(1)(B).
Subsec. (m)(2)(B)(i)(I).
1977—Subsec. (a)(3)(B).
Subsec. (a)(6), (7).
Subsec. (b)(3).
Subsec. (g).
Subsec. (i)(2).
Subsec. (m)(2)(A).
Subsec. (m)(2)(C).
Subsec. (n).
Subsecs. (o), (p).
Subsec. (q).
1976—Subsec. (l).
Subsec. (m).
1975—Subsec. (g)(1)(C).
Subsec. (l).
1973—Subsec. (a).
Subsec. (a)(1).
Subsec. (a)(4).
Subsec. (a)(5).
Subsec. (b).
Subsec. (c).
Subsec. (d)(1).
Subsec. (f)(4).
Subsec. (g)(1)(C).
Subsec. (j).
1972—Subsec. (a)(1).
Subsec. (a)(3).
Subsec. (a)(4).
Subsec. (a)(5).
Subsec. (a)(6).
Subsec. (b)(1).
Subsec. (b)(3).
Subsec. (e).
Subsec. (g).
Subsec. (h).
Subsec. (i).
Subsec. (j).
Subsec. (k).
1969—Subsec. (e).
1968—Subsec. (a)(1).
Subsec. (a)(2).
Subsec. (b).
Subsec. (b)(2).
Subsec. (d)(2).
Subsec. (f).
Effective Date of 1999 Amendments
Amendment by section 201(a)(4), (b) of
Amendment by section 1000(a)(6) [title VI, §604(a)(2)(B), (b)(2)] of
Amendment by section 1000(a)(6) [title VI, §608(e)–(k)] of
Effective Date of 1997 Amendments
Section 162 of
Section 4710 of title IV of
"(a)
"(b)
"(1)
"(2) 75:25
"(3)
"(4)
"(A)
"(B)
"(5)
"(6)
"(7) 6-
"(c)
Amendment by section 4712(b)(2) of
Section 4722(d) of
Section 4724(b)(2) of
Section 4742(b) of
Amendment by section 4753(a) of
Amendment by section 4912(b)(2) of
Amendment by
Effective Date of 1996 Amendments
Section 1(b)(2) of
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13602(b) of
Section 13604(b) of
"(1) Subject to paragraph (2), the amendments made by subsection (a) [amending this section] shall apply as if included in the enactment of OBRA–1986 [
"(2) The Secretary of Health and Human Services shall not disallow expenditures made for the care and services described in section 1903(v)(2)(C) of the Social Security Act [subsec. (v)(2)(C) of this section], as added by subsection (a), furnished before the date of the enactment of this Act [Aug. 10, 1993]."
Amendment by section 13622(a)(2) of
Section 13624(b) of
Section 13631(h)(2) of
Amendment by section 13631(c) of
Effective Date of 1991 Amendment
Amendments by section 2(a), (b)(2) of
Amendment by section 3(b)(2)(B) of
Section 4(b) of
Effective Date of 1990 Amendments
Amendment by section 4402(b), (d)(3) of
Amendment by section 4601(a)(3)(A) of
Section 4701(c) of
Amendment by section 4704(b)(1), (2) of
Amendment by section 4711(c)(2) of
Section 4731(c) of
Amendment by section 4751(b)(1) of
Section 4752(b)(2) of
Section 4801(a)(9) of
Section 4801(e)(16)(B) of
Effective Date of 1989 Amendments
Amendment by section 6401(b) of
Amendment by section 6901(b)(5)(A) of
Amendment by
Effective Date of 1988 Amendments
Amendment by section 608(d)(26)(K)(ii) of
Amendment by section 608(f)(4) of
Amendment by section 202(h)(2) of
Section 301(f) of
Amendment by section 302(c)(3) of
Except as specifically provided in section 411 of
Section 411(k)(12)(B) of
Section 411(k)(13)(B) of
Effective Date of 1987 Amendments
Section 4118(d)(2) of
Amendment by section 4118(h)(1) of
Amendments by sections 4211(d)(1), (g), (i), 4212(c)(1), (2), (d)(1), (e)(2) of
Amendment by section 4212(d)(1) of
Amendment by section 4213(b)(2) of
Amendment by
Effective Date of 1986 Amendments
Amendment by
Amendment by
Amendment by section 9401(e)(2) of
Amendment by section 9403(g)(2) of
Amendment by section 9406(a) of
Amendment by section 9407(c) of
Amendment by section 9431(b)(2) of
Section 9434(a)(3) of
"(A) The amendments made by paragraph (1) [amending this section] shall take effect 6 months after the date of the enactment of this Act [Oct. 21, 1986].
"(B) The amendment made by paragraph (2) [amending this section] shall take effect on the date of the enactment of this Act and shall apply to contracts entered into, renewed, or extended after the end of the 30-day period beginning on the date of the enactment of this Act."
Amendment by section 9503(b), (f) of
Section 9507(b) of
Section 9512(b) of
Section 9517(c)(2), (3) of
"(2)(A) Except as provided in subparagraph (B) and in paragraph (3), the amendments made by paragraph (1) [amending this section] shall apply to expenditures incurred for health insuring organizations which first become operational on or after January 1, 1986. For purposes of this paragraph, a health insuring organization is not considered to be operational until the date on which it first enrolls patients.
"(B) In the case of a health insuring organization—
"(i) which first becomes operational on or after January 1, 1986, but
"(ii) for which the Secretary of Health and Human Services has waived, under section 1915(b) of the Social Security Act [
clauses (ii) and (vi) of section 1903(m)(2)(A) of such Act [subsec. (m)(2)(A)(ii) and (vi) of this section] shall not apply during the period for which such waiver is effective.
"(C) In the case of the Hartford Health Network, Inc., clauses (ii) and (vi) of section 1903(m)(2)(A) of the Social Security Act shall not apply during the period for which a waiver by the Secretary of Health and Human Services, under section 1915(b) of such Act, of certain requirements of section 1902 of such Act is in effect (pursuant to a request for a waiver under section 1915(b) of such Act submitted before January 1, 1986).
"(D) Nothing in section 1903(m)(1)(A) of the Social Security Act shall be construed as requiring a health-insuring organization to be organized under the health maintenance organization laws of a State.
"(3)(A) Subject to subparagraph (C), in the case of up to 3 health insuring organizations which are described in subparagraph (B), which first become operational on or after January 1, 1986, and which are designated by the Governor, and approved by the Legislature, of California, the amendments made by paragraph (1) shall not apply.
"(B) A health insuring organization described in this subparagraph is one that—
"(i) is operated directly by a public entity established by a county government in the State of California under a State enabling statute;
"(ii) enrolls all medicaid beneficiaries residing in the county or counties in which it operates;
"(iii) meets the requirements for health maintenance organizations under the Knox-Keene Act (Cal. Health and Safety Code, section 1340 et seq.) and the Waxman-Duffy Act (Cal. Welfare and Institutions Code, section 14450 et seq.);
"(iv) assures a reasonable choice of providers, which includes providers that have historically served medicaid beneficiaries and which does not impose any restriction which substantially impairs access to covered services of adequate quality where medically necessary;
"(v) provides for a payment adjustment for a disproportionate share hospital (as defined under State law consistent with section 1923 of the Social Security Act [
"(vi) provides for payment, in the case of childrens' hospital services provided to medicaid beneficiaries who are under 21 years of age, who are children with special health care needs under title V of the Social Security Act [subchapter V of this chapter], and who are receiving care coordination services under such title, at rates determined by the California Medical Assistance Commission.
"(C) Subparagraph (A) shall not apply with respect to any period for which the Secretary of Health and Human Services determines that the number of medicaid beneficiaries enrolled with health insuring organizations described in subparagraph (B) exceeds 10 percent of the number of such beneficiaries in the State of California.
"(D) In this paragraph, the term 'medicaid beneficiary' means an individual who is entitled to medical assistance under the State plan under title XIX of the Social Security Act [this subchapter], other than a qualified medicare beneficiary who is only entitled to such assistance because of section 1902(a)(10)(E) of such title [
[
Section 9518(b) of
Effective Date of 1984 Amendments
Amendment by
Amendment by section 2303(g)(2) of
Section 2363(c) of
Effective Date of 1983 Amendment
Amendment by
Effective Date of 1982 Amendment
Section 133(b) of
Amendment by section 137(a)(1), (2) of
Amendment by section 137(b)(11)–(16), (27) of
Section 137(g) of
Amendment by section 146(b) of
Effective Date of 1981 Amendment
Amendment by section 2101(a)(2) of
Section 2103(b)(2) of
Amendment by section 2113(n) of
Section 2161(c)(1) of
Section 2161(c)(2) of
Section 2164(b) of
Amendment by section 2174(b) of
Amendment by section 2178(a) of
Section 2183(b) of
Effective Date of 1980 Amendment
Section 961(b) of
Effective Date of 1977 Amendments
Amendment by section 3(c)(2) of
Amendment by section 8(c) of
Section 10(b) of
Section 11(c) of
Section 17(e)(1) of
Section 20(c) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) The amount of any reduction in the Federal medical assistance percentage of a State, otherwise required to be imposed under section 1903(g)(1) of the Social Security Act [subsec. (g)(1) of this section] because of an unsatisfactory or invalid showing made by the State with respect to a calendar quarter beginning on or after January 1, 1977, shall be determined under such section as amended by this section. Subparagraph (B) of paragraph (4) of section 1903(g) of such Act [subsec. (g)(4)(B) of this section], as added by this section, shall apply to any showing made by a State under such section with respect to a calendar quarter beginning on or after January 1, 1977."
Section 105(a)(3) of
"(A) after October 8, 1976, under contracts under such title [this subchapter] entered into or renegotiated after such date, or
"(B) after the expiration of the one-year period beginning on such date,
whichever occurs first."
Effective Date of 1976 Amendments
Amendment by
Section 202(b) of
"(1) after the date of enactment of subsection (a) [Oct. 8, 1976] under contracts under such title entered into or renegotiated after such date, or
"(2) after the expiration of the 1-year period beginning on such date of enactment,
whichever occurs first."
Effective Date of 1975 Amendment
Section 110(b) of
Amendment by section 111(b) of
Effective Date of 1973 Amendments
Amendment by section 13(a)(11), (12) of
Amendment by section 18(u) of
Section 234(b) of
Effective Date of 1972 Amendment
Section 207(b) of
Amendment by section 226(e) of
Amendment by section 233(c) of
Section 235(b) of
Section 237(d)(1) of
Section 249B of
Effective Date of 1968 Amendments
Section 220(b) of
"(b)(1) In the case of any State whose plan under title XIX of the Social Security Act [this subchapter] is approved by the Secretary of Health, Education, and Welfare under section 1902 [
"(2) In the case of any State whose plan under title XIX of the Social Security Act [this subchapter] was approved by the Secretary of Health, Education, and Welfare under section 1902 of the Social Security Act [
"(A) with respect to the third and fourth calendar quarters of 1968, such subsection shall be applied by substituting in subsection (f) of section 1903 of the Social Security Act [subsec. (f) of this section] 150 percent for 133½ percent each time such latter figure appears in such subsection (f), and
"(B) with respect to all calendar quarters during 1969, such subsection shall be applied by substituting in subsection (f) of section 1903 of such Act [subsec. (f) of this section] 140 percent for 133½ percent each time such latter figure appears in such subsection (f)."
Section 222(d) of
Section 225(b) of
Section 303(b) of
Regulations
Section 5 of
"(a)
"(b)
"(c)
Secretary of Health and Human Services to promulgate final regulations necessary to carry out subsec. (r)(6)(j) of this section within 6 months after Apr. 7, 1986, see section 9503(c) of
References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996
For provisions that certain references to provisions of part A (§601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see
Treatment of Donation or Tax Proceeds Prior to Effective Date of Subsection (w)
Section 2(c)(2) of
Temporary Increase in Federal Match for Administrative Costs
Section 4401(b)(2) of
Report on Errors in Eligibility Determinations; Error Rate Transition Rules
Section 4607 of
Medically Needy Income Levels for Certain 1-Member Families
Section 4718 of
"(a)
"(b)
Day Habilitation and Related Services
Section 6411(g) of
"(1)
"(A) withhold, suspend, disallow, or deny Federal financial participation under section 1903(a) of the Social Security Act [subsec. (a) of this section] for day habilitation and related services under paragraph (9) or (13) of section 1905(a) of such Act [
"(B) withdraw Federal approval of any such State plan provision.
"(2)
"(A) specifies the types of day habilitation and related services that a State may cover under paragraph (9) or (13) of section 1905(a) of the Social Security Act on behalf of persons with mental retardation or with related conditions, and
"(B) any requirements respecting such coverage.
"(3)
Nurse Aide Training and Evaluation Programs; Allocation of Costs Before October 1, 1990
Section 6901(b)(5)(B) of
Clarification of Federal Matching Rate for Survey and Certification Activities
Section 6901(d)(2) of
Quality Control Transition Provisions
Section 608(h) of
Delay Quality Control Sanctions for Medicaid
Section 4117 of
Temporary Technical Error Definition
Section 4118(n) of
Enhanced Funding for Nurse Aide Training
Section 4211(d)(2) of
Expenses Incurred for Review of Care Provided to Residents of Nursing Facilities
Section 4212(c)(3) of
Quality Control Studies and Penalty Moratorium
Section 12301 of
"(a)
"(2) The Secretary shall also contract with the National Academy of Sciences to conduct a concurrent independent study for the purpose described in paragraph (1). For purposes of such study, the Secretary shall provide to the National Academy of Sciences any relevant data available to the Secretary at the onset of the study and on an ongoing basis.
"(3) The Secretary and the National Academy of Sciences shall report the results of their respective studies to the Congress within one year after the date the Secretary and the National Academy of Sciences enter into the contract required under paragraph (2).
"(b)
"(2) During the moratorium period, the Secretary and the States shall continue to operate the quality control systems in effect under title IV–A of the Social Security Act, and to calculate the error rates under the provisions referred to in paragraph (1).
"(c)
"(A) restructure the quality control systems under title XIX of the Social Security Act [this subchapter] to the extent the Secretary determines to be appropriate, taking into account the studies conducted under subsection (a); and
"(B) establish, taking into account the studies conducted under subsection (a), criteria for adjusting the reductions which shall be made for quarters prior to the implementation of the restructured quality control systems so as to eliminate reductions for those quarters which would not be required if the restructured quality control systems had been in effect during those quarters.
"(2) Beginning with the first calendar quarter after the moratorium period, the Secretary shall implement the revised quality control systems under title XIX, and shall reduce payments to States—
"(A) for quarters after the moratorium period in accordance with the restructured quality control systems; and
"(B) for quarters in and before the moratorium period, as provided under the regulations described in paragraph (1)(B).
"(d)
Effectiveness of Laws Limiting Federal Financial Participation With Respect to Erroneous Payments Made by States Under a State Plan Approved Under This Subchapter
Section 133(c) of
Medicaid Payments for Indian Health Service Facilities To Be Paid Entirely by Federal Funds; Exclusion of Payments to States in Computation of Target Amount of Federal Medicaid Expenditures
Promulgation of Regulations for Implementation of Amendments by Section 17 of Pub. L. 95–142
Section 17(e)(2) of
Deferral of Implementation of Decreases in Matching Funds
Section 6 of
Comprehensive Care and Services for Eligible Individuals by July 1, 1977; Requirement Inapplicable for Any Period Prior to July 1, 1971; Regulations; Advice to States
Section 2(b) of
Exemption of Puerto Rico, the Virgin Islands, and Guam From Limitations on Federal Payments for Medical Assistance
Section 248(d) of
Nonduplication of Payments to States; Limitation on Institutional Care
Section 121(b) of
Section Referred to in Other Sections
This section is referred to in
1 See References in Text note below.
2 So in original. The word "or" probably should precede "1396(p)(1)".
3 See References in Text note below.
4 See References in Text note below.
5 So in original. Probably should not be capitalized.
6 So in original. The comma probably should be a semicolon.
7 So in original. Probably should be followed by a comma.
8 See References in Text note below.
9 So in original. The comma probably should be a semicolon.
10 See References in Text note below.
§1396c. Operation of State plans
If the Secretary, after reasonable notice and opportunity for hearing to the State agency administering or supervising the administration of the State plan approved under this subchapter, finds—
(1) that the plan has been so changed that it no longer complies with the provisions of
(2) that in the administration of the plan there is a failure to comply substantially with any such provision;
the Secretary shall notify such State agency that further payments will not be made to the State (or, in his discretion, that payments will be limited to categories under or parts of the State plan not affected by such failure), until the Secretary is satisfied that there will no longer be any such failure to comply. Until he is so satisfied he shall make no further payments to such State (or shall limit payments to categories under or parts of the State plan not affected by such failure).
(Aug. 14, 1935, ch. 531, title XIX, §1904, as added
Section Referred to in Other Sections
This section is referred to in
§1396d. Definitions
For purposes of this subchapter—
(a) Medical assistance
The term "medical assistance" means payment of part or all of the cost of the following care and services (if provided in or after the third month before the month in which the recipient makes application for assistance or, in the case of medicare cost-sharing with respect to a qualified medicare beneficiary described in subsection (p)(1) of this section, if provided after the month in which the individual becomes such a beneficiary) for individuals, and, with respect to physicians' or dentists' services, at the option of the State, to individuals (other than individuals with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in
(i) under the age of 21, or, at the option of the State, under the age of 20, 19, or 18 as the State may choose,
(ii) relatives specified in section 606(b)(1) 1 of this title with whom a child is living if such child is (or would, if needy, be) a dependent child under part A of subchapter IV of this chapter,
(iii) 65 years of age or older,
(iv) blind, with respect to States eligible to participate in the State plan program established under subchapter XVI of this chapter,
(v) 18 years of age or older and permanently and totally disabled, with respect to States eligible to participate in the State plan program established under subchapter XVI of this chapter,
(vi) persons essential (as described in the second sentence of this subsection) to individuals receiving aid or assistance under State plans approved under subchapter I, X, XIV, or XVI of this chapter,
(vii) blind or disabled as defined in
(viii) pregnant women,
(ix) individuals provided extended benefits under
(x) individuals described in
(xi) individuals described in
(xii) employed individuals with a medically improved disability (as defined in subsection (v) of this section),
but whose income and resources are insufficient to meet all of such cost—
(1) inpatient hospital services (other than services in an institution for mental diseases);
(2)(A) outpatient hospital services, (B) consistent with State law permitting such services, rural health clinic services (as defined in subsection (l)(1) of this section) and any other ambulatory services which are offered by a rural health clinic (as defined in subsection (l)(1) of this section) and which are otherwise included in the plan, and (C) Federally-qualified health center services (as defined in subsection (l)(2) of this section) and any other ambulatory services offered by a Federally-qualified health center and which are otherwise included in the plan;
(3) other laboratory and X-ray services;
(4)(A) nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older; (B) early and periodic screening, diagnostic, and treatment services (as defined in subsection (r) of this section) for individuals who are eligible under the plan and are under the age of 21; and (C) family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State plan and who desire such services and supplies;
(5)(A) physicians' services furnished by a physician (as defined in
(6) medical care, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law;
(7) home health care services;
(8) private duty nursing services;
(9) clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician, including such services furnished outside the clinic by clinic personnel to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address;
(10) dental services;
(11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the individual may select;
(13) other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;
(14) inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases;
(15) services in an intermediate care facility for the mentally retarded (other than in an institution for mental diseases) for individuals who are determined, in accordance with
(16) effective January 1, 1973, inpatient psychiatric hospital services for individuals under age 21, as defined in subsection (h) of this section;
(17) services furnished by a nurse-midwife (as defined in
(18) hospice care (as defined in subsection (o) of this section);
(19) case management services (as defined in
(20) respiratory care services (as defined in
(21) services furnished by a certified pediatric nurse practitioner or certified family nurse practitioner (as defined by the Secretary) which the certified pediatric nurse practitioner or certified family nurse practitioner is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), whether or not the certified pediatric nurse practitioner or certified family nurse practitioner is under the supervision of, or associated with, a physician or other health care provider;
(22) home and community care (to the extent allowed and as defined in
(23) community supported living arrangements services (to the extent allowed and as defined in
(24) personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are (A) authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State, (B) provided by an individual who is qualified to provide such services and who is not a member of the individual's family, and (C) furnished in a home or other location;
(25) primary care case management services (as defined in subsection (t) of this section);
(26) services furnished under a PACE program under
(27) any other medical care, and any other type of remedial care recognized under State law, specified by the Secretary,
except as otherwise provided in paragraph (16), such term does not include—
(A) any such payments with respect to care or services for any individual who is an inmate of a public institution (except as a patient in a medical institution); or
(B) any such payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases.
For purposes of clause (vi) of the preceding sentence, a person shall be considered essential to another individual if such person is the spouse of and is living with such individual, the needs of such person are taken into account in determining the amount of aid or assistance furnished to such individual (under a State plan approved under subchapter I, X, XIV, or XVI of this chapter), and such person is determined, under such a State plan, to be essential to the well-being of such individual. The payment described in the first sentence may include expenditures for medicare cost-sharing and for premiums under part B of subchapter XVIII of this chapter for individuals who are eligible for medical assistance under the plan and (A) are receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter, or with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter, or (B) with respect to whom there is being paid a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in
(b) Federal medical assistance percentage; State percentage; Indian health care percentage
Subject to
(c) Nursing facility
For definition of the term "nursing facility", see
(d) Intermediate care facility for mentally retarded
The term "intermediate care facility for the mentally retarded" means an institution (or distinct part thereof) for the mentally retarded or persons with related conditions if—
(1) the primary purpose of such institution (or distinct part thereof) is to provide health or rehabilitative services for mentally retarded individuals and the institution meets such standards as may be prescribed by the Secretary;
(2) the mentally retarded individual with respect to whom a request for payment is made under a plan approved under this subchapter is receiving active treatment under such a program; and
(3) in the case of a public institution, the State or political subdivision responsible for the operation of such institution has agreed that the non-Federal expenditures in any calendar quarter prior to January 1, 1975, with respect to services furnished to patients in such institution (or distinct part thereof) in the State will not, because of payments made under this subchapter, be reduced below the average amount expended for such services in such institution in the four quarters immediately preceding the quarter in which the State in which such institution is located elected to make such services available under its plan approved under this subchapter.
(e) Physicians' services
In the case of any State the State plan of which (as approved under this subchapter)—
(1) does not provide for the payment of services (other than services covered under
(2) at a prior period did provide for the payment of services referred to in paragraph (1);
the term "physicians' services" (as used in subsection (a)(5) of this section) shall include services of the type which an optometrist is legally authorized to perform where the State plan specifically provides that the term "physicians' services", as employed in such plan, includes services of the type which an optometrist is legally authorized to perform, and shall be reimbursed whether furnished by a physician or an optometrist.
(f) Nursing facility services
For purposes of this subchapter, the term "nursing facility services" means services which are or were required to be given an individual who needs or needed on a daily basis nursing care (provided directly by or requiring the supervision of nursing personnel) or other rehabilitation services which as a practical matter can only be provided in a nursing facility on an inpatient basis.
(g) Chiropractors' services
If the State plan includes provision of chiropractors' services, such services include only—
(1) services provided by a chiropractor (A) who is licensed as such by the State and (B) who meets uniform minimum standards promulgated by the Secretary under
(2) services which consist of treatment by means of manual manipulation of the spine which the chiropractor is legally authorized to perform by the State.
(h) Inpatient psychiatric hospital services for individuals under age 21
(1) For purposes of paragraph (16) of subsection (a) of this section, the term "inpatient psychiatric hospital services for individuals under age 21" includes only—
(A) inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined in
(B) inpatient services which, in the case of any individual (i) involve active treatment which meets such standards as may be prescribed in regulations by the Secretary, and (ii) a team, consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof, has determined are necessary on an inpatient basis and can reasonably be expected to improve the condition, by reason of which such services are necessary, to the extent that eventually such services will no longer be necessary; and
(C) inpatient services which, in the case of any individual, are provided prior to (i) the date such individual attains age 21, or (ii) in the case of an individual who was receiving such services in the period immediately preceding the date on which he attained age 21, (I) the date such individual no longer requires such services, or (II) if earlier, the date such individual attains age 22;
(2) Such term does not include services provided during any calendar quarter under the State plan of any State if the total amount of the funds expended, during such quarter, by the State (and the political subdivisions thereof) from non-Federal funds for inpatient services included under paragraph (1), and for active psychiatric care and treatment provided on an outpatient basis for eligible mentally ill children, is less than the average quarterly amount of the funds expended, during the 4-quarter period ending December 31, 1971, by the State (and the political subdivisions thereof) from non-Federal funds for such services.
(i) Institution for mental diseases
The term "institution for mental diseases" means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.
(j) State supplementary payment
The term "State supplementary payment" means any cash payment made by a State on a regular basis to an individual who is receiving supplemental security income benefits under subchapter XVI of this chapter or who would but for his income be eligible to receive such benefits, as assistance based on need in supplementation of such benefits (as determined by the Commissioner of Social Security), but only to the extent that such payments are made with respect to an individual with respect to whom supplemental security income benefits are payable under subchapter XVI of this chapter, or would but for his income be payable under that subchapter.
(k) Supplemental security income benefits
Increased supplemental security income benefits payable pursuant to section 211 of
(l) Rural health clinics
(1) The terms "rural health clinic services" and "rural health clinic" have the meanings given such terms in
(2)(A) The term "Federally-qualified health center services" means services of the type described in subparagraphs (A) through (C) of
(B) The term "Federally-qualified health center" means an entity which—
(i) is receiving a grant under
(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and
(II) meets the requirements to receive a grant under
(iii) based on the recommendation of the Health Resources and Services Administration within the Public Health Service, is determined by the Secretary to meet the requirements for receiving such a grant, including requirements of the Secretary that an entity may not be owned, controlled, or operated by another entity, or
(iv) was treated by the Secretary, for purposes of part B of subchapter XVIII of this chapter, as a comprehensive Federally funded health center as of January 1, 1990;
and includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (
(m) Qualified family member
(1) Subject to paragraph (2), the term "qualified family member" means an individual (other than a qualified pregnant woman or child, as defined in subsection (n) of this section) who is a member of a family that would be receiving aid under the State plan under part A of subchapter IV of this chapter pursuant to section 607 4 of this title if the State had not exercised the option under section 607(b)(2)(B)(i) 4 of this title.
(2) No individual shall be a qualified family member for any period after September 30, 1998.
(n) "Qualified pregnant woman or child" defined
The term "qualified pregnant woman or child" means—
(1) a pregnant woman who—
(A) would be eligible for aid to families with dependent children under part A of subchapter IV of this chapter (or would be eligible for such aid if coverage under the State plan under part A of subchapter IV of this chapter included aid to families with dependent children of unemployed parents pursuant to
(B) is a member of a family which would be eligible for aid under the State plan under part A of subchapter IV of this chapter pursuant to
(C) otherwise meets the income and resources requirements of a State plan under part A of subchapter IV of this chapter; and
(2) a child who has not attained the age of 19, who was born after September 30, 1983 (or such earlier date as the State may designate), and who meets the income and resources requirements of the State plan under part A of subchapter IV of this chapter.
(o) Optional hospice benefits
(1)(A) Subject to subparagraph (B), the term "hospice care" means the care described in
(B) For purposes of this subchapter, with respect to the definition of hospice program under
(2) An individual's voluntary election under this subsection—
(A) shall be made in accordance with procedures that are established by the State and that are consistent with the procedures established under
(B) shall be for such a period or periods (which need not be the same periods described in
(C) may be revoked at any time without a showing of cause and may be modified so as to change the hospice program with respect to which a previous election was made.
(3) In the case of an individual—
(A) who is residing in a nursing facility or intermediate care facility for the mentally retarded and is receiving medical assistance for services in such facility under the plan,
(B) who is entitled to benefits under part A of subchapter XVIII of this chapter and has elected, under
(C) with respect to whom the hospice program under such subchapter and the nursing facility or intermediate care facility for the mentally retarded have entered into a written agreement under which the program takes full responsibility for the professional management of the individual's hospice care and the facility agrees to provide room and board to the individual,
instead of any payment otherwise made under the plan with respect to the facility's services, the State shall provide for payment to the hospice program of an amount equal to the additional amount determined in
(p) Qualified medicare beneficiary; medicare cost-sharing
(1) The term "qualified medicare beneficiary" means an individual—
(A) who is entitled to hospital insurance benefits under part A of subchapter XVIII of this chapter (including an individual entitled to such benefits pursuant to an enrollment under
(B) whose income (as determined under
(C) whose resources (as determined under
(2)(A) The income level established under paragraph (1)(B) shall be at least the percent provided under subparagraph (B) (but not more than 100 percent) of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with
(B) Except as provided in subparagraph (C), the percent provided under this clause, with respect to eligibility for medical assistance on or after—
(i) January 1, 1989, is 85 percent,
(ii) January 1, 1990, is 90 percent, and
(iii) January 1, 1991, is 100 percent.
(C) In the case of a State which has elected treatment under
(i) January 1, 1989, is 80 percent,
(ii) January 1, 1990, is 85 percent,
(iii) January 1, 1991, is 95 percent, and
(iv) January 1, 1992, is 100 percent.
(D)(i) In determining under this subsection the income of an individual who is entitled to monthly insurance benefits under subchapter II of this chapter for a transition month (as defined in clause (ii)) in a year, such income shall not include any amounts attributable to an increase in the level of monthly insurance benefits payable under such subchapter which have occurred pursuant to
(ii) For purposes of clause (i), the term "transition month" means each month in a year through the month following the month in which the annual revision of the official poverty line, referred to in subparagraph (A), is published.
(3) The term "medicare cost-sharing" means (subject to
(A)(i) premiums under
(ii) premiums under
(B) Coinsurance under subchapter XVIII of this chapter (including coinsurance described in
(C) Deductibles established under subchapter XVIII of this chapter (including those described in
(D) The difference between the amount that is paid under
Such term also may include, at the option of a State, premiums for enrollment of a qualified medicare beneficiary with an eligible organization under
(4) Notwithstanding any other provision of this subchapter, in the case of a State (other than the 50 States and the District of Columbia)—
(A) the requirement stated in
(B) for purposes of paragraph (2), the State may substitute for the percent provided under subparagraph (B) 6 or 7 1396a(a)(10)(E)(iii) of this title of such paragraph 6 any percent.
In the case of any State which is providing medical assistance to its residents under a waiver granted under
(q) Qualified severely impaired individual
The term "qualified severely impaired individual" means an individual under age 65—
(1) who for the month preceding the first month to which this subsection applies to such individual—
(A) received (i) a payment of supplemental security income benefits under
(B) was eligible for medical assistance under the State plan approved under this subchapter; and
(2) with respect to whom the Commissioner of Social Security determines that—
(A) the individual continues to be blind or continues to have the disabling physical or mental impairment on the basis of which he was found to be under a disability and, except for his earnings, continues to meet all non-disability-related requirements for eligibility for benefits under subchapter XVI of this chapter,
(B) the income of such individual would not, except for his earnings, be equal to or in excess of the amount which would cause him to be ineligible for payments under
(C) the lack of eligibility for benefits under this subchapter would seriously inhibit his ability to continue or obtain employment, and
(D) the individual's earnings are not sufficient to allow him to provide for himself a reasonable equivalent of the benefits under subchapter XVI of this chapter (including any federally administered State supplementary payments), this subchapter, and publicly funded attendant care services (including personal care assistance) that would be available to him in the absence of such earnings.
In the case of an individual who is eligible for medical assistance pursuant to
(r) Early and periodic screening, diagnostic, and treatment services
The term "early and periodic screening, diagnostic, and treatment services" means the following items and services:
(1) Screening services—
(A) which are provided—
(i) at intervals which meet reasonable standards of medical and dental practice, as determined by the State after consultation with recognized medical and dental organizations involved in child health care and, with respect to immunizations under subparagraph (B)(iii), in accordance with the schedule referred to in
(ii) at such other intervals, indicated as medically necessary, to determine the existence of certain physical or mental illnesses or conditions; and
(B) which shall at a minimum include—
(i) a comprehensive health and developmental history (including assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule referred to in
(iv) laboratory tests (including lead blood level assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).
(2) Vision services—
(A) which are provided—
(i) at intervals which meet reasonable standards of medical practice, as determined by the State after consultation with recognized medical organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include diagnosis and treatment for defects in vision, including eyeglasses.
(3) Dental services—
(A) which are provided—
(i) at intervals which meet reasonable standards of dental practice, as determined by the State after consultation with recognized dental organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health.
(4) Hearing services—
(A) which are provided—
(i) at intervals which meet reasonable standards of medical practice, as determined by the State after consultation with recognized medical organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include diagnosis and treatment for defects in hearing, including hearing aids.
(5) Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.
Nothing in this subchapter shall be construed as limiting providers of early and periodic screening, diagnostic, and treatment services to providers who are qualified to provide all of the items and services described in the previous sentence or as preventing a provider that is qualified under the plan to furnish one or more (but not all) of such items or services from being qualified to provide such items and services as part of early and periodic screening, diagnostic, and treatment services. The Secretary shall, not later than July 1, 1990, and every 12 months thereafter, develop and set annual participation goals for each State for participation of individuals who are covered under the State plan under this subchapter in early and periodic screening, diagnostic, and treatment services.
(s) Qualified disabled and working individual
The term "qualified disabled and working individual" means an individual—
(1) who is entitled to enroll for hospital insurance benefits under part A of subchapter XVIII of this chapter under
(2) whose income (as determined under
(3) whose resources (as determined under
(4) who is not otherwise eligible for medical assistance under this subchapter.
(t) Primary care case management services; primary care case manager; primary care case management contract; and primary care
(1) The term "primary care case management services" means case-management related services (including locating, coordinating, and monitoring of health care services) provided by a primary care case manager under a primary care case management contract.
(2) The term "primary care case manager" means any of the following that provides services of the type described in paragraph (1) under a contract referred to in such paragraph:
(A) A physician, a physician group practice, or an entity employing or having other arrangements with physicians to provide such services.
(B) At State option—
(i) a nurse practitioner (as described in subsection (a)(21) of this section);
(ii) a certified nurse-midwife (as defined in
(iii) a physician assistant (as defined in
(3) The term "primary care case management contract" means a contract between a primary care case manager and a State under which the manager undertakes to locate, coordinate, and monitor covered primary care (and such other covered services as may be specified under the contract) to all individuals enrolled with the manager, and which—
(A) provides for reasonable and adequate hours of operation, including 24-hour availability of information, referral, and treatment with respect to medical emergencies;
(B) restricts enrollment to individuals residing sufficiently near a service delivery site of the manager to be able to reach that site within a reasonable time using available and affordable modes of transportation;
(C) provides for arrangements with, or referrals to, sufficient numbers of physicians and other appropriate health care professionals to ensure that services under the contract can be furnished to enrollees promptly and without compromise to quality of care;
(D) prohibits discrimination on the basis of health status or requirements for health care services in enrollment, disenrollment, or reenrollment of individuals eligible for medical assistance under this subchapter;
(E) provides for a right for an enrollee to terminate enrollment in accordance with
(F) complies with the other applicable provisions of
(4) For purposes of this subsection, the term "primary care" includes all health care services customarily provided in accordance with State licensure and certification laws and regulations, and all laboratory services customarily provided by or through, a general practitioner, family medicine physician, internal medicine physician, obstetrician/gynecologist, or pediatrician.
(u) Conditions for State plans
(1) The conditions described in this paragraph for a State plan are as follows:
(A) The State is complying with the requirement of
(B) The plan provides for such reporting of information about expenditures and payments attributable to the operation of this subsection as the Secretary deems necessary in order to carry out the fourth sentence of subsection (b) of this section and
(2)(A) For purposes of subsection (b) of this section, the expenditures described in this subparagraph are expenditures for medical assistance for optional targeted low-income children described in subparagraph (B).
(B) For purposes of this paragraph, the term "optional targeted low-income child" means a targeted low-income child as defined in
(3) For purposes of subsection (b) of this section, the expenditures described in this paragraph are expenditures for medical assistance for children who are born before October 1, 1983, and who would be described in
(4) The limitations on payment under subsections (f) and (g) of
(v) Employed individual with a medically improved disability
(1) The term "employed individual with a medically improved disability" means an individual who—
(A) is at least 16, but less than 65, years of age;
(B) is employed (as defined in paragraph (2));
(C) ceases to be eligible for medical assistance under
(D) continues to have a severe medically determinable impairment, as determined under regulations of the Secretary.
(2) For purposes of paragraph (1), an individual is considered to be "employed" if the individual—
(A) is earning at least the applicable minimum wage requirement under
(B) is engaged in a work effort that meets substantial and reasonable threshold criteria for hours of work, wages, or other measures, as defined by the State and approved by the Secretary.
(w) Independent foster care adolescent
(1) For purposes of this subchapter, the term "independent foster care adolescent" means an individual—
(A) who is under 21 years of age;
(B) who, on the individual's 18th birthday, was in foster care under the responsibility of a State; and
(C) whose assets, resources, and income do not exceed such levels (if any) as the State may establish consistent with paragraph (2).
(2) The levels established by a State under paragraph (1)(C) may not be less than the corresponding levels applied by the State under
(3) A State may limit the eligibility of independent foster care adolescents under
(Aug. 14, 1935, ch. 531, title XIX, §1905, as added
References in Text
Part A of subchapter IV of this chapter, referred to in subsecs. (a), (m)(1), and (n), is classified to
Parts A and B of subchapter XVIII of this chapter, referred to in subsecs. (a), (l)(2)(B)(iv), (o)(3)(B), (p)(1)(A), and (s)(1), are classified to sections 1395c et seq. and 1395j et seq., respectively, of this title.
Section 211 of
The Indian Self-Determination Act, referred to in subsec. (l)(2)(B), is title I of
The Indian Health Care Improvement Act, referred to in subsec. (l)(2)(B), is
Clause (ii), referred to in subsec. (l)(2)(B), was redesignated as cl. (iii) by
Section 212 of
Amendments
1999—Subsec. (a)(xii).
Subsec. (a)(15).
Subsec. (b).
Subsec. (b)(1).
Subsec. (l)(2)(B).
Subsec. (v).
Subsec. (w).
1997—Subsec. (a)(25).
Subsec. (a)(26).
Subsec. (a)(27).
Subsec. (b).
Subsec. (l)(2)(B)(iii).
Subsec. (o)(3).
Subsec. (p)(3).
Subsec. (t).
Subsec. (u).
Subsec. (u)(1)(B).
Subsec. (u)(2)(A).
Subsec. (u)(2)(B), (C).
"(B) The amount described in this subparagraph, for a State for a fiscal year, is the amount of the State's allotment under
"(C) For purposes of this paragraph, the term 'optional targeted low-income child' means a targeted low-income child as defined in
Subsec. (u)(3).
Subsec. (u)(4).
1996—Subsec. (l)(2)(B)(i), (ii)(II).
1994—Subsecs. (j), (q)(2).
1993—Subsec. (a)(xi).
Subsec. (a)(7).
Subsec. (a)(17).
Subsec. (a)(19).
Subsec. (a)(21).
Subsec. (a)(22).
Subsec. (a)(23).
Subsec. (a)(24).
Subsec. (a)(25).
Subsec. (l)(2)(B).
Subsec. (l)(2)(B)(i).
Subsec. (l)(2)(B)(ii).
Subsec. (l)(2)(B)(iv).
Subsec. (r)(1)(A)(i).
Subsec. (r)(1)(B)(iii).
1990—Subsec. (a).
Subsec. (a)(x).
Subsec. (a)(2)(C).
Subsec. (a)(7).
Subsec. (a)(13).
Subsec. (a)(22).
Subsec. (a)(23).
Subsec. (a)(24).
Subsec. (h)(1)(A).
Subsec. (l)(2)(A).
Subsec. (l)(2)(B).
Subsec. (l)(2)(B)(ii), (iii).
Subsec. (n)(2).
Subsec. (o)(1)(A).
Subsec. (o)(3).
Subsec. (o)(3)(A), (C).
Subsec. (p)(1)(B).
Subsec. (p)(2)(B).
Subsec. (p)(2)(C).
Subsec. (p)(2)(D).
Subsec. (p)(4).
Subsec. (p)(4)(B).
1989—Subsec. (a)(2)(B).
Subsec. (a)(2)(C).
Subsec. (a)(4)(B).
Subsec. (a)(21), (22).
Subsec. (l).
Subsec. (p)(1)(A).
Subsec. (p)(3)(A).
Subsec. (p)(3)(A)(i).
Subsec. (p)(3)(C).
Subsec. (p)(4), (5).
Subsec. (r).
Subsec. (s).
1988—Subsec. (a).
Subsec. (a)(ix).
Subsec. (a)(5)(B).
Subsec. (a)(17).
Subsec. (i).
Subsec. (m).
Subsec. (o)(1).
Subsec. (o)(1)(B).
Subsec. (o)(3).
Subsec. (p)(1).
Subsec. (p)(1)(B).
Subsec. (p)(1)(C).
Subsec. (p)(1)(D).
Subsec. (p)(2)(A).
Subsec. (p)(2)(B).
Subsec. (p)(2)(C).
Subsec. (p)(3).
Subsec. (p)(3)(A).
Subsec. (p)(3)(B).
Subsec. (p)(3)(C).
Subsec. (p)(4).
Subsec. (p)(5).
1987—Subsec. (a)(4)(A).
Subsec. (a)(5).
Subsec. (a)(9).
Subsec. (a)(14).
Subsec. (a)(15).
Subsec. (a)(17).
Subsec. (c).
Subsec. (d).
Subsec. (f).
Subsec. (i).
Subsec. (m).
Subsec. (n)(2).
Subsec. (o)(1).
Subsec. (p)(2)(A).
1986—Subsec. (a).
Subsec. (a)(18).
Subsec. (a)(19).
Subsec. (a)(20).
Subsec. (a)(21).
Subsec. (n)(1)(C).
Subsec. (n)(2).
Subsec. (o).
Subsec. (o)(3).
Subsec. (p).
Subsec. (q).
1984—Subsec. (a).
Subsec. (a)(1).
Subsec. (a)(4).
Subsec. (a)(9).
Subsec. (a)(14), (15).
Subsec. (a)(17).
Subsec. (b).
Subsec. (d)(1).
Subsec. (h)(1)(A).
Subsec. (m).
Subsec. (n).
1982—Subsec. (a)(i).
Subsec. (a)(viii).
Subsec. (b)(2).
Subsec. (h)(1)(C).
1981—Subsec. (a).
Subsec. (b).
1980—Subsec. (a)(17), (18).
Subsec. (c).
Subsec. (m).
1978—Subsec. (c).
1977—Subsec. (a)(2).
Subsec. (l).
1976—Subsec. (b).
1973—Subsec. (a).
Subsec. (a)(iv).
Subsec. (a)(v).
Subsec. (a)(vi).
Subsec. (a)(vii).
Subsec. (a)(16).
Subsec. (b).
Subsec. (c).
Subsec. (h)(1)(B).
Subsec. (h)(2).
Subsec. (i).
Subsecs. (j), (k).
1972—Subsec. (a).
Subsec. (a)(4).
Subsec. (a)(5).
Subsec. (a)(14).
Subsec. (a)(15) to (17).
Subsec. (c).
Subsec. (d)(3).
Subsec. (e).
Subsec. (f).
Subsec. (g).
Subsec. (h).
Subsec. (i).
1971—Subsec. (a)(16).
Subsecs. (c), (d).
1968—Subsec. (a).
Subsec. (a)(ii).
Subsec. (a)(vi).
Subsec. (a)(4).
Subsec. (b).
Effective Date of 1999 Amendments
Amendment by
Amendment by section 121(a)(2) of
Amendment by section 1000(a)(6) [title VI, §608(l), (m)] of
Effective Date of 1997 Amendments
Section 162 of
Amendment by section 4702(a) of
Amendment by section 4711(c)(1) of
Section 4712(d)(2) of
Amendment by section 4714(a)(2) of
Section 4725(b)(2) of
"(A) items and services furnished on or after October 1, 1997;
"(B) payments made on a capitation or other risk-basis for coverage occurring on or after such date; and
"(C) payments attributable to DSH allotments for such States determined under section 1923(f) of such Act (
Amendment by section 4911(a) of
Effective Date of 1996 Amendment
Amendment by
Effective Date of 1994 Amendment
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13601(a) of
Amendment by section 13603(e) of
Section 13605(b) of
Section 13606(b) of
Amendment by section 13631(f)(2) of
Section 13631(g)(2) of
Effective Date of 1990 Amendment
Amendment by section 4402(d)(2) of
Amendment by section 4501(a), (c), (e)(1) of
Amendment by section 4601(a)(2) of
Amendment by section 4704(c), (d), (e)(1) of
Section 4705(b) of
Amendment by section 4711(a) of
Amendment by section 4712(a) of
Amendment by section 4713(b) of
Section 4719(b) of
Section 4721(b) of
Section 4755(a)(1)(B) of
Effective Date of 1989 Amendments
Amendment by section 6403(a), (c), (d)(2) of
Amendment by section 6404(a), (b) of
Amendment by section 6405(a) of
Amendment by section 6408(d)(2), (4)(A), (B) of
Amendment by
Effective Date of 1988 Amendments
Amendment by
Amendment by section 303(b)(2) of
Amendment by section 401(d)(2) of
Amendment by section 608(d)(14)(A)–(G), (J) of
Amendment by section 608(f)(3) of
Amendment by section 301(a)(2)–(d) of
Except as specifically provided in section 411 of
Section 411(k)(14)(B) of
Effective Date of 1987 Amendment
Amendment by section 4073(d) of
Section 4101(c)(3) of
"(A) The amendments made by this subsection [amending this section and
"(B) For purposes of section 1905(n)(2) of the Social Security Act [
Section 4103(b) of
"(1) The amendment made by subsection (a) [amending this section] applies (except as provided under paragraph (2)) to payments under title XIX of the Social Security Act [
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendment made by subsection (a), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act [Dec. 22, 1987]."
Section 4105(b) of
Amendments by section 4211(e), (f), (h)(6) of
Effective Date of 1986 Amendments
Amendment by
Amendment by section 9403(b), (d), (g)(3) of
Amendment by section 9404(b) of
Amendment by section 9408(c)(1) of
Section 9501(d)(1) of
"(A) The amendments made by subsection (a) [amending this section] apply (except as provided under subparagraph (B)) to payments under title XIX of the Social Security Act [this subchapter] for calendar quarters beginning on or after the [sic] July 1, 1986, without regard to whether or not final regulations to carry out the amendments have been promulgated by that date.
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by subsection (a), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act [Apr. 7, 1986]."
Amendment by section 9505(a) of
Section 9511(b) of
Effective Date of 1984 Amendment
Amendment by section 2335(f) of
Amendment by section 2340(b) of
Amendment by section 2361(b) of
Section 2371(b) of
Effective Date of 1982 Amendment
Amendment by section 136(c) of
Amendment by section 137(b)(17), (18) of
Effective Date of 1981 Amendment
Amendment by section 2172(b) of
Effective Date of 1980 Amendment
For effective date of amendment by
Effective Date of 1978 Amendment
Section 8(d)(1) of
Effective Date of 1977 Amendment
Amendment by
Effective Date of 1973 Amendment
Amendment by section 13(a)(13)–(18) of
Effective Date of 1972 Amendment
Section 212(b) of
Amendment by section 247(b) of
Section 275(b) of
Section 297(b) of
Effective Date of 1971 Amendment
Amendment by
Effective Date of 1968 Amendment
Section 248(e) of
Construction of 1999 Amendment
Amendment by
Increased FMAPs for Alaska
Section 4725(a) of
"(1) items and services furnished under a State plan under title XIX [this subchapter] or under a State child health plan under title XXI of such Act [subchapter XXI of this chapter] during fiscal years 1998, 1999, and 2000;
"(2) payments made on a capitation or other risk-basis under such titles for coverage occurring during such period; and
"(3) payments under title XIX of such Act attributable to DSH allotments for such State determined under section 1923(f) of such Act (
EPSDT Benefit Study and Report
Section 4744 of
"(a)
"(1)
"(2)
"(b)
References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996
For provisions that certain references to provisions of part A (§601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see
Limitation on Disallowances or Deferral of Federal Financial Participation for Certain Inpatient Psychiatric Hospital Services for Individuals Under Age 21
Section 4706 of
"(a)
"(2) Any disallowance of Federal financial participation under title XIX of the Social Security Act [this subchapter] relating to the failure of a psychiatric facility to comply with certification of need requirements—
"(A) shall not exceed 25 percent of the amount of Federal financial participation for the period described in paragraph (1); and
"(B) shall not apply to any fiscal year before the fiscal year that is 3 years before the fiscal year in which the determination of noncompliance described in paragraph (1) is made.
"(b)
Intermediate Care Facility; Access and Visitation Rights
Section 411(l)(3)(C)(i), formerly §411(l)(3)(C), of
Regulations for Intermediate Care Facilities for Mentally Retarded
Section 9514 of
Life Safety Code Recognition
Section 9515 of
Study of Federal Medical Assistance Percentage Formula and of Adjustments of Target Amounts for Federal Medicaid Expenditures; Report to Congress
Section 2165 of
Costs Charged to Personal Funds of Patients in Intermediate Care Facilities; Costs Included in Charges for Services; Regulations
Section 8(c), (d)(2) of
Section Referred to in Other Sections
This section is referred to in
1 See References in Text note below.
2 So in original. Probably should be "a".
3 So in original. Probably should be clause "(iii),". See References in Text note below.
4 See References in Text note below.
5 So in original. The comma probably should be a period.
6 So in original. The words "of such paragraph" probably should follow "subparagraph (B)".
7 So in original. Probably should be "or section".
§1396e. Enrollment of individuals under group health plans
(a) Requirements of each State plan; guidelines
Each State plan—
(1) may implement guidelines established by the Secretary, consistent with subsection (b) of this section, to identify those cases in which enrollment of an individual otherwise entitled to medical assistance under this subchapter in a group health plan (in which the individual is otherwise eligible to be enrolled) is cost-effective (as defined in subsection (e)(2) of this section);
(2) may require, in case of an individual so identified and as a condition of the individual being or remaining eligible for medical assistance under this subchapter and subject to subsection (b)(2) of this section, notwithstanding any other provision of this subchapter, that the individual (or in the case of a child, the child's parent) apply for enrollment in the group health plan; and
(3) in the case of such enrollment (except as provided in subsection (c)(1)(B) of this section), shall provide for payment of all enrollee premiums for such enrollment and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under
(b) Timing of enrollment; failure to enroll
(1) In establishing guidelines under subsection (a)(1) of this section, the Secretary shall take into account that an individual may only be eligible to enroll in group health plans at limited times and only if other individuals (not entitled to medical assistance under the plan) are also enrolled in the plan simultaneously.
(2) If a parent of a child fails to enroll the child in a group health plan in accordance with subsection (a)(2) of this section, such failure shall not affect the child's eligibility for benefits under this subchapter.
(c) Premiums considered payments for medical assistance; eligibility
(1)(A) In the case of payments of premiums, deductibles, coinsurance, and other cost-sharing obligations under this section shall be considered, for purposes of
(B) If all members of a family are not eligible for medical assistance under this subchapter and enrollment of the members so eligible in a group health plan is not possible without also enrolling members not so eligible—
(i) payment of premiums for enrollment of such other members shall be treated as payments for medical assistance for eligible individuals, if it would be cost-effective (taking into account payment of all such premiums), but
(ii) payment of deductibles, coinsurance, and other cost-sharing obligations for such other members shall not be treated as payments for medical assistance for eligible individuals.
(2) The fact that an individual is enrolled in a group health plan under this section shall not change the individual's eligibility for benefits under the State plan, except insofar as
(d) Repealed. Pub. L. 105–33, title IV, §4741(b)(2), Aug. 5, 1997, 111 Stat. 523
(e) Definitions
In this section:
(1) The term "group health plan" has the meaning given such term in section 5000(b)(1) of the Internal Revenue Code of 1986, and includes the provision of continuation coverage by such a plan pursuant to title XXII of the Public Health Service Act [
(2) The term "cost-effective" means, as established by the Secretary, that the reduction in expenditures under this subchapter with respect to an individual who is enrolled in a group health plan is likely to be greater than the additional expenditures for premiums and cost-sharing required under this section with respect to such enrollment.
(Aug. 14, 1935, ch. 531, title XIX, §1906, as added
References in Text
The Internal Revenue Code of 1986, referred to in subsec. (e)(1), is classified generally to Title 26, Internal Revenue Code.
The Public Health Service Act, referred to in subsec. (e)(1), is act July 1, 1944, ch. 373,
The Employee Retirement Income Security Act of 1974, referred to in subsec. (e)(1), is
Prior Provisions
A prior section 1396e, act Aug. 14, 1935, ch. 531, title XIX, §1906, as added Jan. 2, 1968,
Amendments
1997—Subsec. (a).
Subsec. (d).
"(1) In the case of any State which is providing medical assistance to its residents under a waiver granted under
"(2) This section, and
Effective Date
Section applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after Jan. 1, 1991, without regard to whether or not final regulations to carry out the amendments by section 4402 of
Section Referred to in Other Sections
This section is referred to in
1 See References in Text note below.
§1396f. Observance of religious beliefs
Nothing in this subchapter shall be construed to require any State which has a plan approved under this subchapter to compel any person to undergo any medical screening, examination, diagnosis, or treatment or to accept any other health care or services provided under such plan for any purpose (other than for the purpose of discovering and preventing the spread of infection or contagious disease or for the purpose of protecting environmental health), if such person objects (or, in case such person is a child, his parent or guardian objects) thereto on religious grounds.
(Aug. 14, 1935, ch. 531, title XIX, §1907, as added
§1396g. State programs for licensing of administrators of nursing homes
(a) Nature of State program
For purposes of
(b) Licensing by State agency or board representative of concerned professions and institutions
Licensing of nursing home administrators shall be carried out by the agency of the State responsible for licensing under the healing arts licensing act of the State, or, in the absence of such act or such an agency, a board representative of the professions and institutions concerned with care of chronically ill and infirm aged patients and established to carry out the purposes of this section.
(c) Functions and duties of State agency or board
It shall be the function and duty of such agency or board to—
(1) develop, impose, and enforce standards which must be met by individuals in order to receive a license as a nursing home administrator, which standards shall be designed to insure that nursing home administrators will be individuals who are of good character and are otherwise suitable, and who, by training or experience in the field of institutional administration, are qualified to serve as nursing home administrators;
(2) develop and apply appropriate techniques, including examinations and investigations, for determining whether an individual meets such standards;
(3) issue licenses to individuals determined, after the application of such techniques, to meet such standards, and revoke or suspend licenses previously issued by the board in any case where the individual holding any such license is determined substantially to have failed to conform to the requirements of such standards;
(4) establish and carry out procedures designed to insure that individuals licensed as nursing home administrators will, during any period that they serve as such, comply with the requirements of such standards;
(5) receive, investigate, and take appropriate action with respect to, any charge or complaint filed with the board to the effect that any individual licensed as a nursing home administrator has failed to comply with the requirements of such standards; and
(6) conduct a continuing study and investigation of nursing homes and administrators of nursing homes within the State with a view to the improvement of the standards imposed for the licensing of such administrators and of procedures and methods for the enforcement of such standards with respect to administrators of nursing homes who have been licensed as such.
(d) Waiver of standards other than good character or suitability standards
No State shall be considered to have failed to comply with the provisions of
(e) "Nursing home" and "nursing home administrator" defined
As used in this section, the term—
(1) "nursing home" means any institution or facility defined as such for licensing purposes under State law, or, if State law does not employ the term nursing home, the equivalent term or terms as determined by the Secretary, but does not include a religious nonmedical health care institution (as defined in
(2) "nursing home administrator" means any individual who is charged with the general administration of a nursing home whether or not such individual has an ownership interest in such home and whether or not his functions and duties are shared with one or more other individuals.
(Aug. 14, 1935, ch. 531, title XIX, §1908, as added
Repeal of Section
Codification
Another section 1908 of act Aug. 14, 1935, was renumbered section 1908A and is classified to
Amendments
1997—Subsec. (e)(1).
1996—Subsec. (e)(1).
1973—Subsec. (d).
"(1) such waiver is for a period which ends after being in effect for two years or on June 30, 1972, whichever is earlier, and
"(2) there is provided in the State (during all of the period for which waiver is in effect), a program of training and instruction designed to enable all individuals with respect to whom any such waiver is granted, to attain the qualifications necessary in order to meet such standards" and also "calendar year" instead of "three calendar years" and reference to "subsection (c)(1) of this section" instead of "subsection (c) of this section".
Subsec. (e).
Subsec. (f).
Subsec. (g).
1972—Subsec. (d).
Subsec. (g)(1).
Effective Date of 1997 Amendment
Amendment by
Effective Date of 1996 Amendment
Section 913 of
Effective Date of 1972 Amendment
Amendment by section 268(b) of
Effective Date
Section 236(c) of
Section Referred to in Other Sections
This section is referred to in
1 So in original. The period probably should be "; and".
§1396g–1. Required laws relating to medical child support
(a) In general
The laws relating to medical child support, which a State is required to have in effect under
(1) A law that prohibits an insurer from denying enrollment of a child under the health coverage of the child's parent on the ground that—
(A) the child was born out of wedlock,
(B) the child is not claimed as a dependent on the parent's Federal income tax return, or
(C) the child does not reside with the parent or in the insurer's service area.
(2) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an insurer, a law that requires such insurer—
(A) to permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without regard to any enrollment season restrictions);
(B) if such a parent is enrolled but fails to make application to obtain coverage of such child, to enroll such child under such family coverage upon application by the child's other parent or by the State agency administering the program under this subchapter or part D of subchapter IV of this chapter; and
(C) not to disenroll (or eliminate coverage of) such a child unless the insurer is provided satisfactory written evidence that—
(i) such court or administrative order is no longer in effect, or
(ii) the child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of such disenrollment.
(3) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an employer doing business in the State, a law that requires such employer—
(A) to permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without regard to any enrollment season restrictions);
(B) if such a parent is enrolled but fails to make application to obtain coverage of such child, to enroll such child under such family coverage upon application by the child's other parent or by the State agency administering the program under this subchapter or part D of subchapter IV of this chapter; and
(C) not to disenroll (or eliminate coverage of) any such child unless—
(i) the employer is provided satisfactory written evidence that—
(I) such court or administrative order is no longer in effect, or
(II) the child is or will be enrolled in comparable health coverage which will take effect not later than the effective date of such disenrollment, or
(ii) the employer has eliminated family health coverage for all of its employees; and
(D) to withhold from such employee's compensation the employee's share (if any) of premiums for health coverage (except that the amount so withheld may not exceed the maximum amount permitted to be withheld under
(4) A law that prohibits an insurer from imposing requirements on a State agency, which has been assigned the rights of an individual eligible for medical assistance under this subchapter and covered for health benefits from the insurer, that are different from requirements applicable to an agent or assignee of any other individual so covered.
(5) A law that requires an insurer, in any case in which a child has health coverage through the insurer of a noncustodial parent—
(A) to provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;
(B) to permit the custodial parent (or provider, with the custodial parent's approval) to submit claims for covered services without the approval of the noncustodial parent; and
(C) to make payment on claims submitted in accordance with subparagraph (B) directly to such custodial parent, the provider, or the State agency.
(6) A law that permits the State agency under this subchapter to garnish the wages, salary, or other employment income of, and requires withholding amounts from State tax refunds to, any person who—
(A) is required by court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under this subchapter,
(B) has received payment from a third party for the costs of such services to such child, but
(C) has not used such payments to reimburse, as appropriate, either the other parent or guardian of such child or the provider of such services,
to the extent necessary to reimburse the State agency for expenditures for such costs under its plan under this subchapter, but any claims for current or past-due child support shall take priority over any such claims for the costs of such services.
(b) "Insurer" defined
For purposes of this section, the term "insurer" includes a group health plan, as defined in
(Aug. 14, 1935, ch. 531, title XIX, §1908A, formerly §1908, as added
References in Text
Part D of subchapter IV of this chapter, referred to in subsec. (a)(2)(B), (3)(B), is classified to
Effective Date
Section 13623(c) of
"(1) Except as provided in paragraph (2), the amendments made by this section [enacting this section and amending
"(2) In the case of a State plan under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of enactment of this Act [Aug. 10, 1993]. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section Referred to in Other Sections
This section is referred to in
§1396h. Transferred
Codification
Section, act Aug. 14, 1935, ch. 531, title XIX, §1909, as added and amended Oct. 30, 1972,
§1396i. Certification and approval of rural health clinics and intermediate care facilities for mentally retarded
(a)(1) Whenever the Secretary certifies a facility in a State to be qualified as a rural health clinic under subchapter XVIII of this chapter, such facility shall be deemed to meet the standards for certification as a rural health clinic for purposes of providing rural health clinic services under this title.
(2) The Secretary shall notify the State agency administering the medical assistance plan of his approval or disapproval of any facility in that State which has applied for certification by him as a qualified rural health clinic.
(b)(1) The Secretary may cancel approval of any intermediate care facility for the mentally retarded at any time if he finds on the basis of a determination made by him as provided in
(2) Any intermediate care facility for the mentally retarded which is dissatisfied with a determination by the Secretary that it no longer qualifies as a 1 intermediate care facility for the mentally retarded for purposes of this subchapter, shall be entitled to a hearing by the Secretary to the same extent as is provided in
(Aug. 14, 1935, ch. 531, title XIX, §1910, as added and amended
Amendments
1999—
1994—Subsec. (b)(2).
1989—
Subsec. (b)(1).
Subsec. (b)(2).
1988—Subsec. (b)(1).
1987—
1980—Subsec. (c).
1977—
Effective Date of 1994 Amendment
Amendment by
Effective Date of 1989 Amendment
Amendment by
Effective Date of 1988 Amendments
Amendment by
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
Amendment by
Effective Date of 1977 Amendment
Amendment by
Effective Date
Section effective with respect to agreements filed with Secretary under
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should be "an".
§1396j. Indian health service facilities
(a) Eligibility for reimbursement for medical assistance
A facility of the Indian Health Service (including a hospital, nursing facility, or any other type of facility which provides services of a type otherwise covered under the State plan), whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in
(b) Facilities deemed to meet requirements upon submission of acceptable plan for achieving compliance
Notwithstanding subsection (a) of this section, a facility of the Indian Health Service (including a hospital, nursing facility, or any other type of facility which provides services of a type otherwise covered under the State plan) which does not meet all of the conditions and requirements of this title which are applicable generally to such facility, but which submits to the Secretary within six months after September 30, 1976, an acceptable plan for achieving compliance with such conditions and requirements, shall be deemed to meet such conditions and requirements (and to be eligible for reimbursement under this subchapter), without regard to the extent of its actual compliance with such conditions and requirements, during the first twelve months after the month in which such plan is submitted.
(c) Agreement to reimburse State agency for providing care and services
The Secretary is authorized to enter into agreements with the State agency for the purpose of reimbursing such agency for health care and services provided in Indian Health Service facilities to Indians who are eligible for medical assistance under the State plan.
(Aug. 14, 1935, ch. 531, title XIX, §1911, as added
Amendments
1988—Subsecs. (a), (b).
1987—Subsecs. (a), (b).
Subsec. (c).
Effective Date of 1988 Amendment
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
Section 4118(f)(2) of
Amendment by section 4211(h)(8) of
Agreements To Reimburse State Agency for Health Care and Services Provided by Agency to Indians
Payments Into Special Fund To Improve Indian Health Service Facilities To Achieve Compliance With Conditions and Requirements; Certification of Compliance by Secretary
Section 402(c) of
Medicaid Payments Not Considered in Determining Appropriations for Indian Health Care
Section 402(d) of
Section Referred to in Other Sections
This section is referred to in
§1396k. Assignment, enforcement, and collection of rights of payments for medical care; establishment of procedures pursuant to State plan; amounts retained by State
(a) For the purpose of assisting in the collection of medical support payments and other payments for medical care owed to recipients of medical assistance under the State plan approved under this subchapter, a State plan for medical assistance shall—
(1) provide that, as a condition of eligibility for medical assistance under the State plan to an individual who has the legal capacity to execute an assignment for himself, the individual is required—
(A) to assign the State any rights, of the individual or of any other person who is eligible for medical assistance under this subchapter and on whose behalf the individual has the legal authority to execute an assignment of such rights, to support (specified as support for the purpose of medical care by a court or administrative order) and to payment for medical care from any third party;
(B) to cooperate with the State (i) in establishing the paternity of such person (referred to in subparagraph (A)) if the person is a child born out of wedlock, and (ii) in obtaining support and payments (described in subparagraph (A)) for himself and for such person, unless (in either case) the individual is described in
(C) to cooperate with the State in identifying, and providing information to assist the State in pursuing, any third party who may be liable to pay for care and services available under the plan, unless such individual has good cause for refusing to cooperate as determined by the State agency in accordance with standards prescribed by the Secretary, which standards shall take into consideration the best interests of the individuals involved; and
(2) provide for entering into cooperative arrangements (including financial arrangements), with any appropriate agency of any State (including, with respect to the enforcement and collection of rights of payment for medical care by or through a parent, with a State's agency established or designated under
(b) Such part of any amount collected by the State under an assignment made under the provisions of this section shall be retained by the State as is necessary to reimburse it for medical assistance payments made on behalf of an individual with respect to whom such assignment was executed (with appropriate reimbursement of the Federal Government to the extent of its participation in the financing of such medical assistance), and the remainder of such amount collected shall be paid to such individual.
(Aug. 14, 1935, ch. 531, title XIX, §1912, as added
Amendments
1990—Subsec. (a)(1)(B).
1986—Subsec. (a)(1)(C).
1984—Subsec. (a).
Effective Date of 1990 Amendment
Section 4606(b) of
Effective Date of 1986 Amendment
Amendment by
Effective Date of 1984 Amendment
Amendment by
Section Referred to in Other Sections
This section is referred to in
§1396l. Hospital providers of nursing facility services
(a) Notwithstanding any other provision of this subchapter, payment may be made, in accordance with this section, under a State plan approved under this subchapter for nursing facility services furnished by a hospital which has in effect an agreement under
(b)(1) Except as provided in paragraph (3), payment to any such hospital, for any nursing facility services furnished pursuant to subsection (a) of this section, shall be at a rate equal to the average rate per patient-day paid for routine services during the previous calendar year under the State plan to nursing facilities, respectively,1 located in the State in which the hospital is located. The reasonable cost of ancillary services shall be determined in the same manner as the reasonable cost of ancillary services provided for inpatient hospital services.
(2) With respect to any period for which a hospital has an agreement under
(3) Payment to all such hospitals, for any nursing facility services furnished pursuant to subsection (a) of this section, may be made at a payment rate established by the State in accordance with the requirements of
(Aug. 14, 1935, ch. 531, title XIX, §1913, as added
Amendments
1987—
Subsec. (a).
Subsec. (b)(1).
Subsec. (b)(3).
1984—Subsec. (b)(1).
Subsec. (b)(3).
Effective Date of 1987 Amendment
Amendment by
Effective Date of 1984 Amendment
Section 2369(b) of
Effective Date
Section effective on date on which final regulations to implement the section are first issued, see section 904(d) of
1 So in original, ", respectively," probably should not appear.
§1396m. Withholding of Federal share of payments for certain medicare providers
(a) Adjustment of Federal matching payments
The Secretary may adjust, in accordance with this section, the Federal matching payment to a State with respect to expenditures for medical assistance for care or services furnished in any quarter by—
(1) an institution (A) which has or previously had in effect an agreement with the Secretary under
(2) any person (A) who (i) has previously accepted payment on the basis of an assignment under
(b) Reductions in payments to and by States
The Secretary may (subject to the remaining provisions of this section) reduce payment to a State under this subchapter for any quarter by an amount equal to the lesser of the Federal matching share of payments to any institution or person specified in subsection (a) of this section, or the total overpayments to such institution or person under subchapter XVIII of this chapter, and may require the State to reduce its payment to such institution or person by such amount.
(c) Notice
The Secretary shall not make any adjustment in the payment to a State, nor require any adjustment in the payment to an institution or person, pursuant to subsection (b) of this section until after he has provided adequate notice (which shall be not less than 60 days) to the State agency and the institution or person.
(d) Regulations
The Secretary shall by regulation provide procedures for implementation of this section, which procedures shall (1) determine the amount of the Federal payment to which the institution or person would otherwise be entitled under this section which shall be treated as a setoff against overpayments under subchapter XVIII of this chapter, and (2) assure the restoration to the institution or person of amounts withheld under this section which are ultimately determined to be in excess of overpayments under subchapter XVIII of this chapter and to which the institution or person would otherwise be entitled under this subchapter.
(e) Restoration to trust funds of recovered amounts
The Secretary shall restore to the trust funds established under
(f) Liability of States for withheld payments
Notwithstanding any other provision of this subchapter, an institution or person shall not be entitled to recover from any State any amount in payment for medical care and services under this subchapter which is withheld by the State agency pursuant to an order by the Secretary under subsection (b) of this section.
(Aug. 14, 1935, ch. 531, title XIX, §1914, as added
Section Referred to in Other Sections
This section is referred to in
§1396n. Compliance with State plan and payment provisions
(a) Activities deemed as compliance
A State shall not be deemed to be out of compliance with the requirements of paragraphs (1), (10), or (23) of
(1) has entered into—
(A) a contract with an organization which has agreed to provide care and services in addition to those offered under the State plan to individuals eligible for medical assistance who reside in the geographic area served by such organization and who elect to obtain such care and services from such organization, or by reason of the fact that the plan provides for payment for rural health clinic services only if those services are provided by a rural health clinic; or
(B) arrangements through a competitive bidding process or otherwise for the purchase of laboratory services referred to in
(i) adequate services or devices will be available under such arrangements, and
(ii) any such laboratory services will be provided only through laboratories—
(I) which meet the applicable requirements of
(II) no more than 75 percent of whose charges for such services are for services provided to individuals who are entitled to benefits under this subchapter or under part A or part B of subchapter XVIII of this chapter; or
(2) restricts for a reasonable period of time the provider or providers from which an individual (eligible for medical assistance for items or services under the State plan) can receive such items or services, if—
(A) the State has found, after notice and opportunity for a hearing (in accordance with procedures established by the State), that the individual has utilized such items or services at a frequency or amount not medically necessary (as determined in accordance with utilization guidelines established by the State), and
(B) under such restriction, individuals eligible for medical assistance for such services have reasonable access (taking into account geographic location and reasonable travel time) to such services of adequate quality.
(b) Waivers to promote cost-effectiveness and efficiency
The Secretary, to the extent he finds it to be cost-effective and efficient and not inconsistent with the purposes of this subchapter, may waive such requirements of
(1) to implement a primary care case-management system or a specialty physician services arrangement which restricts the provider from (or through) whom an individual (eligible for medical assistance under this subchapter) can obtain medical care services (other than in emergency circumstances), if such restriction does not substantially impair access to such services of adequate quality where medically necessary,
(2) to allow a locality to act as a central broker in assisting individuals (eligible for medical assistance under this subchapter) in selecting among competing health care plans, if such restriction does not substantially impair access to services of adequate quality where medically necessary,
(3) to share (through provision of additional services) with recipients of medical assistance under the State plan cost savings resulting from use by the recipient of more cost-effective medical care, and
(4) to restrict the provider from (or through) whom an individual (eligible for medical assistance under this subchapter) can obtain services (other than in emergency circumstances) to providers or practitioners who undertake to provide such services and who meet, accept, and comply with the reimbursement, quality, and utilization standards under the State plan, which standards shall be consistent with the requirements of
No waiver under this subsection may restrict the choice of the individual in receiving services under
(c) Waiver respecting medical assistance requirement in State plan; scope, etc.; "habilitation services" defined; imposition of certain regulatory limits prohibited; computation of expenditures for certain disabled patients; coordinated services; substitution of participants
(1) The Secretary may by waiver provide that a State plan approved under this subchapter may include as "medical assistance" under such plan payment for part or all of the cost of home or community-based services (other than room and board) approved by the Secretary which are provided pursuant to a written plan of care to individuals with respect to whom there has been a determination that but for the provision of such services the individuals would require the level of care provided in a hospital or a nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan. For purposes of this subsection, the term "room and board" shall not include an amount established under a method determined by the State to reflect the portion of costs of rent and food attributable to an unrelated personal caregiver who is residing in the same household with an individual who, but for the assistance of such caregiver, would require admission to a hospital, nursing facility, or intermediate care facility for the mentally retarded.
(2) A waiver shall not be granted under this subsection unless the State provides assurances satisfactory to the Secretary that—
(A) necessary safeguards (including adequate standards for provider participation) have been taken to protect the health and welfare of individuals provided services under the waiver and to assure financial accountability for funds expended with respect to such services;
(B) the State will provide, with respect to individuals who—
(i) are entitled to medical assistance for inpatient hospital services, nursing facility services, or services in an intermediate care facility for the mentally retarded under the State plan,
(ii) may require such services, and
(iii) may be eligible for such home or community-based care under such waiver,
for an evaluation of the need for inpatient hospital services, nursing facility services, or services in an intermediate care facility for the mentally retarded;
(C) such individuals who are determined to be likely to require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded are informed of the feasible alternatives, if available under the waiver, at the choice of such individuals, to the provision of inpatient hospital services, nursing facility services, or services in an intermediate care facility for the mentally retarded;
(D) under such waiver the average per capita expenditure estimated by the State in any fiscal year for medical assistance provided with respect to such individuals does not exceed 100 percent of the average per capita expenditure that the State reasonably estimates would have been made in that fiscal year for expenditures under the State plan for such individuals if the waiver had not been granted; and
(E) the State will provide to the Secretary annually, consistent with a data collection plan designed by the Secretary, information on the impact of the waiver granted under this subsection on the type and amount of medical assistance provided under the State plan and on the health and welfare of recipients.
(3) A waiver granted under this subsection may include a waiver of the requirements of
(4) A waiver granted under this subsection may, consistent with paragraph (2)—
(A) limit the individuals provided benefits under such waiver to individuals with respect to whom the State has determined that there is a reasonable expectation that the amount of medical assistance provided with respect to the individual under such waiver will not exceed the amount of such medical assistance provided for such individual if the waiver did not apply, and
(B) provide medical assistance to individuals (to the extent consistent with written plans of care, which are subject to the approval of the State) for case management services, homemaker/home health aide services and personal care services, adult day health services, habilitation services, respite care, and such other services requested by the State as the Secretary may approve and for day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness.
Except as provided under paragraph (2)(D), the Secretary may not restrict the number of hours or days of respite care in any period which a State may provide under a waiver under this subsection.
(5) For purposes of paragraph (4)(B), the term "habilitation services"—
(A) means services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings; and
(B) includes (except as provided in subparagraph (C)) prevocational, educational, and supported employment services; but
(C) does not include—
(i) special education and related services (as defined in paragraphs (16) and (17) of section 1401(a) 1 of title 20) which otherwise are available to the individual through a local educational agency; and
(ii) vocational rehabilitation services which otherwise are available to the individual through a program funded under
(6) The Secretary may not require, as a condition of approval of a waiver under this section under paragraph (2)(D), that the actual total expenditures for home and community-based services under the waiver (and a claim for Federal financial participation in expenditures for the services) cannot exceed the approved estimates for these services. The Secretary may not deny Federal financial payment with respect to services under such a waiver on the ground that, in order to comply with paragraph (2)(D), a State has failed to comply with such a requirement.
(7)(A) In making estimates under paragraph (2)(D) in the case of a waiver that applies only to individuals with a particular illness or condition who are inpatients in, or who would require the level of care provided in, hospitals, nursing facilities, or intermediate care facilities for the mentally retarded, the State may determine the average per capita expenditure that would have been made in a fiscal year for those individuals under the State plan separately from the expenditures for other individuals who are inpatients in, or who would require the level of care provided in, those respective facilities.
(B) In making estimates under paragraph (2)(D) in the case of a waiver that applies only to individuals with developmental disabilities who are inpatients in a nursing facility and whom the State has determined, on the basis of an evaluation under paragraph (2)(B), to need the level of services provided by an intermediate care facility for the mentally retarded, the State may determine the average per capita expenditures that would have been made in a fiscal year for those individuals under the State plan on the basis of the average per capita expenditures under the State plan for services to individuals who are inpatients in an intermediate care facility for the mentally retarded, without regard to the availability of beds for such inpatients.
(C) In making estimates under paragraph (2)(D) in the case of a waiver to the extent that it applies to individuals with mental retardation or a related condition who are resident in an intermediate care facility for the mentally retarded the participation of which under the State plan is terminated, the State may determine the average per capita expenditures that would have been made in a fiscal year for those individuals without regard to any such termination.
(8) The State agency administering the plan under this subchapter may, whenever appropriate, enter into cooperative arrangements with the State agency responsible for administering the program for children with special health care needs under subchapter V of this chapter in order to assure improved access to coordinated services to meet the needs of such children.
(9) In the case of any waiver under this subsection which contains a limit on the number of individuals who shall receive home or community-based services, the State may substitute additional individuals to receive such services to replace any individuals who die or become ineligible for services under the State plan.
(10) The Secretary shall not limit to fewer than 200 the number of individuals in the State who may receive home and community-based services under a waiver under this subsection.
(d) Home and community-based services for elderly
(1) Subject to paragraph (2), the Secretary shall grant a waiver to provide that a State plan approved under this subchapter shall include as "medical assistance" under such plan payment for part or all of the cost of home or community-based services (other than room and board) which are provided pursuant to a written plan of care to individuals 65 years of age or older with respect to whom there has been a determination that but for the provision of such services the individuals would be likely to require the level of care provided in a skilled nursing facility or intermediate care facility the cost of which could be reimbursed under the State plan. For purposes of this subsection, the term "room and board" shall not include an amount established under a method determined by the State to reflect the portion of costs of rent and food attributable to an unrelated personal caregiver who is residing in the same household with an individual who, but for the assistance of such caregiver, would require admission to a hospital, nursing facility, or intermediate care facility for the mentally retarded.
(2) A waiver shall not be granted under this subsection unless the State provides assurances satisfactory to the Secretary that—
(A) necessary safeguards (including adequate standards for provider participation) have been taken to protect the health and welfare of individuals provided services under the waiver and to assure financial accountability for funds expended with respect to such services;
(B) with respect to individuals 65 years of age or older who—
(i) are entitled to medical assistance for skilled nursing or intermediate care facility services under the State plan,
(ii) may require such services, and
(iii) may be eligible for such home or community-based services under such waiver,
the State will provide for an evaluation of the need for such skilled nursing facility or intermediate care facility services; and
(C) such individuals who are determined to be likely to require the level of care provided in a skilled nursing facility or intermediate care facility are informed of the feasible alternatives to the provision of skilled nursing facility or intermediate care facility services, which such individuals may choose if available under the waiver.
Each State with a waiver under this subsection shall provide to the Secretary annually, consistent with a reasonable data collection plan designed by the Secretary, information on the impact of the waiver granted under this subsection on the type and amount of medical assistance provided under the State plan and on the health and welfare of recipients.
(3) A waiver granted under this subsection may include a waiver of the requirements of
(4) A waiver under this subsection may, consistent with paragraph (2), provide medical assistance to individuals for case management services, homemaker/home health aide services and personal care services, adult day health services, respite care, and other medical and social services that can contribute to the health and well-being of individuals and their ability to reside in a community-based care setting.
(5)(A) In the case of a State having a waiver approved under this subsection, notwithstanding any other provision of
(B) For purposes of subparagraph (A), the projected amount under this subparagraph is the sum of the following:
(i) The aggregate amount of the State's medical assistance under this subchapter for skilled nursing facility services and intermediate care facility services furnished to individuals who have attained the age of 65 for the base year increased by a percentage which is equal to the lesser of 7 percent times the number of years (rounded to the nearest quarter of a year) beginning after the base year and ending at the end of the waiver year involved or the sum of—
(I) the percentage increase (based on an appropriate market-basket index representing the costs of elements of such services) between the beginning of the base year and the beginning of the waiver year involved, plus
(II) the percentage increase between the beginning of the base year and the beginning of the waiver year involved in the number of residents in the State who have attained the age of 65, plus
(III) 2 percent for each year (rounded to the nearest quarter of a year) beginning after the base year and ending at the end of the waiver year.
(ii) The aggregate amount of the State's medical assistance under this subchapter for home and community-based services for individuals who have attained the age of 65 for the base year increased by a percentage which is equal to the lesser of 7 percent times the number of years (rounded to the nearest quarter of a year) beginning after the base year and ending at the end of the waiver year involved or the sum of—
(I) the percentage increase (based on an appropriate market-basket index representing the costs of elements of such services) between the beginning of the base year and the beginning of the waiver year involved, plus
(II) the percentage increase between the beginning of the base year and the beginning of the waiver year involved in the number of residents in the State who have attained the age of 65, plus
(III) 2 percent for each year (rounded to the nearest quarter of a year) beginning after the base year and ending at the end of the waiver year.
(iii) The Secretary shall develop and promulgate by regulation (by not later than October 1, 1989)—
(I) a method, based on an index of appropriately weighted indicators of changes in the wages and prices of the mix of goods and services which comprise both skilled nursing facility services and intermediate care facility services (regardless of the source of payment for such services), for projecting the percentage increase for purposes of clause (i)(I);
(II) a method, based on an index of appropriately weighted indicators of changes in the wages and prices of the mix of goods and services which comprise home and community-based services (regardless of the source of payment for such services), for projecting the percentage increase for purposes of clause (ii)(I); and
(III) a method for projecting, on a State specific basis, the percentage increase in the number of residents in each State who are over 65 years of age for any period.
The Secretary shall develop (by not later than October 1, 1989) a method for projecting, on a State-specific basis, the percentage increase in the number of residents in each State who are over 65 years of age for any period. Effective on and after the date the Secretary promulgates the regulation under clause (iii), any reference in this subparagraph to the "lesser of 7 percent" shall be deemed to be a reference to the "greater of 7 percent".
(iv) If there is enacted after December 22, 1987, an Act which amends this subchapter whose provisions become effective on or after such date and which results in an increase in the aggregate amount of medical assistance under this subchapter for nursing facility services and home and community-based services for individuals who have attained the age of 65 years, the Secretary, at the request of a State with a waiver under this subsection for a waiver year or years and in close consultation with the State, shall adjust the projected amount computed under this subparagraph for the waiver year or years to take into account such increase.
(C) In this paragraph:
(i) The term "home and community-based services" includes services described in
(ii)(I) Subject to subclause (II), the term "base year" means the most recent year (ending before December 22, 1987) for which actual final expenditures under this subchapter have been reported to, and accepted by, the Secretary.
(II) For purposes of subparagraph (C), in the case of a State that does not report expenditures on the basis of the age categories described in such subparagraph for a year ending before December 22, 1987, the term "base year" means fiscal year 1989.
(iii) The term "intermediate care facility services" does not include services furnished in an institution certified in accordance with
(6)(A) A determination by the Secretary to deny a request for a waiver (or extension of waiver) under this subsection shall be subject to review to the extent provided under
(B) Notwithstanding any other provision of this chapter, if the Secretary denies a request of the State for an extension of a waiver under this subsection, any waiver under this subsection in effect on the date such request is made shall remain in effect for a period of not less than 90 days after the date on which the Secretary denies such request (or, if the State seeks review of such determination in accordance with subparagraph (A), the date on which a final determination is made with respect to such review).
(e) Waiver for children infected with AIDS or drug dependent at birth
(1)(A) Subject to paragraph (2), the Secretary shall grant a waiver to provide that a State plan approved under this subchapter shall include as "medical assistance" under such plan payment for part or all of the cost of nursing care, respite care, physicians' services, prescribed drugs, medical devices and supplies, transportation services, and such other services requested by the State as the Secretary may approve which are provided pursuant to a written plan of care to a child described in subparagraph (B) with respect to whom there has been a determination that but for the provision of such services the infants would be likely to require the level of care provided in a hospital or nursing facility the cost of which could be reimbursed under the State plan.
(B) Children described in this subparagraph are individuals under 5 years of age who—
(i) at the time of birth were infected with (or tested positively for) the etiologic agent for acquired immune deficiency syndrome (AIDS),
(ii) have such syndrome, or
(iii) at the time of birth were dependent on heroin, cocaine, or phencyclidine,
and with respect to whom adoption or foster care assistance is (or will be) made available under part E of subchapter IV of this chapter.
(2) A waiver shall not be granted under this subsection unless the State provides assurances satisfactory to the Secretary that—
(A) necessary safeguards (including adequate standards for provider participation) have been taken to protect the health and welfare of individuals provided services under the waiver and to assure financial accountability for funds expended with respect to such services;
(B) under such waiver the average per capita expenditure estimated by the State in any fiscal year for medical assistance provided with respect to such individuals does not exceed 100 percent of the average per capita expenditure that the State reasonably estimates would have been made in that fiscal year for expenditures under the State plan for such individuals if the waiver had not been granted; and
(C) the State will provide to the Secretary annually, consistent with a data collection plan designed by the Secretary, information on the impact of the waiver granted under this subsection on the type and amount of medical assistance provided under the State plan and on the health and welfare of recipients.
(3) A waiver granted under this subsection may include a waiver of the requirements of
(4) The provisions of paragraph (6) of subsection (d) of this section shall apply to this subsection in the same manner as it applies to subsection (d) of this section.
(f) Monitor of implementation of waivers; termination of waiver for noncompliance; time limitation for action on requests for plan approval, amendments, or waivers
(1) The Secretary shall monitor the implementation of waivers granted under this section to assure that the requirements for such waiver are being met and shall, after notice and opportunity for a hearing, terminate any such waiver where he finds noncompliance has occurred.
(2) A request to the Secretary from a State for approval of a proposed State plan or plan amendment or a waiver of a requirement of this subchapter submitted by the State pursuant to a provision of this subchapter shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State agency in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. After the date the Secretary receives such additional information, the request shall be deemed granted unless the Secretary, within 90 days of such date, denies such request.
(g) Optional targeted case management services
(1) A State may provide, as medical assistance, case management services under the plan without regard to the requirements of
(2) For purposes of this subsection, the term "case management services" means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services.
(h) Period of waivers; continuations
No waiver under this section (other than a waiver under subsection (c), (d), or (e) of this section) may extend over a period of longer than two years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State agency in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. After the date the Secretary receives such additional information, the request shall be deemed granted unless the Secretary, within 90 days of such date, denies such request.
(Aug. 14, 1935, ch. 531, title XIX, §1915, as added
Amendment of Subsection (b)
References in Text
Parts A and B of subchapter XVIII of this chapter, referred to in subsec. (a)(1)(B)(ii)(II), are classified to sections 1395c et seq. and 1395j et seq., respectively, of this title.
Part E of subchapter IV of this chapter, referred to in subsec. (e)(1)(B), is classified to
Amendments
1999—Subsec. (b).
Subsec. (d)(5)(B)(iii).
Subsec. (h).
1997—Subsec. (a)(1)(B)(ii)(I).
Subsec. (c)(5).
1993—Subsec. (g)(1).
1991—Subsec. (c)(5)(C)(i).
1990—Subsec. (b).
Subsec. (b)(4).
Subsec. (c)(1).
Subsec. (c)(4).
Subsec. (c)(7)(C).
Subsec. (d)(1).
Subsec. (d)(5)(B)(iv).
1989—Subsec. (a)(1)(B)(ii)(I).
Subsec. (b)(4).
1988—Subsec. (a)(1)(B)(ii)(I).
Subsec. (a)(2).
Subsec. (c)(7).
Subsec. (c)(7)(A).
Subsec. (c)(7)(B).
Subsec. (c)(10).
Subsec. (d)(5)(B)(i), (ii).
Subsec. (d)(5)(B)(iii).
Subsec. (d)(5)(B)(iii)(III).
Subsec. (d)(5)(B)(iv).
Subsec. (d)(5)(C)(i).
Subsec. (e).
Subsec. (f)(1).
Subsec. (f)(2).
Subsec. (h).
1987—Subsec. (a)(1)(B)(ii)(I).
Subsec. (a)(2).
"(A) for a reasonable period of time the provider or providers from which an individual (eligible for medical assistance for items or services under the State plan) can receive such items or services, if the State has found, after notice and opportunity for a hearing (in accordance with procedures established by the State), that the individual has utilized such items or services at a frequency or amount not medically necessary (as determined in accordance with utilization guidelines established by the State), or
"(B) (through suspension or otherwise) for a reasonable period of time the participation of a provider of items or services under the State plan, if the State has found, after notice and opportunity for a hearing (in accordance with procedures established by the State), that the provider has (in a significant number or proportion of cases) provided such items or services either (i) at a frequency or amount not medically necessary (as determined in accordance with utilization guidelines established by the State), or (ii) of a quality which does not meet professionally recognized standards of health care,
if, under such restriction, individuals eligible for medical assistance for such services have reasonable access (taking into account geographic location and reasonable travel time) to such services of adequate quality."
Subsec. (c)(1).
Subsec. (c)(2)(B).
Subsec. (c)(2)(B)(i).
Subsec. (c)(2)(C).
Subsec. (c)(3).
Subsec. (c)(5).
Subsec. (c)(7).
Subsec. (c)(10).
Subsec. (d).
Subsec. (g)(1).
Subsec. (h).
1986—Subsec. (a)(1)(B)(ii)(I).
Subsec. (b).
Subsec. (c)(1).
Subsec. (c)(2)(B).
Subsec. (c)(2)(C).
Subsec. (c)(2)(D).
Subsec. (c)(3).
Subsec. (c)(4)(B).
Subsec. (c)(5).
Subsec. (c)(6).
Subsec. (c)(7).
Subsec. (c)(8).
Subsec. (c)(9).
Subsec. (g).
Subsec. (g)(1).
1984—Subsec. (c)(1).
1983—Subsec. (c)(2)(B).
1982—Subsec. (b).
Subsec. (b)(1).
Subsec. (c)(1).
Subsec. (c)(2)(B).
Subsec. (c)(3).
Subsec. (c)(4).
Subsec. (f).
1981—Subsecs. (c) to (e).
Subsec. (f).
Effective Date of 1999 Amendment
Amendment by section 1000(a)(6) [title VI, §608o] of
Effective Date of 1997 Amendment
Amendment by section 4106(c) of
Section 4743(b) of
Effective Date of 1993 Amendment
Amendment by
Effective Date of 1990 Amendments
Amendment by section 4604(c) of
Amendment by section 4704(b)(3) of
Section 4742(b) of
Section 4742(c)(2) of
Section 4742(d)(2) of
Effective Date of 1989 Amendments
Amendment by section 6115(c) of
Section 6411(c)(4) of
Amendment by
Effective Date of 1988 Amendments
Section 8432(c) of
Section 8437(b) of
Amendment by section 608(d)(26)(M) of
Amendment by section 608(f)(2) of
Amendment by section 204(d)(3) of
Except as specifically provided in section 411 of
Effective Date of 1987 Amendments
For effective date of amendment by section 4072(d) of
Section 4102(a)(2) of
Section 4118(a)(2) of
Section 4118(i)(2) of
Section 4118(l)(2) of
Section 4118(p)(10) of
Amendment by section 4211(h)(10) of
Amendment by
Effective Date of 1986 Amendments
Amendment by section 9320(h)(3) of
Section 9411(e) of
Section 9502(j) of
"(1)
"(2)
"(3)
"(4)
"(5)
"(6)
"(7)
Section 9508(b) of
[Section 4118(j) of
Effective Date of 1983 Amendment
Amendment by
Effective Date of 1982 Amendment
Section 137(b)(19)(B) of
Amendment by section 137(b)(20)–(25) of
Effective Date of 1981 Amendment
Section 2177(b) of
Permitting Adjustment in Estimates To Take Into Account Preadmission Screening Requirement
Section 4742(e) of
Extensions of Waivers Under Subsection (c)
Section 4102(c) of
Section 9502(f) of
Section Referred to in Other Sections
This section is referred to in
§1396o. Use of enrollment fees, premiums, deductions, cost sharing, and similar charges
(a) Imposition of certain charges under plan in case of individuals described in section 1396a(a)(10)(A) or (E)
Subject to subsection (g) of this section, the State plan shall provide that in the case of individuals described in subparagraph (A) or (E)(i) of
(1) no enrollment fee, premium, or similar charge will be imposed under the plan (except for a premium imposed under subsection (c) of this section);
(2) no deduction, cost sharing or similar charge will be imposed under the plan with respect to—
(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over),
(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women),
(C) services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs,
(D) emergency services (as defined by the Secretary), family planning services and supplies described in
(E) services furnished to an individual who is receiving hospice care (as defined in
(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of "nominal" under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services.
(b) Imposition of certain charges under plan in case of individuals other than those described in section 1396a(a)(10)(A) or (E)
The State plan shall provide that in the case of individuals other than those described in subparagraph (A) or (E) of
(1) there may be imposed an enrollment fee, premium, or similar charge, which (as determined in accordance with standards prescribed by the Secretary) is related to the individual's income,
(2) no deduction, cost sharing, or similar charge will be imposed under the plan with respect to—
(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over),
(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women),
(C) services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs,
(D) emergency services (as defined by the Secretary), family planning services and supplies described in
(E) services furnished to an individual who is receiving hospice care (as defined in
(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of "nominal" under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services.
(c) Imposition of monthly premium; persons affected; amount; prepayment; failure to pay; use of funds from other programs
(1) The State plan of a State may at the option of the State provide for imposing a monthly premium (in an amount that does not exceed the limit established under paragraph (2)) with respect to an individual described in subparagraph (A) or (B) of
(2) In no case may the amount of any premium imposed under paragraph (1) exceed 10 percent of the amount by which the family income (less expenses for the care of a dependent child) of an individual exceeds 150 percent of the line described in paragraph (1).
(3) A State shall not require prepayment of a premium imposed pursuant to paragraph (1) and shall not terminate eligibility of an individual for medical assistance under this subchapter on the basis of failure to pay any such premium until such failure continues for a period of not less than 60 days. The State may waive payment of any such premium in any case where the State determines that requiring such payment would create an undue hardship.
(4) A State may permit State or local funds available under other programs to be used for payment of a premium imposed under paragraph (1). Payment of a premium with such funds shall not be counted as income to the individual with respect to whom such payment is made.
(d) Premiums for qualified disabled and working individuals described in section 1396d(s)
With respect to a qualified disabled and working individual described in
(e) Prohibition of denial of services on basis of individual's inability to pay certain charges
The State plan shall require that no provider participating under the State plan may deny care or services to an individual eligible for such care or services under the plan on account of such individual's inability to pay a deduction, cost sharing, or similar charge. The requirements of this subsection shall not extinguish the liability of the individual to whom the care or services were furnished for payment of the deduction, cost sharing, or similar charge.
(f) Charges imposed under waiver authority of Secretary
No deduction, cost sharing, or similar charge may be imposed under any waiver authority of the Secretary, except as provided in subsections (a)(3) and (b)(3) of this section, unless such waiver is for a demonstration project which the Secretary finds after public notice and opportunity for comment—
(1) will test a unique and previously untested use of copayments,
(2) is limited to a period of not more than two years,
(3) will provide benefits to recipients of medical assistance which can reasonably be expected to be equivalent to the risks to the recipients,
(4) is based on a reasonable hypothesis which the demonstration is designed to test in a methodologically sound manner, including the use of control groups of similar recipients of medical assistance in the area, and
(5) is voluntary, or makes provision for assumption of liability for preventable damage to the health of recipients of medical assistance resulting from involuntary participation.
(g) Individuals provided medical assistance under section 1396a(a)(10)(A)(ii)(XV) or (XVI)
With respect to individuals provided medical assistance only under subclause (XV) or (XVI) of
(1) a State may (in a uniform manner for individuals described in either such subclause)—
(A) require such individuals to pay premiums or other cost-sharing charges set on a sliding scale based on income that the State may determine; and
(B) require payment of 100 percent of such premiums for such year in the case of such an individual who has income for a year that exceeds 250 percent of the income official poverty line (referred to in subsection (c)(1) of this section) applicable to a family of the size involved, except that in the case of such an individual who has income for a year that does not exceed 450 percent of such poverty line, such requirement may only apply to the extent such premiums do not exceed 7.5 percent of such income; and
(2) such State shall require payment of 100 percent of such premiums for a year by such an individual whose adjusted gross income (as defined in section 62 of the Internal Revenue Code of 1986) for such year exceeds $75,000, except that a State may choose to subsidize such premiums by using State funds which may not be federally matched under this subchapter.
In the case of any calendar year beginning after 2000, the dollar amount specified in paragraph (2) shall be increased in accordance with the provisions of
(Aug. 14, 1935, ch. 531, title XIX, §1916, as added
References in Text
The Internal Revenue Code of 1986, referred to in subsec. (g)(2), is classified generally to Title 26, Internal Revenue Code.
Amendments
1999—Subsec. (a).
Subsec. (g).
1997—Subsec. (a)(2)(D).
Subsec. (b)(2)(D).
1989—Subsec. (a).
Subsecs. (d) to (f).
1988—Subsec. (c)(1).
1987—Subsec. (a)(1).
Subsecs. (a)(2)(C), (b)(2)(C).
Subsecs. (c) to (e).
1986—Subsec. (a).
Subsec. (a)(2)(E).
Subsec. (b).
Subsec. (b)(2)(E).
1983—Subsec. (c).
Subsec. (d).
Effective Date of 1999 Amendment
Amendment by
Effective Date of 1997 Amendment
Amendment by
Effective Date of 1989 Amendment
Amendment by
Effective Date of 1988 Amendment
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
Section 4101(d)(2) of
Amendment by section 4211(h)(11) of
Effective Date of 1986 Amendments
Amendment by
Amendment by
Effective Date of 1983 Amendment
Amendment by
Effective Date
Section 131(d), formerly §131(c), of
"(1) Except as provided in paragraph (2), the amendments made by this section [enacting this section and amending
"(2) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Sept. 3, 1982]."
Section Referred to in Other Sections
This section is referred to in
§1396p. Liens, adjustments and recoveries, and transfers of assets
(a) Imposition of lien against property of an individual on account of medical assistance rendered to him under a State plan
(1) No lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except—
(A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or
(B) in the case of the real property of an individual—
(i) who is an inpatient in a nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and
(ii) with respect to whom the State determines, after notice and opportunity for a hearing (in accordance with procedures established by the State), that he cannot reasonably be expected to be discharged from the medical institution and to return home,
except as provided in paragraph (2).
(2) No lien may be imposed under paragraph (1)(B) on such individual's home if—
(A) the spouse of such individual,
(B) such individual's child who is under age 21, or (with respect to States eligible to participate in the State program established under subchapter XVI of this chapter) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in
(C) a sibling of such individual (who has an equity interest in such home and who was residing in such individual's home for a period of at least one year immediately before the date of the individual's admission to the medical institution),
is lawfully residing in such home.
(3) Any lien imposed with respect to an individual pursuant to paragraph (1)(B) shall dissolve upon that individual's discharge from the medical institution and return home.
(b) Adjustment or recovery of medical assistance correctly paid under a State plan
(1) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made, except that the State shall seek adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan in the case of the following individuals:
(A) In the case of an individual described in subsection (a)(1)(B) of this section, the State shall seek adjustment or recovery from the individual's estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of the individual.
(B) In the case of an individual who was 55 years of age or older when the individual received such medical assistance, the State shall seek adjustment or recovery from the individual's estate, but only for medical assistance consisting of—
(i) nursing facility services, home and community-based services, and related hospital and prescription drug services, or
(ii) at the option of the State, any items or services under the State plan.
(C)(i) In the case of an individual who has received (or is entitled to receive) benefits under a long-term care insurance policy in connection with which assets or resources are disregarded in the manner described in clause (ii), except as provided in such clause, the State shall seek adjustment or recovery from the individual's estate on account of medical assistance paid on behalf of the individual for nursing facility and other long-term care services.
(ii) Clause (i) shall not apply in the case of an individual who received medical assistance under a State plan of a State which had a State plan amendment approved as of May 14, 1993, which provided for the disregard of any assets or resources—
(I) to the extent that payments are made under a long-term care insurance policy; or
(II) because an individual has received (or is entitled to receive) benefits under a long-term care insurance policy.
(2) Any adjustment or recovery under paragraph (1) may be made only after the death of the individual's surviving spouse, if any, and only at a time—
(A) when he has no surviving child who is under age 21, or (with respect to States eligible to participate in the State program established under subchapter XVI of this chapter) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in
(B) in the case of a lien on an individual's home under subsection (a)(1)(B) of this section, when—
(i) no sibling of the individual (who was residing in the individual's home for a period of at least one year immediately before the date of the individual's admission to the medical institution), and
(ii) no son or daughter of the individual (who was residing in the individual's home for a period of at least two years immediately before the date of the individual's admission to the medical institution, and who establishes to the satisfaction of the State that he or she provided care to such individual which permitted such individual to reside at home rather than in an institution),
is lawfully residing in such home who has lawfully resided in such home on a continuous basis since the date of the individual's admission to the medical institution.
(3) The State agency shall establish procedures (in accordance with standards specified by the Secretary) under which the agency shall waive the application of this subsection (other than paragraph (1)(C)) if such application would work an undue hardship as determined on the basis of criteria established by the Secretary.
(4) For purposes of this subsection, the term "estate", with respect to a deceased individual—
(A) shall include all real and personal property and other assets included within the individual's estate, as defined for purposes of State probate law; and
(B) may include, at the option of the State (and shall include, in the case of an individual to whom paragraph (1)(C)(i) applies), any other real and personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of such interest), including such assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.
(c) Taking into account certain transfers of assets
(1)(A) In order to meet the requirements of this subsection for purposes of
(B)(i) The look-back date specified in this subparagraph is a date that is 36 months (or, in the case of payments from a trust or portions of a trust that are treated as assets disposed of by the individual pursuant to paragraph (3)(A)(iii) or (3)(B)(ii) of subsection (d) of this section, 60 months) before the date specified in clause (ii).
(ii) The date specified in this clause, with respect to—
(I) an institutionalized individual is the first date as of which the individual both is an institutionalized individual and has applied for medical assistance under the State plan, or
(II) a noninstitutionalized individual is the date on which the individual applies for medical assistance under the State plan or, if later, the date on which the individual disposes of assets for less than fair market value.
(C)(i) The services described in this subparagraph with respect to an institutionalized individual are the following:
(I) Nursing facility services.
(II) A level of care in any institution equivalent to that of nursing facility services.
(III) Home or community-based services furnished under a waiver granted under subsection (c) or (d) of
(ii) The services described in this subparagraph with respect to a noninstitutionalized individual are services (not including any services described in clause (i)) that are described in paragraph (7), (22), or (24) of
(D) The date specified in this subparagraph is the first day of the first month during or after which assets have been transferred for less than fair market value and which does not occur in any other periods of ineligibility under this subsection.
(E)(i) With respect to an institutionalized individual, the number of months of ineligibility under this subparagraph for an individual shall be equal to—
(I) the total, cumulative uncompensated value of all assets transferred by the individual (or individual's spouse) on or after the look-back date specified in subparagraph (B)(i), divided by
(II) the average monthly cost to a private patient of nursing facility services in the State (or, at the option of the State, in the community in which the individual is institutionalized) at the time of application.
(ii) With respect to a noninstitutionalized individual, the number of months of ineligibility under this subparagraph for an individual shall not be greater than a number equal to—
(I) the total, cumulative uncompensated value of all assets transferred by the individual (or individual's spouse) on or after the look-back date specified in subparagraph (B)(i), divided by
(II) the average monthly cost to a private patient of nursing facility services in the State (or, at the option of the State, in the community in which the individual is institutionalized) at the time of application.
(iii) The number of months of ineligibility otherwise determined under clause (i) or (ii) with respect to the disposal of an asset shall be reduced—
(I) in the case of periods of ineligibility determined under clause (i), by the number of months of ineligibility applicable to the individual under clause (ii) as a result of such disposal, and
(II) in the case of periods of ineligibility determined under clause (ii), by the number of months of ineligibility applicable to the individual under clause (i) as a result of such disposal.
(2) An individual shall not be ineligible for medical assistance by reason of paragraph (1) to the extent that—
(A) the assets transferred were a home and title to the home was transferred to—
(i) the spouse of such individual;
(ii) a child of such individual who (I) is under age 21, or (II) (with respect to States eligible to participate in the State program established under subchapter XVI of this chapter) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in
(iii) a sibling of such individual who has an equity interest in such home and who was residing in such individual's home for a period of at least one year immediately before the date the individual becomes an institutionalized individual; or
(iv) a son or daughter of such individual (other than a child described in clause (ii)) who was residing in such individual's home for a period of at least two years immediately before the date the individual becomes an institutionalized individual, and who (as determined by the State) provided care to such individual which permitted such individual to reside at home rather than in such an institution or facility;
(B) the assets—
(i) were transferred to the individual's spouse or to another for the sole benefit of the individual's spouse,
(ii) were transferred from the individual's spouse to another for the sole benefit of the individual's spouse,
(iii) were transferred to, or to a trust (including a trust described in subsection (d)(4) of this section) established solely for the benefit of, the individual's child described in subparagraph (A)(ii)(II), or
(iv) were transferred to a trust (including a trust described in subsection (d)(4) of this section) established solely for the benefit of an individual under 65 years of age who is disabled (as defined in
(C) a satisfactory showing is made to the State (in accordance with regulations promulgated by the Secretary) that (i) the individual intended to dispose of the assets either at fair market value, or for other valuable consideration, (ii) the assets were transferred exclusively for a purpose other than to qualify for medical assistance, or (iii) all assets transferred for less than fair market value have been returned to the individual; or
(D) the State determines, under procedures established by the State (in accordance with standards specified by the Secretary), that the denial of eligibility would work an undue hardship as determined on the basis of criteria established by the Secretary; 1
(3) For purposes of this subsection, in the case of an asset held by an individual in common with another person or persons in a joint tenancy, tenancy in common, or similar arrangement, the asset (or the affected portion of such asset) shall be considered to be transferred by such individual when any action is taken, either by such individual or by any other person, that reduces or eliminates such individual's ownership or control of such asset.
(4) A State (including a State which has elected treatment under
(5) In this subsection, the term "resources" has the meaning given such term in
(d) Treatment of trust amounts
(1) For purposes of determining an individual's eligibility for, or amount of, benefits under a State plan under this subchapter, subject to paragraph (4), the rules specified in paragraph (3) shall apply to a trust established by such individual.
(2)(A) For purposes of this subsection, an individual shall be considered to have established a trust if assets of the individual were used to form all or part of the corpus of the trust and if any of the following individuals established such trust other than by will:
(i) The individual.
(ii) The individual's spouse.
(iii) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual's spouse.
(iv) A person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.
(B) In the case of a trust the corpus of which includes assets of an individual (as determined under subparagraph (A)) and assets of any other person or persons, the provisions of this subsection shall apply to the portion of the trust attributable to the assets of the individual.
(C) Subject to paragraph (4), this subsection shall apply without regard to—
(i) the purposes for which a trust is established,
(ii) whether the trustees have or exercise any discretion under the trust,
(iii) any restrictions on when or whether distributions may be made from the trust, or
(iv) any restrictions on the use of distributions from the trust.
(3)(A) In the case of a revocable trust—
(i) the corpus of the trust shall be considered resources available to the individual,
(ii) payments from the trust to or for the benefit of the individual shall be considered income of the individual, and
(iii) any other payments from the trust shall be considered assets disposed of by the individual for purposes of subsection (c) of this section.
(B) In the case of an irrevocable trust—
(i) if there are any circumstances under which payment from the trust could be made to or for the benefit of the individual, the portion of the corpus from which, or the income on the corpus from which, payment to the individual could be made shall be considered resources available to the individual, and payments from that portion of the corpus or income—
(I) to or for the benefit of the individual, shall be considered income of the individual, and
(II) for any other purpose, shall be considered a transfer of assets by the individual subject to subsection (c) of this section; and
(ii) any portion of the trust from which, or any income on the corpus from which, no payment could under any circumstances be made to the individual shall be considered, as of the date of establishment of the trust (or, if later, the date on which payment to the individual was foreclosed) to be assets disposed by the individual for purposes of subsection (c) of this section, and the value of the trust shall be determined for purposes of such subsection by including the amount of any payments made from such portion of the trust after such date.
(4) This subsection shall not apply to any of the following trusts:
(A) A trust containing the assets of an individual under age 65 who is disabled (as defined in
(B) A trust established in a State for the benefit of an individual if—
(i) the trust is composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust),
(ii) the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this subchapter; and
(iii) the State makes medical assistance available to individuals described in
(C) A trust containing the assets of an individual who is disabled (as defined in
(i) The trust is established and managed by a non-profit association.
(ii) A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of funds, the trust pools these accounts.
(iii) Accounts in the trust are established solely for the benefit of individuals who are disabled (as defined in
(iv) To the extent that amounts remaining in the beneficiary's account upon the death of the beneficiary are not retained by the trust, the trust pays to the State from such remaining amounts in the account an amount equal to the total amount of medical assistance paid on behalf of the beneficiary under the State plan under this subchapter.
(5) The State agency shall establish procedures (in accordance with standards specified by the Secretary) under which the agency waives the application of this subsection with respect to an individual if the individual establishes that such application would work an undue hardship on the individual as determined on the basis of criteria established by the Secretary.
(6) The term "trust" includes any legal instrument or device that is similar to a trust but includes an annuity only to such extent and in such manner as the Secretary specifies.
(e) Definitions
In this section, the following definitions shall apply:
(1) The term "assets", with respect to an individual, includes all income and resources of the individual and of the individual's spouse, including any income or resources which the individual or such individual's spouse is entitled to but does not receive because of action—
(A) by the individual or such individual's spouse,
(B) by a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or such individual's spouse, or
(C) by any person, including any court or administrative body, acting at the direction or upon the request of the individual or such individual's spouse.
(2) The term "income" has the meaning given such term in
(3) The term "institutionalized individual" means an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in
(4) The term "noninstitutionalized individual" means an individual receiving any of the services specified in subsection (c)(1)(C)(ii) of this section.
(5) The term "resources" has the meaning given such term in
(Aug. 14, 1935, ch. 531, title XIX, §1917, as added
Amendments
1993—Subsec. (b)(1).
"(A) in the case of an individual described in subsection (a)(1)(B) of this section, from his estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of such individual, and
"(B) in the case of any other individual who was 65 years of age or older when he received such assistance, from his estate."
Subsec. (b)(3).
Subsec. (b)(4).
Subsec. (c)(1).
"(A) 30 months, or
"(B)(i) the total uncompensated value of the resources so transferred, divided by (ii) the average cost, to a private patient at the time of the application, of nursing facility services in the State or, at State option, in the community in which the individual is institutionalized."
Subsec. (c)(2)(A).
Subsec. (c)(2)(B).
Subsec. (c)(2)(C).
Subsec. (c)(2)(D).
Subsec. (c)(3).
Subsec. (c)(4).
Subsec. (d).
Subsec. (e).
1989—Subsec. (c)(1).
Subsec. (c)(2)(B)(i).
Subsec. (c)(2)(B)(ii), (iii).
1988—Subsec. (c).
Subsec. (c)(1).
Subsec. (c)(2)(A)(ii).
Subsec. (c)(2)(A)(iii).
Subsec. (c)(2)(A)(iv).
Subsec. (c)(2)(B).
Subsec. (c)(2)(B)(ii).
Subsec. (c)(3).
Subsec. (c)(5).
1987—Subsecs. (a)(1)(B)(i), (c)(2)(B)(i).
Subsec. (c)(2)(B)(ii).
1983—Subsec. (b)(2)(B).
Subsec. (c)(2)(B)(iii).
Effective Date of 1993 Amendment
Section 13611(e) of
"(1) The amendments made by this section [amending this section and
"(2) The amendments made by this section shall not apply—
"(A) to medical assistance provided for services furnished before October 1, 1993,
"(B) with respect to assets disposed of on or before the date of the enactment of this Act [Aug. 10, 1993], or
"(C) with respect to trusts established on or before the date of the enactment of this Act.
"(3) In the case of a State plan for medical assistance under title XIX of the Social Security Act [this subchapter] which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendment made by subsection (b) [amending this section], the State plan shall not be regarded as failing to comply with the requirements imposed by such amendment solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Aug. 10, 1993]. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature."
Section 13612(d) of
"(1)(A) Except as provided in subparagraph (B), the amendments made by this section [amending this section] shall apply to payments under title XIX of the Social Security Act [this subchapter] for calendar quarters beginning on or after October 1, 1993, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements imposed by such amendments solely on the basis of its failure to meet these 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 begins after the date of the enactment of this Act [Aug. 10, 1993]. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.
"(2) The amendments made by this section shall not apply to individuals who died before October 1, 1993."
Effective Date of 1989 Amendment
Amendment by
Effective Date of 1988 Amendments
Amendment by
Amendment by section 303(b) of
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
Amendment by
Effective Date of 1983 Amendment
Amendment by
Effective Date
Section 132(d) of
Section Referred to in Other Sections
This section is referred to in
1 So in original. The semicolon probably should be a period.
§1396q. Application of provisions of subchapter II relating to subpoenas
The provisions of subsections (d) and (e) of
(Aug. 14, 1935, ch. 531, title XIX, §1918, as added
Amendments
1994—
Effective Date of 1994 Amendment
Amendment by
Effective Date
Section 2370(b) of
§1396r. Requirements for nursing facilities
(a) "Nursing facility" defined
In this subchapter, the term "nursing facility" means an institution (or a distinct part of an institution) which—
(1) is primarily engaged in providing to residents—
(A) skilled nursing care and related services for residents who require medical or nursing care,
(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or
(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities,
and is not primarily for the care and treatment of mental diseases;
(2) has in effect a transfer agreement (meeting the requirements of
(3) meets the requirements for a nursing facility described in subsections (b), (c), and (d) of this section.
Such term also includes any facility which is located in a State on an Indian reservation and is certified by the Secretary as meeting the requirements of paragraph (1) and subsections (b), (c), and (d) of this section.
(b) Requirements relating to provision of services
(1) Quality of life
(A) In general
A nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident.
(B) Quality assessment and assurance
A nursing facility must maintain a quality assessment and assurance committee, consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility's staff, which (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this subparagraph.
(2) Scope of services and activities under plan of care
A nursing facility must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care which—
(A) describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met;
(B) is initially prepared, with the participation to the extent practicable of the resident or the resident's family or legal representative, by a team which includes the resident's attending physician and a registered professional nurse with responsibility for the resident; and
(C) is periodically reviewed and revised by such team after each assessment under paragraph (3).
(3) Residents' assessment
(A) Requirement
A nursing facility must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, which assessment—
(i) describes the resident's capability to perform daily life functions and significant impairments in functional capacity;
(ii) is based on a uniform minimum data set specified by the Secretary under subsection (f)(6)(A) of this section;
(iii) uses an instrument which is specified by the State under subsection (e)(5) of this section; and
(iv) includes the identification of medical problems.
(B) Certification
(i) In general
Each such assessment must be conducted or coordinated (with the appropriate participation of health professionals) by a registered professional nurse who signs and certifies the completion of the assessment. Each individual who completes a portion of such an assessment shall sign and certify as to the accuracy of that portion of the assessment.
(ii) Penalty for falsification
(I) An individual who willfully and knowingly certifies under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 with respect to each assessment.
(II) An individual who willfully and knowingly causes another individual to certify under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 with respect to each assessment.
(III) The provisions of
(iii) Use of independent assessors
If a State determines, under a survey under subsection (g) of this section or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the State may require (for a period specified by the State) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the State.
(C) Frequency
(i) In general
Such an assessment must be conducted—
(I) promptly upon (but no later than 14 days after the date of) admission for each individual admitted on or after October 1, 1990, and by not later than October 1, 1991, for each resident of the facility on that date;
(II) promptly after a significant change in the resident's physical or mental condition; and
(III) in no case less often than once every 12 months.
(ii) Resident review
The nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident's assessment to assure the continuing accuracy of the assessment.
(D) Use
The results of such an assessment shall be used in developing, reviewing, and revising the resident's plan of care under paragraph (2).
(E) Coordination
Such assessments shall be coordinated with any State-required preadmission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. In addition, a nursing facility shall notify the State mental health authority or State mental retardation or developmental disability authority, as applicable, promptly after a significant change in the physical or mental condition of a resident who is mentally ill or mentally retarded.
(F) Requirements relating to preadmission screening for mentally ill and mentally retarded individuals
Except as provided in clauses (ii) and (iii) of subsection (e)(7)(A) of this section, a nursing facility must not admit, on or after January 1, 1989, any new resident who—
(i) is mentally ill (as defined in subsection (e)(7)(G)(i) of this section) unless the State mental health authority has determined (based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority) prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires specialized services for mental illness, or
(ii) is mentally retarded (as defined in subsection (e)(7)(G)(ii) of this section) unless the State mental retardation or developmental disability authority has determined prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires specialized services for mental retardation.
A State mental health authority and a State mental retardation or developmental disability authority may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility).
(4) Provision of services and activities
(A) In general
To the extent needed to fulfill all plans of care described in paragraph (2), a nursing facility must provide (or arrange for the provision of)—
(i) nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
(ii) medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
(iii) pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident;
(iv) dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident;
(v) an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident;
(vi) routine dental services (to the extent covered under the State plan) and emergency dental services to meet the needs of each resident; and
(vii) treatment and services required by mentally ill and mentally retarded residents not otherwise provided or arranged for (or required to be provided or arranged for) by the State.
The services provided or arranged by the facility must meet professional standards of quality.
(B) Qualified persons providing services
Services described in clauses (i), (ii), (iii), (iv), and (vi) of subparagraph (A) must be provided by qualified persons in accordance with each resident's written plan of care.
(C) Required nursing care; facility waivers
(i) General requirements
With respect to nursing facility services provided on or after October 1, 1990, a nursing facility—
(I) except as provided in clause (ii), must provide 24-hour licensed nursing services which are sufficient to meet the nursing needs of its residents, and
(II) except as provided in clause (ii), must use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week.
(ii) Waiver by State
To the extent that a facility is unable to meet the requirements of clause (i), a State may waive such requirements with respect to the facility if—
(I) the facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel,
(II) the State determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility,
(III) the State finds that, for any such periods in which licensed nursing services are not available, a registered professional nurse or a physician is obligated to respond immediately to telephone calls from the facility,
(IV) the State agency granting a waiver of such requirements provides notice of the waiver to the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965 [
(V) the nursing facility that is granted such a waiver by a State notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.
A waiver under this clause shall be subject to annual review and to the review of the Secretary and subject to clause (iii) shall be accepted by the Secretary for purposes of this subchapter to the same extent as is the State's certification of the facility. In granting or renewing a waiver, a State may require the facility to use other qualified, licensed personnel.
(iii) Assumption of waiver authority by Secretary
If the Secretary determines that a State has shown a clear pattern and practice of allowing waivers in the absence of diligent efforts by facilities to meet the staffing requirements, the Secretary shall assume and exercise the authority of the State to grant waivers.
(5) Required training of nurse aides
(A) In general
(i) Except as provided in clause (ii), a nursing facility must not use on a full-time basis any individual as a nurse aide in the facility on or after October 1, 1990, for more than 4 months unless the individual—
(I) has completed a training and competency evaluation program, or a competency evaluation program, approved by the State under subsection (e)(1)(A) of this section, and
(II) is competent to provide nursing or nursing-related services.
(ii) A nursing facility must not use on a temporary, per diem, leased, or on any other basis other than as a permanent employee any individual as a nurse aide in the facility on or after January 1, 1991, unless the individual meets the requirements described in clause (i).
(B) Offering competency evaluation programs for current employees
A nursing facility must provide, for individuals used as a nurse aide by the facility as of January 1, 1990, for a competency evaluation program approved by the State under subsection (e)(1) of this section and such preparation as may be necessary for the individual to complete such a program by October 1, 1990.
(C) Competency
The nursing facility must not permit an individual, other than in a training and competency evaluation program approved by the State, to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency and must not use such an individual as a nurse aide unless the facility has inquired of any State registry established under subsection (e)(2)(A) of this section that the facility believes will include information concerning the individual.
(D) Re-training required
For purposes of subparagraph (A), if, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual performed nursing or nursing-related services for monetary compensation, such individual shall complete a new training and competency evaluation program, or a new competency evaluation program.
(E) Regular in-service education
The nursing facility must provide such regular performance review and regular in-service education as assures that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments.
(F) "Nurse aide" defined
In this paragraph, the term "nurse aide" means any individual providing nursing or nursing-related services to residents in a nursing facility, but does not include an individual—
(i) who is a licensed health professional (as defined in subparagraph (G)) or a registered dietician, or
(ii) who volunteers to provide such services without monetary compensation.
(G) Licensed health professional defined
In this paragraph, the term "licensed health professional" means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, or licensed or certified social worker.
(6) Physician supervision and clinical records
A nursing facility must—
(A) require that the health care of every resident be provided under the supervision of a physician (or, at the option of a State, under the supervision of a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician);
(B) provide for having a physician available to furnish necessary medical care in case of emergency; and
(C) maintain clinical records on all residents, which records include the plans of care (described in paragraph (2)) and the residents' assessments (described in paragraph (3)), as well as the results of any pre-admission screening conducted under subsection (e)(7) of this section.
(7) Required social services
In the case of a nursing facility with more than 120 beds, the facility must have at least one social worker (with at least a bachelor's degree in social work or similar professional qualifications) employed full-time to provide or assure the provision of social services.
(c) Requirements relating to residents' rights
(1) General rights
(A) Specified rights
A nursing facility must protect and promote the rights of each resident, including each of the following rights:
(i) Free choice
The right to choose a personal attending physician, to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident's well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment.
(ii) Free from restraints
The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Restraints may only be imposed—
(I) to ensure the physical safety of the resident or other residents, and
(II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary until such an order could reasonably be obtained).
(iii) Privacy
The right to privacy with regard to accommodations, medical treatment, written and telephonic communications, visits, and meetings of family and of resident groups.
(iv) Confidentiality
The right to confidentiality of personal and clinical records and to access to current clinical records of the resident upon request by the resident or the resident's legal representative, within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request.
(v) Accommodation of needs
The right—
(I) to reside and receive services with reasonable accommodation of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered, and
(II) to receive notice before the room or roommate of the resident in the facility is changed.
(vi) Grievances
The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal for voicing the grievances and the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.
(vii) Participation in resident and family groups
The right of the resident to organize and participate in resident groups in the facility and the right of the resident's family to meet in the facility with the families of other residents in the facility.
(viii) Participation in other activities
The right of the resident to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.
(ix) Examination of survey results
The right to examine, upon reasonable request, the results of the most recent survey of the facility conducted by the Secretary or a State with respect to the facility and any plan of correction in effect with respect to the facility.
(x) Refusal of certain transfers
The right to refuse a transfer to another room within the facility, if a purpose of the transfer is to relocate the resident from a portion of the facility that is not a skilled nursing facility (for purposes of subchapter XVIII of this chapter) to a portion of the facility that is such a skilled nursing facility.
(xi) Other rights
Any other right established by the Secretary.
Clause (iii) shall not be construed as requiring the provision of a private room. A resident's exercise of a right to refuse transfer under clause (x) shall not affect the resident's eligibility or entitlement to medical assistance under this subchapter or a State's entitlement to Federal medical assistance under this subchapter with respect to services furnished to such a resident.
(B) Notice of rights
A nursing facility must—
(i) inform each resident, orally and in writing at the time of admission to the facility, of the resident's legal rights during the stay at the facility and of the requirements and procedures for establishing eligibility for medical assistance under this subchapter, including the right to request an assessment under
(ii) make available to each resident, upon reasonable request, a written statement of such rights (which statement is updated upon changes in such rights) including the notice (if any) of the State developed under subsection (e)(6) of this section;
(iii) inform each resident who is entitled to medical assistance under this subchapter—
(I) at the time of admission to the facility or, if later, at the time the resident becomes eligible for such assistance, of the items and services (including those specified under
(II) of changes in the items and services described in subclause (I) and of changes in the charges imposed for items and services described in that subclause; and
(iv) inform each other resident, in writing before or at the time of admission and periodically during the resident's stay, of services available in the facility and of related charges for such services, including any charges for services not covered under subchapter XVIII of this chapter or by the facility's basic per diem charge.
The written description of legal rights under this subparagraph shall include a description of the protection of personal funds under paragraph (6) and a statement that a resident may file a complaint with a State survey and certification agency respecting resident abuse and neglect and misappropriation of resident property in the facility.
(C) Rights of incompetent residents
In the case of a resident adjudged incompetent under the laws of a State, the rights of the resident under this subchapter shall devolve upon, and, to the extent judged necessary by a court of competent jurisdiction, be exercised by, the person appointed under State law to act on the resident's behalf.
(D) Use of psychopharmacologic drugs
Psychopharmacologic drugs may be administered only on the orders of a physician and only as part of a plan (included in the written plan of care described in paragraph (2)) designed to eliminate or modify the symptoms for which the drugs are prescribed and only if, at least annually an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs.
(2) Transfer and discharge rights
(A) In general
A nursing facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless—
(i) the transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility;
(ii) the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(iii) the safety of individuals in the facility is endangered;
(iv) the health of individuals in the facility would otherwise be endangered;
(v) the resident has failed, after reasonable and appropriate notice, to pay (or to have paid under this subchapter or subchapter XVIII of this chapter on the resident's behalf) for a stay at the facility; or
(vi) the facility ceases to operate.
In each of the cases described in clauses (i) through (iv), the basis for the transfer or discharge must be documented in the resident's clinical record. In the cases described in clauses (i) and (ii), the documentation must be made by the resident's physician, and in the case described in clause (iv) the documentation must be made by a physician. For purposes of clause (v), in the case of a resident who becomes eligible for assistance under this subchapter after admission to the facility, only charges which may be imposed under this subchapter shall be considered to be allowable.
(B) Pre-transfer and pre-discharge notice
(i) In general
Before effecting a transfer or discharge of a resident, a nursing facility must—
(I) notify the resident (and, if known, an immediate family member of the resident or legal representative) of the transfer or discharge and the reasons therefor,
(II) record the reasons in the resident's clinical record (including any documentation required under subparagraph (A)), and
(III) include in the notice the items described in clause (iii).
(ii) Timing of notice
The notice under clause (i)(I) must be made at least 30 days in advance of the resident's transfer or discharge except—
(I) in a case described in clause (iii) or (iv) of subparagraph (A);
(II) in a case described in clause (ii) of subparagraph (A), where the resident's health improves sufficiently to allow a more immediate transfer or discharge;
(III) in a case described in clause (i) of subparagraph (A), where a more immediate transfer or discharge is necessitated by the resident's urgent medical needs; or
(IV) in a case where a resident has not resided in the facility for 30 days.
In the case of such exceptions, notice must be given as many days before the date of the transfer or discharge as is practicable.
(iii) Items included in notice
Each notice under clause (i) must include—
(I) for transfers or discharges effected on or after October 1, 1989, notice of the resident's right to appeal the transfer or discharge under the State process established under subsection (e)(3) of this section;
(II) the name, mailing address, and telephone number of the State long-term care ombudsman (established under title III or VII of the Older Americans Act of 1965 [
(III) in the case of residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy system for developmentally disabled individuals established under part C of the Developmental Disabilities Assistance and Bill of Rights Act [
(IV) in the case of mentally ill residents (as defined in subsection (e)(7)(G)(i) of this section), the mailing address and telephone number of the agency responsible for the protection and advocacy system for mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act [
(C) Orientation
A nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.
(D) Notice on bed-hold policy and readmission
(i) Notice before transfer
Before a resident of a nursing facility is transferred for hospitalization or therapeutic leave, a nursing facility must provide written information to the resident and an immediate family member or legal representative concerning—
(I) the provisions of the State plan under this subchapter regarding the period (if any) during which the resident will be permitted under the State plan to return and resume residence in the facility, and
(II) the policies of the facility regarding such a period, which policies must be consistent with clause (iii).
(ii) Notice upon transfer
At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide written notice to the resident and an immediate family member or legal representative of the duration of any period described in clause (i).
(iii) Permitting resident to return
A nursing facility must establish and follow a written policy under which a resident—
(I) who is eligible for medical assistance for nursing facility services under a State plan,
(II) who is transferred from the facility for hospitalization or therapeutic leave, and
(III) whose hospitalization or therapeutic leave exceeds a period paid for under the State plan for the holding of a bed in the facility for the resident,
will be permitted to be readmitted to the facility immediately upon the first availability of a bed in a semiprivate room in the facility if, at the time of readmission, the resident requires the services provided by the facility.
(E) Information respecting advance directives
A nursing facility must comply with the requirement of
(F) Continuing rights in case of voluntary withdrawal from participation
(i) In general
In the case of a nursing facility that voluntarily withdraws from participation in a State plan under this subchapter but continues to provide services of the type provided by nursing facilities—
(I) the facility's voluntary withdrawal from participation is not an acceptable basis for the transfer or discharge of residents of the facility who were residing in the facility on the day before the effective date of the withdrawal (including those residents who were not entitled to medical assistance as of such day);
(II) the provisions of this section continue to apply to such residents until the date of their discharge from the facility; and
(III) in the case of each individual who begins residence in the facility after the effective date of such withdrawal, the facility shall provide notice orally and in a prominent manner in writing on a separate page at the time the individual begins residence of the information described in clause (ii) and shall obtain from each such individual at such time an acknowledgment of receipt of such information that is in writing, signed by the individual, and separate from other documents signed by such individual.
Nothing in this subparagraph shall be construed as affecting any requirement of a participation agreement that a nursing facility provide advance notice to the State or the Secretary, or both, of its intention to terminate the agreement.
(ii) Information for new residents
The information described in this clause for a resident is the following:
(I) The facility is not participating in the program under this subchapter with respect to that resident.
(II) The facility may transfer or discharge the resident from the facility at such time as the resident is unable to pay the charges of the facility, even though the resident may have become eligible for medical assistance for nursing facility services under this subchapter.
(iii) Continuation of payments and oversight authority
Notwithstanding any other provision of this subchapter, with respect to the residents described in clause (i)(I), a participation agreement of a facility described in clause (i) is deemed to continue in effect under such plan after the effective date of the facility's voluntary withdrawal from participation under the State plan for purposes of—
(I) receiving payments under the State plan for nursing facility services provided to such residents;
(II) maintaining compliance with all applicable requirements of this subchapter; and
(III) continuing to apply the survey, certification, and enforcement authority provided under subsections (g) and (h) of this section (including involuntary termination of a participation agreement deemed continued under this clause).
(iv) No application to new residents
This paragraph (other than subclause (III) of clause (i)) shall not apply to an individual who begins residence in a facility on or after the effective date of the withdrawal from participation under this subparagraph.
(3) Access and visitation rights
A nursing facility must—
(A) permit immediate access to any resident by any representative of the Secretary, by any representative of the State, by an ombudsman or agency described in subclause (II), (III), or (IV) of paragraph (2)(B)(iii), or by the resident's individual physician;
(B) permit immediate access to a resident, subject to the resident's right to deny or withdraw consent at any time, by immediate family or other relatives of the resident;
(C) permit immediate access to a resident, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident;
(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(E) permit representatives of the State ombudsman (described in paragraph (2)(B)(iii)(II)), with the permission of the resident (or the resident's legal representative) and consistent with State law, to examine a resident's clinical records.
(4) Equal access to quality care
(A) In general
A nursing facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services required under the State plan for all individuals regardless of source of payment.
(B) Construction
(i) Nothing prohibiting any charges for non-medicaid patients
Subparagraph (A) shall not be construed as prohibiting a nursing facility from charging any amount for services furnished, consistent with the notice in paragraph (1)(B) describing such charges.
(ii) No additional services required
Subparagraph (A) shall not be construed as requiring a State to offer additional services on behalf of a resident than are otherwise provided under the State plan.
(5) Admissions policy
(A) Admissions
With respect to admissions practices, a nursing facility must—
(i)(I) not require individuals applying to reside or residing in the facility to waive their rights to benefits under this subchapter or subchapter XVIII of this chapter, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this subchapter or subchapter XVIII of this chapter, and (III) prominently display in the facility written information, and provide to such individuals oral and written information, about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits;
(ii) not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility; and
(iii) in the case of an individual who is entitled to medical assistance for nursing facility services, not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan under this subchapter, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the individual to the facility or as a requirement for the individual's continued stay in the facility.
(B) Construction
(i) No preemption of stricter standards
Subparagraph (A) shall not be construed as preventing States or political subdivisions therein from prohibiting, under State or local law, the discrimination against individuals who are entitled to medical assistance under the State plan with respect to admissions practices of nursing facilities.
(ii) Contracts with legal representatives
Subparagraph (A)(ii) shall not be construed as preventing a facility from requiring an individual, who has legal access to a resident's income or resources available to pay for care in the facility, to sign a contract (without incurring personal financial liability) to provide payment from the resident's income or resources for such care.
(iii) Charges for additional services requested
Subparagraph (A)(iii) shall not be construed as preventing a facility from charging a resident, eligible for medical assistance under the State plan, for items or services the resident has requested and received and that are not specified in the State plan as included in the term "nursing facility services".
(iv) Bona fide contributions
Subparagraph (A)(iii) shall not be construed as prohibiting a nursing facility from soliciting, accepting, or receiving a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility.
(6) Protection of resident funds
(A) In general
The nursing facility—
(i) may not require residents to deposit their personal funds with the facility, and
(ii) upon the written authorization of the resident, must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph.
(B) Management of personal funds
Upon written authorization of a resident under subparagraph (A)(ii), the facility must manage and account for the personal funds of the resident deposited with the facility as follows:
(i) Deposit
The facility must deposit any amount of personal funds in excess of $50 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts and credits all interest earned on such separate account to such account. With respect to any other personal funds, the facility must maintain such funds in a non-interest bearing account or petty cash fund.
(ii) Accounting and records
The facility must assure a full and complete separate accounting of each such resident's personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record.
(iii) Notice of certain balances
The facility must notify each resident receiving medical assistance under the State plan under this subchapter when the amount in the resident's account reaches $200 less than the dollar amount determined under
(iv) Conveyance upon death
Upon the death of a resident with such an account, the facility must convey promptly the resident's personal funds (and a final accounting of such funds) to the individual administering the resident's estate.
(C) Assurance of financial security
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
(D) Limitation on charges to personal funds
The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under this subchapter or subchapter XVIII of this chapter.
(7) Limitation on charges in case of medicaid-eligible individuals
(A) In general
A nursing facility may not impose charges, for certain medicaid-eligible individuals for nursing facility services covered by the State under its plan under this subchapter, that exceed the payment amounts established by the State for such services under this subchapter.
(B) "Certain medicaid-eligible individual" defined
In subparagraph (A), the term "certain medicaid-eligible individual" means an individual who is entitled to medical assistance for nursing facility services in the facility under this subchapter but with respect to whom such benefits are not being paid because, in determining the amount of the individual's income to be applied monthly to payment for the costs of such services, the amount of such income exceeds the payment amounts established by the State for such services under this subchapter.
(8) Posting of survey results
A nursing facility must post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted under subsection (g) of this section.
(d) Requirements relating to administration and other matters
(1) Administration
(A) In general
A nursing facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (consistent with requirements established under subsection (f)(5) of this section).
(B) Required notices
If a change occurs in—
(i) the persons with an ownership or control interest (as defined in
(ii) the persons who are officers, directors, agents, or managing employees (as defined in
(iii) the corporation, association, or other company responsible for the management of the facility, or
(iv) the individual who is the administrator or director of nursing of the facility,
the nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause.
(C) Nursing facility administrator
The administrator of a nursing facility must meet standards established by the Secretary under subsection (f)(4) of this section.
(2) Licensing and Life Safety Code
(A) Licensing
A nursing facility must be licensed under applicable State and local law.
(B) Life Safety Code
A nursing facility must meet such provisions of such edition (as specified by the Secretary in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that—
(i) the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of residents or personnel, and
(ii) the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects residents of and personnel in nursing facilities.
(3) Sanitary and infection control and physical environment
A nursing facility must—
(A) establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, and
(B) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents, personnel, and the general public.
(4) Miscellaneous
(A) Compliance with Federal, State, and local laws and professional standards
A nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of
(B) Other
A nursing facility must meet such other requirements relating to the health and safety of residents or relating to the physical facilities thereof as the Secretary may find necessary.
(e) State requirements relating to nursing facility requirements
As a condition of approval of its plan under this subchapter, a State must provide for the following:
(1) Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs
The State must—
(A) by not later than January 1, 1989, specify those training and competency evaluation programs, and those competency evaluation programs, that the State approves for purposes of subsection (b)(5) of this section and that meet the requirements established under subsection (f)(2) of this section, and
(B) by not later than January 1, 1990, provide for the review and reapproval of such programs, at a frequency and using a methodology consistent with the requirements established under subsection (f)(2)(A)(iii) of this section.
The failure of the Secretary to establish requirements under subsection (f)(2) of this section shall not relieve any State of its responsibility under this paragraph.
(2) Nurse aide registry
(A) In general
By not later than January 1, 1989, the State shall establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program, or a nurse aide competency evaluation program, approved under paragraph (1) in the State, or any individual described in subsection (f)(2)(B)(ii) of this section or in subparagraph (B), (C), or (D) of section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.
(B) Information in registry
The registry under subparagraph (A) shall provide (in accordance with regulations of the Secretary) for the inclusion of specific documented findings by a State under subsection (g)(1)(C) of this section of resident neglect or abuse or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings. The State shall make available to the public information in the registry. In the case of inquiries to the registry concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement.
(C) Prohibition against charges
A State may not impose any charges on a nurse aide relating to the registry established and maintained under subparagraph (A).
(3) State appeals process for transfers and discharges
The State, for transfers and discharges from nursing facilities effected on or after October 1, 1989, must provide for a fair mechanism, meeting the guidelines established under subsection (f)(3) of this section, for hearing appeals on transfers and discharges of residents of such facilities; but the failure of the Secretary to establish such guidelines under such subsection shall not relieve any State of its responsibility under this paragraph.
(4) Nursing facility administrator standards
By not later than July 1, 1989, the State must have implemented and enforced the nursing facility administrator standards developed under subsection (f)(4) of this section respecting the qualification of administrators of nursing facilities.
(5) Specification of resident assessment instrument
Effective July 1, 1990, the State shall specify the instrument to be used by nursing facilities in the State in complying with the requirement of subsection (b)(3)(A)(iii) of this section. Such instrument shall be—
(A) one of the instruments designated under subsection (f)(6)(B) of this section, or
(B) an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary under subsection (f)(6)(A) of this section.
(6) Notice of medicaid rights
Each State, as a condition of approval of its plan under this subchapter, effective April 1, 1988, must develop (and periodically update) a written notice of the rights and obligations of residents of nursing facilities (and spouses of such residents) under this subchapter.
(7) State requirements for preadmission screening and resident review
(A) Preadmission screening
(i) In general
Effective January 1, 1989, the State must have in effect a preadmission screening program, for making determinations (using any criteria developed under subsection (f)(8) of this section) described in subsection (b)(3)(F) of this section for mentally ill and mentally retarded individuals (as defined in subparagraph (G)) who are admitted to nursing facilities on or after January 1, 1989. The failure of the Secretary to develop minimum criteria under subsection (f)(8) of this section shall not relieve any State of its responsibility to have a preadmission screening program under this subparagraph or to perform resident reviews under subparagraph (B).
(ii) Clarification with respect to certain readmissions
The preadmission screening program under clause (i) need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(iii) Exception for certain hospital discharges
The preadmission screening program under clause (i) shall not apply to the admission to a nursing facility of an individual—
(I) who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(II) who requires nursing facility services for the condition for which the individual received care in the hospital, and
(III) whose attending physician has certified, before admission to the facility, that the individual is likely to require less than 30 days of nursing facility services.
(B) State requirement for resident review
(i) For mentally ill residents
As of April 1, 1990, in the case of each resident of a nursing facility who is mentally ill, the State mental health authority must review and determine (using any criteria developed under subsection (f)(8) of this section and based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority)—
(I) whether or not the resident, because of the resident's physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an inpatient psychiatric hospital for individuals under age 21 (as described in
(II) whether or not the resident requires specialized services for mental illness.
(ii) For mentally retarded residents
As of April 1, 1990, in the case of each resident of a nursing facility who is mentally retarded, the State mental retardation or developmental disability authority must review and determine (using any criteria developed under subsection (f)(8) of this section)—
(I) whether or not the resident, because of the resident's physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an intermediate care facility described under
(II) whether or not the resident requires specialized services for mental retardation.
(iii) Review required upon change in resident's condition
A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) of this section with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident's physical or mental condition.
(iv) Prohibition of delegation
A State mental health authority, a State mental retardation or developmental disability authority, and a State may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility).
(C) Response to preadmission screening and resident review
As of April 1, 1990, the State must meet the following requirements:
(i) Long-term residents not requiring nursing facility services, but requiring specialized services
In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require specialized services for mental illness or mental retardation, and who has continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident's family or legal representative and care-givers—
(I) inform the resident of the institutional and noninstitutional alternatives covered under the State plan for the resident,
(II) offer the resident the choice of remaining in the facility or of receiving covered services in an alternative appropriate institutional or noninstitutional setting,
(III) clarify the effect on eligibility for services under the State plan if the resident chooses to leave the facility (including its effect on readmission to the facility), and
(IV) regardless of the resident's choice, provide for (or arrange for the provision of) such specialized services for the mental illness or mental retardation.
A State shall not be denied payment under this subchapter for nursing facility services for a resident described in this clause because the resident does not require the level of services provided by such a facility, if the resident chooses to remain in such a facility.
(ii) Other residents not requiring nursing facility services, but requiring specialized services
In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require specialized services for mental illness or mental retardation, and who has not continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident's family or legal representative and care-givers—
(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2) of this section,
(II) prepare and orient the resident for such discharge, and
(III) provide for (or arrange for the provision of) such specialized services for the mental illness or mental retardation.
(iii) Residents not requiring nursing facility services and not requiring specialized services
In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility and not to require specialized services for mental illness or mental retardation, the State must—
(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2) of this section, and
(II) prepare and orient the resident for such discharge.
(iv) Annual report
Each State shall report to the Secretary annually concerning the number and disposition of residents described in each of clauses (ii) and (iii).
(D) Denial of payment
(i) For failure to conduct preadmission screening or review
No payment may be made under
(ii) For certain residents not requiring nursing facility level of services
No payment may be made under
(E) Permitting alternative disposition plans
With respect to residents of a nursing facility who are mentally retarded or mentally ill and who are determined under subparagraph (B) not to require the level of services of such a facility, but who require specialized services for mental illness or mental retardation, a State and the nursing facility shall be considered to be in compliance with the requirements of subparagraphs (A) through (C) of this paragraph if, before April 1, 1989, the State and the Secretary have entered into an agreement relating to the disposition of such residents of the facility and the State is in compliance with such agreement. Such an agreement may provide for the disposition of the residents after the date specified in subparagraph (C). The State may revise such an agreement, subject to the approval of the Secretary, before October 1, 1991, but only if, under the revised agreement, all residents subject to the agreement who do not require the level of services of such a facility are discharged from the facility by not later than April 1, 1994.
(F) Appeals procedures
Each State, as a condition of approval of its plan under this subchapter, effective January 1, 1989, must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (A) or (B).
(G) Definitions
In this paragraph and in subsection (b)(3)(F) of this section:
(i) An individual is considered to be "mentally ill" if the individual has a serious mental illness (as defined by the Secretary in consultation with the National Institute of Mental Health) and does not have a primary diagnosis of dementia (including Alzheimer's disease or a related disorder) or a diagnosis (other than a primary diagnosis) of dementia and a primary diagnosis that is not a serious mental illness.
(ii) An individual is considered to be "mentally retarded" if the individual is mentally retarded or a person with a related condition (as described in
(iii) The term "specialized services" has the meaning given such term by the Secretary in regulations, but does not include, in the case of a resident of a nursing facility, services within the scope of services which the facility must provide or arrange for its residents under subsection (b)(4) of this section.
(f) Responsibilities of Secretary relating to nursing facility requirements
(1) General responsibility
It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in nursing facilities under State plans approved under this subchapter, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys.
(2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs
(A) In general
For purposes of subsections (b)(5) and (e)(1)(A) of this section, the Secretary shall establish, by not later than September 1, 1988—
(i) requirements for the approval of nurse aide training and competency evaluation programs, including requirements relating to (I) the areas to be covered in such a program (including at least basic nursing skills, personal care skills, recognition of mental health and social service needs, care of cognitively impaired residents, basic restorative services, and residents' rights) and content of the curriculum, (II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency;
(ii) requirements for the approval of nurse aide competency evaluation programs, including requirement relating to the areas to be covered in such a program, including at least basic nursing skills, personal care skills, recognition of mental health and social service needs, care of cognitively impaired residents, basic restorative services, and residents' rights, and procedures for determination of competency;
(iii) requirements respecting the minimum frequency and methodology to be used by a State in reviewing such programs' compliance with the requirements for such programs; and
(iv) requirements, under both such programs, that—
(I) provide procedures for determining competency that permit a nurse aide, at the nurse aide's option, to establish competency through procedures or methods other than the passing of a written examination and to have the competency evaluation conducted at the nursing facility at which the aide is (or will be) employed (unless the facility is described in subparagraph (B)(iii)(I)),
(II) prohibit the imposition on a nurse aide who is employed by (or who has received an offer of employment from) a facility on the date on which the aide begins either such program of any charges (including any charges for textbooks and other required course materials and any charges for the competency evaluation) for either such program, and
(III) in the case of a nurse aide not described in subclause (II) who is employed by (or who has received an offer of employment from) a facility not later than 12 months after completing either such program, the State shall provide for the reimbursement of costs incurred in completing such program on a prorata basis during the period in which the nurse aide is so employed.
(B) Approval of certain programs
Such requirements—
(i) may permit approval of programs offered by or in facilities, as well as outside facilities (including employee organizations), and of programs in effect on December 22, 1987;
(ii) shall permit a State to find that an individual who has completed (before July 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved under subsection (b)(5) of this section if the State determines that, at the time the program was offered, the program met the requirements for approval under such paragraph; and
(iii) subject to subparagraph (C), shall prohibit approval of such a program—
(I) offered by or in a nursing facility which, within the previous 2 years—
(a) has operated under a waiver under subsection (b)(4)(C)(ii) of this section that was granted on the basis of a demonstration that the facility is unable to provide the nursing care required under subsection (b)(4)(C)(i) of this section for a period in excess of 48 hours during a week;
(b) has been subject to an extended (or partial extended) survey under
(c) has been assessed a civil money penalty described in
(II) offered by or in a nursing facility unless the State makes the determination, upon an individual's completion of the program, that the individual is competent to provide nursing and nursing-related services in nursing facilities.
A State may not delegate (through subcontract or otherwise) its responsibility under clause (iii)(II) to the nursing facility.
(C) Waiver authorized
Clause (iii)(I) of subparagraph (B) shall not apply to a program offered in (but not by) a nursing facility (or skilled nursing facility for purposes of subchapter XVIII of this chapter) in a State if the State—
(i) determines that there is no other such program offered within a reasonable distance of the facility,
(ii) assures, through an oversight effort, that an adequate environment exists for operating the program in the facility, and
(iii) provides notice of such determination and assurances to the State long-term care ombudsman.
(3) Federal guidelines for State appeals process for transfers and discharges
For purposes of subsections (c)(2)(B)(iii) and (e)(3) of this section, by not later than October 1, 1988, the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) of this section must meet to provide a fair mechanism for hearing appeals on transfers and discharges of residents from nursing facilities.
(4) Secretarial standards qualification of administrators
For purposes of subsections (d)(1)(C) and (e)(4) of this section, the Secretary shall develop, by not later than March 1, 1988, standards to be applied in assuring the qualifications of administrators of nursing facilities.
(5) Criteria for administration
The Secretary shall establish criteria for assessing a nursing facility's compliance with the requirement of subsection (d)(1) of this section with respect to—
(A) its governing body and management,
(B) agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other nursing facilities,
(C) disaster preparedness,
(D) direction of medical care by a physician,
(E) laboratory and radiological services,
(F) clinical records, and
(G) resident and advocate participation.
(6) Specification of resident assessment data set and instruments
The Secretary shall—
(A) not later than January 1, 1989, specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3) of this section, and establish guidelines for utilization of the data set; and
(B) by not later than April 1, 1990, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subsection (e)(5)(A) of this section for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii) of this section.
(7) List of items and services furnished in nursing facilities not chargeable to the personal funds of a resident
(A) Regulations required
Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the Secretary shall issue regulations, on or before the first day of the seventh month to begin after December 22, 1987, that define those costs which may be charged to the personal funds of residents in nursing facilities who are individuals receiving medical assistance with respect to nursing facility services under this subchapter and those costs which are to be included in the payment amount under this subchapter for nursing facility services.
(B) Rule if failure to publish regulations
If the Secretary does not issue the regulations under subparagraph (A) on or before the date required in that subparagraph, in the case of a resident of a nursing facility who is eligible to receive benefits for nursing facility services under this subchapter, for purposes of
(8) Federal minimum criteria and monitoring for preadmission screening and resident review
(A) Minimum criteria
The Secretary shall develop, by not later than October 1, 1988, minimum criteria for States to use in making determinations under subsections (b)(3)(F) and (e)(7)(B) of this section and in permitting individuals adversely affected to appeal such determinations, and shall notify the States of such criteria.
(B) Monitoring compliance
The Secretary shall review, in a sufficient number of cases to allow reasonable inferences, each State's compliance with the requirements of subsection (e)(7)(C)(ii) of this section (relating to discharge and placement for active treatment of certain residents).
(9) Criteria for monitoring State waivers
The Secretary shall develop, by not later than October 1, 1988, criteria and procedures for monitoring State performances in granting waivers pursuant to subsection (b)(4)(C)(ii) of this section.
(g) Survey and certification process
(1) State and Federal responsibility
(A) In general
Under each State plan under this subchapter, the State shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of nursing facilities (other than facilities of the State) with the requirements of subsections (b), (c), and (d) of this section. The Secretary shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of State nursing facilities with the requirements of such subsections.
(B) Educational program
Each State shall conduct periodic educational programs for the staff and residents (and their representatives) of nursing facilities in order to present current regulations, procedures, and policies under this section.
(C) Investigation of allegations of resident neglect and abuse and misappropriation of resident property
The State shall provide, through the agency responsible for surveys and certification of nursing facilities under this subsection, for a process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility or by another individual used by the facility in providing services to such a resident. The State shall, after notice to the individual involved and a reasonable opportunity for a hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. If the State finds that any other individual used by the facility has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the appropriate licensure authority. A State shall not make a finding that an individual has neglected a resident if the individual demonstrates that such neglect was caused by factors beyond the control of the individual.
(D) Removal of name from nurse aide registry
(i) In general
In the case of a finding of neglect under subparagraph (C), the State shall establish a procedure to permit a nurse aide to petition the State to have his or her name removed from the registry upon a determination by the State that—
(I) the employment and personal history of the nurse aide does not reflect a pattern of abusive behavior or neglect; and
(II) the neglect involved in the original finding was a singular occurrence.
(ii) Timing of determination
In no case shall a determination on a petition submitted under clause (i) be made prior to the expiration of the 1-year period beginning on the date on which the name of the petitioner was added to the registry under subparagraph (C).
(E) Construction
The failure of the Secretary to issue regulations to carry out this subsection shall not relieve a State of its responsibility under this subsection.
(2) Surveys
(A) Annual standard survey
(i) In general
Each nursing facility shall be subject to a standard survey, to be conducted without any prior notice to the facility. Any individual who notifies (or causes to be notified) a nursing facility of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The provisions of
(ii) Contents
Each standard survey shall include, for a case-mix stratified sample of residents—
(I) a survey of the quality of care furnished, as measured by indicators of medical, nursing, and rehabilitative care, dietary and nutrition services, activities and social participation, and sanitation, infection control, and the physical environment,
(II) written plans of care provided under subsection (b)(2) of this section and an audit of the residents' assessments under subsection (b)(3) of this section to determine the accuracy of such assessments and the adequacy of such plans of care, and
(III) a review of compliance with residents' rights under subsection (c) of this section.
(iii) Frequency
(I) In general
Each nursing facility shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this subparagraph. The statewide average interval between standard surveys of a nursing facility shall not exceed 12 months.
(II) Special surveys
If not otherwise conducted under subclause (I), a standard survey (or an abbreviated standard survey) may be conducted within 2 months of any change of ownership, administration, management of a nursing facility, or director of nursing in order to determine whether the change has resulted in any decline in the quality of care furnished in the facility.
(B) Extended surveys
(i) In general
Each nursing facility which is found, under a standard survey, to have provided substandard quality of care shall be subject to an extended survey. Any other facility may, at the Secretary's or State's discretion, be subject to such an extended survey (or a partial extended survey).
(ii) Timing
The extended survey shall be conducted immediately after the standard survey (or, if not practicable, not later than 2 weeks after the date of completion of the standard survey).
(iii) Contents
In such an extended survey, the survey team shall review and identify the policies and procedures which produced such substandard quality of care and shall determine whether the facility has complied with all the requirements described in subsections (b), (c), and (d) of this section. Such review shall include an expansion of the size of the sample of residents' assessments reviewed and a review of the staffing, of in-service training, and, if appropriate, of contracts with consultants.
(iv) Construction
Nothing in this paragraph shall be construed as requiring an extended or partial extended survey as a prerequisite to imposing a sanction against a facility under subsection (h) of this section on the basis of findings in a standard survey.
(C) Survey protocol
Standard and extended surveys shall be conducted—
(i) based upon a protocol which the Secretary has developed, tested, and validated by not later than January 1, 1990, and
(ii) by individuals, of a survey team, who meet such minimum qualifications as the Secretary establishes by not later than such date.
The failure of the Secretary to develop, test, or validate such protocols or to establish such minimum qualifications shall not relieve any State of its responsibility (or the Secretary of the Secretary's responsibility) to conduct surveys under this subsection.
(D) Consistency of surveys
Each State shall implement programs to measure and reduce inconsistency in the application of survey results among surveyors.
(E) Survey teams
(i) In general
Surveys under this subsection shall be conducted by a multidisciplinary team of professionals (including a registered professional nurse).
(ii) Prohibition of conflicts of interest
A State may not use as a member of a survey team under this subsection an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the facility surveyed respecting compliance with the requirements of subsections (b), (c), and (d) of this section, or who has a personal or familial financial interest in the facility being surveyed.
(iii) Training
The Secretary shall provide for the comprehensive training of State and Federal surveyors in the conduct of standard and extended surveys under this subsection, including the auditing of resident assessments and plans of care. No individual shall serve as a member of a survey team unless the individual has successfully completed a training and testing program in survey and certification techniques that has been approved by the Secretary.
(3) Validation surveys
(A) In general
The Secretary shall conduct onsite surveys of a representative sample of nursing facilities in each State, within 2 months of the date of surveys conducted under paragraph (2) by the State, in a sufficient number to allow inferences about the adequacies of each State's surveys conducted under paragraph (2). In conducting such surveys, the Secretary shall use the same survey protocols as the State is required to use under paragraph (2). If the State has determined that an individual nursing facility meets the requirements of subsections (b), (c), and (d) of this section, but the Secretary determines that the facility does not meet such requirements, the Secretary's determination as to the facility's noncompliance with such requirements is binding and supersedes that of the State survey.
(B) Scope
With respect to each State, the Secretary shall conduct surveys under subparagraph (A) each year with respect to at least 5 percent of the number of nursing facilities surveyed by the State in the year, but in no case less than 5 nursing facilities in the State.
(C) Reduction in administrative costs for substandard performance
If the Secretary finds, on the basis of such surveys, that a State has failed to perform surveys as required under paragraph (2) or that a State's survey and certification performance otherwise is not adequate, the Secretary may provide for the training of survey teams in the State and shall provide for a reduction of the payment otherwise made to the State under
(D) Special surveys of compliance
Where the Secretary has reason to question the compliance of a nursing facility with any of the requirements of subsections (b), (c), and (d) of this section, the Secretary may conduct a survey of the facility and, on the basis of that survey, make independent and binding determinations concerning the extent to which the nursing facility meets such requirements.
(4) Investigation of complaints and monitoring nursing facility compliance
Each State shall maintain procedures and adequate staff to—
(A) investigate complaints of violations of requirements by nursing facilities, and
(B) monitor, on-site, on a regular, as needed basis, a nursing facility's compliance with the requirements of subsections (b), (c), and (d) of this section, if—
(i) the facility has been found not to be in compliance with such requirements and is in the process of correcting deficiencies to achieve such compliance;
(ii) the facility was previously found not to be in compliance with such requirements, has corrected deficiencies to achieve such compliance, and verification of continued compliance is indicated; or
(iii) the State has reason to question the compliance of the facility with such requirements.
A State may maintain and utilize a specialized team (including an attorney, an auditor, and appropriate health care professionals) for the purpose of identifying, surveying, gathering and preserving evidence, and carrying out appropriate enforcement actions against substandard nursing facilities.
(5) Disclosure of results of inspections and activities
(A) Public information
Each State, and the Secretary, shall make available to the public—
(i) information respecting all surveys and certifications made respecting nursing facilities, including statements of deficiencies, within 14 calendar days after such information is made available to those facilities, and approved plans of correction,
(ii) copies of cost reports of such facilities filed under this subchapter or under subchapter XVIII of this chapter,
(iii) copies of statements of ownership under
(iv) information disclosed under
(B) Notice to ombudsman
Each State shall notify the State long-term care ombudsman (established under title III or VII of the Older Americans Act of 1965 [
(C) Notice to physicians and nursing facility administrator licensing board
If a State finds that a nursing facility has provided substandard quality of care, the State shall notify—
(i) the attending physician of each resident with respect to which such finding is made, and
(ii) any State board responsible for the licensing of the nursing facility administrator of the facility.
(D) Access to fraud control units
Each State shall provide its State medicaid fraud and abuse control unit (established under
(h) Enforcement process
(1) In general
If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) of this section or otherwise, that a nursing facility no longer meets a requirement of subsection (b), (c), or (d) of this section, and further finds that the facility's deficiencies—
(A) immediately jeopardize the health or safety of its residents, the State shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(A)(iii), or terminate the facility's participation under the State plan and may provide, in addition, for one or more of the other remedies described in paragraph (2); or
(B) do not immediately jeopardize the health or safety of its residents, the State may—
(i) terminate the facility's participation under the State plan,
(ii) provide for one or more of the remedies described in paragraph (2), or
(iii) do both.
Nothing in this paragraph shall be construed as restricting the remedies available to a State to remedy a nursing facility's deficiencies. If a State finds that a nursing facility meets the requirements of subsections (b), (c), and (d) of this section, but, as of a previous period, did not meet such requirements, the State may provide for a civil money penalty under paragraph (2)(A)(ii) for the days in which it finds that the facility was not in compliance with such requirements.
(2) Specified remedies
(A) Listing
Except as provided in subparagraph (B)(ii), each State shall establish by law (whether statute or regulation) at least the following remedies:
(i) Denial of payment under the State plan with respect to any individual admitted to the nursing facility involved after such notice to the public and to the facility as may be provided for by the State.
(ii) A civil money penalty assessed and collected, with interest, for each day in which the facility is or was out of compliance with a requirement of subsection (b), (c), or (d) of this section. Funds collected by a State as a result of imposition of such a penalty (or as a result of the imposition by the State of a civil money penalty for activities described in subsections (b)(3)(B)(ii)(I), (b)(3)(B)(ii)(II), or (g)(2)(A)(i) of this section) shall be applied to the protection of the health or property of residents of nursing facilities that the State or the Secretary finds deficient, including payment for the costs of relocation of residents to other facilities, maintenance of operation of a facility pending correction of deficiencies or closure, and reimbursement of residents for personal funds lost.
(iii) The appointment of temporary management to oversee the operation of the facility and to assure the health and safety of the facility's residents, where there is a need for temporary management while—
(I) there is an orderly closure of the facility, or
(II) improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d) of this section.
The temporary management under this clause shall not be terminated under subclause (II) until the State has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d) of this section.
(iv) The authority, in the case of an emergency, to close the facility, to transfer residents in that facility to other facilities, or both.
The State also shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies. In addition, the State may provide for other specified remedies, such as directed plans of correction.
(B) Deadline and guidance
(i) Except as provided in clause (ii), as a condition for approval of a State plan for calendar quarters beginning on or after October 1, 1989, each State shall establish the remedies described in clauses (i) through (iv) of subparagraph (A) by not later than October 1, 1989. The Secretary shall provide, through regulations by not later than October 1, 1988, guidance to States in establishing such remedies; but the failure of the Secretary to provide such guidance shall not relieve a State of the responsibility for establishing such remedies.
(ii) A State may establish alternative remedies (other than termination of participation) other than those described in clauses (i) through (iv) of subparagraph (A), if the State demonstrates to the Secretary's satisfaction that the alternative remedies are as effective in deterring noncompliance and correcting deficiencies as those described in subparagraph (A).
(C) Assuring prompt compliance
If a nursing facility has not complied with any of the requirements of subsections (b), (c), and (d) of this section, within 3 months after the date the facility is found to be out of compliance with such requirements, the State shall impose the remedy described in subparagraph (A)(i) for all individuals who are admitted to the facility after such date.
(D) Repeated noncompliance
In the case of a nursing facility which, on 3 consecutive standard surveys conducted under subsection (g)(2) of this section, has been found to have provided substandard quality of care, the State shall (regardless of what other remedies are provided)—
(i) impose the remedy described in subparagraph (A)(i), and
(ii) monitor the facility under subsection (g)(4)(B) of this section,
until the facility has demonstrated, to the satisfaction of the State, that it is in compliance with the requirements of subsections (b), (c), and (d) of this section, and that it will remain in compliance with such requirements.
(E) Funding
The reasonable expenditures of a State to provide for temporary management and other expenses associated with implementing the remedies described in clauses (iii) and (iv) of subparagraph (A) shall be considered, for purposes of
(F) Incentives for high quality care
In addition to the remedies specified in this paragraph, a State may establish a program to reward, through public recognition, incentive payments, or both, nursing facilities that provide the highest quality care to residents who are entitled to medical assistance under this subchapter. For purposes of
(3) Secretarial authority
(A) For State nursing facilities
With respect to a State nursing facility, the Secretary shall have the authority and duties of a State under this subsection, including the authority to impose remedies described in clauses (i), (ii), and (iii) of paragraph (2)(A).
(B) Other nursing facilities
With respect to any other nursing facility in a State, if the Secretary finds that a nursing facility no longer meets a requirement of subsection (b), (c), (d), or (e) of this section, and further finds that the facility's deficiencies—
(i) immediately jeopardize the health or safety of its residents, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subparagraph (C)(iii), or terminate the facility's participation under the State plan and may provide, in addition, for one or more of the other remedies described in subparagraph (C); or
(ii) do not immediately jeopardize the health or safety of its residents, the Secretary may impose any of the remedies described in subparagraph (C).
Nothing in this subparagraph shall be construed as restricting the remedies available to the Secretary to remedy a nursing facility's deficiencies. If the Secretary finds that a nursing facility meets such requirements but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subparagraph (C)(ii) for the days on which he finds that the facility was not in compliance with such requirements.
(C) Specified remedies
The Secretary may take the following actions with respect to a finding that a facility has not met an applicable requirement:
(i) Denial of payment
The Secretary may deny any further payments to the State for medical assistance furnished by the facility to all individuals in the facility or to individuals admitted to the facility after the effective date of the finding.
(ii) Authority with respect to civil money penalties
The Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of
(iii) Appointment of temporary management
In consultation with the State, the Secretary may appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility's residents, where there is a need for temporary management while—
(I) there is an orderly closure of the facility, or
(II) improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d) of this section.
The temporary management under this clause shall not be terminated under subclause (II) until the Secretary has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d) of this section.
The Secretary shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies. In addition, the Secretary may provide for other specified remedies, such as directed plans of correction.
(D) Continuation of payments pending remediation
The Secretary may continue payments, over a period of not longer than 6 months after the effective date of the findings, under this subchapter with respect to a nursing facility not in compliance with a requirement of subsection (b), (c), or (d) of this section, if—
(i) the State survey agency finds that it is more appropriate to take alternative action to assure compliance of the facility with the requirements than to terminate the certification of the facility, and
(ii) the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action.
The Secretary shall establish guidelines for approval of corrective actions requested by States under this subparagraph.
(4) Effective period of denial of payment
A finding to deny payment under this subsection shall terminate when the State or Secretary (or both, as the case may be) finds that the facility is in substantial compliance with all the requirements of subsections (b), (c), and (d) of this section.
(5) Immediate termination of participation for facility where State or Secretary finds noncompliance and immediate jeopardy
If either the State or the Secretary finds that a nursing facility has not met a requirement of subsection (b), (c), or (d) of this section, and finds that the failure immediately jeopardizes the health or safety of its residents, the State or the Secretary, respectively 3 shall notify the other of such finding, and the State or the Secretary, respectively, shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(A)(iii) or (3)(C)(iii), or terminate the facility's participation under the State plan. If the facility's participation in the State plan is terminated by either the State or the Secretary, the State shall provide for the safe and orderly transfer of the residents eligible under the State plan consistent with the requirements of subsection (c)(2) of this section.
(6) Special rules where State and Secretary do not agree on finding of noncompliance
(A) State finding of noncompliance and no Secretarial finding of noncompliance
If the Secretary finds that a nursing facility has met all the requirements of subsections (b), (c), and (d) of this section, but a State finds that the facility has not met such requirements and the failure does not immediately jeopardize the health or safety of its residents, the State's findings shall control and the remedies imposed by the State shall be applied.
(B) Secretarial finding of noncompliance and no State finding of noncompliance
If the Secretary finds that a nursing facility has not met all the requirements of subsections (b), (c), and (d) of this section, and that the failure does not immediately jeopardize the health or safety of its residents, but the State has not made such a finding, the Secretary—
(i) may impose any remedies specified in paragraph (3)(C) with respect to the facility, and
(ii) shall (pending any termination by the Secretary) permit continuation of payments in accordance with paragraph (3)(D).
(7) Special rules for timing of termination of participation where remedies overlap
If both the Secretary and the State find that a nursing facility has not met all the requirements of subsections (b), (c), and (d) of this section, and neither finds that the failure immediately jeopardizes the health or safety of its residents—
(A)(i) if both find that the facility's participation under the State plan should be terminated, the State's timing of any termination shall control so long as the termination date does not occur later than 6 months after the date of the finding to terminate;
(ii) if the Secretary, but not the State, finds that the facility's participation under the State plan should be terminated, the Secretary shall (pending any termination by the Secretary) permit continuation of payments in accordance with paragraph (3)(D); or
(iii) if the State, but not the Secretary, finds that the facility's participation under the State plan should be terminated, the State's decision to terminate, and timing of such termination, shall control; and
(B)(i) if the Secretary or the State, but not both, establishes one or more remedies which are additional or alternative to the remedy of terminating the facility's participation under the State plan, such additional or alternative remedies shall also be applied, or
(ii) if both the Secretary and the State establish one or more remedies which are additional or alternative to the remedy of terminating the facility's participation under the State plan, only the additional or alternative remedies of the Secretary shall apply.
(8) Construction
The remedies provided under this subsection are in addition to those otherwise available under State or Federal law and shall not be construed as limiting such other remedies, including any remedy available to an individual at common law. The remedies described in clauses (i), (iii), and (iv) of paragraph (2)(A) may be imposed during the pendency of any hearing. The provisions of this subsection shall apply to a nursing facility (or portion thereof) notwithstanding that the facility (or portion thereof) also is a skilled nursing facility for purposes of subchapter XVIII of this chapter.
(9) Sharing of information
Notwithstanding any other provision of law, all information concerning nursing facilities required by this section to be filed with the Secretary or a State agency shall be made available by such facilities to Federal or State employees for purposes consistent with the effective administration of programs established under this subchapter and subchapter XVIII of this chapter, including investigations by State medicaid fraud control units.
(i) Construction
Where requirements or obligations under this section are identical to those provided under
(Aug. 14, 1935, ch. 531, title XIX, §1919, as added and amended
References in Text
The Older Americans Act of 1965, referred to in subsecs. (c)(2)(B)(iii)(II) and (g)(5)(B), is
The Developmental Disabilities Assistance and Bill of Rights Act, referred to in subsec. (c)(2)(B)(iii)(III), is title I of
The Protection and Advocacy for Mentally Ill Individuals Act, referred to in subsec. (c)(2)(B)(iii)(IV), probably means the Protection and Advocacy for Mentally Ill Individuals Act of 1986,
Section 6901(b)(4)(B)–(D) of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (e)(2)(A), is section 6901(b)(4)(B)–(D) of
Section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, referred to in subsec. (f)(7)(A), probably means section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments,
Prior Provisions
A prior section 1919 of act Aug. 14, 1935, was renumbered section 1922 and is classified to
Amendments
1999—Subsec. (b)(3)(C)(i)(I).
Subsec. (c)(2)(F).
Subsec. (d)(4)(A).
1997—Subsec. (f)(2)(B)(iii).
Subsec. (f)(2)(C).
Subsec. (g)(1)(D), (E).
Subsec. (h)(3)(D).
1996—Subsec. (b)(3)(E).
Subsec. (e)(7)(B).
Subsec. (e)(7)(B)(iii).
Subsec. (e)(7)(D)(i).
1992—Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B).
1990—Subsec. (b)(1)(B).
Subsec. (b)(3)(C)(i)(I).
Subsec. (b)(3)(F).
Subsec. (b)(4)(A)(vii).
Subsec. (b)(4)(C)(ii).
Subsec. (b)(4)(C)(ii)(IV), (V).
Subsec. (b)(5)(A).
Subsec. (b)(5)(C).
Subsec. (b)(5)(D).
Subsec. (b)(5)(F)(i).
Subsec. (b)(6)(A).
Subsec. (c)(1)(A).
Subsec. (c)(1)(A)(iv).
Subsec. (c)(1)(A)(x), (xi).
Subsec. (c)(1)(B)(ii).
Subsec. (c)(2)(E).
Subsec. (c)(7), (8).
Subsec. (e)(1)(A).
Subsec. (e)(2)(A).
Subsec. (e)(2)(C).
Subsec. (e)(7)(A).
Subsec. (e)(7)(B)(i)(II), (ii)(II).
Subsec. (e)(7)(B)(iv).
Subsec. (e)(7)(C)(i) to (iii).
Subsec. (e)(7)(C)(iv).
Subsec. (e)(7)(D).
Subsec. (e)(7)(E).
Subsec. (e)(7)(G)(i).
Subsec. (e)(7)(G)(iii).
Subsec. (f)(2)(A)(iv)(II).
Subsec. (f)(2)(A)(iv)(III).
Subsec. (f)(2)(B).
Subsec. (f)(2)(B)(iii)(I).
Subsec. (g)(1)(C).
Subsec. (g)(5)(A)(i).
Subsec. (g)(5)(B).
1989—Subsec. (b)(5)(A).
Subsec. (b)(5)(B).
Subsec. (c)(1)(A)(ii)(II).
Subsec. (c)(1)(A)(v)(I).
Subsec. (f)(2)(A)(i)(I).
Subsec. (f)(2)(A)(ii).
Subsec. (f)(2)(A)(iv).
Subsec. (f)(2)(B)(ii).
Subsec. (h)(3)(D).
Subsec. (h)(8).
1988—Subsec. (b)(3)(A)(iii).
Subsec. (b)(3)(A)(iv).
Subsec. (b)(3)(B)(ii)(III).
Subsec. (b)(4)(C)(i)(II).
Subsec. (b)(4)(C)(ii).
Subsec. (b)(4)(C)(iii).
Subsec. (b)(5)(A).
Subsec. (b)(5)(A)(ii).
Subsec. (b)(5)(G).
Subsec. (c)(1)(B)(i).
Subsec. (c)(2)(A)(v).
Subsec. (c)(2)(B)(iii)(III).
Subsec. (c)(6).
Subsec. (c)(7).
Subsec. (e).
Subsec. (e)(1).
Subsec. (e)(2)(B).
Subsec. (e)(3).
Subsec. (e)(7)(E).
Subsec. (f).
Subsec. (f)(2)(A).
Subsec. (f)(2)(A)(i)(I).
Subsec. (f)(3).
Subsec. (f)(7)(A).
Subsec. (f)(7)(B).
Subsec. (g)(1)(C).
Subsec. (g)(1)(D).
Subsec. (g)(2)(A)(i).
Subsec. (g)(2)(B)(ii).
Subsec. (g)(3)(C).
Subsec. (g)(3)(D).
Subsec. (g)(4).
Subsec. (h).
Subsec. (h)(1).
Subsec. (h)(2)(B)(i).
Subsec. (h)(3)(C)(ii).
Subsec. (h)(5).
Subsec. (h)(9).
1987—Subsec. (c)(7).
Subsecs. (e), (f).
Subsec. (g).
Subsec. (h).
Subsec. (i).
Effective Date of 1999 Amendment
Effective Date of 1997 Amendment
Section 4754(b) of
Effective Date of 1996 Amendment
Section 1(b) of
Section 2(c) of
Effective Date of 1992 Amendment
Amendment by
Amendment by
Effective Date of 1990 Amendment
Amendment by section 4751(b)(2) of
Section 4801(a)(6)(B) of
"(i) had its participation terminated under title XVIII of the Social Security Act [subchapter XVIII of this chapter] or under the State plan under title XIX of such Act [this subchapter];
"(ii) was subject to a denial of payment under either such title;
"(iii) was assessed a civil money penalty not less than $5,000 for deficiencies in nursing facility standards;
"(iv) operated under a temporary management appointed to oversee the operation of the facility and to ensure the health and safety of the facility's residents; or
"(v) pursuant to State action, was closed or had its residents transferred."
Amendment by section 4801(a)(2)–(5), (7) of
Section 4801(b)(9) of
"(A)
"(B)
Section 4801(d)(2) of
Section 4801(e)(7)(B) of
Amendment by section 4801(e)(2)–(6), (8)–(10), (12)–(15), and (18) of
Effective Date of 1989 Amendment
Amendment by section 6901(b)(1), (4)(A) of
Amendment by section 6901(d)(1) of
Effective Date of 1988 Amendments
Amendment by
Amendment by section 303(a)(2) of
Except as specifically provided in section 411 of
Effective Date
Section 4214 of title IV of
"(a)
"(b)
"(2) In applying the amendments made by this part [part 2 of subtitle C (§§4211–4218) of title IV of
"(A) any reference to a nursing facility is deemed a reference to a skilled nursing facility or intermediate care facility (other than an intermediate care facility for the mentally retarded), and
"(B) with respect to such a skilled nursing facility or intermediate care facility, any reference to a requirement of subsection (b), (c), or (d) of section 1919 of the Social Security Act [subsec. (b), (c), or (d) of this section], is deemed a reference to the provisions of section 1861(j) or section 1905(c), respectively, of the Social Security Act [
"(c)
Retroactive Review
For requirement that procedures developed by a State permit individual to petition for review of any finding made by a State under subsec. (g)(1)(C) of this section or
Nurse Aide Training and Competency Evaluation; Compliance Actions
Section 4801(a)(1) of
Preadmission Screening and Annual Resident Review; Compliance Actions
Section 4801(b)(1) of
Restriction on Enforcement Process
Section 4801(c) of
Staffing Requirements
"(A)
"(B)
Nurse Aide Training and Competency Evaluation; Satisfaction of Requirements; Waiver
For satisfaction of training and competency evaluation requirements of subsec. (b)(5)(A) of this section and
Publication of Proposed Regulations Respecting Preadmission Screening and Annual Resident Review
Section 6901(c) of
Evaluation and Report on Implementation of Resident Assessment Process
Section 4211(c) of
Report on Staffing Requirements
Section 4211(k) of
Annual Report on Statutory Compliance and Enforcement Actions
Section 4215 of
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should be "clause".
2 So in original. Probably should be "paragraph".
3 So in original. Probably should be followed by a comma.
§1396r–1. Presumptive eligibility for pregnant women
(a) Ambulatory prenatal care
A State plan approved under
(b) Definitions
For purposes of this section—
(1) the term "presumptive eligibility period" means, with respect to a pregnant woman, the period that—
(A) begins with the date on which a qualified provider determines, on the basis of preliminary information, that the family income of the woman does not exceed the applicable income level of eligibility under the State plan, and
(B) ends with (and includes) the earlier of—
(i) the day on which a determination is made with respect to the eligibility of the woman for medical assistance under the State plan, or
(ii) in the case of a woman who does not file an application by the last day of the month following the month during which the provider makes the determination referred to in subparagraph (A), such last day; and
(2) the term "qualified provider" means any provider that—
(A) is eligible for payments under a State plan approved under this subchapter,
(B) provides services of the type described in subparagraph (A) or (B) of
(C) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A), and
(D)(i) receives funds under—
(I)
(II) subchapter V of this chapter, or
(III) title V of the Indian Health Care Improvement Act [
(ii) participates in a program established under—
(I)
(II) section 4(a) of the Agriculture and Consumer Protection Act of 1973;
(iii) participates in a State perinatal program; or
(iv) is the Indian Health Service or is a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (
(c) Duties of State agency, qualified providers, and presumptively eligible pregnant women
(1) The State agency shall provide qualified providers with—
(A) such forms as are necessary for a pregnant woman to make application for medical assistance under the State plan, and
(B) information on how to assist such women in completing and filing such forms.
(2) A qualified provider that determines under subsection (b)(1)(A) of this section that a pregnant woman is presumptively eligible for medical assistance under a State plan shall—
(A) notify the State agency of the determination within 5 working days after the date on which determination is made, and
(B) inform the woman at the time the determination is made that she is required to make application for medical assistance under the State plan by not later than the last day of the month following the month during which the determination is made.
(3) A pregnant woman who is determined by a qualified provider to be presumptively eligible for medical assistance under a State plan shall make application for medical assistance under such plan by not later than the last day of the month following the month during which the determination is made, which application may be the application used for the receipt of medical assistance by individuals described in
(d) Ambulatory prenatal care as medical assistance
Notwithstanding any other provision of this subchapter, ambulatory prenatal care that—
(1) is furnished to a pregnant woman—
(A) during a presumptive eligibility period,
(B) by a provider that is eligible for payments under the State plan; and
(2) is included in the care and services covered by a State plan;
shall be treated as medical assistance provided by such plan for purposes of
(Aug. 14, 1935, ch. 531, title XIX, §1920, as added
References in Text
The Indian Health Care Improvement Act, referred to in subsec. (b)(2)(D)(i)(III), is
Section 4(a) of the Agriculture and Consumer Protection Act of 1973, referred to in subsec. (b)(2)(D)(ii)(II), is section 4(a) of
The Indian Self-Determination Act (
Prior Provisions
A prior section 1920 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1999—Subsec. (b)(2)(D)(i)(I).
1990—Subsec. (b)(1)(B).
"(ii) the day that is 45 days after the date on which the provider makes the determination referred to in subparagraph (A), or
"(iii) in the case of a woman who does not file an application for medical assistance within 14 calendar days after the date on which the provider makes the determination referred to in subparagraph (A), the fourteenth calendar day after such determination is made; and".
Subsec. (c)(2)(B).
Subsec. (c)(3).
1988—Subsec. (b)(2)(D)(i).
Subsec. (b)(2)(D)(ii)(II).
Subsec. (b)(2)(D)(iii).
Subsec. (b)(2)(D)(iv).
Subsec. (d)(1)(B).
Effective Date of 1990 Amendment
Section 4605(c) of
"(1) The amendments made by subsection (a) [amending this section] apply to payments under title XIX of the Social Security Act [this subchapter] for calendar quarters beginning on or after July 1, 1991, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.
"(2) The amendment made by subsection (b) [amending this section] shall be effective as if included in the enactment of section 9407(b) of the Omnibus Budget Reconciliation Act of 1986 [
Effective Date of 1988 Amendments
Amendment by
Section 411(k)(16)(C) of
Effective Date
Section applicable to ambulatory prenatal care furnished in calendar quarters beginning on or after Apr. 1, 1987, without regard to whether or not final regulations to carry out such section have been promulgated, see section 9407(d) of
Section Referred to in Other Sections
This section is referred to in
§1396r–1a. Presumptive eligibility for children
(a) In general
A State plan approved under
(b) Definitions; regulations
For purposes of this section:
(1) The term "child" means an individual under 19 years of age.
(2) The term "presumptive eligibility period" means, with respect to a child, the period that—
(A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the family income of the child does not exceed the applicable income level of eligibility under the State plan, and
(B) ends with (and includes) the earlier of—
(i) the day on which a determination is made with respect to the eligibility of the child for medical assistance under the State plan, or
(ii) in the case of a child on whose behalf an application is not filed by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.
(3)(A) Subject to subparagraph (B), the term "qualified entity" means any entity that—
(i)(I) is eligible for payments under a State plan approved under this subchapter and provides items and services described in subsection (a) of this section or (II) is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act [
(ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).
(B) The Secretary may issue regulations further limiting those entities that may become qualified entities in order to prevent fraud and abuse and for other reasons.
(C) Nothing in this section shall be construed as preventing a State from limiting the classes of entities that may become qualified entities, consistent with any limitations imposed under subparagraph (B).
(c) Application for medical assistance; procedure upon determination of presumptive eligibility
(1) The State agency shall provide qualified entities with—
(A) such forms as are necessary for an application to be made on behalf of a child for medical assistance under the State plan, and
(B) information on how to assist parents, guardians, and other persons in completing and filing such forms.
(2) A qualified entity that determines under subsection (b)(1)(A) of this section that a child is presumptively eligible for medical assistance under a State plan shall—
(A) notify the State agency of the determination within 5 working days after the date on which determination is made, and
(B) inform the parent or custodian of the child at the time the determination is made that an application for medical assistance under the State plan is required to be made by not later than the last day of the month following the month during which the determination is made.
(3) In the case of a child who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the parent, guardian, or other person shall make application on behalf of the child for medical assistance under such plan by not later than the last day of the month following the month during which the determination is made, which application may be the application used for the receipt of medical assistance by individuals described in
(d) Treatment of medical assistance
Notwithstanding any other provision of this subchapter, medical assistance for items and services described in subsection (a) of this section that—
(1) are furnished to a child—
(A) during a presumptive eligibility period,
(B) by an entity that is eligible for payments under the State plan; and
(2) are included in the care and services covered by a State plan;
shall be treated as medical assistance provided by such plan for purposes of
(Aug. 14, 1935, ch. 531, title XIX, §1920A, as added
References in Text
The Head Start Act, referred to in subsec. (b)(3)(A)(i)(II), is subchapter B (§§635–657) of
The Child Care and Development Block Grant Act of 1990, referred to in subsec. (b)(3)(A)(i)(II), is subchapter C (§§658A–658R) of
Amendments
1999—Subsec. (d)(1)(B).
Section Referred to in Other Sections
This section is referred to in
§1396r–2. Information concerning sanctions taken by State licensing authorities against health care practitioners and providers
(a) Information reporting requirement
The requirement referred to in
(1) Information reporting system
The State must have in effect a system of reporting the following information with respect to formal proceedings (as defined by the Secretary in regulations) concluded against a health care practitioner or entity by any authority of the State (or of a political subdivision thereof) responsible for the licensing of health care practitioners (or any peer review organization or private accreditation entity reviewing the services provided by health care practitioners) or entities:
(A) Any adverse action taken by such licensing authority as a result of the proceeding, including any revocation or suspension of a license (and the length of any such suspension), reprimand, censure, or probation.
(B) Any dismissal or closure of the proceedings by reason of the practitioner or entity surrendering the license or leaving the State or jurisdiction.
(C) Any other loss of the license of the practitioner or entity, whether by operation of law, voluntary surrender, or otherwise.
(D) Any negative action or finding by such authority, organization, or entity regarding the practitioner or entity.
(2) Access to documents
The State must provide the Secretary (or an entity designated by the Secretary) with access to such documents of the authority described in paragraph (1) as may be necessary for the Secretary to determine the facts and circumstances concerning the actions and determinations described in such paragraph for the purpose of carrying out this chapter.
(b) Form of information
The information described in subsection (a)(1) of this section shall be provided to the Secretary (or to an appropriate private or public agency, under suitable arrangements made by the Secretary with respect to receipt, storage, protection of confidentiality, and dissemination of information) in such a form and manner as the Secretary determines to be appropriate in order to provide for activities of the Secretary under this chapter and in order to provide, directly or through suitable arrangements made by the Secretary, information—
(1) to agencies administering Federal health care programs, including private entities administering such programs under contract,
(2) to licensing authorities described in subsection (a)(1) of this section,
(3) to State agencies administering or supervising the administration of State health care programs (as defined in
(4) to utilization and quality control peer review organizations described in part B of subchapter XI of this chapter and to appropriate entities with contracts under
(5) to State medicaid fraud control units (as defined in
(6) to hospitals and other health care entities (as defined in section 431 of the Health Care Quality Improvement Act of 1986 [
(7) to the Attorney General and such other law enforcement officials as the Secretary deems appropriate, and
(8) upon request, to the Comptroller General,
in order for such authorities to determine the fitness of individuals to provide health care services, to protect the health and safety of individuals receiving health care through such programs, and to protect the fiscal integrity of such programs.
(c) Confidentiality of information provided
The Secretary shall provide for suitable safeguards for the confidentiality of the information furnished under subsection (a) of this section. Nothing in this subsection shall prevent the disclosure of such information by a party which is otherwise authorized, under applicable State law, to make such disclosure.
(d) Appropriate coordination
The Secretary shall provide for the maximum appropriate coordination in the implementation of subsection (a) of this section and section 422 of the Health Care Quality Improvement Act of 1986 [
(Aug. 14, 1935, ch. 531, title XIX, §1921, as added
References in Text
Part B of subchapter XI of this chapter, referred to in subsec. (b)(4), is classified to
That Act, referred to in subsec. (b)(6), is title IV of
Prior Provisions
A prior section 1921 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1990—Subsec. (a)(1).
Subsec. (a)(1)(D).
Effective Date of 1990 Amendment
Section 4752(f)(2) of
Effective Date
Section applicable, with certain exceptions, to payments under subchapter XIX of this chapter for calendar quarters beginning more than thirty days after Aug. 18, 1987, without regard to whether or not final regulations to carry out this section have been published by that date, see section 15(c)(1), (2) of
Section Referred to in Other Sections
This section is referred to in
§1396r–3. Correction and reduction plans for intermediate care facilities for mentally retarded
(a) Written plans to remedy substantial deficiencies; time for submission
If the Secretary finds that an intermediate care facility for the mentally retarded has substantial deficiencies which do not pose an immediate threat to the health and safety of residents (including failure to provide active treatment), the State may elect, subject to the limitations in this section, to—
(1) submit, within the number of days specified by the Secretary in regulations which apply to submission of compliance plans with respect to deficiencies of such type, a written plan of correction which details the extent of the facility's current compliance with the standards promulgated by the Secretary, including all deficiencies identified during a validation survey, and which provides for a timetable for completion of necessary steps to correct all staffing deficiencies within 6 months, and a timetable for rectifying all physical plant deficiencies within 6 months; or
(2) submit, within a time period consisting of the number of days specified for submissions under paragraph (1) plus 35 days, a written plan for permanently reducing the number of certified beds, within a maximum of 36 months, in order to permit any noncomplying buildings (or distinct parts thereof) to be vacated and any staffing deficiencies to be corrected (hereinafter in this section referred to as a "reduction plan").
(b) Conditions for approval of reduction plans
As conditions of approval of any reduction plan submitted pursuant to subsection (a)(2) of this section, the State must—
(1) provide for a hearing to be held at the affected facility at least 35 days prior to submission of the reduction plan, with reasonable notice thereof to the staff and residents of the facility, responsible members of the residents' families, and the general public;
(2) demonstrate that the State has successfully provided home and community services similar to the services proposed to be provided under the reduction plan for similar individuals eligible for medical assistance; and
(3) provide assurances that the requirements of subsection (c) of this section shall be met with respect to the reduction plan.
(c) Contents of reduction plan
The reduction plan must—
(1) identify the number and service needs of existing facility residents to be provided home or community services and the timetable for providing such services, in 6 month intervals, within the 36-month period;
(2) describe the methods to be used to select such residents for home and community services and to develop the alternative home and community services to meet their needs effectively;
(3) describe the necessary safeguards that will be applied to protect the health and welfare of the former residents of the facility who are to receive home or community services, including adequate standards for consumer and provider participation and assurances that applicable State licensure and applicable State and Federal certification requirements will be met in providing such home or community services;
(4) provide that residents of the affected facility who are eligible for medical assistance while in the facility shall, at their option, be placed in another setting (or another part of the affected facility) so as to retain their eligibility for medical assistance;
(5) specify the actions which will be taken to protect the health and safety of, and to provide active treatment for, the residents who remain in the affected facility while the reduction plan is in effect;
(6) provide that the ratio of qualified staff to residents at the affected facility (or the part thereof) which is subject to the reduction plan will be the higher of—
(A) the ratio which the Secretary determines is necessary in order to assure the health and safety of the residents of such facility (or part thereof); or
(B) the ratio which was in effect at the time that the finding of substantial deficiencies (referred to in subsection (a) of this section) was made; and
(7) provide for the protection of the interests of employees affected by actions under the reduction plan, including—
(A) arrangements to preserve employee rights and benefits;
(B) training and retraining of such employees where necessary;
(C) redeployment of such employees to community settings under the reduction plan; and
(D) making maximum efforts to guarantee the employment of such employees (but this requirement shall not be construed to guarantee the employment of any employee).
(d) Notice and comment; approval of more than 15 reduction plans in any fiscal year; corrections costing $2,000,000 or more
(1) The Secretary must provide for a period of not less than 30 days after the submission of a reduction plan by a State, during which comments on such reduction plan may be submitted to the Secretary, before the Secretary approves or disapproves such reduction plan.
(2) If the Secretary approves more than 15 reduction plans under this section in any fiscal year, any reduction plans approved in addition to the first 15 such plans approved, must be for a facility (or part thereof) for which the costs of correcting the substantial deficiencies (referred to in subsection (a) of this section) are $2,000,000 or greater (as demonstrated by the State to the satisfaction of the Secretary).
(e) Termination of provider agreements; disallowance of percentage amounts for purposes of Federal financial participation
(1) If the Secretary, at the conclusion of the 6-month plan of correction described in subsection (a)(1) of this section, determines that the State has substantially failed to correct the deficiencies described in subsection (a) of this section, the Secretary may terminate the facility's provider agreement in accordance with the provisions of
(2) In the case of a reduction plan described in subsection (a)(2) of this section, if the Secretary determines, at the conclusion of the initial 6-month period or any 6-month interval thereafter, that the State has substantially failed to meet the requirements of subsection (c) of this section, the Secretary shall—
(A) terminate the facility's provider agreement in accordance with the provisions of
(B) if the State has failed to meet such requirements despite good faith efforts, disallow, for purposes of Federal financial participation, an amount equal to 5 percent of the cost of care for all eligible individuals in the facility for each month for which the State fails to meet such requirements.
(f) Applicability of section limited to plans approved by January 1, 1990
The provisions of this section shall apply only to plans of correction and reduction plans approved by the Secretary by January 1, 1990.
(Aug. 14, 1935, ch. 531, title XIX, §1922, formerly §1919, as added
Prior Provisions
A prior section 1922 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1988—Subsec. (a).
Subsec. (c)(5).
Subsec. (e)(1), (2)(A).
Subsec. (f).
Effective Date of 1988 Amendments
Section 8433(b) of
Except as specifically provided in section 411 of
Effective Date
Section 9516(b) of
"(1) The amendment made by this section [enacting this section] shall become effective on the date of the enactment of this Act [Apr. 7, 1986].
"(2) The Secretary of Health and Human Services shall issue a notice of proposed rulemaking with respect to section 1919 of the Social Security Act [this section] within 60 days after the date of the enactment of this Act, and shall allow a period of 30 days for comment thereon prior to promulgating final regulations implementing such section."
Regulations
Section 4217 of
"(a)
"(b) The regulations promulgated under paragraph (1) shall be effective as if promulgated on the date of enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985 [Apr. 7, 1986]."
Report to Congress on Implementation and Results of This Section
Section 9516(c) of
Section Referred to in Other Sections
This section is referred to in
§1396r–4. Adjustment in payment for inpatient hospital services furnished by disproportionate share hospitals
(a) Implementation of requirement
(1) A State plan under this subchapter shall not be considered to meet the requirement of
(A) specifically defines the hospitals so described (and includes in such definition any disproportionate share hospital described in subsection (b)(1) of this section which meets the requirements of subsection (d) of this section), and
(B) provides, effective for inpatient hospital services provided not later than July 1, 1988, for an appropriate increase in the rate or amount of payment for such services provided by such hospitals, consistent with subsection (c) of this section.
(2)(A) In order to be considered to have met such requirement of
(B) In order to be considered to have met such requirement of
(C) If a State plan under this subchapter provides for payments for inpatient hospital services on a prospective basis (whether per diem, per case, or otherwise), in order for the plan to be considered to have met such requirement of
(D) A State plan under this subchapter shall not be considered to meet the requirements of
(3) The Secretary shall, not later than 90 days after the date a State submits an amendment under this subsection, review each such amendment for compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement.
(4) The requirement of this subsection may not be waived under
(b) Hospitals deemed disproportionate share
(1) For purposes of subsection (a)(1) of this section, a hospital which meets the requirements of subsection (d) of this section is deemed to be a disproportionate share hospital if—
(A) the hospital's medicaid inpatient utilization rate (as defined in paragraph (2)) is at least one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State; or
(B) the hospital's low-income utilization rate (as defined in paragraph (3)) exceeds 25 percent.
(2) For purposes of paragraph (1)(A), the term "medicaid inpatient utilization rate" means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital's number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under a State plan approved under this subchapter in a period, and the denominator of which is the total number of the hospital's inpatient days in that period. In this paragraph, the term "inpatient day" includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.
(3) For purposes of paragraph (1)(B), the term "low-income utilization rate" means, for a hospital, the sum of—
(A) the fraction (expressed as a percentage)—
(i) the numerator of which is the sum (for a period) of (I) the total revenues paid the hospital for patient services under a State plan under this subchapter and (II) the amount of the cash subsidies for patient services received directly from State and local governments, and
(ii) the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and
(B) a fraction (expressed as a percentage)—
(i) the numerator of which is the total amount of the hospital's charges for inpatient hospital services which are attributable to charity care in a period, less the portion of any cash subsidies described in clause (i)(II) of subparagraph (A) in the period reasonably attributable to inpatient hospital services, and
(ii) the denominator of which is the total amount of the hospital's charges for inpatient hospital services in the hospital in the period.
The numerator under subparagraph (B)(i) shall not include contractual allowances and discounts (other than for indigent patients not eligible for medical assistance under a State plan approved under this subchapter).
(4) The Secretary may not restrict a State's authority to designate hospitals as disproportionate share hospitals under this section. The previous sentence shall not be construed to affect the authority of the Secretary to reduce payments pursuant to
(c) Payment adjustment
Subject to subsections (f) and (g) of this section, in order to be consistent with this subsection, a payment adjustment for a disproportionate share hospital must either—
(1) be in an amount equal to at least the product of (A) the amount paid under the State plan to the hospital for operating costs for inpatient hospital services (of the kind described in
(2) provide for a minimum specified additional payment amount (or increased percentage payment) and (without regard to whether the hospital is described in subparagraph (A) or (B) of subsection (b)(1) of this section) for an increase in such a payment amount (or percentage payment) in proportion to the percentage by which the hospital's medicaid utilization rate (as defined in subsection (b)(2) of this section) exceeds one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State or the hospital's low-income utilization rate (as defined in paragraph 1 (b)(3) of this section); or
(3) provide for a minimum specified additional payment amount (or increased percentage payment) that varies according to type of hospital under a methodology that—
(A) applies equally to all hospitals of each type; and
(B) results in an adjustment for each type of hospital that is reasonably related to the costs, volume, or proportion of services provided to patients eligible for medical assistance under a State plan approved under this subchapter or to low-income patients,
except that, for purposes of paragraphs (1)(B) and (2)(A) of subsection (a) of this section, the payment adjustment for a disproportionate share hospital is consistent with this subsection if the appropriate increase in the rate or amount of payment is equal to at least one-third of the increase otherwise applicable under this subsection (in the case of such paragraph (1)(B)) and at least two-thirds of such increase (in the case of paragraph (2)(A)). In the case of a hospital described in subsection (d)(2)(A)(i) of this section (relating to children's hospitals), in computing the hospital's disproportionate share adjustment percentage for purposes of paragraph (1)(B) of this subsection, the disproportionate patient percentage (defined in
(d) Requirements to qualify as disproportionate share hospital
(1) Except as provided in paragraph (2), no hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) of this section unless the hospital has at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are entitled to medical assistance for such services under such State plan.
(2)(A) Paragraph (1) shall not apply to a hospital—
(i) the inpatients of which are predominantly individuals under 18 years of age; or
(ii) which does not offer nonemergency obstetric services to the general population as of December 22, 1987.
(B) In the case of a hospital located in a rural area (as defined for purposes of
(3) No hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) or (e) of this section unless the hospital has a medicaid inpatient utilization rate (as defined in subsection (b)(2) of this section) of not less than 1 percent.
(e) Special rule
(1) A State plan shall be considered to meet the requirement of
(2) In the case of a State that used a health insuring organization before January 1, 1986, to administer a portion of its plan on a statewide basis, beginning on July 1, 1988—
(A) the requirements of subsections (b) and (c) of this section (other than the last sentence of subsection (c) of this section) shall not apply if the aggregate amount of the payment adjustments under the plan for disproportionate share hospitals (as defined under the State plan) is not less than the aggregate amount of payment adjustments otherwise required to be made if such subsections applied,
(B) subsection (d)(2)(B) of this section shall apply to hospitals located in urban areas, as well as in rural areas,
(C) subsection (d)(3) of this section shall apply, and
(D) subsection (g) of this section shall apply.
(f) Limitation on Federal financial participation
(1) In general
Payment under
(2) State DSH allotments for fiscal years 1998 through 2002
The DSH allotment for a State for each fiscal year during the period beginning with fiscal year 1998 and ending with fiscal year 2002 is determined in accordance with the following table:
| State or District | DSH Allotment (in millions of dollars) | ||||
|---|---|---|---|---|---|
| FY 98 | FY 99 | FY 00 | FY 01 | FY 02 | |
| Alabama | 293 | 269 | 248 | 246 | 246 |
| Alaska | 10 | 10 | 10 | 9 | 9 |
| Arizona | 81 | 81 | 81 | 81 | 81 |
| Arkansas | 2 | 2 | 2 | 2 | 2 |
| California | 1,085 | 1,068 | 986 | 931 | 877 |
| Colorado | 93 | 85 | 79 | 74 | 74 |
| Connecticut | 200 | 194 | 164 | 160 | 160 |
| Delaware | 4 | 4 | 4 | 4 | 4 |
| District of Columbia | 23 | 23 | 32 | 32 | 32 |
| Florida | 207 | 203 | 197 | 188 | 160 |
| Georgia | 253 | 248 | 241 | 228 | 215 |
| Hawaii | 0 | 0 | 0 | 0 | 0 |
| Idaho | 1 | 1 | 1 | 1 | 1 |
| Illinois | 203 | 199 | 193 | 182 | 172 |
| Indiana | 201 | 197 | 191 | 181 | 171 |
| Iowa | 8 | 8 | 8 | 8 | 8 |
| Kansas | 51 | 49 | 42 | 36 | 33 |
| Kentucky | 137 | 134 | 130 | 123 | 116 |
| Louisiana | 880 | 795 | 713 | 658 | 631 |
| Maine | 103 | 99 | 84 | 84 | 84 |
| Maryland | 72 | 70 | 68 | 64 | 61 |
| Massachusetts | 288 | 282 | 273 | 259 | 244 |
| Michigan | 249 | 244 | 237 | 224 | 212 |
| Minnesota | 16 | 16 | 33 | 33 | 33 |
| Mississippi | 143 | 141 | 136 | 129 | 122 |
| Missouri | 436 | 423 | 379 | 379 | 379 |
| Montana | 0.2 | 0.2 | 0.2 | 0.2 | 0.2 |
| Nebraska | 5 | 5 | 5 | 5 | 5 |
| Nevada | 37 | 37 | 37 | 37 | 37 |
| New Hampshire | 140 | 136 | 130 | 130 | 130 |
| New Jersey | 600 | 582 | 515 | 515 | 515 |
| New Mexico | 5 | 5 | 9 | 9 | 9 |
| New York | 1,512 | 1,482 | 1,436 | 1,361 | 1,285 |
| North Carolina | 278 | 272 | 264 | 250 | 236 |
| North Dakota | 1 | 1 | 1 | 1 | 1 |
| Ohio | 382 | 374 | 363 | 344 | 325 |
| Oklahoma | 16 | 16 | 16 | 16 | 16 |
| Oregon | 20 | 20 | 20 | 20 | 20 |
| Pennsylvania | 529 | 518 | 502 | 476 | 449 |
| Rhode Island | 62 | 60 | 58 | 55 | 52 |
| South Carolina | 313 | 303 | 262 | 262 | 262 |
| South Dakota | 1 | 1 | 1 | 1 | 1 |
| Tennessee | 0 | 0 | 0 | 0 | 0 |
| Texas | 979 | 950 | 806 | 765 | 765 |
| Utah | 3 | 3 | 3 | 3 | 3 |
| Vermont | 18 | 18 | 18 | 18 | 18 |
| Virginia | 70 | 68 | 66 | 63 | 59 |
| Washington | 174 | 171 | 166 | 157 | 148 |
| West Virginia | 64 | 63 | 61 | 58 | 54 |
| Wisconsin | 7 | 7 | 7 | 7 | 7 |
| Wyoming | 0 | 0 | 0.1 | 0.1 | 0.1. |
(3) State DSH allotments for fiscal year 2003 and thereafter
(A) In general
The DSH allotment for any State for fiscal year 2003 and each succeeding fiscal year is equal to the DSH allotment for the State for the preceding fiscal year under paragraph (2) or this paragraph, increased, subject to subparagraph (B), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.
(B) Limitation
The DSH allotment for a State shall not be increased under subparagraph (A) for a fiscal year to the extent that such an increase would result in the DSH allotment for the year exceeding the greater of—
(i) the DSH allotment for the previous year, or
(ii) 12 percent of the total amount of expenditures under the State plan for medical assistance during the fiscal year.
(4) "State" defined
In this subsection, the term "State" means the 50 States and the District of Columbia.
(g) Limit on amount of payment to hospital
(1) Amount of adjustment subject to uncompensated costs
(A) In general
A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) of this section with respect to a hospital if the payment adjustment exceeds the costs incurred during the year of furnishing hospital services (as determined by the Secretary and net of payments under this subchapter, other than under this section, and by uninsured patients) by the hospital to individuals who either are eligible for medical assistance under the State plan or have no health insurance (or other source of third party coverage) for services provided during the year. For purposes of the preceding sentence, payments made to a hospital for services provided to indigent patients made by a State or a unit of local government within a State shall not be considered to be a source of third party payment.
(B) Limit to public hospitals during transition period
With respect to payment adjustments during a State fiscal year that begins before January 1, 1995, subparagraph (A) shall apply only to hospitals owned or operated by a State (or by an instrumentality or a unit of government within a State).
(C) Modifications for private hospitals
With respect to hospitals that are not owned or operated by a State (or by an instrumentality or a unit of government within a State), the Secretary may make such modifications to the manner in which the limitation on payment adjustments is applied to such hospitals as the Secretary considers appropriate.
(2) Additional amount during transition period for certain hospitals with high disproportionate share
(A) In general
In the case of a hospital with high disproportionate share (as defined in subparagraph (B)), a payment adjustment during a State fiscal year that begins before January 1, 1995, shall be considered consistent with subsection (c) of this section if the payment adjustment does not exceed 200 percent of the costs of furnishing hospital services described in paragraph (1)(A) during the year, but only if the Governor of the State certifies to the satisfaction of the Secretary that the hospital's applicable minimum amount is used for health services during the year. In determining the amount that is used for such services during a year, there shall be excluded any amounts received under the Public Health Service Act [
(B) "Hospital with high disproportionate share" defined
In subparagraph (A), a hospital is a "hospital with high disproportionate share" if—
(i) the hospital is owned or operated by a State (or by an instrumentality or a unit of government within a State); and
(ii) the hospital—
(I) meets the requirement described in subsection (b)(1)(A) of this section, or
(II) has the largest number of inpatient days attributable to individuals entitled to benefits under the State plan of any hospital in such State for the previous State fiscal year.
(C) "Applicable minimum amount" defined
In subparagraph (A), the "applicable minimum amount" for a hospital for a fiscal year is equal to the difference between the amount of the hospital's payment adjustment for the fiscal year and the costs to the hospital of furnishing hospital services described in paragraph (1)(A) during the fiscal year.
(h) Limitation on certain State DSH expenditures
(1) In general
Payment under
(A) 1995 IMD DSH payment adjustments
The total State DSH expenditures that are attributable to fiscal year 1995 for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form 64 as mental health DSH, and as approved by the Secretary).
(B) Applicable percentage of 1995 total DSH payment allotment
The amount of such payment adjustments which are equal to the applicable percentage of the Federal share of payment adjustments made to hospitals in the State under subsection (c) of this section that are attributable to the 1995 DSH allotment for the State for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form 64 as mental health DSH, and as approved by the Secretary).
(2) Applicable percentage
(A) In general
For purposes of paragraph (1), the applicable percentage with respect to—
(i) each of fiscal years 1998, 1999, and 2000, is the percentage determined under subparagraph (B); or
(ii) a succeeding fiscal year is the lesser of the percentage determined under subparagraph (B) or the following percentage:
(I) For fiscal year 2001, 50 percent.
(II) For fiscal year 2002, 40 percent.
(III) For each succeeding fiscal year, 33 percent.
(B) 1995 percentage
The percentage determined under this subparagraph is the ratio (determined as a percentage) of—
(i) the Federal share of payment adjustments made to hospitals in the State under subsection (c) of this section that are attributable to the 1995 DSH allotment for the State (as reported by the State not later than January 1, 1997, on HCFA Form 64, and as approved by the Secretary) for payments to institutions for mental diseases and other mental health facilities, to
(ii) the State 1995 DSH spending amount.
(C) State 1995 DSH spending amount
For purposes of subparagraph (B)(ii), the "State 1995 DSH spending amount", with respect to a State, is the Federal medical assistance percentage (for fiscal year 1995) of the payment adjustments made under subsection (c) of this section under the State plan that are attributable to the fiscal year 1995 DSH allotment for the State (as reported by the State not later than January 1, 1997, on HCFA Form 64, and as approved by the Secretary).
(i) Requirement for direct payment
(1) In general
No payment may be made under
(A) is made directly to the hospital by the State; and
(B) is not used to determine the amount of a prepaid capitation payment under the State plan to the entity or arrangement with respect to such individuals.
(2) Exception for current arrangements
Paragraph (1) shall not apply to a payment adjustment provided pursuant to a payment arrangement in effect on July 1, 1997.
(Aug. 14, 1935, ch. 531, title XIX, §1923, formerly
References in Text
The Public Health Service Act, referred to in subsec. (g)(2)(A), is act July 1, 1944, ch. 373,
Codification
Prior to redesignation by
Prior Provisions
A prior section 1923 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1999—Subsec. (c)(3)(B).
Subsec. (f)(2).
1997—Subsec. (a)(1).
Subsec. (a)(2)(D).
Subsec. (e)(1).
Subsec. (f).
Subsec. (h).
Subsec. (i).
1993—Subsec. (a)(1)(A).
Subsec. (b)(1).
Subsec. (c).
Subsec. (d).
Subsec. (d)(3).
Subsec. (e)(1)(C).
Subsec. (e)(2)(A).
Subsec. (e)(2)(C).
Subsec. (e)(2)(D).
Subsec. (g).
1991—Subsec. (a)(2)(B).
Subsec. (b)(4).
Subsec. (c).
Subsec. (f).
1990—Subsec. (b)(2).
Subsec. (c)(2).
Subsec. (c)(3).
Subsec. (e)(2).
1989—Subsec. (e)(1).
1988—
Subsec. (a).
Subsec. (a)(1).
Subsec. (a)(2)(A).
Subsec. (a)(2)(B).
Subsec. (a)(2)(C).
Subsec. (a)(3).
Subsec. (a)(4).
Subsec. (b)(2).
Subsec. (b)(3).
Subsec. (b)(3)(A)(i).
Subsec. (b)(3)(B)(i).
Subsec. (c).
Subsec. (c)(1).
Subsec. (c)(2).
Subsec. (d)(1).
Subsec. (d)(2)(B).
Subsec. (e).
Effective Date of 1999 Amendment
Amendment by section 1000(a)(6) [title VI, §608(s)] of
Effective Date of 1997 Amendment
Amendment by section 4711(c)(2) of
Section 4721(a)(2) of
Effective Date of 1993 Amendment
Section 13621(a)(2) of
"(A) the end of the State fiscal year that ends during 1994, or
"(B) in the case of a State with a State legislature which is not scheduled to have a regular legislative session in 1994, the end of the State fiscal year that ends during 1995;
without regard to whether or not final regulations to carry out such amendments have been promulgated by either such date."
Section 13621(b)(3) of
"(A)
"(i) the end of the State fiscal year that ends during 1994, or
"(ii) in the case of a State with a State legislature which is not scheduled to have a regular legislative session in 1994, the end of the State fiscal year that ends during 1995;
without regard to whether or not final regulations to carry out such amendments have been promulgated by either such date.
"(B)
Effective Date of 1991 Amendment
Amendments by
Effective Date of 1990 Amendment
Section 4702(b) of
Section 4703(d) of
Effective Date of 1988 Amendments
Amendment by
Amendment by section 302(b)(2) of
Except as specifically provided in section 411 of
DSH Allotments for Specific Years
Similar provisions were contained in the following prior appropriations act:
Similar provisions were contained in the following prior appropriations act:
California Transition Rule
"(1) '(or that begins on or after July 1, 1997)' were inserted in subparagraph (A) of such section after 'January 1, 1995,';
"(2) '(or 175 percent in the case of a State fiscal year that begins on or after July 1, 1997)' were inserted in subparagraph (A) of such section after '200 percent'; and
"(3) effective for State fiscal years that begin on or after July 1, 1999, 'or (b)(1)(B)' were inserted in section 1923(g)(2)(B)(ii)(I) after '(b)(1)(A)'."
[
Study of DSH Payment Adjustments
Section 3(d) of
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should be "subsection".
§1396r–5. Treatment of income and resources for certain institutionalized spouses
(a) Special treatment for institutionalized spouses
(1) Supersedes other provisions
In determining the eligibility for medical assistance of an institutionalized spouse (as defined in subsection (h)(1) of this section), the provisions of this section supersede any other provision of this subchapter (including
(2) No comparable treatment required
Any different treatment provided under this section for institutionalized spouses shall not, by reason of paragraph (10) or (17) of
(3) Does not affect certain determinations
Except as this section specifically provides, this section does not apply to—
(A) the determination of what constitutes income or resources, or
(B) the methodology and standards for determining and evaluating income and resources.
(4) Application in certain States and territories
(A) Application in States operating under demonstration projects
In the case of any State which is providing medical assistance to its residents under a waiver granted under
(B) No application in commonwealths and territories
This section shall only apply to a State that is one of the 50 States or the District of Columbia.
(5) Application to individuals receiving services under PACE programs
This section applies to individuals receiving institutional or noninstitutional services under a PACE demonstration waiver program (as defined in
(b) Rules for treatment of income
(1) Separate treatment of income
During any month in which an institutionalized spouse is in the institution, except as provided in paragraph (2), no income of the community spouse shall be deemed available to the institutionalized spouse.
(2) Attribution of income
In determining the income of an institutionalized spouse or community spouse for purposes of the post-eligibility income determination described in subsection (d) of this section, except as otherwise provided in this section and regardless of any State laws relating to community property or the division of marital property, the following rules apply:
(A) Non-trust property
Subject to subparagraphs (C) and (D), in the case of income not from a trust, unless the instrument providing the income otherwise specifically provides—
(i) if payment of income is made solely in the name of the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse;
(ii) if payment of income is made in the names of the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them; and
(iii) if payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse's interest (or, if payment is made with respect to both spouses and no such interest is specified, one-half of the joint interest shall be considered available to each spouse).
(B) Trust property
In the case of a trust—
(i) except as provided in clause (ii), income shall be attributed in accordance with the provisions of this subchapter (including
(ii) income shall be considered available to each spouse as provided in the trust, or, in the absence of a specific provision in the trust—
(I) if payment of income is made solely to the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse;
(II) if payment of income is made to both the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them; and
(III) if payment of income is made to the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse's interest (or, if payment is made with respect to both spouses and no such interest is specified, one-half of the joint interest shall be considered available to each spouse).
(C) Property with no instrument
In the case of income not from a trust in which there is no instrument establishing ownership, subject to subparagraph (D), one-half of the income shall be considered to be available to the institutionalized spouse and one-half to the community spouse.
(D) Rebutting ownership
The rules of subparagraphs (A) and (C) are superseded to the extent that an institutionalized spouse can establish, by a preponderance of the evidence, that the ownership interests in income are other than as provided under such subparagraphs.
(c) Rules for treatment of resources
(1) Computation of spousal share at time of institutionalization
(A) Total joint resources
There shall be computed (as of the beginning of the first continuous period of institutionalization (beginning on or after September 30, 1989) of the institutionalized spouse)—
(i) the total value of the resources to the extent either the institutionalized spouse or the community spouse has an ownership interest, and
(ii) a spousal share which is equal to ½ of such total value.
(B) Assessment
At the request of an institutionalized spouse or community spouse, at the beginning of the first continuous period of institutionalization (beginning on or after September 30, 1989) of the institutionalized spouse and upon the receipt of relevant documentation of resources, the State shall promptly assess and document the total value described in subparagraph (A)(i) and shall provide a copy of such assessment and documentation to each spouse and shall retain a copy of the assessment for use under this section. If the request is not part of an application for medical assistance under this subchapter, the State may, at its option as a condition of providing the assessment, require payment of a fee not exceeding the reasonable expenses of providing and documenting the assessment. At the time of providing the copy of the assessment, the State shall include a notice indicating that the spouse will have a right to a fair hearing under subsection (e)(2) of this section.
(2) Attribution of resources at time of initial eligibility determination
In determining the resources of an institutionalized spouse at the time of application for benefits under this subchapter, regardless of any State laws relating to community property or the division of marital property—
(A) except as provided in subparagraph (B), all the resources held by either the institutionalized spouse, community spouse, or both, shall be considered to be available to the institutionalized spouse, and
(B) resources shall be considered to be available to an institutionalized spouse, but only to the extent that the amount of such resources exceeds the amount computed under subsection (f)(2)(A) of this section (as of the time of application for benefits).
(3) Assignment of support rights
The institutionalized spouse shall not be ineligible by reason of resources determined under paragraph (2) to be available for the cost of care where—
(A) the institutionalized spouse has assigned to the State any rights to support from the community spouse;
(B) the institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment but the State has the right to bring a support proceeding against a community spouse without such assignment; or
(C) the State determines that denial of eligibility would work an undue hardship.
(4) Separate treatment of resources after eligibility for benefits established
During the continuous period in which an institutionalized spouse is in an institution and after the month in which an institutionalized spouse is determined to be eligible for benefits under this subchapter, no resources of the community spouse shall be deemed available to the institutionalized spouse.
(5) Resources defined
In this section, the term "resources" does not include—
(A) resources excluded under subsection (a) or (d) of
(B) resources that would be excluded under
(d) Protecting income for community spouse
(1) Allowances to be offset from income of institutionalized spouse
After an institutionalized spouse is determined or redetermined to be eligible for medical assistance, in determining the amount of the spouse's income that is to be applied monthly to payment for the costs of care in the institution, there shall be deducted from the spouse's monthly income the following amounts in the following order:
(A) A personal needs allowance (described in
(B) A community spouse monthly income allowance (as defined in paragraph (2)), but only to the extent income of the institutionalized spouse is made available to (or for the benefit of) the community spouse.
(C) A family allowance, for each family member, equal to at least 1/3 of the amount by which the amount described in paragraph (3)(A)(i) exceeds the amount of the monthly income of that family member.
(D) Amounts for incurred expenses for medical or remedial care for the institutionalized spouse (as provided under
In subparagraph (C), the term "family member" only includes minor or dependent children, dependent parents, or dependent siblings of the institutionalized or community spouse who are residing with the community spouse.
(2) Community spouse monthly income allowance defined
In this section (except as provided in paragraph (5)), the "community spouse monthly income allowance" for a community spouse is an amount by which—
(A) except as provided in subsection (e) of this section, the minimum monthly maintenance needs allowance (established under and in accordance with paragraph (3)) for the spouse, exceeds
(B) the amount of monthly income otherwise available to the community spouse (determined without regard to such an allowance).
(3) Establishment of minimum monthly maintenance needs allowance
(A) In general
Each State shall establish a minimum monthly maintenance needs allowance for each community spouse which, subject to subparagraph (C), is equal to or exceeds—
(i) the applicable percent (described in subparagraph (B)) of 1/12 of the income official poverty line (defined by the Office of Management and Budget and revised annually in accordance with
(ii) an excess shelter allowance (as defined in paragraph (4)).
A revision of the official poverty line referred to in clause (i) shall apply to medical assistance furnished during and after the second calendar quarter that begins after the date of publication of the revision.
(B) Applicable percent
For purposes of subparagraph (A)(i), the "applicable percent" described in this paragraph, effective as of—
(i) September 30, 1989, is 122 percent,
(ii) July 1, 1991, is 133 percent, and
(iii) July 1, 1992, is 150 percent.
(C) Cap on minimum monthly maintenance needs allowance
The minimum monthly maintenance needs allowance established under subparagraph (A) may not exceed $1,500 (subject to adjustment under subsections (e) and (g) of this section).
(4) Excess shelter allowance defined
In paragraph (3)(A)(ii), the term "excess shelter allowance" means, for a community spouse, the amount by which the sum of—
(A) the spouse's expenses for rent or mortgage payment (including principal and interest), taxes and insurance and, in the case of a condominium or cooperative, required maintenance charge, for the community spouse's principal residence, and
(B) the standard utility allowance (used by the State under
exceeds 30 percent of the amount described in paragraph (3)(A)(i), except that, in the case of a condominium or cooperative, for which a maintenance charge is included under subparagraph (A), any allowance under subparagraph (B) shall be reduced to the extent the maintenance charge includes utility expenses.
(5) Court ordered support
If a court has entered an order against an institutionalized spouse for monthly income for the support of the community spouse, the community spouse monthly income allowance for the spouse shall be not less than the amount of the monthly income so ordered.
(e) Notice and fair hearing
(1) Notice
Upon—
(A) a determination of eligibility for medical assistance of an institutionalized spouse, or
(B) a request by either the institutionalized spouse, or the community spouse, or a representative acting on behalf of either spouse,
each State shall notify both spouses (in the case described in subparagraph (A)) or the spouse making the request (in the case described in subparagraph (B)) of the amount of the community spouse monthly income allowance (described in subsection (d)(1)(B) of this section), of the amount of any family allowances (described in subsection (d)(1)(C) of this section), of the method for computing the amount of the community spouse resources allowance permitted under subsection (f) of this section, and of the spouse's right to a fair hearing under this subsection respecting ownership or availability of income or resources, and the determination of the community spouse monthly income or resource allowance.
(2) Fair hearing
(A) In general
If either the institutionalized spouse or the community spouse is dissatisfied with a determination of—
(i) the community spouse monthly income allowance;
(ii) the amount of monthly income otherwise available to the community spouse (as applied under subsection (d)(2)(B) of this section);
(iii) the computation of the spousal share of resources under subsection (c)(1) of this section;
(iv) the attribution of resources under subsection (c)(2) of this section; or
(v) the determination of the community spouse resource allowance (as defined in subsection (f)(2) of this section);
such spouse is entitled to a fair hearing described in
(B) Revision of minimum monthly maintenance needs allowance
If either such spouse establishes that the community spouse needs income, above the level otherwise provided by the minimum monthly maintenance needs allowance, due to exceptional circumstances resulting in significant financial duress, there shall be substituted, for the minimum monthly maintenance needs allowance in subsection (d)(2)(A) of this section, an amount adequate to provide such additional income as is necessary.
(C) Revision of community spouse resource allowance
If either such spouse establishes that the community spouse resource allowance (in relation to the amount of income generated by such an allowance) is inadequate to raise the community spouse's income to the minimum monthly maintenance needs allowance, there shall be substituted, for the community spouse resource allowance under subsection (f)(2) of this section, an amount adequate to provide such a minimum monthly maintenance needs allowance.
(f) Permitting transfer of resources to community spouse
(1) In general
An institutionalized spouse may, without regard to
(2) Community spouse resource allowance defined
In paragraph (1), the "community spouse resource allowance" for a community spouse is an amount (if any) by which—
(A) the greatest of—
(i) $12,000 (subject to adjustment under subsection (g) of this section), or, if greater (but not to exceed the amount specified in clause (ii)(II)) an amount specified under the State plan,
(ii) the lesser of (I) the spousal share computed under subsection (c)(1) of this section, or (II) $60,000 (subject to adjustment under subsection (g) of this section),
(iii) the amount established under subsection (e)(2) of this section; or
(iv) the amount transferred under a court order under paragraph (3);
exceeds
(B) the amount of the resources otherwise available to the community spouse (determined without regard to such an allowance).
(3) Transfers under court orders
If a court has entered an order against an institutionalized spouse for the support of the community spouse,
(g) Indexing dollar amounts
For services furnished during a calendar year after 1989, the dollar amounts specified in subsections (d)(3)(C), (f)(2)(A)(i), and (f)(2)(A)(ii)(II) of this section shall be increased by the same percentage as the percentage increase in the consumer price index for all urban consumers (all items; U.S. city average) between September 1988 and the September before the calendar year involved.
(h) Definitions
In this section:
(1) The term "institutionalized spouse" means an individual who—
(A) is in a medical institution or nursing facility or who (at the option of the State) is described in
(B) is married to a spouse who is not in a medical institution or nursing facility;
but does not include any such individual who is not likely to meet the requirements of subparagraph (A) for at least 30 consecutive days.
(2) The term "community spouse" means the spouse of an institutionalized spouse.
(Aug. 14, 1935, ch. 531, title XIX, §1924, as added
Prior Provisions
A prior section 1924 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1997—Subsec. (a)(5).
1994—Subsec. (d)(3)(A)(i).
1993—Subsec. (a)(5).
Subsec. (b)(2)(B)(i).
1990—Subsec. (a)(5).
Subsec. (b)(2).
Subsec. (c)(1).
Subsec. (f)(1).
1989—Subsecs. (b)(2), (d)(1).
1988—Subsec. (c)(1)(B).
Subsec. (c)(2)(B).
Subsec. (d)(3)(A)(i).
Subsec. (d)(4).
Subsec. (e)(2)(A).
Subsec. (f)(1).
Subsec. (f)(3).
Effective Date of 1994 Amendment
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13611(d)(2) of
Effective Date of 1990 Amendment
Section 4714(d) of
Effective Date of 1989 Amendment
Amendment by
Effective Date of 1988 Amendment
Amendment by
Effective Date
Section 303(g) of
"(1)(A) The amendments made by this section [enacting this section and amending
"(B) Section 1924 of the Social Security Act [this section] (as inserted by subsection (a)) shall only apply to institutionalized individuals who begin continuous periods of institutionalization on or after September 30, 1989, except that subsections (b) and (d) of such section (and so much of subsection (e) of such section as relates to such other subsections) shall apply as of such date to individuals institutionalized on or after such date.
"(2)(A) The amendment made by subsection (b) [amending
"(B) Section 1917(c) of the Social Security Act [
"(C) Notwithstanding subparagraphs (A) and (B), a State may continue to apply the policies contained in the State plan as of June 30, 1988, with respect to resources disposed of before July 1, 1988, and the laws and policies established by the State as of June 30, 1988, or provided for before July 1, 1988, shall continue to apply through September 30, 1989, (and may, at a State's option continue after such date) to inter-spousal transfers occurring before October 1, 1989.
"(3) The amendments made by subsection (c) [amending
"(4) The amendment made by subsection (d) [amending
"(5) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section (other than paragraphs (1) and (5) of subsection (e) [amending
"(6) The amendments made by paragraphs (1) and (5) of subsection (e) [amending
Section Referred to in Other Sections
This section is referred to in
§1396r–6. Extension of eligibility for medical assistance
(a) Initial 6-month extension
(1) Requirement
Notwithstanding any other provision of this subchapter, each State plan approved under this subchapter must provide that each family which was receiving aid pursuant to a plan of the State approved under part A of subchapter IV of this chapter in at least 3 of the 6 months immediately preceding the month in which such family becomes ineligible for such aid, because of hours of, or income from, employment of the caretaker relative (as defined in subsection (e) of this section) or because of section 602(a)(8)(B)(ii)(II) 1 of this title (providing for a time-limited earned income disregard), shall, subject to paragraph (3) and without any reapplication for benefits under the plan, remain eligible for assistance under the plan approved under this subchapter during the immediately succeeding 6-month period in accordance with this subsection.
(2) Notice of benefits
Each State, in the notice of termination of aid under part A of subchapter IV of this chapter sent to a family meeting the requirements of paragraph (1)—
(A) shall notify the family of its right to extended medical assistance under this subsection and include in the notice a description of the reporting requirement of subsection (b)(2)(B)(i) of this section and of the circumstances (described in paragraph (3)) under which such extension may be terminated; and
(B) shall include a card or other evidence of the family's entitlement to assistance under this subchapter for the period provided in this subsection.
(3) Termination of extension
(A) No dependent child
Subject to subparagraphs (B) and (C), extension of assistance during the 6-month period described in paragraph (1) to a family shall terminate (during such period) at the close of the first month in which the family ceases to include a child, whether or not the child is (or would if needy be) a dependent child under part A of subchapter IV of this chapter.
(B) Notice before termination
No termination of assistance shall become effective under subparagraph (A) until the State has provided the family with notice of the grounds for the termination.
(C) Continuation in certain cases until redetermination
With respect to a child who would cease to receive medical assistance because of subparagraph (A) but who may be eligible for assistance under the State plan because the child is described in clause (i) of
(4) Scope of coverage
(A) In general
Subject to subparagraph (B), during the 6-month extension period under this subsection, the amount, duration, and scope of medical assistance made available with respect to a family shall be the same as if the family were still receiving aid under the plan approved under part A of subchapter IV of this chapter.
(B) State medicaid "wrap-around" option
A State, at its option, may pay a family's expenses for premiums, deductibles, coinsurance, and similar costs for health insurance or other health coverage offered by an employer of the caretaker relative or by an employer of the absent parent of a dependent child. In the case of such coverage offered by an employer of the caretaker relative—
(i) the State may require the caretaker relative, as a condition of extension of coverage under this subsection for the caretaker and the caretaker's family, to make application for such employer coverage, but only if—
(I) the caretaker relative is not required to make financial contributions for such coverage (whether through payroll deduction, payment of deductibles, coinsurance, or similar costs, or otherwise), and
(II) the State provides, directly or otherwise, for payment of any of the premium amount, deductible, coinsurance, or similar expense that the employee is otherwise required to pay; and
(ii) the State shall treat the coverage under such an employer plan as a third party liability (under
Payments for premiums, deductibles, coinsurance, and similar expenses under this subparagraph shall be considered, for purposes of
(b) Additional 6-month extension
(1) Requirement
Notwithstanding any other provision of this subchapter, each State plan approved under this subchapter shall provide that the State shall offer to each family, which has received assistance during the entire 6-month period under subsection (a) of this section and which meets the requirement of paragraph (2)(B)(i), in the last month of the period the option of extending coverage under this subsection for the succeeding 6-month period, subject to paragraph (3).
(2) Notice and reporting requirements
(A) Notices
(i) Notice during initial extension period of option and requirements
Each State, during the 3rd and 6th month of any extended assistance furnished to a family under subsection (a) of this section, shall notify the family of the family's option for additional extended assistance under this subsection. Each such notice shall include (I) in the 3rd month notice, a statement of the reporting requirement under subparagraph (B)(i), and, in the 6th month notice, a statement of the reporting requirement under subparagraph (B)(ii), (II) a statement as to whether any premiums are required for such additional extended assistance, and (III) a description of other out-of-pocket expenses, benefits, reporting and payment procedures, and any pre-existing condition limitations, waiting periods, or other coverage limitations imposed under any alternative coverage options offered under paragraph (4)(D). The 6th month notice under this subparagraph shall describe the amount of any premium required of a particular family for each of the first 3 months of additional extended assistance under this subsection.
(ii) Notice during additional extension period of reporting requirements and premiums
Each State, during the 3rd month of any additional extended assistance furnished to a family under this subsection, shall notify the family of the reporting requirement under subparagraph (B)(ii) and a statement of the amount of any premium required for such extended assistance for the succeeding 3 months.
(B) Reporting requirements
(i) During initial extension period
Each State shall require (as a condition for additional extended assistance under this subsection) that a family receiving extended assistance under subsection (a) of this section report to the State, not later than the 21st day of the 4th month in the period of extended assistance under subsection (a) of this section, on the family's gross monthly earnings and on the family's costs for such child care as is necessary for the employment of the caretaker relative in each of the first 3 months of that period. A State may permit such additional extended assistance under this subsection notwithstanding a failure to report under this clause if the family has established, to the satisfaction of the State, good cause for the failure to report on a timely basis.
(ii) During additional extension period
Each State shall require that a family receiving extended assistance under this subsection report to the State, not later than the 21st day of the 1st month and of the 4th month in the period of additional extended assistance under this subsection, on the family's gross monthly earnings and on the family's costs for such child care as is necessary for the employment of the caretaker relative in each of the 3 preceding months.
(iii) Clarification on frequency of reporting
A State may not require that a family receiving extended assistance under this subsection or subsection (a) of this section report more frequently than as required under clause (i) or (ii).
(3) Termination of extension
(A) In general
Subject to subparagraphs (B) and (C), extension of assistance during the 6-month period described in paragraph (1) to a family shall terminate (during the period) as follows:
(i) No dependent child
The extension shall terminate at the close of the first month in which the family ceases to include a child, whether or not the child is (or would if needy be) a dependent child under part A of subchapter IV of this chapter.
(ii) Failure to pay any premium
If the family fails to pay any premium for a month under paragraph (5) by the 21st day of the following month, the extension shall terminate at the close of that following month, unless the family has established, to the satisfaction of the State, good cause for the failure to pay such premium on a timely basis.
(iii) Quarterly income reporting and test
The extension under this subsection shall terminate at the close of the 1st or 4th month of the 6-month period if—
(I) the family fails to report to the State, by the 21st day of such month, the information required under paragraph (2)(B)(ii), unless the family has established, to the satisfaction of the State, good cause for the failure to report on a timely basis;
(II) the caretaker relative had no earnings in one or more of the previous 3 months, unless such lack of any earnings was due to an involuntary loss of employment, illness, or other good cause, established to the satisfaction of the State; or
(III) the State determines that the family's average gross monthly earnings (less such costs for such child care as is necessary for the employment of the caretaker relative) during the immediately preceding 3-month period exceed 185 percent of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with
Information described in clause (iii)(I) shall be subject to the restrictions on use and disclosure of information provided under section 602(a)(9) 2 of this title. Instead of terminating a family's extension under clause (iii)(I), a State, at its option, may provide for suspension of the extension until the month after the month in which the family reports information required under paragraph (2)(B)(ii), but only if the family's extension has not otherwise been terminated under subclause (II) or (III) of clause (iii). The State shall make determinations under clause (iii)(III) for a family each time a report under paragraph (2)(B)(ii) for the family is received.
(B) Notice before termination
No termination of assistance shall become effective under subparagraph (A) until the State has provided the family with notice of the grounds for the termination, which notice shall include (in the case of termination under subparagraph (A)(iii)(II), relating to no continued earnings) a description of how the family may reestablish eligibility for medical assistance under the State plan. No such termination shall be effective earlier than 10 days after the date of mailing of such notice.
(C) Continuation in certain cases until redetermination
(i) Dependent children
With respect to a child who would cease to receive medical assistance because of subparagraph (A)(i) but who may be eligible for assistance under the State plan because the child is described in clause (i) of
(ii) Medically needy
With respect to an individual who would cease to receive medical assistance because of clause (ii) or (iii) of subparagraph (A) but who may be eligible for assistance under the State plan because the individual is within a category of person for which medical assistance under the State plan is available under
(4) Coverage
(A) In general
During the extension period under this subsection—
(i) the State plan shall offer to each family medical assistance which (subject to subparagraphs (B) and (C)) is the same amount, duration, and scope as would be made available to the family if it were still receiving aid under the plan approved under part A of subchapter IV of this chapter; and
(ii) the State plan may offer alternative coverage described in subparagraph (D).
(B) Elimination of most non-acute care benefits
At a State's option and notwithstanding any other provision of this subchapter, a State may choose not to provide medical assistance under this subsection with respect to any (or all) of the items and services described in paragraphs (4)(A), (6), (7), (8), (11), (13), (14), (15), (16), (18), (20), and (21) 3 of
(C) State medicaid "wrap-around" option
At a State's option, the State may elect to apply the option described in subsection (a)(4)(B) of this section (relating to "wrap-around" coverage) for families electing medical assistance under this subsection in the same manner as such option applies to families provided extended eligibility for medical assistance under subsection (a) of this section.
(D) Alternative assistance
At a State's option, the State may offer families a choice of health care coverage under one or more of the following, instead of the medical assistance otherwise made available under this subsection:
(i) Enrollment in family option of employer plan
Enrollment of the caretaker relative and dependent children in a family option of the group health plan offered to the caretaker relative.
(ii) Enrollment in family option of State employee plan
Enrollment of the caretaker relative and dependent children in a family option within the options of the group health plan or plans offered by the State to State employees.
(iii) Enrollment in State uninsured plan
Enrollment of the caretaker relative and dependent children in a basic State health plan offered by the State to individuals in the State (or areas of the State) otherwise unable to obtain health insurance coverage.
(iv) Enrollment in medicaid managed care organization
Enrollment of the caretaker relative and dependent children in a medicaid managed care organization (as defined in
If a State elects to offer an option to enroll a family under this subparagraph, the State shall pay any premiums and other costs for such enrollment imposed on the family and may pay deductibles and coinsurance imposed on the family. A State's payment of premiums for the enrollment of families under this subparagraph (not including any premiums otherwise payable by an employer and less the amount of premiums collected from such families under paragraph (5)) and payment of any deductibles and coinsurance shall be considered, for purposes of
(E) Prohibition on cost-sharing for maternity and preventive pediatric care
(i) In general
If a State offers any alternative option under subparagraph (D) for families, under each such option the State must assure that care described in clause (ii) is available without charge to the families through—
(I) payment of any deductibles, coinsurance, and other cost-sharing respecting such care, or
(II) providing coverage under the State plan for such care without any cost-sharing,
or any combination of such mechanisms.
(ii) Care described
The care described in this clause consists of—
(I) services related to pregnancy (including prenatal, delivery, and post partum services), and
(II) ambulatory preventive pediatric care (including ambulatory early and periodic screening, diagnosis, and treatment services under
(5) Premium
(A) Permitted
Notwithstanding any other provision of this subchapter (including
(B) Level may vary by option offered
The level of such premium may vary, for the same family, for each option offered by a State under paragraph (4)(D).
(C) Limit on premium
In no case may the amount of any premium under this paragraph for a family for a month in either of the premium payment periods described in subparagraph (D)(i) exceed 3 percent of the family's average gross monthly earnings (less the average monthly costs for such child care as is necessary for the employment of the caretaker relative) during the premium base period (as defined in subparagraph (D)(ii)).
(D) Definitions
In this paragraph:
(i) A "premium payment period" described in this clause is a 3-month period beginning with the 1st or 4th month of the 6-month additional extension period provided under this subsection.
(ii) The term "premium base period" means, with respect to a particular premium payment period, the period of 3 consecutive months the last of which is 4 months before the beginning of that premium payment period.
(c) Applicability in States and territories
(1) States operating under demonstration projects
In the case of any State which is providing medical assistance to its residents under a waiver granted under
(2) Inapplicability in commonwealths and territories
The provisions of this section shall only apply to the 50 States and the District of Columbia.
(d) General disqualification for fraud
(1) Ineligibility for aid
This section shall not apply to an individual who is a member of a family which has received aid under part A of subchapter IV of this chapter if the State makes a finding that, at any time during the last 6 months in which the family was receiving such aid before otherwise being provided extended eligibility under this section, the individual was ineligible for such aid because of fraud.
(2) General disqualifications
For additional provisions relating to fraud and program abuse, see
(e) "Caretaker relative" defined
In this section, the term "caretaker relative" has the meaning of such term as used in part A of subchapter IV of this chapter.
(f) Sunset
This section shall not apply with respect to families that cease to be eligible for aid under part A of subchapter IV of this chapter after September 30, 2001.
(Aug. 14, 1935, ch. 531, title XIX, §1925, as added
References in Text
Part A of subchapter IV of this chapter, referred to in text, is classified to
Paragraph (21) of
Prior Provisions
A prior section 1925 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1999—Subsec. (a)(3)(C).
Subsec. (b)(3)(C)(i).
1997—Subsec. (b)(4)(D)(iv).
1996—Subsec. (f).
1990—Subsec. (a)(3)(C).
Subsec. (b)(2)(B)(i).
Subsec. (b)(2)(B)(iii).
Subsec. (b)(3)(B).
Subsec. (b)(3)(C)(i).
1989—Subsec. (a)(3)(A).
Subsec. (a)(3)(C).
Subsec. (b)(3)(A)(i).
Subsec. (b)(3)(C)(i).
1988—Subsec. (b)(5)(C).
Effective Date of 1997 Amendment
Amendment by section 4701(b)(2)(A)(ix), (D) of
Amendment by section 4703(b)(2) of
Effective Date of 1996 Amendment
Amendment by
Effective Date of 1990 Amendment
Amendment by section 4601(a)(3)(B) of
Section 4716(b) of
Effective Date of 1989 Amendment
Section 6411(i)(4) of
Effective Date of 1988 Amendment
Section 8436(b) of
Effective Date
Section applicable to payments under this subchapter for calendar quarters beginning on or after Apr. 1, 1990 (or, in the case of the Commonwealth of Kentucky, Oct. 1, 1990) (without regard to whether implementing regulations are promulgated by that date), with respect to families that cease to be eligible for aid under part A of subchapter IV of this chapter on or after that date, see section 303(f)(1) of
References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996
For provisions that certain references to provisions of part A (§601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see
Study and Report to Congress on Impact of Medicaid Extension Provisions
Section 303(c) of
Section Referred to in Other Sections
This section is referred to in
1 See References in Text note below.
2 See References in Text note below.
3 See References in Text note below.
§1396r–7. Repealed. Pub. L. 105–33, title IV, §4713(a), Aug. 5, 1997, 111 Stat. 509
Section, act Aug. 14, 1935, ch. 531, title XIX, §1926, as added Dec. 19, 1989,
Effective Date of Repeal
Section 4713(b) of
§1396r–8. Payment for covered outpatient drugs
(a) Requirement for rebate agreement
(1) In general
In order for payment to be available under
(2) Effective date
Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.
(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and
(4) Effect on existing agreements
In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990, such agreement, for the initial agreement period specified therein, shall be considered to be a rebate agreement in compliance with this section with respect to that State, if the State agrees to report to the Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum aggregate rebate of 10 percent of the State's total expenditures under the State plan for coverage of the manufacturer's drugs under this subchapter. If, after the initial agreement period, the State establishes to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for rebates that are at least as large as the rebates otherwise required under this section, and the State agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to be a rebate agreement in compliance with the section for the renewal periods of such agreement.
(5) Limitation on prices of drugs purchased by covered entities
(A) Agreement with Secretary
A manufacturer meets the requirements of this paragraph if the manufacturer has entered into an agreement with the Secretary that meets the requirements of
(B) "Covered entity" defined
In this subsection, the term "covered entity" means an entity described in
(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates
If the Secretary does not establish a mechanism under
(i) Entities
Each covered entity shall inform the single State agency under
(ii) State agency
Each such single State agency shall provide a means by which a covered entity shall indicate on any drug reimbursement claims form (or format, where electronic claims management is used) that a unit of the drug that is the subject of the form is subject to an agreement under
(D) Effect of subsequent amendments
In determining whether an agreement under subparagraph (A) meets the requirements of
(E) Determination of compliance
A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of
(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certain other Federal agencies
(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisions of
(B) Effect of subsequent amendments
In determining whether a master agreement described in subparagraph (A) meets the requirements of
(C) Determination of compliance
A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of
(b) Terms of rebate agreement
(1) Periodic rebates
(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each State plan approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for which payment was made under the State plan for such period. Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2) for the period involved.
(B) Offset against medical assistance
Amounts received by a State under this section (or under an agreement authorized by the Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) in any quarter shall be considered to be a reduction in the amount expended under the State plan in the quarter for medical assistance for purposes of
(2) State provision of information
(A) State responsibility
Each State agency under this subchapter shall report to each manufacturer not later than 60 days after the end of each rebate period and in a form consistent with a standard reporting format established by the Secretary, information on the total number of units of each dosage form and strength and package size of each covered outpatient drug dispensed after December 31, 1990, for which payment was made under the plan during the period, and shall promptly transmit a copy of such report to the Secretary.
(B) Audits
A manufacturer may audit the information provided (or required to be provided) under subparagraph (A). Adjustments to rebates shall be made to the extent that information indicates that utilization was greater or less than the amount previously specified.
(3) Manufacturer provision of price information
(A) In general
Each manufacturer with an agreement in effect under this section shall report to the Secretary—
(i) not later than 30 days after the last day of each rebate period under the agreement (beginning on or after January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source drugs), the manufacturer's best price (as defined in subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the agreement, and
(ii) not later than 30 days after the date of entering into an agreement under this section on the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 1 for each of the manufacturer's covered outpatient drugs.
(B) Verification surveys of average manufacturer price
The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices reported under subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drug refuses a request for information about charges or prices by the Secretary in connection with a survey under this subparagraph or knowingly provides false information. The provisions of
(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide information required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by $10,000 for each day in which such information has not been provided and such amount shall be paid to the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the agreement shall be suspended for services furnished after the end of such 90-day period and until the date such information is reported (but in no case shall such suspension be for a period of less than 30 days).
(ii) False information
Any manufacturer with an agreement under this section that knowingly provides false information is subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions of
(D) Confidentiality of information
Notwithstanding any other provision of law, information disclosed by manufacturers or wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section is confidential and shall not be disclosed by the Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of a specific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler, except—
(i) as the Secretary determines to be necessary to carry out this section,
(ii) to permit the Comptroller General to review the information provided, and
(iii) to permit the Director of the Congressional Budget Office to review the information provided.
(4) Length of agreement
(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be automatically renewed for a period of not less than one year unless terminated under subparagraph (B).
(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the requirements of the agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a hearing concerning such a termination, but such hearing shall not delay the effective date of the termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any such termination shall not be effective until the calendar quarter beginning at least 60 days after the date the manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement before the effective date of its termination.
(iv) Notice to States
In the case of a termination under this subparagraph, the Secretary shall provide notice of such termination to the States within not less than 30 days before the effective date of such termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described in
(C) Delay before reentry
In the case of any rebate agreement with a manufacturer under this section which is terminated, another such agreement with the manufacturer (or a successor manufacturer) may not be entered into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the Secretary finds good cause for an earlier reinstatement of such an agreement.
(c) Determination of amount of rebate
(1) Basic rebate for single source drugs and innovator multiple source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a single source drug or an innovator multiple source drug shall be equal to the product of—
(i) the total number of units of each dosage form and strength paid for under the State plan in the rebate period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of—
(I) the difference between the average manufacturer price and the best price (as defined in subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer price,
for the rebate period.
(B) Range of rebates required
(i) Minimum rebate percentage
For purposes of subparagraph (A)(ii)(II), the "minimum rebate percentage" for rebate periods beginning—
(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;
(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;
(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;
(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and
(V) after December 31, 1995, is 15.1 percent.
(ii) Temporary limitation on maximum rebate amount
In no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning—
(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or
(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the average manufacturer price.
(C) "Best price" defined
For purposes of this section—
(i) In general
The term "best price" means, with respect to a single source drug or innovator multiple source drug of a manufacturer, the lowest price available from the manufacturer during the rebate period to any wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity within the United States, excluding—
(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department of Veterans Affairs, a State home receiving funds under
(II) any prices charged under the Federal Supply Schedule of the General Services Administration;
(III) any prices used under a State pharmaceutical assistance program; and
(IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of the Federal Government.
(ii) Special rules
The term "best price"—
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement, volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form or product or package; and
(III) shall not take into account prices that are merely nominal in amount.
(2) Additional rebate for single source and innovator multiple source drugs
(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount equal to the product of—
(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State plan for the rebate period; and
(ii) the amount (if any) by which—
(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an entity, including a division or subsidiary of the manufacturer, after the first day of such quarter), increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index for September 1990.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting "the first full calendar quarter after the day on which the drug was first marketed" for "the calendar quarter beginning July 1, 1990" and "the month prior to the first month of the first full calendar quarter after the day on which the drug was first marketed" for "September 1990".
(3) Rebate for other drugs
(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form and strength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs) shall be equal to the product of—
(i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State plan for the rebate period.
(B) "Applicable percentage" defined
For purposes of subparagraph (A)(i), the "applicable percentage" for rebate periods beginning—
(i) before January 1, 1994, is 10 percent, and
(ii) after December 31, 1993, is 11 percent.
(d) Limitations on coverage of drugs
(1) Permissible restrictions
(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of paragraph (5).
(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if—
(i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection (a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in accordance with paragraph (4).
(2) List of drugs subject to restriction
The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:
(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
(I) Barbiturates.
(J) Benzodiazepines.
(3) Update of drug listings
The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by surveillance and utilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriate use.
(4) Requirements for formularies
A State may establish a formulary if the formulary meets the following requirements:
(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State's drug use review board established under subsection (g)(3) of this section).
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any manufacturer which has entered into and complies with an agreement under subsection (a) of this section (other than any drug excluded from coverage or otherwise restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or condition for an identified population (if any) only if, based on the drug's labeling (or, in the case of a drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act [
(D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that is consistent with paragraph (5).
(E) The formulary meets such other requirements as the Secretary may impose in order to achieve program savings consistent with protecting the health of program beneficiaries.
A prior authorization program established by a State under paragraph (5) is not a formulary subject to the requirements of this paragraph.
(5) Requirements of prior authorization programs
A State plan under this subchapter may require, as a condition of coverage or payment for a covered outpatient drug for which Federal financial participation is available in accordance with this section, with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the system providing for such approval—
(A) provides response by telephone or other telecommunication device within 24 hours of a request for prior authorization; and
(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by the Secretary).
(6) Other permissible restrictions
A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or maximum quantities per prescription or on the number of refills, if such limitations are necessary to discourage waste, and may address instances of fraud or abuse by individuals in any manner authorized under this chapter.
(e) Treatment of pharmacy reimbursement limits
(1) In general
During the period beginning on January 1, 1991, and ending on December 31, 1994—
(A) a State may not reduce the payment limits established by regulation under this subchapter or any limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1, 1991, and
(B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph (A).
(2) Special rule
If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not apply to such State until such State is in compliance with such regulations.
(3) Effect on State maximum allowable cost limitations
This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31, 1994, relating to any maximum allowable cost limitation established by a State for payment by the State for covered outpatient drugs, and rebates shall be made under this section without regard to whether or not payment by the State for such drugs is subject to such a limitation or the amount of such a limitation.
[(4)] 2 Establishment of upper payment limits
HCFA shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA has rated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all such additional formulations are rated as such and shall use only such formulations when determining any such upper limit.
(f) Repealed and redesignated
(1) Repealed. Pub. L. 103–66, title XIII, §13602(a)(1), Aug. 10, 1993, 107 Stat. 613
(2) Redesignated (e)[(4)]
(g) Drug use review
(1) In general
(A) In order to meet the requirement of
(B) The program shall assess data on drug use against predetermined standards, consistent with the following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information;
(III) the DRUGDEX Information System; and
(IV) American Medical Association Drug Evaluations; and
(ii) the peer-reviewed medical literature.
(C) The Secretary, under the procedures established in
(D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to residents of nursing facilities which are in compliance with the drug regimen review procedures prescribed by the Secretary for such facilities in regulations implementing
(2) Description of program
Each drug use review program shall meet the following requirements for covered outpatient drugs:
(A) Prospective drug review
(i) The State plan shall provide for a review of drug therapy before each prescription is filled or delivered to an individual receiving benefits under this subchapter, typically at the point-of-sale or point of distribution. The review shall include screening for potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literature referred to in paragraph (1)(B) as its source of standards for such review.
(ii) As part of the State's prospective drug use review program under this subparagraph applicable State law shall establish standards for counseling of individuals receiving benefits under this subchapter by pharmacists which includes at least the following:
(I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapter or caregiver of such individual (in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which in the exercise of the pharmacist's professional judgment (consistent with State law respecting the provision of such information), the pharmacist deems significant including the following:
(aa) The name and description of the medication.
(bb) The route, dosage form, dosage, route of administration, and duration of drug therapy.
(cc) Special directions and precautions for preparation, administration and use by the patient.
(dd) Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur.
(ee) Techniques for self-monitoring drug therapy.
(ff) Proper storage.
(gg) Prescription refill information.
(hh) Action to be taken in the event of a missed dose.
(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the following information regarding individuals receiving benefits under this subchapter:
(aa) Name, address, telephone number, date of birth (or age) and gender.
(bb) Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices.
(cc) Pharmacist comments relevant to the individual's drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to provide consultation when an individual receiving benefits under this subchapter or caregiver of such individual refuses such consultation.
(B) Retrospective drug use review
The program shall provide, through its mechanized drug claims processing and information retrieval systems (approved by the Secretary under
(C) Application of standards
The program shall, on an ongoing basis, assess data on drug use against explicit predetermined standards (using the compendia and literature referred to in subsection 3 (1)(B) as the source of standards for such assessment) including but not limited to monitoring for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical abuse/misuse and, as necessary, introduce remedial strategies, in order to improve the quality of care and to conserve program funds or personal expenditures.
(D) Educational program
The program shall, through its State drug use review board established under paragraph (3), either directly or through contracts with accredited health care educational institutions, State medical societies or State pharmacists associations/societies or other organizations as specified by the State, and using data provided by the State drug use review board on common drug therapy problems, provide for active and ongoing educational outreach programs (including the activities described in paragraph (3)(C)(iii) of this subsection) to educate practitioners on common drug therapy problems with the aim of improving prescribing or dispensing practices.
(3) State drug use review board
(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the "DUR Board") either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed and actively practicing physicians and at least 1/3 * * * 4 licensed and actively practicing pharmacists.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section 5 (2)(B).
(ii) Application of standards as defined in section 5 (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems or individuals identified in the course of retrospective drug use reviews performed under this subsection. Intervention programs shall include, in appropriate instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists in the State of information concerning its duties, powers, and basis for its standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both) information and suggested changes in prescribing or dispensing practices, communicated in a manner designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in rational drug therapy and selected prescribers and pharmacists who have been targeted for educational intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers.
The Board shall re-evaluate interventions after an appropriate period of time to determine if the intervention improved the quality of drug therapy, to evaluate the success of the interventions and make modifications as necessary.
(D) Annual report
Each State shall require the DUR Board to prepare a report on an annual basis. The State shall submit a report on an annual basis to the Secretary which shall include a description of the activities of the Board, including the nature and scope of the prospective and retrospective drug use review programs, a summary of the interventions used, an assessment of the impact of these educational interventions on quality of care, and an estimate of the cost savings generated as a result of such program. The Secretary shall utilize such report in evaluating the effectiveness of each State's drug use review program.
(h) Electronic claims management
(1) In general
In accordance with
(2) Encouragement
In order to carry out paragraph (1)—
(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State plan attributable to development of a system described in paragraph (1) shall receive Federal financial participation under
(B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of Federal Regulations, the substitution of the State's request for proposal in competitive procurement for advance planning and implementation documents otherwise required.
(i) Annual report
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives a report on the operation of this section in the preceding fiscal year.
(2) Details
Each report shall include information on—
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
(C) how the size of such rebates compare with the size or 6 rebates offered to other purchasers of covered outpatient drugs;
(D) the effect of inflation on the value of rebates required under this section;
(E) trends in prices paid under this subchapter for covered outpatient drugs; and
(F) Federal and State administrative costs associated with compliance with the provisions of this subchapter.
(j) Exemption of organized health care settings
(1) Covered outpatient drugs dispensed by health maintenance organizations, including medicaid managed care organizations that contract under
(2) The State plan shall provide that a hospital (providing medical assistance under such plan) that dispenses covered outpatient drugs using drug formulary systems, and bills the plan no more than the hospital's purchasing costs for covered outpatient drugs (as determined under the State plan) shall not be subject to the requirements of this section.
(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid by the institutions described in this subsection should not be taken into account for purposes of determining the best price as described in subsection (c) of this section.
(k) Definitions
In this section—
(1) Average manufacturer price
The term "average manufacturer price" means, with respect to a covered outpatient drug of a manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United States by wholesalers for drugs distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts.
(2) Covered outpatient drug
Subject to the exceptions in paragraph (3), the term "covered outpatient drug" means—
(A) of those drugs which are treated as prescribed drugs for purposes of
(i) which is approved for safety and effectiveness as a prescription drug under section 505 [
(ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the subject of a final determination by the Secretary that it is a "new drug" (within the meaning of section 201(p) of the Federal Food, Drug, and Cosmetic Act [
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food, Drug, and Cosmetic Act [
(B) a biological product, other than a vaccine which—
(i) may only be dispensed upon prescription,
(ii) is licensed under
(iii) is produced at an establishment licensed under such section to produce such product; and
(C) insulin certified under section 506 7 of the Federal Food, Drug, and Cosmetic Act.
(3) Limiting definition
The term "covered outpatient drug" does not include any drug, biological product, or insulin provided as part of, or as incident to and in the same setting as, any of the following (and for which payment may be made under this subchapter as part of payment for the following and not as direct reimbursement for the drug):
(A) Inpatient hospital services.
(B) Hospice services.
(C) Dental services, except that drugs for which the State plan authorizes direct reimbursement to the dispensing dentist are covered outpatient drugs.
(D) Physicians' services.
(E) Outpatient hospital services.
(F) Nursing facility services and services provided by an intermediate care facility for the mentally retarded.
(G) Other laboratory and x-ray services.
(H) Renal dialysis.
Such term also does not include any such drug or product for which a National Drug Code number is not required by the Food and Drug Administration or a drug or biological 8 used for a medical indication which is not a medically accepted indication. Any drug, biological product, or insulin excluded from the definition of such term as a result of this paragraph shall be treated as a covered outpatient drug for purposes of determining the best price (as defined in subsection (c)(1)(C) of this section) for such drug, biological product, or insulin.
(4) Nonprescription drugs
If a State plan for medical assistance under this subchapter includes coverage of prescribed drugs as described in
(5) Manufacturer
The term "manufacturer" means any entity which is engaged in—
(A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis, or
(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products.
Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.
(6) Medically accepted indication
The term "medically accepted indication" means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act [
(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug
(A) Defined
(i) Multiple source drug
The term "multiple source drug" means, with respect to a rebate period, a covered outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or more drug products which—
(I) are rated as therapeutically equivalent (under the Food and Drug Administration's most recent publication of "Approved Drug Products with Therapeutic Equivalence Evaluations"),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug
The term "innovator multiple source drug" means a multiple source drug that was originally marketed under an original new drug application approved by the Food and Drug Administration.
(iii) Noninnovator multiple source drug
The term "noninnovator multiple source drug" means a multiple source drug that is not an innovator multiple source drug.
(iv) Single source drug
The term "single source drug" means a covered outpatient drug which is produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph—
(i) drug products are pharmaceutically equivalent if the products contain identical amounts of the same active drug ingredient in the same dosage form and meet compendial or other applicable standards of strength, quality, purity, and identity;
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if they do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a published national listing of average wholesale prices selected by the Secretary, provided that the listed product is generally available to the public through retail pharmacies in that State.
(8) Rebate period
The term "rebate period" means, with respect to an agreement under subsection (a) of this section, a calendar quarter or other period specified by the Secretary with respect to the payment of rebates under such agreement.
(9) State agency
The term "State agency" means the agency designated under
(Aug. 14, 1935, ch. 531, title XIX, §1927, as added
References in Text
Section 107(c)(3) of the Drug Amendments of 1962, referred to in subsec. (k)(2)(A)(iii)(I), is section 107(c)(3) of
The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (d)(4)(C) and (k)(6), is act June 25, 1938, ch. 675,
Section 507 of the Federal Food, Drug, and Cosmetic Act, referred to in subsec. (k)(2)(A)(i), was repealed by
Section 506 of the Federal Food, Drug, and Cosmetic Act, referred to in subsec. (k)(2)(C), was repealed and a new section 506 enacted by
Prior Provisions
A prior section 1927 of act Aug. 14, 1935, was renumbered section 1928 and is classified to
Amendments
1999—Subsec. (a)(1).
Subsec. (g)(2)(A)(ii)(II)(cc).
Subsec. (i)(1).
Subsec. (k)(7)(A)(iv).
Subsec. (k)(7)(C)(i).
1997—Subsec. (g)(1)(B)(i)(III), (IV).
Subsec. (j)(1).
1993—Subsec. (b)(1)(A).
Subsec. (b)(2)(A).
Subsec. (b)(3)(A)(i).
Subsec. (c).
Subsecs. (d) to (f).
Subsec. (k)(1).
Subsec. (k)(3).
Subsec. (k)(3)(E).
Subsec. (k)(3)(F).
Subsec. (k)(6).
Subsec. (k)(7)(A)(i).
Subsec. (k)(8), (9).
1992—Subsec. (a)(1).
Subsec. (a)(5), (6).
Subsec. (b)(3)(D).
Subsec. (b)(4)(B)(ii).
Subsec. (b)(4)(B)(iv), (v).
Subsec. (c)(1)(B)(i).
Subsec. (c)(1)(B)(ii) to (v).
"(I) the difference between the average manufacturer price for a drug and 85 percent of such price, or
"(II) the difference between the average manufacturer price for a drug and the best price (as defined in paragraph (2)(B)) for such quarter (or period) for such drug."
Subsec. (c)(1)(C).
Change of Name
Committee on Energy and Commerce of House of Representatives treated as referring to Committee on Commerce of House of Representatives by section 1(a) of
Committees on Aging of the Senate and House of Representatives probably mean the Special Committee on Aging of the Senate and the Select Committee on Aging of the House of Representatives which was abolished on Jan. 5, 1993, by House Resolution No. 5, One Hundred Third Congress.
Effective Date of 1999 Amendment
Amendment by section 1000(a)(6) [title VI, §608(u)] of
Effective Date of 1997 Amendment
Amendment by
Effective Date of 1993 Amendments
Section 13602(d) of
"(1) Except as provided in paragraph (2), the amendments made by this section [amending this section and
"(2) The amendment made by subsection (a)(1) [amending this section] (insofar as such subsection amends section 1927(d) of the Social Security Act [subsec. (d) of this section]) and the amendment made by subsection (c) [amending
Section 2(b) of
Effective Date of 1992 Amendment
Section 601(e) of
Reports on Best Price Changes and Payment of Rebates
Section 601(d) of
Demonstration Projects To Evaluate Efficiency and Cost-Effectiveness of Prospective Drug Utilization Review
Section 4401(c) of title IV of
Study of Drug Purchasing and Billing Practices in Health Care Industry; Report
Section 4401(d) of title IV of
"(1)
"(A) The Comptroller General shall conduct a study of the drug purchasing and billing practices of hospitals, other institutional facilities, and managed care plans which provide covered outpatient drugs in the medicaid program. The study shall compare the ingredient costs of drugs for medicaid prescriptions to these facilities and plans and the charges billed to medical assistance programs by these facilities and plans compared to retail pharmacies.
"(B) The study conducted under this subsection shall include an assessment of—
"(i) the prices paid by these institutions for covered outpatient drugs compared to prices that would be paid under this section [enacting this section, amending
"(ii) the quality of outpatient drug use review provided by these institutions as compared to drug use review required under this section, and
"(iii) the efficiency of mechanisms used by these institutions for billing and receiving payment for covered outpatient drugs dispensed under this title [see Tables for classification].
"(C) By not later than May 1, 1991, the Comptroller General shall report to the Secretary of Health and Human Services (hereafter in this section referred to as the 'Secretary'), the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives on the study conducted under subparagraph (A).
"(2)
"(3)
"(A) The Secretary, acting in consultation with the Comptroller General, shall study prior approval procedures utilized by State medical assistance programs conducted under title XIX of the Social Security Act [this subchapter], including—
"(i) the appeals provisions under such programs; and
"(ii) the effects of such procedures on beneficiary and provider access to medications covered under such programs.
"(B) By not later than December 31, 1991, the Secretary and the Comptroller General shall report to the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives on the results of the study conducted under subparagraph (A) and shall make recommendations with respect to which procedures are appropriate or inappropriate to be utilized by State plans for medical assistance.
"(4)
"(A) The Secretary shall conduct a study on (i) the adequacy of current reimbursement rates to pharmacists under each State medical assistance programs conducted under title XIX of the Social Security Act; and (ii) the extent to which reimbursement rates under such programs have an effect on beneficiary access to medications covered and pharmacy services under such programs.
"(B) By not later than December 31, 1991, the Secretary shall report to the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives on the results of the study conducted under subparagraph (A).
"(5)
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should be followed by a comma.
2 See 1993 Amendment note below.
3 So in original. Probably should be "paragraph".
5 So in original. Probably should be "paragraph".
6 So in original. Probably should be "of".
7 See References in Text note below.
8 So in original. Probably should be "biological product".
§1396s. Program for distribution of pediatric vaccines
(a) Establishment of program
(1) In general
In order to meet the requirement of
(A) each vaccine-eligible child (as defined in subsection (b) of this section), in receiving an immunization with a qualified pediatric vaccine (as defined in subsection (h)(8) of this section) from a program-registered provider (as defined in subsection (c) of this section) on or after October 1, 1994, is entitled to receive the immunization without charge for the cost of such vaccine; and
(B)(i) each program-registered provider who administers such a pediatric vaccine to a vaccine-eligible child on or after such date is entitled to receive such vaccine under the program without charge either for the vaccine or its delivery to the provider, and (ii) no vaccine is distributed under the program to a provider unless the provider is a program-registered provider.
(2) Delivery of sufficient quantities of pediatric vaccines to immunize federally vaccine-eligible children
(A) In general
The Secretary shall provide under subsection (d) of this section for the purchase and delivery on behalf of each State meeting the requirement of
(B) Special rules where vaccine is unavailable
To the extent that a sufficient quantity of a vaccine is not available for purchase or delivery under subsection (d) of this section, the Secretary shall provide for the purchase and delivery of the available vaccine in accordance with priorities established by the Secretary, with priority given to federally vaccine-eligible children unless the Secretary finds there are other public health considerations.
(C) Special rules where State is a manufacturer
(i) Payments in lieu of vaccines
In the case of a State that manufactures a pediatric vaccine the Secretary, instead of providing the vaccine on behalf of a State under subparagraph (A), shall provide to the State an amount equal to the value of the quantity of such vaccine that otherwise would have been delivered on behalf of the State under such subparagraph, but only if the State agrees that such payments will only be used for purposes relating to pediatric immunizations.
(ii) Determination of value
In determining the amount to pay a State under clause (i) with respect to a pediatric vaccine, the value of the quantity of vaccine shall be determined on the basis of the price in effect for the qualified pediatric vaccine under contracts under subsection (d) of this section. If more than 1 such contract is in effect, the Secretary shall determine such value on the basis of the average of the prices under the contracts, after weighting each such price in relation to the quantity of vaccine under the contract involved.
(b) Vaccine-eligible children
For purposes of this section:
(1) In general
The term "vaccine-eligible child" means a child who is a federally vaccine-eligible child (as defined in paragraph (2)) or a State vaccine-eligible child (as defined in paragraph (3)).
(2) Federally vaccine-eligible child
(A) In general
The term "federally vaccine-eligible child" means any of the following children:
(i) A medicaid-eligible child.
(ii) A child who is not insured.
(iii) A child who (I) is administered a qualified pediatric vaccine by a federally-qualified health center (as defined in
(iv) A child who is an Indian (as defined in subsection (h)(3) of this section).
(B) Definitions
In subparagraph (A):
(i) The term "medicaid-eligible" means, with respect to a child, a child who is entitled to medical assistance under a state 1 plan approved under this subchapter.
(ii) The term "insured" means, with respect to a child—
(I) for purposes of subparagraph (A)(ii), that the child is enrolled under, and entitled to benefits under, a health insurance policy or plan, including a group health plan, a prepaid health plan, or an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 [
(II) for purposes of subparagraph (A)(iii)(II) with respect to a pediatric vaccine, that the child is entitled to benefits under such a health insurance policy or plan, but such benefits are not available with respect to the cost of the pediatric vaccine.
(3) State vaccine-eligible child
The term "State vaccine-eligible child" means, with respect to a State and a qualified pediatric vaccine, a child who is within a class of children for which the State is purchasing the vaccine pursuant to subsection (d)(4)(B) of this section.
(c) Program-registered providers
(1) Defined
In this section, except as otherwise provided, the term "program-registered provider" means, with respect to a State, any health care provider that—
(A) is licensed or otherwise authorized for administration of pediatric vaccines under the law of the State in which the administration occurs (subject to
(B) submits to the State an executed provider agreement described in paragraph (2); and
(C) has not been found, by the Secretary or the State, to have violated such agreement or other applicable requirements established by the Secretary or the State consistent with this section.
(2) Provider agreement
A provider agreement for a provider under this paragraph is an agreement (in such form and manner as the Secretary may require) that the provider agrees as follows:
(A)(i) Before administering a qualified pediatric vaccine to a child, the provider will ask a parent of the child such questions as are necessary to determine whether the child is a vaccine-eligible child, but the provider need not independently verify the answers to such questions.
(ii) The provider will, for a period of time specified by the Secretary, maintain records of responses made to the questions.
(iii) The provider will, upon request, make such records available to the State and to the Secretary, subject to
(B)(i) Subject to clause (ii), the provider will comply with the schedule, regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines, that is established and periodically reviewed and, as appropriate, revised by the advisory committee referred to in subsection (e) of this section, except in such cases as, in the provider's medical judgment subject to accepted medical practice, such compliance is medically inappropriate.
(ii) The provider will provide pediatric vaccines in compliance with applicable State law, including any such law relating to any religious or other exemption.
(C)(i) In administering a qualified pediatric vaccine to a vaccine-eligible child, the provider will not impose a charge for the cost of the vaccine. A program-registered provider is not required under this section to administer such a vaccine to each child for whom an immunization with the vaccine is sought from the provider.
(ii) The provider may impose a fee for the administration of a qualified pediatric vaccine so long as the fee in the case of a federally vaccine-eligible child does not exceed the costs of such administration (as determined by the Secretary based on actual regional costs for such administration).
(iii) The provider will not deny administration of a qualified pediatric vaccine to a vaccine-eligible child due to the inability of the child's parent to pay an administration fee.
(3) Encouraging involvement of providers
Each program under this section shall provide, in accordance with criteria established by the Secretary—
(A) for encouraging the following to become program-registered providers: private health care providers, the Indian Health Service, health care providers that receive funds under title V of the Indian Health Care Improvement Act [
(B) for identifying, with respect to any population of vaccine-eligible children a substantial portion of whose parents have a limited ability to speak the English language, those program-registered providers who are able to communicate with the population involved in the language and cultural context that is most appropriate.
(4) State requirements
Except as the Secretary may permit in order to prevent fraud and abuse and for related purposes, a State may not impose additional qualifications or conditions, in addition to the requirements of paragraph (1), in order that a provider qualify as a program-registered provider under this section. This subsection does not limit the exercise of State authority under
(d) Negotiation of contracts with manufacturers
(1) In general
For the purpose of meeting obligations under this section, the Secretary shall negotiate and enter into contracts with manufacturers of pediatric vaccines consistent with the requirements of this subsection and, to the maximum extent practicable, consolidate such contracting with any other contracting activities conducted by the Secretary to purchase vaccines. The Secretary may enter into such contracts under which the Federal Government is obligated to make outlays, the budget authority for which is not provided for in advance in appropriations Acts, for the purchase and delivery of pediatric vaccines under subsection (a)(2)(A) of this section.
(2) Authority to decline contracts
The Secretary may decline to enter into such contracts and may modify or extend such contracts.
(3) Contract price
(A) In general
The Secretary, in negotiating the prices at which pediatric vaccines will be purchased and delivered from a manufacturer under this subsection, shall take into account quantities of vaccines to be purchased by States under the option under paragraph (4)(B).
(B) Negotiation of discounted price for current vaccines
With respect to contracts entered into under this subsection for a pediatric vaccine for which the Centers for Disease Control and Prevention has a contract in effect under
(C) Negotiation of discounted price for new vaccines
With respect to contracts entered into for a pediatric vaccine not described in subparagraph (B), the price for the purchase of such vaccine shall be a discounted price negotiated by the Secretary that may be established without regard to such subparagraph.
(4) Quantities and terms of delivery
Under such contracts—
(A) the Secretary shall provide, consistent with paragraph (6), for the purchase and delivery on behalf of States (and tribes and tribal organizations) of quantities of pediatric vaccines for federally vaccine-eligible children; and
(B) each State, at the option of the State, shall be permitted to obtain additional quantities of pediatric vaccines (subject to amounts specified to the Secretary by the State in advance of negotiations) through purchasing the vaccines from the manufacturers at the applicable price negotiated by the Secretary consistent with paragraph (3), if (i) the State agrees that the vaccines will be used to provide immunizations only for children who are not federally vaccine-eligible children and (ii) the State provides to the Secretary such information (at a time and manner specified by the Secretary, including in advance of negotiations under paragraph (1)) as the Secretary determines to be necessary, to provide for quantities of pediatric vaccines for the State to purchase pursuant to this subsection and to determine annually the percentage of the vaccine market that is purchased pursuant to this section and this subparagraph.
The Secretary shall enter into the initial negotiations under the preceding sentence not later than 180 days after August 10, 1993.
(5) Charges for shipping and handling
The Secretary may enter into a contract referred to in paragraph (1) only if the manufacturer involved agrees to submit to the Secretary such reports as the Secretary determines to be appropriate to assure compliance with the contract and if, with respect to a State program under this section that does not provide for the direct delivery of qualified pediatric vaccines, the manufacturer involved agrees that the manufacturer will provide for the delivery of the vaccines on behalf of the State in accordance with such program and will not impose any charges for the costs of such delivery (except to the extent such costs are provided for in the price established under paragraph (3)).
(6) Assuring adequate supply of vaccines
The Secretary, in negotiations under paragraph (1), shall negotiate for quantities of pediatric vaccines such that an adequate supply of such vaccines will be maintained to meet unanticipated needs for the vaccines. For purposes of the preceding sentence, the Secretary shall negotiate for a 6-month supply of vaccines in addition to the quantity that the Secretary otherwise would provide for in such negotiations. In carrying out this paragraph, the Secretary shall consider the potential for outbreaks of the diseases with respect to which the vaccines have been developed.
(7) Multiple suppliers
In the case of the pediatric vaccine involved, the Secretary shall, as appropriate, enter into a contract referred to in paragraph (1) with each manufacturer of the vaccine that meets the terms and conditions of the Secretary for an award of such a contract (including terms and conditions regarding safety and quality). With respect to multiple contracts entered into pursuant to this paragraph, the Secretary may have in effect different prices under each of such contracts and, with respect to a purchase by States pursuant to paragraph (4)(B), the Secretary shall determine which of such contracts will be applicable to the purchase.
(e) Use of pediatric vaccines list
The Secretary shall use, for the purpose of the purchase, delivery, and administration of pediatric vaccines under this section, the list established (and periodically reviewed and as appropriate revised) by the Advisory Committee on Immunization Practices (an advisory committee established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention).
(f) Requirement of State maintenance of immunization laws
In the case of a State that had in effect as of May 1, 1993, a law that requires some or all health insurance policies or plans to provide some coverage with respect to a pediatric vaccine, a State program under this section does not comply with the requirements of this section unless the State certifies to the Secretary that the State has not modified or repealed such law in a manner that reduces the amount of coverage so required.
(g) Termination
This section, and the requirement of
(h) Definitions
For purposes of this section:
(1) The term "child" means an individual 18 years of age or younger.
(2) The term "immunization" means an immunization against a vaccine-preventable disease.
(3) The terms "Indian", "Indian tribe" and "tribal organization" have the meanings given such terms in section 4 of the Indian Health Care Improvement Act [
(4) The term "manufacturer" means any corporation, organization, or institution, whether public or private (including Federal, State, and local departments, agencies, and instrumentalities), which manufactures, imports, processes, or distributes under its label any pediatric vaccine. The term "manufacture" means to manufacture, import, process, or distribute a vaccine.
(5) The term "parent" includes, with respect to a child, an individual who qualifies as a legal guardian under State law.
(6) The term "pediatric vaccine" means a vaccine included on the list under subsection (e) of this section.
(7) The term "program-registered provider" has the meaning given such term in subsection (c) of this section.
(8) The term "qualified pediatric vaccine" means a pediatric vaccine with respect to which a contract is in effect under subsection (d) of this section.
(9) The terms "vaccine-eligible child", "federally vaccine-eligible child", and "State vaccine-eligible child" have the meaning given such terms in subsection (b) of this section.
(Aug. 14, 1935, ch. 531, title XIX, §1928, as added
References in Text
The Employee Retirement Income Security Act of 1974, referred to in subsec. (b)(2)(B)(ii)(I), is
The Indian Health Care Improvement Act, referred to in subsec. (c)(3)(A), is
The Internal Revenue Code of 1986, referred to in subsec. (d)(3)(B), is classified generally to Title 26, Internal Revenue Code.
Prior Provisions
A prior section 1396s, act Aug. 14, 1935, ch. 531, title XIX, §1928, formerly §1920, as added Apr. 7, 1986,
Effective Date
Section applicable to payments under State plans approved under this subchapter for calendar quarters beginning on or after Oct. 1, 1994, see section 13631(i) of
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should be capitalized.
§1396t. Home and community care for functionally disabled elderly individuals
(a) "Home and community care" defined
In this subchapter, the term "home and community care" means one or more of the following services furnished to an individual who has been determined, after an assessment under subsection (c) of this section, to be a functionally disabled elderly individual, furnished in accordance with an individual community care plan (established and periodically reviewed and revised by a qualified community care case manager under subsection (d) of this section):
(1) Homemaker/home health aide services.
(2) Chore services.
(3) Personal care services.
(4) Nursing care services provided by, or under the supervision of, a registered nurse.
(5) Respite care.
(6) Training for family members in managing the individual.
(7) Adult day care.
(8) In the case of an individual with chronic mental illness, day treatment or other partial hospitalization, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility).
(9) Such other home and community-based services (other than room and board) as the Secretary may approve.
(b) "Functionally disabled elderly individual" defined
(1) In general
In this subchapter, the term "functionally disabled elderly individual" means an individual who—
(A) is 65 years of age or older,
(B) is determined to be a functionally disabled individual under subsection (c) of this section, and
(C) subject to
(2) Treatment of certain individuals previously covered under a waiver
(A) In the case of a State which—
(i) at the time of its election to provide coverage for home and community care under this section has a waiver approved under
(ii) subsequently discontinues such waiver, individuals who were eligible for benefits under the waiver as of the date of its discontinuance and who would, but for income or resources, be eligible for medical assistance for home and community care under the plan shall, notwithstanding any other provision of this subchapter, be deemed a functionally disabled elderly individual for so long as the individual would have remained eligible for medical assistance under such waiver.
(B) In the case of a State which used a health insuring organization before January 1, 1986, and which, as of December 31, 1990, had in effect a waiver under
(i) is 65 years of age or older or is disabled (as determined under the supplemental security income program under subchapter XVI of this chapter);
(ii) is determined to meet the test of functional disability applied under the waiver as of such date; and
(iii) meets the resource requirement and income standard that apply in the State to individuals described in
(3) Use of projected income
In applying
(c) Determinations of functional disability
(1) In general
In this section, an individual is "functionally disabled" if the individual—
(A) is unable to perform without substantial assistance from another individual at least 2 of the following 3 activities of daily living: toileting, transferring, and eating; or
(B) has a primary or secondary diagnosis of Alzheimer's disease and is (i) unable to perform without substantial human assistance (including verbal reminding or physical cueing) or supervision at least 2 of the following 5 activities of daily living: bathing, dressing, toileting, transferring, and eating; or (ii) cognitively impaired so as to require substantial supervision from another individual because he or she engages in inappropriate behaviors that pose serious health or safety hazards to himself or herself or others.
(2) Assessments of functional disability
(A) Requests for assessments
If a State has elected to provide home and community care under this section, upon the request of an individual who is 65 years of age or older and who meets the requirements of subsection (b)(1)(C) of this section (or another person on such individual's behalf), the State shall provide for a comprehensive functional assessment under this subparagraph which—
(i) is used to determine whether or not the individual is functionally disabled,
(ii) is based on a uniform minimum data set specified by the Secretary under subparagraph (C)(i), and
(iii) uses an instrument which has been specified by the State under subparagraph (B).
No fee may be charged for such an assessment.
(B) Specification of assessment instrument
The State shall specify the instrument to be used in the State in complying with the requirement of subparagraph (A)(iii) which instrument shall be—
(i) one of the instruments designated under subparagraph (C)(ii); or
(ii) an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary in subparagraph (C)(i).
(C) Specification of assessment data set and instruments
The Secretary shall—
(i) not later than July 1, 1991—
(I) specify a minimum data set of core elements and common definitions for use in conducting the assessments required under subparagraph (A); and
(II) establish guidelines for use of the data set; and
(ii) by not later than July 1, 1991, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subparagraph (B) for use in complying with the requirements of subparagraph (A).
(D) Periodic review
Each individual who qualifies as a functionally disabled elderly individual shall have the individual's assessment periodically reviewed and revised not less often than once every 12 months.
(E) Conduct of assessment by interdisciplinary teams
An assessment under subparagraph (A) and a review under subparagraph (D) must be conducted by an interdisciplinary team designated by the State. The Secretary shall permit a State to provide for assessments and reviews through teams under contracts—
(i) with public organizations; or
(ii) with nonpublic organizations which do not provide home and community care or nursing facility services and do not have a direct or indirect ownership or control interest in, or direct or indirect affiliation or relationship with, an entity that provides, community care or nursing facility services.
(F) Contents of assessment
The interdisciplinary team must—
(i) identify in each such assessment or review each individual's functional disabilities and need for home and community care, including information about the individual's health status, home and community environment, and informal support system; and
(ii) based on such assessment or review, determine whether the individual is (or continues to be) functionally disabled.
The results of such an assessment or review shall be used in establishing, reviewing, and revising the individual's ICCP under subsection (d)(1) of this section.
(G) Appeal procedures
Each State which elects to provide home and community care under this section must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (F).
(d) Individual community care plan (ICCP)
(1) "Individual community care plan" defined
In this section, the terms "individual community care plan" and "ICCP" mean, with respect to a functionally disabled elderly individual, a written plan which—
(A) is established, and is periodically reviewed and revised, by a qualified case manager after a face-to-face interview with the individual or primary caregiver and based upon the most recent comprehensive functional assessment of such individual conducted under subsection (c)(2) of this section;
(B) specifies, within any amount, duration, and scope limitations imposed on home and community care provided under the State plan, the home and community care to be provided to such individual under the plan, and indicates the individual's preferences for the types and providers of services; and
(C) may specify other services required by such individual.
An ICCP may also designate the specific providers (qualified to provide home and community care under the State plan) which will provide the home and community care described in subparagraph (B). Nothing in this section shall be construed as authorizing an ICCP or the State to restrict the specific persons or individuals (who are competent to provide home and community care under the State plan) who will provide the home and community care described in subparagraph (B).
(2) "Qualified community care case manager" defined
In this section, the term "qualified community care case manager" means a nonprofit or public agency or organization which—
(A) has experience or has been trained in establishing, and in periodically reviewing and revising, individual community care plans and in the provision of case management services to the elderly;
(B) is responsible for (i) assuring that home and community care covered under the State plan and specified in the ICCP is being provided, (ii) visiting each individual's home or community setting where care is being provided not less often than once every 90 days, and (iii) informing the elderly individual or primary caregiver on how to contact the case manager if service providers fail to properly provide services or other similar problems occur;
(C) in the case of a nonpublic agency, does not provide home and community care or nursing facility services and does not have a direct or indirect ownership or control interest in, or direct or indirect affiliation or relationship with, an entity that provides, home and community care or nursing facility services;
(D) has procedures for assuring the quality of case management services that includes a peer review process;
(E) completes the ICCP in a timely manner and reviews and discusses new and revised ICCPs with elderly individuals or primary caregivers; and
(F) meets such other standards, established by the Secretary, as to assure that—
(i) such a manager is competent to perform case management functions;
(ii) individuals whose home and community care they manage are not at risk of financial exploitation due to such a manager; and
(iii) meets such other standards as the State may establish.
The Secretary may waive the requirement of subparagraph (C) in the case of a nonprofit agency located in a rural area.
(3) Appeals process
Each State which elects to provide home and community care under this section must have in effect an appeals process for individuals who disagree with the ICCP established.
(e) Ceiling on payment amounts and maintenance of effort
(1) Ceiling on payment amounts
Payments may not be made under
(A) the average number of individuals in the quarter receiving such care under this section;
(B) the average per diem rate of payment which the Secretary has determined (before the beginning of the quarter) will be payable under subchapter XVIII of this chapter (without regard to coinsurance) for extended care services to be provided in the State during such quarter; and
(C) the number of days in such quarter.
(2) Maintenance of effort
(A) Annual reports
As a condition for the receipt of payment under
(B) Reduction in payment if failure to maintain effort
If the amount reported under subparagraph (A) by a State with respect to a fiscal year is less than the amount reported under subparagraph (A) with respect to fiscal year 1989, the Secretary shall provide for a reduction in payments to the State under
(f) Minimum requirements for home and community care
(1) Requirements
Home and Community 1 care provided under this section must meet such requirements for individuals' rights and quality as are published or developed by the Secretary under subsection (k) of this section. Such requirements shall include—
(A) the requirement that individuals providing care are competent to provide such care; and
(B) the rights specified in paragraph (2).
(2) Specified rights
The rights specified in this paragraph are as follows:
(A) The right to be fully informed in advance, orally and in writing, of the care to be provided, to be fully informed in advance of any changes in care to be provided, and (except with respect to an individual determined incompetent) to participate in planning care or changes in care.
(B) The right to voice grievances with respect to services that are (or fail to be) furnished without discrimination or reprisal for voicing grievances, and to be told how to complain to State and local authorities.
(C) The right to confidentiality of personal and clinical records.
(D) The right to privacy and to have one's property treated with respect.
(E) The right to refuse all or part of any care and to be informed of the likely consequences of such refusal.
(F) The right to education or training for oneself and for members of one's family or household on the management of care.
(G) The right to be free from physical or mental abuse, corporal punishment, and any physical or chemical restraints imposed for purposes of discipline or convenience and not included in an individual's ICCP.
(H) The right to be fully informed orally and in writing of the individual's rights.
(I) Guidelines for such minimum compensation for individuals providing such care as will assure the availability and continuity of competent individuals to provide such care for functionally disabled individuals who have functional disabilities of varying levels of severity.
(J) Any other rights established by the Secretary.
(g) Minimum requirements for small community care settings
(1) "Small community care setting" defined
In this section, the term "small community care setting" means—
(A) a nonresidential setting that serves more than 2 and less than 8 individuals; or
(B) a residential setting in which more than 2 and less than 8 unrelated adults reside and in which personal services (other than merely board) are provided in conjunction with residing in the setting.
(2) Minimum requirements
A small community care setting in which community care is provided under this section must—
(A) meet such requirements as are published or developed by the Secretary under subsection (k) of this section;
(B) meet the requirements of paragraphs (1)(A), (1)(C), (1)(D), (3), and (6) of
(C) inform each individual receiving community care under this section in the setting, orally and in writing at the time the individual first receives community care in the setting, of the individual's legal rights with respect to such a setting and the care provided in the setting;
(D) meet any applicable State or local requirements regarding certification or licensure;
(E) meet any applicable State and local zoning, building, and housing codes, and State and local fire and safety regulations; and
(F) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents.
(h) Minimum requirements for large community care settings
(1) "Large community care setting" defined
In this section, the term "large community care setting" means—
(A) a nonresidential setting in which more than 8 individuals are served; or
(B) a residential setting in which more than 8 unrelated adults reside and in which personal services are provided in conjunction with residing in the setting in which home and community care under this section is provided.
(2) Minimum requirements
A large community care setting in which community care is provided under this section must—
(A) meet such requirements as are published or developed by the Secretary under subsection (k) of this section;
(B) meet the requirements of paragraphs (1)(A), (1)(C), (1)(D), (3), and (6) of
(C) inform each individual receiving community care under this section in the setting, orally and in writing at the time the individual first receives home and community care in the setting, of the individual's legal rights with respect to such a setting and the care provided in the setting; and
(D) meet the requirements of paragraphs (2) and (3) of
(3) Disclosure of ownership and control interests and exclusion of repeated violators
A community care setting—
(A) must disclose persons with an ownership or control interest (including such persons as defined in
(B) may not have, as a person with an ownership or control interest in the setting, any individual or person who has been excluded from participation in the program under this subchapter or who has had such an ownership or control interest in one or more community care settings which have been found repeatedly to be substandard or to have failed to meet the requirements of paragraph (2).
(i) Survey and certification process
(1) Certifications
(A) Responsibilities of the State
Under each State plan under this subchapter, the State shall be responsible for certifying the compliance of providers of home and community care and community care settings with the applicable requirements of subsections (f), (g) and (h) of this section. The failure of the Secretary to issue regulations to carry out this subsection shall not relieve a State of its responsibility under this subsection.
(B) Responsibilities of the Secretary
The Secretary shall be responsible for certifying the compliance of State providers of home and community care, and of State community care settings in which such care is provided, with the requirements of subsections (f), (g) and (h) of this section.
(C) Frequency of certifications
Certification of providers and settings under this subsection shall occur no less frequently than once every 12 months.
(2) Reviews of providers
(A) In general
The certification under this subsection with respect to a provider of home or community care must be based on a periodic review of the provider's performance in providing the care required under ICCP's in accordance with the requirements of subsection (f) of this section.
(B) Special reviews of compliance
Where the Secretary has reason to question the compliance of a provider of home or community care with any of the requirements of subsection (f) of this section, the Secretary may conduct a review of the provider and, on the basis of that review, make independent and binding determinations concerning the extent to which the provider meets such requirements.
(3) Surveys of community care settings
(A) In general
The certification under this subsection with respect to community care settings must be based on a survey. Such survey for such a setting must be conducted without prior notice to the setting. Any individual who notifies (or causes to be notified) a community care setting of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The provisions of
(B) Survey protocol
Surveys under this paragraph shall be conducted based upon a protocol which the Secretary has provided for under subsection (k) of this section.
(C) Prohibition of conflict of interest in survey team membership
A State and the Secretary may not use as a member of a survey team under this paragraph an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the community care setting being surveyed (or the person responsible for such setting) respecting compliance with the requirements of subsection (g) or (h) of this section or who has a personal or familial financial interest in the setting being surveyed.
(D) Validation surveys of community care settings
The Secretary shall conduct onsite surveys of a representative sample of community care settings in each State, within 2 months of the date of surveys conducted under subparagraph (A) by the State, in a sufficient number to allow inferences about the adequacies of each State's surveys conducted under subparagraph (A). In conducting such surveys, the Secretary shall use the same survey protocols as the State is required to use under subparagraph (B). If the State has determined that an individual setting meets the requirements of subsection (g) of this section, but the Secretary determines that the setting does not meet such requirements, the Secretary's determination as to the setting's noncompliance with such requirements is binding and supersedes that of the State survey.
(E) Special surveys of compliance
Where the Secretary has reason to question the compliance of a community care setting with any of the requirements of subsection (g) or (h) of this section, the Secretary may conduct a survey of the setting and, on the basis of that survey, make independent and binding determinations concerning the extent to which the setting meets such requirements.
(4) Investigation of complaints and monitoring of providers and settings
Each State and the Secretary shall maintain procedures and adequate staff to investigate complaints of violations of applicable requirements imposed on providers of community care or on community care settings under subsections (f), (g) and (h) of this section.
(5) Investigation of allegations of individual neglect and abuse and misappropriation of individual property
The State shall provide, through the agency responsible for surveys and certification of providers of home or community care and community care settings under this subsection, for a process for the receipt, review, and investigation of allegations of individual neglect and abuse (including injuries of unknown source) by individuals providing such care or in such setting and of misappropriation of individual property by such individuals. The State shall, after notice to the individual involved and a reasonable opportunity for hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that an individual has neglected or abused an individual receiving community care or misappropriated such individual's property, the State shall notify the individual against whom the finding is made. A State shall not make a finding that a person has neglected an individual receiving community care if the person demonstrates that such neglect was caused by factors beyond the control of the person. The State shall provide for public disclosure of findings under this paragraph upon request and for inclusion, in any such disclosure of such findings, of any brief statement (or of a clear and accurate summary thereof) of the individual disputing such findings.
(6) Disclosure of results of inspections and activities
(A) Public information
Each State, and the Secretary, shall make available to the public—
(i) information respecting all surveys, reviews, and certifications made under this subsection respecting providers of home or community care and community care settings, including statements of deficiencies,
(ii) copies of cost reports (if any) of such providers and settings filed under this subchapter,
(iii) copies of statements of ownership under
(iv) information disclosed under
(B) Notices of substandard care
If a State finds that—
(i) a provider of home or community care has provided care of substandard quality with respect to an individual, the State shall make a reasonable effort to notify promptly (I) an immediate family member of each such individual and (II) individuals receiving home or community care from that provider under this subchapter, or
(ii) a community care setting is substandard, the State shall make a reasonable effort to notify promptly (I) individuals receiving community care in that setting, and (II) immediate family members of such individuals.
(C) Access to fraud control units
Each State shall provide its State medicaid fraud and abuse control unit (established under
(j) Enforcement process for providers of community care
(1) State authority
(A) In general
If a State finds, on the basis of a review under subsection (i)(2) of this section or otherwise, that a provider of home or community care no longer meets the requirements of this section, the State may terminate the provider's participation under the State plan and may provide in addition for a civil money penalty. Nothing in this subparagraph shall be construed as restricting the remedies available to a State to remedy a provider's deficiencies. If the State finds that a provider meets such requirements but, as of a previous period, did not meet such requirements, the State may provide for a civil money penalty under paragraph (2)(A) for the period during which it finds that the provider was not in compliance with such requirements.
(B) Civil money penalty
(i) In general
Each State shall establish by law (whether statute or regulation) at least the following remedy: A civil money penalty assessed and collected, with interest, for each day in which the provider is or was out of compliance with a requirement of this section. Funds collected by a State as a result of imposition of such a penalty (or as a result of the imposition by the State of a civil money penalty under subsection (i)(3)(A) of this section) may be applied to reimbursement of individuals for personal funds lost due to a failure of home or community care providers to meet the requirements of this section. The State also shall specify criteria, as to when and how this remedy is to be applied and the amounts of any penalties. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the penalties and shall provide for the imposition of incrementally more severe penalties for repeated or uncorrected deficiencies.
(ii) Deadline and guidance
Each State which elects to provide home and community care under this section must establish the civil money penalty remedy described in clause (i) applicable to all providers of community care covered under this section. The Secretary shall provide, through regulations or otherwise by not later than July 1, 1990, guidance to States in establishing such remedy; but the failure of the Secretary to provide such guidance shall not relieve a State of the responsibility for establishing such remedy.
(2) Secretarial authority
(A) For State providers
With respect to a State provider of home or community care, the Secretary shall have the authority and duties of a State under this subsection, except that the civil money penalty remedy described in subparagraph (C) shall be substituted for the civil money remedy described in paragraph (1)(B)(i).
(B) Other providers
With respect to any other provider of home or community care in a State, if the Secretary finds that a provider no longer meets a requirement of this section, the Secretary may terminate the provider's participation under the State plan and may provide, in addition, for a civil money penalty under subparagraph (C). If the Secretary finds that a provider meets such requirements but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subparagraph (C) for the period during which the Secretary finds that the provider was not in compliance with such requirements.
(C) Civil money penalty
If the Secretary finds on the basis of a review under subsection (i)(2) of this section or otherwise that a home or community care provider no longer meets the requirements of this section, the Secretary shall impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of
(k) Secretarial responsibilities
(1) Publication of interim requirements
(A) In general
The Secretary shall publish, by December 1, 1991, a proposed regulation that sets forth interim requirements, consistent with subparagraph (B), for the provision of home and community care and for community care settings, including—
(i) the requirements of subsection (c)(2) of this section (relating to comprehensive functional assessments, including the use of assessment instruments), of subsection (d)(2)(E) of this section (relating to qualifications for qualified case managers), of subsection (f) of this section (relating to minimum requirements for home and community care), of subsection (g) of this section (relating to minimum requirements for small community care settings), and of subsection (h) of this section (relating to minimum requirements for large community care settings), and
(ii) survey protocols (for use under subsection (i)(3)(A) of this section) which relate to such requirements.
(B) Minimum protections
Interim requirements under subparagraph (A) and final requirements under paragraph (2) shall assure, through methods other than reliance on State licensure processes, that individuals receiving home and community care are protected from neglect, physical and sexual abuse, financial exploitation, inappropriate involuntary restraint, and the provision of health care services by unqualified personnel in community care settings.
(2) Development of final requirements
The Secretary shall develop, by not later than October 1, 1992—
(A) final requirements, consistent with paragraph (1)(B), respecting the provision of appropriate, quality home and community care and respecting community care settings under this section, and including at least the requirements referred to in paragraph (1)(A)(i), and
(B) survey protocols and methods for evaluating and assuring the quality of community care settings.
The Secretary may, from time to time, revise such requirements, protocols, and methods.
(3) No delegation to States
The Secretary's authority under this subsection shall not be delegated to States.
(4) No prevention of more stringent requirements by States
Nothing in this section shall be construed as preventing States from imposing requirements that are more stringent than the requirements published or developed by the Secretary under this subsection.
(l) Waiver of Statewideness
States may waive the requirement of
(m) Limitation on amount of expenditures as medical assistance
(1) Limitation on amount
The amount of funds that may be expended as medical assistance to carry out the purposes of this section shall be for fiscal year 1991, $40,000,000, for fiscal year 1992, $70,000,000, for fiscal year 1993, $130,000,000, for fiscal year 1994, $160,000,000, and for fiscal year 1995, $180,000,000.
(2) Assurance of entitlement to service
A State which receives Federal medical assistance for expenditures for home and community care under this section must provide home and community care specified under the Individual Community Care Plan under subsection (d) of this section to individuals described in subsection (b) of this section for the duration of the election period, without regard to the amount of funds available to the State under paragraph (1). For purposes of this paragraph, an election period is the period of 4 or more calendar quarters elected by the State, and approved by the Secretary, for the provision of home and community care under this section.
(3) Limitation on eligibility
The State may limit eligibility for home and community care under this section during an election period under paragraph (2) to reasonable classifications (based on age, degree of functional disability, and need for services).
(4) Allocation of medical assistance
The Secretary shall establish a limitation on the amount of Federal medical assistance available to any State during the State's election period under paragraph (2). The limitation under this paragraph shall take into account the limitation under paragraph (1) and the number of elderly individuals age 65 or over residing in such State in relation to the number of such elderly individuals in the United States during 1990. For purposes of the previous sentence, elderly individuals shall, to the maximum extent practicable, be low-income elderly individuals.
(Aug. 14, 1935, ch. 531, title XIX, §1929, as added
Codification
Amendments
1999—Subsec. (c)(2)(E)(i), (ii).
Subsec. (k)(1)(A)(i).
Subsec. (l).
Effective Date
Section applicable to home and community care furnished on or after July 1, 1991, without regard to whether or not final regulations to carry out the amendments made by section 4711 of
Section Referred to in Other Sections
This section is referred to in
1 So in original. Probably should not be capitalized.
§1396u. Community supported living arrangements services
(a) Community supported living arrangements services
In this subchapter, the term "community supported living arrangements services" means one or more of the following services meeting the requirements of subsection (h) of this section provided in a State eligible to provide services under this section (as defined in subsection (d) of this section) to assist a developmentally disabled individual (as defined in subsection (b) of this section) in activities of daily living necessary to permit such individual to live in the individual's own home, apartment, family home, or rental unit furnished in a community supported living arrangement setting:
(1) Personal assistance.
(2) Training and habilitation services (necessary to assist the individual in achieving increased integration, independence and productivity).
(3) 24-hour emergency assistance (as defined by the Secretary).
(4) Assistive technology.
(5) Adaptive equipment.
(6) Other services (as approved by the Secretary, except those services described in subsection (g) of this section).
(7) Support services necessary to aid an individual to participate in community activities.
(b) "Developmentally disabled individual" defined
In this subchapter the term,1 "developmentally disabled individual" means an individual who as defined by the Secretary is described within the term "mental retardation and related conditions" as defined in regulations as in effect on July 1, 1990, and who is residing with the individual's family or legal guardian in such individual's own home in which no more than 3 other recipients of services under this section are residing and without regard to whether or not such individual is at risk of institutionalization (as defined by the Secretary).
(c) Criteria for selection of participating States
The Secretary shall develop criteria to review the applications of States submitted under this section to provide community supported living arrangement services. The Secretary shall provide in such criteria that during the first 5 years of the provision of services under this section that no less than 2 and no more than 8 States shall be allowed to receive Federal financial participation for providing the services described in this section.
(d) Quality assurance
A State selected by the Secretary to provide services under this section shall in order to continue to receive Federal financial participation for providing services under this section be required to establish and maintain a quality assurance program, that provides that—
(1) the State will certify and survey providers of services under this section (such surveys to be unannounced and average at least 1 a year);
(2) the State will adopt standards for survey and certification that include—
(A) minimum qualifications and training requirements for provider staff;
(B) financial operating standards; and
(C) a consumer grievance process;
(3) the State will provide a system that allows for monitoring boards consisting of providers, family members, consumers, and neighbors;
(4) the State will establish reporting procedures to make available information to the public;
(5) the State will provide ongoing monitoring of the health and well-being of each recipient;
(6) the State will provide the services defined in subsection (a) of this section in accordance with an individual support plan (as defined by the Secretary in regulations); and
(7) the State plan amendment under this section shall be reviewed by the State Planning Council established under
The Secretary shall not approve a quality assurance plan under this subsection and allow a State to continue to receive Federal financial participation under this section unless the State provides for public hearings on the plan prior to adoption and implementation of its plan under this subsection.
(e) Maintenance of effort
States selected by the Secretary to receive Federal financial participation to provide services under this section shall maintain current levels of spending for such services in order to be eligible to continue to receive Federal financial participation for the provision of such services under this section.
(f) Excluded services
No Federal financial participation shall be allowed for the provision of the following services under this section:
(1) Room and board.
(2) Cost of prevocational, vocational and supported employment.
(g) Waiver of requirements
The Secretary may waive such provisions of this subchapter as necessary to carry out the provisions of this section including the following requirements of this subchapter—
(1) comparability of amount, duration, and scope of services; and
(2) statewideness.
(h) Minimum protections
(1) Publication of interim and final requirements
(A) In general
The Secretary shall publish, by July 1, 1991, a regulation (that shall be effective on an interim basis pending the promulgation of final regulations), and by October 1, 1992, a final regulation, that sets forth interim and final requirements, respectively, consistent with subparagraph (B), to protect the health, safety, and welfare of individuals receiving community supported living arrangements services.
(B) Minimum protections
Interim and final requirements under subparagraph (A) shall assure, through methods other than reliance on State licensure processes or the State quality assurance programs under subsection (d) of this section, that—
(i) individuals receiving community supported living arrangements services are protected from neglect, physical and sexual abuse, and financial exploitation;
(ii) a provider of community supported living arrangements services may not use individuals who have been convicted of child or client abuse, neglect, or mistreatment or of a felony involving physical harm to an individual and shall take all reasonable steps to determine whether applicants for employment by the provider have histories indicating involvement in child or client abuse, neglect, or mistreatment or a criminal record involving physical harm to an individual;
(iii) individuals or entities delivering such services are not unjustly enriched as a result of abusive financial arrangements (such as owner lease-backs); and
(iv) individuals or entities delivering such services to clients, or relatives of such individuals, are prohibited from being named beneficiaries of life insurance policies purchased by (or on behalf of) such clients.
(2) Specified remedies
If the Secretary finds that a provider has not met an applicable requirement under subsection (h) of this section, the Secretary shall impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of
(i) Treatment of funds
Any funds expended under this section for medical assistance shall be in addition to funds expended for any existing services covered under the State plan, including any waiver services for which an individual receiving services under this program is already eligible.
(j) Limitation on amounts of expenditures as medical assistance
The amount of funds that may be expended as medical assistance to carry out the purposes of this section shall be for fiscal year 1991, $5,000,000, for fiscal year 1992, $10,000,000, for fiscal year 1993, $20,000,000, for fiscal year 1994, $30,000,000, for fiscal year 1995, $35,000,000, and for fiscal years thereafter such sums as provided by Congress.
(Aug. 14, 1935, ch. 531, title XIX, §1930, as added
Codification
Effective Date
Section 4712(c) of
"(1)
"(2)
Section Referred to in Other Sections
This section is referred to in
1 So in original. The comma probably should precede "the term".
§1396u–1. Assuring coverage for certain low-income families
(a) References to subchapter IV–A are references to pre-welfare-reform provisions
Subject to the succeeding provisions of this section, with respect to a State any reference in this subchapter (or any other provision of law in relation to the operation of this subchapter) to a provision of part A of subchapter IV of this chapter, or a State plan under such part (or a provision of such a plan), including income and resource standards and income and resource methodologies under such part or plan, shall be considered a reference to such a provision or plan as in effect as of July 16, 1996, with respect to the State.
(b) Application of pre-welfare-reform eligibility criteria
(1) In general
For purposes of this subchapter, subject to paragraphs (2) and (3), in determining eligibility for medical assistance—
(A) an individual shall be treated as receiving aid or assistance under a State plan approved under part A of subchapter IV of this chapter only if the individual meets—
(i) the income and resource standards for determining eligibility under such plan, and
(ii) the eligibility requirements of such plan under subsections (a) through (c) of
as in effect as of July 16, 1996; and
(B) the income and resource methodologies under such plan as of such date shall be used in the determination of whether any individual meets income and resource standards under such plan.
(2) State option
For purposes of applying this section, a State—
(A) may lower its income standards applicable with respect to part A of subchapter IV of this chapter, but not below the income standards applicable under its State plan under such part on May 1, 1988;
(B) may increase income or resource standards under the State plan referred to in paragraph (1) over a period (beginning after July 16, 1996) by a percentage that does not exceed the percentage increase in the Consumer Price Index for all urban consumers (all items; United States city average) over such period; and
(C) may use income and resource methodologies that are less restrictive than the methodologies used under the State plan under such part as of July 16, 1996.
(3) Option to terminate medical assistance for failure to meet work requirement
(A) Individuals receiving cash assistance under TANF
In the case of an individual who—
(i) is receiving cash assistance under a State program funded under part A of subchapter IV of this chapter,
(ii) is eligible for medical assistance under this subchapter on a basis not related to
(iii) has the cash assistance under such program terminated pursuant to
the State may terminate such individual's eligibility for medical assistance under this subchapter until such time as there no longer is a basis for the termination of such cash assistance because of such refusal.
(B) Exception for children
Subparagraph (A) shall not be construed as permitting a State to terminate medical assistance for a minor child who is not the head of a household receiving assistance under a State program funded under part A of subchapter IV of this chapter.
(c) Treatment for purposes of transitional coverage provisions
(1) Transition in the case of child support collections
The provisions of
(2) Transition in the case of earnings from employment
For continued medical assistance in the case of individuals (and families composed of individuals) described in subsection (b)(1)(A) of this section who would otherwise become ineligible because of hours or income from employment, see
(d) Waivers
In the case of a waiver of a provision of part A of subchapter IV of this chapter in effect with respect to a State as of July 16, 1996, or which is submitted to the Secretary before August 22, 1996, and approved by the Secretary on or before July 1, 1997, if the waiver affects eligibility of individuals for medical assistance under this subchapter, such waiver may (but need not) continue to be applied, at the option of the State, in relation to this subchapter after the date the waiver would otherwise expire.
(e) State option to use 1 application form
Nothing in this section, or part A of subchapter IV of this chapter, shall be construed as preventing a State from providing for the same application form for assistance under a State program funded under part A of subchapter IV of this chapter (on or after the welfare reform effective date) and for medical assistance under this subchapter.
(f) Additional rules of construction
(1) With respect to the reference in
(2) Any reference in
(3) In applying
(g) Relation to other provisions
The provisions of this section shall apply notwithstanding any other provision of this chapter.
(h) Transitional increased Federal matching rate for increased administrative costs
(1) In general
Subject to the succeeding provisions of this subsection, the Secretary shall provide that with respect to administrative expenditures described in paragraph (2) the per centum specified in
(2) Administrative expenditures described
The administrative expenditures described in this paragraph are expenditures described in
(3) Limitation
The total amount of additional Federal funds that are expended as a result of the application of this subsection for the period beginning with fiscal year 1997 shall not exceed $500,000,000. In applying this paragraph, the Secretary shall ensure the equitable distribution of additional funds among the States.
(i) Welfare reform effective date
In this section, the term "welfare reform effective date" means the effective date, with respect to a State, of title I of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (as specified in section 116 of such Act).
(Aug. 14, 1935, ch. 531, title XIX, §1931, as added
References in Text
Parts A and D of subchapter IV of this chapter, referred to in text, are classified to sections 601 et seq. and 651 et seq., respectively, of this title.
For effective date, with respect to a State, of title I of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (as specified in section 116 of such Act), referred to in subsec. (i), see section 116 of
Prior Provisions
A prior section 1931 of act Aug. 14, 1935, was renumbered section 1935, and is classified to
Amendments
1999—Subsec. (h)(3).
Subsec. (h)(4).
Effective Date of 1999 Amendment
Effective Date
Section effective July 1, 1997, with transition rules relating to State options to accelerate such date, rules relating to claims, actions, and proceedings commenced before such date, rules relating to closing out of accounts for terminated or substantially modified programs and continuance in office of Assistant Secretary for Family Support, and provisions relating to termination of entitlement under AFDC program, see section 116 of
Section Referred to in Other Sections
This section is referred to in
§1396u–2. Provisions relating to managed care
(a) State option to use managed care
(1) Use of medicaid managed care organizations and primary care case managers
(A) In general
Subject to the succeeding provisions of this section, and notwithstanding paragraph (1), (10)(B), or (23)(A) of
(i) may require an individual who is eligible for medical assistance under the State plan under this subchapter to enroll with a managed care entity as a condition of receiving such assistance (and, with respect to assistance furnished by or under arrangements with such entity, to receive such assistance through the entity), if—
(I) the entity and the contract with the State meet the applicable requirements of this section and
(II) the requirements described in the succeeding paragraphs of this subsection are met; and
(ii) may restrict the number of provider agreements with managed care entities under the State plan if such restriction does not substantially impair access to services.
(B) "Managed care entity" defined
In this section, the term "managed care entity" means—
(i) a medicaid managed care organization, as defined in
(ii) a primary care case manager, as defined in
(2) Special rules
(A) Exemption of certain children with special needs
A State may not require under paragraph (1) the enrollment in a managed care entity of an individual under 19 years of age who—
(i) is eligible for supplemental security income under subchapter XVI of this chapter;
(ii) is described in
(iii) is described in
(iv) is receiving foster care or adoption assistance under part E of subchapter IV of this chapter; or
(v) is in foster care or otherwise in an out-of-home placement.
(B) Exemption of medicare beneficiaries
A State may not require under paragraph (1) the enrollment in a managed care entity of an individual who is a qualified medicare beneficiary (as defined in
(C) Indian enrollment
A State may not require under paragraph (1) the enrollment in a managed care entity of an individual who is an Indian (as defined in section 4(c) of the Indian Health Care Improvement Act of 1976 (
(i) The Indian Health Service.
(ii) An Indian health program operated by an Indian tribe or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act [
(iii) An urban Indian health program operated by an urban Indian organization pursuant to a grant or contract with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act [
(3) Choice of coverage
(A) In general
A State must permit an individual to choose a managed care entity from not less than two such entities that meet the applicable requirements of this section, and of
(B) State option
At the option of the State, a State shall be considered to meet the requirements of subparagraph (A) in the case of an individual residing in a rural area, if the State requires the individual to enroll with a managed care entity if such entity—
(i) permits the individual to receive such assistance through not less than two physicians or case managers (to the extent that at least two physicians or case managers are available to provide such assistance in the area), and
(ii) permits the individual to obtain such assistance from any other provider in appropriate circumstances (as established by the State under regulations of the Secretary).
(C) Treatment of certain county-operated health insuring organizations
A State shall be considered to meet the requirement of subparagraph (A) if—
(i) the managed care entity in which the individual is enrolled is a health-insuring organization which—
(I) first became operational prior to January 1, 1986, or
(II) is described in section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985 (as added by section 4734(2) of the Omnibus Budget Reconciliation Act of 1990), and
(ii) the individual is given a choice between at least two providers within such entity.
(4) Process for enrollment and termination and change of enrollment
As conditions under paragraph (1)(A)—
(A) In general
The State, enrollment broker (if any), and managed care entity shall permit an individual eligible for medical assistance under the State plan under this subchapter who is enrolled with the entity under this subchapter to terminate (or change) such enrollment—
(i) for cause at any time (consistent with
(ii) without cause—
(I) during the 90-day period beginning on the date the individual receives notice of such enrollment, and
(II) at least every 12 months thereafter.
(B) Notice of termination rights
The State shall provide for notice to each such individual of the opportunity to terminate (or change) enrollment under such conditions. Such notice shall be provided at least 60 days before each annual enrollment opportunity described in subparagraph (A)(ii)(II).
(C) Enrollment priorities
In carrying out paragraph (1)(A), the State shall establish a method for establishing enrollment priorities in the case of a managed care entity that does not have sufficient capacity to enroll all such individuals seeking enrollment under which individuals already enrolled with the entity are given priority in continuing enrollment with the entity.
(D) Default enrollment process
In carrying out paragraph (1)(A), the State shall establish a default enrollment process—
(i) under which any such individual who does not enroll with a managed care entity during the enrollment period specified by the State shall be enrolled by the State with such an entity which has not been found to be out of substantial compliance with the applicable requirements of this section and of
(ii) that takes into consideration—
(I) maintaining existing provider-individual relationships or relationships with providers that have traditionally served beneficiaries under this subchapter; and
(II) if maintaining such provider relationships is not possible, the equitable distribution of such individuals among qualified managed care entities available to enroll such individuals, consistent with the enrollment capacities of the entities.
(5) Provision of information
(A) Information in easily understood form
Each State, enrollment broker, or managed care entity shall provide all enrollment notices and informational and instructional materials relating to such an entity under this subchapter in a manner and form which may be easily understood by enrollees and potential enrollees of the entity who are eligible for medical assistance under the State plan under this subchapter.
(B) Information to enrollees and potential enrollees
Each managed care entity that is a medicaid managed care organization shall, upon request, make available to enrollees and potential enrollees in the organization's service area information concerning the following:
(i) Providers
The identity, locations, qualifications, and availability of health care providers that participate with the organization.
(ii) Enrollee rights and responsibilities
The rights and responsibilities of enrollees.
(iii) Grievance and appeal procedures
The procedures available to an enrollee and a health care provider to challenge or appeal the failure of the organization to cover a service.
(iv) Information on covered items and services
All items and services that are available to enrollees under the contract between the State and the organization that are covered either directly or through a method of referral and prior authorization. Each managed care entity that is a primary care case manager shall, upon request, make available to enrollees and potential enrollees in the organization's service area the information described in clause (iii).
(C) Comparative information
A State that requires individuals to enroll with managed care entities under paragraph (1)(A) shall annually (and upon request) provide, directly or through the managed care entity, to such individuals a list identifying the managed care entities that are (or will be) available and information (presented in a comparative, chart-like form) relating to the following for each such entity offered:
(i) Benefits and cost-sharing
The benefits covered and cost-sharing imposed by the entity.
(ii) Service area
The service area of the entity.
(iii) Quality and performance
To the extent available, quality and performance indicators for the benefits under the entity.
(D) Information on benefits not covered under managed care arrangement
A State, directly or through managed care entities, shall, on or before an individual enrolls with such an entity under this subchapter, inform the enrollee in a written and prominent manner of any benefits to which the enrollee may be entitled to under this subchapter but which are not made available to the enrollee through the entity. Such information shall include information on where and how such enrollees may access benefits not made available to the enrollee through the entity.
(b) Beneficiary protections
(1) Specification of benefits
Each contract with a managed care entity under
(2) Assuring coverage to emergency services
(A) In general
Each contract with a medicaid managed care organization under
(i) to provide coverage for emergency services (as defined in subparagraph (B)) without regard to prior authorization or the emergency care provider's contractual relationship with the organization or manager, and
(ii) to comply with guidelines established under
The requirement under clause (ii) shall first apply 30 days after the date of promulgation of the guidelines referred to in such clause.
(B) "Emergency services" defined
In subparagraph (A)(i), the term "emergency services" means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that—
(i) are furnished by a provider that is qualified to furnish such services under this subchapter, and
(ii) are needed to evaluate or stabilize an emergency medical condition (as defined in subparagraph (C)).
(C) "Emergency medical condition" defined
In subparagraph (B)(ii), the term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in—
(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part.
(3) Protection of enrollee-provider communications
(A) In general
Subject to subparagraphs (B) and (C), under a contract under
(B) Construction
Subparagraph (A) shall not be construed as requiring a medicaid managed care organization to provide, reimburse for, or provide coverage of, a counseling or referral service if the organization—
(i) objects to the provision of such service on moral or religious grounds; and
(ii) in the manner and through the written instrumentalities such organization deems appropriate, makes available information on its policies regarding such service to prospective enrollees before or during enrollment and to enrollees within 90 days after the date that the organization adopts a change in policy regarding such a counseling or referral service.
Nothing in this subparagraph shall be construed to affect disclosure requirements under State law or under the Employee Retirement Income Security Act of 1974 [
(C) "Health care professional" defined
For purposes of this paragraph, the term "health care professional" means a physician (as defined in
(4) Grievance procedures
Each medicaid managed care organization shall establish an internal grievance procedure under which an enrollee who is eligible for medical assistance under the State plan under this subchapter, or a provider on behalf of such an enrollee, may challenge the denial of coverage of or payment for such assistance.
(5) Demonstration of adequate capacity and services
Each medicaid managed care organization shall provide the State and the Secretary with adequate assurances (in a time and manner determined by the Secretary) that the organization, with respect to a service area, has the capacity to serve the expected enrollment in such service area, including assurances that the organization—
(A) offers an appropriate range of services and access to preventive and primary care services for the population expected to be enrolled in such service area, and
(B) maintains a sufficient number, mix, and geographic distribution of providers of services.
(6) Protecting enrollees against liability for payment
Each medicaid managed care organization shall provide that an individual eligible for medical assistance under the State plan under this subchapter who is enrolled with the organization may not be held liable—
(A) for the debts of the organization, in the event of the organization's insolvency,
(B) for services provided to the individual—
(i) in the event of the organization failing to receive payment from the State for such services; or
(ii) in the event of a health care provider with a contractual, referral, or other arrangement with the organization failing to receive payment from the State or the organization for such services, or
(C) for payments to a provider that furnishes covered services under a contractual, referral, or other arrangement with the organization in excess of the amount that would be owed by the individual if the organization had directly provided the services.
(7) Antidiscrimination
A medicaid managed care organization shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider who is acting within the scope of the provider's license or certification under applicable State law, solely on the basis of such license or certification. This paragraph shall not be construed to prohibit an organization from including providers only to the extent necessary to meet the needs of the organization's enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the organization.
(8) Compliance with certain maternity and mental health requirements
Each medicaid managed care organization shall comply with the requirements of subpart 2 of part A of title XXVII of the Public Health Service Act [
(c) Quality assurance standards
(1) Quality assessment and improvement strategy
(A) In general
If a State provides for contracts with medicaid managed care organizations under
(i) Access standards
Standards for access to care so that covered services are available within reasonable timeframes and in a manner that ensures continuity of care and adequate primary care and specialized services capacity.
(ii) Other measures
Examination of other aspects of care and service directly related to the improvement of quality of care (including grievance procedures and marketing and information standards).
(iii) Monitoring procedures
Procedures for monitoring and evaluating the quality and appropriateness of care and services to enrollees that reflect the full spectrum of populations enrolled under the contract and that includes requirements for provision of quality assurance data to the State using the data and information set that the Secretary has specified for use under part C of subchapter XVIII of this chapter or such alternative data as the Secretary approves, in consultation with the State.
(iv) Periodic review
Regular, periodic examinations of the scope and content of the strategy.
(B) Standards
The strategy developed under subparagraph (A) shall be consistent with standards that the Secretary first establishes within 1 year after August 5, 1997. Such standards shall not preempt any State standards that are more stringent than such standards. Guidelines relating to quality assurance that are applied under
(C) Monitoring
The Secretary shall monitor the development and implementation of strategies under subparagraph (A).
(D) Consultation
The Secretary shall conduct activities under subparagraphs (B) and (C) in consultation with the States.
(2) External independent review of managed care activities
(A) Review of contracts
(i) In general
Each contract under
(ii) Qualifications of reviewer
The Secretary, in consultation with the States, shall establish a method for the identification of entities that are qualified to conduct reviews under clause (i).
(iii) Use of protocols
The Secretary, in coordination with the National Governors' Association, shall contract with an independent quality review organization (such as the National Committee for Quality Assurance) to develop the protocols to be used in external independent reviews conducted under this paragraph on and after January 1, 1999.
(iv) Availability of results
The results of each external independent review conducted under this subparagraph shall be available to participating health care providers, enrollees, and potential enrollees of the organization, except that the results may not be made available in a manner that discloses the identity of any individual patient.
(B) Nonduplication of accreditation
A State may provide that, in the case of a medicaid managed care organization that is accredited by a private independent entity (such as those described in
(C) Deemed compliance for medicare managed care organizations
At the option of a State, the requirements of subparagraph (A) shall not apply with respect to a medicaid managed care organization if the organization is an eligible organization with a contract in effect under
(d) Protections against fraud and abuse
(1) Prohibiting affiliations with individuals debarred by Federal agencies
(A) In general
A managed care entity may not knowingly—
(i) have a person described in subparagraph (C) as a director, officer, partner, or person with beneficial ownership of more than 5 percent of the entity's equity, or
(ii) have an employment, consulting, or other agreement with a person described in such subparagraph for the provision of items and services that are significant and material to the entity's obligations under its contract with the State.
(B) Effect of noncompliance
If a State finds that a managed care entity is not in compliance with clause (i) or (ii) of subparagraph (A), the State—
(i) shall notify the Secretary of such noncompliance;
(ii) may continue an existing agreement with the entity unless the Secretary (in consultation with the Inspector General of the Department of Health and Human Services) directs otherwise; and
(iii) may not renew or otherwise extend the duration of an existing agreement with the entity unless the Secretary (in consultation with the Inspector General of the Department of Health and Human Services) provides to the State and to Congress a written statement describing compelling reasons that exist for renewing or extending the agreement.
(C) Persons described
A person is described in this subparagraph if such person—
(i) is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order; or
(ii) is an affiliate (as defined in such Regulation) of a person described in clause (i).
(2) Restrictions on marketing
(A) Distribution of materials
(i) In general
A managed care entity, with respect to activities under this subchapter, may not distribute directly or through any agent or independent contractor marketing materials within any State—
(I) without the prior approval of the State, and
(II) that contain false or materially misleading information.
The requirement of subclause (I) shall not apply with respect to a State until such date as the Secretary specifies in consultation with such State.
(ii) Consultation in review of market materials
In the process of reviewing and approving such materials, the State shall provide for consultation with a medical care advisory committee.
(B) Service market
A managed care entity shall distribute marketing materials to the entire service area of such entity covered under the contract under
(C) Prohibition of tie-ins
A managed care entity, or any agency of such entity, may not seek to influence an individual's enrollment with the entity in conjunction with the sale of any other insurance.
(D) Prohibiting marketing fraud
Each managed care entity shall comply with such procedures and conditions as the Secretary prescribes in order to ensure that, before an individual is enrolled with the entity, the individual is provided accurate oral and written information sufficient to make an informed decision whether or not to enroll.
(E) Prohibition of "cold-call" marketing
Each managed care entity shall not, directly or indirectly, conduct door-to-door, telephonic, or other "cold-call" marketing of enrollment under this subchapter.
(3) State conflict-of-interest safeguards in medicaid risk contracting
A medicaid managed care organization may not enter into a contract with any State under
(4) Use of unique physician identifier for participating physicians
Each medicaid managed care organization shall require each physician providing services to enrollees eligible for medical assistance under the State plan under this subchapter to have a unique identifier in accordance with the system established under
(e) Sanctions for noncompliance
(1) Use of intermediate sanctions by the State to enforce requirements
(A) In general
A State may not enter into or renew a contract under
(i) fails substantially to provide medically necessary items and services that are required (under law or under such organization's contract with the State) to be provided to an enrollee covered under the contract;
(ii) imposes premiums or charges on enrollees in excess of the premiums or charges permitted under this subchapter;
(iii) acts to discriminate among enrollees on the basis of their health status or requirements for health care services, including expulsion or refusal to reenroll an individual, except as permitted by this subchapter, or engaging in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment with the organization by eligible individuals whose medical condition or history indicates a need for substantial future medical services;
(iv) misrepresents or falsifies information that is furnished—
(I) to the Secretary or the State under this subchapter; or
(II) to an enrollee, potential enrollee, or a health care provider under such subchapter; or
(v) fails to comply with the applicable requirements of
The State may also impose such intermediate sanction against a managed care entity if the State determines that the entity distributed directly or through any agent or independent contractor marketing materials in violation of subsection (d)(2)(A)(i)(II) of this section.
(B) Rule of construction
Clause (i) of subparagraph (A) shall not apply to the provision of abortion services, except that a State may impose a sanction on any medicaid managed care organization that has a contract to provide abortion services if the organization does not provide such services as provided for under the contract.
(2) Intermediate sanctions
The sanctions described in this paragraph are as follows:
(A) Civil money penalties as follows:
(i) Except as provided in clause (ii), (iii), or (iv), not more than $25,000 for each determination under paragraph (1)(A).
(ii) With respect to a determination under clause (iii) or (iv)(I) of paragraph (1)(A), not more than $100,000 for each such determination.
(iii) With respect to a determination under paragraph (1)(A)(ii), double the excess amount charged in violation of such subsection (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned).
(iv) Subject to clause (ii), with respect to a determination under paragraph (1)(A)(iii), $15,000 for each individual not enrolled as a result of a practice described in such subsection.
(B) The appointment of temporary management—
(i) to oversee the operation of the medicaid managed care organization upon a finding by the State that there is continued egregious behavior by the organization or there is a substantial risk to the health of enrollees; or
(ii) to assure the health of the organization's enrollees, if there is a need for temporary management while—
(I) there is an orderly termination or reorganization of the organization; or
(II) improvements are made to remedy the violations found under paragraph (1),
except that temporary management under this subparagraph may not be terminated until the State has determined that the medicaid managed care organization has the capability to ensure that the violations shall not recur.
(C) Permitting individuals enrolled with the managed care entity to terminate enrollment without cause, and notifying such individuals of such right to terminate enrollment.
(D) Suspension or default of all enrollment of individuals under this subchapter after the date the Secretary or the State notifies the entity of a determination of a violation of any requirement of
(E) Suspension of payment to the entity under this subchapter for individuals enrolled after the date the Secretary or State notifies the entity of such a determination and until the Secretary or State is satisfied that the basis for such determination has been corrected and is not likely to recur.
(3) Treatment of chronic substandard entities
In the case of a medicaid managed care organization which has repeatedly failed to meet the requirements of
(4) Authority to terminate contract
(A) In general
In the case of a managed care entity which has failed to meet the requirements of this part or a contract under
(B) Availability of hearing prior to termination of contract
A State may not terminate a contract with a managed care entity under subparagraph (A) unless the entity is provided with a hearing prior to the termination.
(C) Notice and right to disenroll in cases of termination hearing
A State may—
(i) notify individuals enrolled with a managed care entity which is the subject of a hearing to terminate the entity's contract with the State of the hearing, and
(ii) in the case of such an entity, permit such enrollees to disenroll immediately with the entity without cause.
(5) Other protections for managed care entities against sanctions imposed by State
Before imposing any sanction against a managed care entity other than termination of the entity's contract, the State shall provide the entity with notice and such other due process protections as the State may provide, except that a State may not provide a managed care entity with a pre-termination hearing before imposing the sanction described in paragraph (2)(B).
(f) Timeliness of payment
A contract under
(Aug. 14, 1935, ch. 531, title XIX, §1932, as added and amended
References in Text
Part E of subchapter IV of this chapter, referred to in subsec. (a)(2)(A)(iv), is classified to
The Indian Self-Determination Act, referred to in subsec. (a)(2)(C)(ii), is title I of
The Indian Health Care Improvement Act, referred to in subsec. (a)(2)(C)(iii), is
Section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985, referred to in subsec. (a)(3)(C)(i)(II), is section 9517(c)(3) of
Part C of subchapter XVIII of this chapter, referred to in subsecs. (b)(2)(A)(ii) and (c)(1)(A)(iii), (2)(C), is classified to
The Employee Retirement Income Security Act of 1974, referred to in subsec. (b)(3)(B), is
The Public Health Service Act, referred to in subsec. (b)(8), is act July 1, 1944, ch. 373,
Executive Order No. 12549, referred to in subsec. (d)(1)(C)(i), is set out as a note under
Prior Provisions
A prior section 1932 of act Aug. 14, 1935, was renumbered section 1935 and is classified to
Amendments
1999—Subsec. (c)(2)(C).
Subsec. (d)(1)(C)(ii).
Subsec. (d)(2)(B).
1997—Subsec. (b).
Subsec. (c).
Subsecs. (d), (e).
Subsec. (f).
Effective Date
Section effective Aug. 5, 1997, and applicable to contracts entered into or renewed on or after Oct. 1, 1997, except that, subject to provisions relating to extension of effective date for State law amendments, and to nonapplication to waivers, subsec. (c)(1) effective Jan. 1, 1999, and subsec. (e) applicable to contracts entered into or renewed on or after Apr. 1, 1998, see section 4710(a), (b)(3), (5) of
Studies and Reports
Section 4705(c) of
"(1)
"(A)
"(i) if such programs and standards include consideration of the accessibility and quality of the health care items and services delivered under such contracts to low-income individuals; and
"(ii) the appropriateness of applying such programs and standards to medicaid managed care organizations under section 1932(c) of such Act [subsec. (c) of this section].
"(B)
"(2)
"(A)
"(B)
Section Referred to in Other Sections
This section is referred to in
§1396u–3. State coverage of medicare cost-sharing for additional low-income medicare beneficiaries
(a) In general
A State plan under this subchapter shall provide, under
(b) Selection of qualifying individuals
A State shall select qualifying individuals, and provide such individuals with assistance, under this section consistent with the following:
(1) All qualifying individuals may apply
The State shall permit all qualifying individuals to apply for assistance during a calendar year.
(2) Selection on first-come, first-served basis
(A) In general
For each calendar year (beginning with 1998), from (and to the extent of) the amount of the allocation under subsection (c) of this section for the State for the fiscal year ending in such calendar year, the State shall select qualifying individuals who apply for the assistance in the order in which they apply.
(B) Carryover
For calendar years after 1998, the State shall give preference to individuals who were provided such assistance (or other assistance described in
(3) Limit on number of individuals based on allocation
The State shall limit the number of qualifying individuals selected with respect to assistance in a calendar year so that the aggregate amount of such assistance provided to such individuals in such year is estimated to be equal to (but not exceed) the State's allocation under subsection (c) of this section for the fiscal year ending in such calendar year.
(4) Receipt of assistance during duration of year
If a qualifying individual is selected to receive assistance under this section for a month in a year, the individual is entitled to receive such assistance for the remainder of the year if the individual continues to be a qualifying individual. The fact that an individual is selected to receive assistance under this section at any time during a year does not entitle the individual to continued assistance for any succeeding year.
(c) Allocation
(1) Total allocation
The total amount available for allocation under this section for—
(A) fiscal year 1998 is $200,000,000;
(B) fiscal year 1999 is $250,000,000;
(C) fiscal year 2000 is $300,000,000;
(D) fiscal year 2001 is $350,000,000; and
(E) fiscal year 2002 is $400,000,000.
(2) Allocation to States
The Secretary shall provide for the allocation of the total amount described in paragraph (1) for a fiscal year, among the States that executed a plan amendment in accordance with subsection (a) of this section, based upon the Secretary's estimate of the ratio of—
(A) an amount equal to the sum of—
(i) twice the total number of individuals described in
(ii) the total number of individuals described in
(B) the sum of the amounts computed under subparagraph (A) for all eligible States.
(d) Applicable FMAP
With respect to assistance described in
(1) to the extent that such assistance does not exceed the State's allocation under subsection (c) of this section for the fiscal year ending in the calendar year, the Federal medical assistance percentage shall be equal to 100 percent; and
(2) to the extent that such assistance exceeds such allocation, the Federal medical assistance percentage is 0 percent.
(e) Limitation on entitlement
Except as specifically provided under this section, nothing in this subchapter shall be construed as establishing any entitlement of individuals described in
(f) Coverage of costs through part B of medicare program
For each fiscal year, the Secretary shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund under
(Aug. 14, 1935, ch. 531, title XIX, §1933, as added
Prior Provisions
A prior section 1933 of act Aug. 14, 1935, was renumbered section 1935 and is classified to
Amendments
1999—Subsec. (b)(4).
Section Referred to in Other Sections
This section is referred to in
§1396u–4. Program of all-inclusive care for elderly (PACE)
(a) State option
(1) In general
A State may elect to provide medical assistance under this section with respect to PACE program services to PACE program eligible individuals who are eligible for medical assistance under the State plan and who are enrolled in a PACE program under a PACE program agreement. Such individuals need not be eligible for benefits under part A, or enrolled under part B, of subchapter XVIII of this chapter to be eligible to enroll under this section. In the case of an individual enrolled with a PACE program pursuant to such an election—
(A) the individual shall receive benefits under the plan solely through such program, and
(B) the PACE provider shall receive payment in accordance with the PACE program agreement for provision of such benefits.
A State may establish a numerical limit on the number of individuals who may be enrolled in a PACE program under a PACE program agreement.
(2) "PACE program" defined
For purposes of this section, the term "PACE program" means a program of all-inclusive care for the elderly that meets the following requirements:
(A) Operation
The entity operating the program is a PACE provider (as defined in paragraph (3)).
(B) Comprehensive benefits
The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section.
(C) Transition
In the case of an individual who is enrolled under the program under this section and whose enrollment ceases for any reason (including that the individual no longer qualifies as a PACE program eligible individual, the termination of a PACE program agreement, or otherwise), the program provides assistance to the individual in obtaining necessary transitional care through appropriate referrals and making the individual's medical records available to new providers.
(3) "PACE provider" defined
(A) In general
For purposes of this section, the term "PACE provider" means an entity that—
(i) subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986, and
(ii) has entered into a PACE program agreement with respect to its operation of a PACE program.
(B) Treatment of private, for-profit providers
Clause (i) of subparagraph (A) shall not apply—
(i) to entities subject to a demonstration project waiver under subsection (h) of this section; and
(ii) after the date the report under section 4804(b) of the Balanced Budget Act of 1997 is submitted, unless the Secretary determines that any of the findings described in subparagraph (A), (B), (C), or (D) of paragraph (2) of such section are true.
(4) "PACE program agreement" defined
For purposes of this section, the term "PACE program agreement" means, with respect to a PACE provider, an agreement, consistent with this section,
(5) "PACE program eligible individual" defined
For purposes of this section, the term "PACE program eligible individual" means, with respect to a PACE program, an individual who—
(A) is 55 years of age or older;
(B) subject to subsection (c)(4) of this section, is determined under subsection (c) of this section to require the level of care required under the State medicaid plan for coverage of nursing facility services;
(C) resides in the service area of the PACE program; and
(D) meets such other eligibility conditions as may be imposed under the PACE program agreement for the program under subsection (e)(2)(A)(ii) of this section.
(6) "PACE protocol" defined
For purposes of this section, the term "PACE protocol" means the Protocol for the Program of All-inclusive Care for the Elderly (PACE), as published by On Lok, Inc., as of April 14, 1995, or any successor protocol that may be agreed upon between the Secretary and On Lok, Inc.
(7) "PACE demonstration waiver program" defined
For purposes of this section, the term "PACE demonstration waiver program" means a demonstration program under either of the following sections (as in effect before the date of their repeal):
(A) Section 603(c) of the Social Security Amendments of 1983 (
(B) Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 (
(8) "State administering agency" defined
For purposes of this section, the term "State administering agency" means, with respect to the operation of a PACE program in a State, the agency of that State (which may be the single agency responsible for administration of the State plan under this subchapter in the State) responsible for administering PACE program agreements under this section and
(9) "Trial period" defined
(A) In general
For purposes of this section, the term "trial period" means, with respect to a PACE program operated by a PACE provider under a PACE program agreement, the first 3 contract years under such agreement with respect to such program.
(B) Treatment of entities previously operating PACE demonstration waiver programs
Each contract year (including a year occurring before the effective date of this section) during which an entity has operated a PACE demonstration waiver program shall be counted under subparagraph (A) as a contract year during which the entity operated a PACE program as a PACE provider under a PACE program agreement.
(10) "Regulations" defined
For purposes of this section, the term "regulations" refers to interim final or final regulations promulgated under subsection (f) of this section to carry out this section and
(b) Scope of benefits; beneficiary safeguards
(1) In general
Under a PACE program agreement, a PACE provider shall—
(A) provide to PACE program eligible individuals, regardless of source of payment and directly or under contracts with other entities, at a minimum—
(i) all items and services covered under subchapter XVIII of this chapter (for individuals enrolled under
(ii) all additional items and services specified in regulations, based upon those required under the PACE protocol;
(B) provide such enrollees access to necessary covered items and services 24 hours per day, every day of the year;
(C) provide services to such enrollees through a comprehensive, multidisciplinary health and social services delivery system which integrates acute and long-term care services pursuant to regulations; and
(D) specify the covered items and services that will not be provided directly by the entity, and to arrange for delivery of those items and services through contracts meeting the requirements of regulations.
(2) Quality assurance; patient safeguards
The PACE program agreement shall require the PACE provider to have in effect at a minimum—
(A) a written plan of quality assurance and improvement, and procedures implementing such plan, in accordance with regulations, and
(B) written safeguards of the rights of enrolled participants (including a patient bill of rights and procedures for grievances and appeals) in accordance with regulations and with other requirements of this subchapter and Federal and State law designed for the protection of patients.
(c) Eligibility determinations
(1) In general
The determination of—
(A) whether an individual is a PACE program eligible individual shall be made under and in accordance with the PACE program agreement, and
(B) who is entitled to medical assistance under this subchapter shall be made (or who is not so entitled, may be made) by the State administering agency.
(2) Condition
An individual is not a PACE program eligible individual (with respect to payment under this section) unless the individual's health status has been determined by the Secretary or the State administering agency, in accordance with regulations, to be comparable to the health status of individuals who have participated in the PACE demonstration waiver programs. Such determination shall be based upon information on health status and related indicators (such as medical diagnoses and measures of activities of daily living, instrumental activities of daily living, and cognitive impairment) that are part of a uniform minimum data set collected by PACE providers on potential eligible individuals.
(3) Annual eligibility recertifications
(A) In general
Subject to subparagraph (B), the determination described in subsection (a)(5)(B) of this section for an individual shall be reevaluated at least annually.
(B) Exception
The requirement of annual reevaluation under subparagraph (A) may be waived during a period in accordance with regulations in those cases in which the State administering agency determines that there is no reasonable expectation of improvement or significant change in an individual's condition during the period because of the severity of chronic condition, or degree of impairment of functional capacity of the individual involved.
(4) Continuation of eligibility
An individual who is a PACE program eligible individual may be deemed to continue to be such an individual notwithstanding a determination that the individual no longer meets the requirement of subsection (a)(5)(B) of this section if, in accordance with regulations, in the absence of continued coverage under a PACE program the individual reasonably would be expected to meet such requirement within the succeeding 6-month period.
(5) Enrollment; disenrollment
(A) Voluntary disenrollment at any time
The enrollment and disenrollment of PACE program eligible individuals in a PACE program shall be pursuant to regulations and the PACE program agreement and shall permit enrollees to voluntarily disenroll without cause at any time.
(B) Limitations on disenrollment
(i) In general
Regulations promulgated by the Secretary under this section and
(I) for nonpayment of premiums (if applicable) on a timely basis; or
(II) for engaging in disruptive or threatening behavior, as defined in such regulations (developed in close consultation with State administering agencies).
(ii) No disenrollment for noncompliant behavior
Except as allowed under regulations promulgated to carry out clause (i)(II), a PACE program may not disenroll a PACE program eligible individual on the ground that the individual has engaged in noncompliant behavior if such behavior is related to a mental or physical condition of the individual. For purposes of the preceding sentence, the term "noncompliant behavior" includes repeated noncompliance with medical advice and repeated failure to appear for appointments.
(iii) Timely review of proposed nonvoluntary disenrollment
A proposed disenrollment, other than a voluntary disenrollment, shall be subject to timely review and final determination by the Secretary or by the State administering agency (as applicable), prior to the proposed disenrollment becoming effective.
(d) Payments to PACE providers on a capitated basis
(1) In general
In the case of a PACE provider with a PACE program agreement under this section, except as provided in this subsection or by regulations, the State shall make prospective monthly payments of a capitation amount for each PACE program eligible individual enrolled under the agreement under this section.
(2) Capitation amount
The capitation amount to be applied under this subsection for a provider for a contract year shall be an amount specified in the PACE program agreement for the year. Such amount shall be an amount, specified under the PACE agreement, which is less than the amount that would otherwise have been made under the State plan if the individuals were not so enrolled and shall be adjusted to take into account the comparative frailty of PACE enrollees and such other factors as the Secretary determines to be appropriate. The payment under this section shall be in addition to any payment made under
(e) PACE program agreement
(1) Requirement
(A) In general
The Secretary, in close cooperation with the State administering agency, shall establish procedures for entering into, extending, and terminating PACE program agreements for the operation of PACE programs by entities that meet the requirements for a PACE provider under this section,
(B) Numerical limitation
(i) In general
The Secretary shall not permit the number of PACE providers with which agreements are in effect under this section or under section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 to exceed—
(I) 40 as of August 5, 1997, or
(II) as of each succeeding anniversary of August 5, 1997, the numerical limitation under this subparagraph for the preceding year plus 20.
Subclause (II) shall apply without regard to the actual number of agreements in effect as of a previous anniversary date.
(ii) Treatment of certain private, for-profit providers
The numerical limitation in clause (i) shall not apply to a PACE provider that—
(I) is operating under a demonstration project waiver under subsection (h) of this section, or
(II) was operating under such a waiver and subsequently qualifies for PACE provider status pursuant to subsection (a)(3)(B)(ii) of this section.
(2) Service area and eligibility
(A) In general
A PACE program agreement for a PACE program—
(i) shall designate the service area of the program;
(ii) may provide additional requirements for individuals to qualify as PACE program eligible individuals with respect to the program;
(iii) shall be effective for a contract year, but may be extended for additional contract years in the absence of a notice by a party to terminate, and is subject to termination by the Secretary and the State administering agency at any time for cause (as provided under the agreement);
(iv) shall require a PACE provider to meet all applicable State and local laws and requirements; and
(v) shall contain such additional terms and conditions as the parties may agree to, so long as such terms and conditions are consistent with this section and regulations.
(B) Service area overlap
In designating a service area under a PACE program agreement under subparagraph (A)(i), the Secretary (in consultation with the State administering agency) may exclude from designation an area that is already covered under another PACE program agreement, in order to avoid unnecessary duplication of services and avoid impairing the financial and service viability of an existing program.
(3) Data collection; development of outcome measures
(A) Data collection
(i) In general
Under a PACE program agreement, the PACE provider shall—
(I) collect data;
(II) maintain, and afford the Secretary and the State administering agency access to, the records relating to the program, including pertinent financial, medical, and personnel records; and
(III) submit to the Secretary and the State administering agency such reports as the Secretary finds (in consultation with State administering agencies) necessary to monitor the operation, cost, and effectiveness of the PACE program.
(ii) Requirements during trial period
During the first 3 years of operation of a PACE program (either under this section or under a PACE demonstration waiver program), the PACE provider shall provide such additional data as the Secretary specifies in regulations in order to perform the oversight required under paragraph (4)(A).
(B) Development of outcome measures
Under a PACE program agreement, the PACE provider, the Secretary, and the State administering agency shall jointly cooperate in the development and implementation of health status and quality of life outcome measures with respect to PACE program eligible individuals.
(4) Oversight
(A) Annual, close oversight during trial period
During the trial period (as defined in subsection (a)(9) of this section) with respect to a PACE program operated by a PACE provider, the Secretary (in cooperation with the State administering agency) shall conduct a comprehensive annual review of the operation of the PACE program by the provider in order to assure compliance with the requirements of this section and regulations. Such a review shall include—
(i) an onsite visit to the program site;
(ii) comprehensive assessment of a provider's fiscal soundness;
(iii) comprehensive assessment of the provider's capacity to provide all PACE services to all enrolled participants;
(iv) detailed analysis of the entity's substantial compliance with all significant requirements of this section and regulations; and
(v) any other elements the Secretary or the State administering agency considers necessary or appropriate.
(B) Continuing oversight
After the trial period, the Secretary (in cooperation with the State administering agency) shall continue to conduct such review of the operation of PACE providers and PACE programs as may be appropriate, taking into account the performance level of a provider and compliance of a provider with all significant requirements of this section and regulations.
(C) Disclosure
The results of reviews under this paragraph shall be reported promptly to the PACE provider, along with any recommendations for changes to the provider's program, and shall be made available to the public upon request.
(5) Termination of PACE provider agreements
(A) In general
Under regulations—
(i) the Secretary or a State administering agency may terminate a PACE program agreement for cause, and
(ii) a PACE provider may terminate such an agreement after appropriate notice to the Secretary, the State administering agency, and enrollees.
(B) Causes for termination
In accordance with regulations establishing procedures for termination of PACE program agreements, the Secretary or a State administering agency may terminate a PACE program agreement with a PACE provider for, among other reasons, the fact that—
(i) the Secretary or State administering agency determines that—
(I) there are significant deficiencies in the quality of care provided to enrolled participants; or
(II) the provider has failed to comply substantially with conditions for a program or provider under this section or
(ii) the entity has failed to develop and successfully initiate, within 30 days of the date of the receipt of written notice of such a determination, a plan to correct the deficiencies, or has failed to continue implementation of such a plan.
(C) Termination and transition procedures
An entity whose PACE provider agreement is terminated under this paragraph shall implement the transition procedures required under subsection (a)(2)(C) of this section.
(6) Secretary's oversight; enforcement authority
(A) In general
Under regulations, if the Secretary determines (after consultation with the State administering agency) that a PACE provider is failing substantially to comply with the requirements of this section and regulations, the Secretary (and the State administering agency) may take any or all of the following actions:
(i) Condition the continuation of the PACE program agreement upon timely execution of a corrective action plan.
(ii) Withhold some or all further payments under the PACE program agreement under this section or
(iii) Terminate such agreement.
(B) Application of intermediate sanctions
Under regulations, the Secretary may provide for the application against a PACE provider of remedies described in section 1395w–27(g)(2) (or, for periods before January 1, 1999,
(7) Procedures for termination or imposition of sanctions
Under regulations, the provisions of
(8) Timely consideration of applications for PACE program provider status
In considering an application for PACE provider program status, the application shall be deemed approved unless the Secretary, within 90 days after the date of the submission of the application to the Secretary, either denies such request in writing or informs the applicant in writing with respect to any additional information that is needed in order to make a final determination with respect to the application. After the date the Secretary receives such additional information, the application shall be deemed approved unless the Secretary, within 90 days of such date, denies such request.
(f) Regulations
(1) In general
The Secretary shall issue interim final or final regulations to carry out this section and
(2) Use of PACE protocol
(A) In general
In issuing such regulations, the Secretary shall, to the extent consistent with the provisions of this section, incorporate the requirements applied to PACE demonstration waiver programs under the PACE protocol.
(B) Flexibility
In order to provide for reasonable flexibility in adapting the PACE service delivery model to the needs of particular organizations (such as those in rural areas or those that may determine it appropriate to use nonstaff physicians according to State licensing law requirements) under this section and
(i) The focus on frail elderly qualifying individuals who require the level of care provided in a nursing facility.
(ii) The delivery of comprehensive, integrated acute and long-term care services.
(iii) The interdisciplinary team approach to care management and service delivery.
(iv) Capitated, integrated financing that allows the provider to pool payments received from public and private programs and individuals.
(v) The assumption by the provider of full financial risk.
(3) Application of certain additional beneficiary and program protections
(A) In general
In issuing such regulations and subject to subparagraph (B), the Secretary may apply with respect to PACE programs, providers, and agreements such requirements of part C of subchapter XVIII of this chapter (or, for periods before January 1, 1999,
(B) Considerations
In issuing such regulations, the Secretary shall—
(i) take into account the differences between populations served and benefits provided under this section and under part C of subchapter XVIII of this chapter (or, for periods before January 1, 1999,
(ii) not include any requirement that conflicts with carrying out PACE programs under this section; and
(iii) not include any requirement restricting the proportion of enrollees who are eligible for benefits under this subchapter or subchapter XVIII of this chapter.
(4) Construction
Nothing in this subsection shall be construed as preventing the Secretary from including in regulations provisions to ensure the health and safety of individuals enrolled in a PACE program under this section that are in addition to those otherwise provided under paragraphs (2) and (3).
(g) Waivers of requirements
With respect to carrying out a PACE program under this section, the following requirements of this subchapter (and regulations relating to such requirements) shall not apply:
(1)
(2)
(3)
(4)
(5) Such other provisions of this subchapter that, as added or amended by the Balanced Budget Act of 1997, the Secretary determines are inapplicable to carrying out a PACE program under this section.
(h) Demonstration project for for-profit entities
(1) In general
In order to demonstrate the operation of a PACE program by a private, for-profit entity, the Secretary (in close consultation with State administering agencies) shall grant waivers from the requirement under subsection (a)(3) of this section that a PACE provider may not be a for-profit, private entity.
(2) Similar terms and conditions
(A) In general
Except as provided under subparagraph (B), and paragraph (1), the terms and conditions for operation of a PACE program by a provider under this subsection shall be the same as those for PACE providers that are nonprofit, private organizations.
(B) Numerical limitation
The number of programs for which waivers are granted under this subsection shall not exceed 10. Programs with waivers granted under this subsection shall not be counted against the numerical limitation specified in subsection (e)(1)(B) of this section.
(i) Post-eligibility treatment of income
A State may provide for post-eligibility treatment of income for individuals enrolled in PACE programs under this section in the same manner as a State treats post-eligibility income for individuals receiving services under a waiver under
(j) Miscellaneous provisions
Nothing in this section or
(Aug. 14, 1935, ch. 531, title XIX, §1934, as added
References in Text
Parts A, B, and C of subchapter XVIII of this chapter, referred to in subsecs. (a)(1), (e)(7), (f)(3), and (j), are classified to sections 1395c et seq., 1395j et seq., and 1395w–21 et seq., respectively, of this title.
The Internal Revenue Code of 1986, referred to in subsec. (a)(3)(A)(i), is classified generally to Title 26, Internal Revenue Code.
The Balanced Budget Act of 1997, referred to in subsecs. (a)(3)(B)(ii) and (g)(5), is
Section 603(c) of the Social Security Amendments of 1983, referred to in subsec. (a)(7)(A), is section 603(c) of
Section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985, referred to in subsec. (a)(7)(A), is section 9220 of
Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986, referred to in subsecs. (a)(7)(B) and (e)(1)(B)(i), is section 9412(b) of
For the effective date of this section, referred to in subsec. (a)(9)(B), see section 4803 of
Prior Provisions
A prior section 1934 of act Aug. 14, 1935, was renumbered section 1935 and is classified to
Section Referred to in Other Sections
This section is referred to in
§1396v. References to laws directly affecting medicaid program
(a) Authority or requirements to cover additional individuals
For provisions of law which make additional individuals eligible for medical assistance under this subchapter, see the following:
(1) AFDC
(A) Section 602(a)(32) 1 of this title (relating to individuals who are deemed recipients of aid but for whom a payment is not made).
(B) Section 602(a)(37) 1 of this title (relating to individuals who lose AFDC eligibility due to increased earnings).
(C) Section 606(h) 1 of this title (relating to individuals who lose AFDC eligibility due to increased collection of child or spousal support).
(D) Section 682(e)(6) 1 of this title (relating to certain individuals participating in work supplementation programs).
(2) SSI
(A)
(B)
(C)
(D)
(E)
(3) Foster care and adoption assistance
(4) Refugee assistance
(5) Miscellaneous
(A) Section 230 of
(B) Section 231 of
(C) Section 232 of
(D) Section 13(c) of
(E) Section 503 of
(F) Section 310(b)(1) of
(b) Additional State plan requirements
For other provisions of law that establish additional requirements for State plans to be approved under this subchapter, see the following:
(1)
(2) Section 212(a) of
(Aug. 14, 1935, ch. 531, title XIX, §1935, formerly §1920, as added
References in Text
Sections 230, 231, and 232 of
Section 13(c) of
Section 503 of
Section 310(b)(1) of
Section 212(a) of
Codification
Section was formerly classified to
Amendments
1991—Subsec. (a)(5)(F).
1988—Subsec. (a)(1).
Subsec. (a)(1)(D).
Subsec. (a)(2).
Subsec. (a)(2)(E).
1987—Subsec. (a)(1).
"(1) AFDC.—(A)
"(C)
"(D)
Subsec. (a)(2).
"(2) SSI.—(A)
"(B)
"(B)[(C)]
Subsec. (a)(2)(E).
1986—Subsec. (a)(1).
Subsec. (a)(2).
Subsec. (a)(3).
Effective Date of 1988 Amendments
Amendment by section 202(c)(5) of
Amendment by section 608(d)(28) of
Except as specifically provided in section 411 of
Effective Date of 1986 Amendments
Amendment by
Amendment by
References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996
For provisions that certain references to provisions of part A (§601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see