SUBCHAPTER XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
§1396. Medicaid and CHIP Payment and Access Commission
(a) Establishment
There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as "MACPAC").
(b) Duties
(1) Review of access policies for all States and annual reports
MACPAC shall—
(A) review policies of the Medicaid program established under this subchapter (in this section referred to as "Medicaid") and the State Children's Health Insurance Program established under subchapter XXI (in this section referred to as "CHIP") affecting access to covered items and services, including topics described in paragraph (2);
(B) make recommendations to Congress, the Secretary, and States concerning such access policies;
(C) by not later than March 15 of each year (beginning with 2010), submit a report to Congress containing the results of such reviews and MACPAC's recommendations concerning such policies; and
(D) by not later than June 15 of each year (beginning with 2010), submit a report to Congress containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs.
(2) Specific topics to be reviewed
Specifically, MACPAC shall review and assess the following:
(A) Medicaid and CHIP payment policies
Payment policies under Medicaid and CHIP, including—
(i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of other covered items and services;
(ii) payment methodologies; and
(iii) the relationship of such factors and methodologies to access and quality of care for Medicaid and CHIP beneficiaries (including how such factors and methodologies enable such beneficiaries to obtain the services for which they are eligible, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations).
(B) Eligibility policies
Medicaid and CHIP eligibility policies, including a determination of the degree to which Federal and State policies provide health care coverage to needy populations.
(C) Enrollment and retention processes
Medicaid and CHIP enrollment and retention processes, including a determination of the degree to which Federal and State policies encourage the enrollment of individuals who are eligible for such programs and screen out individuals who are ineligible, while minimizing the share of program expenses devoted to such processes.
(D) Coverage policies
Medicaid and CHIP benefit and coverage policies, including a determination of the degree to which Federal and State policies provide access to the services enrollees require to improve and maintain their health and functional status.
(E) Quality of care
Medicaid and CHIP policies as they relate to the quality of care provided under those programs, including a determination of the degree to which Federal and State policies achieve their stated goals and interact with similar goals established by other purchasers of health care services.
(F) Interaction of Medicaid and CHIP payment policies with health care delivery generally
The effect of Medicaid and CHIP payment policies on access to items and services for children and other Medicaid and CHIP populations other than under this subchapter or subchapter XXI and the implications of changes in health care delivery in the United States and in the general market for health care items and services on Medicaid and CHIP.
(G) Interactions with Medicare and Medicaid
Consistent with paragraph (11), the interaction of policies under Medicaid and the Medicare program under subchapter XVIII, including with respect to how such interactions affect access to services, payments, and dual eligible individuals.
(H) Other access policies
The effect of other Medicaid and CHIP policies on access to covered items and services, including policies relating to transportation and language barriers and preventive, acute, and long-term services and supports.
(3) Recommendations and reports of State-specific data
MACPAC shall—
(A) review national and State-specific Medicaid and CHIP data; and
(B) submit reports and recommendations to Congress, the Secretary, and States based on such reviews.
(4) Creation of early-warning system
MACPAC shall create an early-warning system to identify provider shortage areas, as well as other factors that adversely affect, or have the potential to adversely affect, access to care by, or the health care status of, Medicaid and CHIP beneficiaries. MACPAC shall include in the annual report required under paragraph (1)(D) a description of all such areas or problems identified with respect to the period addressed in the report.
(5) Comments on certain secretarial reports and regulations
(A) Certain secretarial reports
If the Secretary submits to Congress (or a committee of Congress) a report that is required by law and that relates to access policies, including with respect to payment policies, under Medicaid or CHIP, the Secretary shall transmit a copy of the report to MACPAC. MACPAC shall review the report and, not later than 6 months after the date of submittal of the Secretary's report to Congress, shall submit to the appropriate committees of Congress and the Secretary written comments on such report. Such comments may include such recommendations as MACPAC deems appropriate.
(B) Regulations
MACPAC shall review Medicaid and CHIP regulations and may comment through submission of a report to the appropriate committees of Congress and the Secretary, on any such regulations that affect access, quality, or efficiency of health care.
(6) Agenda and additional reviews
(A) In general
MACPAC shall consult periodically with the chairmen and ranking minority members of the appropriate committees of Congress regarding MACPAC's agenda and progress towards achieving the agenda. MACPAC may conduct additional reviews, and submit additional reports to the appropriate committees of Congress, from time to time on such topics relating to the program under this subchapter or subchapter XXI as may be requested by such chairmen and members and as MACPAC deems appropriate.
(B) Review and reports regarding Medicaid DSH
(i) In general
MACPAC shall review and submit an annual report to Congress on disproportionate share hospital payments under
(ii) Required report information
Each report required under this subparagraph shall include the following:
(I) Data relating to changes in the number of uninsured individuals.
(II) Data relating to the amount and sources of hospitals' uncompensated care costs, including the amount of such costs that are the result of providing unreimbursed or under-reimbursed services, charity care, or bad debt.
(III) Data identifying hospitals with high levels of uncompensated care that also provide access to essential community services for low-income, uninsured, and vulnerable populations, such as graduate medical education, and the continuum of primary through quarternary care, including the provision of trauma care and public health services.
(IV) State-specific analyses regarding the relationship between the most recent State DSH allotment and the projected State DSH allotment for the succeeding year and the data reported under subclauses (I), (II), and (III) for the State.
(iii) Data
Notwithstanding any other provision of law, the Secretary regularly shall provide MACPAC with the most recent State reports and most recent independent certified audits submitted under
(iv) Submission deadlines
The first report required under this subparagraph shall be submitted to Congress not later than February 1, 2016. Subsequent reports shall be submitted as part of, or with, each annual report required under paragraph (1)(C) during the period of fiscal years 2017 through 2024.
(7) Availability of reports
MACPAC shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public.
(8) Appropriate committee of Congress
For purposes of this section, the term "appropriate committees of Congress" means the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate.
(9) Voting and reporting requirements
With respect to each recommendation contained in a report submitted under paragraph (1), each member of MACPAC shall vote on the recommendation, and MACPAC shall include, by member, the results of that vote in the report containing the recommendation.
(10) Examination of budget consequences
Before making any recommendations, MACPAC shall examine the budget consequences of such recommendations, directly or through consultation with appropriate expert entities, and shall submit with any recommendations, a report on the Federal and State-specific budget consequences of the recommendations.
(11) Consultation and coordination with MEDPAC
(A) In general
MACPAC shall consult with the Medicare Payment Advisory Commission (in this paragraph referred to as "MedPAC") established under
(B) Information sharing
MACPAC and MedPAC shall have access to deliberations and records of the other such entity, respectively, upon the request of the other such entity.
(12) Consultation with States
MACPAC shall regularly consult with States in carrying out its duties under this section, including with respect to developing processes for carrying out such duties, and shall ensure that input from States is taken into account and represented in MACPAC's recommendations and reports.
(13) Coordinate and consult with the Federal Coordinated Health Care Office
MACPAC shall coordinate and consult with the Federal Coordinated Health Care Office established under section 2081 1 of the Patient Protection and Affordable Care Act before making any recommendations regarding dual eligible individuals.
(14) Programmatic oversight vested in the Secretary
MACPAC's authority to make recommendations in accordance with this section shall not affect, or be considered to duplicate, the Secretary's authority to carry out Federal responsibilities with respect to Medicaid and CHIP.
(c) Membership
(1) Number and appointment
MACPAC shall be composed of 17 members appointed by the Comptroller General of the United States.
(2) Qualifications
(A) In general
The membership of MACPAC shall include individuals who have had direct experience as enrollees or parents or caregivers of enrollees in Medicaid or CHIP and individuals with national recognition for their expertise in Federal safety net health programs, health finance and economics, actuarial science, health plans and integrated delivery systems, reimbursement for health care, health information technology, and other providers of health services, public health, and other related fields, who provide a mix of different professions, broad geographic representation, and a balance between urban and rural representation.
(B) Inclusion
The membership of MACPAC shall include (but not be limited to) physicians, dentists, and other health professionals, employers, third-party payers, and individuals with expertise in the delivery of health services. Such membership shall also include representatives of children, pregnant women, the elderly, individuals with disabilities, caregivers, and dual eligible individuals, current or former representatives of State agencies responsible for administering Medicaid, and current or former representatives of State agencies responsible for administering CHIP.
(C) Majority nonproviders
Individuals who are directly involved in the provision, or management of the delivery, of items and services covered under Medicaid or CHIP shall not constitute a majority of the membership of MACPAC.
(D) Ethical disclosure
The Comptroller General of the United States shall establish a system for public disclosure by members of MACPAC of financial and other potential conflicts of interest relating to such members. Members of MACPAC shall be treated as employees of Congress for purposes of applying subchapter I of
(3) Terms
(A) In general
The terms of members of MACPAC shall be for 3 years except that the Comptroller General of the United States shall designate staggered terms for the members first appointed.
(B) Vacancies
Any member appointed to fill a vacancy occurring before the expiration of the term for which the member's predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member's term until a successor has taken office. A vacancy in MACPAC shall be filled in the manner in which the original appointment was made.
(4) Compensation
While serving on the business of MACPAC (including travel time), a member of MACPAC shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under
(5) Chairman; Vice Chairman
The Comptroller General of the United States shall designate a member of MACPAC, at the time of appointment of the member 2 as Chairman and a member as Vice Chairman for that term of appointment, except that in the case of vacancy of the Chairmanship or Vice Chairmanship, the Comptroller General of the United States may designate another member for the remainder of that member's term.
(6) Meetings
MACPAC shall meet at the call of the Chairman.
(d) Director and staff; experts and consultants
Subject to such review as the Comptroller General of the United States deems necessary to assure the efficient administration of MACPAC, MACPAC may—
(1) employ and fix the compensation of an Executive Director (subject to the approval of the Comptroller General of the United States) and such other personnel as may be necessary to carry out its duties (without regard to the provisions of title 5 governing appointments in the competitive service);
(2) seek such assistance and support as may be required in the performance of its duties from appropriate Federal and State departments and agencies;
(3) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of MACPAC (without regard to
(4) make advance, progress, and other payments which relate to the work of MACPAC;
(5) provide transportation and subsistence for persons serving without compensation; and
(6) prescribe such rules and regulations as it deems necessary with respect to the internal organization and operation of MACPAC.
(e) Powers
(1) Obtaining official data
MACPAC may secure directly from any department or agency of the United States and, as a condition for receiving payments under
(2) Data collection
In order to carry out its functions, MACPAC shall—
(A) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section;
(B) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate; and
(C) adopt procedures allowing any interested party to submit information for MACPAC's use in making reports and recommendations.
(3) Access of GAO to information
The Comptroller General of the United States shall have unrestricted access to all deliberations, records, and nonproprietary data of MACPAC, immediately upon request.
(4) Periodic audit
MACPAC shall be subject to periodic audit by the Comptroller General of the United States.
(f) Funding
(1) Request for appropriations
MACPAC shall submit requests for appropriations (other than for fiscal year 2010) in the same manner as the Comptroller General of the United States submits requests for appropriations, but amounts appropriated for MACPAC shall be separate from amounts appropriated for the Comptroller General of the United States.
(2) Authorization
There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section.
(3) Funding for fiscal year 2010
(A) In general
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to MACPAC to carry out the provisions of this section for fiscal year 2010, $9,000,000.
(B) Transfer of funds
Notwithstanding
(4) Availability
Amounts made available under paragraphs (2) and (3) to MACPAC to carry out the provisions of this section shall remain available until expended.
(Aug. 14, 1935, ch. 531, title XIX, §1900, as added
Editorial Notes
References in Text
Section 2081 of the Patient Protection and Affordable Care Act, referred to in subsec. (b)(13), probably means section 2602 of
Codification
In subsec. (d)(3), "
Prior Provisions
A prior section 1396, act Aug. 14, 1935, ch. 531, title XIX, §1901, as added
Amendments
2022—Subsec. (c)(2)(D).
2014—Subsec. (b)(6).
2010—Subsec. (b)(1).
Subsec. (b)(1)(A).
Subsec. (b)(1)(B).
Subsec. (b)(1)(C).
Subsec. (b)(1)(D).
Subsec. (b)(2)(A)(i).
Subsec. (b)(2)(A)(iii).
Subsec. (b)(2)(B) to (H).
Subsec. (b)(3).
Subsec. (b)(4).
Subsec. (b)(5).
Subsec. (b)(6) to (10).
Subsec. (b)(11) to (14).
Subsec. (c)(2)(A), (B).
Subsec. (d)(2).
Subsec. (e)(1).
Subsec. (f).
Statutory Notes and Related Subsidiaries
Effective Date
"(a)
"(b)
"(c)
"(1) any amounts that are so appropriated that are not so allotted and obligated before April 1, 2009 are rescinded; and
"(2) any amount provided for CHIP allotments to a State under this Act (and the amendments made by this Act) for such fiscal year shall be reduced by the amount of such appropriations so allotted and obligated before such date.
"(d)
"(1) such amendments are effective as of such date whether or not regulations implementing such amendments have been issued; and
"(2) Federal financial participation for medical assistance or child health assistance furnished under title XIX or XXI, respectively, of the Social Security Act [
Purpose
Think Differently Database
"SECTION 1. SHORT TITLE.
"This Act may be cited as the 'Think Differently Database Act'.
"SEC. 2. PROMOTING AWARENESS OF AVAILABLE RESOURCES FOR INDIVIDUALS WITH DISABILITIES.
"(a)
"(1) information on eligibility to receive medical assistance under a State plan under the Medicaid program under title XIX of the Social Security Act (
"(2) which States offer eligibility under subclauses (XIII), (XV), (XVI), and (XIX) of section 1902(a)(10)(A)(ii) of the Social Security Act (
"(3) each State's specific eligibility requirements, if applicable, under subclauses (XIII), (XV), (XVI), and (XIX) of section 1902(a)(10)(A)(ii) of the Social Security Act (
"(4) information about how to contact each State's Medicaid office for information about Medicaid, including links and phone numbers for State contacts;
"(5) general information on Medicaid-covered long-term services and supports that may be available to individuals eligible for medical assistance under a State plan under the Medicaid program under title XIX of the Social Security Act (
"(6) where applicable, the average amount of time that individuals newly enrolled in a State's waiver program for home and community-based services in the past 12 months were on the list of individuals waiting to enroll in such waiver program, in such a manner and process as described in section 441.311(d)(1)(iii) of title 42, Code of Federal Regulations.
"(b)
"(c)
"(d)
Model of Interstate Coordinated Enrollment and Coverage Process
"(a)
"(b)
Improved Accessibility of Dental Provider Information to Enrollees Under Medicaid and CHIP
"(1) work with States, pediatric dentists, and other dental providers (including providers that are, or are affiliated with, a school of dentistry) to include, not later than 6 months after the date of the enactment of this Act [Feb. 4, 2009], on the Insure Kids Now website (http://www.insurekidsnow.gov/) and hotline (1–877–KIDS–NOW) (or on any successor websites or hotlines) a current and accurate list of all such dentists and providers within each State that provide dental services to children enrolled in the State plan (or waiver) under Medicaid or the State child health plan (or waiver) under CHIP, and shall ensure that such list is updated at least quarterly; and
"(2) work with States to include, not later than 6 months after the date of the enactment of this Act, a description of the dental services provided under each State plan (or waiver) under Medicaid and each State child health plan (or waiver) under CHIP on such Insure Kids Now website, and shall ensure that such list is updated at least annually."
Deadline for Initial Appointments
Annual Report
No Federal Funding for Illegal Aliens; Disallowance for Unauthorized Expenditures
Definitions
"(1) CHIP.—The term 'CHIP' means the State Children's Health Insurance Program established under title XXI of the Social Security Act (
"(2)
"(3)
1 See References in Text note below.
2 So in original. Probably should be followed by a comma.
§1396–1. 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
Editorial Notes
Codification
Section was formerly classified to
Amendments
1984—
1973—
Statutory Notes and Related Subsidiaries
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, including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan, and, subject to
(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 (insofar as it relates to the aged) if the State is eligible to participate in the State plan program established under subchapter XVI, 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 if the State is not eligible to participate in the State plan program established under subchapter XVI;
(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—
(A) safeguards which restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with—
(i) the administration of the plan; and
(ii) the exchange of information necessary to certify or verify the certification of eligibility of children for free or reduced price breakfasts under the Child Nutrition Act of 1966 [
(B) that, notwithstanding the Express Lane option under subsection (e)(13), the State may enter into an agreement with the State agency administering the school lunch program established under the Richard B. Russell National School Lunch Act under which the State shall establish procedures to ensure that—
(i) a child receiving medical assistance under the State plan under this subchapter whose family income does not exceed 133 percent of the poverty line (as defined in
(ii) the State agencies responsible for administering the State plan under this subchapter, and for carrying out the school lunch program established under the Richard B. Russell National School Lunch Act (
(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,
(C) that any laboratory services paid for under such plan must be provided by a laboratory which meets the applicable requirements of
(D) that the State maintain a consumer-oriented website providing useful information to consumers regarding all skilled nursing facilities and all nursing facilities in the State, including for each facility, Form 2567 State inspection reports (or a successor form), complaint investigation reports, the facility's plan of correction, and such other information that the State or the Secretary considers useful in assisting the public to assess the quality of long term care options and the quality of care provided by individual facilities;
(10) provide—
(A) for making medical assistance available, including at least the care and services listed in paragraphs (1) through (5), (13)(B), (17), (21), (28), (29), and (30) 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, or part A or part E of subchapter IV (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)(aa) with respect to whom supplemental security income benefits are being paid under subchapter XVI (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) and whose family income does not exceed the minimum income level the State is required to establish under subsection (l)(2)(A) 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) and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(B) for such a family,
(VII) who are described in subparagraph (D) of subsection (l)(1) and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(C) for such a family; 2
(VIII) beginning January 1, 2014, who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in
(IX) who—
(aa) are under 26 years of age;
(bb) are not described in and are not enrolled under any of subclauses (I) through (VII) of this clause or are described in any of such subclauses but have income that exceeds the level of income applicable under the State plan for eligibility to enroll for medical assistance under such subclause;
(cc) were in foster care under the responsibility of a State on the date of attaining 18 years of age or such higher age as the State has elected under
(dd) were enrolled in a State plan under this subchapter or under a waiver of such a plan while in such foster care; 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, 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) 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 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; 2
(IX) who are described in subsection (l)(1) and are not described in clause (i)(IV), clause (i)(VI), or clause (i)(VII); 2
(X) who are described in subsection (m)(1); 2
(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), 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) (relating to certain TB-infected individuals); 2
(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
(XVIII) who are described in subsection (aa) (relating to certain breast or cervical cancer patients); 2
(XIX) who are disabled children described in subsection (cc)(1); 2
(XX) beginning January 1, 2014, who are under 65 years of age and are not described in or enrolled under a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) exceeds 133 percent of the poverty line (as defined in
(XXI) who are described in subsection (ii) (relating to individuals who meet certain income standards); 2
(XXII) who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of
(XXIII) during any portion of the emergency period defined in paragraph (1)(B) of
(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), (13)(B), 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
(F) at the option of a State, for making medical assistance available for COBRA premiums (as defined in subsection (u)(2)) for qualified COBRA continuation beneficiaries described in subsection (u)(1); and
(G) that, in applying eligibility criteria of the supplemental security income program under subchapter XVI 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, (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 5 (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 and for payment of amounts under
(C) payment for primary care services (as defined in subsection (jj)) furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a rate not less than 100 percent of the payment rate that applies to such services and physician under part B of subchapter XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under
(14) provide that enrollment fees, premiums, or similar charges, and deductions, cost sharing, or similar charges, may be imposed only as provided in
(15) provide for payment for services described in clause (B) or (C) of
(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 (e)(14), (e)(15), (l)(3), (m)(3), and (m)(4), 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, and with respect to whom supplemental security income benefits are not being paid under subchapter XVI, 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) 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), 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) 1 or section 1383(a)(4)(A)(i) and (ii) 1 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, self-insured plans, 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 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, except that the State may, if the State determines doing so is cost-effective and will not adversely affect access to care, only make such payment if a third party so liable has not made payment within 90 days after the date the provider of such services has initially submitted a claim to such 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 100 days after the date the provider of such services has initially submitted a claim to such third party for payment for such services, except that the State may make such payment within 30 days after such date if the State determines doing so is cost-effective and necessary to ensure access to care.; 6 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; and
(I) that the State shall provide assurances satisfactory to the Secretary that the State has in effect laws requiring health insurers, including self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 [
(i) provide, with respect to individuals who are eligible (and, at State option, individuals who apply or whose eligibility for medical assistance is being evaluated in accordance with
(ii)(I) accept the State's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the State plan (or under a waiver of such plan); and
(II) in the case of a responsible third party (other than the original medicare fee-for-service program under parts A and B of subchapter XVIII, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under
(iii) not later than 60 days after receiving any inquiry by the State regarding a claim for payment for any health care item or service that is submitted not later than 3 years after the date of the provision of such health care item or service, respond to such inquiry; and
(iv) agree not to deny a claim submitted by the State solely on the basis of the date of submission of the claim, the type or format of the claim form, a failure to present proper documentation at the point-of-sale that is the basis of the claim, or in the case of a responsible third party (other than the original medicare fee-for-service program under parts A and B of subchapter XVIII, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under
(I) the claim is submitted by the State within the 3-year period beginning on the date on which the item or service was furnished; and
(II) any action by the State to enforce its rights with respect to such claim is commenced within 6 years of the State's submission of such claim;
(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, in accordance with subsection (kk)(8) (as applicable), 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—
(A) 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; and
(B) not later than December 31, 2010, the State shall—
(i) establish a program under which the State contracts (consistent with State law and in the same manner as the Secretary enters into contracts with recovery audit contractors under
(ii) provide assurances satisfactory to the Secretary that—
(I) under such contracts, payment shall be made to such a contractor only from amounts recovered;
(II) from such amounts recovered, payment—
(aa) shall be made on a contingent basis for collecting overpayments; and
(bb) may be made in such amounts as the State may specify for identifying underpayments;
(III) the State has an adequate process for entities to appeal any adverse determination made by such contractors; and
(IV) such program is carried out in accordance with such requirements as the Secretary shall specify, including—
(aa) for purposes of
(bb) that
(cc) that the State and any such contractors under contract with the State shall coordinate such recovery audit efforts with other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, including efforts with Federal and State law enforcement with respect to the Department of Justice, including the Federal Bureau of Investigations,7 the Inspector General of the Department of Health and Human Services, and the State medicaid fraud control unit; and
(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 other information relating to the provision of dental services to such children described in section 1397hh(e) 8 of this title 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)(A) 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
(B) provide, with respect to an individual declaring to be a citizen or national of the United States for purposes of establishing eligibility under this subchapter, that the State shall satisfy the requirements of—
(i)
(ii) subsection (ee);
(47) provide—
(A) at the option of the State, for making ambulatory prenatal care available to pregnant women during a presumptive eligibility period in accordance with
(B) that any hospital that is a participating provider under the State plan may elect to be a qualified entity for purposes of determining, on the basis of preliminary information, whether any individual is eligible for medical assistance under the State plan or under a waiver of the plan for purposes of providing the individual with medical assistance during a presumptive eligibility period, in the same manner, and subject to the same requirements, as apply to the State options with respect to populations described in
(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), 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 section 17 of the Child Nutrition Act of 1966 [
(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), (a)(10)(A)(ii)(IX), or (a)(10)(A)(ii)(XXIII)—
(A) at locations which are other than those used for the receipt and processing of applications for aid under part A of subchapter IV 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), 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);
(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 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;
(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
(66) provide for making eligibility determinations under
(67) provide, with respect to services covered under the State plan (but not under subchapter XVIII) that are furnished to a PACE program eligible individual enrolled with a PACE provider by a provider participating under the State plan that does not have a contract or other agreement with the PACE provider that establishes payment amounts for such services, that such participating provider may not require the PACE provider to pay the participating provider an amount greater than the amount that would otherwise be payable for the service to the participating provider under the State plan for the State where the PACE provider is located (in accordance with regulations issued by the Secretary);
(68) provide that any entity that receives or makes annual payments under the State plan of at least $5,000,000, as a condition of receiving such payments, shall—
(A) establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established under
(B) include as part of such written policies, detailed provisions regarding the entity's policies and procedures for detecting and preventing fraud, waste, and abuse; and
(C) include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity's policies and procedures for detecting and preventing fraud, waste, and abuse;
(69) provide that the State must comply with any requirements determined by the Secretary to be necessary for carrying out the Medicaid Integrity Program established under
(70) at the option of the State and notwithstanding paragraphs (1), (10)(B), and (23), provide for the establishment of a non-emergency medical transportation brokerage program in order to more cost-effectively provide transportation for individuals eligible for medical assistance under the State plan who need access to medical care or services and have no other means of transportation which—
(A) may include a wheelchair van, taxi, stretcher car, bus passes and tickets, secured transportation, and such other transportation as the Secretary determines appropriate; and
(B) may be conducted under contract with a broker who—
(i) is selected through a competitive bidding process based on the State's evaluation of the broker's experience, performance, references, resources, qualifications, and costs;
(ii) has oversight procedures to monitor beneficiary access and complaints and ensure that transport personnel are licensed, qualified, competent, and courteous;
(iii) is subject to regular auditing and oversight by the State in order to ensure the quality of the transportation services provided and the adequacy of beneficiary access to medical care and services; and
(iv) complies with such requirements related to prohibitions on referrals and conflict of interest as the Secretary shall establish (based on the prohibitions on physician referrals under
(71) provide that the State will implement an asset verification program as required under
(72) provide that the State will not prevent a Federally-qualified health center from entering into contractual relationships with private practice dental providers in the provision of Federally-qualified health center services;
(73) in the case of any State in which 1 or more Indian Health Programs or Urban Indian Organizations furnishes health care services, provide for a process under which the State seeks advice on a regular, ongoing basis from designees of such Indian Health Programs and Urban Indian Organizations on matters relating to the application of this subchapter that are likely to have a direct effect on such Indian Health Programs and Urban Indian Organizations and that—
(A) shall include solicitation of advice prior to submission of any plan amendments, waiver requests, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs, or Urban Indian Organizations; and
(B) may include appointment of an advisory committee and of a designee of such Indian Health Programs and Urban Indian Organizations to the medical care advisory committee advising the State on its State plan under this subchapter;
(74) provide for maintenance of effort under the State plan or under any waiver of the plan in accordance with subsection (gg);
(75) provide that, beginning January 2015, and annually thereafter, the State shall submit a report to the Secretary that contains—
(A) the total number of enrolled and newly enrolled individuals in the State plan or under a waiver of the plan for the fiscal year ending on September 30 of the preceding calendar year, disaggregated by population, including children, parents, nonpregnant childless adults, disabled individuals, elderly individuals, and such other categories or sub-categories of individuals eligible for medical assistance under the State plan or under a waiver of the plan as the Secretary may require;
(B) a description, which may be specified by population, of the outreach and enrollment processes used by the State during such fiscal year; and
(C) any other data reporting determined necessary by the Secretary to monitor enrollment and retention of individuals eligible for medical assistance under the State plan or under a waiver of the plan;
(76) provide that any data collected under the State plan meets the requirements of section 3101 of the Public Health Service Act [
(77) provide that the State shall comply with provider and supplier screening, oversight, and reporting requirements in accordance with subsection (kk);
(78) provide that, not later than January 1, 2017, in the case of a State that pursuant to its State plan or waiver of the plan for medical assistance pays for medical assistance on a fee-for-service basis, the State shall require each provider furnishing items and services to, or ordering, prescribing, referring, or certifying eligibility for, services for individuals eligible to receive medical assistance under such plan to enroll with the State agency and provide to the State agency the provider's identifying information, including the name, specialty, date of birth, Social Security number, national provider identifier (if applicable), Federal taxpayer identification number, and the State license or certification number of the provider (if applicable);
(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;
(80) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;
(81) provide for implementation of the payment models specified by the Secretary under
(82) provide that the State agency responsible for administering the State plan under this subchapter provides assurances to the Secretary that the State agency is in compliance with subparagraphs (A), (B), and (C) of
(83) provide that, not later than January 1, 2017, in the case of a State plan (or waiver of the plan) that provides medical assistance on a fee-for-service basis or through a primary care case-management system described in
(A) includes—
(i) with respect to each such physician or provider—
(I) the name of the physician or provider;
(II) the specialty of the physician or provider;
(III) the address at which the physician or provider provides services; and
(IV) the telephone number of the physician or provider; and
(ii) with respect to any such physician or provider participating in such a primary care case-management system, information regarding—
(I) whether the physician or provider is accepting as new patients individuals who receive medical assistance under this subchapter; and
(II) the physician's or provider's cultural and linguistic capabilities, including the languages spoken by the physician or provider or by the skilled medical interpreter providing interpretation services at the physician's or provider's office; and
(B) may include, at State option, with respect to each such physician or provider—
(i) the Internet website of such physician or provider; or
(ii) whether the physician or provider is accepting as new patients individuals who receive medical assistance under this subchapter;
(84) provide that—
(A) the State shall not terminate eligibility for medical assistance under the State plan (or waiver of such plan) for an individual who is an eligible juvenile (as defined in subsection (nn)(2)) because the juvenile is an inmate of a public institution (as defined in subsection (nn)(3)), but, subject to subparagraph (D), may suspend coverage during the period the juvenile is such an inmate (or in the case of a State electing the option described in the subdivision (A) following paragraph (31) of
(B) in the case of an individual who is an eligible juvenile described in paragraph (2)(A) of subsection (nn), the State shall, prior to the individual's release from such a public institution, conduct a redetermination of eligibility for such individual with respect to such medical assistance (without requiring a new application from the individual) and, if the State determines pursuant to such redetermination that the individual continues to meet the eligibility requirements for such medical assistance, the State shall restore coverage for such medical assistance to such an individual upon the individual's release from such public institution;
(C) in the case of an individual who is an eligible juvenile described in paragraph (2)(B) of subsection (nn), the State shall process any application for medical assistance submitted by, or on behalf of, such individual such that the State makes a determination of eligibility for such individual with respect to such medical assistance upon release of such individual from such public institution; and
(D) in the case of an individual who is an eligible juvenile described in subsection (nn)(2) and is within 30 days of the date on which such eligible juvenile is scheduled to be released from a public institution following adjudication, the State shall have in place a plan, and in accordance with such plan, provide for—
(i) in the 30 days prior to the release of such eligible juvenile from such public institution (or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with such institution, any screening or diagnostic service which meets reasonable standards of medical and dental practice, as determined by the State, or as indicated as medically necessary, in accordance with paragraphs (1)(A) and (5) of
(ii) in the 30 days prior to the release of such eligible juvenile from such public institution, and for at least 30 days following the release of such eligible juvenile from such institution, targeted case management services, including referrals for such eligible juvenile to the appropriate care and services available in the geographic region of the home or residence of such eligible juvenile (where feasible) under the State plan (or waiver of such plan);
(85) provide that the State is in compliance with the drug review and utilization requirements under subsection (oo)(1);
(86) provide, at the option of the State, for making medical assistance available on an inpatient or outpatient basis at a residential pediatric recovery center (as defined in subsection (pp)) to infants with neonatal abstinence syndrome; and
(87) provide for a mechanism, which may include attestation, that ensures that, with respect to any provider (including a transportation network company) or individual driver of nonemergency transportation to medically necessary services receiving payments under such plan (but excluding any public transit authority), at a minimum—
(A) each such provider and individual driver is not excluded from participation in any Federal health care program (as defined in
(B) each such individual driver has a valid driver's license;
(C) each such provider has in place a process to address any violation of a State drug law; and
(D) each such provider has in place a process to disclose to the State Medicaid program the driving history, including any traffic violations, of each such individual driver employed by such provider, including any traffic violations.
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 (or subchapter XVI, 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 (or subchapter XVI, insofar as it relates to the aged), the State agency which administered or supervised the administration of such plan approved under subchapter X (or subchapter XVI, 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, or part A of subchapter IV and who for such month was entitled to monthly insurance benefits under subchapter II 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 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), 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), the Secretary shall not approve any State plan for medical assistance if the State requires individuals described in subsection (l)(1) to apply for assistance under the State program funded under part A of subchapter IV 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) Continuation and extension of eligibility of certain individuals; Express Lane option for children
(1) Beginning April 1, 1990, for provisions relating to the 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 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.
(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. 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). Notwithstanding the preceding sentence, in the case of a child who is born in the United States to an alien mother for whom medical assistance for the delivery of the child is made available pursuant to
(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) 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) and subsection (l)(1)(A) 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) 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 pursuant to section 602(a)(43) 1 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 and such aid is terminated pursuant to section 602(a)(43) 1 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) 1
(A) the end of the 12-month period beginning on the date of such determination;
(B) the time that such individual attains the age of 19; or
(C) the date that such individual ceases to be a resident of such State.
(13)
(A)
(i)
(I)
(II)
(III)
(IV)
(V)
(ii)
(B)
(i) to limit or prohibit a State from taking any actions otherwise permitted under this subchapter or subchapter XXI in determining eligibility for or enrolling children into medical assistance under this subchapter or child health assistance under subchapter XXI; or
(ii) to modify the limitations in
(C)
(i)
(ii)
(I)
(II)
(III)
(aa) Notice that the child may be eligible to receive medical assistance under the State plan under this subchapter if evaluated for such assistance under the State's regular procedures and notice of the process through which a parent, guardian, or custodial relative can request that the State evaluate the child's eligibility for medical assistance under this subchapter using such regular procedures.
(bb) A description of differences between the medical assistance provided under this subchapter and child health assistance under subchapter XXI, including differences in cost-sharing requirements and covered benefits.
(iii)
(I)
(II)
(III)
(IV)
(V)
(D)
(i)
(ii)
(E)
(i)
(I) assign such codes as the Secretary shall require to the children who are enrolled in the State Medicaid plan or the State CHIP plan through reliance on a finding made by an Express Lane agency for the duration of the State's election under this paragraph;
(II) annually provide the Secretary with a statistically valid sample (that is approved by Secretary) of the children enrolled in such plans through reliance on such a finding by conducting a full Medicaid eligibility review of the children identified for such sample for purposes of determining an eligibility error rate (as described in clause (iv)) with respect to the enrollment of such children (and shall not include such children in any data or samples used for purposes of complying with a Medicaid Eligibility Quality Control (MEQC) review or a payment error rate measurement (PERM) requirement);
(III) submit the error rate determined under subclause (II) to the Secretary;
(IV) if such error rate exceeds 3 percent for either of the first 2 fiscal years in which the State elects to apply this paragraph, demonstrate to the satisfaction of the Secretary the specific corrective actions implemented by the State to improve upon such error rate; and
(V) if such error rate exceeds 3 percent for any fiscal year in which the State elects to apply this paragraph, a reduction in the amount otherwise payable to the State under
(ii)
(iii)
(iv)
(F)
(i)
(I) is determined by the State Medicaid agency or the State CHIP agency (as applicable) to be capable of making the determinations of one or more eligibility requirements described in subparagraph (A)(i);
(II) is identified in the State Medicaid plan or the State CHIP plan; and
(III) notifies the child's family—
(aa) of the information which shall be disclosed in accordance with this paragraph;
(bb) that the information disclosed will be used solely for purposes of determining eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan; and
(cc) that the family may elect to not have the information disclosed for such purposes; and
(IV) enters into, or is subject to, an interagency agreement to limit the disclosure and use of the information disclosed.
(ii)
(I) A public agency that determines eligibility for assistance under any of the following:
(aa) The temporary assistance for needy families program funded under part A of subchapter IV.
(bb) A State program funded under part D of subchapter IV.
(cc) The State Medicaid plan.
(dd) The State CHIP plan.
(ee) The Food and Nutrition Act of 2008 (
(ff) The Head Start Act [
(gg) The Richard B. Russell National School Lunch Act (
(hh) The Child Nutrition Act of 1966 (
(ii) The Child Care and Development Block Grant Act of 1990 [
(jj) The Stewart B. McKinney Homeless Assistance Act 1 (
(kk) The United States Housing Act of 1937 (
(ll) The Native American Housing Assistance and Self-Determination Act of 1996 (
(II) A State-specified governmental agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the State.
(III) A public agency that is subject to an interagency agreement limiting the disclosure and use of the information disclosed for purposes of determining eligibility under the State Medicaid plan or the State CHIP plan.
(IV) The Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (as defined in
(iii)
(iv)
(I) exempting a State Medicaid agency from complying with the requirements of
(II) authorizing a State Medicaid agency that elects to use Express Lane agencies under this subparagraph to use the Express Lane option to avoid complying with such requirements for purposes of making eligibility determinations under the State Medicaid plan.
(v)
(I)
(II)
(III)
(IV)
(V)
(G)
(H)
(I)
(14)
(A)
(B)
(C)
(D)
(i)
(I) Individuals who are eligible for medical assistance under the State plan or under a waiver of the plan on a basis that does not require a determination of income by the State agency administering the State plan or waiver, including as a result of eligibility for, or receipt of, other Federal or State aid or assistance, individuals who are eligible on the basis of receiving (or being treated as if receiving) supplemental security income benefits under subchapter XVI, and individuals who are eligible as a result of being or being deemed to be a child in foster care under the responsibility of the State.
(II) Individuals who have attained age 65.
(III) Individuals who qualify for medical assistance under the State plan or under any waiver of such plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits under subchapter XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of paragraph (3).
(IV) Individuals described in subsection (a)(10)(C).
(V) Individuals described in any clause of subsection (a)(10)(E).
(ii)
(iii)
(iv)
(v)
(E)
(F)
(G)
(H)
(i) the requirement under this subchapter and under the State plan or a waiver of the plan to determine an individual's income as of the point in time at which an application for medical assistance under the State plan or a waiver of the plan is processed; or
(ii) any rules established under this subchapter or under the State plan or a waiver of the plan regarding sources of countable income.
(I)
(i) determine the dollar equivalent of the difference between the upper income limit on eligibility for such an individual (expressed as a percentage of the poverty line) and such upper income limit increased by 5 percentage points; and
(ii) notwithstanding the requirement in subparagraph (A) with respect to use of modified adjusted gross income, utilize as the applicable income of such individual, in determining such income eligibility, an amount equal to the modified adjusted gross income applicable to such individual reduced by such dollar equivalent amount.
(J)
(K)
(i)
(I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000;
(II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000;
(III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and
(IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000.
(ii)
(iii)
(iv)
(I) before the date on which the individual loses such eligibility, inform the individual—
(aa) of the individual's opportunity to enroll in a qualified health plan offered through an Exchange established under title I of the Patient Protection and Affordable Care Act during the special enrollment period specified in section 9801(f)(3) of the Internal Revenue Code of 1986 (relating to loss of Medicaid or CHIP coverage); and
(bb) of the date on which the individual would no longer be considered ineligible by reason of clause (i) to receive medical assistance under the State plan or under any waiver of such plan and be eligible to reapply to receive such medical assistance; and
(II) provide technical assistance to the individual seeking to enroll in such a qualified health plan.
(v)
(vi)
(15)
(16)
(A)
(B)
(i) include all items and services covered under the State plan (or waiver) that are not less in amount, duration, or scope, or are determined by the Secretary to be substantially equivalent, to the medical assistance available for an individual described in subsection (a)(10)(A)(i); and
(ii) be provided for the individual while pregnant and during the 12-month period that begins on the last day of the individual's pregnancy and ends on the last day of the month in which such 12-month period ends.
(C)
(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) 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).
(h) Payments for hospitals serving disproportionate number of low-income patients and for home and community care
(1) 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, home and community-based services provided under subsection (c), (d), or (i) of
(2) Nothing in this subchapter, subchapter XVIII, or subchapter XI shall be construed as prohibiting receipt of any care or services specified in paragraph (1) in an acute care hospital that are—
(A) identified in an individual's person-centered service plan (or comparable plan of care);
(B) provided to meet needs of the individual that are not met through the provision of hospital services;
(C) not a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and
(D) designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual's functional abilities.
(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 13 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) Minimum coverage for individuals with income at or below 133 percent of the poverty line
(1) The medical assistance provided to an individual described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of benchmark coverage described in
(2) Beginning with the first day of any fiscal year quarter that begins on or after April 1, 2010, and before January 1, 2014, a State may elect through a State plan amendment to provide medical assistance to individuals who would be described in subclause (VIII) of subsection (a)(10)(A)(i) if that subclause were effective before January 1, 2014. A State may elect to phase-in the extension of eligibility for medical assistance to such individuals based on income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.
(3) If an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected) who is eligible for medical assistance under the State plan or under a waiver of such plan (under that subclause or under a State plan amendment under paragraph (2),14 the individual may not be enrolled under the State plan unless the individual's child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term "parent" includes an individual treated as a caretaker relative for purposes of carrying out
(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) 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 (or, beginning January 1, 2014, 133 percent) of the income official poverty line described in subparagraph (A) applicable to a family of the size involved.
(3) Notwithstanding subsection (a)(17), 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)—
(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;
(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;
(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 (except to the extent such methodology is inconsistent with clause (D) of subsection (a)(17)), 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), 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) 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) 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).
(C) The provisions of
(3) Notwithstanding subsection (a)(17), for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(X)—
(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), require or permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17), 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), 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 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 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 on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under subchapter XVIII 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 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) 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 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), 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 15 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) or under
(i) in the case of groups consisting of aged, blind, or disabled individuals, under the supplemental security income program under subchapter XVI, 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), 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) 16 , 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) 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), for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(XI)—
(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), 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) 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)—
(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) 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) may have and obtain medical assistance under the plan.
(2) For purposes of subsection (a)(10), 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.
(aa) Certain breast or cervical cancer patients
Individuals described in this subsection are individuals who—
(1) are not described in subsection (a)(10)(A)(i);
(2) have not attained age 65;
(3) have been screened for breast and cervical cancer under the Centers for Disease Control and Prevention breast and cervical cancer early detection program established under title XV of the Public Health Service Act (
(4) are not otherwise covered under creditable coverage, as defined in section 2701(c) 1 of the Public Health Service Act (
(bb) Payment for services provided by Federally-qualified health centers and rural health clinics
(1) In general
Beginning with fiscal year 2001 with respect to services furnished on or after January 1, 2001, and each succeeding fiscal year, the State plan shall provide for payment for services described in
(2) Fiscal year 2001
Subject to paragraph (4), for services furnished on and after January 1, 2001, during fiscal year 2001, the State plan shall provide for payment for such services in an amount (calculated on a per visit basis) that is equal to 100 percent of the average of the costs of the center or clinic of furnishing such services during fiscal years 1999 and 2000 which are reasonable and related to the cost of furnishing such services, or based on such other tests of reasonableness as the Secretary prescribes in regulations under
(3) Fiscal year 2002 and succeeding fiscal years
Subject to paragraph (4), for services furnished during fiscal year 2002 or a succeeding fiscal year, the State plan shall provide for payment for such services in an amount (calculated on a per visit basis) that is equal to the amount calculated for such services under this subsection for the preceding fiscal year—
(A) increased by the percentage increase in the MEI (as defined in
(B) adjusted to take into account any increase or decrease in the scope of such services furnished by the center or clinic during that fiscal year.
(4) Establishment of initial year payment amount for new centers or clinics
In any case in which an entity first qualifies as a Federally-qualified health center or rural health clinic after fiscal year 2000, the State plan shall provide for payment for services described in
(5) Administration in the case of managed care
(A) In general
In the case of services furnished by a Federally-qualified health center or rural health clinic pursuant to a contract between the center or clinic and a managed care entity (as defined in
(B) Payment schedule
The supplemental payment required under subparagraph (A) shall be made pursuant to a payment schedule agreed to by the State and the Federally-qualified health center or rural health clinic, but in no case less frequently than every 4 months.
(6) Alternative payment methodologies
Notwithstanding any other provision of this section, the State plan may provide for payment in any fiscal year to a Federally-qualified health center for services described in
(A) is agreed to by the State and the center or clinic; and
(B) results in payment to the center or clinic of an amount which is at least equal to the amount otherwise required to be paid to the center or clinic under this section.
(cc) Disabled children eligible to receive medical assistance at option of State
(1) Individuals described in this paragraph are individuals—
(A) who are children who have not attained 19 years of age and are born—
(i) on or after January 1, 2001 (or, at the option of a State, on or after an earlier date), in the case of the second, third, and fourth quarters of fiscal year 2007;
(ii) on or after October 1, 1995 (or, at the option of a State, on or after an earlier date), in the case of each quarter of fiscal year 2008; and
(iii) after October 1, 1989, in the case of each quarter of fiscal year 2009 and each quarter of any fiscal year thereafter;
(B) who would be considered disabled under
(C) whose family income does not exceed such income level as the State establishes and does not exceed—
(i) 300 percent of the poverty line (as defined in
(ii) such higher percent of such poverty line as a State may establish, except that—
(I) any medical assistance provided to an individual whose family income exceeds 300 percent of such poverty line may only be provided with State funds; and
(II) no Federal financial participation shall be provided under
(2)(A) If an employer of a parent of an individual described in paragraph (1) offers family coverage under a group health plan (as defined in section 2791(a) of the Public Health Service Act [
(i) notwithstanding
(ii) if such coverage is obtained—
(I) subject to paragraph (2) of section 1396o(h) 17 of this title, reduce the premium imposed by the State under that section in an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and
(II) treat such coverage as a third party liability under subsection (a)(25).
(B) In the case of a parent to which subparagraph (A) applies, a State, notwithstanding
(dd) Electronic transmission of information
If the State agency determining eligibility for medical assistance under this subchapter or child health assistance under subchapter XXI verifies an element of eligibility based on information from an Express Lane Agency 18 (as defined in subsection (e)(13)(F)), or from another public agency, then the applicant's signature under penalty of perjury shall not be required as to such element. Any signature requirement for an application for medical assistance may be satisfied through an electronic signature, as defined in section 1710(1) of the Government Paperwork Elimination Act (
(ee) Alternate State process for verification of citizenship or nationality declaration
(1) For purposes of subsection (a)(46)(B)(ii), the requirements of this subsection with respect to an individual declaring to be a citizen or national of the United States for purposes of establishing eligibility under this subchapter, are, in lieu of requiring the individual to present satisfactory documentary evidence of citizenship or nationality under
(A) The State submits the name and social security number of the individual to the Commissioner of Social Security as part of the program established under paragraph (2).
(B) If the State receives notice from the Commissioner of Social Security that the name or social security number, or the declaration of citizenship or nationality, of the individual is inconsistent with information in the records maintained by the Commissioner—
(i) the State makes a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the individual to confirm the accuracy of the name or social security number submitted or declaration of citizenship or nationality and by taking such additional actions as the Secretary, through regulation or other guidance, or the State may identify, and continues to provide the individual with medical assistance while making such effort; and
(ii) in the case such inconsistency is not resolved under clause (i), the State—
(I) notifies the individual of such fact;
(II) provides the individual with a period of 90 days from the date on which the notice required under subclause (I) is received by the individual to either present satisfactory documentary evidence of citizenship or nationality (as defined in
(III) disenrolls the individual from the State plan under this subchapter within 30 days after the end of such 90-day period if no such documentary evidence is presented or if such inconsistency is not resolved.
(2)(A) Each State electing to satisfy the requirements of this subsection for purposes of
(B) In establishing the State program under this paragraph, the State may enter into an agreement with the Commissioner of Social Security—
(i) to provide, through an on-line system or otherwise, for the electronic submission of, and response to, the information submitted under subparagraph (A) for an individual enrolled in the State plan under this subchapter who declares to be 19 citizen or national on at least a monthly basis; or
(ii) to provide for a determination of the consistency of the information submitted with the information maintained in the records of the Commissioner through such other method as agreed to by the State and the Commissioner and approved by the Secretary, provided that such method is no more burdensome for individuals to comply with than any burdens that may apply under a method described in clause (i).
(C) The program established under this paragraph shall provide that, in the case of any individual who is required to submit a social security number to the State under subparagraph (A) and who is unable to provide the State with such number, shall be provided with at least the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality (as defined in
(3)(A) The State agency implementing the plan approved under this subchapter shall, at such times and in such form as the Secretary may specify, provide information on the percentage each month that the inconsistent submissions bears to the total submissions made for comparison for such month. For purposes of this subparagraph, a name, social security number, or declaration of citizenship or nationality of an individual shall be treated as inconsistent and included in the determination of such percentage only if—
(i) the information submitted by the individual is not consistent with information in records maintained by the Commissioner of Social Security;
(ii) the inconsistency is not resolved by the State;
(iii) the individual was provided with a reasonable period of time to resolve the inconsistency with the Commissioner of Social Security or provide satisfactory documentation of citizenship status and did not successfully resolve such inconsistency; and
(iv) payment has been made for an item or service furnished to the individual under this subchapter.
(B) If, for any fiscal year, the average monthly percentage determined under subparagraph (A) is greater than 3 percent—
(i) the State shall develop and adopt a corrective plan to review its procedures for verifying the identities of individuals seeking to enroll in the State plan under this subchapter and to identify and implement changes in such procedures to improve their accuracy; and
(ii) pay to the Secretary an amount equal to the amount which bears the same ratio to the total payments under the State plan for the fiscal year for providing medical assistance to individuals who provided inconsistent information as the number of individuals with inconsistent information in excess of 3 percent of such total submitted bears to the total number of individuals with inconsistent information.
(C) The Secretary may waive, in certain limited cases, all or part of the payment under subparagraph (B)(ii) if the State is unable to reach the allowable error rate despite a good faith effort by such State.
(D) Subparagraphs (A) and (B) shall not apply to a State for a fiscal year if there is an agreement described in paragraph (2)(B) in effect as of the close of the fiscal year that provides for the submission on a real-time basis of the information described in such paragraph.
(4) Nothing in this subsection shall affect the rights of any individual under this subchapter to appeal any disenrollment from a State plan.
(ff) Disregard of certain property in determination of eligibility of Indians
Notwithstanding any other requirement of this subchapter or any other provision of Federal or State law, a State shall disregard the following property from resources for purposes of determining the eligibility of an individual who is an Indian for medical assistance under this subchapter:
(1) Property, including real property and improvements, that is held in trust, subject to Federal restrictions, or otherwise under the supervision of the Secretary of the Interior, located on a reservation, including any federally recognized Indian Tribe's reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act [
(2) For any federally recognized Tribe not described in paragraph (1), property located within the most recent boundaries of a prior Federal reservation.
(3) Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally protected rights.
(4) Ownership interests in or usage rights to items not covered by paragraphs (1) through (3) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.
(gg) Maintenance of effort
(1) General requirement to maintain eligibility standards until State exchange is fully operational
Subject to the succeeding paragraphs of this subsection, during the period that begins on March 23, 2010, and ends on the date on which the Secretary determines that an Exchange established by the State under
(2) Continuation of eligibility standards for children through September 30, 2029
The requirement under paragraph (1) shall continue to apply to a State through September 30, 2029, (but during the period that begins on October 1, 2019, and ends on September 30, 2029, only with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in
(3) Nonapplication
During the period that begins on January 1, 2011, and ends on December 31, 2013, the requirement under paragraph (1) shall not apply to a State with respect to nonpregnant, nondisabled adults who are eligible for medical assistance under the State plan or under a waiver of the plan at the option of the State and whose income exceeds 133 percent of the poverty line (as defined in
(4) Determination of compliance
(A) States shall apply modified adjusted gross income
A State's determination of income in accordance with subsection (e)(14) shall not be considered to be eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on March 23, 2010, for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).
(B) States may expand eligibility or move waivered populations into coverage under the State plan
With respect to any period applicable under paragraph (1), (2), or (3), a State that applies eligibility standards, methodologies, or procedures under the State plan under this subchapter or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, applied under the State plan or under a waiver of the plan on March 23, 2010, or that makes individuals who, on March 23, 2010, are eligible for medical assistance under a waiver of the State plan, after March 23, 2010, eligible for medical assistance through a State plan amendment with an income eligibility level that is not less than the income eligibility level that applied under the waiver, or as a result of the application of subclause (VIII) of subsection (a)(10)(A)(i), shall not be considered to have in effect eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on March 23, 2010, for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).
(hh) State option for coverage for individuals with income that exceeds 133 percent of the poverty line
(1) A State may elect to phase-in the extension of eligibility for medical assistance to individuals described in subclause (XX) of subsection (a)(10)(A)(ii) based on the categorical group (including nonpregnant childless adults) or income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.
(2) If an individual described in subclause (XX) of subsection (a)(10)(A)(ii) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected) who is eligible for medical assistance under the State plan or under a waiver of such plan, the individual may not be enrolled under the State plan unless the individual's child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term "parent" includes an individual treated as a caretaker relative for purposes of carrying out
(ii) State eligibility option for family planning services
(1) Individuals described in this subsection are individuals—
(A) whose income does not exceed an income eligibility level established by the State that does not exceed the highest income eligibility level established under the State plan under this subchapter (or under its State child health plan under subchapter XXI) for pregnant women; and
(B) who are not pregnant.
(2) At the option of a State, individuals described in this subsection may include individuals who, had individuals applied on or before January 1, 2007, would have been made eligible pursuant to the standards and processes imposed by that State for benefits described in clause (XVI) of the matter following subparagraph (G) of section 20 subsection (a)(10) pursuant to a waiver granted under
(3) At the option of a State, for purposes of subsection (a)(17)(B), in determining eligibility for services under this subsection, the State may consider only the income of the applicant or recipient.
(jj) Primary care services defined
For purposes of subsection (a)(13)(C), the term "primary care services" means—
(1) evaluation and management services that are procedure codes (for services covered under subchapter XVIII) for services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System (established by the Secretary under
(2) services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such System.
(kk) Provider and supplier screening, oversight, and reporting requirements
For purposes of subsection (a)(77), the requirements of this subsection are the following:
(1) Screening
The State complies with the process for screening providers and suppliers under this subchapter, as established by the Secretary under
(2) Provisional period of enhanced oversight for new providers and suppliers
The State complies with procedures to provide for a provisional period of enhanced oversight for new providers and suppliers under this subchapter, as established by the Secretary under
(3) Disclosure requirements
The State requires providers and suppliers under the State plan or under a waiver of the plan to comply with the disclosure requirements established by the Secretary under
(4) Temporary moratorium on enrollment of new providers or suppliers
(A) Temporary moratorium imposed by the Secretary
(i) In general
Subject to clause (ii), the State complies with any temporary moratorium on the enrollment of new providers or suppliers imposed by the Secretary under
(ii) Exceptions
(I) Compliance with moratorium
A State shall not be required to comply with a temporary moratorium described in clause (i) if the State determines that the imposition of such temporary moratorium would adversely impact beneficiaries' access to medical assistance.
(II) FFP available
Notwithstanding
(iii) Limitation on charges to beneficiaries
With respect to any amount expended for items or services furnished during calendar quarters beginning on or after October 1, 2017, the State prohibits, during the period of a temporary moratorium described in clause (i), a provider meeting the requirements specified in subparagraph (C)(iii) of
(B) Moratorium on enrollment of providers and suppliers
At the option of the State, the State imposes, for purposes of entering into participation agreements with providers or suppliers under the State plan or under a waiver of the plan, periods of enrollment moratoria, or numerical caps or other limits, for providers or suppliers identified by the Secretary as being at high-risk for fraud, waste, or abuse as necessary to combat fraud, waste, or abuse, but only if the State determines that the imposition of any such period, cap, or other limits would not adversely impact beneficiaries' access to medical assistance.
(5) Compliance programs
The State requires providers and suppliers under the State plan or under a waiver of the plan to establish, in accordance with the requirements of section 1395cc(j)(7) 1 of this title, a compliance program that contains the core elements established under subparagraph (B) of that section 1395cc(j)(7) 1 of this title for providers or suppliers within a particular industry or category.
(6) Reporting of adverse provider actions
The State complies with the national system for reporting criminal and civil convictions, sanctions, negative licensure actions, and other adverse provider actions to the Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, in accordance with regulations of the Secretary.
(7) Enrollment and NPI of ordering or referring providers
The State requires—
(A) all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the plan as a participating provider; and
(B) the national provider identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional.
(8) Provider terminations
(A) In general
Beginning on July 1, 2018, in the case of a notification under subsection (a)(41) with respect to a termination for a reason specified in section 455.101 of title 42, Code of Federal Regulations (as in effect on November 1, 2015) or for any other reason specified by the Secretary, of the participation of a provider of services or any other person under the State plan (or under a waiver of the plan), the State, not later than 30 days after the effective date of such termination, submits to the Secretary with respect to any such provider or person, as appropriate—
(i) the name of such provider or person;
(ii) the provider type of such provider or person;
(iii) the specialty of such provider's or person's practice;
(iv) the date of birth, Social Security number, national provider identifier (if applicable), Federal taxpayer identification number, and the State license or certification number of such provider or person (if applicable);
(v) the reason for the termination;
(vi) a copy of the notice of termination sent to the provider or person;
(vii) the date on which such termination is effective, as specified in the notice; and
(viii) any other information required by the Secretary.
(B) Effective date defined
For purposes of this paragraph, the term "effective date" means, with respect to a termination described in subparagraph (A), the later of—
(i) the date on which such termination is effective, as specified in the notice of such termination; or
(ii) the date on which all appeal rights applicable to such termination have been exhausted or the timeline for any such appeal has expired.
(9) Other State oversight
Nothing in this subsection shall be interpreted to preclude or limit the ability of a State to engage in provider and supplier screening or enhanced provider and supplier oversight activities beyond those required by the Secretary.
(ll) Termination notification database
In the case of a provider of services or any other person whose participation under this subchapter or subchapter XXI is terminated (as described in subsection (kk)(8)), the Secretary shall, not later than 30 days after the date on which the Secretary is notified of such termination under subsection (a)(41) (as applicable), review such termination and, if the Secretary determines appropriate, include such termination in any database or similar system developed pursuant to section 6401(b)(2) of the Patient Protection and Affordable Care Act (
(mm) Directory physician or provider described
A physician or provider described in this subsection is—
(1) in the case of a physician or provider of a provider type for which the State agency, as a condition on receiving payment for items and services furnished by the physician or provider to individuals eligible to receive medical assistance under the State plan, requires the enrollment of the physician or provider with the State agency, a physician or a provider that—
(A) is enrolled with the agency as of the date on which the directory is published or updated (as applicable) under subsection (a)(83); and
(B) received payment under the State plan in the 12-month period preceding such date; and
(2) in the case of a physician or provider of a provider type for which the State agency does not require such enrollment, a physician or provider that received payment under the State plan (or a waiver of the plan) in the 12-month period preceding the date on which the directory is published or updated (as applicable) under subsection (a)(83).
(nn) Juvenile; eligible juvenile; public institution
For purposes of subsection (a)(84) and this subsection:
(1) Juvenile
The term "juvenile" means an individual who is—
(A) under 21 years of age; or
(B) described in subsection (a)(10)(A)(i)(IX).
(2) Eligible juvenile
The term "eligible juvenile" means a juvenile who is an inmate of a public institution and who—
(A) was determined eligible for medical assistance under the State plan (or waiver of such plan) immediately before becoming an inmate of such a public institution; or
(B) is determined eligible for such medical assistance while an inmate of a public institution.
(3) Inmate of a public institution
The term "inmate of a public institution" has the meaning given such term for purposes of applying the subdivision (A) following the last numbered paragraph of
(oo) Drug review and utilization requirements
(1) In general
For purposes of subsection (a)(85), the drug review and utilization requirements under this subsection are, subject to paragraph (3) and beginning October 1, 2019, the following:
(A) Claims review limitations
(i) In general
The State has in place—
(I) safety edits (as specified by the State) for subsequent fills for opioids and a claims review automated process (as designed and implemented by the State) that indicates when an individual enrolled under the State plan (or under a waiver of the State plan) is prescribed a subsequent fill of opioids in excess of any limitation that may be identified by the State;
(II) safety edits (as specified by the State) on the maximum daily morphine equivalent that can be prescribed to an individual enrolled under the State plan (or under a waiver of the State plan) for treatment of chronic pain and a claims review automated process (as designed and implemented by the State) that indicates when an individual enrolled under the plan (or waiver) is prescribed the morphine equivalent for such treatment in excess of any limitation that may be identified by the State; and
(III) a claims review automated process (as designed and implemented by the State) that monitors when an individual enrolled under the State plan (or under a waiver of the State plan) is concurrently prescribed opioids and—
(aa) benzodiazepines; or
(bb) antipsychotics.
(ii) Managed care entities
The State requires each managed care entity (as defined in
(iii) Rules of construction
Nothing in this subparagraph may be construed as prohibiting a State or managed care entity from designing and implementing a claims review automated process under this subparagraph that provides for prospective or retrospective reviews of claims. Nothing in this subparagraph shall be understood as prohibiting the exercise of clinical judgment from a provider enrolled as a participating provider in a State plan (or waiver of the State plan) or contracting with a managed care entity regarding the best items and services for an individual enrolled under such State plan (or waiver).
(B) Program to monitor antipsychotic medications by children
The State has in place a program (as designed and implemented by the State) to monitor and manage the appropriate use of antipsychotic medications by children enrolled under the State plan (or under a waiver of the State plan) and submits annually to the Secretary such information as the Secretary may require on activities carried out under such program for individuals not more than the age of 18 years generally and children in foster care specifically.
(C) Fraud and abuse identification
The State has in place a process (as designed and implemented by the State) that identifies potential fraud or abuse of controlled substances by individuals enrolled under the State plan (or under a waiver of the State plan), health care providers prescribing drugs to individuals so enrolled, and pharmacies dispensing drugs to individuals so enrolled.
(D) Reports
The State shall include in the annual report submitted to the Secretary under
(E) Clarification
Nothing shall prevent a State from satisfying the requirement—
(i) described in subparagraph (A) by having safety edits or a claims review automated process described in such subparagraph that was in place before October 1, 2019;
(ii) described in subparagraph (B) by having a program described in such subparagraph that was in place before such date; or
(iii) described in subparagraph (C) by having a process described in such subparagraph that was in place before such date.
(2) Annual report by Secretary
For each fiscal year beginning with fiscal year 2020, the Secretary shall submit to Congress a report on the most recent information submitted by States under paragraph (1)(D).
(3) Exceptions
(A) Certain individuals exempted
The drug review and utilization requirements under this subsection shall not apply with respect to an individual who—
(i) is receiving—
(I) hospice or palliative care; or
(II) treatment for cancer;
(ii) is a resident of a long-term care facility, of a facility described in
(iii) the State elects to treat as exempted from such requirements.
(B) Exception relating to ensuring access
In order to ensure reasonable access to health care, the Secretary shall waive the drug review and utilization requirements under this subsection, with respect to a State, in the case of natural disasters and similar situations, and in the case of the provision of emergency services (as defined for purposes of
(pp) Residential pediatric recovery center defined
(1) In general
For purposes of
(2) Counseling and services
A residential pediatric recovery center may offer counseling and other services to mothers (and other appropriate family members and caretakers) of infants receiving treatment at such centers if such services are otherwise covered under the State plan under this subchapter or under a waiver of such plan. Such other services may include the following:
(A) Counseling or referrals for services.
(B) Activities to encourage caregiver-infant bonding.
(C) Training on caring for such infants.
(qq) Application of certain data reporting and program integrity requirements to Northern Mariana Islands, American Samoa, and Guam
(1) In general
Not later than October 1, 2021, the Northern Mariana Islands, American Samoa, and Guam shall—
(A) demonstrate progress in implementing methods, satisfactory to the Secretary, for the collection and reporting of reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system); and
(B) demonstrate progress in establishing a State medicaid fraud control unit described in
(2) Determination of progress
For purposes of paragraph (1), the Secretary shall deem that a territory described in such paragraph has demonstrated satisfactory progress in implementing methods for the collection and reporting of reliable data or establishing a State medicaid fraud control unit if the territory has made a good faith effort to implement such methods or establish such a unit, given the circumstances of the territory.
(rr) Program integrity requirements for Puerto Rico
(1) System for tracking Federal Medicaid funding provided to Puerto Rico
(A) In general
Puerto Rico shall establish and maintain a system, which may include the use of a quarterly Form CMS–64, for tracking any amounts paid by the Federal Government to Puerto Rico with respect to the State plan of Puerto Rico (or a waiver of such plan). Under such system, Puerto Rico shall ensure that information is available, with respect to each quarter in a fiscal year (beginning with the first quarter beginning on or after the date that is 1 year after December 20, 2019), on the following:
(i) In the case of a quarter other than the first quarter of such fiscal year—
(I) the total amount expended by Puerto Rico during any previous quarter of such fiscal year under the State plan of Puerto Rico (or a waiver of such plan); and
(II) a description of how such amount was so expended.
(ii) The total amount that Puerto Rico expects to expend during the quarter under the State plan of Puerto Rico (or a waiver of such plan), and a description of how Puerto Rico expects to expend such amount.
(B) Report to CMS
For each quarter with respect to which Puerto Rico is required under subparagraph (A) to ensure that information described in such subparagraph is available, Puerto Rico shall submit to the Administrator of the Centers for Medicare & Medicaid Services a report on such information for such quarter, which may include the submission of a quarterly Form CMS–37.
(2) Submission of documentation on contracts upon request
Puerto Rico shall, upon request, submit to the Administrator of the Centers for Medicare & Medicaid Services all documentation requested with respect to contracts awarded under the State plan of Puerto Rico (or a waiver of such plan).
(3) Reporting on Medicaid and CHIP Scorecard measures
Beginning 12 months after December 20, 2019, Puerto Rico shall begin to report to the Administrator of the Centers for Medicare & Medicaid Services on selected measures included in the Medicaid and CHIP Scorecard developed by the Centers for Medicare & Medicaid Services.
(ss) Uninsured individual defined
For purposes of this section, the term "uninsured individual" means, notwithstanding any other provision of this subchapter, any individual who is—
(1) not described in subsection (a)(10)(A)(i) (excluding subclause (VIII) of such subsection if the individual is a resident of a State which does not furnish medical assistance to individuals described in such subclause); and
(2) not enrolled in a Federal health care program (as defined in
(tt) Requirements relating to transition from Families First Coronavirus Response Act FMAP increase requirements; enforcement and corrective action
(1) Reporting requirements
For each month occurring during the period that begins on April 1, 2023, and ends on June 30, 2024, each State shall submit to the Secretary, on a timely basis, a report, that the Secretary shall make publicly available, on the activities of the State relating to eligibility redeterminations conducted during such period, and which include, with respect to the month for which the report is submitted, the following information:
(A) The number of eligibility renewals initiated, beneficiaries renewed on a total and ex parte basis, and individuals whose coverage for medical assistance, child health assistance, or pregnancy-related assistance was terminated.
(B) The number of individuals whose coverage for medical assistance, child health assistance, or pregnancy-related assistance was so terminated for procedural reasons.
(C) Where applicable, the number of individuals who were enrolled in a State child health plan or waiver in the form described in paragraph (1) of
(D) Unless the Administrator of the Centers for Medicare & Medicaid Services reports such information on behalf of the State:
(i) In a State with a Federal or State American Health Benefit Exchange established under title I of the Patient Protection and Affordable Care Act in which the systems used to determine eligibility for assistance under this subchapter or subchapter XXI are not integrated with the systems used to determine eligibility for coverage under a qualified health plan with advance payment under section 1412(a) of the Patient Protection and Affordable Care Act [
(I) the number of individuals whose accounts were received via secure electronic transfer by the Federal or State American Health Benefit Exchange, or a basic health program established under section 1331 of the Patient Protection and Affordable Care Act [
(II) the number of individuals identified in subclause (I) who were determined eligible for a qualified health plan, as defined in section 1301(a)(1) of the Patient Protection and Affordable Care Act [
(III) the number of individuals identified in subclause (II) who made a qualified health plan selection or were enrolled in a basic health program plan (if applicable).
(ii) In a State with a State American Health Benefit Exchange established under title I of the Patient Protection and Affordable Care Act in which the systems used to determine eligibility for assistance under this subchapter or subchapter XXI are integrated with the systems used to determine eligibility for coverage under a qualified health plan with advance payment under section 1412(a) of the Patient Protection and Affordable Care Act [
(I) the number of individuals who were determined eligible for a qualified health plan, as defined in section 1301(a)(1) of the Patient Protection and Affordable Care Act [
(II) the number of individuals identified in subclause (I) who made a qualified health plan selection or were enrolled in a basic health program plan (if applicable).
(E) The total call center volume, average wait times, and average abandonment rate (as determined by the Secretary) for each call center of the State agency responsible for administering the State plan under this subchapter (or a waiver of such plan) during such month.
(F) Such other information related to eligibility redeterminations and renewals during the period described in paragraph (1), as identified by the Secretary.
(2) Enforcement and corrective action
(A) In general
For each fiscal quarter that occurs during the period that begins on July 1, 2023, and ends on June 30, 2024, if a State does not satisfy the requirements of paragraph (1), the Federal medical assistance percentage determined for the State for the quarter under
(B) Corrective action plan; additional authority
(i) In general
The Secretary may assess a State's compliance with all Federal requirements applicable to eligibility redeterminations and the reporting requirements described in paragraph (1), and, if the Secretary determines that a State did not comply with any such requirements during the period that begins on April 1, 2023, and ends on June 30, 2024, the Secretary may require the State to submit and implement a corrective action plan in accordance with clause (ii).
(ii) Corrective action plan
A State that receives a written notice from the Secretary that the Secretary has determined that the State is not in compliance with a requirement described in clause (i) shall—
(I) not later than 14 days after receiving such notice, submit a corrective action plan to the Secretary;
(II) not later than 21 days after the date on which such corrective action plan is submitted to the Secretary, receive approval for the plan from the Secretary; and
(III) begin implementation of such corrective action plan not later than 14 days after such approval.
(iii) Effect of failure to submit or implement a corrective action plan
If a State fails to submit or implement an approved corrective action plan in accordance with clause (ii), the Secretary may, in addition to any reduction applied under subparagraph (A) to the Federal medical assistance percentage determined for the State and any other remedy available to the Secretary for the purpose of carrying out this subchapter, require the State to suspend making all or some terminations of eligibility for medical assistance from the State plan under this subchapter (including any waiver of such plan) that are for procedural reasons until the State takes appropriate corrective action, as determined by the Secretary, and may impose a civil money penalty of not more than $100,000 for each day a State is not in compliance.
(Aug. 14, 1935, ch. 531, title XIX, §1902, as added
Amendment of Section
(1) in the subparagraph heading, by striking "by children";
(2) by striking "children enrolled" and inserting "children generally, children in foster care specifically, individuals over the age of 18 receiving home and community-based services (as defined in section 9817(a)(2)(B) of
(3) by striking "not more than the age of 18 years" through the period at the end and inserting "subject to the program, including information with respect to each such category of children and individuals over the age of 18."
See 2024 Amendment note below.
(1) by striking "who is an eligible juvenile (as defined in subsection (nn)(2))";
(2) by striking "because the juvenile" and inserting "because the individual";
(3) by striking "during the period the juvenile" and inserting "during the period the individual";
(4) by inserting "such an individual who is an eligible juvenile (as defined in subsection (nn)(2)) and" after "or in the case of"; and
(5) by striking "paragraph (31)" and inserting "the last numbered paragraph".
See 2024 Amendment notes below.
(1) in subsection (a), by striking paragraph (83) and inserting the following:
"(83) provide that in the case of a State plan (or waiver of the plan) that provides medical assistance on a fee-for-service basis or through a primary care case-management system described in
"(A) the name of the provider;
"(B) the specialty of the provider;
"(C) the address at which the provider provides services;
"(D) the telephone number of the provider;
"(E) information regarding—
"(i) the provider's cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or by a skilled medical interpreter who provides interpretation services at the provider's office;
"(ii) whether the provider is accepting as new patients individuals who receive medical assistance under this subchapter;
"(iii) whether the provider's office or facility has accommodations for individuals with physical disabilities, including offices, exam rooms, and equipment;
"(iv) the Internet website of such provider, if applicable; and
"(v) whether the provider offers covered services via telehealth; and
"(F) other relevant information as required by the Secretary;"; and
(2) by striking subsection (mm) and inserting the following:
"(mm) Directory provider described
"(1) In general
"A provider described in this subsection, at a minimum, includes physicians, hospitals, pharmacies, providers of mental health services, providers of substance use disorder services, providers of long term services and supports as appropriate, and such other providers as required by the Secretary, and—
"(A) in the case of a provider or a provider type for which the State agency, as a condition of receiving payment for items and services furnished by the provider to individuals eligible to receive medical assistance under the State plan (or a waiver of the plan), requires the enrollment of the provider with the State agency, includes a provider that—
"(i) is enrolled with the agency as of the date on which the directory is published or updated (as applicable) under subsection (a)(83); and
"(ii) received payment under the State plan in the 12-month period preceding such date; and
"(B) in the case of a provider or a provider type for which the State agency does not require such enrollment, includes a provider that received payment under the State plan (or a waiver of the plan) in the 12-month period preceding the date on which the directory is published or updated (as applicable) under subsection (a)(83).
"(2) State option to include other participating providers
"At State option, a provider described in this subsection may include any provider who furnishes services and is participating under the State plan under this subchapter or under a waiver of such plan."
See 2022 Amendment notes below.
Editorial Notes
References in Text
The Child Nutrition Act of 1966, referred to in subsecs. (a)(7) and (e)(13)(F)(ii)(I)(hh), is
The Richard B. Russell National School Lunch Act, referred to in subsecs. (a)(7) and (e)(13)(F)(ii)(I)(gg), is act June 4, 1946, ch. 281,
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)(aa), is the date of enactment 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
Section 6401(b)(2) of the Patient Protection and Affordable Care Act, referred to in subsecs. (a)(39) and (ll), is section 6401(b)(2) of
The Food and Nutrition Act of 2008, referred to in subsec. (e)(13)(F)(ii)(I)(ee), is
The Head Start Act, referred to in subsec. (e)(13)(F)(ii)(I)(ff), is subchapter B (§635 et seq.) of
The Child Care and Development Block Grant Act of 1990, referred to in subsec. (e)(13)(F)(ii)(I)(ii), is subchapter C (§658A et seq.) of
The Stewart B. McKinney Homeless Assistance Act, referred to in subsec. (e)(13)(F)(ii)(I)(jj), was
The United States Housing Act of 1937, referred to in subsec. (e)(13)(F)(ii)(I)(kk), is act Sept. 1, 1937, ch. 896, as revised generally by
The Native American Housing Assistance and Self-Determination Act of 1996, referred to in subsec. (e)(13)(F)(ii)(I)(ll), is
The Internal Revenue Code of 1986, referred to in subsecs. (e)(14)(G), (K)(iv)(I)(aa), (v), (u)(3), (ss)(2), and (tt)(1)(D)(i), (ii), is classified generally to Title 26, Internal Revenue Code.
The Patient Protection and Affordable Care Act, referred to in subsecs. (e)(14)(K)(iv)(I)(aa) and (tt)(1)(D)(i), (ii), is
The Public Health Service Act, referred to in subsecs. (u)(3) and (aa)(3), is act July 1, 1944, ch. 373,
The Employee Retirement Income Security Act of 1974, referred to in subsec. (u)(3), is
Section 2701 of the Public Health Service Act, referred to in subsec. (aa)(4), is section 2701 of act July 1, 1944, which was classified to
Section 1710(1) of the Government Paperwork Elimination Act, referred to in subsec. (dd), is section 1710(1) of
The Alaska Native Claims Settlement Act, referred to in subsec. (ff)(1), is
The Families First Coronavirus Response Act, referred to in subsec. (tt), is
Codification
In subsec. (a)(4)(D), "
Amendments
2024—Subsec. (a)(84)(A).
Subsec. (nn)(2)(A).
Subsec. (nn)(3).
Subsec. (oo)(1)(B).
2022—Subsec. (a)(10)(A).
Subsec. (a)(10)(C)(iv).
Subsec. (a)(25)(I)(ii).
Subsec. (a)(25)(I)(iii).
Subsec. (a)(25)(I)(iv).
Subsec. (a)(83).
Subsec. (a)(84)(A).
Subsec. (a)(84)(D).
Subsec. (e)(12).
"(A) the end of a period (not to exceed 12 months) following the determination; or
"(B) the time that the individual exceeds that age."
Subsec. (e)(13)(I).
Subsec. (gg)(2).
Subsec. (mm).
Subsec. (nn)(3).
Subsec. (tt).
2021—Subsec. (a)(10).
Subsec. (e)(16).
2020—Subsec. (a)(4)(A).
Subsec. (a)(10).
Subsec. (a)(10)(A).
Subsec. (a)(10)(A)(ii)(XXIII).
Subsec. (a)(10)(E)(iii), (iv).
Subsec. (a)(55).
Subsec. (a)(87).
Subsec. (h).
Subsec. (ss).
Subsec. (ss)(1).
Subsec. (ss)(2).
2019—Subsec. (a)(25)(F)(i).
Subsec. (j).
Subsec. (qq).
Subsec. (rr).
2018—Subsec. (a)(10)(A).
Subsec. (a)(10)(A)(i)(IX)(bb).
Subsec. (a)(10)(A)(i)(IX)(cc).
Subsec. (a)(10)(A)(i)(IX)(dd).
Subsec. (a)(17).
Subsec. (a)(25)(B).
Subsec. (a)(25)(E).
Subsec. (a)(25)(H).
Subsec. (a)(25)(I)(i).
Subsec. (a)(84).
Subsec. (a)(85).
Subsec. (a)(86).
Subsec. (e)(13)(I).
Subsec. (e)(14).
Subsec. (e)(14)(J).
Subsec. (e)(14)(K).
Subsec. (e)(15).
Subsec. (gg)(2).
Subsec. (nn).
Subsec. (oo).
Subsec. (pp).
2016—Subsec. (a)(39).
Subsec. (a)(41).
Subsec. (a)(78).
Subsec. (a)(82).
Subsec. (a)(83).
Subsec. (kk)(1), (2).
Subsec. (kk)(3).
Subsec. (kk)(4)(A)(i).
Subsec. (kk)(4)(A)(ii).
Subsec. (kk)(4)(A)(iii).
Subsec. (kk)(8), (9).
Subsec. (ll).
Subsec. (mm).
2015—Subsec. (a)(10)(E)(iv).
Subsec. (a)(17).
Subsec. (e)(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 March 31, 2015. 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
Subsec. (e)(13)(I).
Subsec. (e)(14).
2014—Subsec. (a)(10)(E)(iv).
Subsec. (e)(1)(B).
Subsec. (e)(13)(I).
2013—Subsec. (a)(10)(E)(iv).
Subsec. (a)(25)(B).
Subsec. (a)(25)(E)(i).
Subsec. (a)(25)(F)(i).
Subsec. (a)(25)(H).
Subsec. (a)(81) to (83).
Subsec. (e)(1)(B).
Subsec. (e)(13)(I).
2012—Subsec. (a)(10)(E)(iv).
Subsec. (e)(1)(B).
2011—Subsec. (a)(10)(E)(iv).
Subsec. (e)(1)(B).
2010—Subsec. (a)(7).
"(A) the administration of the plan; and
"(B) at State option, the exchange of information necessary to verify the certification of eligibility of children for free or reduced price breakfasts under the Child Nutrition Act of 1966 and free or reduced price lunches under the Richard B. Russell National School Lunch Act, in accordance with section 9(b) of that Act, using data standards and formats established by the State agency;".
Subsec. (a)(9)(D).
Subsec. (a)(10).
Subsec. (a)(10)(A).
Subsec. (a)(10)(A)(i)(VIII).
Subsec. (a)(10)(A)(i)(IX).
Subsec. (a)(10)(A)(ii)(XX).
Subsec. (a)(10)(A)(ii)(XXI).
Subsec. (a)(10)(A)(ii)(XXII).
Subsec. (a)(10)(E)(iv).
Subsec. (a)(13)(C).
Subsec. (a)(17).
Subsec. (a)(23).
Subsec. (a)(39).
Subsec. (a)(42).
Subsec. (a)(47).
Subsec. (a)(47)(A).
Subsec. (a)(47)(B).
Subsec. (a)(74).
Subsec. (a)(75).
Subsec. (a)(76).
Subsec. (a)(77).
Subsec. (a)(78).
"(A) has unpaid overpayments (as defined by the Secretary) under this subchapter during such period determined by the Secretary or the State agency to be delinquent;
"(B) is suspended or excluded from participation under or whose participation is terminated under this subchapter during such period; or
"(C) is affiliated with an individual or entity that has been suspended or excluded from participation under this subchapter or whose participation is terminated under this subchapter during such period;".
Subsec. (a)(79).
Subsec. (a)(80).
Subsec. (a)(81).
Subsec. (a)(82).
Subsec. (a)(83).
Subsec. (e)(1)(B).
Subsec. (e)(13)(F)(ii).
Subsec. (e)(14).
Subsec. (e)(14)(B).
Subsec. (e)(14)(I).
Subsec. (k).
Subsec. (k)(2).
Subsec. (l)(2)(C).
Subsec. (gg).
Subsec. (gg)(4)(A).
Subsec. (hh).
Subsec. (ii).
Subsec. (ii)(2).
Subsec. (jj).
Subsec. (kk).
2009—Subsec. (a)(10)(E)(iv).
Subsec. (a)(25)(I)(i).
Subsec. (a)(43)(D)(iii).
Subsec. (a)(46).
Subsec. (a)(72).
Subsec. (a)(73).
Subsec. (e)(1)(B).
Subsec. (e)(4).
Subsec. (e)(13).
Subsec. (dd).
Subsec. (ee).
Subsec. (ff).
2008—Subsec. (a)(10)(E)(iv).
Subsec. (a)(71).
2007—Subsec. (a)(10)(E)(iv).
2006—Subsec. (a)(10)(A)(i)(II).
Subsec. (a)(10)(A)(ii)(XIX).
Subsec. (a)(25)(A).
Subsec. (a)(25)(G).
Subsec. (a)(25)(I).
Subsec. (a)(68).
Subsec. (a)(69).
Subsec. (a)(70).
Subsec. (cc).
Subsec. (cc)(2).
2005—Subsec. (a)(10)(E)(iv).
2004—Subsec. (a)(7).
Subsec. (a)(10)(E)(iv).
2003—Subsec. (a)(10)(E)(iv).
Subsec. (a)(66).
Subsec. (a)(67).
Subsec. (e)(1)(B).
2002—Subsec. (a)(15).
Subsec. (aa).
Subsec. (aa)(4).
Subsec. (bb).
2000—Subsec. (a)(10).
Subsec. (a)(10)(A)(ii)(XVIII).
Subsec. (a)(13)(A)(iv).
Subsec. (a)(13)(B).
Subsec. (a)(13)(C).
Subsec. (a)(15).
Subsec. (a)(47).
Subsec. (e)(1)(B).
Subsec. (aa).
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, 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)(10)(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).
Subsec. (a)(10)(A).
Subsec. (a)(10)(C), (D).
Subsec. (a)(10)(C)(i).
Subsec. (a)(10)(C)(ii)(I).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2024 Amendment
"(A) subparagraph (A) of paragraph (1) [amending this section] shall take effect on the date of the enactment of this Act [Mar. 9, 2024]; and
"(B) subparagraphs (B) through (F) of paragraph (1) [amending this section] shall take effect on January 1, 2026."
Effective Date of 2022 Amendment
"(1)
"(2)
Effective Date of 2021 Amendment
[
Effective Date of 2020 Amendment
"(i)
"(ii)
Amendment by section 210(b) of
Effective Date of 2019 Amendment
Effective Date of 2018 Amendment
"(1)
"(2)
"(A)
"(B)
Effective Date of 2015 Amendment
Effective Date of 2013 Amendment
[
Effective Date of 2010 Amendment
"(A)
"(B)
Amendment by
"(1)
"(2)
"(a)
"(b)
Amendment by section 8002(a)(2), (b) of
Effective Date of 2009 Amendment
Amendment by section 113(b)(1) of
"(1)
"(A)
"(B)
"(i) paragraphs (1), (2), and (3) of subsection (b) [amending this section and
"(ii) paragraph (4) of subsection (b) [amending
"(2)
"(3)
[For definition of "Medicaid", see section 1(c)(2) of
Effective Date of 2007 Amendment
Effective Date of 2006 Amendment
Effective Date of 2005 Amendment
Effective Date of 2004 Amendment
Amendment by
Effective Date of 2003 Amendment
Amendment by section 236(b)(1) of
Amendment by
Effective Date of 2002 Amendment
"(1)
"(2)
Effective Date of 2000 Amendment
Effective Date of 1999 Amendment
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 Amendment
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
Amendment by
Effective Date of 1996 Amendment
Amendment by sections 108(k) and 114(b)–(d)(1), of
Effective Date of 1994 Amendment
Amendment by
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13581(b)(2) of
Amendment by section 13602(c) of
Amendment by section 13611(d)(1) 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 [
"(3) The amendment made by subsection (a)(2) [amending
Amendment by section 13623(a) 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 [
Effective Date of 1991 Amendment
Effective Date of 1990 Amendment
"(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
"(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."
"(1)
"(2)
"(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
"(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
Effective Date of 1989 Amendment
Amendment by section 6115(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."
"(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."
"(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."
Amendment by section 6411(d)(3)(B) of
"(A)
"(B)
Amendment by
Effective Date of 1988 Amendment
Amendment by section 202(c)(4) 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
"(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 [
[
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
"(1) The amendments made by this section [amending this section and
"(A) monthly premiums under title XVIII of such Act [
"(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 [
"(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 Amendment
For effective date of amendment by section 4072(d) of
Amendment by section 4101(c)(2) 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 [
Amendments by sections 4211(b)(1), (h)(1)–(5), 4212(d)(2), (3), (e)(1) 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
Amendment by section 9115(b) of
Amendment by sections 5(a) and 8(f) of
Amendment by section 7 of
Effective Date of 1986 Amendment
"(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 [
Amendment by
Amendment by section 9320(h)(3) 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 [
"(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."
"(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]."
"(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 [
"(2)
"(3)
"(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 [
"(3) No penalty may be applied against any State for a violation of section 1902(a)(25) of the Social Security Act [
"(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]."
"(b)
"(c)
"(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 [
Amendment by section 12305(b)(3) of
Effective Date of 1984 Amendment
Amendment by
Amendment by section 2303(g)(1) 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 [
Amendment by section 2335(e) 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 [
Amendment by section 2363(a)(1) 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 [
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
Amendment by section 136(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 [
Amendment by section 146(a) of
Effective Date of 1981 Amendment
"(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 [
"(B) In the case of a State plan for medical assistance under title XIX of the Social Security Act [
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
"(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 [
"(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."
"(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 [
"(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."
"(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
"(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 [
Effective Date of 1977 Amendment
Amendment by
Amendment by section 2(a)(3) of
Amendment by section 3(c)(1) 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 [
Amendment by section 20(b) of
Effective Date of 1976 Amendment
Effective Date of 1975 Amendment
Effective Date of 1974 Amendment
Effective Date of 1973 Amendment
Effective Date of 1972 Amendment
Amendment by section 236(b) of
Amendment by section 246(a) of
Amendment by section 299D(b) of
Effective Date of 1971 Amendment
Effective Date of 1968 Amendment
Amendment by section 210(a)(6) of
[
Enactment by section 236(a) of
Regulations
Rule of Construction Related to Income or Resource Disregard Methodology, or Spousal Income and Asset Disregard
"(1) applying an income or resource disregard under a methodology authorized under section 1902(r)(2) of such Act (
"(A) to the income or resources of an individual described in section 1902(a)(10)(A)(ii)(VI) of such Act (
"(B) on the basis of an individual's need for home and community-based services authorized under subsection (c), (d), (i), or (k) of section 1915 of such Act (
"(2) disregarding an individual's spousal income and assets under a plan amendment to provide medical assistance for home and community-based services for individuals by reason of being determined eligible under section 1902(a)(10)(C) of such Act (
Similar provisions were contained in the following prior acts:
Rule of Construction Related to Income or Resource Disregard Methodology
"(1) to the income or resources of an individual described in section 1902(a)(10)(A)(ii)(VI) of such Act (
"(2) on the basis of an individual's need for home and community-based services authorized under subsection (c), (d), (i), or (k) of section 1915 of such Act (
Construction of 2018 Amendment
"(1)
"(2)
Construction of 2016 Amendment
"(1)
"(2)
Construction of 2009 Amendment
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
Addressing Operational Barriers to Promote Continuity of Care for Medicaid and CHIP Beneficiaries Following Incarceration
"(a)
"(1)
"(2)
"(A) identifying and addressing operational gaps with respect to complying with such requirements or adopting such options, in collaboration with public institutions, State human services agencies, Medicaid managed care plans, providers, community-based organizations, and other stakeholders;
"(B) establishing standardized processes and automated systems for activities that may include, but are not limited to—
"(i) determining whether an individual is enrolled in a State Medicaid program or State CHIP at the time such individual becomes an inmate of a public institution;
"(ii) allowing an individual who is an inmate of a public institution to submit an application to enroll or renew coverage in a State Medicaid program or State CHIP prior to the individual's release from such public institution;
"(iii) facilitating the delivery of medical assistance under the State Medicaid program or child health assistance or pregnancy-related assistance under the State CHIP to an individual who is eligible for such assistance while the individual is an inmate of a public institution, such as by establishing claims processing and prior authorization request protocols; and
"(iv) in the case of an eligible individual whose coverage under a State Medicaid program or State CHIP was suspended while the individual was an inmate of a public institution, restoring such coverage upon such individual's release from the public institution;
"(C) investing in information technology to—
"(i) enable bi-directional information sharing between public institutions, the State Medicaid and CHIP agencies, and other entities such as managed care plans and providers (in a manner consistent with applicable State and Federal privacy laws), to support care transitions and coordination of treatment (including access to care in the community after release from a public institution); and
"(ii) develop indicators to ensure Federal financial participation for medical assistance furnished under a State Medicaid program or child health assistance or pregnancy-related assistance furnished under a State CHIP is available only for medical assistance or child health assistance or pregnancy-related assistance for items and services for which such participation is permitted while an individual is an inmate of a public institution; and
"(D) establishing oversight and monitoring processes to ensure public institutions and entities with which they contract are compliant with any applicable Medicaid and CHIP requirements.
"(3)
"(A) provide medical assistance under a State Medicaid program or child health assistance or pregnancy-related assistance under a State CHIP to an individual, or otherwise directly administer health care services for an individual; or
"(B) build prisons, jails, or other carceral facilities, or pay for prison, jail, or other carceral facility-related improvements other than those improvements that are for the direct and primary purpose of meeting the health care needs of individuals who are incarcerated and who are eligible for medical assistance under the State Medicaid program or child health assistance or pregnancy-related assistance under the State CHIP.
"(4)
"(A) The number of individuals in the State who were inmates of non-Federal public institutions (such as State prisons, local and county jails, tribal jails, and youth correctional or detention facilities) and were eligible for medical assistance under a State Medicaid program at any time in calendar year 2022.
"(B) The number of non-Federal public institutions in the State (such as State prisons, local and county jails, tribal jails, and youth correctional or detention facilities).
"(C) The State's progress in developing, implementing, and operating initiatives to promote continuity of care for individuals who are inmates of a public institution and are eligible for medical assistance under the State Medicaid program or are eligible for child health assistance or pregnancy-related assistance under the State CHIP (with favorable consideration given to States with less progress in promoting continuity of care for such individuals).
"(5)
"(b)
"(1)
"(2)
"(A)
"(B)
"(i) Implementing modifications to improve eligibility and enrollment processes, including, but not limited to, completing applications for assistance under the State Medicaid program or the State CHIP on behalf of inmates, transmitting such applications to State Medicaid and CHIP agencies, and screening individuals who are inmates of public institutions for eligibility for medical assistance that is authorized to be furnished to the individual while the individual is such an inmate.
"(ii) Clarifying the availability of relevant Federal financial participation, including the administrative match under sections 1903 and 2105 of the Social Security Act (
"(iii) Expeditiously conducting screening for eligibility under State Medicaid programs and State CHIPs for individuals who are inmates of a public institution, providing application and renewal assistance for those who are not yet enrolled in such programs or whose eligibility needs to be renewed, and coordinating reinstatement of coverage under such programs with managed care enrollment.
"(iv) Ensuring that an individual who is an inmate of a public institution and is eligible for medical assistance under a State Medicaid program or for child health assistance or pregnancy-related assistance under a State CHIP receives, in a timely fashion, any such assistance for which Federal financial participation is authorized, such as, a supply of medications or prescription refill upon release and the services required under sections 1902(a)(84)(D) and 2102(d) of the Social Security Act (
"(v) Establishing community-based provider networks, including those comprised of case managers, for purposes of providing continuity of care to individuals who are eligible for medical assistance under a State Medicaid program or child health assistance or pregnancy-related assistance under a State CHIP before, during, and after incarceration.
"(c)
"(1)
"(2)
"(3)
"(4)
"(5)
Guidance Relating To Improving the Behavioral Health Workforce and Integration of Care Under Medicaid and CHIP
"(a)
"(1) Opportunities to increase access to the mental health and substance use disorder care providers that participate in Medicaid or CHIP, which may include education, training, recruitment and retention of such providers, with a focus on improving the capacity of this workforce in rural and underserved areas by increasing the number, type, and capacity of providers. The guidance relating to such opportunities shall include the following:
"(A) Best practices from States that have used authorities under titles XI, XIX, or XXI of the Social Security Act (
"(B) Opportunities States can leverage to finance, support, and expand the availability of providers of community-based mental health and substance use disorder services who participate in Medicaid and CHIP across the continuum of care, including through the participation of paraprofessionals with behavioral health expertise, such as clinicians with baccalaureate degrees and peer support specialists and including best practices especially pertinent to pediatric care. The guidance shall include examples of innovative policies states [probably should be "States"] have adopted to expand access to behavioral health services; for example, by establishing more expansive and diverse behavioral health workforce roles such as certified wellness coaches.
"(C) Best practices related to financing, supporting, and expanding the education and training of providers of mental health and substance use disorder services in order to increase the workforce of such providers who participate in Medicaid and CHIP across the continuum of care, including innovative public-private partnerships and including such practices that are especially pertinent to pediatric care.
"(2) Opportunities to promote the integration of mental health or substance use disorder services with primary care services. The guidance relating to such opportunities shall include the following:
"(A) An overview of State options for adopting and expanding value-based payment arrangements and alternative payment models, including accountable care organization-like models and other shared savings programs.
"(B) A description of opportunities for States to use and align existing authorities and resources to finance the integration of mental health or substance use disorder services with primary care services, including with respect to the use of electronic health records in mental health care settings and in substance use disorder care settings.
"(C) Strategies to support integration of mental health or substance use disorder services with primary care services through the use of non-clinical professionals and paraprofessionals, including peer support specialists.
"(D) Examples of specific strategies and models designed to support integration of mental health or substance use disorder services with primary care services for differing age groups, including children and youth and individuals over the age of 65, which may include the collaborative care model or primary care behavioral health model for behavioral health integration.
"(b)
"(1) The delivery of mental health or substance use disorder services in a setting that is physically located in the same practice or building as a primary care setting, or when at least 1 provider of mental health or substance use disorder services is available in a primary care setting via telehealth.
"(2) The use of behavioral health integration models primarily intended for pediatric populations with non-severe mental health needs that are focused on prevention and early detection and intervention methods through a multidisciplinary collaborative behavioral health team approach co-managed with primary care, to include same-day access to family-focused mental health treatment services.
"(3) Having providers of mental health or substance use disorder services physically co-located in a primary care setting with same-day visit availability.
"(4) Implementing or maintaining enhanced care coordination or targeted case management which includes regular interactions between and within care teams.
"(5) Providing mental health or substance use disorder screening and follow-up assessments, interventions, or services within the same practice or facility as a primary care or physical service setting.
"(6) The use of assertive community treatment that is integrated with or facilitated by a primary care practice.
"(7) Delivery of integrated primary care and mental health care or substance use disorder care in the home or in community-based settings for individuals who are recipients of Medicaid home and community-based services."
Medicaid and Telehealth
"(a)
"(1) How States can adopt flexibilities under Medicaid and CHIP to expand access to covered services via telehealth, including when States may adopt such flexibilities without the need for approval of a State plan amendment or waiver.
"(2) Best practices regarding billing for services, including recommended voluntary billing codes, modifiers, and place of service designations and how such billing codes, modifiers, and designations can be used to create consistent data sets.
"(3) Strategies for integrating telehealth services into value-based care models.
"(4) Best practices from States that have used Medicaid waivers and other Medicaid authorities to expand access to telehealth, including during the COVID–19 public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act [
"(5) Strategies to promote the delivery of accessible and culturally competent care via telehealth, including addressing the needs of individuals with disabilities, medically underserved urban and rural communities, racial and ethnic minorities such as American Indians and Alaska Natives, individuals with limited English proficiency, and individuals of different age groups including children, young adults, and seniors;[.]
"(6) Strategies for training and providing resources to providers and patients on the use of telehealth, including working with interpreters to furnish health services and providing resources in multiple languages.
"(7) Integrating the use of existing video platforms that enable multi-person video calls.
"(8) Best practices to support the delivery of covered services under Medicaid and CHIP via telehealth in schools, including specifically for the provision of mental health and substance use disorder services in such settings.
"(9) Strategies for evaluating how the delivery of health services via telehealth affects quality, outcomes, and cost under Medicaid and CHIP.
"(10) Best practices for conveying information to beneficiaries regarding the availability of telehealth as an option to receive services covered under Medicaid and CHIP, including the availability of audio-only telehealth, the ability to receive such services from a patient's home, and requirements related to in-person visits.
"(b)
"(1)
"(2)
"(3)
"(4)
Supporting Access to Health Care Services in Schools
"(a)
"(1)
"(A)
"(B)
"(i) include updates to the May 2003 Medicaid School-Based Administrative Claiming Guide, the 1997 Medicaid and Schools Technical Assistance Guide [probably means the 1997 "Medicaid and School Health: A Technical Assistance Guide"], and other relevant guidance in effect on the date of enactment of this Act;
"(ii) clarify that payments may be made to school-based entities under Medicaid for delivering assistance under Medicaid, including any such assistance provided in accordance with an individualized education program or under the policy described in the State Medicaid Director letter on payment for services issued on December 15, 2014 (#14-006);
"(iii) outline strategies and tools to reduce administrative burdens on, and simplify billing for, local educational agencies, in particular small and rural local educational agencies, and support compliance with Federal requirements regarding billing, payment, and recordkeeping, including by aligning direct service billing and school-based administrative claiming payment systems;
"(iv) include a comprehensive list of best practices and examples of approved methods that State Medicaid agencies and local educational agencies have used to pay for, and increase the availability of, assistance under Medicaid, including expanding State programs to include all Medicaid-enrolled students, providing early and periodic screening, diagnostic, and treatment (EPSDT) services in schools, utilizing telehealth, coordinating with community-based mental health and substance use disorder treatment providers and organizations, coordinating with managed care entities, and supporting the provision of culturally competent and trauma-informed care in school settings; and
"(v) provide examples of the types of providers (which may include qualified school health personnel) that States may choose to enroll, deem, or otherwise treat as participating providers for purposes of school-based programs under Medicaid and best practices related to helping such providers enroll in Medicaid for purposes of participating in school-based programs under Medicaid.
"(2)
"(A)
"(i) assist and expand the capacity of State Medicaid agencies and local educational agencies and school-based entities to provide assistance under Medicaid;
"(ii) reduce administrative burdens for such agencies and health centers or entities;
"(iii) support State educational agencies, local educational agencies, and school-based entities in obtaining payment for the provision of assistance under Medicaid;
"(iv) ensure ongoing coordination and collaboration between the Department of Health and Human Services and the Department of Education with respect to the provision of, and payment for, assistance under Medicaid by local educational agencies; and
"(v) provide information to State and local educational agencies and States on how to utilize funding from the Department of Health and Human Services, the Department of Education, and other Federal agencies to ensure payment under Medicaid for assistance provided in school-based settings.
"(B)
"(C)
"(3)
"(b)
"(c)
"(1)
"(2)
"(3)
"(4)
"(A) a school-based health center, as that term is defined in section 2110(c)(9) of the Social Security Act (
"(B) an entity that provides medical assistance in a school-based setting for which Federal financial participation is allowed under Medicaid.
"(5)
"(6)
"(7)
Guidance Review
Consultation Relating to Nonemergency Medical Transportation
Reevaluation of Waivers of Medicaid Fraud Control Unit Requirement
"(A)
"(B)
Guidance on Access to Medicaid for Former Foster Youth
"(1) on best practices for—
"(A) removing barriers and ensuring streamlined, timely access to Medicaid coverage for former foster youth up to age 26; and
"(B) conducting outreach and raising awareness among such youth regarding Medicaid coverage options for such youth; and
"(2) which shall include examples of States that have successfully extended Medicaid coverage to former foster youth up to age 26."
Guidance To Improve Care for Infants With Neonatal Abstinence Syndrome and Their Mothers
"(1) best practices from States with respect to innovative or evidenced-based payment models that focus on prevention, screening, treatment, plans of safe care, and postdischarge services for mothers and fathers with substance use disorders and babies with neonatal abstinence syndrome that improve care and clinical outcomes;
"(2) recommendations for States on available financing options under the Medicaid program under title XIX of such Act [probably means title XIX of the Social Security Act,
"(3) guidance and technical assistance to State Medicaid agencies regarding additional flexibilities and incentives related to screening, prevention, and postdischarge services, including parenting supports, and infant-caregiver bonding, including breastfeeding when it is appropriate; and
"(4) guidance regarding suggested terminology and ICD codes to identify infants with neonatal abstinence syndrome and neonatal opioid withdrawal syndrome, which could include opioid-exposure, opioid withdrawal not requiring pharmacotherapy, and opioid withdrawal requiring pharmacotherapy."
Medicaid Substance Use Disorder Treatment via Telehealth
"(a)
"(1)
"(2)
"(3)
"(4)
"(b)
"(1) State options for Federal reimbursement of expenditures under Medicaid for furnishing services and treatment for substance use disorders, including assessment, medication-assisted treatment, counseling, medication management, and medication adherence with prescribed medication regimes, using services delivered via telehealth. Such guidance shall also include guidance on furnishing services and treatments that address the needs of high-risk individuals, including at least the following groups:
"(A) American Indians and Alaska Natives.
"(B) Adults under the age of 40.
"(C) Individuals with a history of non-fatal overdose.
"(D) Individuals with a co-occurring serious mental illness and substance use disorder.
"(2) State options for Federal reimbursement of expenditures under Medicaid for education directed to providers serving Medicaid beneficiaries with substance use disorders using the hub and spoke model, through contracts with managed care entities, through administrative claiming for disease management activities, and under Delivery System Reform Incentive Payment ('DSRIP') programs.
"(3) State options for Federal reimbursement of expenditures under Medicaid for furnishing services and treatment for substance use disorders for individuals enrolled in Medicaid in a school-based health center using services delivered via telehealth."
Enhancing Patient Access to Non-Opioid Treatment Options
Technical Assistance and Support for Innovative State Strategies To Provide Housing-Related Supports Under Medicaid
"(a)
"(b)
Medicaid Reentry
"SEC. 5031. SHORT TITLE.
"This subtitle may be cited as the 'Medicaid Reentry Act'.
"SEC. 5032. PROMOTING STATE INNOVATIONS TO EASE TRANSITIONS INTEGRATION TO THE COMMUNITY FOR CERTAIN INDIVIDUALS.
"(a)
"(1)
"(A) to ease the health care-related transition of an individual who is an inmate of a public institution from the public institution to the community, including best practices for ensuring continuity of health insurance coverage or coverage under the State Medicaid plan under title XIX of the Social Security Act [
"(B) to carry out, with respect to such an individual, such health care-related transition not later than 30 days after such individual is released from the public institution.
"(2)
"(b)
"(1) providing assistance and education for enrollment under a State plan under the Medicaid program under title XIX of such Act for such individuals during such period; and
"(2) providing health care services for such individuals during such period.
"(c)
Development of Uniform Terminology for Reasons for Provider Termination
Exception for State Legislation
Rule of Construction Related to Medicaid Coverage of Mental Health Services and Primary Care Services Furnished on the Same Day
"(1) a primary care service furnished to the individual by a provider at a facility on the same day a mental health service is furnished to such individual by such provider (or another provider) at the facility; or
"(2) a mental health service furnished to the individual by a provider at a facility on the same day a primary care service is furnished to such individual by such provider (or another provider) at the facility."
Demonstration Programs To Improve Community Mental Health Services
"(a)
"(1)
"(2)
"(A)
"(B)
"(C)
"(i) Federally-qualified health centers (and as applicable, rural health clinics) to provide Federally-qualified health center services (and as applicable, rural health clinic services) to the extent such services are not provided directly through the certified community behavioral health clinic.
"(ii) Inpatient psychiatric facilities and substance use detoxification, post-detoxification step-down services, and residential programs.
"(iii) Other community or regional services, supports, and providers, including schools, child welfare agencies, juvenile and criminal justice agencies and facilities, Indian Health Service youth regional treatment centers, State licensed and nationally accredited child placing agencies for therapeutic foster care service, and other social and human services.
"(iv) Department of Veterans Affairs medical centers, independent outpatient clinics, drop-in centers, and other facilities of the Department as defined in section 1801 [probably should be 1701] of
"(v) Inpatient acute care hospitals and hospital outpatient clinics.
"(D)
"(i) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization.
"(ii) Screening, assessment, and diagnosis, including risk assessment.
"(iii) Patient-centered treatment planning or similar processes, including risk assessment and crisis planning.
"(iv) Outpatient mental health and substance use services.
"(v) Outpatient clinic primary care screening and monitoring of key health indicators and health risk.
"(vi) Targeted case management.
"(vii) Psychiatric rehabilitation services.
"(viii) Peer support and counselor services and family supports.
"(ix) Intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas, provided the care is consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration.
"(E)
"(F)
"(b)
"(1)
"(2)
"(A) no payment shall be made for inpatient care, residential treatment, room and board expenses, or any other non-ambulatory services, as determined by the Secretary; and
"(B) no payment shall be made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this Act [Apr. 1, 2014].
"(c)
"(1)
"(2)
"(A) solicit input with respect to the development of such a demonstration program from patients, providers, and other stakeholders;
"(B) certify clinics as certified community behavioral health clinics for purposes of participating in a demonstration program conducted under subsection (d); and
"(C) establish a prospective payment system for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program under subsection (d) in accordance with the guidance issued under subsection (b).
"(3)
"(d)
"(1)
"(2)
"(A)
"(B)
"(i) The target Medicaid population to be served under the demonstration program.
"(ii) A list of participating certified community behavioral health clinics.
"(iii) Verification that the State has certified a participating clinic as a certified community behavioral health clinic in accordance with the requirements of subsection (b).
"(iv) A description of the scope of the mental health services available under the State Medicaid program that will be paid for under the prospective payment system tested in the demonstration program.
"(v) Verification that the State has agreed to pay for such services at the rate established under the prospective payment system.
"(vi) Such other information as the Secretary may require relating to the demonstration program including with respect to determining the soundness of the proposed prospective payment system.
"(3)
"(4)
"(A)
"(i) provide the most complete scope of services described in subsection (a)(2)(D) to individuals eligible for medical assistance under the State Medicaid program;
"(ii) will improve availability of, access to, and participation in, services described in subsection (a)(2)(D) to individuals eligible for medical assistance under the State Medicaid program;
"(iii) will improve availability of, access to, and participation in assisted outpatient mental health treatment in the State; or
"(iv) demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net Federal spending.
"(5)
"(A)
"(B)
"(i) to a newly eligible individual described in paragraph (2) of section 1905(y) of the Social Security Act (
"(ii) to an individual who is not a newly eligible individual (as so described) but who is eligible for medical assistance under the State Medicaid program, the enhanced FMAP applicable to the State.
"(C)
"(i)
"(I) that are described in the demonstration program application in accordance with paragraph (2)(iv);
"(II) for which payment is available under the State Medicaid program; and
"(III) that are provided to an individual who is eligible for medical assistance under the State Medicaid program.
"(ii)
"(I) for inpatient care, residential treatment, room and board expenses, or any other non-ambulatory services, as determined by the Secretary; or
"(II) with respect to payments made to satellite facilities of certified community behavioral health clinics if such facilities are established after the date of enactment of this Act [Apr. 1, 2014].
"(iii)
"(I) in the case of a State participating in the demonstration program as of January 1, 2020, apply to amounts expended by the State through September 30, 2025;
"(II) in the case of a State selected to participate in the demonstration program under paragraph (8), during the first 24 fiscal quarter period (or any portion of such period) that the State participates in the demonstration program; and
"(III) in the case of a State selected to participate in the demonstration program under paragraph (9), during the first 16 fiscal quarter period (or any portion of such period) that the State participates in the demonstration program.
"(D)
"(6)
"(7)
"(A)
"(i) an assessment of access to community-based mental health services under the Medicaid program in the area or areas of a State targeted by a demonstration program compared to other areas of the State;
"(ii) an assessment of the quality and scope of services provided by certified community behavioral health clinics compared to community-based mental health services provided in States not participating in a demonstration program under this subsection and in areas of a demonstration State that are not participating in the demonstration program; and
"(iii) an assessment of the impact of the demonstration programs on the Federal and State costs of a full range of mental health services (including inpatient, emergency and ambulatory services).
"(B)
"(C)
"(8)
"(A)
"(B)
"(i)
"(I) shall select States that—
"(aa) were awarded planning grants under subsection (c); and
"(bb) applied to participate in the demonstration programs under this subsection under paragraph (1) but, as of the date of enactment of this paragraph, were not selected to participate under paragraph (1); and
"(II) shall use the results of the Secretary's evaluation of each State's application under paragraph (1) to determine which States to select, and shall not require the submission of any additional application.
"(C)
"(i) submit a plan to monitor certified community behavioral health clinics under the demonstration program to ensure compliance with certified community behavioral health criteria during the demonstration period; and
"(ii) commit to collecting data, notifying the Secretary of any planned changes that would deviate from the prospective payment system methodology outlined in the State's demonstration application, and obtaining approval from the Secretary for any such change before implementing the change.
"(9)
"(A)
"(B)
"(i) was awarded a planning grant under paragraph (1) or (3) of subsection (c); and
"(ii) submits an application (in addition to any application that the State may have previously submitted under this section) that includes the information described in paragraph (2)(B).
"(C)
"(D)
"(e)
"(1)
"(2)
"(3)
"(4)
"(f)
"(1)
"(A) for purposes of carrying out subsections (a), (b), and (d)(7), $2,000,000 for fiscal year 2014;
"(B) for purposes of awarding planning grants under subsection (c), $25,000,000 for fiscal year 2016; and
"(C) for purposes of awarding planning grants under subsection (c)(3), providing technical assistance to States applying for grants under such subsection, and carrying out demonstration programs under subsection (d), $40,000,000 for fiscal year 2023, to remain available until expended.
"(2)
Reports to Congress
Demonstration Project To Evaluate Integrated Care Around a Hospitalization
"(a)
"(1)
"(A) with respect to an episode of care that includes a hospitalization; and
"(B) for concurrent physicians services provided during a hospitalization.
"(2)
"(b)
"(1) The demonstration project shall be conducted in up to 8 States, determined by the Secretary based on consideration of the potential to lower costs under the Medicaid program while improving care for Medicaid beneficiaries. A State selected to participate in the demonstration project may target the demonstration project to particular categories of beneficiaries, beneficiaries with particular diagnoses, or particular geographic regions of the State, but the Secretary shall insure [sic] that, as a whole, the demonstration project is, to the greatest extent possible, representative of the demographic and geographic composition of Medicaid beneficiaries nationally.
"(2) The demonstration project shall focus on conditions where there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished to Medicaid beneficiaries while reducing total expenditures under the State Medicaid programs selected to participate, as determined by the Secretary.
"(3) A State selected to participate in the demonstration project shall specify the 1 or more episodes of care the State proposes to address in the project, the services to be included in the bundled payments, and the rationale for the selection of such episodes of care and services. The Secretary may modify the episodes of care as well as the services to be included in the bundled payments prior to or after approving the project. The Secretary may also vary such factors among the different States participating in the demonstration project.
"(4) The Secretary shall ensure that payments made under the demonstration project are adjusted for severity of illness and other characteristics of Medicaid beneficiaries within a category or having a diagnosis targeted as part of the demonstration project. States shall ensure that Medicaid beneficiaries are not liable for any additional cost sharing than if their care had not been subject to payment under the demonstration project.
"(5) Hospitals participating in the demonstration project shall have or establish robust discharge planning programs to ensure that Medicaid beneficiaries requiring post-acute care are appropriately placed in, or have ready access to, post-acute care settings.
"(6) The Secretary and each State selected to participate in the demonstration project shall ensure that the demonstration project does not result in the Medicaid beneficiaries whose care is subject to payment under the demonstration project being provided with less items and services for which medical assistance is provided under the State Medicaid program than the items and services for which medical assistance would have been provided to such beneficiaries under the State Medicaid program in the absence of the demonstration project.
"(c)
"(d)
"(1)
"(2)
Pediatric Accountable Care Organization Demonstration Project
"(a)
"(1)
"(2)
"(b)
"(c)
"(1)
"(2)
"(3)
"(d)
"(e)
Medicaid Emergency Psychiatric Demonstration Project
"(a)
"(1) have attained age 21, but have not attained age 65;
"(2) are eligible for medical assistance under such plan; and
"(3) require such medical assistance to stabilize an emergency medical condition.
"(b)
"(c)
"(1)
"(2)
"(3)
"(4)
"(d)
"(1)
"(2)
"(A)
"(i) the Secretary determines that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act [
"(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such extension for that State is projected not to increase net program spending under title XIX of the Social Security Act.
"(B)
"(3)
"(A)
"(i) the Secretary determines that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act [
"(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the continued participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act.
"(B)
"(i) the Secretary determines that the participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act; and
"(ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the participation of the State in the demonstration project is projected not to increase net program spending under title XIX of the Social Security Act.
"(C)
"(i) in the case of a State participating in the demonstration project as of the date the Secretary submits recommendations to Congress under subsection (f)(3), not later than August 31, 2016; and
"(ii) in the case of an additional State that applies to be added to the demonstration project, prior to the State making a final election to participate in the project.
"(4)
"(e)
"(1)
"(A)
"(B)
"(2)
"(3)
"(4)
"(f)
"(1)
"(A) An assessment of access to inpatient mental health services under the Medicaid program; average lengths of inpatient stays; and emergency room visits.
"(B) An assessment of discharge planning by participating hospitals.
"(C) An assessment of the impact of the demonstration project on the costs of the full range of mental health services (including inpatient, emergency and ambulatory care).
"(D) An analysis of the percentage of consumers with Medicaid coverage who are admitted to inpatient facilities as a result of the demonstration project as compared to those admitted to these same facilities through other means.
"(E) A recommendation regarding whether the demonstration project should be continued after December 31, 2013, and expanded on a national basis.
"(2)
"(3)
"(A) whether the demonstration project should be continued after September 30, 2016; and
"(B) whether the demonstration project should be expanded to additional States.
"(4)
"(A)
"(i) whether the demonstration project should be permanently continued after December 31, 2019, in 1 or more States; and
"(ii) whether the demonstration project should be expanded (including on a nationwide basis).
"(B)
"(C)
"(i) ensure that each State's participation in the project complies with budget neutrality requirements; and
"(ii) require the Secretary to treat any expenditures of a State participating in the demonstration project that are [in] excess of the expenditures projected under the budget neutrality standard for the State as an overpayment under title XIX of the Social Security Act.
"(5)
"(g)
"(1)
"(2)
"(h)
"(1)
"(2)
"(3)
"(4)
"(5)
"(6)
[
Incentives for Prevention of Chronic Diseases in Medicaid
"(a)
"(1)
"(A)
"(i) successfully participate in a program described in paragraph (3); and
"(ii) upon completion of such participation, demonstrate changes in health risk and outcomes, including the adoption and maintenance of healthy behaviors by meeting specific targets (as described in subsection (c)(2)).
"(B)
"(2)
"(A)
"(B)
"(3)
"(A)
"(i) Ceasing use of tobacco products.
"(ii) Controlling or reducing their weight.
"(iii) Lowering their cholesterol.
"(iv) Lowering their blood pressure.
"(v) Avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition.
"(B)
"(C)
"(D)
"(4)
"(b)
"(1)
"(2)
"(c)
"(1) track Medicaid beneficiary participation in the program and validate changes in health risk and outcomes with clinical data, including the adoption and maintenance of health behaviors by such beneficiaries;
"(2) to the extent practicable, establish standards and health status targets for Medicaid beneficiaries participating in the program and measure the degree to which such standards and targets are met;
"(3) evaluate the effectiveness of the program and provide the Secretary with such evaluations;
"(4) report to the Secretary on processes that have been developed and lessons learned from the program; and
"(5) report on preventive services as part of reporting on quality measures for Medicaid managed care programs.
"(d)
"(1)
"(A) the effect of such initiatives on the use of health care services by Medicaid beneficiaries participating in the program;
"(B) the extent to which special populations (including adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program;
"(C) the level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and
"(D) the administrative costs incurred by State agencies that are responsible for administration of the program.
"(2)
"(A) the specific uses of the grant funds;
"(B) an assessment of program implementation and lessons learned from the programs;
"(C) an assessment of quality improvements and clinical outcomes under such programs; and
"(D) estimates of cost savings resulting from such programs.
"(3)
"(4)
"(e)
"(f)
"(g)
"(1)
"(2)
Coordination of Expansion of the Recovery Audit Contractor Program; Regulations
"(A)
"(B)
Annual Report
Purposes of 2009 Amendment
"(1) To provide fiscal relief to States in a period of economic downturn.
"(2) To protect and maintain State Medicaid programs during a period of economic downturn, including by helping to avert cuts to provider payment rates and benefits or services, and to prevent constrictions of income eligibility requirements for such programs, but not to promote increases in such requirements."
Limitation on Waiver Authority
Extension of SSI Web-Based Asset Demonstration Project to the Medicaid Program
Demonstration Projects Regarding Home and Community-Based Alternatives to Psychiatric Residential Treatment Facilities for Children
"(a)
"(b)
"(1)
"(2)
"(c)
"(1)
"(2)
"(3)
"(d)
"(1)
"(2)
"(e)
"(f)
"(1)
"(A) the amount specified in paragraph (2) shall be available for each of fiscal years 2007 through 2011; and
"(B) a total of $1,000,000 shall be available to the Secretary for the evaluations and report under subsection (e).
"(2)
"(A)
"(B)
"(i) fiscal year 2007 is $21,000,000;
"(ii) fiscal year 2008 is $37,000,000;
"(iii) fiscal year 2009 is $49,000,000;
"(iv) fiscal year 2010 is $53,000,000; and
"(v) fiscal year 2011 is $57,000,000."
Money Follows the Person Rebalancing Demonstration
"(a)
"(1)
"(2)
"(3)
"(4)
"(b)
"(1)
"(2)
"(A) who, immediately before beginning participation in the MFP demonstration project—
"(i) resides (and has resided for a period of not less than 60 consecutive days) in an inpatient facility;
"(ii) is receiving Medicaid benefits for inpatient services furnished by such inpatient facility; and
"(iii) with respect to whom a determination has been made that, but for the provision of home and community-based long-term care services, the individual would continue to require the level of care provided in an inpatient facility and, in any case in which the State applies a more stringent level of care standard as a result of implementing the State plan option permitted under section 1915(i) of the Social Security Act [
"(B) who resides in a qualified residence beginning on the initial date of participation in the demonstration project.
"(3)
"(4)
"(5)
"(6)
"(A) a home owned or leased by the individual or the individual's family member;
"(B) an apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control; and
"(C) a residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside.
"(7)
"(8)
"(A)
"(B)
"(i) specifies those services, if any, which the individual or the individual's authorized representative would be responsible for directing;
"(ii) identifies the methods by which the individual or the individual's authorized representative or an agency designated by an individual or representative will select, manage, and dismiss providers of such services;
"(iii) specifies the role of family members and others whose participation is sought by the individual or the individual's authorized representative with respect to such services;
"(iv) is developed through a person-centered process that—
"(I) is directed by the individual or the individual's authorized representative;
"(II) builds upon the individual's capacity to engage in activities that promote community life and that respects the individual's preferences, choices, and abilities; and
"(III) involves families, friends, and professionals as desired or required by the individual or the individual's authorized representative;
"(v) includes appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assure the appropriateness of such plan based upon the resources and capabilities of the individual or the individual's authorized representative; and
"(vi) may include an individualized budget which identifies the dollar value of the services and supports under the control and direction of the individual or the individual's authorized representative.
"(C)
"(i) describes the method for calculating the dollar values in such budgets based on reliable costs and service utilization;
"(ii) defines a process for making adjustments in such dollar values to reflect changes in individual assessments and service plans; and
"(iii) provides a procedure to evaluate expenditures under such budgets.
"(9)
"(10)
"(c)
"(1)
"(2)
"(3)
"(4)
"(5)
"(A) the target groups of eligible individuals to be assisted to transition from an inpatient facility to a qualified residence during each fiscal year of the MFP demonstration project;
"(B) the projected numbers of eligible individuals in each targeted group of eligible individuals to be so assisted during each such year; and
"(C) the estimated total annual qualified expenditures for each fiscal year of the MFP demonstration project.
"(6)
"(A) each eligible individual or the individual's authorized representative will be provided the opportunity to make an informed choice regarding whether to participate in the MFP demonstration project;
"(B) each eligible individual or the individual's authorized representative will choose the qualified residence in which the individual will reside and the setting in which the individual will receive home and community-based long-term care services;
"(C) the State will continue to make available, so long as the State operates its qualified HCB program consistent with applicable requirements, home and community-based long-term care services to each individual who completes participation in the MFP demonstration project for as long as the individual remains eligible for medical assistance for such services under such qualified HCB program (including meeting a requirement relating to requiring a level of care provided in an inpatient facility and continuing to require such services, and, if the State applies a more stringent level of care standard as a result of implementing the State plan option permitted under section 1915(i) of the Social Security Act [
"(7)
"(A) provide such information as the Secretary may require concerning the dollar amounts of State Medicaid expenditures for the fiscal year, immediately preceding the first fiscal year of the State's MFP demonstration project, for long-term care services and the percentage of such expenditures that were for institutional long-term care services or were for home and community-based long-term care services; and
"(B)(i) specify the methods to be used by the State to increase, for each fiscal year during the MFP demonstration project, the dollar amount of such total expenditures for home and community-based long-term care services and the percentage of such total expenditures for long-term care services that are for home and community-based long-term care services;
"(ii) describe the extent to which the MFP demonstration project will contribute to accomplishment of objectives described in subsection (a); and
"(iii) include a work plan that describes for each Federal fiscal year that occurs during the proposed MFP demonstration project—
"(I) the use of grant funds for each proposed initiative that is designed to accomplish the objective described in subsection (a)(1), including a funding source for each activity that is part of each such proposed initiative;
"(II) an evaluation plan that identifies expected results for each such proposed initiative; and
"(III) a sustainability plan for components of such proposed initiatives that are intended to improve transitions, which shall be updated with actual expenditure information for each Federal fiscal year that occurs during the MFP demonstration project; and
"(iv) contain assurances that grant funds used to accomplish the objective described in subsection (a)(1) shall be obligated not later than 24 months after the date on which the funds are awarded and shall be expended not later than 60 months after the date on which the funds are awarded (unless the Secretary waives either such requirement).
"(8)
"(9)
"(A) total expenditures under the State Medicaid program for home and community-based long-term care services will not be less for any fiscal year during the MFP demonstration project than for the greater of such expenditures for—
"(i) fiscal year 2005; or
"(ii) any succeeding fiscal year before the first year of the MFP demonstration project; and
"(B) in the case of a qualified HCB program operating under a waiver under subsection (c) or (d) of section 1915 of the Social Security Act (
"(10)
"(11)
"(A) a plan satisfactory to the Secretary for quality assurance and quality improvement for home and community-based long-term care services under the State Medicaid program, including a plan to assure the health and welfare of individuals participating in the MFP demonstration project; and
"(B) an assurance that the State will cooperate in carrying out activities under subsection (f) to develop and implement continuous quality assurance and quality improvement systems for home and community-based long-term care services.
"(12)
"(A)
"(B)
"(C)
"(D)
Nothing in this section shall be construed as requiring a State to make an election under the project to provide for home and community-based long-term care services as self-directed services, or as requiring an individual to elect to receive self-directed services under the project.
"(13)
"(A) the State will furnish to the Secretary such reports concerning the MFP demonstration project, on such timetable, in such uniform format, and containing such information as the Secretary may require, as will allow for reliable comparisons of MFP demonstration projects across States, and in such manner as will meet the reporting requirements set forth for the Transformed Medicaid Statistical Information System (T–MSIS);
"(B) the State shall report on a quarterly basis on the use of grant funds by distinct activity, as described in the approved work plan, and by specific population as targeted by the State;
"(C) if the State fails to report the information required under subparagraph (B), fails to report such information on a quarterly basis, or fails to make progress under the approved work plan, the State shall implement a corrective action plan approved by the Secretary; and
"(D) the State will participate in and cooperate with the evaluation of the MFP demonstration project.
"(d)
"(1)
"(2)
"(A) shall take into consideration the manner in which, and extent to which, the State proposes to achieve the objectives specified in subsection (a);
"(B) shall seek to achieve an appropriate national balance in the numbers of eligible individuals, within different target groups of eligible individuals, who are assisted to transition to qualified residences under MFP demonstration projects, and in the geographic distribution of States operating MFP demonstration projects;
"(C) shall give preference to State applications proposing—
"(i) to provide transition assistance to eligible individuals within multiple target groups; and
"(ii) to provide eligible individuals with the opportunity to receive home and community-based long-term care services as self-directed services, as defined in subsection (b)(8); and
"(D) shall take such objectives into consideration in setting the annual amounts of State grant awards under this section.
"(3)
"(A)
"(B)
"(C)
"(D)
"(4)
"(A)
"(i) increasing State Medicaid support for home and community-based long-term care services under subsection (c)(5); and
"(ii) numbers of eligible individuals assisted to transition to qualified residences.
"(B)
"(C)
"(e)
"(1)
"(A) the MFP-enhanced FMAP (as defined in paragraph (5)) of the amount of qualified expenditures made during such quarter; or
"(B) the total amount remaining in such grant award for such fiscal year (taking into account the application of paragraph (2)).
"(2)
"(3)
"(4)
"(5) MFP-
"(f)
"(1)
"(A) dissemination of information on promising practices;
"(B) guidance on system design elements addressing the unique needs of participating beneficiaries;
"(C) ongoing consultation on quality, including assistance in developing necessary tools, resources, and monitoring systems; and
"(D) guidance on remedying programmatic and systemic problems.
"(2)
"(g)
"(1)
"(2)
"(3)
"(h)
"(1)
"(A) $250,000,000 for the portion of fiscal year 2007 beginning on January 1, 2007, and ending on September 30, 2007;
"(B) $300,000,000 for fiscal year 2008;
"(C) $350,000,000 for fiscal year 2009;
"(D) $400,000,000 for fiscal year 2010;
"(E) $450,000,000 for each of fiscal years 2011 through 2016;
"(F) $254,500,000 for fiscal year 2019;
"(G) $337,500,000 for the period beginning on January 1, 2020, and ending on September 30, 2020;
"(H) for the period beginning on October 1, 2020, and ending on December 18, 2020, the amount equal to the pro rata portion of the amount appropriated for such period for fiscal year 2020;
"(I) for the period beginning on December 19, 2020, and ending on September 30, 2021, the amount equal to the pro rata portion of an annual appropriation of $450,000,000;
"(J) $450,000,000 for fiscal year 2022;
"(K) $450,000,000 for fiscal year 2023; and
"(L) $450,000,000 for each of fiscal years 2024 through 2027.
"(2)
"(3)
"(i)
"(1)
"(A) The most effective State strategies for transitioning beneficiaries from institutional to qualified community settings carried out under MFP demonstration projects and how such strategies may vary for different types of beneficiaries, such as beneficiaries who are aged, physically disabled, intellectually or developmentally disabled, or individuals with serious mental illnesses, and other targeted waiver beneficiary populations under section 1915(c) of the Social Security Act [
"(B) The most common and the most effective State uses of grant funds carried out under demonstration projects for transitioning beneficiaries from institutional to qualified community settings and improving health outcomes, including differentiating funding for current initiatives that are designed for such purpose and funding for proposed initiatives that are designed for such purpose.
"(C) The most effective State approaches carried out under MFP demonstration projects for improving person-centered care and planning.
"(D) Identification of program, financing, and other flexibilities available under MFP demonstration projects, that are not available under the traditional Medicaid program, and which directly contributed to successful transitions and improved health outcomes under MFP demonstration projects.
"(E) State strategies and financing mechanisms for effective coordination of housing financed or supported under MFP demonstration projects with local housing authorities and other resources.
"(F) Effective State approaches for delivering Money Follows the Person transition services through managed care entities.
"(G) Other best practices and effective transition strategies demonstrated by States with approved MFP demonstration projects, as determined by the Secretary.
"(H) Identification and analyses of opportunities and challenges to integrating effective Money Follows the Person practices and State strategies into the traditional Medicaid program.
"(2)
"(3)
"(4)
"(j)
"(1) identifies the types of home and community-based settings and associated services that are available to eligible individuals in both the MFP demonstration program and sites in compliance with the HCBS final rule; and
"(2) if determined appropriate by the Commission, recommends policies to align the criteria for a qualified residence under subsection (b)(6) (as in effect on October 1, 2017) with the criteria in the HCBS final rule."
[
[
[
Study Regarding Barriers to Participation of Farmworkers in Health Programs
"(a)
"(1)
"(2)
"(3)
"(b)
"(1)
"(2)
"(3)
"(4)
"(5)
"(6)
"(c)
"(1) Farmworkers affected by the lack of portability of coverage under the Medicaid program or the State children's health insurance program (under titles XIX and XXI of the Social Security Act [
"(2) Individuals with expertise in providing health care to farmworkers, including designees of national and local organizations representing migrant health centers and other providers.
"(3) Resources with expertise in health care financing.
"(4) Representatives of foundations and other nonprofit entities that have conducted or supported research on farmworker health care financial issues.
"(5) Representatives of Federal agencies which are involved in the provision or financing of health care to farmworkers, including the Centers for Medicare & Medicaid Services and the Health Resources and Services Administration.
"(6) Representatives of State governments.
"(7) Representatives from the farm and agricultural industries.
"(8) Designees of labor organizations representing farmworkers.
"(d)
"(1)
"(2)
"(3) SCHIP.—The term 'SCHIP' means the State children's health insurance program under title XXI of the Social Security Act [
"(e)
Study on Limitation on State Payment for Medicare Cost-Sharing Affecting Access to Services for Qualified Medicare Beneficiaries
"(a)
"(b)
GAO Study of Future Rebasing
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
"(1)
"(2)
Dual Eligibles; Monitoring Payments
Extension of Effective Date for State Law Amendment
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
"(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 [
"(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)."
[
Demonstration Project To Provide Medicaid Coverage for HIV-Positive Individuals
"(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
"(1)
"(2)
"(3)
"(4)
Physician Identifier System; Deadline and Considerations
Foreign Medical Graduate Certification
"(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
Development of Model Applications for Medicaid Program
"(1)
"(2)
Clarification of Federal Financial Participation for Case-Management Services
Treatment of States Operating Under Demonstration Projects
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
Technical Assistance With Respect to Facilities That Take Into Account Case Mix of Residents
State Utilization Review Systems
"(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 [
"(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 [
"(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."
Study by Comptroller General of Effect of Amendment to Subsection (a)(13)
Task Force on Technology-Dependent Children
Medicaid Coverage Relating to Adoption Assistance Agreements Entered Into Before April 7, 1986
"(A) the requirements of subdivisions (aa) and (bb) of section 1902(a)(10)(A)(ii)(VIII) of the Social Security Act [
"(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
Moratorium on Regulatory Actions by Secretary
"(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 [
"(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 [
[Amendment of section 2373(c) of
Evaluation and Study of Reasons for Termination by Medicaid Beneficiaries of Membership in Health Maintenance Organizations
Continuing Medicaid Eligibility for Certain Recipients of Veterans' Administration Pensions
"(A) For purposes of section 1902(a)(10)(A) of the Social Security Act [
"(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
"(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 [
Federal matching under title XIX of the Social Security Act [
Coverage of Essential Persons Under Medicaid
"(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 [
Persons in Medical Institutions
"(1) was an inpatient in an institution qualified for reimbursement under title XIX of the Social Security Act [
"(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 [
"(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 [
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 [
Federal matching under title XIX of the Social Security Act [
Blind and Disabled Medically Indigent Persons
Impact of 1972 Social Security Benefits Increase Under Pub. L. 92–336 Upon Eligibility for Assistance Under This Subchapter
Nursing Homes Eligible for Matching Funds for Home Services When Meeting State Licensure Requirements After June 30, 1968
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 [
"(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 [
"(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 [
"(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."
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. Probably should be followed by a comma.
7 So in original. Probably should be "Investigation,".
9 So in original. Probably should be section "1396d(l)(2)(B)".
10 So in original. Probably should be "a quality improvement organization".
11 So in original. Probably should be "subparagraph (A)(i)(V),".
12 So in original. The closing parenthesis probably should not appear.
13 So in original. Probably should be "an".
14 So in original. Another closing parenthesis probably should precede the comma.
15 So in original. Probably should be "this subsection".
16 So in original. Probably should be subsection "(a)(56)".
17 So in original. Probably should be section "1396o(i)".
18 So in original. Probably should be "agency".
19 So in original. Probably should be followed by "a".
20 So in original. The word "section" probably should not appear.
§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
(E) 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 translation or interpretation services in connection with the enrollment of, retention of, and use of services under this subchapter by, children of families for whom English is not the primary language; plus
(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, 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 subchapter,
(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
(iii) an amount equal to the Federal medical assistance percentage (as defined in
(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 1 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
(E) 50 percent of the sums expended with respect to costs incurred during such quarter as are attributable to providing—
(i) services to identify and educate individuals who are likely to be eligible for medical assistance under this subchapter and who have Sickle Cell Disease or who are carriers of the sickle cell gene, including education regarding how to identify such individuals; or
(ii) education regarding the risks of stroke and other complications, as well as the prevention of stroke and other complications, in individuals who are likely to be eligible for medical assistance under this subchapter and who have Sickle Cell Disease; and
(F)(i) 100 percent of so much of the sums expended during such quarter as are attributable to payments to Medicaid providers described in subsection (t)(1) to encourage the adoption and use of certified EHR technology; and
(ii) 90 percent of so much of the sums expended during such quarter as are attributable to payments for reasonable administrative expenses related to the administration of payments described in clause (i) if the State meets the condition described in subsection (t)(9); plus
(H)(i) 2 90 percent of the sums expended during the quarter as are attributable to the design, development, or installation of such mechanized verification and information retrieval systems as the Secretary determines are necessary to implement
(ii) 75 percent of the sums expended during the quarter as are attributable to the operation of systems to which clause (i) applies,3 plus
(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), 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 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)); 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) 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 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, 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) 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), 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 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) for any State shall be decreased in a quarter by the amount of any health care related taxes (described in subsection (w)(3)(A)) 4 that are imposed on a hospital described in subsection (w)(3)(F) 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) 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) 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) 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 1 year 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 1-year period, whether or not recovery was made.
(D)(i) 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).
(ii) 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 due to fraud within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment (including, if applicable, a final determination on an appeal) is made.
(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), 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)) 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)(i)(VIII), 1396a(a)(10)(A)(i)(IX), 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 5 1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI), 1396a(a)(10)(A)(ii)(XVII), 1396a(a)(10)(A)(ii)(XVIII), 1396a(a)(10)(A)(ii)(XIX), 1396a(a)(10)(A)(ii)(XX), 1396a(a)(10)(A)(ii)(XXI), 1396a(a)(10)(A)(ii)(XXII), 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, 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 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 or under this subchapter pursuant to
(C) by any individual or entity to whom the State has failed to suspend payments under the plan during any period when there is pending an investigation of a credible allegation of fraud against the individual or entity, as determined by the State in accordance with regulations promulgated by the Secretary for purposes of
(D) beginning on July 1, 2018, under the plan by any provider of services or person whose participation in the State plan is terminated (as described in
(E) with respect to any amount expended for such an item or service furnished during calendar quarters beginning on or after October 1, 2017, subject 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 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) with respect to any amount expended for non-emergency transportation authorized under
(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
(C) with respect to covered outpatient drugs described in
(D) with respect to any amount expended for reimbursement to a pharmacy under this subchapter for the ingredient cost of a covered outpatient drug for which the pharmacy has already received payment under this subchapter (other than with respect to a reasonable restocking fee for such drug); and
(E) with respect to any amount expended for a covered outpatient drug for which a suspension under
(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) with respect to any amounts expended for—
(A) a vacuum erection system that is not medically necessary; or
(B) the insertion, repair, or removal and replacement of a penile prosthetic implant (unless such insertion, repair, or removal and replacement is medically necessary); or
(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);
(20) with respect to amounts expended for medical assistance provided to an individual described in subclause (XV) or (XVI) of
(21) with respect to amounts expended for covered outpatient drugs described in
(22) with respect to amounts expended for medical assistance for an individual who declares under
(23) with respect to amounts expended for medical assistance for covered outpatient drugs (as defined in
(24) if a State is required to implement an asset verification program under
(A) the State demonstrates to the Secretary's satisfaction that the State made a good faith effort to comply;
(B) not later than 60 days after the date of a finding that the State is in noncompliance, the State submits to the Secretary (and the Secretary approves) a corrective action plan to remedy such noncompliance; and
(C) not later than 12 months after the date of such submission (and approval), the State fulfills the terms of such corrective action plan;
(25) with respect to any amounts expended for medical assistance for individuals for whom the State does not report enrollee encounter data (as defined by the Secretary) to the Medicaid Statistical Information System (MSIS) in a timely manner (as determined by the Secretary);
(26) with respect to any amounts expended for medical assistance for individuals described in subclause (VIII) of subsection (a)(10)(A)(i) 6 other than medical assistance provided through benchmark coverage described in
(27) with respect to any amounts expended by the State on the basis of a fee schedule for items described in
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) 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) Electronic visit verification system for personal care services and home health care services
(1) Subject to paragraphs (3) and (4), with respect to any amount expended for personal care services or home health care services requiring an in-home visit by a provider that are provided under a State plan under this subchapter (or under a waiver of the plan) and furnished in a calendar quarter beginning on or after January 1, 2020 (or, in the case of home health care services, on or after January 1, 2023), unless a State requires the use of an electronic visit verification system for such services furnished in such quarter under the plan or such waiver, the Federal medical assistance percentage shall be reduced—
(A) in the case of personal care services—
(i) for calendar quarters in 2020, by .25 percentage points;
(ii) for calendar quarters in 2021, by .5 percentage points;
(iii) for calendar quarters in 2022, by .75 percentage points; and
(iv) for calendar quarters in 2023 and each year thereafter, by 1 percentage point; and
(B) in the case of home health care services—
(i) for calendar quarters in 2023 and 2024, by .25 percentage points;
(ii) for calendar quarters in 2025, by .5 percentage points;
(iii) for calendar quarters in 2026, by .75 percentage points; and
(iv) for calendar quarters in 2027 and each year thereafter, by 1 percentage point.
(2) Subject to paragraphs (3) and (4), in implementing the requirement for the use of an electronic visit verification system under paragraph (1), a State shall—
(A) consult with agencies and entities that provide personal care services, home health care services, or both under the State plan (or under a waiver of the plan) to ensure that such system—
(i) is minimally burdensome;
(ii) takes into account existing best practices and electronic visit verification systems in use in the State; and
(iii) is conducted in accordance with the requirements of HIPAA privacy and security law (as defined in
(B) take into account a stakeholder process that includes input from beneficiaries, family caregivers, individuals who furnish personal care services or home health care services, and other stakeholders, as determined by the State in accordance with guidance from the Secretary; and
(C) ensure that individuals who furnish personal care services, home health care services, or both under the State plan (or under a waiver of the plan) are provided the opportunity for training on the use of such system.
(3) Paragraphs (1) and (2) shall not apply in the case of a State that, as of December 13, 2016, requires the use of any system for the electronic verification of visits conducted as part of both personal care services and home health care services, so long as the State continues to require the use of such system with respect to the electronic verification of such visits.
(4)(A) In the case of a State described in subparagraph (B), the reduction under paragraph (1) shall not apply—
(i) in the case of personal care services, for calendar quarters in 2020; and
(ii) in the case of home health care services, for calendar quarters in 2023.
(B) For purposes of subparagraph (A), a State described in this subparagraph is a State that demonstrates to the Secretary that the State—
(i) has made a good faith effort to comply with the requirements of paragraphs (1) and (2) (including by taking steps to adopt the technology used for an electronic visit verification system); and
(ii) in implementing such a system, has encountered unavoidable system delays.
(5) In this subsection:
(A) The term "electronic visit verification system" means, with respect to personal care services or home health care services, a system under which visits conducted as part of such services are electronically verified with respect to—
(i) the type of service performed;
(ii) the individual receiving the service;
(iii) the date of the service;
(iv) the location of service delivery;
(v) the individual providing the service; and
(vi) the time the service begins and ends.
(B) The term "home health care services" means services described in
(C) The term "personal care services" means personal care services provided under a State plan under this subchapter (or under a waiver of the plan), including services provided under
(6)(A) In the case in which a State requires personal care service and home health care service providers to utilize an electronic visit verification system operated by the State or a contractor on behalf of the State, the Secretary shall pay to the State, for each quarter, an amount equal to 90 per centum of so much of the sums expended during such quarter as are attributable to the design, development, or installation of such system, and 75 per centum of so much of the sums for the operation and maintenance of such system.
(B) Subparagraph (A) shall not apply in the case in which a State requires personal care service and home health care service providers to utilize an electronic visit verification system that is not operated by the State or a contractor on behalf of the State.
(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 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,3
(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 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 for the provision of such data to the State at a frequency and level of detail to be specified by the Secretary;
(xii) such contract, and the entity complies with the applicable requirements of
(xiii) such contract provides that (I) covered outpatient drugs dispensed to individuals eligible for medical assistance who are enrolled with the entity shall be subject to the same rebate required by the agreement entered into under
(B) Subparagraph (A) 8 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 1965,4 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) No payment shall be made under this subchapter to a State with respect to expenditures incurred by the State for payment for services provided by a managed care entity (as defined under
(A) beginning on July 1, 2018, has a contract with such entity that complies with the requirement specified in
(B) beginning on January 1, 2018, complies with the requirement specified in
(4)(A) Each medicaid managed care organization which is not a qualified health maintenance organization (as defined in section 300e–9(d) 4 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,3 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
(7) Payment shall be made under this subchapter to a State for expenditures for capitation payments described in section 438.6(e) of title 42, Code of Federal Regulations (or any successor regulation).
(8)(A) The State agency administering the State plan under this subchapter may have reasonable access, as determined by the State, to 1 or more prescription drug monitoring program databases administered or accessed by the State to the extent the State agency is permitted to access such databases under State law.
(B) Such State agency may facilitate reasonable access, as determined by the State, to 1 or more prescription drug monitoring program databases administered or accessed by the State, to same extent that the State agency is permitted under State law to access such databases, for—
(i) any provider enrolled under the State plan to provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
(C) Such State agency may share information in such databases, to the same extent that the State agency is permitted under State law to share information in such databases, with—
(i) any provider enrolled under the State plan to provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
(9)(A) With respect to expenditures described in subparagraph (B) that are incurred by a State for any fiscal year after fiscal year 2020, in determining the pro rata share to which the United States is equitably entitled under subsection (d)(3), the Secretary shall substitute the Federal medical assistance percentage that applies for such fiscal year to the State under
(B) Expenditures described in this subparagraph, with respect to a fiscal year to which subparagraph (A) applies, are expenditures incurred by a State for payment for medical assistance provided to individuals described in subclause (VIII) of
(i) has satisfied the requirement of section 438.8 of title 42, Code of Federal Regulations (or any successor regulation), by electing—
(I) in the case of a State described in subparagraph (C), to apply a minimum medical loss ratio (as defined in subparagraph (D)(ii)) that is at least 85 percent but not greater than the minimum medical loss ratio (as so defined) that such State applied as of May 31, 2018; or
(II) in the case of a State not described in subparagraph (C), to apply a minimum medical loss ratio that is equal to 85 percent; and
(ii) recovered all or a portion of the expenditures as a result of the entity's failure to meet such ratio.
(C) For purposes of subparagraph (B), a State described in this subparagraph is a State that as of May 31, 2018, applied a minimum medical loss ratio (as calculated under subsection (d) of section 438.8 of title 42, Code of Federal Regulations (as in effect on June 1, 2018)) for payment for services provided by entities described in such subparagraph under the State plan under this subchapter (or a waiver of the plan) that is equal to or greater than 85 percent.
(D) For purposes of this paragraph:
(i) The term "managed care entity" means a medicaid managed care organization described in
(ii) The term "minimum medical loss ratio" means, with respect to a State, a minimum medical loss ratio (as calculated under subsection (d) of section 438.8 of title 42, Code of Federal Regulations (as in effect on June 1, 2018)) for payment for services provided by entities described in subparagraph (B) under the State plan under this subchapter (or a waiver of the plan).
(iii) The term "other specified entity" means—
(I) a prepaid inpatient health plan, as defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation); and
(II) a prepaid ambulatory health plan, as defined in such section (or any successor regulation).
(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 of patients (who are receiving medical assistance under the State plan under this subchapter (or waiver of such plan)) in a noninstitutional or other setting; 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) for use of automated data systems in administration of the State plan under this subchapter, a State must, in addition to meeting the requirements of paragraph (3), 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, and for this purpose—
(i) have a uniform identification coding system for providers, other payees, and beneficiaries under this subchapter or subchapter XVIII;
(ii) provide liaison between States and carriers and intermediaries with agreements under subchapter XVIII to facilitate timely exchange of appropriate data;
(iii) provide for exchange of data between the States and the Secretary with respect to persons sanctioned under this subchapter or subchapter XVIII; and
(iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the Secretary identifies in accordance with paragraph (4);
(C) are capable of providing accurate and timely data;
(D) are complying with the applicable provisions of part C of subchapter XI;
(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 and including, for data submitted to the Secretary on or after January 1, 2010, data elements from the automated data system that the Secretary determines to be necessary for program integrity, program oversight, and administration, at such frequency as the Secretary shall determine).
(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.
(3) In order to meet the requirements of this paragraph, a State must have in operation an eligibility determination system which provides for data matching through the Public Assistance Reporting Information System (PARIS) facilitated by the Secretary (or any successor system), including matching with medical assistance programs operated by other States.
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) which are compatible to claims filed under this subchapter.
(ii) Identify those methodologies of such Initiative (or such other national correct coding methodologies) that should be incorporated into claims filed under this subchapter with respect to items or services for which States provide medical assistance under this subchapter and no national correct coding methodologies have been established under such Initiative with respect to subchapter XVIII.
(iii) Notify States of—
(I) the methodologies identified under subparagraphs (A) and (B) (and of any other national correct coding methodologies identified under subparagraph (B)); and
(II) how States are to incorporate such methodologies into claims filed under this subchapter.
(B) Not later than March 1, 2011, submit a report to Congress that includes the notice to States under clause (iii) of subparagraph (A) and an analysis supporting the identification of the methodologies made under clauses (i) and (ii) of subparagraph (A).
(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) Payments to encourage adoption and use of certified EHR technology
(1) For purposes of subsection (a)(3)(F), the payments described in this paragraph to encourage the adoption and use of certified EHR technology are payments made by the State in accordance with this subsection—
(A) to Medicaid providers described in paragraph (2)(A) not in excess of 85 percent of net average allowable costs (as defined in paragraph (3)(E)) for certified EHR technology (and support services including maintenance and training that is for, or is necessary for the adoption and operation of, such technology) with respect to such providers; and
(B) to Medicaid providers described in paragraph (2)(B) not in excess of the maximum amount permitted under paragraph (5) for the provider involved.
(2) In this subsection and subsection (a)(3)(F), the term "Medicaid provider" means—
(A) an eligible professional (as defined in paragraph (3)(B))—
(i) who is not hospital-based and has at least 30 percent of the professional's patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to individuals who are receiving medical assistance under this subchapter;
(ii) who is not described in clause (i), who is a pediatrician, who is not hospital-based, and who has at least 20 percent of the professional's patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to individuals who are receiving medical assistance under this subchapter; and
(iii) who practices predominantly in a Federally qualified health center or rural health clinic and has at least 30 percent of the professional's patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to needy individuals (as defined in paragraph (3)(F)); and
(B)(i) a children's hospital, or
(ii) an acute-care hospital that is not described in clause (i) and that has at least 10 percent of the hospital's patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to individuals who are receiving medical assistance under this subchapter.
An eligible professional shall not qualify as a Medicaid provider under this subsection unless any right to payment under
(3) In this subsection and subsection (a)(3)(F):
(A) The term "certified EHR technology" means a qualified electronic health record (as defined in 9 300jj(13) of this title) that is certified pursuant to
(B) The term "eligible professional" means a—
(i) physician;
(ii) dentist;
(iii) certified nurse mid-wife;
(iv) nurse practitioner; and
(v) physician assistant insofar as the assistant is practicing in a rural health clinic that is led by a physician assistant or is practicing in a Federally qualified health center that is so led.
(C) The term "average allowable costs" means, with respect to certified EHR technology of Medicaid providers described in paragraph (2)(A) for—
(i) the first year of payment with respect to such a provider, the average costs for the purchase and initial implementation or upgrade of such technology (and support services including training that is for, or is necessary for the adoption and initial operation of, such technology) for such providers, as determined by the Secretary based upon studies conducted under paragraph (4)(C); and
(ii) a subsequent year of payment with respect to such a provider, the average costs not described in clause (i) relating to the operation, maintenance, and use of such technology for such providers, as determined by the Secretary based upon studies conducted under paragraph (4)(C).
(D) The term "hospital-based" means, with respect to an eligible professional, a professional (such as a pathologist, anesthesiologist, or emergency physician) who furnishes substantially all of the individual's professional services in a hospital inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.
(E) The term "net average allowable costs" means, with respect to a Medicaid provider described in paragraph (2)(A), average allowable costs reduced by the average payment the Secretary estimates will be made to such Medicaid providers (determined on a percentage or other basis for such classes or types of providers as the Secretary may specify) from other sources (other than under this subsection, or by the Federal government or a State or local government) that is directly attributable to payment for certified EHR technology or support services described in subparagraph (C).
(F) The term "needy individual" means, with respect to a Medicaid provider, an individual—
(i) who is receiving assistance under this subchapter;
(ii) who is receiving assistance under subchapter XXI;
(iii) who is furnished uncompensated care by the provider; or
(iv) for whom charges are reduced by the provider on a sliding scale basis based on an individual's ability to pay.
(4)(A) With respect to a Medicaid provider described in paragraph (2)(A), subject to subparagraph (B), in no case shall—
(i) the net average allowable costs under this subsection for the first year of payment (which may not be later than 2016), which is intended to cover the costs described in paragraph (3)(C)(i), exceed $25,000 (or such lesser amount as the Secretary determines based on studies conducted under subparagraph (C));
(ii) the net average allowable costs under this subsection for a subsequent year of payment, which is intended to cover costs described in paragraph (3)(C)(ii), exceed $10,000; and
(iii) payments be made for costs described in clause (ii) after 2021 or over a period of longer than 5 years.
(B) In the case of Medicaid 10 provider described in paragraph (2)(A)(ii), the dollar amounts specified in subparagraph (A) shall be 2/3 of the dollar amounts otherwise specified.
(C) For the purposes of determining average allowable costs under this subsection, the Secretary shall study the average costs to Medicaid providers described in paragraph (2)(A) of purchase and initial implementation and upgrade of certified EHR technology described in paragraph (3)(C)(i) and the average costs to such providers of operations, maintenance, and use of such technology described in paragraph (3)(C)(ii). In determining such costs for such providers, the Secretary may utilize studies of such amounts submitted by States.
(5)(A) In no case shall the payments described in paragraph (1)(B) with respect to a Medicaid provider described in paragraph (2)(B) exceed—
(i) in the aggregate the product of—
(I) the overall hospital EHR amount for the provider computed under subparagraph (B); and
(II) the Medicaid share for such provider computed under subparagraph (C);
(ii) in any year 50 percent of the product described in clause (i); and
(iii) in any 2-year period 90 percent of such product.
(B) For purposes of this paragraph, the overall hospital EHR amount, with respect to a Medicaid provider, is the sum of the applicable amounts specified in
(C) The Medicaid share computed under this subparagraph, for a Medicaid provider for a period specified by the Secretary, shall be calculated in the same manner as the Medicare share under
(D) In no case may the payments described in paragraph (1)(B) with respect to a Medicaid provider described in paragraph (2)(B) be paid—
(i) for any year beginning after 2016 unless the provider has been provided payment under paragraph (1)(B) for the previous year; and
(ii) over a period of more than 6 years of payment.
(6) Payments described in paragraph (1) are not in accordance with this subsection unless the following requirements are met:
(A)(i) The State provides assurances satisfactory to the Secretary that amounts received under subsection (a)(3)(F) with respect to payments to a Medicaid provider are paid, subject to clause (ii), directly to such provider (or to an employer or facility to which such provider has assigned payments) without any deduction or rebate.
(ii) Amounts described in clause (i) may also be paid to an entity promoting the adoption of certified EHR technology, as designated by the State, if participation in such a payment arrangement is voluntary for the eligible professional involved and if such entity does not retain more than 5 percent of such payments for costs not related to certified EHR technology (and support services including maintenance and training) that is for, or is necessary for the operation of, such technology.
(B) A Medicaid provider described in paragraph (2)(A) is responsible for payment of the remaining 15 percent of the net average allowable cost and shall be determined to have met such responsibility to the extent that the payment to the Medicaid provider is not in excess of 85 percent of the net average allowable cost.
(C)(i) Subject to clause (ii), with respect to payments to a Medicaid provider—
(I) for the first year of payment to the Medicaid provider under this subsection, the Medicaid provider demonstrates that it is engaged in efforts to adopt, implement, or upgrade certified EHR technology; and
(II) for a year of payment, other than the first year of payment to the Medicaid provider under this subsection, the Medicaid provider demonstrates meaningful use of certified EHR technology through a means that is approved by the State and acceptable to the Secretary, and that may be based upon the methodologies applied under
(ii) In the case of a Medicaid provider who has completed adopting, implementing, or upgrading such technology prior to the first year of payment to the Medicaid provider under this subsection, clause (i)(I) shall not apply and clause (i)(II) shall apply to each year of payment to the Medicaid provider under this subsection, including the first year of payment.
(D) To the extent specified by the Secretary, the certified EHR technology is compatible with State or Federal administrative management systems.
For purposes of subparagraph (B), a Medicaid provider described in paragraph (2)(A) may accept payments for the costs described in such subparagraph from a State or local government. For purposes of subparagraph (C), in establishing the means described in such subparagraph, which may include clinical quality reporting to the State, the State shall ensure that populations with unique needs, such as children, are appropriately addressed.
(7) With respect to Medicaid providers described in paragraph (2)(A), the Secretary shall ensure coordination of payment with respect to such providers under
(8) In carrying out paragraph (6)(C), the State and Secretary shall seek, to the maximum extent practicable, to avoid duplicative requirements from Federal and State governments to demonstrate meaningful use of certified EHR technology under this subchapter and subchapter XVIII. In doing so, the Secretary may deem satisfaction of requirements for such meaningful use for a payment year under subchapter XVIII to be sufficient to qualify as meaningful use under this subsection. The Secretary may also specify the reporting periods under this subsection in order to carry out this paragraph.
(9) In order to be provided Federal financial participation under subsection (a)(3)(F)(ii), a State must demonstrate to the satisfaction of the Secretary, that the State—
(A) is using the funds provided for the purposes of administering payments under this subsection, including tracking of meaningful use by Medicaid providers;
(B) is conducting adequate oversight of the program under this subsection, including routine tracking of meaningful use attestations and reporting mechanisms; and
(C) is pursuing initiatives to encourage the adoption of certified EHR technology to promote health care quality and the exchange of health care information under this subchapter, subject to applicable laws and regulations governing such exchange.
(10) The Secretary shall periodically submit reports to the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate on status, progress, and oversight of payments described in paragraph (1), including steps taken to carry out paragraph (7). Such reports shall also describe the extent of adoption of certified EHR technology among Medicaid providers resulting from the provisions of this subsection and any improvements in health outcomes, clinical quality, or efficiency resulting from such adoption.
(u) Limitation of Federal financial participation in erroneous medical assistance expenditures
(1)(A) Notwithstanding subsection (a)(1), 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), 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), for purposes of payment to the State under subsection (d)(3), 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)).
(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) 4 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 paragraphs (2) and (4), 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, supplemental security income benefits under subchapter XVI, 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.
(4)(A) A State may elect (in a plan amendment under this subchapter) to provide medical assistance under this subchapter, notwithstanding
(i) Pregnant women
Women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy).
(ii) Children
Individuals under 21 years of age, including optional targeted low-income children described in
(B) In the case of a State that has elected to provide medical assistance to a category of aliens under subparagraph (A), no debt shall accrue under an affidavit of support against any sponsor of such an alien on the basis of provision of assistance to such category and the cost of such assistance shall not be considered as an unreimbursed cost.
(C) As part of the State's ongoing eligibility redetermination requirements and procedures for an individual provided medical assistance as a result of an election by the State under subparagraph (A), a State shall verify that the individual continues to lawfully reside in the United States using the documentation presented to the State by the individual on initial enrollment. If the State cannot successfully verify that the individual is lawfully residing in the United States in this manner, it shall require that the individual provide the State with further documentation or other evidence to verify that the individual is lawfully residing in the United States.
(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) 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) 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).
(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).
(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, 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.
(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.
(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)(i) 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.
(ii) For purposes of clause (i), a determination of the existence of an indirect guarantee shall be made under paragraph (3)(i) of section 433.68(f) of title 42, Code of Federal Regulations, as in effect on November 1, 2006, except that for portions of fiscal years beginning on or after January 1, 2008, and before October 1, 2011, "5.5 percent" shall be substituted for "6 percent" each place it appears.
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 managed care organizations (including health maintenance organizations, preferred provider organizations, and such other similar organizations as the Secretary may specify by regulation).
(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.
(x) Satisfactory documentary evidence of citizenship or nationality by individual declaring to be citizen or national of United States
(1) For purposes of
(2) The requirement of paragraph (1) shall not apply to an individual declaring to be a citizen or national of the United States who is eligible for medical assistance under this subchapter—
(A) and is entitled to or enrolled for benefits under any part of subchapter XVIII;
(B) and is receiving—
(i) disability insurance benefits under
(ii) supplemental security income benefits under subchapter XVI;
(C) and with respect to whom—
(i) child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care; or
(ii) adoption or foster care assistance is made available under part E of subchapter IV;
(D) pursuant to the application of
(E) on such basis as the Secretary may specify under which satisfactory documentary evidence of citizenship or nationality has been previously presented.
(3)(A) For purposes of this subsection, the term "satisfactory documentary evidence of citizenship or nationality" means—
(i) any document described in subparagraph (B); or
(ii) a document described in subparagraph (C) and a document described in subparagraph (D).
(B) The following are documents described in this subparagraph:
(i) A United States passport.
(ii) Form N–550 or N–570 (Certificate of Naturalization).
(iii) Form N–560 or N–561 (Certificate of United States Citizenship).
(iv) A valid State-issued driver's license or other identity document described in
(v)(I) Except as provided in subclause (II), a document issued by a federally recognized Indian tribe evidencing membership or enrollment in, or affiliation with, such tribe (such as a tribal enrollment card or certificate of degree of Indian blood).
(II) With respect to those federally recognized Indian tribes located within States having an international border whose membership includes individuals who are not citizens of the United States, the Secretary shall, after consulting with such tribes, issue regulations authorizing the presentation of such other forms of documentation (including tribal documentation, if appropriate) that the Secretary determines to be satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this subsection.
(vi) Such other document as the Secretary may specify, by regulation, that provides proof of United States citizenship or nationality and that provides a reliable means of documentation of personal identity.
(C) The following are documents described in this subparagraph:
(i) A certificate of birth in the United States.
(ii) Form FS–545 or Form DS–1350 (Certification of Birth Abroad).
(iii) Form I–197 (United States Citizen Identification Card).
(iv) Form FS–240 (Report of Birth Abroad of a Citizen of the United States).
(v) Such other document (not described in subparagraph (B)(iv)) as the Secretary may specify that provides proof of United States citizenship or nationality.
(D) The following are documents described in this subparagraph:
(i) Any identity document described in
(ii) Any other documentation of personal identity of such other type as the Secretary finds, by regulation, provides a reliable means of identification.
(E) A reference in this paragraph to a form includes a reference to any successor form.
(4) In the case of an individual declaring to be a citizen or national of the United States with respect to whom a State requires the presentation of satisfactory documentary evidence of citizenship or nationality under
(5) Nothing in subparagraph (A) or (B) of
(y) Payments for establishment of alternate non-emergency services providers
(1) Payments
In addition to the payments otherwise provided under subsection (a), subject to paragraph (2), the Secretary shall provide for payments to States under such subsection for the establishment of alternate non-emergency service providers (as defined in section 1396o–1(e)(5)(B) 12 of this title), or networks of such providers.
(2) Limitation
The total amount of payments under this subsection shall not exceed $50,000,000 during the 4-year period beginning with 2006. This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this subsection.
(3) Preference
In providing for payments to States under this subsection, the Secretary shall provide preference to States that establish, or provide for, alternate non-emergency services providers or networks of such providers that—
(A) serve rural or underserved areas where beneficiaries under this subchapter may not have regular access to providers of primary care services; or
(B) are in partnership with local community hospitals.
(4) Form and manner of payment
Payment to a State under this subsection shall be made only upon the filing of such application in such form and in such manner as the Secretary shall specify. Payment to a State under this subsection shall be made in the same manner as other payments under subsection (a).
(z) Medicaid transformation payments
(1) In general
In addition to the payments provided under subsection (a), subject to paragraph (4), the Secretary shall provide for payments to States for the adoption of innovative methods to improve the effectiveness and efficiency in providing medical assistance under this subchapter.
(2) Permissible uses of funds
The following are examples of innovative methods for which funds provided under this subsection may be used:
(A) Methods for reducing patient error rates through the implementation and use of electronic health records, electronic clinical decision support tools, or e-prescribing programs.
(B) Methods for improving rates of collection from estates of amounts owed under this subchapter.
(C) Methods for reducing waste, fraud, and abuse under the program under this subchapter, such as reducing improper payment rates as measured by annual payment error rate measurement (PERM) project rates.
(D) Implementation of a medication risk management program as part of a drug use review program under
(E) Methods in reducing, in clinically appropriate ways, expenditures under this subchapter for covered outpatient drugs, particularly in the categories of greatest drug utilization, by increasing the utilization of generic drugs through the use of education programs and other incentives to promote greater use of generic drugs.
(F) Methods for improving access to primary and specialty physician care for the uninsured using integrated university-based hospital and clinic systems.
(3) Application; terms and conditions
(A) In general
No payments shall be made to a State under this subsection unless the State applies to the Secretary for such payments in a form, manner, and time specified by the Secretary.
(B) Terms and conditions
Such payments are made under such terms and conditions consistent with this subsection as the Secretary prescribes.
(C) Annual report
Payment to a State under this subsection is conditioned on the State submitting to the Secretary an annual report on the programs supported by such payment. Such report shall include information on—
(i) the specific uses of such payment;
(ii) an assessment of quality improvements and clinical outcomes under such programs; and
(iii) estimates of cost savings resulting from such programs.
(4) Funding
(A) Limitation on funds
The total amount of payments under this subsection shall be equal to, and shall not exceed—
(i) $75,000,000 for fiscal year 2007; and
(ii) $75,000,000 for fiscal year 2008.
This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this subsection.
(B) Allocation of funds
The Secretary shall specify a method for allocating the funds made available under this subsection among States. Such method shall provide preference for States that design programs that target health providers that treat significant numbers of Medicaid beneficiaries. Such method shall provide that not less than 25 percent of such funds shall be allocated among States the population of which (as determined according to data collected by the United States Census Bureau) as of July 1, 2004, was more than 105 percent of the population of the respective State (as so determined) as of April 1, 2000.
(C) Form and manner of payment
Payment to a State under this subsection shall be made in the same manner as other payments under subsection (a). There is no requirement for State matching funds to receive payments under this subsection.
(5) Medication risk management program
(A) In general
For purposes of this subsection, the term "medication risk management program" means a program for targeted beneficiaries that ensures that covered outpatient drugs are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events.
(B) Elements
Such program may include the following elements:
(i) The use of established principles and standards for drug utilization review and best practices to analyze prescription drug claims of targeted beneficiaries and identify outlier physicians.
(ii) On an ongoing basis provide outlier physicians—
(I) a comprehensive pharmacy claims history for each targeted beneficiary under their care;
(II) information regarding the frequency and cost of relapses and hospitalizations of targeted beneficiaries under the physician's care; and
(III) applicable best practice guidelines and empirical references.
(iii) Monitor outlier physician's prescribing, such as failure to refill, dosage strengths, and provide incentives and information to encourage the adoption of best clinical practices.
(C) Targeted beneficiaries
For purposes of this paragraph, the term "targeted beneficiaries" means Medicaid eligible beneficiaries who are identified as having high prescription drug costs and medical costs, such as individuals with behavioral disorders or multiple chronic diseases who are taking multiple medications.
(aa) Demonstration project to increase substance use provider capacity
(1) In general
Not later than the date that is 180 days after October 24, 2018, the Secretary shall, in consultation, as appropriate, with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, conduct a 54-month demonstration project for the purpose described in paragraph (2) under which the Secretary shall—
(A) for the first 18-month period of such project, award planning grants described in paragraph (3); and
(B) for the remaining 36-month period of such project, provide to each State selected under paragraph (4) payments in accordance with paragraph (5).
(2) Purpose
The purpose described in this paragraph is for each State selected under paragraph (4) to increase the treatment capacity of providers participating under the State plan (or a waiver of such plan) to provide substance use disorder treatment or recovery services under such plan (or waiver) through the following activities:
(A) For the purpose described in paragraph (3)(C)(i), activities that support an ongoing assessment of the behavioral health treatment needs of the State, taking into account the matters described in subclauses (I) through (IV) of such paragraph.
(B) Activities that, taking into account the results of the assessment described in subparagraph (A), support the recruitment, training, and provision of technical assistance for providers participating under the State plan (or a waiver of such plan) that offer substance use disorder treatment or recovery services.
(C) Improved reimbursement for and expansion of, through the provision of education, training, and technical assistance, the number or treatment capacity of providers participating under the State plan (or waiver) that—
(i) are authorized to dispense drugs approved by the Food and Drug Administration for individuals with a substance use disorder who need withdrawal management or maintenance treatment for such disorder; and
(ii) are qualified under applicable State law to provide substance use disorder treatment or recovery services.
(D) Improved reimbursement for and expansion of, through the provision of education, training, and technical assistance, the number or treatment capacity of providers participating under the State plan (or waiver) that have the qualifications to address the treatment or recovery needs of—
(i) individuals enrolled under the State plan (or a waiver of such plan) who have neonatal abstinence syndrome, in accordance with guidelines issued by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists relating to maternal care and infant care with respect to neonatal abstinence syndrome;
(ii) pregnant women, postpartum women, and infants, particularly the concurrent treatment, as appropriate, and comprehensive case management of pregnant women, postpartum women and infants, enrolled under the State plan (or a waiver of such plan);
(iii) adolescents and young adults between the ages of 12 and 21 enrolled under the State plan (or a waiver of such plan); or
(iv) American Indian and Alaska Native individuals enrolled under the State plan (or a waiver of such plan).
(3) Planning grants
(A) In general
The Secretary shall, with respect to the first 18-month period of the demonstration project conducted under paragraph (1), award planning grants to at least 10 States selected in accordance with subparagraph (B) for purposes of preparing an application described in paragraph (4)(C) and carrying out the activities described in subparagraph (C).
(B) Selection
In selecting States for purposes of this paragraph, the Secretary shall—
(i) select States that have a State plan (or waiver of the State plan) approved under this subchapter;
(ii) select States in a manner that ensures geographic diversity; and
(iii) give preference to States with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita drug overdoses, or any other measure that the Secretary deems appropriate.
(C) Activities described
Activities described in this subparagraph are, with respect to a State, each of the following:
(i) Activities that support the development of an initial assessment of the behavioral health treatment needs of the State to determine the extent to which providers are needed (including the types of such providers and geographic area of need) to improve the network of providers that treat substance use disorders under the State plan (or waiver), including the following:
(I) An estimate of the number of individuals enrolled under the State plan (or a waiver of such plan) who have a substance use disorder.
(II) Information on the capacity of providers to provide substance use disorder treatment or recovery services to individuals enrolled under the State plan (or waiver), including information on providers who provide such services and their participation under the State plan (or waiver).
(III) Information on the gap in substance use disorder treatment or recovery services under the State plan (or waiver) based on the information described in subclauses (I) and (II).
(IV) Projections regarding the extent to which the State participating under the demonstration project would increase the number of providers offering substance use disorder treatment or recovery services under the State plan (or waiver) during the period of the demonstration project.
(ii) Activities that, taking into account the results of the assessment described in clause (i), support the development of State infrastructure to, with respect to the provision of substance use disorder treatment or recovery services under the State plan (or a waiver of such plan), recruit prospective providers and provide training and technical assistance to such providers.
(D) Funding
For purposes of subparagraph (A), there is appropriated, out of any funds in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended.
(4) Post-planning states
(A) In general
The Secretary shall, with respect to the remaining 36-month period of the demonstration project conducted under paragraph (1), select not more than 5 States in accordance with subparagraph (B) for purposes of carrying out the activities described in paragraph (2) and receiving payments in accordance with paragraph (5).
(B) Selection
In selecting States for purposes of this paragraph, the Secretary shall—
(i) select States that received a planning grant under paragraph (3);
(ii) select States that submit to the Secretary an application in accordance with the requirements in subparagraph (C), taking into consideration the quality of each such application;
(iii) select States in a manner that ensures geographic diversity; and
(iv) give preference to States with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita drug overdoses, or any other measure that the Secretary deems appropriate.
(C) Applications
(i) In general
A State seeking to be selected for purposes of this paragraph shall submit to the Secretary, at such time and in such form and manner as the Secretary requires, an application that includes such information, provisions, and assurances, as the Secretary may require, in addition to the following:
(I) A proposed process for carrying out the ongoing assessment described in paragraph (2)(A), taking into account the results of the initial assessment described in paragraph (3)(C)(i).
(II) A review of reimbursement methodologies and other policies related to substance use disorder treatment or recovery services under the State plan (or waiver) that may create barriers to increasing the number of providers delivering such services.
(III) The development of a plan, taking into account activities carried out under paragraph (3)(C)(ii), that will result in long-term and sustainable provider networks under the State plan (or waiver) that will offer a continuum of care for substance use disorders. Such plan shall include the following:
(aa) Specific activities to increase the number of providers (including providers that specialize in providing substance use disorder treatment or recovery services, hospitals, health care systems, Federally qualified health centers, and, as applicable, certified community behavioral health clinics) that offer substance use disorder treatment, recovery, or support services, including short-term detoxification services, outpatient substance use disorder services, and evidence-based peer recovery services.
(bb) Strategies that will incentivize providers described in subparagraphs (C) and (D) of paragraph (2) to obtain the necessary training, education, and support to deliver substance use disorder treatment or recovery services in the State.
(cc) Milestones and timeliness for implementing activities set forth in the plan.
(dd) Specific measurable targets for increasing the substance use disorder treatment and recovery provider network under the State plan (or a waiver of such plan).
(IV) A proposed process for reporting the information required under paragraph (6)(A), including information to assess the effectiveness of the efforts of the State to expand the capacity of providers to deliver substance use disorder treatment or recovery services during the period of the demonstration project under this subsection.
(V) The expected financial impact of the demonstration project under this subsection on the State.
(VI) A description of all funding sources available to the State to provide substance use disorder treatment or recovery services in the State.
(VII) A preliminary plan for how the State will sustain any increase in the capacity of providers to deliver substance use disorder treatment or recovery services resulting from the demonstration project under this subsection after the termination of such demonstration project.
(VIII) A description of how the State will coordinate the goals of the demonstration project with any waiver granted (or submitted by the State and pending) pursuant to
(ii) Consultation
In completing an application under clause (i), a State shall consult with relevant stakeholders, including Medicaid managed care plans, health care providers, and Medicaid beneficiary advocates, and include in such application a description of such consultation.
(5) Payment
(A) In general
For each quarter occurring during the period for which the demonstration project is conducted (after the first 18 months of such period), the Secretary shall pay under this subsection, subject to subparagraph (C), to each State selected under paragraph (4) an amount equal to 80 percent of so much of the qualified sums expended during such quarter.
(B) Qualified sums defined
For purposes of subparagraph (A), the term "qualified sums" means, with respect to a State and a quarter, the amount equal to the amount (if any) by which the sums expended by the State during such quarter attributable to substance use disorder treatment or recovery services furnished by providers participating under the State plan (or a waiver of such plan) exceeds 1/4 of such sums expended by the State during fiscal year 2018 attributable to substance use disorder treatment or recovery services.
(C) Non-duplication of payment
In the case that payment is made under subparagraph (A) with respect to expenditures for substance use disorder treatment or recovery services furnished by providers participating under the State plan (or a waiver of such plan), payment may not also be made under subsection (a) with respect to expenditures for the same services so furnished.
(6) Reports
(A) State reports
A State receiving payments under paragraph (5) shall, for the period of the demonstration project under this subsection, submit to the Secretary a quarterly report, with respect to expenditures for substance use disorder treatment or recovery services for which payment is made to the State under this subsection, on the following:
(i) The specific activities with respect to which payment under this subsection was provided.
(ii) The number of providers that delivered substance use disorder treatment or recovery services in the State under the demonstration project compared to the estimated number of providers that would have otherwise delivered such services in the absence of such demonstration project.
(iii) The number of individuals enrolled under the State plan (or a waiver of such plan) who received substance use disorder treatment or recovery services under the demonstration project compared to the estimated number of such individuals who would have otherwise received such services in the absence of such demonstration project.
(iv) Other matters as determined by the Secretary.
(B) CMS reports
(i) Initial report
Not later than October 1, 2020, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress an initial report on—
(I) the States awarded planning grants under paragraph (3);
(II) the criteria used in such selection; and
(III) the activities carried out by such States under such planning grants.
(ii) Interim report
Not later than October 1, 2022, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress an interim report—
(I) on activities carried out under the demonstration project under this subsection;
(II) on the extent to which States selected under paragraph (4) have achieved the stated goals submitted in their applications under subparagraph (C) of such paragraph;
(III) with a description of the strengths and limitations of such demonstration project; and
(IV) with a plan for the sustainability of such project.
(iii) Final report
Not later than October 1, 2024, the Administrator of the Centers for Medicare & Medicaid Services shall, in consultation with the Director of the Agency for Healthcare Research and Quality and the Assistant Secretary for Mental Health and Substance Use, submit to Congress a final report—
(I) providing updates on the matters reported in the interim report under clause (ii);
(II) including a description of any changes made with respect to the demonstration project under this subsection after the submission of such interim report; and
(III) evaluating such demonstration project.
(C) AHRQ report
Not later than 3 years after October 24, 2018, the Director of the Agency for Healthcare Research and Quality, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, shall submit to Congress a summary on the experiences of States awarded planning grants under paragraph (3) and States selected under paragraph (4).
(7) Data sharing and best practices
During the period of the demonstration project under this subsection, the Secretary shall, in collaboration with States selected under paragraph (4), facilitate data sharing and the development of best practices between such States and States that were not so selected.
(8) CMS funding
There is appropriated, out of any funds in the Treasury not otherwise appropriated, $5,000,000 to the Centers for Medicare & Medicaid Services for purposes of implementing this subsection. Such amount shall remain available until expended.
(bb) Supplemental payment reporting requirements
(1) Collection and availability of supplemental payment data
(A) In general
Not later than October 1, 2021, the Secretary shall establish a system for each State to submit reports, as determined appropriate by the Secretary, on supplemental payments data, as a requirement for a State plan or State plan amendment that would provide for a supplemental payment.
(B) Requirements
Each report submitted by a State in accordance with the requirement established under subparagraph (A) shall include the following:
(i) An explanation of how supplemental payments made under the State plan or a State plan amendment will result in payments that are consistent with
(ii) The criteria used to determine which providers are eligible to receive the supplemental payment.
(iii) A comprehensive description of the methodology used to calculate the amount of, and distribute, the supplemental payment to each eligible provider, including—
(I) data on the amount of the supplemental payment made to each eligible provider, if known, or, if the total amount is distributed using a formula based on data from 1 or more fiscal years, data on the total amount of the supplemental payments for the fiscal year or years available to all providers eligible to receive a supplemental payment;
(II) if applicable, the specific criteria with respect to Medicaid service, utilization, or cost data to be used as the basis for calculations regarding the amount or distribution of the supplemental payment; and
(III) the timing of the supplemental payment made to each eligible provider.
(iv) An assurance that the total Medicaid payments made to an inpatient hospital provider, including the supplemental payment, will not exceed upper payment limits.
(v) If not already submitted, an upper payment limit demonstration under section 447.272 of title 42, Code of Federal Regulations (as such section is in effect as of December 27, 2020).
(C) Public availability
The Secretary shall make all reports and related data submitted under this paragraph publicly available on the website of the Centers for Medicare & Medicaid Services on a timely basis.
(2) Supplemental payment defined
(A) In general
Subject to subparagraph (B), in this subsection, the term "supplemental payment" means a payment to a provider that is in addition to any base payment made to the provider under the State plan under this subchapter or under demonstration authority.
(B) DSH payments excluded
Such term does not include a disproportionate share hospital payment made under
(Aug. 14, 1935, ch. 531, title XIX, §1903, as added
Editorial Notes
References in Text
Subsection (w)(3)(A), 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
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.
The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (i)(16), is
The Appalachian Regional Development Act of 1965, referred to in subsec. (m)(2)(B)(ii), (G), is
The Deficit Reduction Act of 2005, referred to in subsec. (x)(5), is
Amendments
2024—Subsec. (m)(9)(A).
2022—Subsec. (aa)(2)(C)(ii).
Subsec. (aa)(2)(C)(iii).
2020—Subsec. (a)(6).
Subsec. (i)(9).
Subsec. (q)(4)(A)(ii).
Subsec. (bb).
2019—Subsec. (i)(10)(C) to (E).
Subsec. (i)(12).
2018—Subsec. (l)(1).
Subsec. (l)(1)(A)(i).
Subsec. (l)(4)(A)(i).
Subsec. (m)(7).
Subsec. (m)(8).
Subsec. (m)(9).
Subsec. (aa).
2016—Subsec. (i)(2)(A).
Subsec. (i)(2)(D).
Subsec. (i)(2)(E).
Subsec. (i)(21).
Subsec. (i)(27).
Subsec. (l).
Subsec. (m)(3).
2015—Subsec. (i)(27).
2010—Subsec. (a)(3)(E).
Subsec. (a)(3)(H).
Subsec. (d)(2)(C).
Subsec. (d)(2)(D).
Subsec. (f)(4).
Subsec. (i)(2)(C).
Subsec. (i)(25).
Subsec. (i)(26).
Subsec. (m)(2)(A)(xi).
Subsec. (m)(2)(A)(xiii).
Subsec. (r)(1)(B)(iv).
Subsec. (r)(1)(F).
Subsec. (r)(4).
Subsec. (t)(3)(D).
Subsec. (t)(3)(E).
Subsec. (t)(6)(B).
Subsec. (u)(1)(D)(v).
2009—Subsec. (a)(2)(E).
Subsec. (a)(3)(A)(iii).
Subsec. (a)(3)(D).
Subsec. (a)(3)(E)(ii).
Subsec. (a)(3)(F).
Subsec. (a)(3)(H).
Subsec. (i)(22).
Subsec. (t).
Subsec. (v)(1).
Subsec. (v)(4).
Subsec. (x)(1).
Subsec. (x)(2)(B), (C).
Subsec. (x)(2)(D), (E).
Subsec. (x)(3)(B)(v), (vi).
Subsec. (x)(4), (5).
2008—Subsec. (i)(24).
Subsec. (r)(1).
Subsec. (r)(3).
2007—Subsec. (i)(23).
2006—Subsec. (f)(4).
Subsec. (i)(10)(C).
Subsec. (i)(10)(D).
Subsec. (i)(22).
Subsec. (w)(4)(C).
Subsec. (w)(7)(A)(viii).
Subsec. (x).
Subsec. (x)(1).
Subsec. (x)(2).
Subsec. (x)(2)(B).
Subsec. (x)(2)(C).
Subsec. (x)(2)(D).
Subsec. (x)(3)(C)(iii).
Subsec. (y).
Subsec. (z).
2005—Subsec. (i)(21).
2004—Subsec. (a)(3)(D).
Subsec. (a)(3)(E).
Subsec. (c).
2000—Subsec. (f)(4).
Subsec. (m)(2)(A)(ix).
Subsec. (u)(1)(D)(v).
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).
Statutory Notes and Related Subsidiaries
Change of Name
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of
Effective Date of 2020 Amendment
Amendment by section 209(a)(3) of
Effective Date of 2019 Amendment
Amendment by section 6(a)(2)(A) of
Effective Date of 2018 Amendment
Effective Date of 2016 Amendment
Effective Date of 2010 Amendment
Amendment by
Amendment by section 2004(c)(1) of
Amendment by section 2202(b) of
Amendment by section 2303(a)(4)(B), (b)(2)(B) of
Amendment by section 2402(d)(2)(A) of
Amendment by sections 6504(a) and 6507 of
Effective Date of 2009 Amendment
Amendment by sections 201(b)(2)(A), 214(a), and 401(b) of
Amendment by section 211 of
Effective Date of 2008 Amendment
"(1)
"(2)
Effective Date of 2007 Amendment
[
Effective Date of 2006 Amendment
"(1)
"(2)
"(A)
"(B)
Amendment by section 6062(c)(1) of
Effective Date of 2005 Amendment
Effective Date of 2004 Amendment
Effective Date of 2000 Amendments
Amendment by section 702(c)(1) of
"(1) The amendment made by subsection (a)(1) [amending this section] shall be effective as if included in the enactment of section 121 of the Foster Care Independence Act of 1999 (
"(2) The amendment made by subsection (a)(2) [amending this section] shall be effective as if included in the enactment of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (
Amendment by
Effective Date of 1999 Amendment
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 Amendment
"(a)
"(b)
"(1)
"(2) 75:25
"(3)
"(4)
"(A)
"(B)
"(5)
"(6)
"(7) 6-
"(c)
Amendment by section 4712(b)(2) of
Amendment by section 4753(a) of
Amendment by section 4912(b)(2) of
Amendment by
Effective Date of 1996 Amendment
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13602(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 [
Amendment by section 13622(a)(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
Effective Date of 1990 Amendments
Amendment by section 4402(b), (d)(3) of
Amendment by section 4601(a)(3)(A) of
Amendment by section 4704(b)(1), (2) of
Amendment by section 4711(c)(2) of
Amendment by section 4751(b)(1) of
Effective Date of 1989 Amendment
Amendment by section 6401(b) of
Amendment by section 6901(b)(5)(A) of
Amendment by
Effective Date of 1988 Amendment
Amendment by section 608(d)(26)(K)(ii) of
Amendment by section 608(f)(4) of
Amendment by section 202(h)(2) of
Amendment by section 302(c)(3) of
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
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 Amendment
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
"(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
"(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 [
"(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), in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Ventura County, and in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Merced County, 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 [
"(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 16 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 [
[
[
[
Effective Date of 1984 Amendment
Amendment by
Amendment by section 2303(g)(2) of
Effective Date of 1983 Amendment
Amendment by
Effective Date of 1982 Amendment
Amendment by section 137(a)(1), (2) of
Amendment by section 137(b)(11)–(16), (27) of
Amendment by section 146(b) of
Effective Date of 1981 Amendment
Amendment by section 2101(a)(2) of
Amendment by section 2113(n) of
Amendment by section 2174(b) of
Amendment by section 2178(a) of
Effective Date of 1980 Amendment
Effective Date of 1977 Amendment
Amendment by section 3(c)(2) of
Amendment by section 8(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 [
"(A) after October 8, 1976, under contracts under such title [
"(B) after the expiration of the one-year period beginning on such date,
whichever occurs first."
Effective Date of 1976 Amendment
Amendment by
"(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
Amendment by section 111(b) of
Effective Date of 1973 Amendment
Amendment by section 13(a)(11), (12) of
Amendment by section 18(u) of
Effective Date of 1972 Amendment
Amendment by section 226(e) of
Amendment by section 233(c) of
Effective Date of 1968 Amendment
"(b)(1) In the case of any State whose plan under title XIX of the Social Security Act [
"(2) In the case of any State whose plan under title XIX 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 [
"(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 [
Regulations
"(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
Implementation of Subsections (i)(22) and (x) Requirements
Construction of 2016 Amendment
Nothing in amendment by section 5005 of
"(1)
"(2)
"(3)
"(4)
Construction of 2015 Amendment
Security and Privacy
Collection and Dissemination of Best Practices
"(1) training individuals who furnish personal care services, home health care services, or both under the State plan under title XIX of such Act [
"(2) the provision of notice and educational materials to family caregivers and beneficiaries with respect to the use of such electronic visit verification systems and other means to prevent such fraud."
Clarification Regarding Non-Regulation of Transfers
"(a)
"(b)
"(1) provides level 1 trauma and burn care services;
"(2) provides level 3 neonatal care services;
"(3) is obligated to serve all patients, regardless of ability to pay;
"(4) is located within a Standard Metropolitan Statistical Area (SMSA) that includes at least 3 States;
"(5) provides services as a tertiary care provider for patients residing within a 125-mile radius; and
"(6) meets the criteria for a disproportionate share hospital under section 1923 of such Act (
"(1)
"(2)
"(A) provides level 1 trauma and burn care services;
"(B) provides level 3 neonatal care services;
"(C) is obligated to serve all patients, regardless of State of origin;
"(D) is located within a Standard Metropolitan Statistical Area (SMSA) that includes at least 3 States, including the States described in paragraph (1);
"(E) serves as a tertiary care provider for patients residing within a 125 mile radius; and
"(F) meets the criteria for a disproportionate share hospital under section 1923 of such Act [
"(3)
Treatment of Donation or Tax Proceeds Prior to Effective Date of Subsection (w)
Temporary Increase in Federal Match for Administrative Costs
Report on Errors in Eligibility Determinations; Error Rate Transition Rules
Medically Needy Income Levels for Certain 1-Member Families
"(a)
"(b)
Day Habilitation and Related Services
"(1)
"(A) withhold, suspend, disallow, or deny Federal financial participation under section 1903(a) of the Social Security 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
Clarification of Federal Matching Rate for Survey and Certification Activities
Quality Control Transition Provisions
Delay Quality Control Sanctions for Medicaid
Temporary Technical Error Definition
Enhanced Funding for Nurse Aide Training
Expenses Incurred for Review of Care Provided to Residents of Nursing Facilities
Quality Control Studies and Penalty Moratorium
"(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 [
"(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
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
Deferral of Implementation of Decreases in Matching Funds
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
Exemption of Puerto Rico, the Virgin Islands, and Guam From Limitations on Federal Payments for Medical Assistance
Nonduplication of Payments to States; Limitation on Institutional Care
1 So in original. Probably should be "a quality improvement organization".
2 So in original. There is no subpar. (G).
3 So in original. The comma probably should be a semicolon.
4 See References in Text note below.
5 So in original. The word "or" probably should precede "1396d(p)(1)".
6 Probably means subclause (VIII) of subsection (a)(10)(A)(i) of
7 So in original. Probably should be "waiver".
8 So in original. Probably should be followed by a comma.
9 So in original. The word "section" probably should appear.
10 So in original. Probably should be preceded by "a".
11 So in original. The word "or" probably should not appear.
12 So in original. Probably should be section "1396o–1(e)(4)(B)".
§1396b–1. Payment adjustment for health care-acquired conditions
(a) In general
The Secretary of Health and Human Services (in this subsection referred to as the "Secretary") shall identify current State practices that prohibit payment for health care-acquired conditions and shall incorporate the practices identified, or elements of such practices, which the Secretary determines appropriate for application to the Medicaid program in regulations. Such regulations shall be effective as of July 1, 2011, and shall prohibit payments to States under section 1903 of the Social Security Act [
(b) Health care-acquired condition
In this section.1 the term "health care-acquired condition" means a medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of the Social Security Act (
(c) Medicare provisions
In carrying out this section, the Secretary shall apply to State plans (or waivers) under title XIX of the Social Security Act [
(
Editorial Notes
References in Text
The Social Security Act, referred to in subsec. (c), is act Aug. 14, 1935, ch. 531,
Codification
Section was enacted as part of the Patient Protection and Affordable Care Act, and not as part of the Social Security Act which comprises this chapter.
1 So in original. The period probably should be a comma.
§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
Editorial Notes
Constitutionality
For information regarding the constitutionality of section 121(a) of
§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 or the care and services themselves, or both (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), 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,
(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,
(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,
(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,
(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)),
(xiii) individuals described in
(xiv) individuals described in
(xv) individuals described in
(xvi) individuals described in
(xvii) individuals who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of
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)) and any other ambulatory services which are offered by a rural health clinic (as defined in subsection (l)(1)) and which are otherwise included in the plan, and (C) Federally-qualified health center services (as defined in subsection (l)(2)) and any other ambulatory services offered by a Federally-qualified health center and which are otherwise included in the plan;
(3)(A) other laboratory and X-ray services; and
(B) in vitro diagnostic products (as defined in section 809.3(a) of title 21, Code of Federal Regulations) administered during any portion of the emergency period defined in paragraph (1)(B) of
(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)) for individuals who are eligible under the plan and are under the age of 21; (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; and 2 (D) counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in subsection (bb)); and 2 (E) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(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—
(A) any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force;
(B) with respect to an adult individual, approved vaccines recommended 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) and their administration; and
(C) 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)(A) effective January 1, 1973, inpatient psychiatric hospital services for individuals under age 21, as defined in subsection (h), and, (B) for individuals receiving services described in subparagraph (A), early and periodic screening, diagnostic, and treatment services (as defined in subsection (r)), whether or not such screening, diagnostic, and treatment services are furnished by the provider of the services described in such subparagraph;
(17) services furnished by a nurse-midwife (as defined in
(18) hospice care (as defined in subsection (o));
(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));
(26) services furnished under a PACE program under
(27) subject to subsection (x), primary and secondary medical strategies and treatment and services for individuals who have Sickle Cell Disease;
(28) freestanding birth center services (as defined in subsection (l)(3)(A)) and other ambulatory services that are offered by a freestanding birth center (as defined in subsection (l)(3)(B)) and that are otherwise included in the plan;
(29) subject to paragraphs (2) and (3) of subsection (ee), beginning on October 1, 2020, medication-assisted treatment (as defined in paragraph (1) of such subsection);
(30) subject to subsection (gg), routine patient costs for items and services furnished in connection with participation in a qualifying clinical trial (as defined in such subsection);
(31) certified community behavioral health clinic services, as defined in subsection (jj); and
(32) 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 in the case of an eligible juvenile described in
(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 (except in the case of services provided under a State plan amendment described in
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), 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 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, or part A of subchapter IV, or with respect to whom supplemental security income benefits are being paid under subchapter XVI, 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 subsections (y), (z), (aa), (ff), (hh), and (ii) and
(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)) 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), 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 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, 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, 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 (
(3)(A) The term "freestanding birth center services" means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)) at such center.
(B) The term "freestanding birth center" means a health facility—
(i) that is not a hospital;
(ii) where childbirth is planned to occur away from the pregnant woman's residence;
(iii) that is licensed or otherwise approved by the State to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the plan; and
(iv) that complies with such other requirements relating to the health and safety of individuals furnished services by the facility as the State shall establish.
(C) A State shall provide separate payments to providers administering prenatal labor and delivery or postpartum care in a freestanding birth center (as defined in subparagraph (B)), such as nurse midwives and other providers of services such as birth attendants recognized under State law, as determined appropriate by the Secretary. For purposes of the preceding sentence, the term "birth attendant" means an individual who is recognized or registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law (or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a birth attendant.
(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)) who is a member of a family that would be receiving aid under the State plan under part A of subchapter IV pursuant to section 607 1 of this title if the State had not exercised the option under section 607(b)(2)(B)(i) 1 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 (or would be eligible for such aid if coverage under the State plan under part A of subchapter IV 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 pursuant to
(C) otherwise meets the income and resources requirements of a State plan under part A of subchapter IV; 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.
(o) Optional hospice benefits
(1)(A) Subject to subparagraphs (B) and (C), the term "hospice care" means the care described in
(B) For purposes of this subchapter, with respect to the definition of hospice program under
(C) A voluntary election to have payment made for hospice care for a child (as defined by the State) shall not constitute a waiver of any rights of the child to be provided with, or to have payment made under this subchapter for, services that are related to the treatment of the child's condition for which a diagnosis of terminal illness has been made.
(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 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 (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 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 (including coinsurance described in
(C) Deductibles established under subchapter XVIII (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
(5)(A) The Secretary shall develop and distribute to States a simplified application form for use by individuals (including both qualified medicare beneficiaries and specified low-income medicare beneficiaries) in applying for medical assistance for medicare cost-sharing under this subchapter in the States which elect to use such form. Such form shall be easily readable by applicants and uniform nationally. The Secretary shall provide for the translation of such application form into at least the 10 languages (other than English) that are most often used by individuals applying for hospital insurance benefits under
(B) In developing such form, the Secretary shall consult with beneficiary groups and the States.
(6) For provisions relating to outreach efforts to increase awareness of the availability of medicare cost-sharing, see
(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,
(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 (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) 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 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));
(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).
(2)(A) For purposes of subsection (b), 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), 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
(x) Strategies, treatment, and services
For purposes of subsection (a)(27), the strategies, treatment, and services described in that subsection include the following:
(1) Chronic blood transfusion (with deferoxamine chelation) to prevent stroke in individuals with Sickle Cell Disease who have been identified as being at high risk for stroke.
(2) Genetic counseling and testing for individuals with Sickle Cell Disease or the sickle cell trait to allow health care professionals to treat such individuals and to prevent symptoms of Sickle Cell Disease.
(3) Other treatment and services to prevent individuals who have Sickle Cell Disease and who have had a stroke from having another stroke.
(y) Increased FMAP for medical assistance for newly eligible mandatory individuals
(1) Amount of increase
Notwithstanding subsection (b), the Federal medical assistance percentage for a State that is one of the 50 States or the District of Columbia, with respect to amounts expended by such State for medical assistance for newly eligible individuals described in subclause (VIII) of
(A) 100 percent for calendar quarters in 2014, 2015, and 2016;
(B) 95 percent for calendar quarters in 2017;
(C) 94 percent for calendar quarters in 2018;
(D) 93 percent for calendar quarters in 2019; and
(E) 90 percent for calendar quarters in 2020 and each year thereafter.
(2) Definitions
In this subsection:
(A) Newly eligible
The term "newly eligible" means, with respect to an individual described in subclause (VIII) of
(B) Full benefits
The term "full benefits" means, with respect to an individual, medical assistance for all services covered under the State plan under this subchapter that is not less in amount, duration, or scope, or is determined by the Secretary to be substantially equivalent, to the medical assistance available for an individual described in
(z) Equitable support for certain States
(1)(A) During the period that begins on January 1, 2014, and ends on December 31, 2015, notwithstanding subsection (b), the Federal medical assistance percentage otherwise determined under subsection (b) with respect to a fiscal year occurring during that period shall be increased by 2.2 percentage points for any State described in subparagraph (B) for amounts expended for medical assistance for individuals who are not newly eligible (as defined in subsection (y)(2)) individuals described in subclause (VIII) of
(B) For purposes of subparagraph (A), a State described in this subparagraph is a State that—
(i) is an expansion State described in paragraph (3);
(ii) the Secretary determines will not receive any payments under this subchapter on the basis of an increased Federal medical assistance percentage under subsection (y) for expenditures for medical assistance for newly eligible individuals (as so defined); and
(iii) has not been approved by the Secretary to divert a portion of the DSH allotment for a State to the costs of providing medical assistance or other health benefits coverage under a waiver that is in effect on July 2009.8
(2)(A) For calendar quarters in 2014 and each year thereafter, the Federal medical assistance percentage otherwise determined under subsection (b) for an expansion State described in paragraph (3) with respect to medical assistance for individuals described in
(B)(i) The percent specified in this subparagraph for a State for a year is equal to the Federal medical assistance percentage (as defined in the first sentence of subsection (b)) for the State increased by a number of percentage points equal to the transition percentage (specified in clause (ii) for the year) of the number of percentage points by which—
(I) such Federal medical assistance percentage for the State, is less than
(II) the percent specified in subsection (y)(1) for the year.
(ii) The transition percentage specified in this clause for—
(I) 2014 is 50 percent;
(II) 2015 is 60 percent;
(III) 2016 is 70 percent;
(IV) 2017 is 80 percent;
(V) 2018 is 90 percent; and
(VI) 2019 and each subsequent year is 100 percent.
(3) A State is an expansion State if, on March 23, 2010, the State offers health benefits coverage statewide to parents and nonpregnant, childless adults whose income is at least 100 percent of the poverty line, that includes inpatient hospital services, is not dependent on access to employer coverage, employer contribution, or employment and is not limited to premium assistance, hospital-only benefits, a high deductible health plan, or alternative benefits under a demonstration program authorized under
(aa) Special adjustment to FMAP determination for certain States recovering from a major disaster
(1) Notwithstanding subsection (b), beginning January 1, 2011, the Federal medical assistance percentage for a fiscal year for a disaster-recovery FMAP adjustment State shall be equal to the following:
(A) In the case of the first fiscal year (or part of a fiscal year) for which this subsection applies to the State, the State's regular FMAP shall be increased by 50 percent of the number of percentage points by which the State's regular FMAP for such fiscal year is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year after the application of only subsection (a) of section 5001 of
(B) In the case of the second or any succeeding fiscal year for which this subsection applies to the State, the State's regular FMAP for such fiscal year shall be increased by 25 percent (or 50 percent in the case of fiscal year 2013) of the number of percentage points by which the State's regular FMAP for such fiscal year is less than the Federal medical assistance percentage received by the State during the preceding fiscal year.
(2) In this subsection, the term "disaster-recovery FMAP adjustment State" means a State that is one of the 50 States or the District of Columbia, for which, at any time during the preceding 7 fiscal years, the President has declared a major disaster under section 401 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act [
(A) in the case of the first fiscal year (or part of a fiscal year) for which this subsection applies to the State, the State's regular FMAP for the fiscal year is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year after the application of only subsection (a) of section 5001 of
(B) in the case of the second or any succeeding fiscal year for which this subsection applies to the State, the State's regular FMAP for the fiscal year is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year under this subsection by at least 3 percentage points.
(3) In this subsection, the term "regular FMAP" means, for each fiscal year for which this subsection applies to a State, the Federal medical assistance percentage that would otherwise apply to the State for the fiscal year, as determined under subsection (b) and without regard to this subsection, subsections (y) and (z), and section 10202 of the Patient Protection and Affordable Care Act.
(4) The Federal medical assistance percentage determined for a disaster-recovery FMAP adjustment State under paragraph (1) shall apply for purposes of this subchapter (other than with respect to disproportionate share hospital payments described in
(bb) Counseling and pharmacotherapy for cessation of tobacco use by pregnant women
(1) For purposes of this subchapter, the term "counseling and pharmacotherapy for cessation of tobacco use by pregnant women" means diagnostic, therapy, and counseling services and pharmacotherapy (including the coverage of prescription and nonprescription tobacco cessation agents approved by the Food and Drug Administration) for cessation of tobacco use by pregnant women who use tobacco products or who are being treated for tobacco use that is furnished—
(A) by or under the supervision of a physician; or
(B) by any other health care professional who—
(i) is legally authorized to furnish such services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished; and
(ii) is authorized to receive payment for other services under this subchapter or is designated by the Secretary for this purpose.
(2) Subject to paragraph (3), such term is limited to—
(A) services recommended with respect to pregnant women in "Treating Tobacco Use and Dependence: 2008 Update: A Clinical Practice Guideline", published by the Public Health Service in May 2008, or any subsequent modification of such Guideline; and
(B) such other services that the Secretary recognizes to be effective for cessation of tobacco use by pregnant women.
(3) Such term shall not include coverage for drugs or biologicals that are not otherwise covered under this subchapter.
(cc) Requirement for certain States
Notwithstanding subsections (y), (z), and (aa), in the case of a State that requires political subdivisions within the State to contribute toward the non-Federal share of expenditures required under the State plan under
(dd) Increased FMAP for additional expenditures for primary care services
Notwithstanding subsection (b), with respect to the portion of the amounts expended for medical assistance for services described in
(ee) Medication-assisted treatment
(1) Definition
For purposes of subsection (a)(29), the term "medication-assisted treatment"—
(A) means all drugs approved under
(B) includes, with respect to the provision of such drugs and biological products, counseling services and behavioral therapy.
(2) Exception
The provisions of paragraph (29) of subsection (a) shall not apply with respect to a State if such State certifies, not less than every 5 years and to the satisfaction of the Secretary, that implementing such provisions statewide for all individuals eligible to enroll in the State plan (or waiver of the State plan) would not be feasible by reason of a shortage of qualified providers of medication-assisted treatment, or facilities providing such treatment, that will contract with the State or a managed care entity with which the State has a contract under
(3) Application of rebate requirements
The requirements of
(A) furnished as medical assistance in accordance with subsection (a)(29) and
(B) a covered outpatient drug (as defined in
(ff) Increase in FMAP for territories for certain fiscal years
Notwithstanding subsection (b) or (z)(2), subject to subsections (hh) and (ii)—
(1) for the period beginning October 1, 2019, and ending December 20, 2019, the Federal medical assistance percentage for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa shall be equal to 100 percent;
(2) for the period beginning December 21, 2019, and ending December 3, 2021, and for the period beginning January 1, 2022, and ending September 30, 2027, the Federal medical assistance percentage for Puerto Rico shall be equal to 76 percent; and
(3) subject to
(gg)(1) Routine patient costs
For purposes of subsection (a)(30), with respect to a State and an individual enrolled under the State plan (or a waiver of such plan) who participates in a qualifying clinical trial, routine patient costs—
(A) include any item or service provided to the individual under the qualifying clinical trial, including—
(i) any item or service provided to prevent, diagnose, monitor, or treat complications resulting from such participation, to the extent that the provision of such an item or service to the individual outside the course of such participation would otherwise be covered under the State plan or waiver; and
(ii) any item or service required solely for the provision of the investigational item or service that is the subject of such trial, including the administration of such investigational item or service; and
(B) does not include—
(i) an item or service that is the investigational item or service that is—
(I) the subject of the qualifying clinical trial; and
(II) not otherwise covered outside of the clinical trial under the State plan or waiver; or
(ii) an item or service that is—
(I) provided to the individual solely to satisfy data collection and analysis needs for the qualifying clinical trial and is not used in the direct clinical management of the individual; and
(II) not otherwise covered under the State plan or waiver.
(2) Qualifying clinical trial defined
(A) In general
For purposes of this subsection and subsection (a)(30), the term "qualifying clinical trial" means a clinical trial (in any clinical phase of development) that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition and is described in any of the following clauses:
(i) The study or investigation is approved, conducted, or supported (which may include funding through in-kind contributions) by one or more of the following:
(I) The National Institutes of Health.
(II) The Centers for Disease Control and Prevention.
(III) The Agency for Healthcare Research and Quality.
(IV) The Centers for Medicare & Medicaid Services.
(V) A cooperative group or center of any of the entities described in subclauses (I) through (IV) or the Department of Defense or the Department of Veterans Affairs.
(VI) A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.
(VII) Any of the following if the conditions described in subparagraph (B) are met:
(aa) The Department of Veterans Affairs.
(bb) The Department of Defense.
(cc) The Department of Energy.
(ii) The clinical trial is conducted pursuant to an investigational new drug exemption under
(iii) The clinical trial is a drug trial that is exempt from being required to have an exemption described in clause (ii).
(B) Conditions
For purposes of subparagraph (A)(i)(VII), the conditions described in this subparagraph, with respect to a clinical trial approved or funded by an entity described in such subparagraph (A)(i)(VII), are that the clinical trial has been reviewed and approved through a system of peer review that the Secretary determines—
(i) to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health; and
(ii) assures unbiased review of the highest scientific standards by qualified individuals with no interest in the outcome of the review.
(3) Coverage determination requirements
A determination with respect to coverage under subsection (a)(30) for an individual participating in a qualifying clinical trial—
(A) shall be expedited and completed within 72 hours;
(B) shall be made without limitation on the geographic location or network affiliation of the health care provider treating such individual or the principal investigator of the qualifying clinical trial;
(C) shall be based on attestation regarding the appropriateness of the qualifying clinical trial by the health care provider and principal investigator described in subparagraph (B), which shall be made using a streamlined, uniform form developed for State use by the Secretary and that includes the option to reference information regarding the qualifying clinical trial that is publicly available on a website maintained by the Secretary, such as clinicaltrials.gov (or a successor website); and
(D) shall not require submission of the protocols of the qualifying clinical trial, or any other documentation that may be proprietary or determined by the Secretary to be burdensome to provide.
(hh) Temporary increased FMAP for medical assistance for coverage and administration of COVID–19 vaccines
(1) In general
Notwithstanding any other provision of this subchapter, during the period described in paragraph (2), the Federal medical assistance percentage for a State, with respect to amounts expended by the State for medical assistance for a vaccine described in subsection (a)(4)(E) (and the administration of such a vaccine), shall be equal to 100 percent.
(2) Period described
The period described in this paragraph is the period that—
(A) begins on the first day of the first quarter beginning after March 11, 2021; and
(B) ends on the last day of the first quarter that begins one year after the last day of the emergency period described in
(3) Exclusion of expenditures from territorial caps
Any payment made to a territory for expenditures for medical assistance under subsection (a)(4)(E) that are subject to the Federal medical assistance percentage specified under paragraph (1) shall not be taken into account for purposes of applying payment limits under subsections (f) and (g) of
(ii) Temporary increase in FMAP for medical assistance under State medicaid plans which begin to expend amounts for certain mandatory individuals
(1) In general
For each quarter occurring during the 8-quarter period beginning with the first calendar quarter during which a qualifying State (as defined in paragraph (3)) expends amounts for all individuals described in
(2) Special application rules
Any increase described in paragraph (1) (or payment made for expenditures on medical assistance that are subject to such increase)—
(A) shall not apply with respect to disproportionate share hospital payments described in
(B) shall not be taken into account in calculating the enhanced FMAP of a State under
(C) shall not be taken into account for purposes of part A, D, or E of subchapter IV; and
(D) shall not be taken into account for purposes of applying payment limits under subsections (f) and (g) of
(3) Definition
For purposes of this subsection, the term "qualifying State" means a State which has not expended amounts for all individuals described in
(jj) Certified community behavioral health clinic services
(1) In general
The term "certified community behavioral health services" means any of the following services when furnished to an individual as a patient of a certified community behavioral health clinic (as defined in paragraph (2)), in a manner reflecting person-centered care and which, if not available directly through a certified community behavioral health clinic, may be provided or referred through formal relationships with other providers:
(A) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization.
(B) Screening, assessment, and diagnosis, including risk assessment.
(C) Patient-centered treatment planning or similar processes, including risk assessment and crisis planning.
(D) Outpatient mental health and substance use services.
(E) Outpatient clinic primary care screening and monitoring of key health indicators and health risk.
(F) Intensive case management services.
(G) Psychiatric rehabilitation services.
(H) Peer support and counselor services and family supports.
(I) Intensive, community-based mental health care for members of the armed forces and veterans who are eligible for medical assistance, particularly such members and veterans located in rural areas, provided the care is consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration, including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration.
(2) Certified community behavioral health clinic
The term "certified community behavioral health clinic" means an organization that—
(A) has been certified by a State as meeting the criteria established by the Secretary pursuant to subsection (a) of section 223 of the Protecting Access to Medicare Act 1 as of January 1, 2024, and any subsequent updates to such criteria, regardless of whether the State is carrying out a demonstration program under this subchapter under subsection (d) of such section;
(B) is engaged in furnishing all of the services described in paragraph (1); and
(C) agrees, as a condition of the certification described in subparagraph (A), to furnish to the State or Secretary any data required as part of ongoing monitoring of the organization's provision of services, including encounter data, clinical outcomes data, quality data, and such other data as the State or Secretary may require.
(Aug. 14, 1935, ch. 531, title XIX, §1905, as added
Editorial Notes
References in Text
The Indian Health Care Improvement Act, referred to in subsecs. (b) and (l)(2)(B), is
For the effective date of this clause, referred to in subsec. (b)(6), see Effective Date of 2022 Amendment note set out under
Section 211 of
The Indian Self-Determination Act, referred to in subsec. (l)(2)(B), is title I of
Clause (ii), referred to in subsec. (l)(2)(B), was redesignated as cl. (iii) by
Section 212 of
Section 5001 of
The Robert T. Stafford Disaster Relief and Emergency Assistance Act, referred to in subsec. (aa)(2), is
Section 10202 of the Patient Protection and Affordable Care Act, referred to in subsec. (aa)(3), is section 10202 of
Section 6008 of the Families First Coronavirus Response Act, referred to in subsecs. (cc) and (ii)(1), is section 6008 of
Section 223 of the Protecting Access to Medicare Act, referred to in subsec. (jj)(2)(A), probably means section 223 of
Amendments
2024—Subsec. (a).
Subsec. (a).
Subsec. (a)(29).
Subsec. (a)(31), (32).
Subsec. (ee)(2).
Subsec. (jj).
2022—Subsec. (a).
Subsec. (b).
Subsec. (b)(6).
Subsec. (ff).
Subsec. (ff)(2).
Subsec. (ff)(3).
2021—Subsec. (a)(4).
Subsec. (b).
Subsec. (ff).
Subsec. (ff)(3).
Subsec. (hh).
Subsec. (ii).
2020—Subsec. (a)(3)(A).
Subsec. (a)(3)(B).
Subsec. (a)(29).
Subsec. (a)(30), (31).
Subsec. (b).
Subsec. (p)(1)(A).
Subsec. (cc).
Subsec. (ee)(3).
Subsec. (gg).
2019—Subsec. (b).
Subsec. (ff).
2018—Subsec. (a).
Subsec. (a)(29), (30).
Subsec. (ee).
2016—Subsec. (a)(16).
2012—Subsec. (aa)(1)(A).
Subsec. (aa)(1)(B).
Subsec. (aa)(2)(A).
Subsec. (aa)(2)(B).
Subsec. (aa)(3), (4).
2010—Subsec. (a).
Subsec. (a)(xiv).
Subsec. (a)(xv).
Subsec. (a)(xvi).
Subsec. (a)(xvii).
Subsec. (a)(4).
Subsec. (a)(13).
Subsec. (a)(28), (29).
Subsec. (b).
Subsec. (l)(3).
Subsec. (o)(1)(A).
Subsec. (o)(1)(C).
Subsec. (y).
Subsec. (y)(1).
Subsec. (y)(1)(B)(ii)(II).
Subsec. (y)(2)(A).
Subsec. (z).
Subsec. (z)(1)(A).
Subsec. (z)(1)(B)(i).
Subsec. (z)(2).
"(A) During the period that begins on January 1, 2014, and ends on December 31, 2016, notwithstanding subsection (b), the Federal medical assistance percentage otherwise determined under subsection (b) with respect to all or any portion of a fiscal year occurring during that period shall be increased by .5 percentage point for a State described in subparagraph (B) for amounts expended for medical assistance under the State plan under this subchapter or under a waiver of that plan during that period.
"(B) For purposes of subparagraph (A), a State described in this subparagraph is a State that—
"(i) is described in clauses (i) and (ii) of paragraph (1)(B); and
"(ii) is the State with the highest percentage of its population insured during 2008, based on the Current Population Survey."
Subsec. (z)(3).
Subsec. (z)(4).
"(A) disproportionate share hospital payments described in
"(B) payments under subchapter IV;
"(C) payments under subchapter XXI; and
"(D) payments under this subchapter that are based on the enhanced FMAP described in
Subsec. (z)(5).
Subsec. (aa).
Subsec. (aa)(1), (2).
Subsec. (bb).
Subsec. (cc).
Subsec. (dd).
2008—Subsec. (p)(1)(C).
Subsec. (p)(5)(A).
2006—Subsec. (u)(2)(B).
2004—Subsec. (a)(27), (28).
Subsec. (x).
2000—Subsec. (a)(xiii).
Subsec. (b).
Subsec. (p)(5).
Subsec. (p)(6).
Subsec. (u)(1)(B).
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).
1971—Subsec. (a)(16).
Subsecs. (c), (d).
1968—Subsec. (a).
Subsec. (a)(ii).
Subsec. (a)(vi).
Subsec. (a)(4).
Subsec. (b).
Statutory Notes and Related Subsidiaries
Effective Date of 2024 Amendment
Effective Date of 2022 Amendment
Amendment by section 5121(b) of
Amendment by section 5122(a)(1) of
Amendment by
Effective Date of 2020 Amendment
Amendment by section 210(a) of
Effective Date of 2018 Amendment
Amendment by section 1006(b)(2), (3) of
"(1)
"(2)
Effective Date of 2016 Amendment
Effective Date of 2012 Amendment
Effective Date of 2010 Amendment
Amendment by section 2301(a) of
Amendment by section 2303(a)(4)(A) of
Amendment by section 2402(d)(2)(B) of
Effective Date of 2008 Amendment
Effective Date of 2006 Amendment
Amendment by
Effective Date of 2004 Amendment
Amendment by
Effective Date of 2000 Amendments
Amendment by section 1(a)(6) [title IX, §911(a)(2)] of
Amendment by
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 Amendment
Amendment by section 4702(a) of
Amendment by section 4711(c)(1) of
Amendment by section 4714(a)(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
Amendment by section 13631(f)(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
Amendment by section 4711(a) of
Amendment by section 4712(a) of
Amendment by section 4713(b) of
Effective Date of 1989 Amendment
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 Amendment
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
Effective Date of 1987 Amendment
Amendment by section 4073(d) 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 [
"(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]."
Amendments by section 4211(e), (f), (h)(6) of
Effective Date of 1986 Amendment
Amendment by
Amendment by section 9403(b), (d), (g)(3) of
Amendment by section 9404(b) of
Amendment by section 9408(c)(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 [
"(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
Effective Date of 1984 Amendment
Amendment by section 2335(f) of
Amendment by section 2340(b) of
Amendment by section 2361(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
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
Amendment by section 247(b) of
Effective Date of 1971 Amendment
Amendment by
Effective Date of 1968 Amendment
Construction of 2004 Amendment
Construction of 1999 Amendment
Amendment by
Review of State Implementation of Early and Periodic Screening, Diagnostic, and Treatment Services
"(a)
"(1)
"(A) review State implementation of the requirements for providing early and periodic screening, diagnostic, and treatment services under Medicaid in accordance with sections 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security Act (
"(B) identify gaps and deficiencies with respect to State compliance with such requirements;
"(C) provide technical assistance to States to address such gaps and deficiencies; and
"(D) issue guidance to States on the Medicaid coverage requirements for such services that includes best practices for ensuring children have access to comprehensive health care services, including children without a mental health or substance use disorder diagnosis.
"(2)
"(3)
"(b)
"(1)
"(2)
"(c)
"(1)
"(2)
"(3)
Additional Support for Medicaid Home and Community-Based Services During the COVID–19 Emergency
"(a)
"(1)
"(2)
"(A)
"(i) beginning on April 1, 2021; and
"(ii) ending on March 31, 2022.
"(B)
"(i) Home health care services authorized under paragraph (7) of section 1905(a) of the Social Security Act (
"(ii) Personal care services authorized under paragraph (24) of such section.
"(iii) PACE services authorized under paragraph (26) of such section.
"(iv) Home and community-based services authorized under subsections (b), (c), (i), (j), and (k) of section 1915 of such Act (
"(v) Case management services authorized under section 1905(a)(19) of the Social Security Act (
"(vi) Rehabilitative services, including those related to behavioral health, described in section 1905(a)(13) of such Act (
"(vii) Such other services specified by the Secretary of Health and Human Services.
"(C)
"(D)
"(E)
"(b)
"(1)
"(2)
Temporary Increase of Medicaid FMAP
"(a)
"(1)
"(2)
"(A) For each calendar quarter that occurs during the portion of the period described in paragraph (1) that ends on March 31, 2023, 6.2 percentage points.
"(B) For the calendar quarter that begins on April 1, 2023, and ends on June 30, 2023, 5 percentage points.
"(C) For the calendar quarter that begins on July 1, 2023, and ends on September 30, 2023, 2.5 percentage points.
"(D) For the calendar quarter that begins on October 1, 2023, and ends on December 31, 2023, 1.5 percentage points.
"(b)
"(1) eligibility standards, methodologies, or procedures under the State plan of such State under title XIX of the Social Security Act (
"(2) the amount of any premium imposed by the State pursuant to section 1916 or 1916A of such Act (
"(3) the State fails to provide that an individual who is enrolled for benefits under such plan (or waiver) as of March 18, 2020, or enrolls for benefits under such plan (or waiver) during the period beginning on March 18, 2020, and ending March 31, 2023, shall be treated as eligible for such benefits through March 31, 2023, unless the individual requests a voluntary termination of eligibility or the individual ceases to be a resident of the State; or
"(4) the State does not provide coverage under such plan (or waiver), without the imposition of cost sharing, during such quarter for any testing services and treatments for COVID–19, including vaccines, specialized equipment, and therapies.
"(d)
"(e)
"(f)
"(1)
"(2)
"(A)
"(B)
"(C)
"(g)
Incentives for States To Offer Home and Community-Based Services as a Long-Term Care Alternative to Nursing Homes
"(a)
"(b)
"(1) in which less than 50 percent of the total expenditures for medical assistance under the State Medicaid program for a fiscal year for long-term services and supports (as defined by the Secretary under subsection (f))(1)) [sic] are for non-institutionally-based long-term services and supports described in subsection (f)(1)(B);
"(2) that submits an application and meets the conditions described in subsection (c); and
"(3) that is selected by the Secretary to participate in the State balancing incentive payment program established under this section.
"(c)
"(1)
"(A) a proposed budget that details the State's plan to expand and diversify medical assistance for non-institutionally-based long-term services and supports described in subsection (f)(1)(B) under the State Medicaid program during the balancing incentive period and achieve the target spending percentage applicable to the State under paragraph (2), including through structural changes to how the State furnishes such assistance, such as through the establishment of a 'no wrong door—single entry point system', optional presumptive eligibility, case management services, and the use of core standardized assessment instruments, and that includes a description of the new or expanded offerings of such services that the State will provide and the projected costs of such services; and
"(B) in the case of a State that proposes to expand the provision of home and community-based services under its State Medicaid program through a State plan amendment under section 1915(i) of the Social Security Act [
"(2)
"(A) In the case of a balancing incentive payment State in which less than 25 percent of the total expenditures for long-term services and supports under the State Medicaid program for fiscal year 2009 are for home and community-based services, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 25 percent of the total expenditures for long-term services and supports under the State Medicaid program are for home and community-based services.
"(B) In the case of any other balancing incentive payment State, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 50 percent of the total expenditures for long-term services and supports under the State Medicaid program are for home and community-based services.
"(3)
"(4)
"(5)
"(A) '
"(B)
"(C)
"(6)
"(A)
"(B)
"(C)
"(i) measures of beneficiary and family caregiver experience with providers;
"(ii) measures of beneficiary and family caregiver satisfaction with services; and
"(iii) measures for achieving desired outcomes appropriate to a specific beneficiary, including employment, participation in community life, health stability, and prevention of loss in function.
"(d)
"(1) in the case of a balancing incentive payment State subject to the target spending percentage described in subsection (c)(2)(A), 5 percentage points; and
"(2) in the case of any other balancing incentive payment State, 2 percentage points.
"(e)
"(1)
"(2)
"(f)
"(1)
"(A) Institutionally-based long-term services and supports.—Services provided in an institution, including the following:
"(i) Nursing facility services.
"(ii) Services in an intermediate care facility for the mentally retarded described in subsection (a)(15) of section 1905 of such Act [
"(B) Non-institutionally-based long-term services and supports.—Services not provided in an institution, including the following:
"(i) Home and community-based services provided under subsection (c), (d), or (i) of section 1915 of such Act [
"(ii) Home health care services.
"(iii) Personal care services.
"(iv) Services described in subsection (a)(26) of section 1905 of such Act [
"(v) Self-directed personal assistance services described in section 1915(j) of such Act [
"(2)
"(3)
"(4)
State Authority Under Medicaid
[For definitions of "CHIP", "Medicaid", and "Secretary", see section 1(c) of
Adjustment in Computation of FMAP To Disregard an Extraordinary Employer Pension Contribution
"(a)
"(b)
"(1)
"(2)
"(3)
"(c)
"(d)
"(e) FMAP
[For definitions of "Medicaid" and "Secretary", see section 1(c) of
Temporary State Fiscal Relief
Alaska FMAPs
"(1) items and services furnished under a State plan under title XIX [
"(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
"(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
"(a)
"(2) Any disallowance of Federal financial participation under title XIX of the Social Security Act [
"(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
Regulations for Intermediate Care Facilities for Mentally Retarded
Life Safety Code Recognition
Study of Federal Medical Assistance Percentage Formula and of Adjustments of Target Amounts for Federal Medicaid Expenditures; Report to Congress
Costs Charged to Personal Funds of Patients in Intermediate Care Facilities; Costs Included in Charges for Services; Regulations
1 See References in Text note below.
2 So in original. The word "and" probably should not appear.
3 So in original. Probably should be "a".
4 So in original. Probably should be clause "(iii),". 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".
9 So in original. Probably should be preceded by "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), 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));
(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), 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)), 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), 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), 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" has the meaning given that term in
(Aug. 14, 1935, ch. 531, title XIX, §1906, as added
Editorial Notes
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
2010—Subsec. (e)(2).
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
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
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
1 See References in Text note below.
§1396e–1. Premium assistance
(a) In general
A State may elect to offer a premium assistance subsidy (as defined in subsection (c)) for qualified employer-sponsored coverage (as defined in subsection (b)) to all individuals who are entitled to medical assistance under this subchapter (and, in the case of an individual under age 19, to the parent of such an individual) who have access to such coverage if the State meets the requirements of this section and the offering of such a subsidy is cost-effective, as defined for purposes of
(b) Qualified employer-sponsored coverage
(1) In general
Subject to paragraph (2)),1 in this paragraph, the term "qualified employer-sponsored coverage" means a group health plan or health insurance coverage offered through an employer—
(A) that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act; 2
(B) for which the employer contribution toward any premium for such coverage is at least 40 percent; and
(C) that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).
(2) Exception
Such term does not include coverage consisting of—
(A) benefits provided under a health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or
(B) a high deductible health plan (as defined in section 223(c)(2) of such Code), without regard to whether the plan is purchased in conjunction with a health savings account (as defined under section 223(d) of such Code).
(3) Treatment as third party liability
The State shall treat the coverage provided under qualified employer-sponsored coverage as a third party liability under
(c) Premium assistance subsidy
In this section, the term "premium assistance subsidy" means the amount of the employee contribution for enrollment in the qualified employer-sponsored coverage by the individual or by the individual's family. Premium assistance subsidies under this section shall be considered, for purposes of
(d) Voluntary participation
(1) Employers
Participation by an employer in a premium assistance subsidy offered by a State under this section shall be voluntary. An employer may notify a State that it elects to opt-out of being directly paid a premium assistance subsidy on behalf of an employee.
(2) Beneficiaries
No subsidy shall be provided to an individual under this section unless the individual (or the individual's parent) voluntarily elects to receive such a subsidy. A State may not require such an election as a condition of receipt of medical assistance. A State may not require, as a condition of an individual (or the individual's parent) being or remaining eligible for medical assistance under this subchapter, that the individual (or the individual's parent) apply for enrollment in qualified employer-sponsored coverage under this section.
(3) Opt-out permitted for any month
A State shall establish a process for permitting an individual (or the parent of an individual) receiving a premium assistance subsidy to disenroll the individual from the qualified employer-sponsored coverage.
(e) Requirement to pay premiums and cost-sharing and provide supplemental coverage
In the case of the participation of an individual (or the individual's parent) in a premium assistance subsidy under this section for qualified employer-sponsored coverage, the State shall provide for payment of all enrollee premiums for enrollment in such coverage 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
(Aug. 14, 1935, ch. 531, title XIX, §1906A, as added
Editorial Notes
References in Text
Section 2701 of the Public Health Service Act, referred to in subsec. (b)(1)(A), is section 2701 of act July 1, 1944, which was classified to
The Internal Revenue Code of 1986, referred to in subsec. (b)(1)(C), (2), is classified generally to Title 26, Internal Revenue Code.
Amendments
2010—
Subsec. (a).
Subsec. (c).
Subsec. (d)(2).
Subsec. (d)(3).
Subsec. (e).
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
Effective Date
Section effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of
Effect of Certain Amendment by Pub. L. 111–148
1 So in original. The second closing parenthesis probably should not appear.
2 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
Editorial Notes
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).
Statutory Notes and Related Subsidiaries
Effective Date of 1997 Amendment
Amendment by
Effective Date of 1996 Amendment
Effective Date of 1972 Amendment
Amendment by section 268(b) of
Effective Date
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; 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; 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
Statutory Notes and Related Subsidiaries
Effective Date
"(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 [
§1396h. State false claims act requirements for increased State share of recoveries
(a) In general
Notwithstanding
(b) Requirements
For purposes of subsection (a), the requirements of this subsection are that the Inspector General of the Department of Health and Human Services, in consultation with the Attorney General, determines that the State has in effect a law that meets the following requirements:
(1) The law establishes liability to the State for false or fraudulent claims described in
(2) The law contains provisions that are at least as effective in rewarding and facilitating qui tam actions for false or fraudulent claims as those described in
(3) The law contains a requirement for filing an action under seal for 60 days with review by the State Attorney General.
(4) The law contains a civil penalty that is not less than the amount of the civil penalty authorized under
(c) Deemed compliance
A State that, as of January 1, 2007, has a law in effect that meets the requirements of subsection (b) shall be deemed to be in compliance with such requirements for so long as the law continues to meet such requirements.
(d) No preclusion of broader laws
Nothing in this section shall be construed as prohibiting a State that has in effect a law that establishes liability to the State for false or fraudulent claims described in
(Aug. 14, 1935, ch. 531, title XIX, §1909, as added
Editorial Notes
Prior Provisions
A prior section 1396h, act Aug. 14, 1935, ch. 531, title XIX, §1909, as added and amended Oct. 30, 1972,
Statutory Notes and Related Subsidiaries
Effective Date
§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, 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 subchapter.
(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
Editorial Notes
Amendments
1999—
1994—Subsec. (b)(2).
1989—
Subsec. (b)(1).
Subsec. (b)(2).
1988—Subsec. (b)(1).
1987—
1980—Subsec. (c).
1977—
Statutory Notes and Related Subsidiaries
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
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), 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 subchapter 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.
(d) Cross reference
For provisions relating to the authority of certain Indian tribes, tribal organizations, and Alaska Native health organizations to elect to directly bill for, and receive payment for, health care services provided by a hospital or clinic of such tribes or organizations and for which payment may be made under this subchapter, see
(Aug. 14, 1935, ch. 531, title XIX, §1911, as added
Editorial Notes
References in Text
Amendments
2000—Subsec. (d).
1988—Subsecs. (a), (b).
1987—Subsecs. (a), (b).
Subsec. (c).
Statutory Notes and Related Subsidiaries
Effective Date of 2000 Amendment
Amendment by
Effective Date of 1988 Amendment
Except as specifically provided in section 411 of
Effective Date of 1987 Amendment
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
Medicaid Payments Not Considered in Determining Appropriations for Indian Health Care
1 See References in Text note below.
§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
Editorial Notes
Amendments
2018—Subsec. (a)(1)(A).
2013—Subsec. (a)(1)(A).
1990—Subsec. (a)(1)(B).
1986—Subsec. (a)(1)(C).
1984—Subsec. (a).
Statutory Notes and Related Subsidiaries
Effective Date of 2018 Amendment
Effective Date of 1990 Amendment
Effective Date of 1986 Amendment
Amendment by
Effective Date of 1984 Amendment
Amendment by
§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), 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), 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
Editorial Notes
Amendments
1987—
Subsec. (a).
Subsec. (b)(1).
Subsec. (b)(3).
1984—Subsec. (b)(1).
Subsec. (b)(3).
Statutory Notes and Related Subsidiaries
Effective Date of 1987 Amendment
Amendment by
Effective Date of 1984 Amendment
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), or the total overpayments to such institution or person under subchapter XVIII, 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) 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, 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 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).
(Aug. 14, 1935, ch. 531, title XIX, §1914, as added
§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; 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 such terms are defined in
(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 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.
(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) shall apply to this subsection in the same manner as it applies to subsection (d).
(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:
(A)(i) 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.
(ii) Such term includes the following:
(I) Assessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services. Such assessment activities include the following:
(aa) Taking client history.
(bb) Identifying the needs of the individual, and completing related documentation.
(cc) Gathering information from other sources such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the eligible individual.
(II) Development of a specific care plan based on the information collected through an assessment, that specifies the goals and actions to address the medical, social, educational, and other services needed by the eligible individual, including activities such as ensuring the active participation of the eligible individual and working with the individual (or the individual's authorized health care decision maker) and others to develop such goals and identify a course of action to respond to the assessed needs of the eligible individual.
(III) Referral and related activities to help an individual obtain needed services, including activities that help link eligible individuals with medical, social, educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the individual.
(IV) Monitoring and followup activities, including activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the eligible individual, and which may be with the individual, family members, providers, or other entities and conducted as frequently as necessary to help determine such matters as—
(aa) whether services are being furnished in accordance with an individual's care plan;
(bb) whether the services in the care plan are adequate; and
(cc) whether there are changes in the needs or status of the eligible individual, and if so, making necessary adjustments in the care plan and service arrangements with providers.
(iii) Such term does not include the direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred, including, with respect to the direct delivery of foster care services, services such as (but not limited to) the following:
(I) Research gathering and completion of documentation required by the foster care program.
(II) Assessing adoption placements.
(III) Recruiting or interviewing potential foster care parents.
(IV) Serving legal papers.
(V) Home investigations.
(VI) Providing transportation.
(VII) Administering foster care subsidies.
(VIII) Making placement arrangements.
(B) The term "targeted case management services" are case management services that are furnished without regard to the requirements of
(3) With respect to contacts with individuals who are not eligible for medical assistance under the State plan or, in the case of targeted case management services, individuals who are eligible for such assistance but are not part of the target population specified in the State plan, such contacts—
(A) are considered an allowable case management activity, when the purpose of the contact is directly related to the management of the eligible individual's care; and
(B) are not considered an allowable case management activity if such contacts relate directly to the identification and management of the noneligible or nontargeted individual's needs and care.
(4)(A) In accordance with
(B) A State shall allocate the costs of any part of such services which are reimbursable under another federally funded program in accordance with OMB Circular A–87 (or any related or successor guidance or regulations regarding allocation of costs among federally funded programs) under an approved cost allocation program.
(5) Nothing in this subsection shall be construed as affecting the application of rules with respect to third party liability under programs, or activities carried out under title XXVI of the Public Health Service Act [
(h) Period of waivers; continuations
(1) No waiver under this section (other than a waiver under subsection (c), (d), or (e), or a waiver described in paragraph (2)) 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.
(2)(A) Notwithstanding subsections (c)(3) and (d)(3), any waiver under subsection (b), (c), or (d), or a waiver under
(B) In this paragraph, the term "dual eligible individual" means an individual who is entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and is eligible for medical assistance under the State plan under this subchapter or under a waiver of such plan.
(i) State plan amendment option to provide home and community-based services for elderly and disabled individuals
(1) In general
Subject to the succeeding provisions of this subsection, a State may provide through a State plan amendment for the provision of medical assistance for home and community-based services (within the scope of services described in paragraph (4)(B) of subsection (c) for which the Secretary has the authority to approve a waiver and not including room and board) for individuals eligible for medical assistance under the State plan whose income does not exceed 150 percent of the poverty line (as defined in
(A) Needs-based criteria for eligibility for, and receipt of, home and community-based services
The State establishes needs-based criteria for determining an individual's eligibility under the State plan for medical assistance for such home and community-based services, and if the individual is eligible for such services, the specific home and community-based services that the individual will receive.
(B) Establishment of more stringent needs-based eligibility criteria for institutionalized care
The State establishes needs-based criteria for determining whether an individual requires the level of care provided in a hospital, a nursing facility, or an intermediate care facility for the mentally retarded under the State plan or under any waiver of such plan that are more stringent than the needs-based criteria established under subparagraph (A) for determining eligibility for home and community-based services.
(C) Projection of number of individuals to be provided home and community-based services
The State submits to the Secretary, in such form and manner, and upon such frequency as the Secretary shall specify, the projected number of individuals to be provided home and community-based services.
(D) Criteria based on individual assessment
(i) In general
The criteria established by the State for purposes of subparagraphs (A) and (B) requires an assessment of an individual's support needs and capabilities, and may take into account the inability of the individual to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) or the need for significant assistance to perform such activities, and such other risk factors as the State determines to be appropriate.
(ii) Adjustment authority
The State plan amendment provides the State with the option to modify the criteria established under subparagraph (A) (without having to obtain prior approval from the Secretary) in the event that the enrollment of individuals eligible for home and community-based services exceeds the projected enrollment submitted for purposes of subparagraph (C), but only if—
(I) the State provides at least 60 days notice to the Secretary and the public of the proposed modification;
(II) the State deems an individual receiving home and community-based services on the basis of the most recent version of the criteria in effect prior to the effective date of the modification to continue to be eligible for such services after the effective date of the modification and until such time as the individual no longer meets the standard for receipt of such services under such pre-modified criteria; and
(III) after the effective date of such modification, the State, at a minimum, applies the criteria for determining whether an individual requires the level of care provided in a hospital, a nursing facility, or an intermediate care facility for the mentally retarded under the State plan or under any waiver of such plan which applied prior to the application of the more stringent criteria developed under subparagraph (B).
(E) Independent evaluation and assessment
(i) Eligibility determination
The State uses an independent evaluation for making the determinations described in subparagraphs (A) and (B).
(ii) Assessment
In the case of an individual who is determined to be eligible for home and community-based services, the State uses an independent assessment, based on the needs of the individual to—
(I) determine a necessary level of services and supports to be provided, consistent with an individual's physical and mental capacity;
(II) prevent the provision of unnecessary or inappropriate care; and
(III) establish an individualized care plan for the individual in accordance with subparagraph (G).
(F) Assessment
The independent assessment required under subparagraph (E)(ii) shall include the following:
(i) An objective evaluation of an individual's inability to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) or the need for significant assistance to perform such activities.
(ii) A face-to-face evaluation of the individual by an individual trained in the assessment and evaluation of individuals whose physical or mental conditions trigger a potential need for home and community-based services.
(iii) Where appropriate, consultation with the individual's family, spouse, guardian, or other responsible individual.
(iv) Consultation with appropriate treating and consulting health and support professionals caring for the individual.
(v) An examination of the individual's relevant history, medical records, and care and support needs, guided by best practices and research on effective strategies that result in improved health and quality of life outcomes.
(vi) If the State offers individuals the option to self-direct the purchase of, or control the receipt of, home and community-based service, an evaluation of the ability of the individual or the individual's representative to self-direct the purchase of, or control the receipt of, such services if the individual so elects.
(G) Individualized care plan
(i) In general
In the case of an individual who is determined to be eligible for home and community-based services, the State uses the independent assessment required under subparagraph (E)(ii) to establish a written individualized care plan for the individual.
(ii) Plan requirements
The State ensures that the individualized care plan for an individual—
(I) is developed—
(aa) in consultation with the individual, the individual's treating physician, health care or support professional, or other appropriate individuals, as defined by the State, and, where appropriate the individual's family, caregiver, or representative; and
(bb) taking into account the extent of, and need for, any family or other supports for the individual;
(II) identifies the necessary home and community-based services to be furnished to the individual (or, if the individual elects to self-direct the purchase of, or control the receipt of, such services, funded for the individual); and
(III) is reviewed at least annually and as needed when there is a significant change in the individual's circumstances.
(iii) State option to offer election for self-directed services
(I) Individual choice
At the option of the State, the State may allow an individual or the individual's representative to elect to receive self-directed home and community-based services in a manner which gives them the most control over such services consistent with the individual's abilities and the requirements of subclauses (II) and (III).
(II) Self-directed services
The term "self-directed" means, with respect to the home and community-based services offered under the State plan amendment, such services for the individual which are planned and purchased under the direction and control of such individual or the individual's authorized representative, including the amount, duration, scope, provider, and location of such services, under the State plan consistent with the following requirements:
(aa) Assessment
There is an assessment of the needs, capabilities, and preferences of the individual with respect to such services.
(bb) Service plan
Based on such assessment, there is developed jointly with such individual or the individual's authorized representative a plan for such services for such individual that is approved by the State and that satisfies the requirements of subclause (III).
(III) Plan requirements
For purposes of subclause (II)(bb), the requirements of this subclause are that the plan—
(aa) specifies those services which the individual or the individual's authorized representative would be responsible for directing;
(bb) identifies the methods by which the individual or the individual's authorized representative will select, manage, and dismiss providers of such services;
(cc) specifies the role of family members and others whose participation is sought by the individual or the individual's authorized representative with respect to such services;
(dd) is developed through a person-centered process that is directed by the individual or the individual's authorized representative, builds upon the individual's capacity to engage in activities that promote community life and that respects the individual's preferences, choices, and abilities, and involves families, friends, and professionals as desired or required by the individual or the individual's authorized representative;
(ee) includes appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assure the appropriateness of such plan based upon the resources and capabilities of the individual or the individual's authorized representative; and
(ff) may include an individualized budget which identifies the dollar value of the services and supports under the control and direction of the individual or the individual's authorized representative.
(IV) Budget process
With respect to individualized budgets described in subclause (III)(ff), the State plan amendment—
(aa) describes the method for calculating the dollar values in such budgets based on reliable costs and service utilization;
(bb) defines a process for making adjustments in such dollar values to reflect changes in individual assessments and service plans; and
(cc) provides a procedure to evaluate expenditures under such budgets.
(H) Quality assurance; conflict of interest standards
(i) Quality assurance
The State ensures that the provision of home and community-based services meets Federal and State guidelines for quality assurance.
(ii) Conflict of interest standards
The State establishes standards for the conduct of the independent evaluation and the independent assessment to safeguard against conflicts of interest.
(I) Redeterminations and appeals
The State allows for at least annual redeterminations of eligibility, and appeals in accordance with the frequency of, and manner in which, redeterminations and appeals of eligibility are made under the State plan.
(J) Presumptive eligibility for assessment
The State, at its option, elects to provide for a period of presumptive eligibility (not to exceed a period of 60 days) only for those individuals that the State has reason to believe may be eligible for home and community-based services. Such presumptive eligibility shall be limited to medical assistance for carrying out the independent evaluation and assessment under subparagraph (E) to determine an individual's eligibility for such services and if the individual is so eligible, the specific home and community-based services that the individual will receive.
(2) Definition of individual's representative
In this section, the term "individual's representative" means, with respect to an individual, a parent, a family member, or a guardian of the individual, an advocate for the individual, or any other individual who is authorized to represent the individual.
(3) Nonapplication
A State may elect in the State plan amendment approved under this section to not comply with the requirements of
(4) No effect on other waiver authority
Nothing in this subsection shall be construed as affecting the option of a State to offer home and community-based services under a waiver under subsections (c) or (d) of this section or under
(5) Continuation of Federal financial participation for medical assistance provided to individuals as of effective date of State plan amendment
Notwithstanding paragraph (1)(B), Federal financial participation shall continue to be available for an individual who is receiving medical assistance in an institutionalized setting, or home and community-based services provided under a waiver under this section or
(6) State option to provide home and community-based services to individuals eligible for services under a waiver
(A) In general
A State that provides home and community-based services in accordance with this subsection to individuals who satisfy the needs-based criteria for the receipt of such services established under paragraph (1)(A) may, in addition to continuing to provide such services to such individuals, elect to provide home and community-based services in accordance with the requirements of this paragraph to individuals who are eligible for home and community-based services under a waiver approved for the State under subsection (c), (d), or (e) or under
(B) Application of same requirements for individuals satisfying needs-based criteria
Subject to subparagraph (C), a State shall provide home and community-based services to individuals under this paragraph in the same manner and subject to the same requirements as apply under the other paragraphs of this subsection to the provision of home and community-based services to individuals who satisfy the needs-based criteria established under paragraph (1)(A).
(C) Authority to offer different type, amount, duration, or scope of home and community-based services
A State may offer home and community-based services to individuals under this paragraph that differ in type, amount, duration, or scope from the home and community-based services offered for individuals who satisfy the needs-based criteria established under paragraph (1)(A), so long as such services are within the scope of services described in paragraph (4)(B) of subsection (c) for which the Secretary has the authority to approve a waiver and do not include room or board.
(7) State option to offer home and community-based services to specific, targeted populations
(A) In general
A State may elect in a State plan amendment under this subsection to target the provision of home and community-based services under this subsection to specific populations and to differ the type, amount, duration, or scope of such services to such specific populations.
(B) 5-year term
(i) In general
An election by a State under this paragraph shall be for a period of 5 years.
(ii) Phase-in of services and eligibility permitted during initial 5-year period
A State making an election under this paragraph may, during the first 5-year period for which the election is made, phase-in the enrollment of eligible individuals, or the provision of services to such individuals, or both, so long as all eligible individuals in the State for such services are enrolled, and all such services are provided, before the end of the initial 5-year period.
(C) Renewal
An election by a State under this paragraph may be renewed for additional 5-year terms if the Secretary determines, prior to beginning 1 of each such renewal period, that the State has—
(i) adhered to the requirements of this subsection and paragraph in providing services under such an election; and
(ii) met the State's objectives with respect to quality improvement and beneficiary outcomes.
(j) Optional choice of self-directed personal assistance services
(1) A State may provide, as "medical assistance", payment for part or all of the cost of self-directed personal assistance services (other than room and board) under the plan 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 and receive personal care services under the plan, or home and community-based services provided pursuant to a waiver under subsection (c). Self-directed personal assistance services may not be provided under this subsection to individuals who reside in a home or property that is owned, operated, or controlled by a provider of services, not related by blood or marriage.
(2) The Secretary shall not grant approval for a State self-directed personal assistance services program under this section unless the State provides assurances satisfactory to the Secretary of the following:
(A) Necessary safeguards have been taken to protect the health and welfare of individuals provided services under the program, 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 personal care services under the plan, or receive home and community-based services under a waiver granted under subsection (c);
(ii) may require self-directed personal assistance services; and
(iii) may be eligible for self-directed personal assistance services,
an evaluation of the need for personal care under the plan, or personal services under a waiver granted under subsection (c).
(C) Such individuals who are determined to be likely to require personal care under the plan, or home and community-based services under a waiver granted under subsection (c) are informed of the feasible alternatives, if available under the State's self-directed personal assistance services program, at the choice of such individuals, to the provision of personal care services under the plan, or personal assistance services under a waiver granted under subsection (c).
(D) The State will provide for a support system that ensures participants in the self-directed personal assistance services program are appropriately assessed and counseled prior to enrollment and are able to manage their budgets. Additional counseling and management support may be provided at the request of the participant.
(E) The State will provide to the Secretary an annual report on the number of individuals served and total expenditures on their behalf in the aggregate. The State shall also provide an evaluation of overall impact on the health and welfare of participating individuals compared to non-participants every three years.
(3) A State may provide self-directed personal assistance services under the State plan without regard to the requirements of
(4)(A) For purposes of this subsection, the term "self-directed personal assistance services" means personal care and related services, or home and community-based services otherwise available under the plan under this subchapter or subsection (c), that are provided to an eligible participant under a self-directed personal assistance services program under this section, under which individuals, within an approved self-directed services plan and budget, purchase personal assistance and related services, and permits participants to hire, fire, supervise, and manage the individuals providing such services.
(B) At the election of the State—
(i) a participant may choose to use any individual capable of providing the assigned tasks including legally liable relatives as paid providers of the services; and
(ii) the individual may use the individual's budget to acquire items that increase independence or substitute (such as a microwave oven or an accessibility ramp) for human assistance, to the extent that expenditures would otherwise be made for the human assistance.
(5) For purpose of this section, the term "approved self-directed services plan and budget" means, with respect to a participant, the establishment of a plan and budget for the provision of self-directed personal assistance services, consistent with the following requirements:
(A) Self-direction
The participant (or in the case of a participant who is a minor child, the participant's parent or guardian, or in the case of an incapacitated adult, another individual recognized by State law to act on behalf of the participant) exercises choice and control over the budget, planning, and purchase of self-directed personal assistance services, including the amount, duration, scope, provider, and location of service provision.
(B) Assessment of needs
There is an assessment of the needs, strengths, and preferences of the participants for such services.
(C) Service plan
A plan for such services (and supports for such services) for the participant has been developed and approved by the State based on such assessment through a person-centered process that—
(i) builds upon the participant's capacity to engage in activities that promote community life and that respects the participant's preferences, choices, and abilities; and
(ii) involves families, friends, and professionals in the planning or delivery of services or supports as desired or required by the participant.
(D) Service budget
A budget for such services and supports for the participant has been developed and approved by the State based on such assessment and plan and on a methodology that uses valid, reliable cost data, is open to public inspection, and includes a calculation of the expected cost of such services if those services were not self-directed. The budget may not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget.
(E) Application of quality assurance and risk management
There are appropriate quality assurance and risk management techniques used in establishing and implementing such plan and budget that recognize the roles and responsibilities in obtaining services in a self-directed manner and assure the appropriateness of such plan and budget based upon the participant's resources and capabilities.
(6) A State may employ a financial management entity to make payments to providers, track costs, and make reports under the program. Payment for the activities of the financial management entity shall be at the administrative rate established in
(k) State plan option to provide home and community-based attendant services and supports
(1) In general
Subject to the succeeding provisions of this subsection, beginning October 1, 2011, a State may provide through a State plan amendment for the provision of medical assistance for home and community-based attendant services and supports for individuals who are eligible for medical assistance under the State plan whose income does not exceed 150 percent of the poverty line (as defined in
(A) Availability
The State shall make available home and community-based attendant services and supports to eligible individuals, as needed, to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing—
(i) under a person-centered plan of services and supports that is based on an assessment of functional need and that is agreed to in writing by the individual or, as appropriate, the individual's representative;
(ii) in a home or community setting, which does not include a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded;
(iii) under an agency-provider model or other model (as defined in paragraph (6)(C)); and
(iv) the furnishing of which—
(I) is selected, managed, and dismissed by the individual, or, as appropriate, with assistance from the individual's representative;
(II) is controlled, to the maximum extent possible, by the individual or where appropriate, the individual's representative, regardless of who may act as the employer of record; and
(III) provided by an individual who is qualified to provide such services, including family members (as defined by the Secretary).
(B) Included services and supports
In addition to assistance in accomplishing activities of daily living, instrumental activities of daily living, and health related tasks, the home and community-based attendant services and supports made available include—
(i) the acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living, instrumental activities of daily living, and health related tasks;
(ii) back-up systems or mechanisms (such as the use of beepers or other electronic devices) to ensure continuity of services and supports; and
(iii) voluntary training on how to select, manage, and dismiss attendants.
(C) Excluded services and supports
Subject to subparagraph (D), the home and community-based attendant services and supports made available do not include—
(i) room and board costs for the individual;
(ii) special education and related services provided under the Individuals with Disabilities Education Act [
(iii) assistive technology devices and assistive technology services other than those under (1)(B)(ii);
(iv) medical supplies and equipment; or
(v) home modifications.
(D) Permissible services and supports
The home and community-based attendant services and supports may include—
(i) expenditures for transition costs such as rent and utility deposits, first month's rent and utilities, bedding, basic kitchen supplies, and other necessities required for an individual to make the transition from a nursing facility, institution for mental diseases, or intermediate care facility for the mentally retarded to a community-based home setting where the individual resides; and
(ii) expenditures relating to a need identified in an individual's person-centered plan of services that increase independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance.
(2) Increased Federal financial participation
For purposes of payments to a State under
(3) State requirements
In order for a State plan amendment to be approved under this subsection, the State shall—
(A) develop and implement such amendment in collaboration with a Development and Implementation Council established by the State that includes a majority of members with disabilities, elderly individuals, and their representatives and consults and collaborates with such individuals;
(B) provide consumer controlled home and community-based attendant services and supports to individuals on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual's needs, and without regard to the individual's age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires in order to lead an independent life;
(C) with respect to expenditures during the first full fiscal year in which the State plan amendment is implemented, maintain or exceed the level of State expenditures for medical assistance that is provided under
(D) establish and maintain a comprehensive, continuous quality assurance system with respect to community-based attendant services and supports that—
(i) includes standards for agency-based and other delivery models with respect to training, appeals for denials and reconsideration procedures of an individual plan, and other factors as determined by the Secretary;
(ii) incorporates feedback from consumers and their representatives, disability organizations, providers, families of disabled or elderly individuals, members of the community, and others and maximizes consumer independence and consumer control;
(iii) monitors the health and well-being of each individual who receives home and community-based attendant services and supports, including a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports; and
(iv) provides information about the provisions of the quality assurance required under clauses (i) through (iii) to each individual receiving such services; and
(E) collect and report information, as determined necessary by the Secretary, for the purposes of approving the State plan amendment, providing Federal oversight, and conducting an evaluation under paragraph (5)(A), including data regarding how the State provides home and community-based attendant services and supports and other home and community-based services, the cost of such services and supports, and how the State provides individuals with disabilities who otherwise qualify for institutional care under the State plan or under a waiver the choice to instead receive home and community-based services in lieu of institutional care.
(4) Compliance with certain laws
A State shall ensure that, regardless of whether the State uses an agency-provider model or other models to provide home and community-based attendant services and supports under a State plan amendment under this subsection, such services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 [
(A) withholding and payment of Federal and State income and payroll taxes;
(B) the provision of unemployment and workers compensation insurance;
(C) maintenance of general liability insurance; and
(D) occupational health and safety.
(5) Evaluation, data collection, and report to Congress
(A) Evaluation
The Secretary shall conduct an evaluation of the provision of home and community-based attendant services and supports under this subsection in order to determine the effectiveness of the provision of such services and supports in allowing the individuals receiving such services and supports to lead an independent life to the maximum extent possible; the impact on the physical and emotional health of the individuals who receive such services; and an 2 comparative analysis of the costs of services provided under the State plan amendment under this subsection and those provided under institutional care in a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded.
(B) Data collection
The State shall provide the Secretary with the following information regarding the provision of home and community-based attendant services and supports under this subsection for each fiscal year for which such services and supports are provided:
(i) The number of individuals who are estimated to receive home and community-based attendant services and supports under this subsection during the fiscal year.
(ii) The number of individuals that received such services and supports during the preceding fiscal year.
(iii) The specific number of individuals served by type of disability, age, gender, education level, and employment status.
(iv) Whether the specific individuals have been previously served under any other home and community based services program under the State plan or under a waiver.
(C) Reports
Not later than—
(i) December 31, 2013, the Secretary shall submit to Congress and make available to the public an interim report on the findings of the evaluation under subparagraph (A); and
(ii) December 31, 2015, the Secretary shall submit to Congress and make available to the public a final report on the findings of the evaluation under subparagraph (A).
(6) Definitions
In this subsection:
(A) Activities of daily living
The term "activities of daily living" includes tasks such as eating, toileting, grooming, dressing, bathing, and transferring.
(B) Consumer controlled
The term "consumer controlled" means a method of selecting and providing services and supports that allow the individual, or where appropriate, the individual's representative, maximum control of the home and community-based attendant services and supports, regardless of who acts as the employer of record.
(C) Delivery models
(i) Agency-provider model
The term "agency-provider model" means, with respect to the provision of home and community-based attendant services and supports for an individual, subject to paragraph (4), a method of providing consumer controlled services and supports under which entities contract for the provision of such services and supports.
(ii) Other models
The term "other models" means, subject to paragraph (4), methods, other than an agency-provider model, for the provision of consumer controlled services and supports. Such models may include the provision of vouchers, direct cash payments, or use of a fiscal agent to assist in obtaining services.
(D) Health-related tasks
The term "health-related tasks" means specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under State law to be performed by an attendant.
(E) Individual's representative
The term "individual's representative" means a parent, family member, guardian, advocate, or other authorized representative of an individual 3
(F) Instrumental activities of daily living
The term "instrumental activities of daily living" includes (but is not limited to) meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
(l) State plan amendment option to provide medical assistance for certain individuals who are patients in certain institutions for mental diseases
(1) In general
With respect to calendar quarters beginning on or after October 1, 2019, a State may elect, through a State plan amendment, to provide medical assistance for items and services furnished to an eligible individual who is a patient in an eligible institution for mental diseases in accordance with the requirements of this subsection.
(2) Payments
Subject to paragraphs (3) and (4), amounts expended under a State plan amendment under paragraph (1) for services described in such paragraph furnished, with respect to a 12-month period, to an eligible individual who is a patient in an eligible institution for mental diseases shall be treated as medical assistance for which payment is made under
(3) Maintenance of effort
(A) In general
As a condition for a State receiving payments under
(i) fiscal year 2018; or
(ii) the most recently ended fiscal year as of the date the State submits a State plan amendment to the Secretary to provide such medical assistance in accordance with this subsection.
(B) Services described
For purposes of subparagraph (A), services described in this subparagraph are the following:
(i) Outpatient and community-based substance use disorder treatment.
(ii) Evidence-based recovery and support services.
(iii) Clinically-directed therapeutic treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies.
(iv) Outpatient medication-assisted treatment, related therapies, and pharmacology.
(v) Counseling and clinical monitoring.
(vi) Outpatient withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress resulting from, or occurring with, an individual's use of alcohol and other drugs.
(vii) Routine monitoring of medication adherence.
(viii) Other outpatient and community-based services for the treatment of substance use disorders, as designated by the Secretary.
(C) State reporting requirement
(i) In general
Prior to approval of a State plan amendment under this subsection, as a condition for a State receiving payments under
(ii) Process
Not later than the date that is 8 months after October 24, 2018, the Secretary shall establish a process for States to report to the Secretary, at such time and in such manner as the Secretary deems appropriate, such information as the Secretary deems necessary to verify a State's compliance with subparagraph (A).
(D) Application of maintenance of effort requirements to certain States
In the case of a State with a State plan amendment in effect on September 30, 2023, for the 1-year period beginning on March 9, 2024, the provisions of subparagraph (A) shall be applied as if the amendments to such subparagraph made by the Consolidated Appropriations Act, 2024 had never been made.
(4) Ensuring a continuum of services
(A) In general
As a condition for a State receiving payments under
(B) Notification
The State shall have in place evidence-based, substance use disorder-specific individual placement criteria and utilization management approaches to ensure placement of eligible individuals in an appropriate level of care, including criteria and approaches to ensure that eligible individuals receive appropriate evidence-based clinical screening prior to being furnished with items and services in an eligible institution for mental diseases, including initial and periodic assessments to determine the appropriate level of care, length of stay, and setting for such care for each individual. The State shall notify the Secretary at such time and in such form and manner as the Secretary shall require of such criteria and utilization management approaches.
(C) Outpatient services; inpatient and residential services
(i) Outpatient services
The State shall, at a minimum, provide medical assistance for services that could otherwise be covered under the State plan, consistent with each of the following outpatient levels of care:
(I) Early intervention for individuals who, for a known reason, are at risk of developing substance-related problems and for individuals for whom there is not yet sufficient information to document a diagnosable substance use disorder.
(II) Outpatient services for less than 9 hours per week for adults, and for less than 6 hours per week for adolescents, for recovery or motivational enhancement therapies and strategies.
(III) Intensive outpatient services for 9 hours or more per week for adults, and for 6 hours or more per week for adolescents, to treat multidimensional instability.
(IV) Partial hospitalization services for 20 hours or more per week for adults and adolescents to treat multidimensional instability that does not require 24-hour care.
(ii) Inpatient and residential services
The State shall provide medical assistance for services that could otherwise be covered under the State plan, consistent with at least 2 of the following inpatient and residential levels of care:
(I) Clinically managed, low-intensity residential services that provide adults and adolescents with 24-hour living support and structure with trained personnel and at least 5 hours of clinical service per week per individual.
(II) Clinically managed, population-specific, high-intensity residential services that provide adults with 24-hour care with trained counselors to stabilize multidimensional imminent danger along with less intense milieu and group treatment for those with cognitive or other impairments unable to use full active milieu or therapeutic community.
(III) Clinically managed, medium-intensity residential services for adolescents, and clinically managed, high-intensity residential services for adults, that provide 24-hour care with trained counselors to stabilize multidimensional imminent danger and preparation for outpatient treatment.
(IV) Medically monitored, high-intensity inpatient services for adolescents, and medically monitored, intensive inpatient services withdrawal management for adults, that provide 24-hour nursing care, make physicians available for significant conditions, and provide counseling services 16 hours per day.
(V) Medically managed, intensive inpatient services for adolescents and adults that provide 24-hour nursing care and daily physician care for severe, unstable conditions.
(D) Transition of care
In order to ensure an appropriate transition for an eligible individual from receiving care in an eligible institution for mental diseases to receiving care at a lower level of clinical intensity within the continuum of care (including outpatient services), the State shall ensure that—
(i) a placement in such eligible institution for mental diseases would allow for an eligible individual's successful transition to the community, considering such factors as proximity to an individual's support network (such as family members, employment, and counseling and other services near an individual's residence); and
(ii) all eligible institutions for mental diseases that furnish items and services to individuals for which medical assistance is provided under the State plan—
(I) are able to provide care at such lower level of clinical intensity; or
(II) have an established relationship with another facility or provider that is able to provide care at such lower level of clinical intensity and accepts patients receiving medical assistance under this subchapter under which the eligible institution for mental diseases may arrange for individuals to receive such care from such other facility or provider.
(E) Review process
The State shall, using nationally recognized substance use disorder-specific program standards, have in place a process to review the compliance of eligible institutions for mental diseases with such program standards specified by the State.
(F) Assessment
(i) In general
The State shall, not later than 12 months after the approval of a State plan amendment described in this subsection (or, in the case of a State that has such an amendment approved as of September 30, 2023, not later than 12 months after March 9, 2024), commence an assessment of—
(I) the availability of treatment for individuals enrolled under a State plan under this subchapter (or waiver of such plan) in each level of care described in subparagraph (C), including how such availability varies by region of the State; and
(II) the availability of medication-assisted treatment and medically supervised withdrawal management services for such individuals, including how such availability varies by region of the State.
(ii) Required completion
The State shall complete an assessment described in clause (i) not later than 12 months after the date the State commences such assessment.
(5) Application to managed care
Payments for, and limitations to, medical assistance furnished in accordance with this subsection shall be in addition to and shall not be construed to limit or supersede the ability of States to make monthly capitation payments to managed care organizations for individuals receiving treatment in institutions for mental diseases in accordance with section 438.6(e) of title 42, Code of Federal Regulations (or any successor regulation).
(6) Other medical assistance
The provision of medical assistance for items and services furnished to an eligible individual who is a patient in an eligible institution for mental diseases in accordance with the requirements of this subsection shall not prohibit Federal financial participation for medical assistance for items or services that are provided to such eligible individual in or away from the eligible institution for mental disease during any period in which the eligible individual is receiving items or services in accordance with this subsection.
(7) Definitions
In this subsection:
(A) Eligible individual
The term "eligible individual" means an individual who—
(i) with respect to a State, is enrolled for medical assistance under the State plan or a waiver of such plan;
(ii) is at least 21 years of age;
(iii) has not attained 65 years of age; and
(iv) has at least 1 substance use disorder.
(B) Eligible institution for mental diseases
The term "eligible institution for mental diseases" means an institution for mental diseases that—
(i) follows reliable, evidence-based practices; and
(ii) offers at least 2 forms of medication-assisted treatment for substance use disorders on site, including, in the case of medication-assisted treatment for opioid use disorder, at least 1 antagonist and 1 partial agonist.
(C) Institution for mental diseases
The term "institution for mental diseases" has the meaning given that term in
(Aug. 14, 1935, ch. 531, title XIX, §1915, as added
Applicability of Amendment
Amendment by section 204(c)(1)(A) of title I of div. G of
Editorial Notes
References in Text
The Public Health Service Act, referred to in subsec. (g)(5), is act July 1, 1944, ch. 373,
Section 7702B(c)(2)(B) of the Internal Revenue Code of 1986, referred to in subsec. (i)(1)(D)(i), (F)(i), is classified to
The Individuals with Disabilities Education Act, referred to in subsec. (k)(1)(C)(ii), is title VI of
The Rehabilitation Act of 1973, referred to in subsec. (k)(1)(C)(ii), is
The Fair Labor Standards Act of 1938, referred to in subsec. (k)(4), is act June 25, 1938, ch. 676,
The Consolidated Appropriations Act, 2024, referred to in subsec. (l)(3)(D), is
Amendments
2024—Subsec. (l)(1).
Subsec. (l)(3)(A).
"(i) items and services furnished to eligible individuals who are patients in eligible institutions for mental diseases that is not less than the level of such funding for such items and services for the most recently ended fiscal year as of October 24, 2018, or, if higher, for the most recently ended fiscal year as of the date the State submits a State plan amendment to the Secretary to provide such medical assistance in accordance with this subsection; and
"(ii) items and services (including services described in subparagraph (B))"
and "such items and services for, at the option of the State—" and cls. (i) and (ii) for "such items and services for the most recently ended fiscal year as of October 24, 2018, or, if higher, for the most recently ended fiscal year as of the date the State submits a State plan amendment to the Secretary to provide such medical assistance in accordance with this subsection."
Subsec. (l)(3)(B).
Subsec. (l)(3)(D).
Subsec. (l)(4)(A).
Subsec. (l)(4)(B).
Subsec. (l)(4)(C)(ii).
Subsec. (l)(4)(E).
Subsec. (l)(4)(F).
Subsec. (l)(7).
2018—Subsec. (l).
2010—Subsec. (b).
Subsec. (c)(3).
Subsec. (d)(3).
Subsec. (h).
Subsec. (i)(1).
Subsec. (i)(1)(C).
Subsec. (i)(1)(D)(ii)(II).
Subsec. (i)(3).
Subsec. (i)(6), (7).
Subsec. (k).
Subsec. (k)(1).
2006—Subsec. (g)(2) to (5).
Subsec. (i).
Subsec. (j).
2004—Subsec. (c)(5)(C)(i).
2002—Subsec. (b).
2000—Subsec. (b).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2024 Amendment
Effective Date of 2010 Amendment
Amendment by section 2402(b), (c), (e), (f) of
Effective Date of 2006 Amendment
Effective Date of 2002 Amendment
Amendment by
Effective Date of 2000 Amendment
Amendment by
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
Effective Date of 1993 Amendment
Amendment by
Effective Date of 1990 Amendment
Amendment by section 4604(c) of
Amendment by section 4704(b)(3) of
Effective Date of 1989 Amendment
Amendment by section 6115(c) of
Amendment by
Effective Date of 1988 Amendment
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 Amendment
For effective date of amendment by section 4072(d) of
Amendment by section 4211(h)(10) of
Amendment by
Effective Date of 1986 Amendment
Amendment by section 9320(h)(3) of
"(1)
"(2)
"(3)
"(4)
"(5)
"(6)
"(7)
[
Effective Date of 1983 Amendment
Amendment by
Effective Date of 1982 Amendment
Amendment by section 137(b)(20)–(25) of
Effective Date of 1981 Amendment
Regulations
Construction of 2018 Amendment
Application to Certain States
"(1) had approval for a State plan amendment under such section as of September 30, 2023; and
"(2) submits the request to renew such amendment not later than 60 days after the date of enactment of this Act [Mar. 9, 2024]."
Oversight and Assessment of the Administration of Home and Community-based Services
"(1) allocate resources for services in a manner that is responsive to the changing needs and choices of beneficiaries receiving non-institutionally-based long-term services and supports (including such services and supports that are provided under programs other [than] the State Medicaid program), and that provides strategies for beneficiaries receiving such services to maximize their independence, including through the use of client-employed providers;
"(2) provide the support and coordination needed for a beneficiary in need of such services (and their family caregivers or representative, if applicable) to design an individualized, self-directed, community-supported life; and
"(3) improve coordination among, and the regulation of, all providers of such services under federally and State-funded programs in order to—
"(A) achieve a more consistent administration of policies and procedures across programs in relation to the provision of such services; and
"(B) oversee and monitor all service system functions to assure—
"(i) coordination of, and effectiveness of, eligibility determinations and individual assessments;
"(ii) development and service monitoring of a complaint system, a management system, a system to qualify and monitor providers, and systems for role-setting and individual budget determinations; and
"(iii) an adequate number of qualified direct care workers to provide self-directed personal assistance services."
Quality of Care Measures
"(1)
"(2)
"(A) use the indicators and measures developed under paragraph (1) to assess such home and community-based services, the outcomes associated with the receipt of such services (particularly with respect to the health and welfare of the recipient of the services), and the overall system for providing home and community-based services under the Medicaid program under title XIX of the Social Security Act [
"(B) make publicly available the best practices identified through such assessment and a comparative analyses of the system features of each State.
"(3)
Permitting Adjustment in Estimates To Take Into Account Preadmission Screening Requirement
Extensions of Waivers Under Subsection (c)
1 So in original. Probably should be preceded by "the".
2 So in original. Probably should be "a".
3 So in original. Probably should be followed by a period.
§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 subsections (g), (i), and (j), 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));
(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, and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in
(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
(F) any in vitro diagnostic product described in
(G) COVID–19 testing-related services for which payment may be made under the State plan,
(H) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(I) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(J) vaccines described 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, and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in
(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
(F) any in vitro diagnostic product described in
(G) COVID–19 testing-related services for which payment may be made under the State plan,
(H) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(I) during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(J) vaccines described 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) and
(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)) 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
(h) Indexing nominal cost sharing
In applying this section and subsections (c) and (e) of
(i) State option to impose income-related premiums for families of disabled children
(1) With respect to disabled children provided medical assistance under
(2) A premium requirement imposed under paragraph (1) may only apply to the extent that—
(A) in the case of a disabled child described in that paragraph whose family income—
(i) does not exceed 200 percent of the poverty line, the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under
(ii) exceeds 200, but does not exceed 300, percent of the poverty line, the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under
(B) the requirement is imposed consistent with
(3) A State shall not require prepayment of a premium imposed pursuant to paragraph (1) and shall not terminate eligibility of a child under
(j) No premiums or cost sharing for Indians furnished items or services directly by Indian health programs or through referral under contract health services
(1) No cost sharing for items or services furnished to Indians through Indian health programs
(A) In general
No enrollment fee, premium, or similar charge, and no deduction, copayment, cost sharing, or similar charge shall be imposed against an Indian who is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services for which payment may be made under this subchapter.
(B) No reduction in amount of payment to Indian health providers
Payment due under this subchapter to the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or a health care provider through referral under contract health services for the furnishing of an item or service to an Indian who is eligible for assistance under such subchapter, may not be reduced by the amount of any enrollment fee, premium, or similar charge, or any deduction, copayment, cost sharing, or similar charge that would be due from the Indian but for the operation of subparagraph (A).
(2) Rule of construction
Nothing in this subsection shall be construed as restricting the application of any other limitations on the imposition of premiums or cost sharing that may apply to an individual receiving medical assistance under this subchapter who is an Indian.
(Aug. 14, 1935, ch. 531, title XIX, §1916, as added
Editorial Notes
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
2022—Subsec. (a)(2)(G).
Subsec. (a)(2)(J).
Subsec. (b)(2)(G).
Subsec. (b)(2)(J).
2021—Subsecs. (a)(2)(H), (I), (b)(2)(H), (I).
2020—Subsecs. (a)(2)(F), (G), (b)(2)(F), (G).
2010—Subsecs. (a)(2)(B), (b)(2)(B).
2009—Subsec. (a).
Subsec. (j).
2006—Subsec. (a).
Subsec. (f).
Subsec. (h).
Subsec. (i).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2022 Amendment
Amendment by
Effective Date of 2010 Amendment
Amendment by
Effective Date of 2009 Amendment
Amendment by
Effective Date of 2006 Amendment
Amendment by section 6062(b) of
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
Amendment by section 4211(h)(11) of
Effective Date of 1986 Amendment
Amendment by
Amendment by
Effective Date of 1983 Amendment
Amendment by
Effective Date
"(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 [
Applicability of 2020 Amendment to Territories
§1396o–1. State option for alternative premiums and cost sharing
(a) State flexibility
(1) In general
Notwithstanding
(2) Exemption for individuals with family income not exceeding 100 percent of the poverty line
(A) In general
Paragraph (1) and subsection (d) shall not apply, and
(B) Limit on aggregate cost sharing
To the extent cost sharing under subsections (c) and (e) or under
(3) Definitions
In this section:
(A) Premium
The term "premium" includes any enrollment fee or similar charge.
(B) Cost sharing
The term "cost sharing" includes any deduction, copayment, or similar charge.
(b) Limitations on exercise of authority
(1) Individuals with family income between 100 and 150 percent of the poverty line
In the case of an individual whose family income exceeds 100 percent, but does not exceed 150 percent, of the poverty line applicable to a family of the size involved—
(A) no premium may be imposed under the plan; and
(B) with respect to cost sharing—
(i) the cost sharing imposed under subsection (a) with respect to any item or service may not exceed 10 percent of the cost of such item or service; and
(ii) the total aggregate amount of cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State).
(2) Individuals with family income above 150 percent of the poverty line
In the case of an individual whose family income exceeds 150 percent of the poverty line applicable to a family of the size involved—
(A) the total aggregate amount of premiums and cost sharing imposed under this section (including any cost sharing imposed under subsection (c) or (e)) for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis (as specified by the State); and
(B) with respect to cost sharing, the cost sharing imposed with respect to any item or service under subsection (a) may not exceed 20 percent of the cost of such item or service.
(3) Additional limitations
(A) Premiums
No premiums shall be imposed under this section with respect to the following:
(i) Individuals under 18 years of age that are required to be provided medical assistance under
(ii) Pregnant women.
(iii) Any terminally ill individual who is receiving hospice care (as defined in
(iv) 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 the individual's income required for personal needs.
(v) Women who are receiving medical assistance by virtue of the application of
(vi) Disabled children who are receiving medical assistance by virtue of the application of
(vii) An Indian who is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization or Urban Indian Organization or through referral under contract health services.
(B) Cost sharing
Subject to the succeeding provisions of this section, no cost sharing shall be imposed under subsection (a) with respect to the following:
(i) Services furnished to individuals under 18 years of age that are required to be provided medical assistance under
(ii) Preventive services (such as well baby and well child care and immunizations) provided to children under 18 years of age regardless of family income.
(iii) Services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy, and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in
(iv) Services furnished to a terminally ill individual who is receiving hospice care (as defined in
(v) 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 the individual's income required for personal needs.
(vi) Emergency services (as defined by the Secretary for purposes of
(vii) Family planning services and supplies described in
(viii) Services furnished to women who are receiving medical assistance by virtue of the application of
(ix) Services furnished to disabled children who are receiving medical assistance by virtue of the application of
(x) Items and services furnished to an Indian directly by the Indian Health Service, an Indian Tribe, Tribal Organization or Urban Indian Organization or through referral under contract health services.
(xi) Any in vitro diagnostic product described in
(xii) During the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(xiii) During the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(xiv) Vaccines described in
(C) Construction
Nothing in this paragraph shall be construed as preventing a State from exempting additional classes of individuals from premiums under this section or from exempting additional individuals or services from cost sharing under subsection (a).
(4) Determinations of family income
In applying this subsection, family income shall be determined in a manner specified by the State for purposes of this subsection, including the use of such disregards as the State may provide. Family income shall be determined for such period and at such periodicity as the State may provide under this subchapter.
(5) Poverty line defined
For purposes of this section, the term "poverty line" has the meaning given such term in
(6) Construction
Nothing in this section shall be construed—
(A) as preventing a State from further limiting the premiums and cost sharing imposed under this section beyond the limitations provided under this section;
(B) as affecting the authority of the Secretary through waiver to modify limitations on premiums and cost sharing under this section; or
(C) as affecting any such waiver of requirements in effect under this subchapter before February 8, 2006, with regard to the imposition of premiums and cost sharing.
(c) Special rules for cost sharing for prescription drugs
(1) In general
In order to encourage beneficiaries to use drugs (in this subsection referred to as "preferred drugs") identified by the State as the most (or more) cost effective prescription drugs within a class of drugs (as defined by the State), with respect to one or more groups of beneficiaries specified by the State, subject to paragraph (2), the State may—
(A) provide cost sharing (instead of the level of cost sharing otherwise permitted under
(B) waive or reduce the cost sharing otherwise applicable for preferred drugs within such class and shall not apply any such cost sharing for such preferred drugs for individuals for whom cost sharing may not be imposed under subsection (a) due to the application of subsection (b)(3)(B).
(2) Limitations
(A) By income group
In no case may the cost sharing under paragraph (1)(A) with respect to a non-preferred drug exceed—
(i) in the case of an individual whose family income does not exceed 150 percent of the poverty line applicable to a family of the size involved, the amount of nominal cost sharing (as otherwise determined under
(ii) in the case of an individual whose family income exceeds 150 percent of the poverty line applicable to a family of the size involved, 20 percent of the cost of the drug.
(B) Limitation to nominal for exempt populations
In the case of an individual who is not subject to cost sharing under subsection (a) due to the application of paragraph (1)(B), any cost sharing under paragraph (1)(A) with respect to a non-preferred drug may not exceed a nominal amount (as otherwise determined under
(C) Continued application of aggregate cap
In addition to the limitations imposed under subparagraphs (A) and (B), any cost sharing under paragraph (1)(A) continues to be subject to the aggregate cap on cost sharing applied under subsection (a)(2)(B) or under paragraph (1) or (2) of subsection (b), as the case may be.
(3) Waiver
In carrying out paragraph (1), a State shall provide for the application of cost sharing levels applicable to a preferred drug in the case of a drug that is not a preferred drug if the prescribing physician determines that the preferred drug for treatment of the same condition either would not be as effective for the individual or would have adverse effects for the individual or both.
(4) Exclusion authority
Nothing in this subsection shall be construed as preventing a State from excluding specified drugs or classes of drugs from the application of paragraph (1).
(d) Enforceability of premiums and other cost sharing
(1) Premiums
Notwithstanding
(2) Cost sharing
Notwithstanding
(e) State option for permitting hospitals to impose cost sharing for non-emergency care furnished in an emergency department
(1) In general
Notwithstanding
(A) Access to non-emergency room provider
The individual has actually available and accessible (as such terms are applied by the Secretary under
(B) Notice
The hospital must inform the beneficiary after receiving an appropriate medical screening examination under
(i) The hospital may require the payment of the State specified cost sharing before the service can be provided.
(ii) The name and location of an alternate non-emergency services provider (described in subparagraph (A)) that is actually available and accessible (as described in such subparagraph).
(iii) The fact that such alternate provider can provide the services without the imposition of cost sharing described in clause (i).
(iv) The hospital provides a referral to coordinate scheduling of this treatment.
Nothing in this subsection shall be construed as preventing a State from applying (or waiving) cost sharing otherwise permissible under this section to services described in clause (iii).
(2) Limitations
(A) Individuals with family income between 100 and 150 percent of the poverty line
In the case of an individual described in subsection (b)(1) who is not described in subparagraph (B), the cost sharing imposed under this subsection may not exceed twice the amount determined to be nominal under
(B) Application to exempt populations
In the case of an individual described in subsection (a)(2)(A) or who is not subject to cost sharing under subsection (b)(3)(B) with respect to non-emergency services described in paragraph (1), a State may impose cost sharing under paragraph (1) for care in an amount that does not exceed a nominal amount (as otherwise determined under
(C) Continued application of aggregate cap; relation to other cost sharing
In addition to the limitations imposed under subparagraphs (A) and (B), any cost sharing under paragraph (1) is subject to the aggregate cap on cost sharing applied under subsection (a)(2)(B) or under paragraph (1) or (2) of subsection (b), as the case may be. Cost sharing imposed for services under this subsection shall be instead of any cost sharing that may be imposed for such services under subsection (a) or
(3) Construction
Nothing in this section shall be construed—
(A) to limit a hospital's obligations with respect to screening and stabilizing treatment of an emergency medical condition under
(B) to modify any obligations under either State or Federal standards relating to the application of a prudent-layperson standard with respect to payment or coverage of emergency services by any managed care organization.
(4) Definitions
For purposes of this subsection:
(A) Non-emergency services
The term "non-emergency services" means any care or services furnished in an emergency department of a hospital that do not constitute an appropriate medical screening examination or stabilizing examination and treatment required to be provided by the hospital under
(B) Alternate non-emergency services provider
The term "alternative non-emergency services provider" means, with respect to non-emergency services for the diagnosis or treatment of a condition, a health care provider, such as a physician's office, health care clinic, community health center, hospital outpatient department, or similar health care provider, that can provide clinically appropriate services for the diagnosis or treatment of a condition contemporaneously with the provision of the non-emergency services that would be provided in an emergency department of a hospital for the diagnosis or treatment of a condition, and that is participating in the program under this subchapter.
(Aug. 14, 1935, ch. 531, title XIX, §1916A, as added and amended
Editorial Notes
Amendments
2022—Subsec. (b)(3)(B)(xiv).
2021—Subsec. (b)(3)(B)(xi).
Subsec. (b)(3)(B)(xii), (xiii).
2020—Subsec. (b)(3)(B)(xi).
2010—Subsec. (a)(1).
Subsec. (b)(3)(B)(iii).
2009—Subsec. (b)(3)(A)(vii).
Subsec. (b)(3)(B)(x).
2006—Subsec. (a)(1).
Subsec. (a)(2), (3).
Subsec. (b)(1), (2).
Subsec. (b)(3)(A)(i).
Subsec. (b)(3)(A)(vi).
Subsec. (b)(3)(B)(i).
Subsec. (b)(3)(B)(ix).
Subsec. (c).
Subsec. (c)(1).
Subsec. (c)(1)(B).
Subsec. (c)(2)(B).
Subsec. (c)(2)(C).
Subsec. (e).
Subsec. (e)(2)(A).
Subsec. (e)(2)(B).
Subsec. (e)(2)(C).
Subsec. (e)(4)(A).
Statutory Notes and Related Subsidiaries
Effective Date of 2022 Amendment
Amendment by
Effective Date of 2010 Amendment
Amendment by section 4107(c)(2) of
Effective Date of 2009 Amendment
Amendment by
Effective Date of 2006 Amendment
Amendment by section 6043(a) of
Effective Date
Section applicable to cost sharing imposed for items and services furnished on or after Mar. 31, 2006, see section 6041(c) of
Applicability of 2020 Amendment to Territories
Amendment by
§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) 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), 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 (but not including medical assistance for medicare cost-sharing or for benefits described in
(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, and which satisfies clause (iv), or which has a State plan amendment that provides for a qualified State long-term care insurance partnership (as defined in clause (iii)) 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.
(iii) For purposes of this paragraph, the term "qualified State long-term care insurance partnership" means an approved State plan amendment under this subchapter that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a long-term care insurance policy if the following requirements are met:
(I) The policy covers an insured who was a resident of such State when coverage first became effective under the policy.
(II) The policy is a qualified long-term care insurance policy (as defined in section 7702B(b) of the Internal Revenue Code of 1986) issued not earlier than the effective date of the State plan amendment.
(III) The policy meets the model regulations and the requirements of the model Act specified in paragraph (5).
(IV) If the policy is sold to an individual who—
(aa) has not attained age 61 as of the date of purchase, the policy provides compound annual inflation protection;
(bb) has attained age 61 but has not attained age 76 as of such date, the policy provides some level of inflation protection; and
(cc) has attained age 76 as of such date, the policy may (but is not required to) provide some level of inflation protection.
(V) The State Medicaid agency under
(VI) The issuer of the policy provides regular reports to the Secretary, in accordance with regulations of the Secretary, that include notification regarding when benefits provided under the policy have been paid and the amount of such benefits paid, notification regarding when the policy otherwise terminates, and such other information as the Secretary determines may be appropriate to the administration of such partnerships.
(VII) The State does not impose any requirement affecting the terms or benefits of such a policy unless the State imposes such requirement on long-term care insurance policies without regard to whether the policy is covered under the partnership or is offered in connection with such a partnership.
In the case of a long-term care insurance policy which is exchanged for another such policy, subclause (I) shall be applied based on the coverage of the first such policy that was exchanged. For purposes of this clause and paragraph (5), the term "long-term care insurance policy" includes a certificate issued under a group insurance contract.
(iv) With respect to a State which had a State plan amendment approved as of May 14, 1993, such a State satisfies this clause for purposes of clause (ii) if the Secretary determines that the State plan amendment provides for consumer protection standards which are no less stringent than the consumer protection standards which applied under such State plan amendment as of December 31, 2005.
(v) The regulations of the Secretary required under clause (iii)(VI) shall be promulgated after consultation with the National Association of Insurance Commissioners, issuers of long-term care insurance policies, States with experience with long-term care insurance partnership plans, other States, and representatives of consumers of long-term care insurance policies, and shall specify the type and format of the data and information to be reported and the frequency with which such reports are to be made. The Secretary, as appropriate, shall provide copies of the reports provided in accordance with that clause to the State involved.
(vi) The Secretary, in consultation with other appropriate Federal agencies, issuers of long-term care insurance, the National Association of Insurance Commissioners, State insurance commissioners, States with experience with long-term care insurance partnership plans, other States, and representatives of consumers of long-term care insurance policies, shall develop recommendations for Congress to authorize and fund a uniform minimum data set to be reported electronically by all issuers of long-term care insurance policies under qualified State long-term care insurance partnerships to a secure, centralized electronic query and report-generating mechanism that the State, the Secretary, and other Federal agencies can access.
(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) 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), 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)(A) 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.
(B) The standards specified by the Secretary under subparagraph (A) shall require that the procedures established by the State agency under subparagraph (A) exempt income, resources, and property that are exempt from the application of this subsection as of April 1, 2003, under manual instructions issued to carry out this subsection (as in effect on such date) because of the Federal responsibility for Indian Tribes and Alaska Native Villages. Nothing in this subparagraph shall be construed as preventing the Secretary from providing additional estate recovery exemptions under this subchapter for Indians.
(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.
(5)(A) For purposes of clause (iii)(III), the model regulations and the requirements of the model Act specified in this paragraph are:
(i) In the case of the model regulation, the following requirements:
(I) Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the model Act relating to such section 6A.
(II) Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.
(III) Section 6C (relating to extension of benefits).
(IV) Section 6D (relating to continuation or conversion of coverage).
(V) Section 6E (relating to discontinuance and replacement of policies).
(VI) Section 7 (relating to unintentional lapse).
(VII) Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.
(VIII) Section 9 (relating to required disclosure of rating practices to consumer).
(IX) Section 11 (relating to prohibitions against post-claims underwriting).
(X) Section 12 (relating to minimum standards).
(XI) Section 14 (relating to application forms and replacement coverage).
(XII) Section 15 (relating to reporting requirements).
(XIII) Section 22 (relating to filing requirements for marketing).
(XIV) Section 23 (relating to standards for marketing), including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C.
(XV) Section 24 (relating to suitability).
(XVI) Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).
(XVII) The provisions of section 26 relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in paragraph (4).
(XVIII) Section 29 (relating to standard format outline of coverage).
(XIX) Section 30 (relating to requirement to deliver shopper's guide).
(ii) In the case of the model Act, the following:
(I) Section 6C (relating to preexisting conditions).
(II) Section 6D (relating to prior hospitalization).
(III) The provisions of section 8 relating to contingent nonforfeiture benefits.
(IV) Section 6F (relating to right to return).
(V) Section 6G (relating to outline of coverage).
(VI) Section 6H (relating to requirements for certificates under group plans).
(VII) Section 6J (relating to policy summary).
(VIII) Section 6K (relating to monthly reports on accelerated death benefits).
(IX) Section 7 (relating to incontestability period).
(B) For purposes of this paragraph and paragraph (1)(C)—
(i) the terms "model regulation" and "model Act" mean the long-term care insurance model regulation, and the long-term care insurance model Act, respectively, promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000);
(ii) any provision of the model regulation or model Act listed under subparagraph (A) shall be treated as including any other provision of such regulation or Act necessary to implement the provision; and
(iii) with respect to a long-term care insurance policy issued in a State, the policy shall be deemed to meet applicable requirements of the model regulation or the model Act if the State plan amendment under paragraph (1)(C)(iii) provides that the State insurance commissioner for the State certifies (in a manner satisfactory to the Secretary) that the policy meets such requirements.
(C) Not later than 12 months after the National Association of Insurance Commissioners issues a revision, update, or other modification of a model regulation or model Act provision specified in subparagraph (A), or of any provision of such regulation or Act that is substantively related to a provision specified in such subparagraph, the Secretary shall review the changes made to the provision, determine whether incorporating such changes into the corresponding provision specified in such subparagraph would improve qualified State long-term care insurance partnerships, and if so, shall incorporate the changes into such provision.
(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) or in the case of any other disposal of assets made on or after February 8, 2006, 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)(i) In the case of a transfer of asset made before February 8, 2006, 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.
(ii) In the case of a transfer of asset made on or after February 8, 2006, the date specified in this subparagraph is the first day of a month during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care described in subparagraph (C) based on an approved application for such care but for the application of the penalty period, whichever is later, and which does not occur during any other period 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.
(iv) A State shall not round down, or otherwise disregard any fractional period of ineligibility determined under clause (i) or (ii) with respect to the disposal of assets.
(F) For purposes of this paragraph, the purchase of an annuity shall be treated as the disposal of an asset for less than fair market value unless—
(i) the State is named as the remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the institutionalized individual under this subchapter; or
(ii) the State is named as such a beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or a representative of such child disposes of any such remainder for less than fair market value.
(G) For purposes of this paragraph with respect to a transfer of assets, the term "assets" includes an annuity purchased by or on behalf of an annuitant who has applied for medical assistance with respect to nursing facility services or other long-term care services under this subchapter unless—
(i) the annuity is—
(I) an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue Code of 1986; or
(II) purchased with proceeds from—
(aa) an account or trust described in subsection (a), (c), or (p) of section 408 of such Code;
(bb) a simplified employee pension (within the meaning of section 408(k) of such Code); or
(cc) a Roth IRA described in section 408A of such Code; or
(ii) the annuity—
(I) is irrevocable and nonassignable;
(II) is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); and
(III) provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.
(H) Notwithstanding the preceding provisions of this paragraph, in the case of an individual (or individual's spouse) who makes multiple fractional transfers of assets in more than 1 month for less than fair market value on or after the applicable look-back date specified in subparagraph (B), a State may determine the period of ineligibility applicable to such individual under this paragraph by—
(i) treating the total, cumulative uncompensated value of all assets transferred by the individual (or individual's spouse) during all months on or after the look-back date specified in subparagraph (B) as 1 transfer for purposes of clause (i) or (ii) (as the case may be) of subparagraph (E); and
(ii) beginning such period on the earliest date which would apply under subparagraph (D) to any of such transfers.
(I) For purposes of this paragraph with respect to a transfer of assets, the term "assets" includes funds used to purchase a promissory note, loan, or mortgage unless such note, loan, or mortgage—
(i) has a repayment term that is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration);
(ii) provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and
(iii) prohibits the cancellation of the balance upon the death of the lender.
In the case of a promissory note, loan, or mortgage that does not satisfy the requirements of clauses (i) through (iii), the value of such note, loan, or mortgage shall be the outstanding balance due as of the date of the individual's application for medical assistance for services described in subparagraph (C).
(J) For purposes of this paragraph with respect to a transfer of assets, the term "assets" includes the purchase of a life estate interest in another individual's home unless the purchaser resides in the home for a period of at least 1 year after the date of the purchase.
(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) 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)) 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)) 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.
The procedures established under subparagraph (D) shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual with the consent of the individual or the personal representative of the individual. While an application for an undue hardship waiver is pending under subparagraph (D) in the case of an individual who is a resident of a nursing facility, if the application meets such criteria as the Secretary specifies, the State may provide for payments for nursing facility services in order to hold the bed for the individual at the facility, but not in excess of payments for 30 days.
(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).
(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); 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), 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) Disclosure and treatment of annuities
(1) In order to meet the requirements of this section for purposes of
(2)(A) In the case of disclosure concerning an annuity under subsection (c)(1)(F), the State shall notify the issuer of the annuity of the right of the State under such subsection as a preferred remainder beneficiary in the annuity for medical assistance furnished to the individual. Nothing in this paragraph shall be construed as preventing such an issuer from notifying persons with any other remainder interest of the State's remainder interest under such subsection.
(B) In the case of such an issuer receiving notice under subparagraph (A), the State may require the issuer to notify the State when there is a change in the amount of income or principal being withdrawn from the amount that was being withdrawn at the time of the most recent disclosure described in paragraph (1). A State shall take such information into account in determining the amount of the State's obligations for medical assistance or in the individual's eligibility for such assistance.
(3) The Secretary may provide guidance to States on categories of transactions that may be treated as a transfer of asset for less than fair market value.
(4) Nothing in this subsection shall be construed as preventing a State from denying eligibility for medical assistance for an individual based on the income or resources derived from an annuity described in paragraph (1).
(f) Disqualification for long-term care assistance for individuals with substantial home equity
(1)(A) Notwithstanding any other provision of this subchapter, subject to subparagraphs (B) and (C) of this paragraph and paragraph (2), in determining eligibility of an individual for medical assistance with respect to nursing facility services or other long-term care services, the individual shall not be eligible for such assistance if the individual's equity interest in the individual's home exceeds $500,000.
(B) A State may elect, without regard to the requirements of
(C) The dollar amounts specified in this paragraph shall be increased, beginning with 2011, from year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1,000.
(2) Paragraph (1) shall not apply with respect to an individual if—
(A) the spouse of such individual, or
(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) 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
is lawfully residing in the individual's home.
(3) Nothing in this subsection shall be construed as preventing an individual from using a reverse mortgage or home equity loan to reduce the individual's total equity interest in the home.
(4) The Secretary shall establish a process whereby paragraph (1) is waived in the case of a demonstrated hardship.
(g) Treatment of entrance fees of individuals residing in continuing care retirement communities
(1) In general
For purposes of determining an individual's eligibility for, or amount of, benefits under a State plan under this subchapter, the rules specified in paragraph (2) shall apply to individuals residing in continuing care retirement communities or life care communities that collect an entrance fee on admission from such individuals.
(2) Treatment of entrance fee
For purposes of this subsection, an individual's entrance fee in a continuing care retirement community or life care community shall be considered a resource available to the individual to the extent that—
(A) the individual has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the individual be insufficient to pay for such care;
(B) the individual is eligible for a refund of any remaining entrance fee when the individual dies or terminates the continuing care retirement community or life care community contract and leaves the community; and
(C) the entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.
(h) 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).
(5) The term "resources" has the meaning given such term in
(Aug. 14, 1935, ch. 531, title XIX, §1917, as added
Editorial Notes
References in Text
The Internal Revenue Code of 1986, referred to in subsecs. (b)(1)(C)(iii)(II) and (c)(1)(G)(i), is classified generally to Title 26, Internal Revenue Code.
Amendments
2018—Subsec. (a)(1)(A).
2016—Subsec. (d)(4)(A).
2013—Subsec. (a)(1)(A).
"(i) the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or
"(ii) rights acquired by or assigned to the State in accordance with
was repealed by
2009—Subsec. (b)(3).
2008—Subsec. (b)(1)(B)(ii).
2006—Subsec. (b)(1)(C)(ii).
Subsec. (b)(1)(C)(iii) to (vi).
Subsec. (b)(5).
Subsec. (c)(1)(B)(i).
Subsec. (c)(1)(D).
Subsec. (c)(1)(E)(iv).
Subsec. (c)(1)(F).
Subsec. (c)(1)(F)(i).
Subsec. (c)(1)(G).
Subsec. (c)(1)(H).
Subsec. (c)(1)(I).
Subsec. (c)(1)(J).
Subsec. (c)(2).
Subsec. (e).
Subsec. (f).
Subsec. (g).
Subsec. (h).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2018 Amendment
Effective Date of 2016 Amendment
Effective Date of 2009 Amendment
Amendment by
Effective Date of 2008 Amendment
Effective Date of 2006 Amendment
"(1)
"(2)
"(A) to medical assistance provided for services furnished before the date of enactment;
"(B) with respect to assets disposed of on or before the date of enactment of this Act; or
"(C) with respect to trusts established on or before the date of enactment of this Act.
"(3)
Effective Date of 1993 Amendment
"(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 [
"(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 [
"(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
Availability of Hardship Waivers
"(1) under which an undue hardship exists when application of the transfer of assets provision would deprive the individual—
"(A) of medical care such that the individual's health or life would be endangered; or
"(B) of food, clothing, shelter, or other necessities of life; and
"(2) which provides for—
"(A) notice to recipients that an undue hardship exception exists;
"(B) a timely process for determining whether an undue hardship waiver will be granted; and
"(C) a process under which an adverse determination can be appealed."
Expansion of State Long-Term Care Partnership Program
"(a)
"(1)
"(2)
"(3)
"(b)
"(1) benefits paid under such policies will be treated the same by all such States; and
"(2) States with such partnerships shall be subject to such standards unless the State notifies the Secretary in writing of the State's election to be exempt from such standards.
"(c)
"(1)
"(2)
"(d)
"(1)
"(2)
"(A)
"(i) educate consumers with respect to the availability and limitations of coverage for long-term care under the Medicaid program and provide contact information for obtaining State-specific information on long-term care coverage, including eligibility and estate recovery requirements under State Medicaid programs;
"(ii) provide objective information to assist consumers with the decisionmaking process for determining whether to purchase long-term care insurance or to pursue other private market alternatives for purchasing long-term care and provide contact information for additional objective resources on planning for long-term care needs; and
"(iii) maintain a list of States with State long-term care insurance partnerships under the Medicaid program that provide reciprocal recognition of long-term care insurance policies issued under such partnerships.
"(B)
"(3)
§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
Editorial Notes
Amendments
1994—
Statutory Notes and Related Subsidiaries
Effective Date of 1994 Amendment
Amendment by
Effective Date
§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).
(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);
(iii) uses an instrument which is specified by the State under subsection (e)(5); 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) 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), 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)) 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)) 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) 1 of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and the mentally retarded, and
(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), 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) 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) 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.
Such term includes an individual who provides such services through an agency or under a contract with the facility.
(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).
(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.
(8) Information on nurse staffing
(A) In general
A nursing facility shall post daily for each shift the current number of licensed and unlicensed nursing staff directly responsible for resident care in the facility. The information shall be displayed in a uniform manner (as specified by the Secretary) and in a clearly visible place.
(B) Publication of data
A nursing facility shall, upon request, make available to the public the nursing staff data described in subparagraph (A).
(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) 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);
(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 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 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);
(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 subtitle C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 [
(IV) in the case of mentally ill residents (as defined in subsection (e)(7)(G)(i)), 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 1 [
(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) (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, (II) subject to subparagraph (B)(v), 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, 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.
(v) Treatment of continuing care retirement communities admission contracts
Notwithstanding subclause (II) of subparagraph (A)(i), subject to subsections (c) and (d) of
(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.
(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).
(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)).
(B) Nursing facility administrator
The administrator of a nursing facility must meet standards established by the Secretary under subsection (f)(4).
(V) 2 Availability of survey, certification, and complaint investigation reports
A nursing facility must—
(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and
(ii) post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
The facility shall not make available under clause (i) identifying information about complainants or residents.
(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) and that meet the requirements established under subsection (f)(2), 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).
The failure of the Secretary to establish requirements under subsection (f)(2) 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) 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 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), 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) 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). Such instrument shall be—
(A) one of the instruments designated under subsection (f)(6)(B), 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).
(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)) described in subsection (b)(3)(F) 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) 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) 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))—
(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) 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),
(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), 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):
(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).
(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), 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 (including, in the case of initial training and, if the Secretary determines appropriate, in the case of ongoing training, dementia management training, and patient abuse prevention training 3, (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) 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 subparagraphs (C) and (D), 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) 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) 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) 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.
(D) Waiver of disapproval of nurse-aide training programs
Upon application of a nursing facility, the Secretary may waive the application of subparagraph (B)(iii)(I)(c) if the imposition of the civil monetary penalty was not related to the quality of care provided to residents of the facility. Nothing in this subparagraph shall be construed as eliminating any requirement upon a facility to pay a civil monetary penalty described in the preceding sentence.
(3) Federal guidelines for State appeals process for transfers and discharges
For purposes of subsections (c)(2)(B)(iii) and (e)(3), by not later than October 1, 1988, the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) 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), 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) 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), 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) for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii).
(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) 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) (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).
(10) Special focus facility program
(A) In general
The Secretary shall conduct a special focus facility program for enforcement of requirements for nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirements of this chapter.
(B) Periodic surveys
Under such program the Secretary shall conduct surveys of each facility in the program not less often than once every 6 months.
(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). 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) and an audit of the residents' assessments under subsection (b)(3) 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).
(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). 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) 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), 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), 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), 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), 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,
(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
(E) Submission of survey and certification information to the Secretary
In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.
(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) or otherwise, that a nursing facility no longer meets a requirement of subsection (b), (c), or (d), 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), 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). 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)) 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).
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).
(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), 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), 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),
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), 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), 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
(I) In general
Subject to subclause (II), the Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of
(II) Reduction of civil money penalties in certain circumstances
Subject to subclause (III), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent.
(III) Prohibitions on reduction for certain deficiencies
(aa) Repeat deficiencies
The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had reduced a penalty imposed on the facility in the preceding year under such subclause with respect to a repeat deficiency.
(bb) Certain other deficiencies
The Secretary may not reduce the amount of a penalty under subclause (II) if the penalty is imposed on the facility for a deficiency that is found to result in a pattern of harm or widespread harm, immediately jeopardizes the health or safety of a resident or residents of the facility, or results in the death of a resident of the facility.
(IV) Collection of civil money penalties
In the case of a civil money penalty imposed under this clause, the Secretary shall issue regulations that—
(aa) subject to item (cc), not later than 30 days after the imposition of the penalty, provide for the facility to have the opportunity to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty;
(bb) in the case where the penalty is imposed for each day of noncompliance, provide that a penalty may not be imposed for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed;
(cc) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty;
(dd) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals;
(ee) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and
(ff) in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities implementing quality assurance programs, the appointment of temporary management firms, and other activities approved by the Secretary).
(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).
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).
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), 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).
(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), and finds that the failure immediately jeopardizes the health or safety of its residents, the State or the Secretary, respectively 6 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).
(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), 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), 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), 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), (ii)(IV),7 (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.
(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, including investigations by State medicaid fraud control units.
(i) Nursing Home Compare website
(1) Inclusion of additional information
(A) In general
The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the "Nursing Home Compare" Medicare website) (or a successor website), the following information in a manner that is prominent, updated on a timely basis, easily accessible, readily understandable to consumers of long-term care services, and searchable:
(i) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under
(I) concise explanations of how to interpret the data (such as plain English explanation of data reflecting "nursing home staff hours per resident day");
(II) differences in types of staff (such as training associated with different categories of staff);
(III) the relationship between nurse staffing levels and quality of care; and
(IV) an explanation that appropriate staffing levels vary based on patient case mix.
(ii) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report. Any such links shall be posted on a timely basis.
(iii) The standardized complaint form developed under
(iv) Summary information on the number, type, severity, and outcome of substantiated complaints.
(v) The number of adjudicated instances of criminal violations by a facility or the employees of a facility—
(I) that were committed inside of the facility; and
(II) with respect to such instances of violations or crimes committed outside of the facility, that were violations or crimes that resulted in the serious bodily injury of an elder.
(B) Deadline for provision of information
(i) In general
Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after March 23, 2010.
(ii) Exception
The Secretary shall ensure that the information described in subparagraph (A)(i) is included on such website (or a successor website) not later than the date on which the requirements under
(2) Review and modification of website
(A) In general
The Secretary shall establish a process—
(i) to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before March 23, 2010; and
(ii) not later than 1 year after March 23, 2010, to modify or revamp such website in accordance with the review conducted under clause (i).
(B) Consultation
In conducting the review under subparagraph (A)(i), the Secretary shall consult with—
(i) State long-term care ombudsman programs;
(ii) consumer advocacy groups;
(iii) provider stakeholder groups;
(iv) skilled nursing facility employees and their representatives; and
(v) any other representatives of programs or groups the Secretary determines appropriate.
(j) Construction
Where requirements or obligations under this section are identical to those provided under
(k) Funding for State strike teams
In addition to amounts otherwise available, there is appropriated to the Secretary, out of any monies in the Treasury not otherwise appropriated, $250,000,000, to remain available until expended, for purposes of allocating such amount among the States (including the District of Columbia and each territory of the United States) for such a State to establish and implement a strike team that will be deployed to a nursing facility in the State with diagnosed or suspected cases of COVID–19 among residents or staff for the purposes of assisting with clinical care, infection control, or staffing during the emergency period described in
(Aug. 14, 1935, ch. 531, title XIX, §1919, as added and amended
Editorial Notes
References in Text
The Older Americans Act of 1965, referred to in subsecs. (b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is
The Developmental Disabilities Assistance and Bill of Rights Act of 2000, referred to in subsec. (c)(2)(B)(iii)(III), is
The Protection and Advocacy for Mentally Ill Individuals Act [of 1986], referred to in subsec. (c)(2)(B)(iii)(IV), was
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
2021—Subsec. (k).
2010—Subsec. (b)(5)(F).
Subsec. (d)(1)(B).
Subsec. (d)(1)(V).
Subsec. (f)(2)(A)(i)(I).
Subsec. (f)(10).
Subsec. (g)(5)(E).
Subsec. (h)(3)(C)(ii).
Subsec. (h)(8).
Subsecs. (i), (j).
2006—Subsec. (c)(5)(A)(i)(II).
Subsec. (c)(5)(B)(v).
2003—Subsec. (f)(2)(B)(iii).
Subsec. (f)(2)(D).
2000—Subsec. (b)(8).
Subsec. (c)(2)(B)(iii)(III).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
Amendment by section 6101(c)(1)(B) of
Amendment by section 6103(c)(2) of
Amendment by section 6111(b) of
Amendment by section 6121(b) of
Effective Date of 2006 Amendment
Effective Date of 2003 Amendment
Amendment by
Effective Date of 2000 Amendment
Amendment by
Effective Date of 1999 Amendment
Effective Date of 1997 Amendment
Effective Date of 1996 Amendment
Effective Date of 1992 Amendment
Amendment by
Amendment by
Effective Date of 1990 Amendment
Amendment by section 4751(b)(2) of
"(i) had its participation terminated under title XVIII of the Social Security Act [
"(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
"(A)
"(B)
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 Amendment
Amendment by
Amendment by section 303(a)(2) of
Except as specifically provided in section 411 of
Effective Date
"(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 [
"(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
Preadmission Screening and Annual Resident Review; Compliance Actions
Restriction on Enforcement Process
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
Evaluation and Report on Implementation of Resident Assessment Process
Report on Staffing Requirements
Annual Report on Statutory Compliance and Enforcement Actions
1 See References in Text note below.
2 So in original. There are no subpars. (C) to (U).
3 So in original. Probably should be followed by a closing parenthesis.
4 So in original. Probably should be "clause".
5 So in original. Probably should be "paragraph".
6 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 (
The term "qualified provider" also includes a qualified entity, as defined in
(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) 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
(e) Option to provide presumptive eligibility
If the State has elected the option to provide a presumptive eligibility period under this section or
(Aug. 14, 1935, ch. 531, title XIX, §1920, as added
Editorial Notes
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 1939 and is classified to
Amendments
2010—Subsec. (e).
2009—Subsec. (b).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
Amendment by section 2004(b) of
Effective Date of 2009 Amendment
Amendment by
Effective Date of 1990 Amendment
"(1) The amendments made by subsection (a) [amending this section] apply to payments under title XIX of the Social Security Act [
"(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
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
1 So in original. Probably means subsection (a)(10)(A) of
§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), (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 (2).
(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)(2) 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) 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
Editorial Notes
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 et seq.) of
The Stewart B. McKinney Homeless Assistance Act, referred to in subsec. (b)(3)(A)(i)(III), was
The United States Housing Act of 1937, referred to in subsec. (b)(3)(A)(i)(III), is act Sept. 1, 1937, ch. 896, as revised generally by
The Native American Housing Assistance and Self-Determination Act of 1996, referred to in subsec. (b)(3)(A)(i)(III), is
Amendments
2000—Subsec. (b)(3)(A)(i).
Subsec. (b)(3)(A)(ii).
Subsec. (c)(2).
1999—Subsec. (d)(1)(B).
1 So in original. A comma probably should appear after "title".
2 See References in Text note below.
§1396r–1b. Presumptive eligibility for certain breast or cervical cancer patients
(a) State option
A State plan approved under
(b) Definitions
For purposes of this section:
(1) Presumptive eligibility period
The term "presumptive eligibility period" means, with respect to an individual described in subsection (a), the period that—
(A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in
(B) ends with (and includes) the earlier of—
(i) the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or
(ii) in the case of such an individual who does not file an application 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.
(2) Qualified entity
(A) In general
Subject to subparagraph (B), the term "qualified entity" means any entity that—
(i) is eligible for payments under a State plan approved under this subchapter; and
(ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).
(B) Regulations
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) Rule of construction
Nothing in this paragraph 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) Administration
(1) In general
The State agency shall provide qualified entities with—
(A) such forms as are necessary for an application to be made by an individual described in subsection (a) for medical assistance under the State plan; and
(B) information on how to assist such individuals in completing and filing such forms.
(2) Notification requirements
A qualified entity that determines under subsection (b)(1)(A) that an individual described in subsection (a) 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 such individual 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) Application for medical assistance
In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply 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.
(d) Payment
Notwithstanding any other provision of this subchapter, medical assistance that—
(1) is furnished to an individual described in subsection (a)—
(A) during a presumptive eligibility period;
(B) by a 1 entity that is eligible for payments under the State plan; and
(2) is included in the care and services covered by the State plan,
shall be treated as medical assistance provided by such plan for purposes of clause (4) of the first sentence of
(Aug. 14, 1935, ch. 531, title XIX, §1920B, as added
Statutory Notes and Related Subsidiaries
Effective Date
Section applicable to medical assistance for items and services furnished on or after Oct. 1, 2000, without regard to whether final regulations to carry out such amendments have been promulgated by such date, see section 2(d) of
1 So in original. Probably should be "an".
§1396r–1c. Presumptive eligibility for family planning services
(a) State option
State 1 plan approved under
(b) Definitions
For purposes of this section:
(1) Presumptive eligibility period
The term "presumptive eligibility period" means, with respect to an individual described in subsection (a), the period that—
(A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in
(B) ends with (and includes) the earlier of—
(i) the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or
(ii) in the case of such an individual who does not file an application 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.
(2) Qualified entity
(A) In general
Subject to subparagraph (B), the term "qualified entity" means any entity that—
(i) is eligible for payments under a State plan approved under this subchapter; and
(ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).
(B) Rule of construction
Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse.
(c) Administration
(1) In general
The State agency shall provide qualified entities with—
(A) such forms as are necessary for an application to be made by an individual described in subsection (a) for medical assistance under the State plan; and
(B) information on how to assist such individuals in completing and filing such forms.
(2) Notification requirements
A qualified entity that determines under subsection (b)(1)(A) that an individual described in subsection (a) 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 such individual at the time the determination is made that an application for medical assistance 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) Application for medical assistance
In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance by not later than the last day of the month following the month during which the determination is made.
(d) Payment
Notwithstanding any other provision of law, medical assistance that—
(1) is furnished to an individual described in subsection (a)—
(A) during a presumptive eligibility period; and
(B) by a 3 entity that is eligible for payments under the State plan; and
(2) is included in the care and services covered by the State plan,
shall be treated as medical assistance provided by such plan for purposes of clause (4) of the first sentence of
(Aug. 14, 1935, ch. 531, title XIX, §1920C, as added
Statutory Notes and Related Subsidiaries
Effective Date
Section effective Mar. 23, 2010, and applicable to items and services furnished on or after such date, see section 2303(d) of
1 So in original. Probably should be preceded by "A".
2 So in original. Probably should be preceded by "section".
3 So in original. Probably should be "an".
§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
(A) Licensing or certification actions
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 a State licensing or certification agency:
(i) 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.
(ii) Any dismissal or closure of the proceedings by reason of the practitioner or entity surrendering the license or leaving the State or jurisdiction.
(iii) Any other loss of license or the right to apply for, or renew, a license by the practitioner or entity, whether by operation of law, voluntary surrender, nonrenewability, or otherwise.
(iv) Any negative action or finding by such authority, organization, or entity regarding the practitioner or entity.
(B) Other final adverse actions
The State must have in effect a system of reporting information with respect to any final adverse action (not including settlements in which no findings of liability have been made) taken against a health care provider, supplier, or practitioner by a State law or fraud enforcement agency.
(2) Access to documents
The State must provide the Secretary (or an entity designated by the Secretary) with access to such documents of a State licensing or certification agency or State law or fraud enforcement agency 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) 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 State licensing or certification agencies and Federal agencies responsible for the licensing and certification of health care providers, suppliers, and licensed health care practitioners; 1
(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 2 described in part B of subchapter XI and to appropriate entities with contracts under section 1320c–3(a)(4)(C) 3 of this title with respect to eligible organizations reviewed under the contracts, but only with respect to information provided pursuant to subsection (a)(1)(A),
(5) to State law or fraud enforcement agencies,
(6) to hospitals and other health care entities (as defined in section 431 of the Health Care Quality Improvement Act of 1986 [
(7) to health plans (as defined in
(8) to the Attorney General and such other law enforcement officials as the Secretary deems appropriate, and
(9) 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). 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) Disclosure and correction of information
(1) Disclosure
With respect to information reported pursuant to subsection (a)(1), the Secretary shall—
(A) provide for disclosure of the information, upon request, to the health care practitioner who, or the entity that, is the subject of the information reported; and
(B) establish procedures for the case where the health care practitioner or entity disputes the accuracy of the information reported.
(2) Corrections
Each State licensing or certification agency and State law or fraud enforcement agency shall report corrections of information already reported about any formal proceeding or final adverse action described in subsection (a), in such form and manner as the Secretary prescribes by regulation.
(e) Fees for disclosure
The Secretary may establish or approve reasonable fees for the disclosure of information under this section. The amount of such a fee may not exceed the costs of processing the requests for disclosure and of providing such information. Such fees shall be available to the Secretary to cover such costs.
(f) Protection from liability for reporting
No person or entity, including any agency designated by the Secretary in subsection (b), shall be held liable in any civil action with respect to any reporting of information as required under this section, without knowledge of the falsity of the information contained in the report.
(g) References
For purposes of this section:
(1) State licensing or certification agency
The term "State licensing or certification agency" includes any authority of a 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.
(2) State law or fraud enforcement agency
The term "State law or fraud enforcement agency" includes—
(A) a State law enforcement agency; and
(B) a State medicaid fraud control unit (as defined in
(3) Final adverse action
(A) In general
Subject to subparagraph (B), the term "final adverse action" includes—
(i) civil judgments against a health care provider, supplier, or practitioner in State court related to the delivery of a health care item or service;
(ii) State criminal convictions related to the delivery of a health care item or service;
(iii) exclusion from participation in State health care programs (as defined in
(iv) any licensing or certification action described in subsection (a)(1)(A) taken against a supplier by a State licensing or certification agency; and
(v) any other adjudicated actions or decisions that the Secretary shall establish by regulation.
(B) Exception
Such term does not include any action with respect to a malpractice claim.
(h) Appropriate coordination
In implementing this section, the Secretary shall provide for the maximum appropriate coordination with part B of the Health Care Quality Improvement Act of 1986 (
(Aug. 14, 1935, ch. 531, title XIX, §1921, as added
Editorial Notes
References in Text
The Health Care Quality Improvement Act of 1986 and that Act, referred to in subsecs. (b)(6) and (h), are title IV of
Prior Provisions
A prior section 1921 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2010—Subsec. (a)(1).
Subsec. (a)(1)(A)(iii).
Subsec. (a)(1)(B).
Subsec. (a)(2).
Subsec. (b)(2).
Subsec. (b)(4).
Subsec. (b)(5).
Subsec. (b)(6).
Subsec. (b)(7) to (9).
Subsecs. (d) to (g).
Subsec. (h).
1990—Subsec. (a)(1).
Subsec. (a)(1)(D).
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
Amendment by
Effective Date of 1990 Amendment
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
1 So in original. The semicolon probably should be a comma.
2 So in original. Probably should be "to quality improvement organizations".
3 See References in Text note below.
§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), 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) 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)) 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)) 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), determines that the State has substantially failed to correct the deficiencies described in subsection (a), 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), 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), 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
Editorial Notes
Prior Provisions
A prior section 1922 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
1988—Subsec. (a).
Subsec. (c)(5).
Subsec. (e)(1), (2)(A).
Subsec. (f).
Statutory Notes and Related Subsidiaries
Effective Date of 1988 Amendment
Except as specifically provided in section 411 of
Effective Date
"(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 [
Regulations
"(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
§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) which meets the requirements of subsection (d)), 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).
(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), a hospital which meets the requirements of subsection (d) 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 (regardless of whether such patients receive medical assistance on a fee-for-service basis or through a managed care entity), 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 (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) 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), 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)) 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)) 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)); 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), 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 such paragraph (2)(A)). In the case of a hospital described in subsection (d)(2)(A)(i) (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 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) (other than the last sentence of subsection (c)) 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) shall apply to hospitals located in urban areas, as well as in rural areas,
(C) subsection (d)(3) shall apply, and
(D) subsection (g) shall apply.
(f) Limitation on Federal financial participation
(1) In general
Payment under
(2) State DSH allotments for fiscal years 1998 through 2002
Subject to paragraph (4), 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 | 49 | 49 | 49 |
| 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
Except as provided in paragraphs (6), (7), and (8) and subparagraphs (E) and (F), 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 subparagraphs (B) and (C) and paragraph (5), 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.
(C) Special, temporary increase in allotments on a one-time, non-cumulative basis
The DSH allotment for any State (other than a State with a DSH allotment determined under paragraph (5))—
(i) for fiscal year 2004 is equal to 116 percent of the DSH allotment for the State for fiscal year 2003 under this paragraph, notwithstanding subparagraph (B); and
(ii) for each succeeding fiscal year is equal to the DSH allotment for the State for fiscal year 2004 or, in the case of fiscal years beginning with the fiscal year specified in subparagraph (D) for that State, the DSH allotment for the State for the previous fiscal year increased by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.
(D) Fiscal year specified
For purposes of subparagraph (C)(ii), the fiscal year specified in this subparagraph for a State is the first fiscal year for which the Secretary estimates that the DSH allotment for that State will equal (or no longer exceed) the DSH allotment for that State under the law as in effect before December 8, 2003.
(E) Temporary increase in allotments during recession
(i) In general
Subject to clause (ii), the DSH allotment for any State—
(I) for fiscal year 2009 is equal to 102.5 percent of the DSH allotment that would be determined under this paragraph for the State for fiscal year 2009 without application of this subparagraph, notwithstanding subparagraphs (B) and (C);
(II) for fiscal year 2010 is equal to 102.5 percent of the DSH allotment for the State for fiscal year 2009, as determined under subclause (I); and
(III) for each succeeding fiscal year is equal to the DSH allotment for the State under this paragraph determined without applying subclauses (I) and (II).
(ii) Application
Clause (i) shall not apply to a State for a year in the case that the DSH allotment for such State for such year under this paragraph determined without applying clause (i) would grow higher than the DSH allotment specified under clause (i) for the State for such year.
(F) Allotments during the coronavirus temporary medicaid FMAP increase
(i) In general
Notwithstanding any other provision of this subsection, for any fiscal year for which the Federal medical assistance percentage applicable to expenditures under this section is increased pursuant to section 6008 of the Families First Coronavirus Response Act, the Secretary shall recalculate the annual DSH allotment, including the DSH allotment specified under paragraph (6)(A)(vi), to ensure that the total DSH payments (including both Federal and State shares) that a State may make related to a fiscal year is equal to the total DSH payments that the State could have made for such fiscal year without such increase to the Federal medical assistance percentage.
(ii) No application to allotments beginning after COVID–19 emergency period
The DSH allotment for any State for the first fiscal year beginning after the end of the emergency period described in
(4) Special rule for fiscal years 2001 and 2002
(A) In general
Notwithstanding paragraph (2), the DSH allotment for any State for—
(i) fiscal year 2001, shall be the DSH allotment determined under paragraph (2) for fiscal year 2000 increased, subject to subparagraph (B) and paragraph (5), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average) for fiscal year 2000; and
(ii) fiscal year 2002, shall be the DSH allotment determined under clause (i) increased, subject to subparagraph (B) and paragraph (5), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average) for fiscal year 2001.
(B) Limitation
Subparagraph (B) of paragraph (3) shall apply to subparagraph (A) of this paragraph in the same manner as that subparagraph (B) applies to paragraph (3)(A).
(C) No application to allotments after fiscal year 2002
The DSH allotment for any State for fiscal year 2003 or any succeeding fiscal year shall be determined under paragraph (3) without regard to the DSH allotments determined under subparagraph (A) of this paragraph.
(5) Special rule for low DSH States
(A) For fiscal years 2001 through 2003 for extremely low DSH States
In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 1999, as reported to the Administrator of the Health Care Financing Administration as of August 31, 2000, is greater than 0 but less than 1 percent of the State's total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for fiscal year 2001 shall be increased to 1 percent of the State's total amount of expenditures under such plan for such assistance during such fiscal year. In subsequent fiscal years before fiscal year 2004, such increased allotment is subject to an increase for inflation as provided in paragraph (3)(A).
(B) For fiscal year 2004 and subsequent fiscal years
In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 2000, as reported to the Administrator of the Centers for Medicare & Medicaid Services as of August 31, 2003, is greater than 0 but less than 3 percent of the State's total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for the State with respect to—
(i) fiscal year 2004 shall be the DSH allotment for the State for fiscal year 2003 increased by 16 percent;
(ii) each succeeding fiscal year before fiscal year 2009 shall be the DSH allotment for the State for the previous fiscal year increased by 16 percent; and
(iii) fiscal year 2009 and any subsequent fiscal year, shall be the DSH allotment for the State for the previous year subject to an increase for inflation as provided in paragraph (3)(A).
(6) Allotment adjustments
(A) Tennessee
(i) In general
Only with respect to fiscal year 2007, the DSH allotment for Tennessee for such fiscal year, notwithstanding the table set forth in paragraph (2) or the terms of the TennCare Demonstration Project in effect for the State, shall be the greater of—
(I) the amount that the Secretary determines is equal to the Federal medical assistance percentage component attributable to disproportionate share hospital payment adjustments for the demonstration year ending in 2006 that is reflected in the budget neutrality provision of the TennCare Demonstration Project; and
(II) $280,000,000.
Only with respect to fiscal years 2008, 2009, 2010, and 2011, the DSH allotment for Tennessee for the fiscal year, notwithstanding such table or terms, shall be the amount specified in the previous sentence for fiscal year 2007. Only with respect to fiscal year 2012 for the period ending on December 31, 2011, the DSH allotment for Tennessee for such portion of the fiscal year, notwithstanding such table or terms, shall be ¼ of the amount specified in the first sentence for fiscal year 2007.
(ii) Limitation on amount of payment adjustments eligible for Federal financial participation
Payment under
(iii) State plan amendment
The Secretary shall permit Tennessee to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children's hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals. For purposes of demonstrating budget neutrality under the TennCare Demonstration Project, payment adjustments made pursuant to a State plan amendment approved in accordance with this subparagraph shall be considered expenditures under such project.
(iv) Offset of Federal share of payment adjustments for fiscal years 2007 through 2011 and the first calendar quarter of fiscal year 2012 against Essential Access Hospital supplemental pool payments under the TennCare Demonstration Project
(I) The total amount of Essential Access Hospital supplemental pool payments that may be made under the TennCare Demonstration Project for fiscal year 2007, 2008, 2009, 2010, 2011, or for a period in fiscal year 2012 described in clause (i) shall be reduced on a dollar for dollar basis by the amount of any payments made under
(II) The sum of the total amount of payments made under
(v) Allotment for 2d, 3rd, and 4th quarters of fiscal year 2012 and for fiscal year 2013
Notwithstanding the table set forth in paragraph (2):
(I) 2d, 3rd, and 4th quarters of fiscal year 2012
In the case of a State that has a DSH allotment of $0 for the 2d, 3rd, and 4th quarters of fiscal year 2012, the DSH allotment shall be $47,200,000 for such quarters.
(II) Fiscal year 2013
In the case of a State that has a DSH allotment of $0 for fiscal year 2013, the DSH allotment shall be $53,100,000 for such fiscal year.
(vi) Allotment for fiscal years 2015 through 2025
Notwithstanding any other provision of this subsection, any other provision of law, or the terms of the TennCare Demonstration Project in effect for the State, the DSH allotment for Tennessee for fiscal year 2015, and for each fiscal year thereafter through fiscal year 2025, shall be $53,100,000 for each such fiscal year.
(B) Hawaii
(i) In general
Only with respect to each of fiscal years 2007 through 2011, the DSH allotment for Hawaii for such fiscal year, notwithstanding the table set forth in paragraph (2), shall be $10,000,000. Only with respect to fiscal year 2012 for the period ending on December 31, 2011, the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $2,500,000.
(ii) State plan amendment
The Secretary shall permit Hawaii to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children's hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals.
(iii) Allotment for 2d, 3rd, and 4th quarter of fiscal year 2012, fiscal year 2013, and succeeding fiscal years
Notwithstanding the table set forth in paragraph (2):
(I) 2d, 3rd, and 4th quarter of fiscal year 2012
The DSH allotment for Hawaii for the 2d, 3rd, and 4th quarters of fiscal year 2012 shall be $7,500,000.
(II) Treatment as a low-DSH State for fiscal year 2013 and succeeding fiscal years
With respect to fiscal year 2013, and each fiscal year thereafter, the DSH allotment for Hawaii shall be increased in the same manner as allotments for low DSH States are increased for such fiscal year under clause (iii) of paragraph (5)(B).
(III) Certain hospital payments
The Secretary may not impose a limitation on the total amount of payments made to hospitals under the QUEST section 1115 Demonstration Project except to the extent that such limitation is necessary to ensure that a hospital does not receive payments in excess of the amounts described in subsection (g), or as necessary to ensure that such payments under the waiver and such payments pursuant to the allotment provided in this clause do not, in the aggregate in any year, exceed the amount that the Secretary determines is equal to the Federal medical assistance percentage component attributable to disproportionate share hospital payment adjustments for such year that is reflected in the budget neutrality provision of the QUEST Demonstration Project.
(7) Medicaid DSH reductions
(A) Reductions
(i) In general
For each of fiscal years 2026 through 2028, the Secretary shall effect the following reductions:
(I) Reduction in DSH allotments
The Secretary shall reduce DSH allotments to States in the amount specified under the DSH health reform methodology under subparagraph (B) for the State for the fiscal year.
(II) Reductions in payments
The Secretary shall reduce payments to States under
(ii) Aggregate reductions
The aggregate reductions in DSH allotments for all States under clause (i)(I) shall be equal to $8,000,000,000 for each of fiscal years 2026 through 2028.
(iii) Manner of payment reduction
The amount of the payment reduction under clause (i)(II) for a State for a quarter shall be deemed an overpayment to the State under this subchapter to be disallowed against the State's regular quarterly draw for all spending under
(iv) Definition
In this paragraph, the term "State" means the 50 States and the District of Columbia.
(v) Distribution of aggregate reductions
The Secretary shall distribute the aggregate reductions under clause (ii) among States in accordance with subparagraph (B).
(B) DSH Health Reform methodology
The Secretary shall carry out subparagraph (A) through use of a DSH Health Reform methodology that meets the following requirements:
(i) The methodology imposes the largest percentage reductions on the States that—
(I) have the lowest percentages of uninsured individuals (determined on the basis of data from the Bureau of the Census, audited hospital cost reports, and other information likely to yield accurate data) during the most recent year for which such data are available; or
(II) do not target their DSH payments on—
(aa) hospitals with high volumes of Medicaid inpatients (as defined in subsection (b)(1)(A)); and
(bb) hospitals that have high levels of uncompensated care (excluding bad debt).
(ii) The methodology imposes a smaller percentage reduction on low DSH States described in paragraph (5)(B).
(iii) The methodology takes into account the extent to which the DSH allotment for a State was included in the budget neutrality calculation for a coverage expansion approved under
(8) Calculation of DSH allotments after reductions period
The DSH allotment for a State for fiscal years after fiscal year 2027 shall be calculated under paragraph (3) without regard to paragraph (7).
(9) "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) In general
(A) Amount of adjustment subject to uncompensated costs
A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) with respect to a hospital (other than a hospital described in paragraph (2)(B)) if the payment adjustment exceeds an amount equal to—
(i) the costs incurred during the year of furnishing hospital services by the hospital to individuals described in subparagraph (B) minus—
(ii) the sum of—
(I) payments under this subchapter (other than under this section) for such services; and
(II) payments by uninsured patients for such services.
(B) Individuals described
For purposes of subparagraph (A), the individuals described in this clause are the following:
(i) Individuals who are eligible for medical assistance under the State plan or under a waiver of such plan and for whom the State plan or waiver is the primary payor for such services.
(ii) Subject to subparagraph (C), individuals who have no health insurance (or other source of third party coverage) for services provided during the year, as determined by the Secretary.
(C) Exclusion of certain payments
For purposes of subparagraph (B)(ii), 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 coverage.
(2) Application of limits for certain hospitals
(A) In general
A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) with respect to a hospital described in subparagraph (B) if the payment adjustment exceeds the higher of—
(i) the amount determined for the hospital and fiscal year under paragraph (1)(A); and
(ii) the amount determined for the hospital under paragraph (1)(A) as in effect on January 1, 2020.
(B) Hospitals described
A hospital is described in this subparagraph for a fiscal year if, for the most recent cost reporting period, the hospital is in at least the 97th percentile of all hospitals with respect to—
(i) the number of inpatient days for such period that were made up of patients who (for such days) were entitled to benefits under part A of subchapter XVIII and were entitled to supplemental security income benefits under subchapter XVI (excluding any State supplementary benefits paid with respect to such patients); or
(ii) the percentage of total inpatient days that were made up of patients who (for such days) were described in clause (i).
(3) Continued application of grandfathered transition rule
Notwithstanding paragraph (2) of this subsection (as in effect on October 1, 2021), paragraph (2) of this subsection (as in effect on September 30, 2021, and as applied under section 4721(e) of the Balanced Budget Act of 1997, and amended by section 607 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (
(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) 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) 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) 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.
(j) Annual reports and other requirements regarding payment adjustments
With respect to fiscal year 2004 and each fiscal year thereafter, the Secretary shall require a State, as a condition of receiving a payment under
(1) Report
The State shall submit an annual report that includes the following:
(A) An identification of each disproportionate share hospital that received a payment adjustment under this section for the preceding fiscal year and the amount of the payment adjustment made to such hospital for the preceding fiscal year.
(B) Such other information as the Secretary determines necessary to ensure the appropriateness of the payment adjustments made under this section for the preceding fiscal year.
(2) Independent certified audit
The State shall annually submit to the Secretary an independent certified audit that verifies each of the following:
(A) The extent to which hospitals in the State have reduced their uncompensated care costs to reflect the total amount of claimed expenditures made under this section.
(B) Payments under this section to hospitals that comply with the requirements of subsection (g).
(C) Only the uncompensated care costs of providing inpatient hospital and outpatient hospital services to individuals described in paragraph (1)(A) of such subsection are included in the calculation of the hospital-specific limits under such subsection.
(D) The State included all payments under this subchapter, including supplemental payments, in the calculation of such hospital-specific limits.
(E) The State has separately documented and retained a record of all of its costs under this subchapter, claimed expenditures under this subchapter, uninsured costs in determining payment adjustments under this section, and any payments made on behalf of the uninsured from payment adjustments under this section.
(Aug. 14, 1935, ch. 531, title XIX, §1923, formerly
Editorial Notes
References in Text
Section 6008 of the Families First Coronavirus Response Act, referred to in subsec. (f)(3)(F), is section 6008 of
Section 4721(e) of the Balanced Budget Act of 1997, and amended by section 607 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (
Codification
Prior to redesignation by
Prior Provisions
A prior section 1923 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2025—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(i)(I).
Subsec. (f)(7)(A)(i)(II).
Subsec. (f)(7)(A)(ii).
2024—Subsec. (f)(7)(A).
2023—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii).
2021—Subsec. (f)(3)(A).
Subsec. (f)(3)(F).
Subsec. (g)(3).
2020—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii).
"(I) $4,000,000,000 for the period beginning December 19, 2020, and ending September 30, 2021; and
"(II) $8,000,000,000 for each of fiscal years 2022 through 2025."
Subsec. (f)(7)(A)(ii)(I).
Subsec. (f)(7)(A)(ii)(II).
Subsec. (f)(8).
Subsec. (g).
2019—Subsec. (f)(7)(A).
Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii)(I).
2018—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii)(I) to (VIII).
2015—Subsec. (f)(6)(A)(vi).
Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii).
Subsec. (f)(7)(A)(v).
Subsec. (f)(8).
2014—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii)(I) to (VIII).
Subsec. (f)(8).
2013—Subsec. (f)(7)(A)(i).
Subsec. (f)(7)(A)(ii).
"(I) $500,000,000 for fiscal year 2014;
"(II) $600,000,000 for fiscal year 2015;".
Subsec. (f)(8).
Subsec. (f)(8)(C), (D).
2012—Subsec. (f)(3)(A).
Subsec. (f)(8), (9).
2010—Subsec. (f)(1).
Subsec. (f)(3)(A).
Subsec. (f)(6).
Subsec. (f)(6)(A)(v).
Subsec. (f)(6)(B)(iii).
Subsec. (f)(7).
Subsec. (f)(7)(A).
Subsec. (f)(7)(B)(i).
"(I) if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to 25 percent; and
"(II) if the State is any other State, the applicable percentage is 50 percent."
Subsec. (f)(7)(B)(ii).
"(I) if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to the product of the percentage reduction in uncovered individuals for the fiscal year from the preceding fiscal year and 25 percent; and
"(II) if the State is any other State, the applicable percentage is equal to the product of the percentage reduction in uncovered individuals for the fiscal year from the preceding fiscal year and 50 percent."
Subsec. (f)(7)(E).
Subsec. (f)(7)(G).
Subsec. (f)(8).
2009—Subsec. (f)(3)(A).
Subsec. (f)(3)(E).
Subsec. (f)(6).
Subsec. (f)(6)(A)(i).
Subsec. (f)(6)(A)(ii).
Subsec. (f)(6)(A)(iv).
Subsec. (f)(6)(A)(iv)(I), (II).
Subsec. (f)(6)(B)(i).
2008—Subsec. (f)(6).
Subsec. (f)(6)(A)(i).
Subsec. (f)(6)(A)(ii).
Subsec. (f)(6)(A)(iv).
Subsec. (f)(6)(B)(i).
2007—Subsec. (f)(6).
Subsec. (f)(6)(A)(i).
Subsec. (f)(6)(A)(ii).
Subsec. (f)(6)(A)(iv).
Subsec. (f)(6)(B)(i).
2006—Subsec. (f)(2).
Subsec. (f)(6).
2003—Subsec. (f)(3)(A).
Subsec. (f)(3)(C), (D).
Subsec. (f)(5).
Subsec. (f)(5)(A).
Subsec. (f)(6), (7).
Subsec. (j).
2000—Subsec. (a)(2)(D).
Subsec. (b)(2).
Subsec. (b)(3)(A)(i)(I).
Subsec. (f)(2).
Subsec. (f)(3)(A).
Subsec. (f)(4).
Subsec. (f)(5).
Subsec. (f)(6).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2021 Amendment
Effective Date of 2020 Amendment
Effective Date of 2013 Amendment
Effective Date of 2010 Amendment
Effective Date of 2009 Amendment
Amendment by
Effective Date of 2006 Amendment
Effective Date of 2000 Amendment
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
Effective Date of 1993 Amendment
"(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."
"(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
Effective Date of 1988 Amendment
Amendment by
Amendment by section 302(b)(2) of
Except as specifically provided in section 411 of
Application of Medicaid DSH Transition Rule to Public Hospitals in All States
"(1)
"(A) 'September 30, 2002' were substituted for 'July 1, 1997' each place it appears;
"(B) 'hospitals owned or operated by a State (as defined for purposes of title XIX of such Act [
"(C) paragraph (3) were redesignated as paragraph (4);
"(D) 'and' were omitted from the end of paragraph (2); and
"(E) the following new paragraph were inserted after paragraph (2):
'(3) "(as defined in subparagraph (B) but without regard to clause (ii) of that subparagraph and subject to subsection (d))" were substituted for "(as defined in subparagraph (B))" in subparagraph (A) of such section; and'.
"(2)
"(3)
"(4)
Assistance for Certain Public Hospitals
"(1)
"(2)
"(A) is owned or operated by a State (as defined for purposes of title XIX of the Social Security Act [
"(B) as of October 1, 2000—
"(i) is in existence and operating as a hospital described in subparagraph (A); and
"(ii) is not receiving disproportionate share hospital payments from the State in which it is located under title XIX of such Act [
"(C) has a low-income utilization rate (as defined in section 1923(b)(3) of the Social Security Act (
"(3)
"(A)
"(B)
"(i) For fiscal year 2002, $15,000,000.
"(ii) For fiscal year 2003, $176,000,000.
"(iii) For fiscal year 2004, $269,000,000.
"(iv) For fiscal year 2005, $330,000,000.
"(v) For fiscal year 2006 and each fiscal year thereafter, $375,000,000."
DSH Payment Accountability Standards
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
1 So in original. Probably should be "subsection".
2 So in original. Probably should be preceded by "a".
§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)), 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), 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).
(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) (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), 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)).
(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.
(6) Application of "income first" rule to revision of community spouse resource allowance
For purposes of this subsection and subsections (c) and (e), a State must consider that all income of the institutionalized spouse that could be made available to a community spouse, in accordance with the calculation of the community spouse monthly income allowance under this subsection, has been made available before the State allocates to the community spouse an amount of resources adequate to provide the difference between the minimum monthly maintenance needs allowance and all income available to the community spouse.
(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 the amount of any family allowances (described in subsection (d)(1)(C)), of the method for computing the amount of the community spouse resources allowance permitted under subsection (f), 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));
(iii) the computation of the spousal share of resources under subsection (c)(1);
(iv) the attribution of resources under subsection (c)(2); or
(v) the determination of the community spouse resource allowance (as defined in subsection (f)(2));
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), 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), 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)), 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), or (II) $60,000 (subject to adjustment under subsection (g)),
(iii) the amount established under subsection (e)(2); 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) 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
Editorial Notes
Codification
Prior Provisions
A prior section 1924 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2008—Subsec. (d)(4)(B).
2006—Subsec. (d)(6).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2008 Amendment
Amendment of this section and repeal of
Amendment by section 4002(b)(1)(B), (2)(V) of
Effective Date of 2006 Amendment
Effective Date of 1994 Amendment
Amendment by
Effective Date of 1993 Amendment
Amendment by section 13611(d)(2) of
Effective Date of 1990 Amendment
Effective Date of 1989 Amendment
Amendment by
Effective Date of 1988 Amendment
Amendment by
Effective Date
"(1)(A) The amendments made by this section [enacting this section and amending
"(B) Section 1924 of the Social Security Act [
"(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
Rule of Construction
"(1)
"(2)
"(A) A waiver or plan amendment to provide medical assistance for home and community-based services under a waiver or plan amendment under subsection (c), (d), or (i) of section 1915 of the Social Security Act (
"(B) A plan amendment to provide medical assistance for home and community-based services for individuals by reason of being determined eligible under section 1902(a)(10)(C) of such Act (
"(C) A plan amendment to provide medical assistance for home and community-based attendant services and supports under section 1915(k) of such Act (
Similar provisions were contained in the following prior act:
[For additional provisions relating to construction of this section, see section 3(b) of
Protection for Recipients of Home and Community-Based Services Against Spousal Impoverishment
[For provisions relating to construction of section 2404 of
§1396r–6. Extension of eligibility for medical assistance
(a) Initial 6-month extension
(1) Requirement
(A) In general
Notwithstanding any other provision of this subchapter but subject to subparagraph (B) and paragraph (5), 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 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)) 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.
(B) State option to waive requirement for 3 months before receipt of medical assistance
A State may, at its option, elect also to apply subparagraph (A) in the case of a family that was receiving such aid for fewer than three months or that had applied for and was eligible for such aid for fewer than 3 months during the 6 immediately preceding months described in such subparagraph.
(2) Notice of benefits
Each State, in the notice of termination of aid under part A of subchapter IV 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) 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.
(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.
(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
(5) Option of 12-month initial eligibility period
A State may elect to treat any reference in this subsection to a 6-month period (or 6 months) as a reference to a 12-month period (or 12 months). In the case of such an election, subsection (b) shall not apply.
(b) Additional 6-month extension
(1) Requirement
Notwithstanding any other provision of this subchapter but subject to subsection (a)(5), 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) 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), 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) report to the State, not later than the 21st day of the 4th month in the period of extended assistance under subsection (a), 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) 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.
(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) 1 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; 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) 1 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) (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).
(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 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.
(f) Collection and reporting of participation information
(1) Collection of information from States
Each State shall collect and submit to the Secretary (and make publicly available), in a format specified by the Secretary, information on average monthly enrollment and average monthly participation rates for adults and children under this section and of the number and percentage of children who become ineligible for medical assistance under this section whose medical assistance is continued under another eligibility category or who are enrolled under the State's child health plan under subchapter XXI. Such information shall be submitted at the same time and frequency in which other enrollment information under this subchapter is submitted to the Secretary.
(2) Annual reports to Congress
Using the information submitted under paragraph (1), the Secretary shall submit to Congress annual reports concerning enrollment and participation rates described in such paragraph.
(Aug. 14, 1935, ch. 531, title XIX, §1925, as added
Editorial Notes
References in Text
Paragraph (21) of
Prior Provisions
A prior section 1925 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2015—Subsecs. (f), (g).
2014—Subsec. (f).
2013—Subsec. (f).
2012—Subsec. (f).
2011—Subsec. (f).
2010—Subsec. (f).
2009—Subsec. (a)(1).
Subsec. (a)(5).
Subsec. (b)(1).
Subsec. (f).
Subsec. (g).
2003—Subsec. (f).
2000—Subsec. (f).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2009 Amendment
Amendment by section 5004(a)(1) of
Effective Date of 2003 Amendment
Amendment by
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
Effective Date of 1989 Amendment
Effective Date of 1988 Amendment
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
1 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,
Statutory Notes and Related Subsidiaries
Effective Date of Repeal
§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
(7) Requirement for submission of utilization data for certain physician administered drugs
(A) Single source drugs
In order for payment to be available under
(B) Multiple source drugs
(i) Identification of most frequently physician administered multiple source drugs
Not later than January 1, 2007, the Secretary shall publish a list of the 20 physician administered multiple source drugs that the Secretary determines have the highest dollar volume of physician administered drugs dispensed under this subchapter. The Secretary may modify such list from year to year to reflect changes in such volume.
(ii) Requirement
In order for payment to be available under
(C) Use of NDC codes
Not later than January 1, 2007, the information shall be submitted under subparagraphs (A) and (B)(ii) using National Drug Code codes unless the Secretary specifies that an alternative coding system should be used.
(D) Hardship waiver
The Secretary may delay the application of subparagraph (A) or (B)(ii), or both, in the case of a State to prevent hardship to States which require additional time to implement the reporting system required under the respective subparagraph.
(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) for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for which payment was made under the State plan for such period, including such drugs dispensed to individuals enrolled with a medicaid managed care organization if the organization is responsible for coverage of such drugs. 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) or an agreement described in subsection (a)(4)) in any quarter, including amounts received by a State under subsection (c)(4), shall be considered to be a reduction in the amount expended under the State plan in the quarter for medical assistance for purposes of
(C) Special rule for increased minimum rebate percentage
(i) In general
In addition to the amounts applied as a reduction under subparagraph (B), for rebate periods beginning on or after January 1, 2010, during a fiscal year, the Secretary shall reduce payments to a State under
(I) 100 percent minus the Federal medical assistance percentage applicable to the rebate period for the State; and
(II) the amounts received by the State under such subparagraph that are attributable (as estimated by the Secretary based on utilization and other data) to the increase in the minimum rebate percentage effected by the amendments made by subsections (a)(1), (b), and (d) of section 2501 of the Patient Protection and Affordable Care Act, taking into account the additional drugs included under the amendments made by subsection (c) of section 2501 of such Act.
The Secretary shall adjust such payment reduction for a calendar quarter to the extent the Secretary determines, based upon subsequent utilization and other data, that the reduction for such quarter was greater or less than the amount of payment reduction that should have been made.
(ii) Manner of payment reduction
The amount of the payment reduction under clause (i) for a State for a quarter shall be deemed an overpayment to the State under this subchapter to be disallowed against the State's regular quarterly draw for all Medicaid spending under
(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, including such information reported by each medicaid managed care organization, 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 and drug product 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—
(I) on the average manufacturer price (as defined in subsection (k)(1)) for covered outpatient drugs for the rebate period under the agreement (including for all such drugs that are sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act [
(II) for single source drugs and innovator multiple source drugs (including all such drugs that are sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act), on the manufacturer's best price (as defined in subsection (c)(1)(C)) for such drugs for the rebate period under the agreement;
(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)) as of October 1, 1990 for each of the manufacturer's covered outpatient drugs (including for such drugs that are sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act);
(iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with reporting required under clause (i) and by National Drug Code (including package size)—
(I) the manufacturer's average sales price (as defined in
(II) if required to make payment under
(III) information on those sales that were made at a nominal price or otherwise described in
for a drug or biological described in subparagraph (C), (D), (E), or (G) of
(iv) not later than 30 days after the last day of each month of a rebate period under the agreement, on the manufacturer's total number of units that are used to calculate the monthly average manufacturer price for each covered outpatient drug; and
(v) not later than 30 days after the last day of each month of a rebate period under the agreement, such drug product information as the Secretary shall require for each of the manufacturer's covered outpatient drugs.
Information reported under this subparagraph is subject to audit by the Inspector General of the Department of Health and Human Services. Beginning July 1, 2006, the Secretary shall provide on a monthly basis to States under subparagraph (D)(iv) the most recently reported average manufacturer prices for single source drugs and for multiple source drugs and shall, on at least a quarterly basis, update the information posted on the website under subparagraph (D)(v) (relating to the weighted average of the most recently reported monthly average manufacturer prices). For purposes of applying clause (iii), for calendar quarters beginning on or after January 1, 2022, a drug or biological described in the flush matter following such clause includes items, services, supplies, and products that are payable under part B of subchapter XVIII as a drug or biological.
(B) Verification surveys of average manufacturer price and manufacturer's average sales price
The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices and manufacturer's average sales prices (including wholesale acquisition cost) if required to make payment 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, including information related to drug pricing, drug product information, and data related to drug pricing or drug product 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
(iii) Misclassified drug product or misreported information
(I) In general
Any manufacturer with an agreement under this section that knowingly (as defined in section 1003.110 of title 42, Code of Federal Regulations (or any successor regulation)) misclassifies a covered outpatient drug, such as by knowingly submitting incorrect drug product information, is subject to a civil money penalty for each covered outpatient drug that is misclassified in an amount not to exceed 2 times the amount of the difference between—
(aa) the total amount of rebates that the manufacturer paid with respect to the drug to all States for all rebate periods during which the drug was misclassified; and
(bb) the total amount of rebates that the manufacturer would have been required to pay, as determined by the Secretary using drug product information provided by the manufacturer, with respect to the drug to all States for all rebate periods during which the drug was misclassified if the drug had been correctly classified.
(II) Other penalties and recovery of underpaid rebates
The civil money penalties described in subclause (I) are in addition to other penalties as may be prescribed by law and any other recovery of the underlying underpayment for rebates due under this section or the terms of the rebate agreement as determined by the Secretary.
(iv) Increasing oversight and enforcement
Each year the Secretary shall retain, in addition to any amount retained by the Secretary to recoup investigation and litigation costs related to the enforcement of the civil money penalties under this subparagraph and subsection (c)(4)(B)(ii)(III), an amount equal to 25 percent of the total amount of civil money penalties collected under this subparagraph and subsection (c)(4)(B)(ii)(III) for the year, and such retained amount shall be available to the Secretary, without further appropriation and until expended, for activities related to the oversight and enforcement of this section and agreements under this section, including—
(I) improving drug data reporting systems;
(II) evaluating and ensuring manufacturer compliance with rebate obligations; and
(III) oversight and enforcement related to ensuring that manufacturers accurately and fully report drug information, including data related to drug classification.
(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) (other than the wholesale acquisition cost for purposes of carrying out
(i) as the Secretary determines to be necessary to carry out this section, to carry out
(ii) to permit the Comptroller General to review the information provided,
(iii) to permit the Director of the Congressional Budget Office to review the information provided,
(iv) to States to carry out this subchapter,
(v) to the Secretary to disclose (through a website accessible to the public) the weighted average of the most recently reported monthly average manufacturer prices and the average retail survey price determined for each multiple source drug in accordance with subsection (f),
(vi) in the case of categories of drug product or classification information that were not considered confidential by the Secretary on the day before April 18, 2019, and
(vii) to permit the Executive Director of the Medicare Payment Advisory Commission and the Executive Director of the Medicaid and CHIP Payment and Access Commission to review the information provided.
The previous sentence shall also apply to information disclosed under
(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)) 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;
(V) after December 31, 1995, and before January 1, 2010 1 is 15.1 percent; and
(VI) except as provided in clause (iii), after December 31, 2009,2 23.1 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.
(iii) Minimum rebate percentage for certain drugs
(I) In general
In the case of a single source drug or an innovator multiple source drug described in subclause (II), the minimum rebate percentage for rebate periods specified in clause (i)(VI) is 17.1 percent.
(II) Drug described
For purposes of subclause (I), a single source drug or an innovator multiple source drug described in this subclause is any of the following drugs:
(aa) A clotting factor for which a separate furnishing payment is made under
(bb) A drug approved by the Food and Drug Administration exclusively for pediatric indications.
(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 (including the lowest price available to any entity for any such drug of a manufacturer that is sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act [
(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;
(IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of the Federal Government;
(V) the prices negotiated from drug manufacturers for covered discount card drugs under an endorsed discount card program under
(VI) subject to clause (ii)(V), any prices charged which are negotiated by a prescription drug plan under part D of subchapter XVIII, by an MA–PD plan under part C of such subchapter with respect to covered part D drugs or by a qualified retiree prescription drug plan (as defined in
(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;
(III) shall not take into account prices that are merely nominal in amount 3
(IV) in the case of a manufacturer that approves, allows, or otherwise permits any other drug of the manufacturer to be sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act [
(V) in the case of a rebate period and a covered outpatient drug that is a selected drug (as referred to in
(iii) Application of auditing and recordkeeping requirements
With respect to a covered entity described in
(D) Limitation on sales at a nominal price
(i) In general
For purposes of subparagraph (C)(ii)(III) and subsection (b)(3)(A)(iii)(III), only sales by a manufacturer of covered outpatient drugs at nominal prices to the following shall be considered to be sales at a nominal price or merely nominal in amount:
(I) A covered entity described in
(II) An intermediate care facility for the mentally retarded.
(III) A State-owned or operated nursing facility.
(IV) An entity that—
(aa) is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Act or is State-owned or operated; and
(bb) would be a covered entity described in section 256b(a)(4) 4 of this title insofar as the entity provides the same type of services to the same type of populations as a covered entity described in such section provides, but does not receive funding under a provision of law referred to in such section;
(V) A public or nonprofit entity, or an entity based at an institution of higher learning whose primary purpose is to provide health care services to students of that institution, that provides a service or services described under
(VI) Any other facility or entity that the Secretary determines is a safety net provider to which sales of such drugs at a nominal price would be appropriate based on the factors described in clause (ii).
(ii) Factors
The factors described in this clause with respect to a facility or entity are the following:
(I) The type of facility or entity.
(II) The services provided by the facility or entity.
(III) The patient population served by the facility or entity.
(IV) The number of other facilities or entities eligible to purchase at nominal prices in the same service area.
(iii) Nonapplication
Clause (i) shall not apply with respect to sales by a manufacturer at a nominal price of covered outpatient drugs pursuant to a master agreement under
(iv) Rule of construction
Nothing in this subparagraph shall be construed to alter any existing statutory or regulatory prohibition on services with respect to an entity described in clause (i)(IV), including the prohibition set forth in
(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".
(C) Treatment of new formulations
(i) In general
In the case of a drug that is a line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form, the rebate obligation for a rebate period with respect to such drug under this subsection shall be the greater of the amount described in clause (ii) for such drug or the amount described in clause (iii) for such drug.
(ii) Amount 1
For purposes of clause (i), the amount described in this clause with respect to a drug described in clause (i) and rebate period is the amount computed under paragraph (1) for such drug, increased by the amount computed under subparagraph (A) and, as applicable, subparagraph (B) for such drug and rebate period.
(iii) Amount 2
For purposes of clause (i), the amount described in this clause with respect to a drug described in clause (i) and rebate period is the amount computed under paragraph (1) for such drug, increased by the product of—
(I) the average manufacturer price for the rebate period of the line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form;
(II) the highest additional rebate (calculated as a percentage of average manufacturer price) under this paragraph for the rebate period for any strength of the original single source drug or innovator multiple source drug; and
(III) the total number of units of each dosage form and strength of the line extension product paid for under the State plan in the rebate period (as reported by the State).
In this subparagraph, the term "line extension" means, with respect to a drug, a new formulation of the drug, such as an extended release formulation, but does not include an abuse-deterrent formulation of the drug (as determined by the Secretary), regardless of whether such abuse-deterrent formulation is an extended release formulation.
(D) Maximum rebate amount
In no case shall the sum of the amounts applied under paragraph (1)(A)(ii) and this paragraph with respect to each dosage form and strength of a single source drug or an innovator multiple source drug for a rebate period beginning after December 31, 2009, and before January 1, 2024, exceed 100 percent of the average manufacturer price of the drug.
(3) Rebate for other drugs
(A) In general
Except as provided in subparagraph (C), 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,
(ii) after December 31, 1993, and before January 1, 2010, is 11 percent; 5 and
(iii) after December 31, 2009, is 13 percent.
(C) Additional rebate
(i) In general
The amount of the rebate specified in this paragraph for a rebate period, with respect to each dosage form and strength of a covered outpatient drug other than a single source drug or an innovator multiple source drug of a manufacturer, shall be increased in the manner that the rebate for a dosage form and strength of a single source drug or an innovator multiple source drug is increased under subparagraphs (A) and (D) of paragraph (2), except as provided in clause (ii).
(ii) Special rules for application of provision
In applying subparagraphs (A) and (D) of paragraph (2) under clause (i)—
(I) the reference in subparagraph (A)(i) of such paragraph to "1990" shall be deemed a reference to "2014";
(II) subject to clause (iii), the reference in subparagraph (A)(ii) of such paragraph to "the calendar quarter beginning July 1, 1990" shall be deemed a reference to "the calendar quarter beginning July 1, 2014"; and
(III) subject to clause (iii), the reference in subparagraph (A)(ii) of such paragraph to "September 1990" shall be deemed a reference to "September 2014";
(IV) the references in subparagraph (D) of such paragraph to "paragraph (1)(A)(ii)", "this paragraph", and "December 31, 2009" shall be deemed references to "subparagraph (A)", "this subparagraph", and "December 31, 2014", respectively; and
(V) any reference in such paragraph to a "single source drug or an innovator multiple source drug" shall be deemed to be a reference to a drug to which clause (i) applies.
(iii) Special rule for certain noninnovator multiple source drugs
In applying paragraph (2)(A)(ii)(II) under clause (i) with respect to a covered outpatient drug that is first marketed as a drug other than a single source drug or an innovator multiple source drug after April 1, 2013, such paragraph shall be applied—
(I) by substituting "the applicable quarter" for "the calendar quarter beginning July 1, 1990"; and
(II) by substituting "the last month in such applicable quarter" for "September 1990".
(iv) Applicable quarter defined
In this subsection, the term "applicable quarter" means, with respect to a drug described in clause (iii), the fifth full calendar quarter after which the drug is marketed as a drug other than a single source drug or an innovator multiple source drug.
(4) Recovery of unpaid rebate amounts due to misclassification of covered outpatient drugs
(A) In general
If the Secretary determines that a manufacturer with an agreement under this section paid a lower per-unit rebate amount to a State for a rebate period as a result of the misclassification by the manufacturer of a covered outpatient drug (without regard to whether the manufacturer knowingly made the misclassification or should have known that the misclassification would be made) than the per-unit rebate amount that the manufacturer would have paid to the State if the drug had been correctly classified, the manufacturer shall pay to the State an amount equal to the product of—
(i) the difference between—
(I) the per-unit rebate amount paid to the State for the period; and
(II) the per-unit rebate amount that the manufacturer would have paid to the State for the period, as determined by the Secretary, if the drug had been correctly classified; and
(ii) the total units of the drug paid for under the State plan in the period.
(B) Authority to correct misclassifications
(i) In general
If the Secretary determines that a manufacturer with an agreement under this section has misclassified a covered outpatient drug (without regard to whether the manufacturer knowingly made the misclassification or should have known that the misclassification would be made), the Secretary shall notify the manufacturer of the misclassification and require the manufacturer to correct the misclassification in a timely manner.
(ii) Enforcement
If, after receiving notice of a misclassification from the Secretary under clause (i), a manufacturer fails to correct the misclassification by such time as the Secretary shall require, until the manufacturer makes such correction, the Secretary may do any or all of the following:
(I) Correct the misclassification, using drug product information provided by the manufacturer, on behalf of the manufacturer.
(II) Suspend the misclassified drug and the drug's status as a covered outpatient drug under the manufacturer's national rebate agreement, and exclude the misclassified drug from Federal financial participation in accordance with
(III) Impose a civil money penalty (which shall be in addition to any other recovery or penalty which may be available under this section or any other provision of law) for each rebate period during which the drug is misclassified not to exceed an amount equal to the product of—
(aa) the total number of units of each dosage form and strength of such misclassified drug paid for under any State plan during such a rebate period; and
(bb) 23.1 percent of the average manufacturer price for the dosage form and strength of such misclassified drug.
(C) Reporting and transparency
(i) In general
The Secretary shall submit a report to Congress on at least an annual basis that includes information on the covered outpatient drugs that have been identified as misclassified, any steps taken to reclassify such drugs, the actions the Secretary has taken to ensure the payment of any rebate amounts which were unpaid as a result of such misclassification, and a disclosure of expenditures from the fund created in subsection (b)(3)(C)(iv), including an accounting of how such funds have been allocated and spent in accordance with such subsection.
(ii) Public access
The Secretary shall make the information contained in the report required under clause (i) available to the public on a timely basis.
(D) Other penalties and actions
Actions taken and penalties imposed under this clause shall be in addition to other remedies available to the Secretary including terminating the manufacturer's rebate agreement for noncompliance with the terms of such agreement and shall not exempt a manufacturer from, or preclude the Secretary from pursuing, any civil money penalty under this subchapter or subchapter XI, or any other penalty or action as may be prescribed by law.
(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));
(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) or in effect pursuant to subsection (a)(4); 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) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
(F) Nonprescription drugs, except, in the case of pregnant women when recommended in accordance with the Guideline referred to in
(G) 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.
(H) Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration.
(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)).
(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) (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)) 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.
(7) Non-excludable drugs
The following drugs or classes of drugs, or their medical uses, shall not be excluded from coverage:
(A) Agents when used to promote smoking cessation, including agents approved by the Food and Drug Administration under the over-the-counter monograph process for purposes of promoting, and when used to promote, tobacco cessation.
(B) Barbiturates.
(C) Benzodiazepines.
(D) Drugs and biological products described in subsection (ee)(1)(A) of
(E) Drugs and biological products to which
(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)] 6 Establishment of upper payment limits
Subject to paragraph (5), the Secretary 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.
(5) Use of amp in upper payment limits
The Secretary shall calculate the Federal upper reimbursement limit established under paragraph (4) as no less than 175 percent of the weighted average (determined on the basis of utilization) of the most recently reported monthly average manufacturer prices for pharmaceutically and therapeutically equivalent multiple source drug products that are available for purchase by retail community pharmacies on a nationwide basis. The Secretary shall implement a smoothing process for average manufacturer prices. Such process shall be similar to the smoothing process used in determining the average sales price of a drug or biological under
(f) Survey of retail prices; State payment and utilization rates; and performance rankings
(1) Survey of retail prices
(A) Use of vendor
The Secretary may contract services for—
(i) with respect to a retail community pharmacy, the determination on a monthly basis of retail survey prices for covered outpatient drugs that represent a nationwide average of consumer purchase prices for such drugs, net of all discounts and rebates (to the extent any information with respect to such discounts and rebates is available); and
(ii) the notification of the Secretary when a drug product that is therapeutically and pharmaceutically equivalent and bioequivalent becomes generally available.
(B) Secretary response to notification of availability of multiple source products
If contractor notifies the Secretary under subparagraph (A)(ii) that a drug product described in such subparagraph has become generally available, the Secretary shall make a determination, within 7 days after receiving such notification, as to whether the product is now described in subsection (e)(4).4
(C) Use of competitive bidding
In contracting for such services, the Secretary shall competitively bid for an outside vendor that has a demonstrated history in—
(i) surveying and determining, on a representative nationwide basis, retail prices for ingredient costs of prescription drugs;
(ii) working with retail community pharmacies, commercial payers, and States in obtaining and disseminating such price information; and
(iii) collecting and reporting such price information on at least a monthly basis.
In contracting for such services, the Secretary may waive such provisions of the Federal Acquisition Regulation as are necessary for the efficient implementation of this subsection, other than provisions relating to confidentiality of information and such other provisions as the Secretary determines appropriate.
(D) Additional provisions
A contract with a vendor under this paragraph shall include such terms and conditions as the Secretary shall specify, including the following:
(i) The vendor must monitor the marketplace and report to the Secretary each time there is a new covered outpatient drug generally available.
(ii) The vendor must update the Secretary no less often than monthly on the retail survey prices for covered outpatient drugs.
(iii) The contract shall be effective for a term of 2 years.
(E) Availability of information to States
Information on retail survey prices obtained under this paragraph, including applicable information on single source drugs, shall be provided to States on at least a monthly basis. The Secretary shall devise and implement a means for providing access to each State agency designated under
(2) Annual State report
Each State shall annually report to the Secretary information on—
(A) the payment rates under the State plan under this subchapter for covered outpatient drugs;
(B) the dispensing fees paid under such plan for such drugs; and
(C) utilization rates for noninnovator multiple source drugs under such plan.
(3) Annual State performance rankings
(A) Comparative analysis
The Secretary annually shall compare, for the 50 most widely prescribed drugs identified by the Secretary, the national retail sales price data (collected under paragraph (1)) for such drugs with data on prices under this subchapter for each such drug for each State.
(B) Availability of information
The Secretary shall submit to Congress and the States full information regarding the annual rankings made under subparagraph (A).
(4) Appropriation
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary of Health and Human Services $5,000,000 for each of fiscal years 2006 through 2010 to carry out this subsection.
(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 (or its successor publications); and
(III) the DRUGDEX Information System; 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, or to require verification of the offer to provide consultation or a refusal of such offer.
(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 7 (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 * * * 8 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 7 (2)(B).
(ii) Application of standards as defined in section 7 (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) Omitted
(j) Exemption of organized health care settings
(1) Covered outpatient drugs are not subject to the requirements of this section if such drugs are—
(A) dispensed by health maintenance organizations, including Medicaid managed care organizations that contract under
(B) subject to discounts 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).
(k) Definitions
In this section—
(1) Average manufacturer price
(A) In general
Subject to subparagraph (B), 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—
(i) wholesalers for drugs distributed to retail community pharmacies; and
(ii) retail community pharmacies that purchase drugs directly from the manufacturer.
(B) Exclusion of customary prompt pay discounts and other payments
(i) In general
The average manufacturer price for a covered outpatient drug shall exclude—
(I) customary prompt pay discounts extended to wholesalers;
(II) bona fide service fees paid by manufacturers to wholesalers or retail community pharmacies, including (but not limited to) distribution service fees, inventory management fees, product stocking allowances, and fees associated with administrative services agreements and patient care programs (such as medication compliance programs and patient education programs);
(III) reimbursement by manufacturers for recalled, damaged, expired, or otherwise unsalable returned goods, including (but not limited to) reimbursement for the cost of the goods and any reimbursement of costs associated with return goods handling and processing, reverse logistics, and drug destruction;
(IV) payments received from, and rebates or discounts provided to, pharmacy benefit managers, managed care organizations, health maintenance organizations, insurers, hospitals, clinics, mail order pharmacies, long term care providers, manufacturers, or any other entity that does not conduct business as a wholesaler or a retail community pharmacy, unless the drug is an inhalation, infusion, instilled, implanted, or injectable drug that is not generally dispensed through a retail community pharmacy 3
(V) discounts provided by manufacturers under
(VI) any reduction in price paid during the rebate period to the manufacturer for a drug by reason of application of part E of subchapter XI;
(VII) rebates paid by manufacturers under
(VIII) rebates paid by manufacturers under
(ii) Inclusion of other discounts and payments
Notwithstanding clause (i), any other discounts, rebates, payments, or other financial transactions that are received by, paid by, or passed through to, retail community pharmacies shall be included in the average manufacturer price for a covered outpatient drug.
(C) Exclusion of section 505(c) drugs
In the case of a manufacturer that approves, allows, or otherwise permits any drug of the manufacturer to be sold under the manufacturer's new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act [
(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 3 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 9 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)) 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, including a drug product approved for marketing as a non-prescription drug that is regarded as a covered outpatient drug under paragraph (4), for which there 2 at least 1 other drug product which—
(I) is 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), is pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and
(III) is sold or marketed in the United States during the period.
(ii) Innovator multiple source drug
The term "innovator multiple source drug" means a multiple source drug that is marketed under a new drug application approved by the Food and Drug Administration, unless the Secretary determines that a narrow exception applies (as described in section 447.502 of title 42, Code of Federal Regulations (or any successor regulation)).
(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, including a drug product approved for marketing as a non-prescription drug that is regarded as a covered outpatient drug under paragraph (4), which is produced or distributed under a 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 unless the Secretary determines that a narrow exception applies (as described in section 447.502 of title 42, Code of Federal Regulations (or any successor regulation)). Such term also includes a covered outpatient drug that is a biological product licensed, produced, or distributed under a biologics license application approved by the Food and Drug Administration.
(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; and
(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.
(8) Rebate period
The term "rebate period" means, with respect to an agreement under subsection (a), 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
(10) Retail community pharmacy
The term "retail community pharmacy" means an independent pharmacy, a chain pharmacy, a supermarket pharmacy, or a mass merchandiser pharmacy that is licensed as a pharmacy by the State and that dispenses medications to the general public at retail prices. Such term does not include a pharmacy that dispenses prescription medications to patients primarily through the mail, nursing home pharmacies, long-term care facility pharmacies, hospital pharmacies, clinics, charitable or not-for-profit pharmacies, government pharmacies, or pharmacy benefit managers.
(11) Wholesaler
The term "wholesaler" means a drug wholesaler that is engaged in wholesale distribution of prescription drugs to retail community pharmacies, including (but not limited to) repackers, distributors, own-label distributors, private-label distributors, jobbers, brokers, warehouses (including distributor's warehouses, chain drug warehouses, and wholesale drug warehouses) independent wholesale drug traders, and retail community pharmacies that conduct wholesale distributions.
(Aug. 14, 1935, ch. 531, title XIX, §1927, as added
Editorial Notes
References in Text
The Internal Revenue Code of 1986, referred to in subsecs. (a)(3) and (c)(1)(D)(i)(IV)(aa), is classified generally to Title 26, Internal Revenue Code.
The amendments made by subsections (a)(1), (b), (c), and (d) of section 2501 of the Patient Protection and Affordable Care Act, referred to in subsec. (b)(1)(C)(i)(II), mean the amendments made by section 2501(a)(1), (b), (c), and (d) 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,
Paragraph (4) and subsection (e)(4), referred to in subsecs. (e)(5) and (f)(1)(B), probably means text that was editorially designated as par. (4) of subsec. (e). See 1993 Amendment note below.
Section 507 of the Federal Food, Drug, and Cosmetic Act, referred to in subsec. (k)(2)(A)(i), was repealed by
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
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
Codification
Subsec. (i) of this section, which required the Secretary to 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 an annual report on the operation of this section in the preceding fiscal year, terminated, effective May 15, 2000, pursuant to section 3003 of
Prior Provisions
A prior section 1927 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2022—Subsec. (a)(3).
Subsec. (b)(3)(D)(i).
Subsec. (c)(1)(C)(i)(VI).
Subsec. (c)(1)(C)(ii)(I).
Subsec. (c)(1)(C)(ii)(V).
Subsec. (k)(1)(B)(i)(V).
Subsec. (k)(1)(B)(i)(VI).
Subsec. (k)(1)(B)(i)(VII).
Subsec. (k)(1)(B)(i)(VIII).
2021—Subsec. (c)(2)(D).
Subsec. (d)(7)(E).
2020—Subsec. (b)(3)(A).
Subsec. (b)(3)(A)(iii).
Subsec. (b)(3)(D).
Subsec. (b)(3)(D)(vii).
Subsec. (d)(7)(D).
2019—Subsec. (b)(1)(B).
Subsec. (b)(3).
Subsec. (b)(3)(A)(ii), (iii).
Subsec. (b)(3)(A)(v).
Subsec. (b)(3)(C)(ii).
Subsec. (b)(3)(C)(iii), (iv).
Subsec. (b)(3)(D)(vi).
Subsec. (c)(4).
Subsec. (k)(1)(C).
Subsec. (k)(2)(A).
Subsec. (k)(7)(A)(i).
Subsec. (k)(7)(A)(ii).
Subsec. (k)(7)(A)(iv).
Subsec. (k)(11).
2018—Subsec. (c)(2)(C).
"(i) the average manufacturer price of the line extension of a single source drug or an innovator multiple source drug that is an oral solid dosage form;
"(ii) the highest additional rebate (calculated as a percentage of average manufacturer price) under this section for any strength of the original single source drug or innovator multiple source drug; and
"(iii) the total number of units of each dosage form and strength of the line extension product paid for under the State plan in the rebate period (as reported by the State)."
Subsec. (g)(1)(A).
Subsec. (g)(2)(B).
2016—Subsec. (c)(2)(C).
2015—Subsec. (c)(3)(A).
Subsec. (c)(3)(C).
2010—Subsec. (a)(5)(B).
Subsec. (b)(1)(A).
Subsec. (b)(1)(C).
Subsec. (b)(2)(A).
Subsec. (b)(3)(A).
Subsec. (b)(3)(A)(iv).
Subsec. (b)(3)(D)(v).
Subsec. (c)(1)(B)(i)(IV) to (VI).
Subsec. (c)(1)(B)(iii).
Subsec. (c)(1)(C)(i)(VI).
Subsec. (c)(2)(C).
"(i)
"(I) the average manufacturer price for each dosage form and strength of the new formulation of the single source drug or innovator multiple source drug;
"(II) the highest additional rebate (calculated as a percentage of average manufacturer price) under this section for any strength of the original single source drug or innovator multiple source drug; and
"(III) the total number of units of each dosage form and strength of the new formulation paid for under the State plan in the rebate period (as reported by the State).
"(ii)
Subsec. (c)(2)(D).
Subsec. (c)(3)(B).
Subsec. (d)(2)(E).
Subsec. (d)(2)(F).
Subsec. (d)(2)(G) to (K).
"(I) Barbiturates.
"(J) Benzodiazepines."
Subsec. (d)(7).
Subsec. (e)(4).
Subsec. (e)(5).
Subsec. (f)(1)(A)(i).
Subsec. (f)(1)(C)(ii).
Subsec. (j)(1).
Subsec. (k)(1)(A).
Subsec. (k)(1)(B).
Subsec. (k)(1)(B)(i)(IV).
Subsec. (k)(1)(B)(i)(V).
Subsec. (k)(1)(C).
Subsec. (k)(7)(A)(i)(III).
Subsec. (k)(7)(C).
Subsec. (k)(10), (11).
2009—Subsec. (c)(1)(D)(i)(IV) to (VI).
Subsec. (c)(1)(D)(iv).
2006—Subsec. (a)(5)(B).
Subsec. (a)(7).
Subsec. (b)(3)(A).
Subsec. (b)(3)(A)(i).
Subsec. (b)(3)(A)(ii).
Subsec. (b)(3)(A)(iii).
Subsec. (b)(3)(D)(iv), (v).
Subsec. (c)(1)(C)(i).
Subsec. (c)(1)(C)(ii)(IV).
Subsec. (c)(1)(D).
Subsec. (e)(4).
Subsec. (e)(5).
Subsec. (f).
Subsec. (g)(1)(B)(i)(II).
Subsec. (g)(2)(A)(ii).
Subsec. (k)(1).
Subsec. (k)(1)(C).
Subsec. (k)(7)(A)(i).
2005—Subsec. (d)(2)(K).
2003—Subsec. (a)(1).
Subsec. (b)(3)(A).
Subsec. (b)(3)(B).
Subsec. (b)(3)(D).
Subsec. (b)(3)(D)(i).
Subsec. (c)(1)(C)(i)(I).
Subsec. (c)(1)(C)(i)(V), (VI).
Subsec. (c)(1)(C)(iii).
Subsec. (e)[(4)].
Subsec. (g)(1)(B)(i)(II).
Subsec. (g)(1)(B)(i)(IV).
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).
Statutory Notes and Related Subsidiaries
Effective Date of 2020 Amendment
Amendment made by
Effective Date of 2019 Amendment
Amendment by
Effective Date of 2018 Amendment
Effective Date of 2016 Amendment
Effective Date of 2015 Amendment
Effective Date of 2010 Amendment
Amendment by section 3301(d)(2) of
Amendment by section 4107(b) of
Effective Date of 2009 Amendment
Effective Date of 2006 Amendment
Effective Date of 2005 Amendment
Amendment by
Effective Date of 2003 Amendment
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 Amendment
"(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 [
Effective Date of 1992 Amendment
Regulations
"(A)
"(i) review the requirements for, and manner in which, average manufacturer prices are determined under section 1927 of the Social Security Act [
"(ii) shall submit to the Secretary of Health and Human Services and Congress such recommendations for changes in such requirements or manner as the Inspector General determines to be appropriate.
"(B)
Inclusion in the Medicaid Drug Rebate Program of Covered Outpatient Drugs Used for COVID–19 Treatment
"(A)
"(i) furnished as medical assistance in accordance with section 1902(a)(10)(A) of such Act and such subparagraph (F) [probably means
"(ii) a covered outpatient drug (as defined in section 1927(k) of such Act, except that, in applying paragraph (2)(A) of such section [probably means
Pharmacy Reimbursement Under Medicaid
"(a)
"(1) the specific upper limit under section 447.332 of title 42, Code of Federal Regulations (as in effect on December 31, 2006) applicable to payments made by a State for multiple source drugs under a State Medicaid plan shall continue to apply through September 30, 2009, for purposes of the availability of Federal financial participation for such payments; and
"(2) the Secretary of Health and Human Services shall not, prior to October 1, 2009, finalize, implement, enforce, or otherwise take any action (through promulgation of regulation, issuance of regulatory guidance, use of Federal payment audit procedures, or other administrative action, policy, or practice, including a Medical Assistance Manual transmittal or letter to State Medicaid directors) to impose the specific upper limit established under section 447.514(b) of title 42, Code of Federal Regulations as published on July 17, 2007 (72 Federal Register 39142).
"(b)
"(c)
"(1) The term 'multiple source drug' has the meaning given that term in section 1927(k)(7)(A)(i) of the Social Security Act (
"(2) The term 'AMP' has the meaning given 'average manufacturer price' in section 1927(k)(1) of the Social Security Act (
Application of 2003 Amendment to Physician Specialties
Amendment by section 303 of
Notwithstanding section 303(j) of
Reports on Best Price Changes and Payment of Rebates
Demonstration Projects To Evaluate Efficiency and Cost-Effectiveness of Prospective Drug Utilization Review
Study of Drug Purchasing and Billing Practices in Health Care Industry; Report
1 So in original. Probably should be followed by a comma.
2 So in original. Probably should be followed by "is".
3 So in original. Probably should be followed by a semicolon.
4 See References in Text note below.
5 So in original. The semicolon probably should be a comma.
6 See 1993 Amendment note below.
7 So in original. Probably should be "paragraph".
9 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)), in receiving an immunization with a qualified pediatric vaccine (as defined in subsection (h)(8)) from a program-registered provider (as defined in subsection (c)) 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) 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), 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). 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)).
(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).
(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), 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).
(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).
(7) The term "program-registered provider" has the meaning given such term in subsection (c).
(8) The term "qualified pediatric vaccine" means a pediatric vaccine with respect to which a contract is in effect under subsection (d).
(9) The terms "vaccine-eligible child", "federally vaccine-eligible child", and "State vaccine-eligible child" have the meaning given such terms in subsection (b).
(Aug. 14, 1935, ch. 531, title XIX, §1928, as added
Editorial Notes
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,
Statutory Notes and Related Subsidiaries
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
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), 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)):
(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), 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);
(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) (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).
(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);
(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 (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). 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);
(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);
(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). 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).
(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).
(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), 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).
(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) 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), 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), 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).
(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) 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)) 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) 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) (relating to comprehensive functional assessments, including the use of assessment instruments), of subsection (d)(2)(E) (relating to qualifications for qualified case managers), of subsection (f) (relating to minimum requirements for home and community care), of subsection (g) (relating to minimum requirements for small community care settings), and of subsection (h) (relating to minimum requirements for large community care settings), and
(ii) survey protocols (for use under subsection (i)(3)(A)) 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) to individuals described in subsection (b) 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
Editorial Notes
Codification
Amendments
1999—Subsec. (c)(2)(E)(i), (ii).
Subsec. (k)(1)(A)(i).
Subsec. (l).
Statutory Notes and Related Subsidiaries
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
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) provided in a State eligible to provide services under this section (as defined in subsection (d)) to assist a developmentally disabled individual (as defined in subsection (b)) 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)).
(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) 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 Council on Developmental Disabilities established under section 125 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 [42 U.S.C. §15025] and the protection and advocacy system established under subtitle C of that Act [
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), 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), 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
Editorial Notes
References in Text
The Developmental Disabilities Assistance and Bill of Rights Act of 2000, referred to in subsec. (d)(7), is
Codification
Amendments
2000—Subsec. (d)(7).
Statutory Notes and Related Subsidiaries
Effective Date
"(1)
"(2)
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, 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 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, 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,
(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.
(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) 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 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, 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 (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
Editorial Notes
References in Text
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 1939 and is classified to
Amendments
1999—Subsec. (h)(3).
Subsec. (h)(4).
Statutory Notes and Related Subsidiaries
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
§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;
(ii) is described in
(iii) is described in
(iv) is receiving foster care or adoption assistance under part E of subchapter IV; 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) 1 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.
(D) Emergency services furnished by non-contract providers
Any provider of emergency services that does not have in effect a contract with a Medicaid managed care entity that establishes payment amounts for services furnished to a beneficiary enrolled in the entity's Medicaid managed care plan must accept as payment in full no more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that it could collect if the beneficiary received medical assistance under this subchapter other than through enrollment in such an entity. In a State where rates paid to hospitals under the State plan are negotiated by contract and not publicly released, the payment amount applicable under this subparagraph shall be the average contract rate that would apply under the State plan for general acute care hospitals or the average contract rate that would apply under such plan for tertiary hospitals.
(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 1 insofar as such requirements apply and are effective with respect to a health insurance issuer that offers group health insurance coverage. In applying the previous sentence with respect to requirements under paragraph (8) of
(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 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
(5) Contract requirement for managed care entities
With respect to any contract with a managed care entity under
(6) Enrollment of participating providers
(A) In general
Beginning not later than January 1, 2018, a State shall require that, in order to participate as a provider in the network of a managed care entity that provides services to, or orders, prescribes, refers, or certifies eligibility for services for, individuals who are eligible for medical assistance under the State plan under this subchapter (or under a waiver of the plan) and who are enrolled with the entity, the provider is enrolled consistent with
(B) Rule of construction
Nothing in subparagraph (A) shall be construed as requiring a provider described in such subparagraph to provide services to individuals who are not enrolled with a managed care entity under this subchapter.
(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).
(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; adequacy of payment for primary care services
A contract under
(g) Identification of patients for purposes of making DSH payments
Each contract with a managed care entity under
(1) to report to the State information necessary to determine the hospital services provided under the contract (and the identity of hospitals providing such services) for purposes of applying
(2) to include a sponsorship code in the identification card issued to individuals covered under this subchapter in order that a hospital may identify a patient as being entitled to benefits under this subchapter.
(h) Special rules with respect to Indian enrollees, Indian health care providers, and Indian managed care entities
(1) Enrollee option to select an Indian health care provider as primary care provider
In the case of a non-Indian Medicaid managed care entity that—
(A) has an Indian enrolled with the entity; and
(B) has an Indian health care provider that is participating as a primary care provider within the network of the entity,
insofar as the Indian is otherwise eligible to receive services from such Indian health care provider and the Indian health care provider has the capacity to provide primary care services to such Indian, the contract with the entity under
(2) Assurance of payment to Indian health care providers for provision of covered services
Each contract with a managed care entity under
(A) Demonstration of access to Indian health care providers and application of alternative payment arrangements
Subject to subparagraph (C), to—
(i) demonstrate that the number of Indian health care providers that are participating providers with respect to such entity are sufficient to ensure timely access to covered Medicaid managed care services for those Indian enrollees who are eligible to receive services from such providers; and
(ii) agree to pay Indian health care providers, whether such providers are participating or nonparticipating providers with respect to the entity, for covered Medicaid managed care services provided to those Indian enrollees who are eligible to receive services from such providers at a rate equal to the rate negotiated between such entity and the provider involved or, if such a rate has not been negotiated, at a rate 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 participating provider which is not an Indian health care provider.
The Secretary shall establish procedures for applying the requirements of clause (i) in States where there are no or few Indian health providers.
(B) Prompt payment
To agree to make prompt payment (consistent with rule for prompt payment of providers under
(C) Application of special payment requirements for federally-qualified health centers and for services provided by certain Indian health care providers
(i) Federally-qualified health centers
(I) Managed care entity payment requirement
To agree to pay any Indian health care provider that is a federally-qualified health center under this subchapter but not a participating provider with respect to the entity, for the provision of covered Medicaid managed care services by such provider to an Indian enrollee of the entity at a rate equal to the amount of payment that the entity would pay a federally-qualified health center that is a participating provider with respect to the entity but is not an Indian health care provider for such services.
(II) Continued application of State requirement to make supplemental payment
Nothing in subclause (I) or subparagraph (A) or (B) shall be construed as waiving the application of
(ii) Payment rate for services provided by certain Indian health care providers
If the amount paid by a managed care entity to an Indian health care provider that is not a federally-qualified health center for services provided by the provider to an Indian enrollee with the managed care entity is less than the rate that applies to the provision of such services by the provider under the State plan, the plan shall provide for payment to the Indian health care provider, whether the provider is a participating or nonparticipating provider with respect to the entity, of the difference between such applicable rate and the amount paid by the managed care entity to the provider for such services.
(D) Construction
Nothing in this paragraph shall be construed as waiving the application of
(3) Special rule for enrollment for Indian managed care entities
Regarding the application of a Medicaid managed care program to Indian Medicaid managed care entities, an Indian Medicaid managed care entity may restrict enrollment under such program to Indians in the same manner as Indian Health Programs may restrict the delivery of services to Indians.
(4) Definitions
For purposes of this subsection:
(A) Indian health care provider
The term "Indian health care provider" means an Indian Health Program or an Urban Indian Organization.
(B) Indian Medicaid managed care entity
The term "Indian Medicaid managed care entity" means a managed care entity that is controlled (within the meaning of the last sentence of
(C) Non-Indian Medicaid managed care entity
The term "non-Indian Medicaid managed care entity" means a managed care entity that is not an Indian Medicaid managed care entity.
(D) Covered Medicaid managed care services
The term "covered Medicaid managed care services" means, with respect to an individual enrolled with a managed care entity, items and services for which benefits are available with respect to the individual under the contract between the entity and the State involved.
(E) Medicaid managed care program
The term "Medicaid managed care program" means a program under
(i) Drug utilization review activities and requirements
Beginning not later than October 1, 2019, each contract under a State plan with a managed care entity (other than a primary care case manager) under
(Aug. 14, 1935, ch. 531, title XIX, §1932, as added and amended
Amendment of Subsection (a)(5)
(1) in subparagraph (B)(i), by inserting ", including as required by subparagraph (E)" before the period at the end; and
(2) by adding at the end the following new subparagraph:
(E) Provider directories
(i) In general
Each managed care organization, prepaid inpatient health plan (as defined by the Secretary), prepaid ambulatory health plan (as defined by the Secretary), and, when appropriate, primary care case management entity (as defined by the Secretary) with a contract with a State to enroll individuals who are eligible for medical assistance under the State plan under this subchapter or under a waiver of such plan, shall publish (and update on at least a quarterly basis or more frequently as required by the Secretary) on a public website, a searchable directory of network providers, which shall include physicians, hospitals, pharmacies, providers of mental health services, providers of substance use disorder services, providers of long term services and supports as appropriate, and such other providers as required by the Secretary, and that includes with respect to each such provider—
(I) the name of the provider;
(II) the specialty of the provider;
(III) the address at which the provider provides services;
(IV) the telephone number of the provider; and
(V) information regarding—
(aa) the provider's cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or by a skilled medical interpreter who provides interpretation services at the provider's office;
(bb) whether the provider is accepting as new patients, individuals who receive medical assistance under this subchapter;
(cc) whether the provider's office or facility has accommodations for individuals with physical disabilities, including offices, exam rooms, and equipment;
(dd) the Internet website of such provider, if applicable; and
(ee) whether the provider offers covered services via telehealth; and
(VI) other relevant information, as required by the Secretary.
(ii) Network provider defined
In this subparagraph, the term "network provider" includes any provider, group of providers, or entity that has a network provider agreement with a managed care organization, a prepaid inpatient health plan (as defined by the Secretary), a prepaid ambulatory health plan (as defined by the Secretary), or a primary care case management entity (as defined by the Secretary) or a subcontractor of any such entity or plan, and receives payment under this subchapter directly or indirectly to order, refer, or render covered services as a result of the State's contract with the entity or plan. For purposes of this subparagraph, a network provider shall not be considered to be a subcontractor by virtue of the network provider agreement.
See 2022 Amendment notes below.
Editorial Notes
References in Text
Section 4(c) of the Indian Health Care Improvement Act of 1976, referred to in subsec. (a)(2)(C), probably means section 4(c) of the Indian Health Care Improvement Act, which was redesignated section 4(13) of the Act by
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
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
Codification
In subsec. (d)(3), "
Prior Provisions
A prior section 1932 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2022—Subsec. (a)(5)(B)(i).
Subsec. (a)(5)(E).
2020—Subsec. (b)(8).
2018—Subsec. (i).
2016—Subsec. (d)(5).
Subsec. (d)(6).
2010—Subsec. (f).
2009—Subsec. (h).
2006—Subsec. (b)(2)(D).
2000—Subsec. (g).
1999—Subsec. (c)(2)(C).
Subsec. (d)(1)(C)(ii).
Subsec. (d)(2)(B).
1997—Subsec. (b).
Subsec. (c).
Subsecs. (d), (e).
Subsec. (f).
Statutory Notes and Related Subsidiaries
Change of Name
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of
Effective Date of 2022 Amendment
Amendment by
Effective Date of 2009 Amendment
Amendment by
Effective Date of 2006 Amendment
Effective Date of 2000 Amendment
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
Construction of 2016 Amendment
Nothing in amendment by
Studies and Reports
"(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 [
"(B)
"(2)
"(A)
"(B)
1 See References in Text note below.
3 So in original. Probably should be section "438.3(s)(5)".
§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) 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) 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) each of fiscal years 2002 and 2003 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), based upon the Secretary's estimate of the ratio of—
(A) an amount equal to 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) 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
(g) Special rules
(1) In general
With respect to each period described in paragraph (2), a State shall select qualifying individuals, subject to paragraph (3), and provide such individuals with assistance, in accordance with the provisions of this section as in effect with respect to calendar year 2003, except that for such purpose—
(A) references in the preceding subsections of this section to a year, whether fiscal or calendar, shall be deemed to be references to such period; and
(B) the total allocation amount under subsection (c) for such period shall be the amount described in paragraph (2) for that period.
(2) Periods and total allocation amounts described
For purposes of this subsection—
(A) for the period that begins on January 1, 2008, and ends on September 30, 2008, the total allocation amount is $315,000,000;
(B) for the period that begins on October 1, 2008, and ends on December 31, 2008, the total allocation amount is $130,000,000;
(C) for the period that begins on January 1, 2009, and ends on September 30, 2009, the total allocation amount is $350,000,000;
(D) for the period that begins on October 1, 2009, and ends on December 31, 2009, the total allocation amount is $150,000,000;
(E) for the period that begins on January 1, 2010, and ends on September 30, 2010, the total allocation amount is $462,500,000;
(F) for the period that begins on October 1, 2010, and ends on December 31, 2010, the total allocation amount is $165,000,000;
(G) for the period that begins on January 1, 2011, and ends on September 30, 2011, the total allocation amount is $720,000,000;
(H) for the period that begins on October 1, 2011, and ends on December 31, 2011, the total allocation amount is $280,000,000;
(I) for the period that begins on January 1, 2012, and ends on September 30, 2012, the total allocation amount is $450,000,000;
(J) for the period that begins on October 1, 2012, and ends on December 31, 2012, the total allocation amount is $280,000,000;
(K) for the period that begins on January 1, 2013, and ends on September 30, 2013, the total allocation amount is $485,000,000;
(L) for the period that begins on October 1, 2013, and ends on December 31, 2013, the total allocation amount is $300,000,000;
(M) for the period that begins on January 1, 2014, and ends on September 30, 2014, the total allocation amount is $485,000,000;
(N) for the period that begins on October 1, 2014, and ends on December 31, 2014, the total allocation amount is $300,000,000;
(O) for the period that begins on January 1, 2015, and ends on March 31, 2015, the total allocation amount is $250,000,000;
(P) for the period that begins on April 1, 2015, and ends on December 31, 2015, the total allocation amount is $535,000,000; and
(Q) for 2016 and, subject to paragraph (4), for each subsequent year, the total allocation amount is $980,000,000.
(3) Rules for periods that begin after January 1
For any specific period described in subparagraph (B), (D), (F), (H), (J), (L), (N), or (P) of paragraph (2), the following applies:
(A) The specific period shall be treated as a continuation of the immediately preceding period in that calendar year for purposes of applying subsection (b)(2) and qualifying individuals who received assistance in the last month of such immediately preceding period shall be deemed to be selected for the specific period (without the need to complete an application for assistance for such period).
(B) The limit to be applied under subsection (b)(3) for the specific period shall be the same as the limit applied under such subsection for the immediately preceding period.
(C) The ratio to be applied under subsection (c)(2) for the specific period shall be the same as the ratio applied under such subsection for the immediately preceding period.
(4) Adjustment to allocations
The Secretary may increase the allocation amount under paragraph (2)(Q) for a year (beginning with 2017) up to an amount that does not exceed the product of the following:
(A) Maximum allocation amount for previous year
In the case of 2017, the allocation amount for 2016, or in the case of a subsequent year, the maximum allocation amount allowed under this paragraph for the previous year.
(B) Increase in part B premium
The monthly premium rate determined under
(C) Increase in part B enrollment
The average number of individuals (as estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services in September of the previous year) to be enrolled under part B of subchapter XVIII for months in the year divided by the average number of such individuals (as so estimated) under this subparagraph with respect to enrollments in months in the previous year.
(Aug. 14, 1935, ch. 531, title XIX, §1933, as added
Editorial Notes
Prior Provisions
A prior section 1933 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2015—Subsec. (g)(2).
Subsec. (g)(3).
Subsec. (g)(4).
2014—Subsec. (g)(2)(T).
Subsec. (g)(2)(U).
Subsec. (g)(2)(V), (W).
Subsec. (g)(3).
2013—Subsec. (g)(2)(S), (T).
Subsec. (g)(2)(U).
Subsec. (g)(3).
2012—Subsec. (g)(2)(Q), (R).
Subsec. (g)(3).
2011—Subsec. (g)(2)(Q).
2010—Subsec. (g)(2)(M).
Subsec. (g)(2)(N).
Subsec. (g)(2)(O), (P).
Subsec. (g)(3).
2009—Subsec. (g)(2)(M), (N).
Subsec. (g)(3).
2008—Subsec. (g)(2)(I).
Subsec. (g)(2)(J).
Subsec. (g)(2)(K), (L).
Subsec. (g)(3).
2007—Subsec. (g)(2)(H).
Subsec. (g)(2)(I).
Subsec. (g)(3).
2005—Subsec. (g)(2)(D) to (G).
Subsec. (g)(3).
2004—Subsec. (g).
"(1) references in the preceding subsections of this section to 'fiscal year' and 'calendar year' shall be deemed to be references to such period; and
"(2) the total allocation amount under subsection (c) of this section for such period shall be $300,000,000."
2003—Subsec. (c)(1)(E).
Subsec. (c)(2)(A).
"(i) twice the total number of individuals described in
"(ii) the total number of individuals described in
Subsec. (g).
Subsec. (g)(2).
1999—Subsec. (b)(4).
Statutory Notes and Related Subsidiaries
Effective Date of 2007 Amendment
Amendment by
Effective Date of 2005 Amendment
Amendment by
Effective Date of 2003 Amendment
Amendment by
§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 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); 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), is determined under subsection (c) 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).
(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) 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 (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.
(3) Treatment of medicare services furnished by noncontract physicians and other entities
(A) Application of medicare advantage requirement with respect to medicare services furnished by noncontract physicians and other entities
(B) Reference to related provision for noncontract providers of services
For the provision relating to limitations on balance billing against PACE providers for services covered under subchapter XVIII furnished by noncontract providers of services, see
(4) Reference to related provision for services covered under this subchapter but not under subchapter XVIII
For provisions relating to limitations on payments to providers participating under the State plan under this subchapter that do not have a contract or other agreement with a PACE provider establishing payment amounts for services covered under such plan (but not under subchapter XVIII) when such services are furnished to enrollees of that PACE provider, see
(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) 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) 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), or
(II) was operating under such a waiver and subsequently qualifies for PACE provider status pursuant to subsection (a)(3)(B)(ii).
(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)) 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).
(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.
(C) Continuation of modifications or waivers of operational requirements under demonstration status
If a PACE program operating under demonstration authority has contractual or other operating arrangements which are not otherwise recognized in regulation and which were in effect on July 1 1 2000, the Secretary (in close consultation with, and with the concurrence of, the State administering agency) shall permit any such program to continue such arrangements so long as such arrangements are found by the Secretary and the State to be reasonably consistent with the objectives of the PACE program.
(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 (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 (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.
(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) 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).
(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
Editorial Notes
References in Text
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 1939 and is classified to
Amendments
2003—Subsec. (b)(3), (4).
2000—Subsec. (f)(2)(C).
Statutory Notes and Related Subsidiaries
Change of Name
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of
Effective Date of 2003 Amendment
Amendment by
Effective Date of 2000 Amendment
Amendment by
1 So in original. Probably should be followed by a comma.
§1396u–5. Special provisions relating to medicare prescription drug benefit
(a) Requirements relating to medicare prescription drug low-income subsidies, medicare transitional prescription drug assistance, and medicare cost-sharing
As a condition of its State plan under this subchapter under
(1) Information for transitional prescription drug assistance verification
The State shall provide the Secretary with information to carry out
(2) Eligibility determinations for low-income subsidies
The State shall—
(A) make determinations of eligibility for premium and cost-sharing subsidies under and in accordance with
(B) inform the Secretary of such determinations in cases in which such eligibility is established; and
(C) otherwise provide the Secretary with such information as may be required to carry out part D, other than subpart 4, of subchapter XVIII (including
(3) Screening for eligibility, and enrollment of, beneficiaries for medicare cost-sharing
As part of making an eligibility determination required under paragraph (2) for an individual, the State shall make a determination of the individual's eligibility for medical assistance for any medicare cost-sharing described in
(4) Consideration of data transmitted by the Social Security Administration for purposes of Medicare Savings Program
The State shall accept data transmitted under
(b) Regular Federal subsidy of administrative costs
The amounts expended by a State in carrying out subsection (a) are expenditures reimbursable under the appropriate paragraph of
(c) Federal assumption of medicaid prescription drug costs for dually eligible individuals
(1) Phased-down State contribution
(A) In general
Each of the 50 States and the District of Columbia for each month beginning with January 2006 shall provide for payment under this subsection to the Secretary of the product of—
(i) the amount computed under paragraph (2)(A) for the State and month;
(ii) the total number of full-benefit dual eligible individuals (as defined in paragraph (6)) for such State and month; and
(iii) the factor for the month specified in paragraph (5).
(B) Form and manner of payment
Payment under subparagraph (A) shall be made in a manner specified by the Secretary that is similar to the manner in which State payments are made under an agreement entered into under
(C) Compliance
If a State fails to pay to the Secretary an amount required under subparagraph (A), interest shall accrue on such amount at the rate provided under
(D) Data match
The Secretary shall perform such periodic data matches as may be necessary to identify and compute the number of full-benefit dual eligible individuals for purposes of computing the amount under subparagraph (A).
(2) Amount
(A) In general
The amount computed under this paragraph for a State described in paragraph (1) and for a month in a year is equal to—
(i) 1/12 of the product of—
(I) the base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals (as computed under paragraph (3)); and
(II) a proportion equal to 100 percent minus the Federal medical assistance percentage (as defined in
(ii) increased for each year (beginning with 2004 up to and including the year involved) by the applicable growth factor specified in paragraph (4) for that year.
(B) Notice
The Secretary shall notify each State described in paragraph (1) not later than October 15 before the beginning of each year (beginning with 2006) of the amount computed under subparagraph (A) for the State for that year.
(3) Base year state medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals
(A) In general
For purposes of paragraph (2)(A), the "base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals" for a State is equal to the weighted average (as weighted under subparagraph (C)) of—
(i) the gross per capita medicaid expenditures for prescription drugs for 2003, determined under subparagraph (B); and
(ii) the estimated actuarial value of prescription drug benefits provided under a capitated managed care plan per full-benefit dual eligible individual for 2003, as determined using such data as the Secretary determines appropriate.
(B) Gross per capita medicaid expenditures for prescription drugs
(i) In general
The gross per capita medicaid expenditures for prescription drugs for 2003 under this subparagraph is equal to the expenditures, including dispensing fees, for the State under this subchapter during 2003 for covered outpatient drugs, determined per full-benefit-dual-eligible-individual for such individuals not receiving medical assistance for such drugs through a medicaid managed care plan.
(ii) Determination
In determining the amount under clause (i), the Secretary shall—
(I) use data from the Medicaid Statistical Information System (MSIS) and other available data;
(II) exclude expenditures attributable to covered outpatient prescription drugs that are not covered part D drugs (as defined in
(III) reduce such expenditures by the product of such portion and the adjustment factor (described in clause (iii)).
(iii) Adjustment factor
The adjustment factor described in this clause for a State is equal to the ratio for the State for 2003 of—
(I) aggregate payments under agreements under
(II) the gross expenditures under this subchapter for covered outpatient drugs referred to in clause (i).
Such factor shall be determined based on information reported by the State in the medicaid financial management reports (form CMS–64) for the 4 quarters of calendar year 2003 and such other data as the Secretary may require.
(C) Weighted average
The weighted average under subparagraph (A) shall be determined taking into account—
(i) with respect to subparagraph (A)(i), the average number of full-benefit dual eligible individuals in 2003 who are not described in clause (ii); and
(ii) with respect to subparagraph (A)(ii), the average number of full-benefit dual eligible individuals in such year who received in 2003 medical assistance for covered outpatient drugs through a medicaid managed care plan.
(4) Applicable growth factor
The applicable growth factor under this paragraph for—
(A) each of 2004, 2005, and 2006, is the average annual percent change (to that year from the previous year) of the per capita amount of prescription drug expenditures (as determined based on the most recent National Health Expenditure projections for the years involved); and
(B) a succeeding year, is the annual percentage increase specified in
(5) Factor
The factor under this paragraph for a month—
(A) in 2006 is 90 percent;
(B) in 2007 is 881/3 percent;
(C) in 2008 is 862/3 percent;
(D) in 2009 is 85 percent;
(E) in 2010 is 831/3 percent;
(F) in 2011 is 812/3 percent;
(G) in 2012 is 80 percent;
(H) in 2013 is 781/3 percent;
(I) in 2014 is 762/3 percent; or
(J) after December 2014, is 75 percent.
(6) Full-benefit dual eligible individual defined
(A) In general
For purposes of this section, the term "full-benefit dual eligible individual" means for a State for a month an individual who—
(i) has coverage for the month for covered part D drugs under a prescription drug plan under part D of subchapter XVIII, or under an MA–PD plan under part C of such subchapter; and
(ii) is determined eligible by the State for medical assistance for full benefits under this subchapter for such month under
(B) Treatment of medically needy and other individuals required to spend down
In applying subparagraph (A) in the case of an individual determined to be eligible by the State for medical assistance under
(d) Coordination of prescription drug benefits
(1) Medicare as primary payor
In the case of a part D eligible individual (as defined in
(2) Coverage of certain excludable drugs
In the case of medical assistance under this subchapter with respect to a covered outpatient drug (other than a covered part D drug) furnished to an individual who is enrolled in a prescription drug plan under part D of subchapter XVIII or an MA–PD plan under part C of such subchapter, the State may elect to provide such medical assistance in the manner otherwise provided in the case of individuals who are not full-benefit dual eligible individuals or through an arrangement with such plan.
(e) Treatment of territories
(1) In general
In the case of a State, other than the 50 States and the District of Columbia—
(A) the previous provisions of this section shall not apply to residents of such State; and
(B) subject to paragraph (4), if the State establishes and submits to the Secretary a plan described in paragraph (2) (for providing medical assistance with respect to the provision of prescription drugs to part D eligible individuals), the amount otherwise determined under
(2) Plan
The Secretary shall determine that a plan is described in this paragraph if the plan—
(A) provides medical assistance with respect to the provision of covered part D drugs (as defined in
(B) provides assurances that additional amounts received by the State that are attributable to the operation of this subsection shall be used only for such assistance and related administrative expenses and that no more than 10 percent of the amount specified in paragraph (3)(A) for the State for any fiscal period shall be used for such administrative expenses; and
(C) meets such other criteria as the Secretary may establish.
(3) Increased amount
(A) In general
The amount specified in this paragraph for a State for a year is equal to the product of—
(i) the aggregate amount specified in subparagraph (B); and
(ii) the ratio (as estimated by the Secretary) of—
(I) the number of individuals who are entitled to benefits under part A 1 or enrolled under part B 1 and who reside in the State (as determined by the Secretary based on the most recent available data before the beginning of the year); to
(II) the sum of such numbers for all States that submit a plan described in paragraph (2).
(B) Aggregate amount
The aggregate amount specified in this subparagraph for—
(i) the last 3 quarters of fiscal year 2006, is equal to $28,125,000;
(ii) fiscal year 2007, is equal to $37,500,000; or
(iii) a subsequent year, is equal to the aggregate amount specified in this subparagraph for the previous year increased by annual percentage increase specified in
(4) Treatment of funding for certain fiscal years
Notwithstanding paragraph (1)(B), in the case that Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa establishes and submits to the Secretary a plan described in paragraph (2) with respect to any of fiscal years 2020 through 2021, the amount specified for such a year in paragraph (3) for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa, as the case may be, shall be taken into account in applying, as applicable, subparagraph (A)(ii), (B)(ii), (C)(ii), (D)(ii), or (E)(ii) of
(5) Report
The Secretary shall submit to Congress a report on the application of this subsection and may include in the report such recommendations as the Secretary deems appropriate.
(Aug. 14, 1935, ch. 531, title XIX, §1935, as added and amended
Editorial Notes
References in Text
No act with the title Federal Claims Collection Act of 1996, referred to in subsec. (c)(1)(C), has been enacted. However,
Parts A and B, referred to in subsec. (e)(3)(A)(ii)(I), probably means parts A and B of subchapter XVIII of this chapter. This subchapter does not contain parts.
Prior Provisions
A prior section 1935 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2019—Subsec. (e)(1)(B).
Subsec. (e)(4), (5).
2008—Subsec. (a).
2005—Subsec. (c)(3)(B)(ii)(II).
2003—Subsec. (a).
Subsec. (c).
Subsec. (c)(1)(C).
Subsec. (d).
Subsec. (e).
Statutory Notes and Related Subsidiaries
Effective Date of 2008 Amendment
Amendment by
Effective Date of 2005 Amendment
Amendment by
1 See References in Text note below.
§1396u–6. Medicaid Integrity Program
(a) In general
There is hereby established the Medicaid Integrity Program (in this section referred to as the "Program") under which the Secretary shall promote the integrity of the program under this subchapter by entering into contracts in accordance with this section with eligible entities, or otherwise, to carry out the activities described in subsection (b).
(b) Activities described
Activities described in this subsection are as follows:
(1) Review of the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk, or other basis) for which payment may be made under a State plan approved under this subchapter (or under any waiver of such plan approved under
(2) Audit of claims for payment for items or services furnished, or administrative services rendered, under a State plan under this subchapter, including—
(A) cost reports;
(B) consulting contracts; and
(C) risk contracts under
(3) Identification of overpayments to individuals or entities receiving Federal funds under this subchapter.
(4) Education or training, including at such national, State, or regional conferences as the Secretary may establish, of State or local officers, employees, or independent contractors responsible for the administration or the supervision of the administration of the State plan under this subchapter, providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care.
(c) Eligible entity and contracting requirements
(1) In general
An entity is eligible to enter into a contract under the Program to carry out any of the activities described in subsection (b) if the entity satisfies the requirements of paragraphs (2) and (3).
(2) Eligibility requirements
The requirements of this paragraph are the following:
(A) The entity has demonstrated capability to carry out the activities described in subsection (b).
(B) In carrying out such activities, the entity agrees to cooperate with the Inspector General of the Department of Health and Human Services, the Attorney General, and other law enforcement agencies, as appropriate, in the investigation and deterrence of fraud and abuse in relation to this subchapter and in other cases arising out of such activities.
(C) The entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement.
(D) The entity agrees to provide the Secretary and the Inspector General of the Department of Health and Human Services with such performance statistics (including the number and amount of overpayments recovered, the number of fraud referrals, and the return on investment of such activities by the entity) as the Secretary or the Inspector General may request.
(E) The entity meets such other requirements as the Secretary may impose.
(3) Contracting requirements
The entity has contracted with the Secretary in accordance with such procedures as the Secretary shall by regulation establish, except that such procedures shall include the following:
(A) Procedures for identifying, evaluating, and resolving organizational conflicts of interest that are generally applicable to Federal acquisition and procurement.
(B) Competitive procedures to be used—
(i) when entering into new contracts under this section;
(ii) when entering into contracts that may result in the elimination of responsibilities under section 202(b) of the Health Insurance Portability and Accountability Act of 1996; and
(iii) at any other time considered appropriate by the Secretary.
(C) Procedures under which a contract under this section may be renewed without regard to any provision of law requiring competition if the contractor has met or exceeded the performance requirements established in the current contract.
The Secretary may enter into such contracts without regard to final rules having been promulgated.
(4) Limitation on contractor liability
The Secretary shall by regulation provide for the limitation of a contractor's liability for actions taken to carry out a contract under the Program, and such regulation shall, to the extent the Secretary finds appropriate, employ the same or comparable standards and other substantive and procedural provisions as are contained in
(d) Comprehensive plan for program integrity
(1) 5-year plan
With respect to the 5-fiscal year period beginning with fiscal year 2006, and each such 5-fiscal year period that begins thereafter, the Secretary shall establish a comprehensive plan for ensuring the integrity of the program established under this subchapter by combatting fraud, waste, and abuse.
(2) Consultation
Each 5-fiscal year plan established under paragraph (1) shall be developed by the Secretary in consultation with the Attorney General, the Director of the Federal Bureau of Investigation, the Comptroller General of the United States, the Inspector General of the Department of Health and Human Services, and State officials with responsibility for controlling provider fraud and abuse under State plans under this subchapter.
(e) Appropriation
(1) In general
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to carry out the Medicaid Integrity Program under this section (including the costs of equipment, salaries and benefits, and travel and training), without further appropriation—
(A) for fiscal year 2006, $5,000,000;
(B) for each of fiscal years 2007 and 2008, $50,000,000;
(C) for each of fiscal years 2009 and 2010, $75,000,000; and
(D) for each fiscal year after fiscal year 2010, the amount appropriated under this paragraph for the previous fiscal year, increased by the percentage increase in the consumer price index for all urban consumers (all items; United States city average) over the previous year.
(2) Availability; authority for use of funds
(A) Availability
Amounts appropriated pursuant to paragraph (1) shall remain available until expended.
(B) Authority for use of funds for transportation and travel expenses for attendees at education, training, or consultative activities
(i) In general
The Secretary may use amounts appropriated pursuant to paragraph (1) to pay for transportation and the travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of
(ii) Public disclosure
The Secretary shall make available on a website of the Centers for Medicare & Medicaid Services that is accessible to the public—
(I) the total amount of funds expended for each conference conducted under the authority of subsection (b)(4); and
(II) the amount of funds expended for each such conference that were for transportation and for travel expenses.
(3) Increase in CMS staffing devoted to protecting Medicaid program integrity
From the amounts appropriated under paragraph (1), the Secretary shall increase by 100, or such number as determined necessary by the Secretary to carry out the Program, the number of full-time equivalent employees whose duties consist solely of protecting the integrity of the Medicaid program established under this section by providing effective support and assistance to States to combat provider fraud and abuse.
(4) Evaluations
The Secretary shall conduct evaluations of eligible entities which the Secretary contracts with under the Program not less frequently than every 3 years.
(5) Annual report
Not later than 180 days after the end of each fiscal year (beginning with fiscal year 2006), the Secretary shall submit a report to Congress which identifies—
(A) the use of funds appropriated pursuant to paragraph (1); and
(B) the effectiveness of the use of such funds.
(Aug. 14, 1935, ch. 531, title XIX, §1936, as added
Editorial Notes
References in Text
Section 202(b) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (c)(3)(B)(ii), is section 202(b) of title II of
Prior Provisions
A prior section 1936 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2015—Subsec. (a).
Subsec. (e)(1).
Subsec. (e)(3).
2010—Subsec. (c)(2)(D), (E).
Subsec. (e)(1)(C).
Subsec. (e)(1)(D).
Subsec. (e)(4), (5).
2008—Subsec. (b)(4).
Subsec. (e)(2).
Subsec. (e)(2)(B)(ii).
Statutory Notes and Related Subsidiaries
Effective Date of 2008 Amendment
§1396u–7. State flexibility in benefit packages
(a) State option of providing benchmark benefits
(1) Authority
(A) In general
Notwithstanding
(i) provides benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2); and
(ii) for any individual described in
(B) Limitation
The State may only exercise the option under subparagraph (A) for an individual eligible under subclause (VIII) of
(C) Option of additional benefits
In the case of coverage described in subparagraph (A), a State, at its option, may provide such additional benefits as the State may specify.
(D) Treatment as medical assistance
Payment of premiums for such coverage under this subsection shall be treated as payment of other insurance premiums described in the third sentence of
(E) Rule of construction
Nothing in this paragraph shall be construed as—
(i) requiring a State to offer all or any of the items and services required by subparagraph (A)(ii) through an issuer of benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2);
(ii) preventing a State from offering all or any of the items and services required by subparagraph (A)(ii) through an issuer of benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2); or
(iii) affecting a child's entitlement to care and services described in subsections (a)(4)(B) and (r) of
(F) Necessary transportation
Notwithstanding the preceding provisions of this paragraph, a State may not provide medical assistance through the enrollment of an individual with benchmark coverage or benchmark equivalent coverage described in subparagraph (A)(i) unless, subject to
(i) ensures necessary transportation for individuals enrolled under such package or coverage to and from providers; and
(ii) provides a description of the methods that will be used to ensure such transportation.
(2) Application
(A) In general
Except as provided in subparagraph (B), a State may require that a full-benefit eligible individual (as defined in subparagraph (C)) within a group obtain benefits under this subchapter through enrollment in coverage described in paragraph (1)(A). A State may apply the previous sentence to individuals within 1 or more groups of such individuals.
(B) Limitation on application
A State may not require under subparagraph (A) an individual to obtain benefits through enrollment described in paragraph (1)(A) if the individual is within one of the following categories of individuals:
(i) Mandatory pregnant women
The individual is a pregnant woman who is required to be covered under the State plan under
(ii) Blind or disabled individuals
The individual qualifies for medical assistance under the State plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits under subchapter XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of
(iii) Dual eligibles
The individual is entitled to benefits under any part of subchapter XVIII.
(iv) Terminally ill hospice patients
The individual is terminally ill and is receiving benefits for hospice care under this subchapter.
(v) Eligible on basis of institutionalization
The individual is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, and 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 the individual's income required for personal needs.
(vi) Medically frail and special medical needs individuals
The individual is medically frail or otherwise an individual with special medical needs (as identified in accordance with regulations of the Secretary).
(vii) Beneficiaries qualifying for long-term care services
The individual qualifies based on medical condition for medical assistance for long-term care services described in
(viii) Children in foster care receiving child welfare services and children receiving foster care or adoption assistance
The individual is an individual with respect to whom child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care or with respect to whom adoption or foster care assistance is made available under part E of such subchapter, without regard to age, or the individual qualifies for medical assistance on the basis of
(ix) TANF and section 1396u–1 parents
The individual qualifies for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of subchapter IV (as in effect on or after the welfare reform effective date defined in
(x) Women in the breast or cervical cancer program
The individual is a woman who is receiving medical assistance by virtue of the application of
(xi) Limited services beneficiaries
The individual—
(I) qualifies for medical assistance on the basis of
(II) is not a qualified alien (as defined in
(C) Full-benefit eligible individuals
(i) In general
For purposes of this paragraph, subject to clause (ii), the term "full-benefit eligible individual" means for a State for a month an individual who is determined eligible by the State for medical assistance for all services defined in
(ii) Exclusion of medically needy and spend-down populations
Such term shall not include an individual determined to be eligible by the State for medical assistance under
(b) Benchmark benefit packages
(1) In general
For purposes of subsection (a)(1), subject to paragraphs (5) and (6), each of the following coverages shall be considered to be benchmark coverage:
(A) FEHBP-equivalent health insurance coverage
The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under
(B) State employee coverage
A health benefits coverage plan that is offered and generally available to State employees in the State involved.
(C) Coverage offered through HMO
The health insurance coverage plan that—
(i) is offered by a health maintenance organization (as defined in
(ii) has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.
(D) Secretary-approved coverage
Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population proposed to be provided such coverage.
(2) Benchmark-equivalent coverage
For purposes of subsection (a)(1), subject to paragraphs (5) and (6) 1 coverage that meets the following requirement shall be considered to be benchmark-equivalent coverage:
(A) Inclusion of basic services
The coverage includes benefits for items and services within each of the following categories of basic services:
(i) Inpatient and outpatient hospital services.
(ii) Physicians' surgical and medical services.
(iii) Laboratory and x-ray services.
(iv) Coverage of prescription drugs.
(v) Mental health services.
(vi) Well-baby and well-child care, including age-appropriate immunizations.
(vii) Other appropriate preventive services, as designated by the Secretary.
(B) Aggregate actuarial value equivalent to benchmark package
The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages described in paragraph (1).
(C) Substantial actuarial value for additional services included in benchmark package
With respect to each of the following categories of additional services for which coverage is provided under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package:
(i) Vision services.
(ii) Hearing services.
(3) Determination of actuarial value
The actuarial value of coverage of benchmark benefit packages shall be set forth in an actuarial opinion in an actuarial report that has been prepared—
(A) by an individual who is a member of the American Academy of Actuaries;
(B) using generally accepted actuarial principles and methodologies;
(C) using a standardized set of utilization and price factors;
(D) using a standardized population that is representative of the population involved;
(E) applying the same principles and factors in comparing the value of different coverage (or categories of services);
(F) without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and
(G) taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under this subchapter that results from the limitations on cost sharing under such coverage.
The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D).
(4) Coverage of rural health clinic and FQHC services
Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark equivalent coverage under this section unless—
(A) the individual has access, through such coverage or otherwise, to services described in subparagraphs (B) and (C) of
(B) payment for such services is made in accordance with the requirements of
(5) Minimum standards
Effective January 1, 2014, any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) must provide at least essential health benefits as described in
(6) Mental health services parity
(A) In general
In the case of any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) that is offered by an entity that is not a medicaid managed care organization and that provides both medical and surgical benefits and mental health or substance use disorder benefits, the entity shall ensure that the financial requirements and treatment limitations applicable to such mental health or substance use disorder benefits comply with the requirements of
(B) Deemed compliance
Coverage provided with respect to an individual described in
(7) Coverage of family planning services and supplies
Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless such coverage includes for any individual described in
(8) COVID–19 vaccines, testing, and treatment
Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless, during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in
(A) COVID–19 vaccines and administration of the vaccines; and
(B) testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of such an individual who is diagnosed with or presumed to have COVID–19, during the period such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State plan (or waiver of such plan).
(c) Publication of provisions affected
With respect to a State plan amendment to provide benchmark benefits in accordance with subsections (a) and (b) that is approved by the Secretary, the Secretary shall publish on the Internet website of the Centers for Medicare & Medicaid Services, a list of the provisions of this subchapter that the Secretary has determined do not apply in order to enable the State to carry out the plan amendment and the reason for each such determination on the date such approval is made, and shall publish such list in the Federal Register and 2 not later than 30 days after such date of approval.
(Aug. 14, 1935, ch. 531, title XIX, §1937, as added
Editorial Notes
Prior Provisions
A prior section 1937 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Amendments
2021—Subsec. (b)(8).
2020—Subsec. (a)(1)(A).
Subsec. (a)(1)(F).
Subsec. (b)(5).
Subsec. (b)(6)(A).
2010—Subsec. (a)(1)(B).
Subsec. (a)(2)(B)(viii).
Subsec. (b)(1).
Subsec. (b)(2).
Subsec. (b)(2)(A)(iv) to (vii).
Subsec. (b)(2)(C).
"(i) Coverage of prescription drugs.
"(ii) Mental health services."
Subsec. (b)(5), (6).
Subsec. (b)(7).
2009—Subsec. (a)(1)(A).
Subsec. (a)(1)(A)(i).
Subsec. (a)(1)(A)(ii).
Subsec. (a)(1)(C).
Subsec. (a)(1)(E).
Subsec. (a)(2)(B)(viii).
Subsec. (c).
Statutory Notes and Related Subsidiaries
Effective Date of 2020 Amendment
Amendment by section 209(a)(2) of
Amendment by section 210(c) of
Effective Date of 2010 Amendment
Amendment by section 2004(c)(2) of
Amendment by section 2303(c) of
Effective Date of 2009 Amendment
Effective Date
1 So in original. Probably should be followed by a comma.
§1396u–8. Health opportunity accounts
(a) Authority
(1) In general
Notwithstanding any other provision of this subchapter, the Secretary shall establish a demonstration program under which States may provide under their State plans under this subchapter (including such a plan operating under a statewide waiver under
(2) Initial demonstration
(A) In general
The demonstration program under this section shall begin on January 1, 2007. During the first 5 years of such program, the Secretary shall not approve more than 10 States to conduct demonstration programs under this section, with each State demonstration program covering 1 or more geographic areas specified by the State. After such 5-year period—
(i) unless the Secretary finds, taking into account cost-effectiveness, quality of care, and other criteria that the Secretary specifies, that a State demonstration program previously implemented has been unsuccessful, such a demonstration program may be extended or made permanent in the State; and
(ii) unless the Secretary finds, taking into account cost-effectiveness, quality of care, and other criteria that the Secretary specifies, that all State demonstration programs previously implemented were unsuccessful, other States may implement State demonstration programs.
(B) GAO report
(i) In general
Not later than 3 months after the end of the 5-year period described in subparagraph (A), the Comptroller General of the United States shall submit a report to Congress evaluating the demonstration programs conducted under this section during such period.
(ii) Appropriation
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Comptroller General of the United States, $550,000 for the period of fiscal years 2007 through 2010 to carry out clause (i).
(3) Approval
The Secretary shall not approve a State demonstration program under paragraph (1) unless the program includes the following:
(A) Creating patient awareness of the high cost of medical care.
(B) Providing incentives to patients to seek preventive care services.
(C) Reducing inappropriate use of health care services.
(D) Enabling patients to take responsibility for health outcomes.
(E) Providing enrollment counselors and ongoing education activities.
(F) Providing transactions involving health opportunity accounts to be conducted electronically and without cash.
(G) Providing access to negotiated provider payment rates consistent with this section.
Nothing in this section shall be construed as preventing a State demonstration program from providing incentives for patients obtaining appropriate preventive care (as defined for purposes of section 223(c)(2)(C) of the Internal Revenue Code of 1986), such as additional account contributions for an individual demonstrating healthy prevention practices.
(4) No requirement for statewideness
Nothing in this section or any other provision of law shall be construed to require that a State must provide for the implementation of a State demonstration program on a Statewide 1 basis.
(b) Eligible population groups
(1) In general
A State demonstration program under this section shall specify the eligible population groups consistent with paragraphs (2) and (3).
(2) Eligibility limitations during initial demonstration period
During the initial 5 years of the demonstration program under this section, a State demonstration program shall not apply to any of the following individuals:
(A) Individuals who are 65 years of age or older.
(B) Individuals who are disabled, regardless of whether or not their eligibility for medical assistance under this subchapter is based on such disability.
(C) Individuals who are eligible for medical assistance under this subchapter only because they are (or were within the previous 60 days) pregnant.
(D) Individuals who have been eligible for medical assistance for a continuous period of less than 3 months.
(3) Additional limitations
A State demonstration program shall not apply to any individual within a category of individuals described in
(4) Limitations
(A) State option
This subsection shall not be construed as preventing a State from further limiting eligibility.
(B) On enrollees in Medicaid managed care organizations
Insofar as the State provides for eligibility of individuals who are enrolled in Medicaid managed care organizations, such individuals may participate in the State demonstration program only if the State provides assurances satisfactory to the Secretary that the following conditions are met with respect to any such organization:
(i) In no case may the number of such individuals enrolled in the organization who participate in the program exceed 5 percent of the total number of individuals enrolled in such organization.
(ii) The proportion of enrollees in the organization who so participate is not significantly disproportionate to the proportion of such enrollees in other such organizations who participate.
(iii) The State has provided for an appropriate adjustment in the per capita payments to the organization to account for such participation, taking into account differences in the likely use of health services between enrollees who so participate and enrollees who do not so participate.
(5) Voluntary participation
An eligible individual shall be enrolled in a State demonstration program only if the individual voluntarily enrolls. Except in such hardship cases as the Secretary shall specify, such an enrollment shall be effective for a period of 12 months, but may be extended for additional periods of 12 months each with the consent of the individual.
(6) 1-year moratorium for reenrollment
An eligible individual who, for any reason, is disenrolled from a State demonstration program conducted under this section shall not be permitted to reenroll in such program before the end of the 1-year period that begins on the effective date of such disenrollment.
(c) Alternative benefits
(1) In general
The alternative benefits provided under this section shall consist, consistent with this subsection, of at least—
(A) coverage for medical expenses in a year for items and services for which benefits are otherwise provided under this subchapter after an annual deductible described in paragraph (2) has been met; and
(B) contribution into a health opportunity account.
Nothing in subparagraph (A) shall be construed as preventing a State from providing for coverage of preventive care (referred to in subsection (a)(3)) within the alternative benefits without regard to the annual deductible.
(2) Annual deductible
The amount of the annual deductible described in paragraph (1)(A) shall be at least 100 percent, but no more than 110 percent, of the annualized amount of contributions to the health opportunity account under subsection (d)(2)(A)(i), determined without regard to any limitation described in subsection (d)(2)(C)(i)(II).
(3) Access to negotiated provider payment rates
(A) Fee-for-service enrollees
In the case of an individual who is participating in a State demonstration program and who is not enrolled with a Medicaid managed care organization, the State shall provide that the individual may obtain demonstration program Medicaid services from—
(i) any participating provider under this subchapter at the same payment rates that would be applicable to such services if the deductible described in paragraph (1)(A) was not applicable; or
(ii) any other provider at payment rates that do not exceed 125 percent of the payment rate that would be applicable to such services furnished by a participating provider under this subchapter if the deductible described in paragraph (1)(A) was not applicable.
(B) Treatment under medicaid managed care plans
In the case of an individual who is participating in a State demonstration program and is enrolled with a Medicaid managed care organization, the State shall enter into an arrangement with the organization under which the individual may obtain demonstration program Medicaid services from any provider described in clause (ii) of subparagraph (A) at payment rates that do not exceed the payment rates that may be imposed under that clause.
(C) Computation
The payment rates described in subparagraphs (A) and (B) shall be computed without regard to any cost sharing that would be otherwise applicable under
(D) Definitions
For purposes of this paragraph:
(i) The term "demonstration program Medicaid services" means, with respect to an individual participating in a State demonstration program, services for which the individual would be provided medical assistance under this subchapter but for the application of the deductible described in paragraph (1)(A).
(ii) The term "participating provider" means—
(I) with respect to an individual described in subparagraph (A), a health care provider that has entered into a participation agreement with the State for the provision of services to individuals entitled to benefits under the State plan; or
(II) with respect to an individual described in subparagraph (B) who is enrolled in a Medicaid managed care organization, a health care provider that has entered into an arrangement for the provision of services to enrollees of the organization under this subchapter.
(4) No effect on subsequent benefits
Except as provided under paragraphs (1) and (2), alternative benefits for an eligible individual shall consist of the benefits otherwise provided to the individual, including cost sharing relating to such benefits.
(5) Overriding cost sharing and comparability requirements for alternative benefits
The provisions of this subchapter relating to cost sharing for benefits (including
(6) Treatment as medical assistance
Subject to subparagraphs (D) and (E) of subsection (d)(2), payments for alternative benefits under this section (including contributions into a health opportunity account) shall be treated as medical assistance for purposes of
(7) Use of tiered deductible and cost sharing
(A) In general
A State—
(i) may vary the amount of the annual deductible applied under paragraph (1)(A) based on the income of the family involved so long as it does not favor families with higher income over those with lower income; and
(ii) may vary the amount of the maximum out-of-pocket cost sharing (as defined in subparagraph (B)) based on the income of the family involved so long as it does not favor families with higher income over those with lower income.
(B) Maximum out-of-pocket cost sharing
For purposes of subparagraph (A)(ii), the term "maximum out-of-pocket cost sharing" means, for an individual or family, the amount by which the annual deductible level applied under paragraph (1)(A) to the individual or family exceeds the balance in the health opportunity account for the individual or family.
(8) Contributions by employers
Nothing in this section shall be construed as preventing an employer from providing health benefits coverage consisting of the coverage described in paragraph (1)(A) to individuals who are provided alternative benefits under this section.
(d) Health opportunity account
(1) In general
For purposes of this section, the term "health opportunity account" means an account that meets the requirements of this subsection.
(2) Contributions
(A) In general
No contribution may be made into a health opportunity account except—
(i) contributions by the State under this subchapter; and
(ii) contributions by other persons and entities, such as charitable organizations, as permitted under
(B) State contribution
A State shall specify the contribution amount that shall be deposited under subparagraph (A)(i) into a health opportunity account.
(C) Limitation on annual State contribution provided and permitting imposition of maximum account balance
(i) In general
A State—
(I) may impose limitations on the maximum contributions that may be deposited under subparagraph (A)(i) into a health opportunity account in a year;
(II) may limit contributions into such an account once the balance in the account reaches a level specified by the State; and
(III) subject to clauses (ii) and (iii) and subparagraph (D)(i), may not provide contributions described in subparagraph (A)(i) to a health opportunity account on behalf of an individual or family to the extent the amount of such contributions (including both State and Federal shares) exceeds, on an annual basis, $2,500 for each individual (or family member) who is an adult and $1,000 for each individual (or family member) who is a child.
(ii) Indexing of dollar limitations
For each year after 2006, the dollar amounts specified in clause (i)(III) shall be annually increased by the Secretary by a percentage that reflects the annual percentage increase in the medical care component of the consumer price index for all urban consumers.
(iii) Budget neutral adjustment
A State may provide for dollar limitations in excess of those specified in clause (i)(III) (as increased under clause (ii)) for specified individuals if the State provides assurances satisfactory to the Secretary that contributions otherwise made to other individuals will be reduced in a manner so as to provide for aggregate contributions that do not exceed the aggregate contributions that would otherwise be permitted under this subparagraph.
(D) Limitations on Federal matching
(i) State contribution
A State may contribute under subparagraph (A)(i) amounts to a health opportunity account in excess of the limitations provided under subparagraph (C)(i)(III), but no Federal financial participation shall be provided under
(ii) No FFP for private contributions
No Federal financial participation shall be provided under
(E) Application of different matching rates
The Secretary shall provide a method under which, for expenditures made from a health opportunity account for medical care for which the Federal matching rate under
(3) Use
(A) General uses
(i) In general
Subject to the succeeding provisions of this paragraph, amounts in a health opportunity account may be used for payment of such health care expenditures as the State specifies.
(ii) General limitation
Subject to subparagraph (B)(ii), in no case shall such account be used for payment for health care expenditures that are not payment of medical care (as defined by section 213(d) of the Internal Revenue Code of 1986).
(iii) State restrictions
In applying clause (i), a State may restrict payment for—
(I) providers of items and services to providers that are licensed or otherwise authorized under State law to provide the item or service and may deny payment for such a provider on the basis that the provider has been found, whether with respect to this subchapter or any other health benefit program, to have failed to meet quality standards or to have committed 1 or more acts of fraud or abuse; and
(II) items and services insofar as the State finds they are not medically appropriate or necessary.
(iv) Electronic withdrawals
The State demonstration program shall provide for a method whereby withdrawals may be made from the account for such purposes using an electronic system and shall not permit withdrawals from the account in cash.
(B) Maintenance of health opportunity account after becoming ineligible for public benefit
(i) In general
Notwithstanding any other provision of law, if an account holder of a health opportunity account becomes ineligible for benefits under this subchapter because of an increase in income or assets—
(I) no additional contribution shall be made into the account under paragraph (2)(A)(i);
(II) subject to clause (iii), the balance in the account shall be reduced by 25 percent; and
(III) subject to the succeeding provisions of this subparagraph, the account shall remain available to the account holder for 3 years after the date on which the individual becomes ineligible for such benefits for withdrawals under the same terms and conditions as if the account holder remained eligible for such benefits, and such withdrawals shall be treated as medical assistance in accordance with subsection (c)(6).
(ii) Special rules
Withdrawals under this subparagraph from an account—
(I) shall be available for the purchase of health insurance coverage; and
(II) may, subject to clause (iv), be made available (at the option of the State) for such additional expenditures (such as job training and tuition expenses) specified by the State (and approved by the Secretary) as the State may specify.
(iii) Exception from 25 percent savings to Government for private contributions
Clause (i)(II) shall not apply to the portion of the account that is attributable to contributions described in paragraph (2)(A)(ii). For purposes of accounting for such contributions, withdrawals from a health opportunity account shall first be attributed to contributions described in paragraph (2)(A)(i).
(iv) Condition for non-health withdrawals
No withdrawal may be made from an account under clause (ii)(II) unless the account holder has participated in the program under this section for at least 1 year.
(v) No requirement for continuation of coverage
An account holder of a health opportunity account, after becoming ineligible for medical assistance under this subchapter, is not required to purchase high-deductible or other insurance as a condition of maintaining or using the account.
(4) Administration
A State may coordinate administration of health opportunity accounts through the use of a third party administrator and reasonable expenditures for the use of such administrator shall be reimbursable to the State in the same manner as other administrative expenditures under
(5) Treatment
Amounts in, or contributed to, a health opportunity account shall not be counted as income or assets for purposes of determining eligibility for benefits under this subchapter.
(6) Unauthorized withdrawals
A State may establish procedures—
(A) to penalize or remove an individual from the health opportunity account based on nonqualified withdrawals by the individual from such an account; and
(B) to recoup costs that derive from such nonqualified withdrawals.
(Aug. 14, 1935, ch. 531, title XIX, §1938, as added
Editorial Notes
References in Text
The Internal Revenue Code of 1986, referred to in subsecs. (a)(3) and (d)(3)(A)(ii), is classified generally to Title 26, Internal Revenue Code.
Prior Provisions
A prior section 1938 of act Aug. 14, 1935, was renumbered section 1939 and is classified to
Statutory Notes and Related Subsidiaries
Prohibiting Initiation of New Health Opportunity Account Demonstration Programs
1 So in original. Probably should not be capitalized.
§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, §1939, formerly §1920, as added
Editorial Notes
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).
Statutory Notes and Related Subsidiaries
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
1 See References in Text note below.
§1396w. Asset verification through access to information held by financial institutions
(a) Implementation
(1) In general
Subject to the provisions of this section, each State shall implement an asset verification program described in subsection (b), for purposes of determining or redetermining the eligibility of an individual for medical assistance under the State plan under this subchapter.
(2) Plan submittal
In order to meet the requirement of paragraph (1), each State shall—
(A) submit not later than a deadline specified by the Secretary consistent with paragraph (3), a State plan amendment under this subchapter that describes how the State intends to implement the asset verification program; and
(B) provide for implementation of such program for eligibility determinations and redeterminations made on or after 6 months after the deadline established for submittal of such plan amendment.
(3) Phase-in
(A) In general
(i) Implementation in current asset verification demo States
The Secretary shall require those States specified in subparagraph (C) (to which an asset verification program has been applied before June 30, 2008) to implement an asset verification program under this subsection by the end of fiscal year 2009.
(ii) Implementation in other States
The Secretary shall require other States to submit and implement an asset verification program under this subsection in such manner as is designed to result in the application of such programs, in the aggregate for all such other States, to enrollment of approximately, but not less than, the following percentage of enrollees, in the aggregate for all such other States, by the end of the fiscal year involved:
(I) 12.5 percent by the end of fiscal year 2009.
(II) 25 percent by the end of fiscal year 2010.
(III) 50 percent by the end of fiscal year 2011.
(IV) 75 percent by the end of fiscal year 2012.
(V) 100 percent by the end of fiscal year 2013.
(iii) Implementation in Puerto Rico
The Secretary shall require Puerto Rico to implement an asset verification program under this subsection by January 1, 2026.
(B) Consideration
In selecting States under subparagraph (A)(ii), the Secretary shall consult with the States involved and take into account the feasibility of implementing asset verification programs in each such State.
(C) States specified
The States specified in this subparagraph are California, New York, and New Jersey.
(D) Construction
Nothing in subparagraph (A)(ii) shall be construed as preventing a State from requesting, and the Secretary from approving, the implementation of an asset verification program in advance of the deadline otherwise established under such subparagraph.
(4) Exemption of certain territories
This section shall only apply to the 50 States, the District of Columbia, and Puerto Rico.
(b) Asset verification program
(1) In general
For purposes of this section, an asset verification program means a program described in paragraph (2) under which a State—
(A) requires each applicant for, or recipient of, medical assistance under the State plan under this subchapter on the basis of being aged, blind, or disabled to provide authorization by such applicant or recipient (and any other person whose resources are required by law to be disclosed to determine the eligibility of the applicant or recipient for such assistance) for the State to obtain (subject to the cost reimbursement requirements of section 1115(a) of the Right to Financial Privacy Act 1 [
(B) uses the authorization provided under subparagraph (A) to verify the financial resources of such applicant or recipient (and such other person, as applicable), in order to determine or redetermine the eligibility of such applicant or recipient for medical assistance under the State plan.
(2) Program described
A program described in this paragraph is a program for verifying individual assets in a manner consistent with the approach used by the Commissioner of Social Security under
(c) Duration of authorization
Notwithstanding section 1104(a)(1) of the Right to Financial Privacy Act 1 [
(1) the rendering of a final adverse decision on the applicant's application for medical assistance under the State's plan under this subchapter;
(2) the cessation of the recipient's eligibility for such medical assistance; or
(3) the express revocation by the applicant or recipient (or such other person described in subsection (b)(1), as applicable) of the authorization, in a written notification to the State.
(d) Treatment of Right to Financial Privacy Act requirements
(1) An authorization obtained by the State under subsection (b)(1) shall be considered to meet the requirements of the Right to Financial Privacy Act 1 for purposes of section 1103(a) of such Act [
(2) The certification requirements of section 1103(b) of the Right to Financial Privacy Act 1 [
(3) A request by the State pursuant to an authorization provided under subsection (b)(1) is deemed to meet the requirements of section 1104(a)(3) of the Right to Financial Privacy Act 1 [
(e) Required disclosure
The State shall inform any person who provides authorization pursuant to subsection (b)(1)(A) of the duration and scope of the authorization.
(f) Refusal or revocation of authorization
If an applicant for, or recipient of, medical assistance under the State plan under this subchapter (or such other person described in subsection (b)(1), as applicable) refuses to provide, or revokes, any authorization made by the applicant or recipient (or such other person, as applicable) under subsection (b)(1)(A) for the State to obtain from any financial institution any financial record, the State may, on that basis, determine that the applicant or recipient is ineligible for medical assistance.
(g) Use of contractor
For purposes of implementing an asset verification program under this section, a State may select and enter into a contract with a public or private entity meeting such criteria and qualifications as the State determines appropriate, consistent with requirements in regulations relating to general contracting provisions and with
(h) Technical assistance
The Secretary shall provide States with technical assistance to aid in implementation of an asset verification program under this section.
(i) Reports
A State implementing an asset verification program under this section shall furnish to the Secretary such reports concerning the program, at such times, in such format, and containing such information as the Secretary determines appropriate.
(j) Treatment of program expenses
Notwithstanding any other provision of law, reasonable expenses of States in carrying out the program under this section shall be treated, for purposes of
(k) Reduction in FMAP after 2020 for non-compliant States
(1) In general
With respect to a calendar quarter, the Federal medical assistance percentage otherwise determined under
(A) a non-compliant State that is one of the 50 States or the District of Columbia shall be reduced—
(i) for calendar quarters in 2021 and 2022, by 0.12 percentage points;
(ii) for calendar quarters in 2023, by 0.25 percentage points;
(iii) for calendar quarters in 2024, by 0.35 percentage points; and
(iv) for calendar quarters in 2025 and each year thereafter, by 0.5 percentage points; and
(B) a non-compliant State that is Puerto Rico shall be reduced—
(i) for calendar quarters in fiscal year 2026 beginning on or after January 1, 2026, by 0.12 percentage points;
(ii) for calendar quarters in fiscal year 2027, by 0.25 percentage points;
(iii) for calendar quarters in fiscal year 2028, by 0.35 percentage points; and
(iv) for calendar quarters in fiscal year 2029 and each fiscal year thereafter, by 0.5 percentage points.
(2) Non-compliant State defined
For purposes of this subsection, the term "non-compliant State" means a State—
(A) that is one of the 50 States, the District of Columbia, or Puerto Rico;
(B) with respect to which the Secretary has not approved a State plan amendment submitted under subsection (a)(2); and
(C) that is not operating, on an ongoing basis, an asset verification program in accordance with this section.
(Aug. 14, 1935, ch. 531, title XIX, §1940, as added
Editorial Notes
References in Text
The Right to Financial Privacy Act, referred to in subsec. (d)(1), probably means the Right to Financial Privacy Act of 1978, title XI of
Amendments
2022—Subsec. (a)(3)(A)(iii).
Subsec. (a)(4).
Subsec. (k)(1).
Subsec. (k)(2)(A).
2019—Subsec. (k).
1 See References in Text note below.
§1396w–1. Medicaid Improvement Fund
(a) Establishment
The Secretary shall establish under this subchapter a Medicaid Improvement Fund (in this section referred to as the "Fund") which shall be available to the Secretary to improve the management of the Medicaid program by the Centers for Medicare & Medicaid Services, including oversight of contracts and contractors and evaluation of demonstration projects, and, in accordance with subsection (b)(3), for the purposes of subparagraph (B) of such subsection. Payments made for activities under this subsection shall be in addition to payments that would otherwise be made for such activities.
(b) Funding
(1) In general
There shall be available to the Fund, for expenditures from the Fund for fiscal year 2023 and thereafter, $0.
(2) Funding limitation
Amounts in the Fund pursuant to paragraph (1) shall be available in advance of appropriations but only if the total amount obligated from the Fund does not exceed the amount available to the Fund under paragraph (1). Amounts in the Fund pursuant to paragraph (3) shall be available in advance of appropriations but only if the total amount obligated from the Fund does not exceed the amount available to the Fund under such paragraph (3). The Secretary may obligate funds from the Fund only if the Secretary determines (and the Chief Actuary of the Centers for Medicare & Medicaid Services and the appropriate budget officer certify) that there are available in the Fund sufficient amounts to cover all such obligations incurred consistent with the previous sentences.
(3) Additional funding for State activities relating to mechanized claims systems
(A) In general
In addition to the amount made available under paragraph (1), there shall be available to the Fund, for expenditures from the Fund in accordance with subparagraph (B), for fiscal year 2028 and thereafter, $0, to remain available until expended.
(B) Purposes
The Secretary shall use amounts made available to the Fund under subparagraph (A) to pay to each State which has a plan approved under this subchapter, for each quarter beginning during or after fiscal year 2025 an amount equal to—
(i) 100 percent minus the percent specified in clause (i) of
(ii) 100 percent minus the Federal medical assistance percentage applied under clause (iii) of such section of so much of the sums expended during such quarter (as found necessary by the Secretary under such clause) by the State as are attributable to the activities described in such clause; and
(iii) 100 percent minus the percent specified in
(Aug. 14, 1935, ch. 531, title XIX, §1941, as added
Editorial Notes
Amendments
2024—Subsec. (b)(3)(A).
2023—Subsec. (b)(3)(A).
2022—Subsec. (b)(3)(A).
2020—Subsec. (b)(1).
Subsec. (b)(3)(A).
2019—Subsec. (b)(1).
Subsec. (b)(3).
Subsec. (b)(3)(A).
2018—Subsec. (a).
Subsec. (b)(1).
Subsec. (b)(2).
Subsec. (b)(3).
Subsec. (b)(3)(A).
2016—Subsec. (b)(1).
"(A) for fiscal year 2014, $0; and
"(B) for each of fiscal years 2015 through 2018, $0."
2010—Subsec. (b)(1)(A).
Subsec. (b)(1)(B).
2009—Subsec. (b)(1)(B).
§1396w–2. Authorization to receive relevant information
(a) In general
Notwithstanding any other provision of law, a Federal or State agency or private entity in possession of the sources of data directly relevant to eligibility determinations under this subchapter (including eligibility files maintained by Express Lane agencies described in
(b) Requirements for conveyance
Data or information may be conveyed pursuant to subsection (a) only if the following requirements are met:
(1) The individual whose circumstances are described in the data or information (or such individual's parent, guardian, caretaker relative, or authorized representative) has either provided advance consent to disclosure or has not objected to disclosure after receiving advance notice of disclosure and a reasonable opportunity to object.
(2) Such data or information are used solely for the purposes of—
(A) identifying individuals who are eligible or potentially eligible for medical assistance under this subchapter and enrolling or attempting to enroll such individuals in the State plan; and
(B) verifying the eligibility of individuals for medical assistance under the State plan.
(3) An interagency or other agreement, consistent with standards developed by the Secretary—
(A) prevents the unauthorized use, disclosure, or modification of such data and otherwise meets applicable Federal requirements safeguarding privacy and data security; and
(B) requires the State agency administering the State plan to use the data and information obtained under this section to seek to enroll individuals in the plan.
(c) Penalties for improper disclosure
(1) Civil money penalty
A private entity described in the 1 subsection (a) that publishes, discloses, or makes known in any manner, or to any extent not authorized by Federal law, any information obtained under this section is subject to a civil money penalty in an amount equal to $10,000 for each such unauthorized publication or disclosure. The provisions of
(2) Criminal penalty
A private entity described in the 1 subsection (a) that willfully publishes, discloses, or makes known in any manner, or to any extent not authorized by Federal law, any information obtained under this section shall be fined not more than $10,000 or imprisoned not more than 1 year, or both, for each such unauthorized publication or disclosure.
(d) Rule of construction
The limitations and requirements that apply to disclosure pursuant to this section shall not be construed to prohibit the conveyance or disclosure of data or information otherwise permitted under Federal law (without regard to this section).
(Aug. 14, 1935, ch. 531, title XIX, §1942, as added
Statutory Notes and Related Subsidiaries
Authorization for States Electing Express Lane Option To Receive Certain Data Directly Relevant to Determining Eligibility and Correct Amount of Assistance
"(1) The National Directory of New Hires established under section 453(i) of the Social Security Act (
"(2) Data regarding enrollment in insurance that may help to facilitate outreach and enrollment under the State Medicaid plan, the State CHIP plan, and such other programs as the Secretary may specify."
[For definitions of "CHIP", "Medicaid", and "Secretary", see section 1(c) of
§1396w–3. Enrollment simplification and coordination with State health insurance exchanges
(a) Condition for participation in Medicaid
As a condition of the State plan under this subchapter and receipt of any Federal financial assistance under
(b) Enrollment simplification and coordination with State health insurance exchanges and CHIP
(1) In general
A State shall establish procedures for—
(A) enabling individuals, through an Internet website that meets the requirements of paragraph (4), to apply for medical assistance under the State plan or under a waiver of the plan, to be enrolled in the State plan or waiver, to renew their enrollment in the plan or waiver, and to consent to enrollment or reenrollment in the State plan through electronic signature;
(B) enrolling, without any further determination by the State and through such website, individuals who are identified by an Exchange established by the State under
(i) medical assistance under the State plan or under a waiver of the plan; or
(ii) child health assistance under the State child health plan under subchapter XXI;
(C) ensuring that individuals who apply for but are determined to be ineligible for medical assistance under the State plan or a waiver or ineligible for child health assistance under the State child health plan under subchapter XXI, are screened for eligibility for enrollment in qualified health plans offered through such an Exchange and, if applicable, premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under
(D) ensuring that the State agency responsible for administering the State plan under this subchapter (in this section referred to as the "State Medicaid agency"), the State agency responsible for administering the State child health plan under subchapter XXI (in this section referred to as the "State CHIP agency") and an Exchange established by the State under
(E) coordinating, for individuals who are enrolled in the State plan or under a waiver of the plan and who are also enrolled in a qualified health plan offered through such an Exchange, and for individuals who are enrolled in the State child health plan under subchapter XXI and who are also enrolled in a qualified health plan, the provision of medical assistance or child health assistance to such individuals with the coverage provided under the qualified health plan in which they are enrolled, including services described in
(F) conducting outreach to and enrolling vulnerable and underserved populations eligible for medical assistance under this subchapter or for child health assistance under subchapter XXI, including children, unaccompanied homeless youth, children and youth with special health care needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental health or substance-related disorders, and individuals with HIV/AIDS.
(2) Agreements with State health insurance exchanges
The State Medicaid agency and the State CHIP agency may enter into an agreement with an Exchange established by the State under
(3) Streamlined enrollment system
The State Medicaid agency and State CHIP agency shall participate in and comply with the requirements for the system established under
(4) Enrollment website requirements
The procedures established by State under paragraph (1) shall include establishing and having in operation, not later than January 1, 2014, an Internet website that is linked to any website of an Exchange established by the State under
(5) Continued need for assessment for home and community-based services
Nothing in paragraph (1) shall limit or modify the requirement that the State assess an individual for purposes of providing home and community-based services under the State plan or under any waiver of such plan for individuals described in subsection (a)(10)(A)(ii)(VI).2
(Aug. 14, 1935, ch. 531, title XIX, §1943, as added
Editorial Notes
References in Text
The Internal Revenue Code of 1986, referred to in subsec. (b)(1)(C), (2), (4), is classified generally to Title 26, Internal Revenue Code.
1 So in original. Probably should be "are".
2 Probably means subsection (a)(10)(A)(ii)(VI) of
§1396w–3a. Requirements relating to qualified prescription drug monitoring programs and prescribing certain controlled substances
(a) In general
Subject to subsection (d), beginning October 1, 2021, a State—
(1) shall require each covered provider to check, in accordance with such timing, manner, and form as specified by the State, the prescription drug history of a covered individual being treated by the covered provider through a qualified prescription drug monitoring program described in subsection (b) before prescribing to such individual a controlled substance; and
(2) in the case that such a provider is not able to conduct such a check despite a good faith effort by such provider—
(A) shall require the provider to document such good faith effort, including the reasons why the provider was not able to conduct the check; and
(B) may require the provider to submit, upon request, such documentation to the State.
(b) Qualified prescription drug monitoring program described
A qualified prescription drug monitoring program described in this subsection is, with respect to a State, a prescription drug monitoring program administered by the State that, at a minimum, satisfies each of the following criteria:
(1) The program facilitates access by a covered provider to, at a minimum, the following information with respect to a covered individual, in as close to real-time as possible:
(A) Information regarding the prescription drug history of a covered individual with respect to controlled substances.
(B) The number and type of controlled substances prescribed to and filled for the covered individual during at least the most recent 12-month period.
(C) The name, location, and contact information (or other identifying number selected by the State, such as a national provider identifier issued by the National Plan and Provider Enumeration System of the Centers for Medicare & Medicaid Services) of each covered provider who prescribed a controlled substance to the covered individual during at least the most recent 12-month period.
(2) The program facilitates the integration of information described in paragraph (1) into the workflow of a covered provider, which may include the electronic system the covered provider uses to prescribe controlled substances.
A qualified prescription drug monitoring program described in this subsection, with respect to a State, may have in place, in accordance with applicable State and Federal law, a data-sharing agreement with the State Medicaid program that allows the medical director and pharmacy director of such program (and any designee of such a director who reports directly to such director) to access the information described in paragraph (1) in an electronic format. The State Medicaid program under this subchapter may facilitate reasonable and limited access, as determined by the State and ensuring documented beneficiary protections regarding the use of such data, to such qualified prescription drug monitoring program for the medical director or pharmacy director of any managed care entity (as defined under
(c) Application of privacy rules clarification
The Secretary shall clarify privacy requirements, including requirements under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (
(d) Ensuring access
In order to ensure reasonable access to health care, the Secretary shall waive the application of the requirement under subsection (a), with respect to a State, in the case of natural disasters and similar situations, and in the case of the provision of emergency services (as defined for purposes of
(e) Reports
(1) State reports
Each State shall include in the annual report submitted to the Secretary under
(A) The percentage of covered providers (as determined pursuant to a process established by the State) who checked the prescription drug history of a covered individual through a qualified prescription drug monitoring program described in subsection (b) before prescribing to such individual a controlled substance.
(B) Aggregate trends with respect to prescribing controlled substances such as—
(i) the quantity of daily morphine milligram equivalents prescribed for controlled substances;
(ii) the number and quantity of daily morphine milligram equivalents prescribed for controlled substances per covered individual; and
(iii) the types of controlled substances prescribed, including the dates of such prescriptions, the supplies authorized (including the duration of such supplies), and the period of validity of such prescriptions, in different populations (such as individuals who are elderly, individuals with disabilities, and individuals who are enrolled under both this subchapter and subchapter XVIII).
(C) Whether or not the State requires (and a detailed explanation as to why the State does or does not require) pharmacists to check the prescription drug history of a covered individual through a qualified prescription drug monitoring program described in subsection (b) before dispensing a controlled substance to such individual.
(D) An accounting of any data or privacy breach of a qualified prescription drug monitoring program described in subsection (b), the number of covered individuals impacted by each such breach, and a description of the steps the State has taken to address each such breach, including, to the extent required by State or Federal law or otherwise determined appropriate by the State, alerting any such impacted individual and law enforcement of the breach.
(2) Report by CMS
Not later than October 1, 2023, the Administrator of the Centers for Medicare & Medicaid Services shall publish on the publicly available website of the Centers for Medicare & Medicaid Services a report including the following information:
(A) Guidance for States on how States can increase the percentage of covered providers who use qualified prescription drug monitoring programs described in subsection (b).
(B) Best practices for how States and covered providers should use such qualified prescription drug monitoring programs to reduce the occurrence of abuse of controlled substances.
(f) Increase to FMAP and Federal matching rates for certain expenditures relating to qualified prescription drug monitoring programs
(1) In general
With respect to a State that meets the condition described in paragraph (2) and any quarter occurring during fiscal year 2019 or fiscal year 2020, the Federal medical assistance percentage or Federal matching rate that would otherwise apply to such State under
(2) Condition
The condition described in this paragraph, with respect to a State, is that the State (in this paragraph referred to as the "administering State") has in place agreements with all States that are contiguous to such administering State that, when combined, enable covered providers in all such contiguous States to access, through the prescription drug monitoring program, the information that is described in subsection (b)(1) of covered individuals of such administering State and that covered providers in such administering State are able to access through such program.
(g) Rule of construction
Nothing in this section prevents a State from requiring pharmacists to check the prescription drug history of covered individuals through a qualified prescription drug monitoring program before dispensing controlled substances to such individuals.
(h) Definitions
In this section:
(1) Controlled substance
The term "controlled substance" means a drug that is included in schedule II of
(2) Covered individual
The term "covered individual" means, with respect to a State, an individual who is enrolled in the State plan (or under a waiver of such plan). Such term does not include an individual who—
(A) is receiving—
(i) hospice or palliative care; or
(ii) treatment for cancer;
(B) is a resident of a long-term care facility, of a facility described in
(C) the State elects to treat as exempted from such term.
(3) Covered provider
(A) In general
The term "covered provider" means, subject to subparagraph (B), with respect to a State, a health care provider who is participating under the State plan (or waiver of the State plan) and licensed, registered, or otherwise permitted by the State to prescribe a controlled substance (or the designee of such provider).
(B) Exceptions
(i) In general
Beginning October 1, 2021, for purposes of this section, such term does not include a health care provider included in any type of health care provider determined by the Secretary to be exempt from application of this section under clause (ii).
(ii) Exceptions process
Not later than October 1, 2020, the Secretary, after consultation with the National Association of Medicaid Directors, national health care provider associations, Medicaid beneficiary advocates, and advocates for individuals with rare diseases, shall determine, based on such consultations, the types of health care providers (if any) that should be exempted from the definition of the term "covered provider" for purposes of this section.
(Aug. 14, 1935, ch. 531, title XIX, §1944, as added
Editorial Notes
References in Text
Section 264(c) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (c), is section 264(c) of
Statutory Notes and Related Subsidiaries
Guidance
Development of Model State Practices
"(1)
"(A) Monitoring and preventing fraud, waste, and abuse.
"(B) Improving health care for individuals enrolled in a State plan under title XIX of such Act [
"(i) transition in and out of coverage under such title;
"(ii) may have sources of health care coverage in addition to coverage under such title; or
"(iii) pay for prescription drugs with cash.
"(C) Any other purposes specified by the Secretary.
"(2)
"(A) shall include strategies for assisting States in allowing the medical director or pharmacy director (or designees of such a director) of managed care organizations or pharmaceutical benefit managers to access information with respect to all covered individuals served by such managed care organizations or pharmaceutical benefit managers to access as a single data set, in an electronic format; and
"(B) shall include any appropriate beneficiary protections and privacy guidelines.
"(3)
§1396w–4. State option to provide coordinated care through a health home for individuals with chronic conditions
(a) In general
Notwithstanding
(b) Health home qualification standards
The Secretary shall establish standards for qualification as a designated provider for the purpose of being eligible to be a health home for purposes of this section.
(c) Payments
(1) In general
A State shall provide a designated provider, a team of health care professionals operating with such a provider, or a health team with payments for the provision of health home services to each eligible individual with chronic conditions that selects such provider, team of health care professionals, or health team as the individual's health home. Payments made to a designated provider, a team of health care professionals operating with such a provider, or a health team for such services shall be treated as medical assistance for purposes of
(2) Methodology
(A) In general
The State shall specify in the State plan amendment the methodology the State will use for determining payment for the provision of health home services. Such methodology for determining payment—
(i) may be tiered to reflect, with respect to each eligible individual with chronic conditions provided such services by a designated provider, a team of health care professionals operating with such a provider, or a health team, as well as the severity or number of each such individual's chronic conditions or the specific capabilities of the provider, team of health care professionals, or health team; and
(ii) shall be established consistent with
(B) Alternate models of payment
The methodology for determining payment for provision of health home services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the State and subject to approval by the Secretary) for alternate models of payment.
(3) Planning grants
(A) In general
Beginning January 1, 2011, the Secretary may award planning grants to States for purposes of developing a State plan amendment under this section. A planning grant awarded to a State under this paragraph shall remain available until expended.
(B) State contribution
A State awarded a planning grant shall contribute an amount equal to the State percentage determined under
(C) Limitation
The total amount of payments made to States under this paragraph shall not exceed $25,000,000.
(4) Special rule relating to substance use disorder health homes
(A) In general
In the case of a State with an SUD-focused State plan amendment approved by the Secretary on or after October 1, 2018, the Secretary may, at the request of the State, extend the application of the Federal medical assistance percentage described in paragraph (1) to payments for the provision of health home services to SUD-eligible individuals under such State plan amendment, in addition to the first 8 fiscal year quarters the State plan amendment is in effect, for the subsequent 2 fiscal year quarters that the State plan amendment is in effect. Nothing in this section shall be construed as prohibiting a State with a State plan amendment that is approved under this section and that is not an SUD-focused State plan amendment from additionally having approved on or after such date an SUD-focused State plan amendment under this section, including for purposes of application of this paragraph.
(B) Report requirements
In the case of a State with an SUD-focused State plan amendment for which the application of the Federal medical assistance percentage has been extended under subparagraph (A), such State shall, at the end of the period of such State plan amendment, submit to the Secretary a report on the following, with respect to SUD-eligible individuals provided health home services under such State plan amendment:
(i) The quality of health care provided to such individuals, with a focus on outcomes relevant to the recovery of each such individual.
(ii) The access of such individuals to health care.
(iii) The total expenditures of such individuals for health care.
For purposes of this subparagraph, the Secretary shall specify all applicable measures for determining quality, access, and expenditures.
(C) Best practices
Not later than October 1, 2020, the Secretary shall make publicly available on the internet website of the Centers for Medicare & Medicaid Services best practices for designing and implementing an SUD-focused State plan amendment, based on the experiences of States that have State plan amendments approved under this section that include SUD-eligible individuals.
(D) Definitions
For purposes of this paragraph:
(i) SUD-eligible individuals
The term "SUD-eligible individual" means, with respect to a State, an individual who satisfies all of the following:
(I) The individual is an eligible individual with chronic conditions.
(II) The individual is an individual with a substance use disorder.
(III) The individual has not previously received health home services under any other State plan amendment approved for the State under this section by the Secretary.
(ii) SUD-focused State plan amendment
The term "SUD-focused State plan amendment" means a State plan amendment under this section that is designed to provide health home services primarily to SUD-eligible individuals.
(d) Hospital referrals
A State shall include in the State plan amendment a requirement for hospitals that are participating providers under the State plan or a waiver of such plan to establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers.
(e) Coordination
A State shall consult and coordinate, as appropriate, with the Substance Abuse and Mental Health Services Administration in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.
(f) Monitoring
A State shall include in the State plan amendment—
(1) a methodology for tracking avoidable hospital readmissions and calculating savings that result from improved chronic care coordination and management under this section; and
(2) a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).
(g) Report on quality measures
As a condition for receiving payment for health home services provided to an eligible individual with chronic conditions, a designated provider shall report to the State, in accordance with such requirements as the Secretary shall specify, on all applicable measures for determining the quality of such services. When appropriate and feasible, a designated provider shall use health information technology in providing the State with such information.
(h) Definitions
In this section:
(1) Eligible individual with chronic conditions
(A) In general
Subject to subparagraph (B), the term "eligible individual with chronic conditions" means an individual who—
(i) is eligible for medical assistance under the State plan or under a waiver of such plan; and
(ii) has at least—
(I) 2 chronic conditions;
(II) 1 chronic condition and is at risk of having a second chronic condition; or
(III) 1 serious and persistent mental health condition.
(B) Rule of construction
Nothing in this paragraph shall prevent the Secretary from establishing higher levels as to the number or severity of chronic or mental health conditions for purposes of determining eligibility for receipt of health home services under this section.
(2) Chronic condition
The term "chronic condition" has the meaning given that term by the Secretary and shall include, but is not limited to, the following:
(A) A mental health condition.
(B) Substance use disorder.
(C) Asthma.
(D) Diabetes.
(E) Heart disease.
(F) Being overweight, as evidenced by having a Body Mass Index (BMI) over 25.
(3) Health home
The term "health home" means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services.
(4) Health home services
(A) In general
The term "health home services" means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.
(B) Services described
The services described in this subparagraph are—
(i) comprehensive care management;
(ii) care coordination and health promotion;
(iii) comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;
(iv) patient and family support (including authorized representatives);
(v) referral to community and social support services, if relevant; and
(vi) use of health information technology to link services, as feasible and appropriate.
(5) Designated provider
The term "designated provider" means a physician, clinical practice or clinical group practice, rural clinic, community health center, community mental health center, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined by the State and approved by the Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation evidencing that the physician, practice, or clinic—
(A) has the systems and infrastructure in place to provide health home services; and
(B) satisfies the qualification standards established by the Secretary under subsection (b).
(6) Team of health care professionals
The term "team of health care professionals" means a team of health professionals (as described in the State plan amendment) that may—
(A) include physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State; and
(B) be free standing, virtual, or based at a hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity deemed appropriate by the State and approved by the Secretary.
(7) Health team
The term "health team" has the meaning given such term for purposes of
(Aug. 14, 1935, ch. 531, title XIX, §1945, as added
Editorial Notes
References in Text
Section 5001 of
Amendments
2018—Subsec. (c)(1).
Subsec. (c)(4).
Statutory Notes and Related Subsidiaries
Survey and Interim Report
"(A)
"(i) hospital admission rates;
"(ii) chronic disease management;
"(iii) coordination of care for individuals with chronic conditions;
"(iv) assessment of program implementation;
"(v) processes and lessons learned (as described in subparagraph (B));
"(vi) assessment of quality improvements and clinical outcomes under such option; and
"(vii) estimates of cost savings.
"(B)
§1396w–4a. State option to provide coordinated care through a health home for children with medically complex conditions
(a) In general
Notwithstanding
(b) Health home qualification standards
The Secretary shall establish standards for qualification as a health home for purposes of this section. Such standards shall include requiring designated providers, teams of health care professionals operating with such providers, and health teams to demonstrate to the State the ability to do the following:
(1) Coordinate prompt care for children with medically complex conditions, including access to pediatric emergency services at all times.
(2) Develop an individualized comprehensive pediatric family-centered care plan for children with medically complex conditions that accommodates patient preferences.
(3) Work in a culturally and linguistically appropriate manner with the family of a child with medically complex conditions to develop and incorporate into such child's care plan, in a manner consistent with the needs of the child and the choices of the child's family, ongoing home care, community-based pediatric primary care, pediatric inpatient care, social support services, and local hospital pediatric emergency care.
(4) Coordinate access to—
(A) subspecialized pediatric services and programs for children with medically complex conditions, including the most intensive diagnostic, treatment, and critical care levels as medically necessary; and
(B) palliative services if the State provides such services under the State plan (or a waiver of such plan).
(5) Coordinate care for children with medically complex conditions with out-of-State providers furnishing care to such children to the maximum extent practicable for the families of such children and where medically necessary, in accordance with guidance issued under subsection (e)(1) and section 431.52 of title 42, Code of Federal Regulations.
(6) Collect and report information under subsection (g)(1).
(c) Payments
(1) In general
A State shall provide a designated provider, a team of health care professionals operating with such a provider, or a health team with payments for the provision of health home services to each child with medically complex conditions that selects such provider, team of health care professionals, or health team as the child's health home. Payments made to a designated provider, a team of health care professionals operating with such a provider, or a health team for such services shall be treated as medical assistance for purposes of
(2) Methodology
(A) In general
The State shall specify in the State plan amendment the methodology the State will use for determining payment for the provision of health home services. Such methodology for determining payment—
(i) may be tiered to reflect, with respect to each child with medically complex conditions provided such services by a designated provider, a team of health care professionals operating with such a provider, or a health team, the severity or number of each such child's chronic conditions, life-threatening illnesses, disabilities, or rare diseases, or the specific capabilities of the provider, team of health care professionals, or health team; and
(ii) shall be established consistent with
(B) Alternate models of payment
The methodology for determining payment for provision of health home services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the State and subject to approval by the Secretary) for alternate models of payment.
(3) Planning grants
(A) In general
Beginning October 1, 2022, the Secretary may award planning grants to States for purposes of developing a State plan amendment under this section. A planning grant awarded to a State under this paragraph shall remain available until expended.
(B) State contribution
A State awarded a planning grant shall contribute an amount equal to the State percentage determined under
(C) Limitation
The total amount of payments made to States under this paragraph shall not exceed $5,000,000.
(d) Coordinating care
(1) Hospital notification
A State with a State plan amendment approved under this section shall require each hospital that is a participating provider under the State plan (or a waiver of such plan) to establish procedures for, in the case of a child with medically complex conditions who is enrolled in a health home pursuant to this section and seeks treatment in the emergency department of such hospital, notifying the health home of such child of such treatment.
(2) Education with respect to availability of health home services
In order for a State plan amendment to be approved under this section, a State shall include in the State plan amendment a description of the State's process for educating providers participating in the State plan (or a waiver of such plan) on the availability of health home services for children with medically complex conditions, including the process by which such providers can refer such children to a designated provider, team of health care professionals operating such 1 a provider, or health team for the purpose of establishing a health home through which such children may receive such services.
(3) Family education
In order for a State plan amendment to be approved under this section, a State shall include in the State plan amendment a description of the State's process for educating families with children eligible to receive health home services pursuant to this section of the availability of such services. Such process shall include the participation of family-to-family entities or other public or private organizations or entities who provide outreach and information on the availability of health care items and services to families of individuals eligible to receive medical assistance under the State plan (or a waiver of such plan).
(4) Mental health coordination
A State with a State plan amendment approved under this section shall consult and coordinate, as appropriate, with the Secretary in addressing issues regarding the prevention and treatment of mental illness and substance use among children with medically complex conditions receiving health home services under this section.
(e) Guidance on coordinating care from out-of-State providers
(1) In general
Not later than October 1, 2020, the Secretary shall issue (and update as the Secretary determines necessary) guidance to State Medicaid directors on—
(A) best practices for using out-of-State providers to provide care to children with medically complex conditions;
(B) coordinating care for such children provided by such out-of-State providers (including when provided in emergency and non-emergency situations);
(C) reducing barriers for such children receiving care from such providers in a timely fashion; and
(D) processes for screening and enrolling such providers in the respective State plan (or a waiver of such plan), including efforts to streamline such processes or reduce the burden of such processes on such providers.
(2) Stakeholder input
In carrying out paragraph (1), the Secretary shall issue a request for information to seek input from children with medically complex conditions and their families, States, providers (including children's hospitals, hospitals, pediatricians, and other providers), managed care plans, children's health groups, family and beneficiary advocates, and other stakeholders with respect to coordinating the care for such children provided by out-of-State providers.
(f) Monitoring
A State shall include in the State plan amendment—
(1) a methodology for tracking reductions in inpatient days and reductions in the total cost of care resulting from improved care coordination and management under this section;
(2) a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider); and
(3) a methodology for tracking prompt and timely access to medically necessary care for children with medically complex conditions from out-of-State providers.
(g) Data collection
(1) Provider reporting requirements
In order to receive payments from a State under subsection (c), a designated provider, a team of health care professionals operating with such a provider, or a health team shall report to the State, at such time and in such form and manner as may be required by the State, the following information:
(A) With respect to each such provider, team of health care professionals, or health team, the name, National Provider Identification number, address, and specific health care services offered to be provided to children with medically complex conditions who have selected such provider, team of health care professionals, or health team as the health home of such children.
(B) Information on all applicable measures for determining the quality of health home services provided by such provider, team of health care professionals, or health team, including, to the extent applicable, child health quality measures and measures for centers of excellence for children with complex needs developed under this subchapter, subchapter XXI, and
(C) Such other information as the Secretary shall specify in guidance.
When appropriate and feasible, such provider, team of health care professionals, or health team, as the case may be, shall use health information technology in providing the State with such information.
(2) State reporting requirements
(A) Comprehensive report
A State with a State plan amendment approved under this section shall report to the Secretary (and, upon request, to the Medicaid and CHIP Payment and Access Commission), at such time and in such form and manner determined by the Secretary to be reasonable and minimally burdensome, the following information:
(i) Information reported under paragraph (1).
(ii) The number of children with medically complex conditions who have selected a health home pursuant to this section.
(iii) The nature, number, and prevalence of chronic conditions, life-threatening illnesses, disabilities, or rare diseases that such children have.
(iv) The type of delivery systems and payment models used to provide services to such children under this section.
(v) The number and characteristics of designated providers, teams of health care professionals operating with such providers, and health teams selected as health homes pursuant to this section, including the number and characteristics of out-of-State providers, teams of health care professionals operating with such providers, and health teams who have provided health care items and services to such children.
(vi) The extent to which such children receive health care items and services under the State plan.
(vii) Quality measures developed specifically with respect to health care items and services provided to children with medically complex conditions.
(B) Report on best practices
Not later than 90 days after a State has a State plan amendment approved under this section, such State shall submit to the Secretary, and make publicly available on the appropriate State website, a report on how the State is implementing guidance issued under subsection (e)(1), including through any best practices adopted by the State.
(h) Rule of construction
Nothing in this section may be construed—
(1) to require a child with medically complex conditions to enroll in a health home under this section;
(2) to limit the choice of a child with medically complex conditions in selecting a designated provider, team of health care professionals operating with such a provider, or health team that meets the health home qualification standards established under subsection (b) as the child's health home; or
(3) to reduce or otherwise modify—
(A) the entitlement of children with medically complex conditions to early and periodic screening, diagnostic, and treatment services (as defined in
(B) the informing, providing, arranging, and reporting requirements of a State under
(i) Definitions
In this section:
(1) Child with medically complex conditions
(A) In general
Subject to subparagraph (B), the term "child with medically complex conditions" means an individual under 21 years of age who—
(i) is eligible for medical assistance under the State plan (or under a waiver of such plan); and
(ii) has at least—
(I) one or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning (such as the ability to eat, drink, or breathe independently) and that also requires the use of medication, durable medical equipment, therapy, surgery, or other treatments; or
(II) one life-limiting illness or rare pediatric disease (as defined in
(B) Rule of construction
Nothing in this paragraph shall prevent the Secretary from establishing higher levels as to the number or severity of chronic, life threatening illnesses, disabilities, rare diseases or mental health conditions for purposes of determining eligibility for receipt of health home services under this section.
(2) Chronic condition
The term "chronic condition" means a serious, long-term physical, mental, or developmental disability or disease, including the following:
(A) Cerebral palsy.
(B) Cystic fibrosis.
(C) HIV/AIDS.
(D) Blood diseases, such as anemia or sickle cell disease.
(E) Muscular dystrophy.
(F) Spina bifida.
(G) Epilepsy.
(H) Severe autism spectrum disorder.
(I) Serious emotional disturbance or serious mental health illness.
(3) Health home
The term "health home" means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by a child with medically complex conditions (or the family of such child) to provide health home services.
(4) Health home services
(A) In general
The term "health home services" means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.
(B) Services described
The services described in this subparagraph shall include—
(i) comprehensive care management;
(ii) care coordination, health promotion, and providing access to the full range of pediatric specialty and subspecialty medical services, including services from out-of-State providers, as medically necessary;
(iii) comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;
(iv) patient and family support (including authorized representatives);
(v) referrals to community and social support services, if relevant; and
(vi) use of health information technology to link services, as feasible and appropriate.
(5) Designated provider
The term "designated provider" means a physician (including a pediatrician or a pediatric specialty or subspecialty provider), children's hospital, clinical practice or clinical group practice, prepaid inpatient health plan or prepaid ambulatory health plan (as defined by the Secretary), rural clinic, community health center, community mental health center, home health agency, or any other entity or provider that is determined by the State and approved by the Secretary to be qualified to be a health home for children with medically complex conditions on the basis of documentation evidencing that the entity has the systems, expertise, and infrastructure in place to provide health home services. Such term may include providers who are employed by, or affiliated with, a children's hospital.
(6) Team of health care professionals
The term "team of health care professionals" means a team of health care professionals (as described in the State plan amendment under this section) that may—
(A) include—
(i) physicians and other professionals, such as pediatricians or pediatric specialty or subspecialty providers, nurse care coordinators, dietitians, nutritionists, social workers, behavioral health professionals, physical therapists, occupational therapists, speech pathologists, nurses, individuals with experience in medical supportive technologies, or any professionals determined to be appropriate by the State and approved by the Secretary;
(ii) an entity or individual who is designated to coordinate such a team; and
(iii) community health workers, translators, and other individuals with culturally-appropriate expertise; and
(B) be freestanding, virtual, or based at a children's hospital, hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity determined to be appropriate by the State and approved by the Secretary.
(7) Health team
The term "health team" has the meaning given such term for purposes of
(Aug. 14, 1935, ch. 531, title XIX, §1945A, as added
Editorial Notes
References in Text
Section 5001 of
1 So in original. Probably should be preceded by "with".
§1396w–5. Addressing health care disparities
(a) Evaluating data collection approaches
The Secretary shall evaluate approaches for the collection of data under this subchapter and subchapter XXI, to be performed in conjunction with existing quality reporting requirements and programs under this subchapter and subchapter XXI, that allow for the ongoing, accurate, and timely collection and evaluation of data on disparities in health care services and performance on the basis of race, ethnicity, sex, primary language, and disability status. In conducting such evaluation, the Secretary shall consider the following objectives:
(1) Protecting patient privacy.
(2) Minimizing the administrative burdens of data collection and reporting on States, providers, and health plans participating under this subchapter or subchapter XXI.
(3) Improving program data under this subchapter and subchapter XXI on race, ethnicity, sex, primary language, and disability status.
(b) Reports to Congress
(1) Report on evaluation
Not later than 18 months after March 23, 2010, the Secretary shall submit to Congress a report on the evaluation conducted under subsection (a). Such report shall, taking into consideration the results of such evaluation—
(A) identify approaches (including defining methodologies) for identifying and collecting and evaluating data on health care disparities on the basis of race, ethnicity, sex, primary language, and disability status for the programs under this subchapter and subchapter XXI; and
(B) include recommendations on the most effective strategies and approaches to reporting HEDIS quality measures as required under
(2) Reports on data analyses
Not later than 4 years after March 23, 2010, and 4 years thereafter, the Secretary shall submit to Congress a report that includes recommendations for improving the identification of health care disparities for beneficiaries under this subchapter and under subchapter XXI based on analyses of the data collected under subsection (c).
(c) Implementing effective approaches
Not later than 24 months after March 23, 2010, the Secretary shall implement the approaches identified in the report submitted under subsection (b)(1) for the ongoing, accurate, and timely collection and evaluation of data on health care disparities on the basis of race, ethnicity, sex, primary language, and disability status.
(Aug. 14, 1935, ch. 531, title XIX, §1946, as added
§1396w–6. State option to provide qualifying community-based mobile crisis intervention services
(a) In general
Notwithstanding
(b) Qualifying community-based mobile crisis intervention services defined
For purposes of this section, the term "qualifying community-based mobile crisis intervention services" means, with respect to a State, items and services for which medical assistance is available under the State plan under this subchapter or a waiver of such plan, that are—
(1) furnished to an individual otherwise eligible for medical assistance under the State plan (or waiver of such plan) who is—
(A) outside of a hospital or other facility setting; and
(B) experiencing a mental health or substance use disorder crisis;
(2) furnished by a multidisciplinary mobile crisis team—
(A) that includes at least 1 behavioral health care professional who is capable of conducting an assessment of the individual, in accordance with the professional's permitted scope of practice under State law, and other professionals or paraprofessionals with appropriate expertise in behavioral health or mental health crisis response, including nurses, social workers, peer support specialists, and others, as designated by the State through a State plan amendment (or waiver of such plan);
(B) whose members are trained in trauma-informed care, de-escalation strategies, and harm reduction;
(C) that is able to respond in a timely manner and, where appropriate, provide—
(i) screening and assessment;
(ii) stabilization and de-escalation; and
(iii) coordination with, and referrals to, health, social, and other services and supports as needed, and health services as needed;
(D) that maintains relationships with relevant community partners, including medical and behavioral health providers, primary care providers, community health centers, crisis respite centers, and managed care organizations (if applicable); and
(E) that maintains the privacy and confidentiality of patient information consistent with Federal and State requirements; and
(3) available 24 hours per day, every day of the year.
(c) Payments
Notwithstanding
(d) Requirements
The requirements described in this subsection are the following:
(1) The State demonstrates, to the satisfaction of the Secretary that it will be able to support the provision of qualifying community-based mobile crisis intervention services that meet the conditions specified in subsection (b).
(2) The State provides assurances satisfactory to the Secretary that—
(A) any additional Federal funds received by the State for qualifying community-based mobile crisis intervention services provided under this section that are attributable to the increased Federal medical assistance percentage under subection (c) will be used to supplement, and not supplant, the level of State funds expended for such services for the fiscal year preceding the first fiscal quarter occurring during the period described in subsection (a);
(B) if the State made qualifying community-based mobile crisis intervention services available in a region of the State in such fiscal year, the State will continue to make such services available in such region under this section during each month occurring during the period described in subsection (a) for which the Federal medical assistance percentage under subsection (c) is applicable with respect to the State.
(e) Funding for State planning grants
There is appropriated, out of any funds in the Treasury not otherwise appropriated, $15,000,000 to the Secretary for purposes of implementing, administering, and making planning grants to States as soon as practicable for purposes of developing a State plan amendment or
(Aug. 14, 1935, ch. 531, title XIX, §1947, as added
§1396w–7. Supporting access to a continuum of crisis response services under Medicaid and CHIP
(a) Guidance
Not later than July 1, 2025, the Secretary, in coordination with the Administrator of the Centers for Medicare & Medicaid Services and the Assistant Secretary for Mental Health and Substance Use, shall issue guidance to States regarding Medicaid and CHIP that includes the following:
(1) Provides, in consultation with health care providers and stakeholders with expertise in mental health and substance use disorder crisis response services, recommendations for an effective continuum of crisis response services that—
(A) includes crisis call centers, including 988 crisis services hotlines, mobile crisis teams, crisis response services delivered in home, community, residential facility, and hospital settings, and coordination with follow-on mental health and substance use disorder services, such as intensive outpatient and partial hospitalization programs, as well as connections to social services and supports;
(B) promotes access to appropriate and timely mental health and substance use disorder crisis response services in the least restrictive setting appropriate to an individual's needs; and
(C) promotes culturally competent, trauma-informed care, and crisis de-escalation.
(2) Outlines the Federal authorities through which States may finance and enhance under Medicaid and CHIP the availability of crisis response services across each stage of the continuum of crisis response services.
(3) Addresses how States under Medicaid and CHIP may support the ongoing implementation of crisis call centers, including 988 crisis services hotlines, and how Medicaid administrative funding, including enhanced matching, and the Medicaid Information Technology Architecture 3.0 framework, may be used to establish or enhance regional or statewide crisis call centers, including 988 crisis services hotlines, that coordinate in real time.
(4) Identifies how States under Medicaid and CHIP may support access to crisis response services that are responsive to the needs of children, youth, and families, including through CHIP health services initiatives, behavioral disorder-specific crisis response, trained peer support services, and establishing or enhancing crisis call centers that are youth-focused.
(5) Identifies policies and practices to meet the need for crisis response services with respect to differing patient populations, including urban, rural, and frontier communities, differing age groups, cultural and linguistic minorities, individuals with co-occurring mental health and substance use disorder conditions, and individuals with disabilities.
(6) Identifies policies and practices to promote evidence-based suicide risk screenings and assessments.
(7) Identifies strategies to facilitate timely provision of crisis response services, including how States can enable access to crisis response services without requiring a diagnosis, the use of presumptive eligibility at different stages of the continuum of crisis response services, the use of telehealth to deliver crisis response services, strategies to make crisis response services available 24/7 in medically underserved regions, and best practices used by States and health providers for maximizing capacity to deliver crisis response services, such as identifying and repurposing available beds, space, and staff for crisis response services.
(8) Describes best practices for coordinating Medicaid and CHIP funding with other payors and sources of Federal funding for mental health and substance use disorder crisis response services, and best practices for Medicaid and CHIP financing when the continuum of crisis response services serves individuals regardless of payor.
(9) Describes best practices for establishing effective connections with follow-on mental health and substance use disorder services, as well as with social services and supports.
(10) Describes best practices for coordinating and financing a continuum of crisis response services through Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and fee-for-service delivery systems, including when States carve-out from delivery through Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, or fee-for-service systems, mental health or substance use disorder benefits or a subset of such services.
(11) Identifies strategies and best practices for measuring and monitoring utilization of, and outcomes related to, crisis response services.
(b) Technical assistance center
(1) In general
Not later than July 1, 2025, the Secretary, in coordination with the Administrator of the Centers for Medicare & Medicaid Services and the Assistant Secretary for Mental Health and Substance Use, shall establish a technical assistance center to help States under Medicaid and CHIP design, implement, or enhance a continuum of crisis response services for children, youth, and adults. Such technical assistance shall, at least in part, provide support to States in—
(A) leveraging the Federal authorities through which Medicaid and CHIP may finance mental health and substance use disorder crisis response services;
(B) coordinating Medicaid and CHIP funds with other sources of Federal funding for mental health and substance use disorder crisis response services; and
(C) after the guidance described in subsection (a) is issued, adopting the best practices and strategies identified in such guidance.
(2) Compendium of best practices
The Secretary shall develop and maintain a publicly available compendium of best practices for the successful operation under Medicaid and CHIP of a continuum of crisis response services. The Secretary annually shall review the information available through the compendium and shall update such information when appropriate.
(c) Funding
There is appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, to remain available until expended for purposes of carrying out subsections (a) and (b), $8,000,000.
(d) Definitions
In this section:
(1) Secretary
The term "Secretary" means the Secretary of Health and Human Services.
(2) State
The term "State" means each of the 50 States, the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.
(
Editorial Notes
Codification
Section was enacted as part of the Health Extenders, Improving Access to Medicare, Medicaid, and CHIP, and Strengthening Public Health Act of 2022 and also as part of the Consolidated Appropriations Act, 2023, and not as part of the Social Security Act which comprises this chapter.
§1396w–8. Collection and reporting of comprehensive data for specified populations
(a) Recurring analysis and publication of health care data related to treatment for substance use disorder or a mental health condition
(1) In general
The Secretary, on an annual basis, shall link, analyze, and publish on a publicly available website data reported by States through the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system) relating to substance use disorder and mental health services provided to individuals enrolled under a State plan under this subchapter or a State child health plan under subchapter XXI (or under a waiver of such plans) who have been diagnosed with a substance use disorder or mental health condition, including an analysis that is disaggregated by age. Such enrollee information shall be de-identified of any personally identifying information, shall adhere to privacy standards established by the Department of Health and Human Services, and shall be aggregated to protect the privacy of enrollees, as necessary.
(2) Requirements
The analysis required under paragraph (1) shall include, at a minimum, the following data for each State (including, to the extent available, for the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa):
(A) The number and percentage of individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) in each of the major enrollment categories (as defined in a public letter from the Medicaid and CHIP Payment and Access Commission to the Secretary) who have been diagnosed with—
(i) a substance use disorder;
(ii) a mental health condition; or
(iii) a co-occurring substance use disorder and mental health condition.
(B) With respect to individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who have received a diagnosis described in subparagraph (A), a list of the substance use disorder and mental health treatment services, including, to the extent such data are available, specific adult and pediatric services by each major type of service, such as counseling, intensive home-based services, intensive care coordination, crisis services tailored to children and youth, peer support services, family-to-family support, inpatient hospitalization, medication-assisted treatment, residential treatment, and other appropriate services as identified by the Secretary, for which beneficiaries in each State received at least 1 service under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans).
(C) With respect to each diagnosis described in subparagraph (A), the number and percentage of individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who have such diagnosis and received services for such diagnosis under such plan or waiver by each major type of treatment service listed under subparagraph (B) within each major setting type, such as outpatient, inpatient, residential, and other home-based and community-based settings.
(D) The number of services provided under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) per individual enrolled under such plan or waiver who has a diagnosis described in subparagraph (A) for each such diagnosis and each major type of treatment service listed under subparagraph (B).
(E) The number and percentage of individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) by major enrollment category, who have a diagnosis described in subparagraph (A) and received substance use disorder or mental health treatment through—
(i) a Medicaid managed care entity (as defined in
(ii) a fee-for-service payment model; or
(iii) an alternative payment model, to the extent available.
(F) The number and percentage of individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who have a diagnosis described in subparagraph (A) and received services for a mental health condition or a substance use disorder in an outpatient or community-based or home-based setting after receiving mental health or substance use disorder services in an inpatient or residential setting, and the number of mental health or substance use disorder services received by such individuals in the outpatient or community-based or home-based setting.
(G) The number and percentage of inpatient admissions in which services for a mental health condition or substance use disorder were provided to an individual enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) that occurred within 30 days after discharge from a hospital or residential facility in which services for a mental health condition or substance use disorder previously were provided to such individual, disaggregated by each diagnosis described in subparagraph (A) and type of facility, to the extent such information is available.
(H) The number of emergency department visits by an individual enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who has a diagnosis described in subparagraph (A) within 7 days of such individual being discharged from an inpatient stay at a hospital during which services for a mental health condition or substance use disorder were provided, or from a mental health facility, an independent psychiatric wing of an acute care hospital, an intermediate care facility for individuals with intellectual disabilities, or a residential treatment facility, disaggregated by each diagnosis described in subparagraph (A) and type of facility, to the extent such information is available.
(I) The number and percentage of individuals who are enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) and received an assessment for a mental health condition.
(J) The number and percentage of individuals who are enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) and received an assessment for a substance use disorder.
(K) The number of mental health services provided to individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who received an assessment described in subparagraph (I) in the 30 days post-assessment.
(L) The number of substance use disorder treatment services provided to individuals enrolled under the State plan under this subchapter or the State child health plan under subchapter XXI (or under a waiver of such plans) who received an assessment described in subparagraph (J) in the 30 days post-assessment.
(M) Prescription National Drug Code codes, fill dates, and number of days supply of any covered outpatient drug (as defined in
(i) to treat a mental health condition; or
(ii) to treat a substance use disorder.
(b) Publication
(1) In general
Not later than 18 months after March 9, 2024, the Secretary shall make publicly available the first analysis required by subsection (a).
(2) Annual updates
The Secretary shall issue an updated version of the analysis required under subsection (a) not later than January 1 of each calendar year.
(3) Use of T–MSIS data
The analysis required under subsection (a) and updates required under paragraph (4) shall—
(A) use data and definitions from the T–MSIS data set that is no more than 12 months old on the date that the analysis or update is published; and
(B) as appropriate, include a description with respect to each State of the quality and completeness of the data and caveats describing the limitations of the data reported to the Secretary by the State that is sufficient to communicate the appropriate uses for the information.
(4) Revised publication
Beginning not later than 3 years after March 9, 2024, the Secretary annually shall publish a revised publication of the analysis required by subsection (a) that allows for a research-ready and publicly accessible interface of the publication and is developed after consultation with stakeholders on the usability of the data contained in the publication.
(5) Making T–MSIS data on substance use disorders and mental health conditions available to researchers
(A) Requirement to publish system of records notice
(i) In general
Subject to subparagraph (B), the Secretary shall publish in the Federal Register a system of records notice for the data specified in clause (ii) for the Transformed Medicaid Statistical Information System, in accordance with
(ii) Required data
The data covered by the systems of records notice required under clause (i) shall be sufficient for researchers and States to analyze the prevalence of conditions described in subsection (a)(2)(A) in the Medicaid and Children's Health Insurance Program beneficiary population and the treatment of such conditions under Medicaid across all States (including the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa), forms of treatment, and treatment settings.
(iii) Initiation of data-sharing activities
Not later than January 1, 2025, the Secretary shall initiate the data-sharing activities outlined in the notice required under clause (i).
(B) Satisfaction of requirement through existing system of records notice
The Secretary shall not be required to publish a new system of records notice as required under subparagraph (A) if, not later than January 1, 2025, the Secretary determines that the system of records notice published by the Secretary in the Federal Register on February 6, 2019 (84 Fed. Reg. 2230), satisfies the requirements described in subparagraph (A).
(Aug. 14, 1935, ch. 531, title XIX, §1948, as added