Keeping Incarceration Discharges Streamlined for Children and Accommodating Resources in Education Act (June 16, 2022)
Summary
House Report 117–374, dated June 16, 2022, is the report of the Committee on Energy and Commerce on H.R. 7233, the Keeping Incarceration Discharges Streamlined for Children and Accommodating Resources in Education Act (the KIDS CARE Act), which the committee reports favorably with amendments. The amendments would require Medicaid State plans to provide health screenings and referrals for eligible juveniles scheduled to be released from a public institution, beginning October 1, 2023. They would also direct the Secretary of Health and Human Services to issue guidance on health care services in schools not later than 180 days after enactment. The purpose section states that the bill creates two limited exceptions to Medicaid's inmate exclusion for certain juveniles.
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“Keeping Incarceration Discharges Streamlined for Children and Accommodating Resources in Education Act (June 16, 2022).”
Original at www.govinfo.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/crpt-crpt-117hrpt374-crpt-117hrpt374/
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117TH CONGRESS REPORT
" HOUSE OF REPRESENTATIVES !
2d Session 117–374
KEEPING INCARCERATION DISCHARGES STREAMLINED
FOR CHILDREN AND ACCOMMODATING RESOURCES IN
EDUCATION ACT
JUNE 16, 2022.—Committed to the Committee of the Whole House on the State of
the Union and ordered to be printed
Mr. PALLONE, from the Committee on Energy and Commerce,
submitted the following
R E P O R T
[To accompany H.R. 7233]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 7233) to amend title XIX of the Social Security Act
to provide for requirements under Medicaid State plans for health
screenings and referrals for certain eligible juveniles in public insti-
tutions; and to require the Secretary of Health and Human Serv-
ices to issue clear and specific guidance under the Medicaid and
Children’s Health Insurance programs to improve the delivery of
health care services, including mental health services, in elemen-
tary and secondary schools and school-based health centers, having
considered the same, reports favorably thereon with amendments
and recommends that the bill as amended do pass.
CONTENTS
Page
I. Purpose and Summary .................................................................................. 4
II. Background and Need for the Legislation ................................................... 5
III. Committee Hearings ...................................................................................... 6
IV. Committee Consideration .............................................................................. 7
V. Committee Votes ............................................................................................ 7
VI. Oversight Findings ........................................................................................ 11
VII. New Budget Authority, Entitlement Authority, and Tax Expenditures 11
VIII. Federal Mandates Statement ....................................................................... 11
IX. Statement of General Performance Goals and Objectives .......................... 11
X. Duplication of Federal Programs .................................................................. 11
XI. Committee Cost Estimate ............................................................................. 11
XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits .................. 11
XIII. Advisory Committee Statement .................................................................... 12
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XIV. Applicability to Legislative Branch .............................................................. 12
29–006
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2
XV. Section-by-Section Analysis of the Legislation ............................................ 12
XVI. Changes in Existing Law Made by the Bill, as Reported ........................... 13
The amendments are as follows:
Strike all after the enacting clause and insert the following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Keeping Incarceration Discharges Streamlined for
Children and Accommodating Resources in Education Act’’ or the ‘‘KIDS CARE Act’’.
SEC. 2. MEDICAID AND CHIP REQUIREMENTS FOR HEALTH SCREENINGS AND REFERRALS
FOR ELIGIBLE JUVENILES IN PUBLIC INSTITUTIONS.
(a) MEDICAID STATE PLAN REQUIREMENT.—Section 1902 of the Social Security Act
(42 U.S.C. 1396a) is amended—
(1) in subsection (a)(84)—
(A) in subparagraph (B), by striking ‘‘and’’ at the end;
(B) in subparagraph (C), by adding ‘‘and’’ at the end; and
(C) by adding at the end the following new subparagraph:
‘‘(D) beginning October 1, 2023, in the case of individuals who are eligible
juveniles described in subsection (nn)(2), are scheduled to be released from
placement in a public institution following adjudication, and who the State
determines pursuant to subparagraph (B) or (C), as applicable, meet the eli-
gibility requirements for medical assistance under the State plan, the State
shall have in place a plan to ensure, and in accordance with such plan, pro-
vide—
‘‘(i) for, prior to the release of such an eligible juvenile from such pub-
lic institution (or not later than one week after release from the public
institution), and in coordination with such institution—
‘‘(I) any screening described in section 1905(r) for which such eli-
gible juvenile qualifies based on the intervals established pursuant
to such section;
‘‘(II) any screening which such eligible juvenile did not receive in
accordance with such intervals due to the incarceration of such eli-
gible juvenile; and
‘‘(III) a behavioral health or mental health screening that is a
screening service described under section 1905(r)(1), if such screen-
ing was not otherwise conducted pursuant to this clause;
‘‘(ii) for, not later than the latter of the date on which such eligible
juvenile is released from such institution, or the date on which the
screenings pursuant to clause (i) for such eligible juvenile are con-
ducted, referrals for such eligible juvenile to the appropriate services,
including necessary health care, diagnostic services, treatment, and
other measures described in section 1905(a), giving preference to pro-
viders of such services who are located in the geographic region of the
home or residence of such eligible juvenile when available, based on
such screenings; and
‘‘(iii) for, following the release of such eligible juvenile from such in-
stitution, and the completion of the screenings conducted pursuant to
clause (i), not less than 30 days of targeted case management services
furnished by a provider in the geographic region of the home or resi-
dence of such eligible juvenile.’’; and
(2) in subsection (nn)(3), by striking ‘‘(30)’’ and inserting ‘‘(31)’’.
(b) CLARIFICATION OF FEDERAL FINANCIAL PARTICIPATION.—The subdivision (A) of
section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) following paragraph
(31) of such section is amended by striking ‘‘(except as a patient in a medical institu-
tion)’’ and inserting ‘‘(except in the case of eligible juveniles described in section
1902(a)(84)(D), and individuals as a patient in a medical institution)’’.
(c) CHIP REQUIREMENT.—Section 2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)) is amended by adding at the end the following new subparagraph:
‘‘(U) Section 1902(a)(84)(D) (relating to eligible juveniles scheduled to be
released from placement in a public institution following adjudication).’’.
SEC. 3. GUIDANCE ON REDUCING ADMINISTRATIVE BARRIERS TO PROVIDING HEALTH CARE
SERVICES IN SCHOOLS.
(a) IN GENERAL.—Not later than 180 days after the date of enactment of this Act,
the Secretary of Health and Human Services shall issue guidance to State Medicaid
agencies, elementary and secondary schools, and school-based health centers on re-
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ducing administrative barriers to such schools and centers furnishing medical as-
sistance and obtaining payment for such assistance under titles XIX and XXI of the
Social Security Act (42 U.S.C. 1396 et seq., 1397aa et seq.).
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3
(b) CONTENTS OF GUIDANCE.—The guidance issued pursuant to subsection (a)
shall—
(1) include proposed revisions to the May 2003 Medicaid School-Based Admin-
istrative Claiming Guide, the 1997 Medicaid and Schools Technical Assistance
Guide, and other guidance in effect on the date of enactment of this Act;
(2) provide information on payment under titles XIX and XXI of the Social
Security Act (42 U.S.C. 1396 et seq., 1397aa et seq.) for the provision of medical
assistance, including such assistance provided in accordance with an individual-
ized education program or under the ‘‘free care’’ policy described in the State
Medicaid Director letter on payment for services issued on December 15, 2014
(#14-006);
(3) take into account reasons why small and rural local education agencies
may not provide medical assistance, and consider approaches to encourage such
agencies to provide such assistance; and
(4) include best practices and examples of methods that State Medicaid agen-
cies and local education agencies have used to pay for, and increase the avail-
ability of, medical assistance.
(c) DEFINITIONS.—In this Act:
(1) INDIVIDUALIZED EDUCATION PROGRAM.—The term ‘‘individualized education
program’’ has the meaning given such term in section 602(14) of the Individuals
with Disabilities Education Act (20 U.S.C. 1401(14)).
(2) SCHOOL-BASED HEALTH CENTER.—The term ‘‘school-based health center’’
has the meaning given such term in section 2110(c)(9) of the Social Security Act
(42 U.S.C. 1397jj(c)(9)).
SEC. 4. GUIDANCE TO STATES ON SUPPORTING MENTAL, EMOTIONAL, AND BEHAVIORAL
HEALTH SERVICES, AND ON THE AVAILABILITY OF TELEHEALTH UNDER MED-
ICAID.
Not later than January 1, 2024, the Secretary of Health and Human Services
shall issue guidance to States on how to expand the provision of mental, emotional,
and behavioral health services covered under State plans (or waivers of such plans)
under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), including a de-
scription of best practices for—
(1) effective programs for the provision of such services;
(2) provision of such services to underserved communities;
(3) flexibilities for children’s hospitals and other providers to expand access
to such services while ensuring high quality and safety; and
(4) recruitment and retention of providers of such services.
SEC. 5. ENSURING CHILDREN RECEIVE TIMELY ACCESS TO CARE.
(a) GUIDANCE TO STATES ON FLEXIBILITIES TO ENSURE PROVIDER CAPACITY TO
PROVIDE PEDIATRIC MENTAL, EMOTIONAL, AND BEHAVIORAL CRISIS CARE.—Not later
than July 1, 2024, the Secretary of Health and Human Services shall provide guid-
ance to States on existing flexibilities under State plans (or waivers of such plans)
under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) to support chil-
dren in crisis or in need of intensive mental, emotional, or behavioral health serv-
ices.
(b) ENSURING CONSISTENT REVIEW AND STATE IMPLEMENTATION OF EARLY AND
PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICES.—Section 1905(r) of
the Social Security Act (42 U.S.C. 1396d(r)) is amended by adding at the end the
following: ‘‘Not later than January 1, 2025, and not later than each January 1 there-
after, the Secretary shall review implementation of the requirements of this sub-
section by States, including such requirements relating to services provided by a
managed care entity, identify and disseminate best practices for ensuring com-
prehensive coverage of services, identify gaps and deficiencies in meeting Federal
requirements, and provide guidance to States on addressing identified gaps and dis-
parities and meeting Federal coverage requirements in order to ensure children
have access to behavioral health services.’’.
SEC. 6. STRATEGIES TO INCREASE ACCESS TO TELEHEALTH UNDER MEDICAID AND CHIL-
DREN’S HEALTH INSURANCE PROGRAM.
Not later than 1 year after the date of the enactment of this Act, and not less
frequently than once every five years thereafter, the Secretary of Health and
Human Services shall update guidance issued by the Centers for Medicare & Med-
icaid Services to States, the State Medicaid & CHIP Telehealth Toolkit, to clarify
strategies to overcome existing barriers and increase access to telehealth services
under the Medicaid program under title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) and the Children’s Health Insurance Program under title XXI of such
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Act (42 U.S.C. 1397aa et seq.). Such updated guidance shall include examples of and
promising practices regarding—
(1) telehealth delivery of covered services;
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(2) recommended voluntary billing codes, modifiers, and place-of-service des-
ignations for telehealth and other virtual health care services;
(3) the simplification or alignment (including through reciprocity) of provider
licensing, credentialing, and enrollment protocols with respect to telehealth
across States, State Medicaid plans under such title XIX, and Medicaid man-
aged care organizations, including during national public health emergencies;
(4) strategies States can use to integrate telehealth and other virtual health
care services into value-based health care models; and
(5) waivers under the Medicaid program to test expanded access to telehealth,
including during the emergency period described in section 1135(g)(1)(B) of the
Social Security Act (42 U.S.C. 1320b–5(g)(1)(B)).
SEC. 7. REMOVAL OF INMATE LIMITATIONS ON BENEFITS UNDER MEDICAID.
(a) IN GENERAL.—The subdivision (A) of section 1905(a) of the Social Security Act
(42 U.S.C. 1396d(a)) following paragraph (31) of such section, as amended by section
2(b), is further amended by striking ‘‘and individuals as a patient in a medical insti-
tution’’ and inserting ‘‘individuals as a patient in a medical institution, or, at the
option of the State, for an individual who is a juvenile, while such individual is an
inmate of a public institution pending disposition of charges’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a) shall take effect on
the first day of the first calendar quarter that begins after the date that is 18
months after the date of enactment of this Act and shall apply to items and services
furnished for periods beginning on or after such date.
Amend the title so as to read:
A bill to amend titles XIX and XXI of the Social Security Act to
provide for requirements under Medicaid State plans for health
screenings and referrals for certain eligible juveniles in public insti-
tutions; to require the Secretary of Health and Human Services to
issue and update guidance under the Medicaid and Children’s
Health Insurance Programs to improving access to, and the deliv-
ery of, timely health care services, including mental and behavioral
health services; and for other purposes.
I. PURPOSE AND SUMMARY
H.R. 7233, the ‘‘Keeping Incarceration Discharges Streamlined
for Children and Accommodating Resources in Education Act,’’ or
the ‘‘KIDS CARE Act,’’ requires the Centers for Medicare & Med-
icaid Services (CMS) to provide guidances to states intended to in-
crease access to care and monitor children’s access to Medicaid
services. The bill also creates two limited exceptions to Medicaid’s
inmate exclusion for certain juveniles.
H.R. 7233 requires state Medicaid and CHIP programs to con-
duct screenings and referrals covered by Medicaid upon a juvenile’s
discharge from incarceration. It also provides for a limited excep-
tion to the inmate exclusion for screenings and referrals conducted
shortly before the juvenile’s release. It directs CMS to issue guid-
ance to help reduce barriers to Medicaid reimbursement for school-
based services. It further directs CMS to issue guidance to states
on ways to expand access to behavioral health services in Medicaid,
as well as on existing flexibilities available under current law that
can be used to ensure children experiencing behavioral health cri-
sis have access to the care they need. It also directs CMS to con-
duct annual reviews of state compliance with the requirements of
the Medicaid Early and Periodic Screening, Detection, and Treat-
ment (EPSDT) benefit for children and to provide guidance on ad-
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dressing identified deficiencies. It directs CMS to periodically up-
date its guidance to states on strategies to expand access to tele-
health in Medicaid and CHIP. Finally, it provides another limited
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5
exception to the inmate exclusion through a state option to con-
tinue to provide Medicaid to incarcerated juveniles pre-trial.
II. BACKGROUND AND NEED FOR LEGISLATION
Medicaid and CHIP provide coverage for nearly half of all chil-
dren in the United States.1 Medicaid is also the largest payer of
mental health services.2 At a time when children are increasingly
needing access to mental and behavioral health care services and
given Medicaid’s substantial role in both covering children and pay-
ing for health care and mental health services, it is crucial that
state Medicaid programs be better equipped at offering care to chil-
dren and that behavioral health providers have sufficient resources
in order to better furnish care to children.3
Confusion over federal requirements and lack of up-to-date fed-
eral guidance related to Medicaid in schools and the use of tele-
medicine—which can be effective strategies to increase access to
care—can create barriers to states implementing these ap-
proaches.4 5 Similarly, while Medicaid’s EPSDT benefit requires
states to cover all services that can be covered under the Medicaid
state plan, including optional services that a state has not other-
wise chosen to cover, inconsistent enforcement of this coverage re-
quirement can perpetuate barriers to access for children.6 7 8
Additionally, statutory restrictions that prohibit the use of fed-
eral funds for care for incarcerated Medicaid beneficiaries can re-
sult in disruptions in access to care upon arrest and lead to juve-
niles being released from incarceration without linkages to treat-
ment.9 Ensuring access to care for justice-involved populations is
particularly crucial given the well-established connection between
incarceration and increased likelihood of mental illness and sub-
stance use disorder.10 Ensuring that states are able to identify
beneficiaries with these conditions prior to their release so that
they can be connected to treatment upon discharge will help to
minimize disruptions and promote continuity of care.
CMS has begun its own process to address some of these issues
by releasing guidances on both the requirements for school-based
1 Children’s Defense Fund, New Report Shows Half of Children are Covered by Medicaid.
States Must Ensure These Children Don’t Lose Coverage (February 25, 2022)
(www.childrensdefense.org/blog/ccf-report-medicaid-phe/#:∼:text=Our%20partners%20at%20Geor
getown%20University,covered%20by%20Medicaid%20or%20CHIP).
2 Medicaid.Gov, Behavioral Health Services (www.medicaid.gov/medicaid/benefits/behavioral-
health-services/index.html) (accessed June 6, 2022).
3 Samji, H., Wu, J., Ladak, A., Vossen, C., Stewart, E., Dove, N., Long, D., & Snell, G. (2021).
Review: Mental health impacts of the COVID–19 pandemic on Children and Youth—a system-
atic review. Child and Adolescent Mental Health, 27(2), 173–189 (https://doi.org/10.1111/
camh.12501).
4 Andra Wilkinson et al., Early Evidence of Medicaid’s Important Role in School-based Health
Services, Child Trends (Dec. 14, 2020) (www.childtrends.org/publications/early-evidence-
medicaid-role-school-based-heath-services).
5 Medicaid.Gov, Telemedicine (www.medicaid.gov/medicaid/benefits/telemedicine/index.html)
(accessed June 6, 2022).
6 Medicaid and CHIP Payment and Access Commission, EPSDT in Medicaid (https://
www.macpac.gov/subtopic/epsdt-in-medicaid/) (accessed June 6, 2022)
7 Georgetown University Health Policy Institute Center for Children and Families, Children
Struggle to Access Autism Treatment (Oct. 1, 2018) (ccf.georgetown.edu/2018/10/01/children-
struggle-to-access-autism-treatment-in-medicaid/).
8 National Health Law Program, Addressing Barriers to Behavioral Health Coverage for Low-
Income Youth (Fall 2021) (healthlaw.org/wp-content/uploads/2021/10/NHeLP-EPSDT-
Behavioral-Health-Flipbook-for-healthlaworg.pdf).
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9 Kevin Fiscella, Leo Beletsky, and Sarah Wakeman, The Inmate Exception and Reform of Cor-
rectional Health Care, American Journal of Public Health (March 2017).
10 Lauren Brinkley-Rubinstein, Incarceration as a Catalyst for Worsening Health, Health &
Justice (Oct. 24, 2013).
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6
Medicaid services and the use of telehealth in Medicaid.11 12 13
However, the utility of these guidances decreases if CMS does not
regularly update it to account for material changes, including
changes in law, care delivery systems, and technology, and more
guidance and changes to the law are needed in order to ensure
greater access to care for children.
H.R. 7233 contains several provisions that will help address
these barriers to access. It requires CMS to update its Medicaid
guidance on school-based care and regularly update its guidance on
telehealth, as well as identify existing flexibilities states can use to
increase access to care. These provisions will ensure that states
have timely and accurate information on Medicaid authorities and
flexibilities that will enable states to provide services to bene-
ficiaries in settings that are convenient to them. H.R. 7233 will
help to minimize disruptions in access to health care by continuing
Medicaid coverage for juveniles in pre-trial detention and requiring
states to screen incarcerated juveniles for medical and behavioral
health needs prior to discharge. Together, these policies will pro-
mote continuity of coverage and also ensure beneficiaries health
care needs are identified prior to release so that they can be better
connected to the services they need. Finally, H.R. 7233 will ensure
that children on Medicaid do not have coverage without access by
requiring CMS to regularly monitor state compliance with the re-
quirements of EPSDT. This provision will bring important over-
sight and accountability to ensure that state Medicaid programs
are meeting their obligations to furnish medically necessary care to
low-income children.
III. COMMITTEE HEARINGS
For the purposes of section 3(c) of rule XIII of the Rules of the
House of Representatives, the following hearings were used to de-
velop and consider H.R. 7233:
The Subcommittee on Health held a hearing on April 1, 2022, en-
titled ‘‘Communities in Need: Legislation to Support Mental Health
and Well-Being.’’ The Subcommittee received testimony from the
following witnesses:
PANEL I
• Miriam E. Delphin-Rittmon, Ph.D., Assistant Secretary for
Mental Health and Substance Use, Substance Abuse and Men-
tal Health Services Administration
• Carole Johnson, M.A., Administrator, Health Resources
and Services Administration
11 The Center for Medicaid and State Operations, Medicaid and School Health: A Technical
Assistance Guide (August 1997) (https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-
documents/Medicaid_and_School_Health_Technical_Assistance_Guide__59.pdf).
12 Centers for Medicare & Medicaid Services, Medicaid School-Based Administrative Claiming
Guide (May 2003) (https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-
systems/medicaidbudgetexpendsystem/downloads/schoolhealthsvcs.pdf).
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13 Centers for Medicare & Medicaid Services, State Medicaid & CHIP Telehealth Toolkit: Pol-
icy Considerations for States Expanding Use of Telehealth COVID–19 Version (https://
www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf) (accessed
June 6, 2022).
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PANEL II
• Rebecca W. Brendel, M.D., J.D., President-Elect, American
Psychiatric Association
• Sandy L. Chung, M.D., F.A.A.P., F.A.C.H.E., President-
Elect, American Academy of Pediatrics
• Steven Adelsheim, M.D., Clinical Professor of Psychiatry
and Director, Stanford Center for Youth Mental Health and
Wellbeing, Stanford University School of Medicine, Stanford
Children’s Health
• Debra Pinals, M.D., Medical Director, Behavioral Health
and Forensic Programs, Michigan Department of Health and
Human Services
• Cassandra Price, M.B.A., Director, Office of Addictive Dis-
eases, Georgia Department of Behavioral Health and Develop-
mental Disabilities
• LeVail W. Smith, Peer Support Specialist Instructor and
Mentor
IV. COMMITTEE CONSIDERATION
H.R. 7233, ‘‘Keeping Incarceration Discharges Streamlined for
Children and Accommodating Resources in Education Act,’’ or the
‘‘KIDS CARE Act,’’ was introduced on March 28, 2022, by Rep-
resentatives Richard Hudson (R–NC) and Ann M. Kuster (D–NH)
and was referred to the Committee on Energy and Commerce. Sub-
sequently, on March 29, 2022, the bill was referred to the Sub-
committee on Health.
On May 11, 2022, the Subcommittee on Health met in open
markup session, pursuant to notice, to consider H.R. 7233 and five
other bills. During consideration of the bill, an amendment in the
nature of a substitute (AINS), offered by Representative Hudson,
was agreed to by a voice vote. Two amendments to the AINS, one
filed by Representative Eshoo (D–CA) and the other filed by Rep-
resentative Blunt Rochester (D–DE), were both agreed to by a voice
vote. Two amendments filed by Representative Burgess (R–TX)
were offered and withdrawn. Upon conclusion of consideration of
the bill, the Subcommittee on Health agreed to report the bill fa-
vorably to the full Committee, amended, by a roll call vote of 32
yeas to 0 nays.
On May 18, 2022, the full Committee met in open markup ses-
sion, pursuant to notice, to consider H.R. 7233 and five other bills.
An AINS, offered by Representative Hudson, was agreed to by a
voice vote. Upon conclusion of consideration of the bill, the full
Committee agreed to a motion on final passage offered by Rep-
resentative Pallone, Chairman of the Committee, to order H.R.
7233 reported favorably to the House, amended, by a roll call vote
of 52 yeas to 0 nays.
V. COMMITTEE VOTES
Clause 3(b) of rule XIII of the Rules of the House of Representa-
tives requires the Committee to list each record vote on the motion
to report legislation and amendments thereto. The Committee ad-
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vises that there were two record votes taken on H.R. 7233, includ-
ing a motion by Chairman Pallone ordering H.R. 7233 favorably re-
ported to the House, amended. The motion on final passage of the
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8
bill was approved by a record vote of 52 yeas to 0 nays. The fol-
lowing are the record votes taken during Committee consideration,
including the names of those members voting for and against:
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lll:ommittee on l!Enerll!' anb lll:ommerce
117 th Congress
Subcommittee ou Health
(ratio: 19-15)
ROLL CALL VOTE #3
Bill: R.R. 7233, the "Keeping Incarceration Discharges Streamlined for Children and
Accommodating Resources in Education Act" or "KIDS CARES Act"
Motion: A motion by Ms. Eshoo of California to order R.R. 7233 transmitted favorably to
the full Committee, amended (Final Passage).
Disposition: AGREED TO by a roll call vote of32 yeas to O nays
Mr. Butterfield X
Ms.Matsui X Mr. Burgess X
Ms. Castor X Mr. Griffith X
Mr. Sarbanes X Mr. Bilirakis X
Mr. Welch X Mr.Long X
Mr. Schrader X Mr. Bucshon X
Mr. Cardenas X Mr.Mullin X
Mr. Ruiz X Mr. Hudson X
Mrs.Dingell X Mr. Carter X
Ms. Kuster X Mr.Dunn X
Ms. Kelly Mr. Curtis X
Ms. Barragan X Mr. Crenshaw X
Ms. Blunt Rochester X Mr. Joyce X
Ms. Craig X Mrs. Rodgers X
Ms. Schrier X
Ms. Trahan X
Ms. Fletcher X
Mr. Pallone X
05/11/22
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Insert offset folio 10 here HR374.001
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Ql:ommittee on Qenerm,, anb Ql:ommerte
117"' Congress
Full Committee
(ratio: 32-26)
ROLL CALL VOTE# 124
Bill: H.R. 7233, the "Keeping Incarceration Discharges Streamlined for Child
and Accommodating Resources in Education Act" or "KIDS CARES Act"
Vote: Final Passage
Disposition: AGREED TO by a roll call vote of 52 yeas to Onays
REPRESENTATIVE YEAS NAYS PRESENT REPRESENTATIVE YEAS NAYS PRESENT
Mr. Pallone X Mrs. Rodgers X
Mr. Rush X Mr. Uoton X
Ms. Eshoo X Mr. Burgess X
Ms. DeGette X Mr. Scalise
Mr. Doyle X Mr. Latta X
Ms. Schakowsky X Mr. Guthrie X
Mr. Butterfield Mr. McKinley X
Ms. Matsui X Mr. Kinzinger
Ms. Castor X Mr. Griffith X
Mr. Sarbanes X Mr. Bilirakis
Mr.McNemey X Mr. Johnson X
Mr. Welch X Mr. Long X
Mr. Tonko X Mr. Bucshon X
Ms. Clarke X Mr.Mullin X
Mr. Schrader X Mr. Hudson X
Mr. Cardenas X Mr. Walberg X
Mr. Ruiz X Mr. Carter X
Mr. Peters X Mr. Duncan
Mrs. Dingell X Mr. Palmer X
Mr. Veasev X Mr. Dunn X
Ms. Kuster X Mr. Curtis X
Ms.Kelly X Ms. Lesko X
- an X Mr. Pence X
Mr. McEachin X Mr. Crenshaw X
Ms. Blunt Rochester X Mr. Joyce X
Mr. Soto X Mr. Armstrong X
Mr. O'Halleran X
Ms.Rice X
Ms. Craig
Ms. Schrier X
Ms. Trahan X
Ms. Fletcher X
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11
VI. OVERSIGHT FINDINGS
Pursuant to clause 3(c)(1) of rule XIII and clause 2(b)(1) of rule
X of the Rules of the House of Representatives, the oversight find-
ings and recommendations of the Committee are reflected in the
descriptive portion of the report.
VII. NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND
TAX EXPENDITURES
Pursuant to 3(c)(2) of rule XIII of the Rules of the House of Rep-
resentatives, the Committee adopts as its own the estimate of new
budget authority, entitlement authority, or tax expenditures or rev-
enues contained in the cost estimate prepared by the Director of
the Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974.
The Committee has requested but not received from the Director
of the Congressional Budget Office a statement as to whether this
bill contains any new budget authority, spending authority, credit
authority, or an increase or decrease in revenues or tax expendi-
tures.
VIII. FEDERAL MANDATES STATEMENT
The Committee adopts as its own the estimate of Federal man-
dates prepared by the Director of the Congressional Budget Office
pursuant to section 423 of the Unfunded Mandates Reform Act.
IX. STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES
Pursuant to clause 3(c)(4) of rule XIII, the general performance
goal or objective of this legislation is to ensure that state Medicaid
programs have updated guidance on Medicaid in schools and the
use of telehealth in Medicaid and CHIP; to ensure that CMS mon-
itors access to care for children covered by Medicaid; and to mini-
mize disruptions in access for incarcerated juveniles covered by
Medicaid.
X. DUPLICATION OF FEDERAL PROGRAMS
Pursuant to clause 3(c)(5) of rule XIII, no provision of H.R. 7233
is known to be duplicative of another Federal program, including
any program that was included in a report to Congress pursuant
to section 21 of Public Law 111–139 or the most recent Catalog of
Federal Domestic Assistance.
XI. COMMITTEE COST ESTIMATE
Pursuant to clause 3(d)(1) of rule XIII, the Committee adopts as
its own the cost estimate prepared by the Director of the Congres-
sional Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
XII. EARMARKS, LIMITED TAX BENEFITS, AND LIMITED TARIFF
BENEFITS
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Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the Committee
finds that H.R. 7233 contains no earmarks, limited tax benefits, or
limited tariff benefits.
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12
XIII. ADVISORY COMMITTEE STATEMENT
No advisory committee within the meaning of section 5(b) of the
Federal Advisory Committee Act was created by this legislation.
XIV. APPLICABILITY TO LEGISLATIVE BRANCH
The Committee finds that the legislation does not relate to the
terms and conditions of employment or access to public services or
accommodations within the meaning of section 102(b)(3) of the Con-
gressional Accountability Act.
XV. SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION
Section 1. Short title
Section 1 designates that the short title may be cited as the
‘‘Keeping Incarceration Discharges Streamlined for Children and
Accommodating Resources in Education (KIDS CARE) Act.’’
Sec. 2. Medicaid and CHIP requirements for health screenings and
referrals for eligible juveniles in public institutions
Section 2 requires state Medicaid and CHIP programs to provide
medical and behavioral health screenings to incarcerated juveniles
prior to their release. It specifically requires screenings for which
the beneficiary is eligible for under the state’s periodicity schedule,
any screenings the beneficiary was eligible for under the periodicity
schedule but did not receive due to their incarceration, and any
covered behavioral health or mental health screening regardless of
the periodicity schedule. It also requires referrals to the appro-
priate services after such screenings are conducted.
Sec. 3. Guidance on reducing administrative barriers to providing
health care services in schools
Section 3 directs the Centers for Medicare & Medicaid Services
(CMS) to issue guidance on reducing administrative barriers to
school-based services and obtaining payments for such services
under the Medicaid program.
Sec. 4. Guidance to states on supporting mental, emotional, and be-
havioral health services, and the availability of telehealth
under Medicaid
Section 4 directs CMS to issue guidance on how to expand access
to mental, emotional, and behavioral health services covered by
Medicaid.
Sec. 5. Ensuring children receive timely access to care
Section 5 directs CMS to issue guidance on existing Medicaid
flexibilities to support children in crisis who may need intensive
services. It also requires CMS to monitor state implementation of
the Medicaid Early and Periodic Screening, Detection, and Treat-
ment (EPSDT) benefit to ensure that states are providing children
on Medicaid with the services they are entitled to under law.
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13
Sec. 6. Strategies to increase access to telehealth under Medicaid
and the Children’s Health Insurance Program
Section 6 requires CMS to regularly update its guidance to states
on how to increase access to telehealth under Medicaid.
Sec. 7. Removal of inmate limitations on benefits under Medicaid
Section 7 eliminates the inmate exclusion for children on Med-
icaid who are in pre-trial detention, allowing for eligible children
to maintain coverage and ensure continuity of services during de-
tainment and, if applicable, upon release from detention.
XVI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
In compliance with clause 3(e) of rule XIII of the Rules of the
House of Representatives, changes in existing law made by the bill,
as reported, are shown as follows (existing law proposed to be omit-
ted is enclosed in black brackets, new matter is printed in italics,
and existing law in which no change is proposed is shown in
roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE
PROGRAMS
* * * * * * *
STATE PLANS FOR MEDICAL ASSISTANCE
SEC. 1902. (a) A State plan for medical assistance must—
(1) provide that it shall be in effect in all political subdivi-
sions 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 ex-
penditures under the plan with respect to which payments
under section 1903 are authorized by this title; and, effective
July 1, 1969, provide for financial participation by the State
equal to all of such non-Federal share or provide for distribu-
tion of funds from Federal or State sources, for carrying out
the State plan, on an equalization or other basis which will as-
sure that the lack of adequate funds from local sources will not
result in lowering the amount, duration, scope, or quality of
care and services available under the plan;
(3) provide for granting an opportunity for a fair hearing be-
fore 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 per-
sonnel standards on a merit basis, except that the Secretary
shall exercise no authority with respect to the selection, tenure
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of office, and compensation of any individual employed in ac-
cordance with such methods, including provision for utilization
of professional medical personnel in the administration and,
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14
where administered locally, supervision of administration of
the plan, and, subject to section 1903(i), including a specifica-
tion that the single State agency described in paragraph (5)
will ensure necessary transportation for beneficiaries under the
State plan to and from providers and a description of the meth-
ods that such agency will use to ensure such transportation) as
are found by the Secretary to be necessary for the proper and
efficient operation of the plan, (B) for the training and effective
use of paid subprofessional staff, with particular emphasis on
the full-time or part-time employment of recipients and other
persons of low income, as community service aides, in the ad-
ministration of the plan and for the use of nonpaid or partially
paid volunteers in a social service volunteer program in pro-
viding services to applicants and recipients and in assisting
any advisory committees established by the State agency, (C)
that each State or local officer, employee, or independent con-
tractor who is responsible for the expenditure of substantial
amounts of funds under the State plan, each individual who
formerly was such an officer, employee, or contractor, and each
partner of such an officer, employee, or contractor shall be pro-
hibited from committing any act, in relation to any activity
under the plan, the commission of which, in connection with
any activity concerning the United States Government, by an
officer or employee of the United States Government, an indi-
vidual who was such an officer or employee, or a partner of
such an officer or employee is prohibited by section 207 or 208
of title 18, United States Code, and (D) that each State or local
officer, employee, or independent contractor who is responsible
for selecting, awarding, or otherwise obtaining items and serv-
ices under the State plan shall be subject to safeguards against
conflicts of interest that are at least as stringent as the safe-
guards that apply under section 27 of the Office of Federal Pro-
curement Policy Act (41 U.S.C. 423) to persons described in
subsection (a)(2) of such section of that Act;
(5) either provide for the establishment or designation of a
single State agency to administer or to supervise the adminis-
tration of the plan; or provide for the establishment or designa-
tion 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 ap-
proved under title I or XVI (insofar as it relates to the aged)
if the State is eligible to participate in the State plan program
established under title XVI, or by the agency or agencies ad-
ministering the supplemental security income program estab-
lished under title XVI or the State plan approved under part
A of title IV if the State is not eligible to participate in the
State plan program established under title 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 provi-
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sions as the Secretary may from time to time find necessary
to assure the correctness and verification of such reports;
(7) provide—
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15
(A) safeguards which restrict the use or disclosure of in-
formation 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 Nu-
trition 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; and
(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 pro-
gram 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 title whose family income does
not exceed 133 percent of the poverty line (as defined
in section 673(2) of the Community Services Block
Grant Act, including any revision required by such
section), as determined without regard to any expense,
block, or other income disregard, applicable to a family
of the size involved, may be certified as eligible for
free lunches under the Richard B. Russell National
School Lunch Act and free breakfasts under the Child
Nutrition Act of 1966 without further application; and
(ii) the State agencies responsible for administering
the State plan under this title, and for carrying out
the school lunch program established under the Rich-
ard B. Russell National School Lunch Act (42 U.S.C.
1751 et seq.) or the school breakfast program estab-
lished by section 4 of the Child Nutrition Act of 1966
(42 U.S.C. 1773), cooperate in carrying out paragraphs
(3)(F) and (15) of section 9(b) of that 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 reason-
able promptness to all eligible individuals;
(9) provide—
(A) that the State health agency, or other appropriate
State medical agency (whichever is utilized by the Sec-
retary for the purpose specified in the first sentence of sec-
tion 1864(a)), shall be responsible for establishing and
maintaining health standards for private or public institu-
tions in which recipients of medical assistance under the
plan may receive care or services,
(B) for the establishment or designation of a State au-
thority or authorities which shall be responsible for estab-
lishing and maintaining standards, other than those relat-
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ing to health, for such institutions,
(C) that any laboratory services paid for under such plan
must be provided by a laboratory which meets the applica-
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16
ble requirements of section 1861(e)(9) or paragraphs (16)
and (17) of section 1861(s), or, in the case of a laboratory
which is in a rural health clinic, of section 1861(aa)(2)(G),
and
(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 inspec-
tion reports (or a successor form), complaint investigation
reports, the facility’s plan of correction, and such other in-
formation 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), (17), (21), (28), (29), and (30) of section 1905(a), to—
(i) all individuals—
(I) who are receiving aid or assistance under
any plan of the State approved under title I, X,
XIV, or XVI, or part A or part E of title IV (includ-
ing individuals eligible under this title by reason
of section 402(a)(37), 406(h), or 473(b), or consid-
ered by the State to be receiving such aid as au-
thorized under section 482(e)(6)),
(II)(aa) with respect to whom supplemental se-
curity income benefits are being paid under title
XVI (or were being paid as of the date of the en-
actment of section 211(a) of the Personal Respon-
sibility and Work Opportunity Reconciliation Act
of 1996 (P.L. 104–193) and would continue to be
paid but for the enactment of that section), (bb)
who are qualified severely impaired individuals
(as defined in section 1905(q)), or (cc) who are
under 21 years of age and with respect to whom
supplemental security income benefits would be
paid under title XVI if subparagraphs (A) and (B)
of section 1611(c)(7) were applied without regard
to the phrase ‘‘the first day of the month fol-
lowing’’,
(III) who are qualified pregnant women or chil-
dren as defined in section 1905(n),
(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;
(V) who are qualified family members as defined
in section 1905(m)(1),
(VI) who are described in subparagraph (C) of
subsection (l)(1) and whose family income does not
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exceed the income level the State is required to
establish under subsection (l)(2)(B) for such a fam-
ily,
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17
(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 fam-
ily;
(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 title
XVIII, or enrolled for benefits under part B of title
XVIII, and are not described in a previous sub-
clause of this clause, and whose income (as deter-
mined under subsection (e)(14)) does not exceed
133 percent of the poverty line (as defined in sec-
tion 2110(c)(5)) applicable to a family of the size
involved, subject to subsection (k); or
(IX) who—
(aa) are under 26 years of age;
(bb) are not described in or enrolled under
any of subclauses (I) through (VII) of this
clause or are described in any of such sub-
clauses but have income that exceeds the
level of income applicable under the State
plan for eligibility to enroll for medical assist-
ance under such subclause;
(cc) were in foster care under the responsi-
bility of the State on the date of attaining 18
years of age or such higher age as the State
has elected under section 475(8)(B)(iii); and
(dd) were enrolled in the State plan under
this title or under a waiver of the plan while
in such foster care;
(ii) at the option of the State, to any group or groups
of individuals described in section 1905(a) (or, in the
case of individuals described in section 1905(a)(i), to
any reasonable categories of such individuals) who are
not individuals described in clause (i) of this subpara-
graph but—
(I) who meet the income and resources require-
ments of the appropriate State plan described in
clause (i) or the supplemental security income pro-
gram (as the case may be),
(II) who would meet the income and resources
requirements of the appropriate State plan de-
scribed 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 al-
lowed under Federal law,
(IV) with respect to whom there is being paid,
or who are eligible, or would be eligible if they
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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), sup-
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18
plemental security income benefits under title
XVI, or a State supplementary payment;
(V) who are in a medical institution for a period
of not less than 30 consecutive days (with eligi-
bility by reason of this subclause beginning on the
first day of such period), who meet the resource
requirements of the appropriate State plan de-
scribed in clause (i) or the supplemental security
income program, and whose income does not ex-
ceed a separate income standard established by
the State which is consistent with the limit estab-
lished under section 1903(f)(4)(C),
(VI) who would be eligible under the State plan
under this title if they were in a medical institu-
tion, with respect to whom there has been a deter-
mination that but for the provision of home or
community-based services described in subsection
(c), (d), or (e) of section 1915 they would require
the level of care provided in a hospital, nursing fa-
cility or intermediate care facility for the mentally
retarded the cost of which could be reimbursed
under the State plan, and who will receive home
or community-based services pursuant to a waiver
granted by the Secretary under subsection (c), (d),
or (e) of section 1915,
(VII) who would be eligible under the State plan
under this title if they were in a medical institu-
tion, who are terminally ill, and who will receive
hospice care pursuant to a voluntary election de-
scribed in section 1905(o);
(VIII) who is a child described in section
1905(a)(i)—
(aa) for whom there is in effect an adoption
assistance agreement (other than an agree-
ment under part E of title 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 as-
sistance agreement being entered into, or who
would have been eligible for medical assist-
ance at such time if the eligibility standards
and methodologies of the State’s foster care
program under part E of title 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 title IV;
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(IX) who are described in subsection (l)(1) and
are not described in clause (i)(IV), clause (i)(VI), or
clause (i)(VII);
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19
(X) who are described in subsection (m)(1);
(XI) who receive only an optional State supple-
mentary 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
title XVI), which are available to all individuals in
the State (but which may be based on different in-
come 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 section
1616 or 1634;
(XII) who are described in subsection (z)(1) (re-
lating to certain TB-infected individuals);
(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
section 673(2) of the Omnibus Budget Reconcili-
ation Act of 1981) applicable to a family of the size
involved, and who but for earnings in excess of the
limit established under section 1905(q)(2)(B),
would be considered to be receiving supplemental
security income (subject, notwithstanding section
1916, to payment of premiums or other cost-shar-
ing charges (set on a sliding scale based on in-
come) that the State may determine);
(XIV) who are optional targeted low-income chil-
dren described in section 1905(u)(2)(B);
(XV) who, but for earnings in excess of the limit
established under section 1905(q)(2)(B), would be
considered to be receiving supplemental security
income, who is at least 16, but less than 65, years
of age, and whose assets, resources, and earned or
unearned income (or both) do not exceed such lim-
itations (if any) as the State may establish;
(XVI) who are employed individuals with a
medically improved disability described in section
1905(v)(1) and whose assets, resources, and
earned or unearned income (or both) do not exceed
such limitations (if any) as the State may estab-
lish, but only if the State provides medical assist-
ance to individuals described in subclause (XV);
(XVII) who are independent foster care adoles-
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cents (as defined in section 1905(w)(1)), or who are
within any reasonable categories of such adoles-
cents specified by the State;
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20
(XVIII) who are described in subsection (aa) (re-
lating to certain breast or cervical cancer pa-
tients);
(XIX) who are disabled children described in
subsection (cc)(1);
(XX) beginning January 1, 2014, who are under
65 years of age and are not described in or en-
rolled under a previous subclause of this clause,
and whose income (as determined under sub-
section (e)(14)) exceeds 133 percent of the poverty
line (as defined in section 2110(c)(5)) applicable to
a family of the size involved but does not exceed
the highest income eligibility level established
under the State plan or under a waiver of the
plan, subject to subsection (hh);
(XXI) who are described in subsection (ii) (relat-
ing to individuals who meet certain income stand-
ards);
(XXII) who are eligible for home and commu-
nity-based services under needs-based criteria es-
tablished under paragraph (1)(A) of section
1915(i), or who are eligible for home and commu-
nity-based services under paragraph (6) of such
section, and who will receive home and commu-
nity-based services pursuant to a State plan
amendment under such subsection; or
(XXIII) during any portion of the emergency pe-
riod defined in paragraph (1)(B) of section 1135(g)
beginning on or after the date of the enactment of
this subclause, who are uninsured individuals (as
defined in subsection (ss));
(B) that the medical assistance made available to any in-
dividual 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 individ-
uals not described in subparagraph (A);
(C) that if medical assistance is included for any group
of individuals described in section 1905(a) who are not de-
scribed in subparagraph (A) or (E), then—
(i) the plan must include a description of (I) the cri-
teria for determining eligibility of individuals in the
group for such medical assistance, (II) the amount, du-
ration, and scope of medical assistance made available
to individuals in the group, and (III) the single stand-
ard to be employed in determining income and re-
source eligibility for all such groups, and the method-
ology to be employed in determining such eligibility,
which shall be no more restrictive than the method-
ology which would be employed under the supple-
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mental 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
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21
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 assist-
ance—
(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 re-
sources) 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 de-
livery services; and
(iv) if such medical assistance includes services in
institutions for mental diseases or in an intermediate
care facility for the mentally retarded (or both) for any
such group, it also must include for all groups covered
at least the care and services listed in paragraphs (1)
through (5) and (17) of section 1905(a) or the care and
services listed in any 7 of the paragraphs numbered
(1) through (24) of such section;
(D) for the inclusion of home health services for any in-
dividual who, under the State plan, is entitled to nursing
facility services;
(E)(i) for making medical assistance available for medi-
care cost-sharing (as defined in section 1905(p)(3)) for
qualified medicare beneficiaries described in section
1905(p)(1);
(ii) for making medical assistance available for payment
of medicare cost-sharing described in section
1905(p)(3)(A)(i) for qualified disabled and working individ-
uals described in section 1905(s);
(iii) for making medical assistance available for medicare
cost sharing described in section 1905(p)(3)(A)(ii) subject to
section 1905(p)(4), for individuals who would be qualified
medicare beneficiaries described in section 1905(p)(1) (in-
cluding such individuals enrolled under section 1836(b))
but for the fact that their income exceeds the income level
established by the State under section 1905(p)(2) but is
less than 110 percent in 1993 and 1994, and 120 percent
in 1995 and years thereafter of the official poverty line (re-
ferred to in such section) for a family of the size involved;
and
(iv) subject to sections 1933 and 1905(p)(4), for making
medical assistance available for medicare cost-sharing de-
SSpencer on DSK126QN23PROD with REPORTS
scribed in section 1905(p)(3)(A)(ii) for individuals who
would be qualified medicare beneficiaries described in sec-
tion 1905(p)(1) (including such individuals enrolled under
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22
section 1836(b)) but for the fact that their income exceeds
the income level established by the State under section
1905(p)(2) and is at least 120 percent, but less than 135
percent, of the official poverty line (referred to in such sec-
tion) for a family of the size involved and who are not oth-
erwise eligible for medical assistance under the State plan;
(F) at the option of a State, for making medical assist-
ance available for COBRA premiums (as defined in sub-
section (u)(2)) for qualified COBRA continuation bene-
ficiaries described in section 1902(u)(1); and
(G) that, in applying eligibility criteria of the supple-
mental security income program under title XVI for pur-
poses 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 section 1613;
except that (I) the making available of the services described
in paragraph (4), (14), or (16) of section 1905(a) to individuals
meeting the age requirements prescribed therein shall not, by
reason of this paragraph (10), require the making available of
any such services, or the making available of such services of
the same amount, duration, and scope, to individuals of any
other ages, (II) the making available of supplementary medical
insurance benefits under part B of title XVIII to individuals el-
igible therefor (either pursuant to an agreement entered into
under section 1843 or by reason of the payment of premiums
under such title by the State agency on behalf of such individ-
uals), or provision for meeting part or all of the cost of
deductibles, cost sharing, or similar charges under part B of
title XVIII for individuals eligible for benefits under such part,
shall not, by reason of this paragraph (10), require the making
available of any such benefits, or the making available of serv-
ices of the same amount, duration, and scope, to any other in-
dividuals, (III) the making available of medical assistance
equal in amount, duration, and scope to the medical assistance
made available to individuals described in clause (A) to any
classification of individuals approved by the Secretary with re-
spect 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
shall not, by reason of this paragraph (10), require the making
available of any such assistance, or the making available of
such assistance of the same amount, duration, and scope, to
any other individuals not described in clause (A), (IV) the im-
position of a deductible, cost sharing, or similar charge for any
item or service furnished to an individual not eligible for the
exemption under section 1916(a)(2) or (b)(2) shall not require
the imposition of a deductible, cost sharing, or similar charge
for the same item or service furnished to an individual who is
eligible for such exemption, (V) the making available to preg-
nant women covered under the plan of services relating to
pregnancy (including prenatal, delivery, and postpartum serv-
SSpencer on DSK126QN23PROD with REPORTS
ices) or to any other condition which may complicate pregnancy
shall not, by reason of this paragraph (10), require the making
available of such services, or the making available of such serv-
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23
ices of the same amount, duration, and scope, to any other in-
dividuals, provided such services are made available (in the
same amount, duration, and scope) to all pregnant women cov-
ered under the State plan, (VI) with respect to the making
available of medical assistance for hospice care to terminally ill
individuals who have made a voluntary election described in
section 1905(o) to receive hospice care instead of medical as-
sistance for certain other services, such assistance may not be
made available in an amount, duration, or scope less than that
provided under title XVIII, and the making available of such
assistance shall not, by reason of this paragraph (10), require
the making available of medical assistance for hospice care to
other individuals or the making available of medical assistance
for services waived by such terminally ill individuals, (VII) the
medical assistance made available to an individual described in
subsection (l)(1)(A) who is eligible for medical assistance only
because of subparagraph (A)(i)(IV) or (A)(ii)(IX) shall be limited
to medical assistance for services related to pregnancy (includ-
ing prenatal, delivery, postpartum, and family planning serv-
ices), medical assistance for services related to other conditions
which may complicate pregnancy, and medical assistance for
vaccines described in section 1905(a)(4)(E) and the administra-
tion of such vaccines during the period described in such sec-
tion, (VIII) the medical assistance made available to a qualified
medicare beneficiary described in section 1905(p)(1) who is
only entitled to medical assistance because the individual is
such a beneficiary shall be limited to medical assistance for
medicare cost-sharing (described in section 1905(p)(3)), subject
to the provisions of subsection (n) and section 1916(b), (IX) the
making available of respiratory care services in accordance
with subsection (e)(9) shall not, by reason of this paragraph
(10), require the making available of such services, or the mak-
ing available of such services of the same amount, duration,
and scope, to any individuals not included under subsection
(e)(9)(A), provided such services are made available (in the
same amount, duration, and scope) to all individuals described
in such subsection, (X) if the plan provides for any fixed
durational limit on medical assistance for inpatient hospital
services (whether or not such a limit varies by medical condi-
tion or diagnosis), the plan must establish exceptions to such
a limit for medically necessary inpatient hospital services fur-
nished with respect to individuals under one year of age in a
hospital defined under the State plan, pursuant to section
1923(a)(1)(A), as a disproportionate share hospital and sub-
paragraph (B) (relating to comparability) shall not be con-
strued as requiring such an exception for other individuals,
services, or hospitals, (XI) the making available of medical as-
sistance to cover the costs of premiums, deductibles, coinsur-
ance, and other cost-sharing obligations for certain individuals
for private health coverage as described in section 1906 shall
not, by reason of paragraph (10), require the making available
of any such benefits or the making available of services of the
SSpencer on DSK126QN23PROD with REPORTS
same amount, duration, and scope of such private coverage to
any other individuals, (XII) the medical assistance made avail-
able to an individual described in subsection (u)(1) who is eligi-
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24
ble for medical assistance only because of subparagraph (F)
shall be limited to medical assistance for COBRA continuation
premiums (as defined in subsection (u)(2)), (XIII) the medical
assistance made available to an individual described in sub-
section (z)(1) who is eligible for medical assistance only because
of subparagraph (A)(ii)(XII) shall be limited to medical assist-
ance for TB-related services (described in subsection (z)(2)) and
medical assistance for vaccines described in section
1905(a)(4)(E) and the administration of such vaccines during
the period described in such section, (XIV) the medical assist-
ance made available to an individual described in subsection
(aa) who is eligible for medical assistance only because of sub-
paragraph (A)(10)(ii)(XVIII) shall be limited to medical assist-
ance provided during the period in which such an individual
requires treatment for breast or cervical cancer (XV) the med-
ical assistance made available to an individual described in
subparagraph (A)(i)(VIII) shall be limited to medical assistance
described in subsection (k)(1) and medical assistance for vac-
cines described in section 1905(a)(4)(E) and the administration
of such vaccines during the period described in such section,
(XVI) the medical assistance made available to an individual
described in subsection (ii) shall be limited to family planning
services and supplies described in section 1905(a)(4)(C) includ-
ing medical diagnosis and treatment services that are provided
pursuant to a family planning service in a family planning set-
ting and medical assistance for vaccines described in section
1905(a)(4)(E) and the administration of such vaccines during
the period described in such section, (XVII) if an individual is
described in subclause (IX) of subparagraph (A)(i) and is also
described in subclause (VIII) of that subparagraph, the medical
assistance shall be made available to the individual through
subclause (IX) instead of through subclause (VIII), and (XVIII)
the medical assistance made available to an uninsured indi-
vidual (as defined in subsection (ss)) who is eligible for medical
assistance only because of subparagraph (A)(ii)(XXIII) shall be
limited to medical assistance for any in vitro diagnostic prod-
uct described in section 1905(a)(3)(B) that is administered dur-
ing any portion of the period at the end of the emergency sen-
tence described in such section beginning on or after the date
of the enactment of this subclause (and the administration of
such product), any service described in section 1916(a)(2)(G)
that is furnished during any such portion, any vaccine de-
scribed in section 1905(a)(4)(E) (and the administration of such
vaccine) that is furnished during any such portion, and testing
and treatments for COVID–19, including specialized equipment
and therapies (including preventive therapies), and, in the case
of an individual who is diagnosed with or presumed to have
COVID–19, during the period such individual has (or is pre-
sumed to have) COVID–19, the treatment of a condition that
may seriously complicate the treatment of COVID–19, if other-
wise covered under the State plan (or waiver of such plan), and
(XIX) medical assistance shall be made available during the
SSpencer on DSK126QN23PROD with REPORTS
period described in section 1905(a)(4)(E) for vaccines described
in such section and the administration of such vaccines, for
any individual who is eligible for and receiving medical assist-
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25
ance under the State plan or under a waiver of such plan
(other than an individual who is eligible for medical assistance
consisting only of payment of premiums pursuant to subpara-
graph (E) or (F) or section 1933), notwithstanding any provi-
sion of this title or waiver under section 1115 impacting such
individual’s eligibility for medical assistance under such plan
or waiver to coverage for a limited type of benefits and services
that would not otherwise include coverage of a COVID–19 vac-
cine and its administration;
(11)(A) provide for entering into cooperative arrangements
with the State agencies responsible for administering or super-
vising the administration of health services and vocational re-
habilitation services in the State looking toward maximum uti-
lization 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, insti-
tution, or organization receiving payments under (or through
an allotment under) title V, (i) providing for utilizing such
agency, institution, or organization in furnishing care and serv-
ices which are available under such title or allotment and
which are included in the State plan approved under this sec-
tion (ii) making such provision as may be appropriate for reim-
bursing 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 section 1903, and (iii) providing for coordi-
nation of information and education on pediatric vaccinations
and delivery of immunization services, and (C) provide for co-
ordination of the operations under this title, including the pro-
vision of information and education on pediatric vaccinations
and the delivery of immunization services, with the State’s op-
erations under the special supplemental nutrition program for
women, infants, and children under section 17 of the Child Nu-
trition Act of 1966;
(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 in-
dividual may select;
(13) provide—
(A) for a public process for determination of rates of pay-
ment 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 representa-
tives, 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 es-
tablishment of such rates, and justifications for such
SSpencer on DSK126QN23PROD with REPORTS
final rates are published, and
(iv) in the case of hospitals, such rates take into ac-
count (in a manner consistent with section 1923) the
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26
situation of hospitals which serve a disproportionate
number of low-income patients with special needs;
(B) for payment for hospice care in amounts no lower
than the amounts, using the same methodology, used
under part A of title XVIII and for payment of amounts
under section 1905(o)(3); except that in the case of hospice
care which is furnished to an individual who is a resident
of a nursing facility or intermediate care facility for the
mentally retarded, and who would be eligible under the
plan for nursing facility services or services in an inter-
mediate care facility for the mentally retarded if he had
not elected to receive hospice care, there shall be paid an
additional amount, to take into account the room and
board furnished by the facility, equal to at least 95 percent
of the rate that would have been paid by the State under
the plan for facility services in that facility for that indi-
vidual; and
(C) payment for primary care services (as defined in sub-
section (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 title XVIII
(or, if greater, the payment rate that would be applicable
under such part if the conversion factor under section
1848(d) for the year involved were the conversion factor
under such section for 2009);
(14) provide that enrollment fees, premiums, or similar
charges, and deductions, cost sharing, or similar charges, may
be imposed only as provided in section 1916;
(15) provide for payment for services described in clause (B)
or (C) of section 1905(a)(2) under the plan in accordance with
subsection (bb);
(16) provide for inclusion, to the extent required by regula-
tions prescribed by the Secretary, of provisions (conforming to
such regulations) with respect to the furnishing of medical as-
sistance 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 in-
come levels, but only in the case of applicants or recipients of
assistance under the plan who are not receiving aid or assist-
ance under any plan of the State approved under title I, X,
XIV, or XVI, or part A of title IV, and with respect to whom
supplemental security income benefits are not being paid
under title 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 title, (B) provide
for taking into account only such income and resources as are,
SSpencer on DSK126QN23PROD with REPORTS
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
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27
and resources, be eligible for aid or assistance in the form of
money payments under any plan of the State approved under
title I, X, XIV, or XVI, or part A of title IV, or to have paid
with respect to him supplemental security income benefits
under title XVI) as would not be disregarded (or set aside for
future needs) in determining his eligibility for such aid, assist-
ance, 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 par-
ticipate in the State program established under title XVI), is
blind or permanently and totally disabled, or is blind or dis-
abled as defined in section 1614 (with respect to States which
are not eligible to participate in such program); and provide for
flexibility in the application of such standards with respect to
income by taking into account, except to the extent prescribed
by the Secretary, the costs (whether in the form of insurance
premiums, payments made to the State under section
1903(f)(2)(B), or otherwise and regardless of whether such costs
are reimbursed under another public program of the State or
political subdivision thereof) incurred for medical care or for
any other type of remedial care recognized under State law;
(18) comply with the provisions of section 1917 with respect
to liens, adjustments and recoveries of medical assistance cor-
rectly paid, transfers of assets, and treatment of certain trusts;
(19) provide such safeguards as may be necessary to assure
that eligibility for care and services under the plan will be de-
termined, 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 in-
stitutions for mental diseases—
(A) provide for having in effect such agreements or other
arrangements with State authorities concerned with men-
tal diseases, and, where appropriate, with such institu-
tions, as may be necessary for carrying out the State plan,
including arrangements for joint planning and for develop-
ment 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 facili-
ties, 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
SSpencer on DSK126QN23PROD with REPORTS
in the institution; and
(C) provide for the development of alternate plans of
care, making maximum utilization of available resources,
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28
for recipients 65 years of age or older who would otherwise
need care in such institutions, including appropriate med-
ical treatment and other aid or assistance; for services re-
ferred to in section 3(a)(4)(A)(i) and (ii) or section
1603(a)(4)(A)(i) and (ii) which are appropriate for such re-
cipients and for such patients; and for methods of adminis-
tration necessary to assure that the responsibilities of the
State agency under the State plan with respect to such re-
cipients 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 pub-
lic institutions for mental diseases, show that the State is mak-
ing satisfactory progress toward developing and implementing
a comprehensive mental health program, including provision
for utilization of community mental health centers, nursing fa-
cilities, 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 respon-
sibilities 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 as-
sure that medical or remedial care and services provided to re-
cipients of medical assistance are of high quality;
(23) provide that (A) any individual eligible for medical as-
sistance (including drugs) may obtain such assistance from any
institution, agency, community pharmacy, or person, qualified
to perform the service or services required (including an orga-
nization which provides such services, or arranges for their
availability, on a prepayment basis), who undertakes to pro-
vide him such services, and (B) an enrollment of an individual
eligible for medical assistance in a primary care case-manage-
ment system (described in section 1915(b)(1)), a medicaid man-
aged care organization, or a similar entity shall not restrict the
choice of the qualified person from whom the individual may
receive services under section 1905(a)(4)(C), except as provided
in subsection (g) and in section 1915, except that this para-
graph shall not apply in the case of Puerto Rico, the Virgin Is-
lands, and Guam, and except that nothing in this paragraph
shall be construed as requiring a State to provide medical as-
sistance for such services furnished by a person or entity con-
victed of a felony under Federal or State law for an offense
which the State agency determines is inconsistent with the
SSpencer on DSK126QN23PROD with REPORTS
best interests of beneficiaries under the State plan or by a pro-
vider or supplier to which a moratorium under subsection
(kk)(4) is applied during the period of such moratorium’;
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29
(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 Act, (B) to establish and maintain such fiscal
records as may be necessary for the proper and efficient ad-
ministration of this Act, and (C) to provide information needed
to determine payments due under this Act 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 sec-
tion 607(1) of the Employee Retirement Income Security
Act of 1974), service benefit plans, managed care organiza-
tions, pharmacy benefit managers, or other parties that
are, by statute, contract, or agreement, legally responsible
for payment of a claim for a health care item or service)
to pay for care and services available under the plan, in-
cluding—
(i) the collection of sufficient information (as speci-
fied 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 de-
termination or redetermination of eligibility for med-
ical assistance, and
(ii) the submission to the Secretary of a plan (sub-
ject to approval by the Secretary) for pursuing claims
against such third parties, which plan shall be inte-
grated with, and be monitored as a part of the Sec-
retary’s review of, the State’s mechanized claims proc-
essing and information retrieval systems required
under section 1903(r);
(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 reim-
bursement the State can reasonably expect to recover ex-
ceeds 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 liabil-
ities of third parties for that service is at least equal to the
amount payable for that service under the plan (dis-
regarding section 1916), or (ii) in an amount which exceeds
SSpencer on DSK126QN23PROD with REPORTS
the lesser of (I) the amount which may be collected under
section 1916, or (II) the amount by which the amount pay-
able for that service under the plan (disregarding section
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30
1916) exceeds the total of the amount of the liabilities of
third parties for that service;
(D) that a person who furnishes services and is partici-
pating 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) be-
cause of a third party’s potential liability for payment for
the service;
(E) that in the case of preventive pediatric care (includ-
ing early and periodic screening and diagnosis services
under section 1905(a)(4)(B)) covered under the State plan,
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 the liability of a third
party for payment for such services; and
(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-ef-
fective 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 serv-
ices; and
(ii) seek reimbursement from such third party in ac-
cordance 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 title IV of this Act, 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 liabil-
ity for payment for such services, if such third-party
liability is derived (through insurance or otherwise)
from the parent whose obligation to pay support is
being enforced by such agency, if payment has not
been made by such third party within 30 days after
such services are furnished;
(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 liabil-
ity 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 sub-
SSpencer on DSK126QN23PROD with REPORTS
mitted 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
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31
determines doing so is cost-effective and necessary to
ensure access to care.;
(ii) seek reimbursement from such third party in ac-
cordance with subparagraph (B);
(G) that the State prohibits any health insurer (includ-
ing a group health plan, as defined in section 607(1) of the
Employee Retirement Income Security Act of 1974, a self-
insured plan, a service benefit plan, a managed care orga-
nization, a pharmacy benefit manager, or other party that
is, by statute, contract, or agreement, legally responsible
for payment of a claim for a health care item or service),
in enrolling an individual or in making any payments for
benefits to the individual or on the individual’s behalf,
from taking into account that the individual is eligible for
or is provided medical assistance under a plan under this
title for such State, or any other State;
(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 consid-
ered to have acquired the rights of such individual to pay-
ment 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 Retire-
ment Income Security Act of 1974), service benefit plans,
managed care organizations, pharmacy benefit managers,
or other parties that are, by statute, contract, or agree-
ment, legally responsible for payment of a claim for a
health care item or service, as a condition of doing busi-
ness in the State, to—
(i) provide, with respect to individuals who are eligi-
ble (and, at State option, individuals who apply or
whose eligibility for medical assistance is being evalu-
ated in accordance with section 1902(e)(13)(D)) for, or
are provided, medical assistance under a State plan
(or under a waiver of the plan) under this title and
child health assistance under title XXI, upon the re-
quest of the State, information to determine during
what period the individual or their spouses or their
dependents may be (or may have been) covered by a
health insurer and the nature of the coverage that is
or was provided by the health insurer (including the
name, address, and identifying number of the plan) in
a manner prescribed by the Secretary;
(ii)(I) accept the State’s right of recovery and the as-
signment to the State of any right of an individual or
SSpencer on DSK126QN23PROD with REPORTS
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
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32
(II) in the case of a responsible third party (other
than the original medicare fee-for-service program
under parts A and B of title XVIII, a Medicare Advan-
tage plan offered by a Medicare Advantage organiza-
tion under part C of such title, a reasonable cost reim-
bursement plan under section 1876, a health care pre-
payment plan under section 1833, or a prescription
drug plan offered by a PDP sponsor under part D of
such title) that requires prior authorization for an
item or service furnished to an individual eligible to
receive medical assistance under this title, accept au-
thorization provided by the State that the item or
service is covered under the State plan (or waiver of
such plan) for such individual, as if such authorization
were the prior authorization made by the third party
for such item or service;
(iii) not later than 60 days after receiving any in-
quiry 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 in-
quiry; 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 re-
sponsible third party (other than the original medicare
fee-for-service program under parts A and B of title
XVIII, a Medicare Advantage plan offered by a Medi-
care Advantage organization under part C of such
title, a reasonable cost reimbursement plan under sec-
tion 1876, a health care prepayment plan under sec-
tion 1833, or a prescription drug plan offered by a
PDP sponsor under part D of such title) a failure to
obtain a prior authorization for the item or service for
which the claim is being submitted, if—
(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 inpa-
tient mental hospital services, provide, with respect to each pa-
tient receiving such services, for a regular program of medical
review (including medical evaluation) of his need for such serv-
ices, 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 per-
son or institution agrees (A) to keep such records as are nec-
essary fully to disclose the extent of the services provided to
SSpencer on DSK126QN23PROD with REPORTS
individuals receiving assistance under the State plan, and (B)
to furnish the State agency or the Secretary with such infor-
mation, regarding any payments claimed by such person or in-
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33
stitution 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 section 1919 as they apply to such facili-
ties;
(B) for including in ‘‘nursing facility services’’ at least
the items and services specified (or deemed to be specified)
by the Secretary under section 1919(f)(7) and making
available upon request a description of the items and serv-
ices so included;
(C) for procedures to make available to the public the
data and methodology used in establishing payment rates
for nursing facilities under this title; and
(D) for compliance (by the date specified in the respec-
tive sections) with the requirements of—
(i) section 1919(e);
(ii) section 1919(g) (relating to responsibility for sur-
vey and certification of nursing facilities); and
(iii) sections 1919(h)(2)(B) and 1919(h)(2)(D) (relat-
ing to establishment and application of remedies);
(29) include a State program which meets the requirements
set forth in section 1908, for the licensing of administrators of
nursing homes;
(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 section 1903(i)(4)) as may be necessary
to safeguard against unnecessary utilization of such care and
services and to assure that payments are consistent with effi-
ciency, economy, and quality of care and are sufficient to enlist
enough providers so that care and services are available under
the plan at least to the extent that such care and services are
available to the general population in the geographic area; and
(B) provide, under the program described in subparagraph
(A), that—
(i) each admission to a hospital, intermediate care facil-
ity for the mentally retarded, or hospital for mental dis-
eases 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 fi-
nancial interest in any such institution and are not, except
in the case of a hospital, employed by the institution pro-
viding 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 pa-
tients by such professional personnel, shall be used as the
basis for establishing the size and composition of the sam-
ple of admissions to be subject to review and evaluation by
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such personnel, and any such sample may be of any size
up to 100 percent of all admissions and must be of suffi-
cient size to serve the purpose of (I) identifying the pat-
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34
terns of care being provided and the changes occurring
over time in such patterns so that the need for modifica-
tion may be ascertained, and (II) subjecting admissions to
early or more extensive review where information indi-
cates that such consideration is warranted to a hospital,
intermediate care facility for the mentally retarded, or hos-
pital for mental diseases;
(31) with respect to services in an intermediate care facility
for the mentally retarded (where the State plan includes med-
ical 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 phy-
sician, dentist, or other individual practitioner, such pay-
ment 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 em-
ployer, 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 practi-
tioner 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 pur-
suant 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 com-
pensation 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 (di-
rectly or indirectly) to the amount of such payments or the
billings therefor, and is not dependent upon the actual col-
lection 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
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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
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35
the claim for such services, payment shall be made to the
physician submitting the claim (as if the services were fur-
nished by, or incident to, the physician’s services), but only
if the claim identifies (in a manner specified by the Sec-
retary) the physician who furnished the services; and
(D) in the case of payment for a childhood vaccine ad-
ministered 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) sup-
plies 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 Sec-
retary, 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 agen-
cy 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 section 1919(g), the State
or local agency utilized by the Secretary for the purpose
specified in the first sentence of section 1864(a), or, if such
agency is not the State agency which is responsible for li-
censing health institutions, the State agency responsible
for such licensing, will perform for the State agency ad-
ministering or supervising the administration of the plan
approved under this title the function of determining
whether institutions and agencies meet the requirements
for participation in the program under such plan, except
that, if the Secretary has cause to question the adequacy
of such determinations, the Secretary is authorized to vali-
date State determinations and, on that basis, make inde-
pendent and binding determinations concerning the extent
to which individual institutions and agencies meet the re-
quirements for participation;
(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
SSpencer on DSK126QN23PROD with REPORTS
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;
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36
(35) provide that any disclosing entity (as defined in section
1124(a)(2)) receiving payments under such plan complies with
the requirements of section 1124;
(36) provide that within 90 days following the completion of
each survey of any health care facility, laboratory, agency, clin-
ic, or organization, by the appropriate State agency described
in paragraph (9), such agency shall (in accordance with regula-
tions 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 title, and (B) the major ad-
ditional 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 re-
view of appropriate data with respect to the recipient and pro-
vider of a service and the nature of the service for which pay-
ment 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 practi-
tioner 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 admin-
isters or supervises the administration of the plan) upon re-
quest specifically addressed to such entity by the Secretary or
such State agency, the information described in section
1128(b)(9);
(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 section 1128 or section
1128A, terminate the participation of any individual or entity
in such program if (subject to such exceptions as are permitted
with respect to exclusion under sections 1128(c)(3)(B) and
1128(d)(3)(B)) participation of such individual or entity is ter-
minated under title XVIII, any other State plan under this title
(or waiver of the plan), or any State child health plan under
title XXI (or waiver of the plan) and such termination is in-
cluded by the Secretary in any database or similar system de-
veloped pursuant to section 6401(b)(2) of the Patient Protection
SSpencer on DSK126QN23PROD with REPORTS
and Affordable Care Act, and provide that no payment may be
made under the plan with respect to any item or service fur-
nished by such individual or entity during such period;
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37
(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
section 1121(a) to make reports to the Secretary of information
described in such section in accordance with the uniform re-
porting system (established under such section) for that type of
facility or organization;
(41) provide, in accordance with subsection (kk)(8) (as appli-
cable), that whenever a provider of services or any other per-
son is terminated, suspended, or otherwise sanctioned or pro-
hibited 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 med-
ical 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 nec-
essary 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 con-
tracts (consistent with State law and in the same
manner as the Secretary enters into contracts with re-
covery audit contractors under section 1893(h), subject
to such exceptions or requirements as the Secretary
may require for purposes of this title or a particular
State) with 1 or more recovery audit contractors for
the purpose of identifying underpayments and over-
payments and recouping overpayments under the
State plan and under any waiver of the State plan
with respect to all services for which payment is made
to any entity under such plan or waiver; and
(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 underpay-
ments;
(III) the State has an adequate process for enti-
ties 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 section 1903(a)(7), that
amounts expended by the State to carry out
the program shall be considered amounts ex-
SSpencer on DSK126QN23PROD with REPORTS
pended as necessary for the proper and effi-
cient administration of the State plan or a
waiver of the plan;
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38
(bb) that section 1903(d) shall apply to
amounts recovered under the program; and
(cc) that the State and any such contractors
under contract with the State shall coordinate
such recovery audit efforts with other contrac-
tors 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 re-
spect to the Department of Justice, including
the Federal Bureau of Investigations, the In-
spector 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 section
1905(a)(4)(B), of the availability of early and periodic
screening, diagnostic, and treatment services as described
in section 1905(r) and the need for age-appropriate immu-
nizations against vaccine-preventable diseases,
(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 appro-
priate 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 den-
tal services to such children described in section
2108(e) and
(iv) the State’s results in attaining the participation
goals set for the State under section 1905(r);
(44) in each case for which payment for inpatient hospital
services, services in an intermediate care facility for the men-
tally 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,
SSpencer on DSK126QN23PROD with REPORTS
or a nurse practitioner or clinical nurse specialist who is
not an employee of the facility but is working in collabora-
tion with a physician) certifies at the time of admission, or,
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39
if later, the time the individual applies for medical assist-
ance 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
section 1903(g)(6) (or, in the case of services that are serv-
ices provided in an intermediate care facility for the men-
tally retarded, every year), and accompanied by such sup-
porting material, appropriate to the case involved, as may
be provided in regulations of the Secretary), that such
services are or were required to be given on an inpatient
basis because the individual needs or needed such services,
and
(B) such services were furnished under a plan estab-
lished and periodically reviewed and evaluated by a physi-
cian, 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 em-
ployee 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 section 1912;
(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 section
1137 of this Act; and
(B) provide, with respect to an individual declaring to be a
citizen or national of the United States for purposes of estab-
lishing eligibility under this title, that the State shall satisfy
the requirements of—
(i) section 1903(x); or
(ii) subsection (ee);
(47) provide—
(A) at the option of the State, for making ambulatory
prenatal care available to pregnant women during a pre-
sumptive eligibility period in accordance with section 1920
and provide for making medical assistance for items and
services described in subsection (a) of section 1920A avail-
able to children during a presumptive eligibility period in
accordance with such section and provide for making med-
ical assistance available to individuals described in sub-
section (a) of section 1920B during a presumptive eligi-
bility period in accordance with such section and provide
for making medical assistance available to individuals de-
scribed in subsection (a) of section 1920C during a pre-
sumptive eligibility period in accordance with such section;
and
SSpencer on DSK126QN23PROD with REPORTS
(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 infor-
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40
mation, whether any individual is eligible for medical as-
sistance 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 de-
scribed in section 1920, 1920A, 1920B, or 1920C (but with-
out regard to whether the State has elected to provide for
a presumptive eligibility period under any such sections),
subject to such guidance as the Secretary shall establish;
(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 ac-
cess to certain information respecting sanctions taken against
health care practitioners and providers by State licensing au-
thorities in accordance with section 1921;
(50) provide, in accordance with subsection (q), for a monthly
personal needs allowance for certain institutionalized individ-
uals and couples;
(51) meet the requirements of section 1924 (relating to pro-
tection of community spouses);
(52) meet the requirements of section 1925 (relating to exten-
sion of eligibility for medical assistance);
(53) provide—
(A) for notifying in a timely manner all individuals in
the State who are determined to be eligible for medical as-
sistance and who are pregnant women, breastfeeding or
postpartum women (as defined in section 17 of the Child
Nutrition Act of 1966), or children below the age of 5, of
the availability of benefits furnished by the special supple-
mental nutrition program under such section, and
(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 assist-
ance for covered outpatient drugs (as defined in section
1927(k)), comply with the applicable requirements of section
1927;
(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 title IV and which include facilities defined as dispropor-
tionate share hospitals under section 1923(a)(1)(A) and
Federally-qualified health centers described in section
1905(1)(2)(B), and
(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
SSpencer on DSK126QN23PROD with REPORTS
payments for certain inpatient hospital services;
(57) provide that each hospital, nursing facility, provider of
home health care or personal care services, hospice program,
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41
or medicaid managed care organization (as defined in section
1903(m)(1)(A)) receiving funds under the plan shall comply
with the requirements of subsection (w);
(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 rec-
ognized by the courts of the State) concerning advance direc-
tives 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 physi-
cians 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 section
1908A;
(61) provide that the State must demonstrate that it oper-
ates a medicaid fraud and abuse control unit described in sec-
tion 1903(q) that effectively carries out the functions and re-
quirements described in such section, as determined in accord-
ance with standards established by the Secretary, unless the
State demonstrates to the satisfaction of the Secretary that the
effective operation of such a unit in the State would not be
cost-effective because minimal fraud exists in connection with
the provision of covered services to eligible individuals under
the State plan, and that beneficiaries under the plan will be
protected from abuse and neglect in connection with the provi-
sion of medical assistance under the plan without the existence
of such a unit;
(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 section 1928;
(63) provide for administration and determinations of eligi-
bility with respect to individuals who are (or seek to be) eligi-
ble for medical assistance based on the application of section
1931;
(64) provide, not later than 1 year after the date of the en-
actment of this paragraph, a mechanism to receive reports
from beneficiaries and others and compile data concerning al-
leged instances of waste, fraud, and abuse relating to the oper-
ation of this title;
(65) provide that the State shall issue provider numbers for
all suppliers of medical assistance consisting of durable med-
ical equipment, as defined in section 1861(n), and the State
shall not issue or renew such a supplier number for any such
supplier unless—
(A)(i) full and complete information as to the identity of
each person with an ownership or control interest (as de-
fined in section 1124(a)(3)) in the supplier or in any sub-
contractor (as defined by the Secretary in regulations) in
which the supplier directly or indirectly has a 5 percent or
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more ownership interest; and
(ii) to the extent determined to be feasible under regula-
tions of the Secretary, the name of any disclosing entity
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42
(as defined in section 1124(a)(2)) with respect to which a
person with such an ownership or control interest in the
supplier is a person with such an ownership or control in-
terest in the disclosing entity; and
(B) a surety bond in a form specified by the Secretary
under section 1834(a)(16)(B) and in an amount that is not
less than $50,000 or such comparable surety bond as the
Secretary may permit under the second sentence of such
section;
(66) provide for making eligibility determinations under sec-
tion 1935(a);
(67) provide, with respect to services covered under the State
plan (but not under title 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 con-
dition of receiving such payments, shall—
(A) establish written policies for all employees of the en-
tity (including management), and of any contractor or
agent of the entity, that provide detailed information about
the False Claims Act established under sections 3729
through 3733 of title 31, United States Code, administra-
tive remedies for false claims and statements established
under chapter 38 of title 31, United States Code, any State
laws pertaining to civil or criminal penalties for false
claims and statements, and whistleblower protections
under such laws, with respect to the role of such laws in
preventing and detecting fraud, waste, and abuse in Fed-
eral health care programs (as defined in section 1128B(f));
(B) include as part of such written policies, detailed pro-
visions 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 whistle-
blowers, and the entity’s policies and procedures for detect-
ing and preventing fraud, waste, and abuse;
(69) provide that the State must comply with any require-
ments determined by the Secretary to be necessary for carrying
out the Medicaid Integrity Program established under section
1936;
(70) at the option of the State and notwithstanding para-
graphs (1), (10)(B), and (23), provide for the establishment of
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a non-emergency medical transportation brokerage program in
order to more cost-effectively provide transportation for indi-
viduals eligible for medical assistance under the State plan
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43
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 appro-
priate; 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 experi-
ence, performance, references, resources, qualifica-
tions, and costs;
(ii) has oversight procedures to monitor beneficiary
access and complaints and ensure that transport per-
sonnel are licensed, qualified, competent, and cour-
teous;
(iii) is subject to regular auditing and oversight by
the State in order to ensure the quality of the trans-
portation services provided and the adequacy of bene-
ficiary access to medical care and services; and
(iv) complies with such requirements related to pro-
hibitions on referrals and conflict of interest as the
Secretary shall establish (based on the prohibitions on
physician referrals under section 1877 and such other
prohibitions and requirements as the Secretary deter-
mines to be appropriate);
(71) provide that the State will implement an asset
verification program as required under section 1940;
(72) provide that the State will not prevent a Federally-
qualified health center from entering into contractual relation-
ships 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 Organiza-
tions on matters relating to the application of this title that
are likely to have a direct effect on such Indian Health Pro-
grams and Urban Indian Organizations and that—
(A) shall include solicitation of advice prior to submis-
sion of any plan amendments, waiver requests, and pro-
posals for demonstration projects likely to have a direct ef-
fect 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
title;
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(74) provide for maintenance of effort under the State plan
or under any waiver of the plan in accordance with subsection
(gg); and
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44
(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 indi-
viduals 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 chil-
dren, parents, nonpregnant childless adults, disabled indi-
viduals, 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 indi-
viduals 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 cer-
tifying 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 identi-
fying information, including the name, specialty, date of birth,
Social Security number, national provider identifier (if applica-
ble), Federal taxpayer identification number, and the State li-
cense 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 be-
half 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 speci-
fied by the Secretary under section 1115A(c) for implementa-
tion on a nationwide basis unless the State demonstrates to
the satisfaction of the Secretary that implementation would
not be administratively feasible or appropriate to the health
care delivery system of the State;
(82) provide that the State agency responsible for admin-
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istering the State plan under this title provides assurances to
the Secretary that the State agency is in compliance with sub-
paragraphs (A), (B), and (C) of section 1128K(b)(2);
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45
(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 section 1915(b)(1) (other
than a primary care case management entity (as defined by
the Secretary)), the State shall publish (and update on at least
an annual basis) on the public website of the State agency ad-
ministering the State plan, a directory of the physicians de-
scribed in subsection (mm) and, at State option, other pro-
viders described in such subsection that—
(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 pro-
vider 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 accept-
ing as new patients individuals who receive med-
ical assistance under this title; 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 interpreta-
tion 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 pro-
vider; or
(ii) whether the physician or provider is accepting as
new patients individuals who receive medical assist-
ance under this title;
(84) provide that—
(A) the State shall not terminate eligibility for medical
assistance under the State plan for an individual who is
an eligible juvenile (as defined in subsection (nn)(2)) be-
cause the juvenile is an inmate of a public institution (as
defined in subsection (nn)(3)), but may suspend coverage
during the period the juvenile is such an inmate;
(B) in the case of an individual who is an eligible juve-
nile 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 redetermina-
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tion that the individual continues to meet the eligibility re-
quirements for such medical assistance, the State shall re-
store coverage for such medical assistance to such an indi-
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46
vidual upon the individual’s release from such public insti-
tution; øand¿
(C) in the case of an individual who is an eligible juve-
nile 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 in-
dividual with respect to such medical assistance upon re-
lease of such individual from such public institution; and
(D) beginning October 1, 2023, in the case of individuals
who are eligible juveniles described in subsection (nn)(2),
are scheduled to be released from placement in a public in-
stitution following adjudication, and who the State deter-
mines pursuant to subparagraph (B) or (C), as applicable,
meet the eligibility requirements for medical assistance
under the State plan, the State shall have in place a plan
to ensure, and in accordance with such plan, provide—
(i) for, prior to the release of such an eligible juvenile
from such public institution (or not later than one week
after release from the public institution), and in coordi-
nation with such institution—
(I) any screening described in section 1905(r) for
which such eligible juvenile qualifies based on the
intervals established pursuant to such section;
(II) any screening which such eligible juvenile
did not receive in accordance with such intervals
due to the incarceration of such eligible juvenile;
and
(III) a behavioral health or mental health
screening that is a screening service described
under section 1905(r)(1), if such screening was not
otherwise conducted pursuant to this clause;
(ii) for, not later than the latter of the date on which
such eligible juvenile is released from such institution,
or the date on which the screenings pursuant to clause
(i) for such eligible juvenile are conducted, referrals for
such eligible juvenile to the appropriate services, in-
cluding necessary health care, diagnostic services,
treatment, and other measures described in section
1905(a), giving preference to providers of such services
who are located in the geographic region of the home
or residence of such eligible juvenile when available,
based on such screenings; and
(iii) for, following the release of such eligible juvenile
from such institution, and the completion of the
screenings conducted pursuant to clause (i), not less
than 30 days of targeted case management services fur-
nished by a provider in the geographic region of the
home or residence of such eligible juvenile.
(85) provide that the State is in compliance with the drug re-
view and utilization requirements under subsection (oo)(1);
(86) provide, at the option of the State, for making medical
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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
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47
(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 non-
emergency transportation to medically necessary services re-
ceiving payments under such plan (but excluding any public
transit authority), at a minimum—
(A) each such provider and individual driver is not ex-
cluded from participation in any Federal health care pro-
gram (as defined in section 1128B(f)) and is not listed on
the exclusion list of the Inspector General of the Depart-
ment of Health and Human Services;
(B) each such individual driver has a valid driver’s li-
cense;
(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, includ-
ing 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
title, the State agency which administered or supervised the ad-
ministration of the plan of such State approved under title X (or
title 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 title I (or title XVI, insofar as it
relates to the aged), the State agency which administered or super-
vised the administration of such plan approved under title X (or
title 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 title (except for purposes of paragraph
(10)). The provisions of paragraphs (9)(A), (31), and (33) and of sec-
tion 1903(i)(4) shall not apply to a religious nonmedical health care
institution (as defined in section 1861(ss)(1)).
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 title I, X, XIV, or XVI, or part A of
title IV and who for such month was entitled to monthly insurance
benefits under title II shall for purposes of this title 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 in-
surance benefits under title II resulting from enactment of Public
Law 92-336 not been applicable to such individual.
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
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State has exercised good faith in trying to meet such requirement.
For purposes of this title, any child who meets the requirements of
paragraph (1) or (2) of section 473(b) shall be deemed to be a de-
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48
pendent child as defined in section 406 and shall be deemed to be
a recipient of aid to families with dependent children under part
A of title IV in the State where such child resides. Notwithstanding
paragraph (10)(B) or any other provision of this subsection, a State
plan shall provide medical assistance with respect to an alien who
is not lawfully admitted for permanent residence or otherwise per-
manently residing in the United States under color of law only in
accordance with section 1903(v).
(b) The Secretary shall approve any plan which fulfills the condi-
tions specified in subsection (a) of this section, except that he shall
not approve any plan which imposes, as a condition of eligibility for
medical assistance under the plan—
(1) an age requirement of more than 65 years; or
(2) any residence requirement which excludes any individual
who resides in the State, regardless of whether or not the resi-
dence is maintained permanently or at a fixed address; or
(3) any citizenship requirement which excludes any citizen of
the United States.
(c) Notwithstanding subsection (b), the Secretary shall not ap-
prove any State plan for medical assistance if the State requires in-
dividuals described in subsection (l)(1) to apply for assistance under
the State program funded under part A of title IV as a condition
of applying for or receiving medical assistance under this title.
(d) If a State contracts with an entity which meets the require-
ments of section 1152, as determined by the Secretary, or a utiliza-
tion and quality control peer review organization having a contract
with the Secretary under part B of title XI for the performance of
medical or utilization review functions (including quality review
functions described in subsection (a)(30)(C)) required under this
title of a State plan with respect to specific services or providers
(or services or providers in a geographic area of the State), such re-
quirements shall be deemed to be met for those services or pro-
viders (or services or providers in that area) by delegation to such
an entity or organization under the contract of the State’s authority
to conduct such review activities if the contract provides for the
performance of activities not inconsistent with part B of title XI
and provides for such assurances of satisfactory performance by
such an entity or organization as the Secretary may prescribe.
(e)(1) Beginning April 1, 1990, for provisions relating to the ex-
tension of eligibility for medical assistance for certain families who
have received aid pursuant to a State plan approved under part A
of title IV and have earned income, see section 1925.
(2)(A) In the case of an individual who is enrolled with a med-
icaid managed care organization (as defined in section
1903(m)(1)(A)), with a primary care case manager (as defined in
section 1905(t)), or with an eligible organization with a contract
under section 1876 and who would (but for this paragraph) lose eli-
gibility for benefits under this title before the end of the minimum
enrollment period (defined in subparagraph (B)), the State plan
may provide, notwithstanding any other provision of this title, that
the individual shall be deemed to continue to be eligible for such
benefits until the end of such minimum period, but, except for ben-
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efits furnished under section 1905(a)(4)(C), only with respect to
such benefits provided to the individual as an enrollee of such orga-
nization or entity or by or through the case manager.
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49
(B) For purposes of subparagraph (A), the term ‘‘minimum enroll-
ment period’’ means, with respect to an individual’s enrollment
with an organization or entity under a State plan, a period, estab-
lished by the State, of not more than six months beginning on the
date the individual’s enrollment with the organization or entity be-
comes 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 section 1614(a);
(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 indi-
vidual 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
title,
shall be deemed, for purposes of this title only, to be an indi-
vidual with respect to whom a supplemental security income
payment, or State supplemental payment, respectively, is being
paid under title XVI.
(4) A child born to a woman eligible for and receiving medical as-
sistance 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 section 1903(v), the State immediately
shall issue a separate identification number for the child upon noti-
fication by the facility at which such delivery occurred of the child’s
birth.
(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 preg-
nant, 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.
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(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
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50
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 section 1920 during a presumptive eligibility pe-
riod and is then, in accordance with such section, determined to be
ineligible for medical assistance under the State plan.
(7) In the case of an infant or child described in subparagraph
(B), (C), or (D) of subsection (l)(1) or paragraph (2) of section
1905(n)—
(A) who is receiving inpatient services for which medical as-
sistance 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 de-
scribed 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 ben-
eficiary (as defined in section 1905(p)(1)), such determination shall
apply to services furnished after the end of the month in which the
determination first occurs. For purposes of payment to a State
under section 1903(a), such determination shall be considered to be
valid for an individual for a period of 12 months, except that a
State may provide for such determinations more frequently, but not
more frequently than once every 6 months for an individual.
(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 in-
termediate 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 profes-
sional trained in respiratory therapy (as determined by the State),
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payment for which is not otherwise included within other items
and services furnished to such individual as medical assistance
under the plan.
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51
(10)(A) The fact that an individual, child, or pregnant woman
may be denied aid under part A of title IV pursuant to section
402(a)(43) shall not be construed as denying (or permitting a State
to deny) medical assistance under this title to such individual,
child, or woman who is eligible for assistance under this title 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 title IV and such aid is terminated pursuant to sec-
tion 402(a)(43), the State may not discontinue medical assistance
under this title for the individual, child, or woman until the State
has determined that the individual, child, or woman is not eligible
for assistance under this title 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 section 1906 and who would (but for this para-
graph) lose eligibility for benefits under this title before the end of
the minimum enrollment period (defined in subparagraph (B)), the
State plan may provide, notwithstanding any other provision of
this title, that the individual shall be deemed to continue to be eli-
gible for such benefits until the end of such minimum period, but
only with respect to such benefits provided to the individual as an
enrollee of such plan.
(B) For purposes of subparagraph (A), the term ‘‘minimum enroll-
ment 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 enroll-
ment under the plan becomes effective.
(12) At the option of the State, the plan may provide that an in-
dividual who is under an age specified by the State (not to exceed
19 years of age) and who is determined to be eligible for benefits
under a State plan approved under this title under subsection
(a)(10)(A) shall remain eligible for those benefits until the earlier
of—
(A) the end of a period (not to exceed 12 months) following
the determination; or
(B) the time that the individual exceeds that age.
(13) EXPRESS LANE OPTION.—
(A) IN GENERAL.—
(i) OPTION TO USE A FINDING FROM AN EXPRESS LANE
AGENCY.—At the option of the State, the State plan may
provide that in determining eligibility under this title for
a child (as defined in subparagraph (G)), the State may
rely on a finding made within a reasonable period (as de-
termined by the State) from an Express Lane agency (as
defined in subparagraph (F)) when it determines whether
a child satisfies one or more components of eligibility for
medical assistance under this title. The State may rely on
a finding from an Express Lane agency notwithstanding
sections 1902(a)(46)(B) and 1137(d) or any differences in
budget unit, disregard, deeming or other methodology, if
the following requirements are met:
(I) PROHIBITION ON DETERMINING CHILDREN INELI-
SSpencer on DSK126QN23PROD with REPORTS
GIBLE FOR COVERAGE.—If a finding from an Express
Lane agency would result in a determination that a
child does not satisfy an eligibility requirement for
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52
medical assistance under this title and for child health
assistance under title XXI, the State shall determine
eligibility for assistance using its regular procedures.
(II) NOTICE REQUIREMENT.—For any child who is
found eligible for medical assistance under the State
plan under this title or child health assistance under
title XXI and who is subject to premiums based on an
Express Lane agency’s finding of such child’s income
level, the State shall provide notice that the child may
qualify for lower premium payments if evaluated by
the State using its regular policies and of the proce-
dures for requesting such an evaluation.
(III) COMPLIANCE WITH SCREEN AND ENROLL RE-
QUIREMENT.—The State shall satisfy the requirements
under subparagraphs (A) and (B) of section 2102(b)(3)
(relating to screen and enroll) before enrolling a child
in child health assistance under title XXI. At its op-
tion, the State may fulfill such requirements in accord-
ance with either option provided under subparagraph
(C) of this paragraph.
(IV) VERIFICATION OF CITIZENSHIP OR NATIONALITY
STATUS.—The State shall satisfy the requirements of
section 1902(a)(46)(B) or 2105(c)(9), as applicable for
verifications of citizenship or nationality status.
(V) CODING.—The State meets the requirements of
subparagraph (E).
(ii) OPTION TO APPLY TO RENEWALS AND REDETERMINA-
TIONS.—The State may apply the provisions of this para-
graph when conducting initial determinations of eligibility,
redeterminations of eligibility, or both, as described in the
State plan.
(B) RULES OF CONSTRUCTION.—Nothing in this paragraph
shall be construed—
(i) to limit or prohibit a State from taking any actions
otherwise permitted under this title or title XXI in deter-
mining eligibility for or enrolling children into medical as-
sistance under this title or child health assistance under
title XXI; or
(ii) to modify the limitations in section 1902(a)(5) con-
cerning the agencies that may make a determination of eli-
gibility for medical assistance under this title.
(C) OPTIONS FOR SATISFYING THE SCREEN AND ENROLL RE-
QUIREMENT.—
(i) IN GENERAL.—With respect to a child whose eligibility
for medical assistance under this title or for child health
assistance under title XXI has been evaluated by a State
agency using an income finding from an Express Lane
agency, a State may carry out its duties under subpara-
graphs (A) and (B) of section 2102(b)(3) (relating to screen
and enroll) in accordance with either clause (ii) or clause
(iii).
(ii) ESTABLISHING A SCREENING THRESHOLD.—
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(I) IN GENERAL.—Under this clause, the State estab-
lishes a screening threshold set as a percentage of the
Federal poverty level that exceeds the highest income
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53
threshold applicable under this title to the child by a
minimum of 30 percentage points or, at State option,
a higher number of percentage points that reflects the
value (as determined by the State and described in the
State plan) of any differences between income meth-
odologies used by the program administered by the
Express Lane agency and the methodologies used by
the State in determining eligibility for medical assist-
ance under this title.
(II) CHILDREN WITH INCOME NOT ABOVE THRESH-
OLD.—If the income of a child does not exceed the
screening threshold, the child is deemed to satisfy the
income eligibility criteria for medical assistance under
this title regardless of whether such child would other-
wise satisfy such criteria.
(III) CHILDREN WITH INCOME ABOVE THRESHOLD.—If
the income of a child exceeds the screening threshold,
the child shall be considered to have an income above
the Medicaid applicable income level described in sec-
tion 2110(b)(4) and to satisfy the requirement under
section 2110(b)(1)(C) (relating to the requirement that
CHIP matching funds be used only for children not eli-
gible for Medicaid). If such a child is enrolled in child
health assistance under title XXI, the State shall pro-
vide the parent, guardian, or custodial relative with
the following:
(aa) Notice that the child may be eligible to re-
ceive medical assistance under the State plan
under this title 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 assist-
ance under this title using such regular proce-
dures.
(bb) A description of differences between the
medical assistance provided under this title and
child health assistance under title XXI, including
differences in cost-sharing requirements and cov-
ered benefits.
(iii) TEMPORARY ENROLLMENT IN CHIP PENDING SCREEN
AND ENROLL.—
(I) IN GENERAL.—Under this clause, a State enrolls
a child in child health assistance under title XXI for
a temporary period if the child appears eligible for
such assistance based on an income finding by an Ex-
press Lane agency.
(II) DETERMINATION OF ELIGIBILITY.—During such
temporary enrollment period, the State shall deter-
mine the child’s eligibility for child health assistance
under title XXI or for medical assistance under this
title in accordance with this clause.
SSpencer on DSK126QN23PROD with REPORTS
(III) PROMPT FOLLOW UP.—In making such a deter-
mination, the State shall take prompt action to deter-
mine whether the child should be enrolled in medical
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54
assistance under this title or child health assistance
under title XXI pursuant to subparagraphs (A) and (B)
of section 2102(b)(3) (relating to screen and enroll).
(IV) REQUIREMENT FOR SIMPLIFIED DETERMINA-
TION.—In making such a determination, the State
shall use procedures that, to the maximum feasible ex-
tent, reduce the burden imposed on the individual of
such determination. Such procedures may not require
the child’s parent, guardian, or custodial relative to
provide or verify information that already has been
provided to the State agency by an Express Lane
agency or another source of information unless the
State agency has reason to believe the information is
erroneous.
(V) AVAILABILITY OF CHIP MATCHING FUNDS DURING
TEMPORARY ENROLLMENT PERIOD.—Medical assistance
for items and services that are provided to a child en-
rolled in title XXI during a temporary enrollment pe-
riod under this clause shall be treated as child health
assistance under such title.
(D) OPTION FOR AUTOMATIC ENROLLMENT.—
(i) IN GENERAL.—The State may initiate and determine
eligibility for medical assistance under the State Medicaid
plan or for child health assistance under the State CHIP
plan without a program application from, or on behalf of,
the child based on data obtained from sources other than
the child (or the child’s family), but a child can only be
automatically enrolled in the State Medicaid plan or the
State CHIP plan if the child or the family affirmatively
consents to being enrolled through affirmation in writing,
by telephone, orally, through electronic signature, or
through any other means specified by the Secretary or by
signature on an Express Lane agency application, if the re-
quirement of clause (ii) is met.
(ii) INFORMATION REQUIREMENT.—The requirement of
this clause is that the State informs the parent, guardian,
or custodial relative of the child of the services that will
be covered, appropriate methods for using such services,
premium or other cost sharing charges (if any) that apply,
medical support obligations (under section 1912(a)) created
by enrollment (if applicable), and the actions the parent,
guardian, or relative must take to maintain enrollment
and renew coverage.
(E) CODING; APPLICATION TO ENROLLMENT ERROR RATES.—
(i) IN GENERAL.—For purposes of subparagraph (A)(iv),
the requirement of this subparagraph for a State is that
the State agrees to—
(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 dura-
tion of the State’s election under this paragraph;
SSpencer on DSK126QN23PROD with REPORTS
(II) annually provide the Secretary with a statis-
tically valid sample (that is approved by Secretary) of
the children enrolled in such plans through reliance on
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55
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 sub-
clause (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 imple-
mented 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 section 1903(a) for quarters for that fiscal
year, equal to the total amount of erroneous excess
payments determined for the fiscal year only with re-
spect to the children included in the sample for the fis-
cal year that are in excess of a 3 percent error rate
with respect to such children.
(ii) NO PUNITIVE ACTION BASED ON ERROR RATE.—The
Secretary shall not apply the error rate derived from the
sample under clause (i) to the entire population of children
enrolled in the State Medicaid plan or the State CHIP
plan through reliance on a finding made by an Express
Lane agency, or to the population of children enrolled in
such plans on the basis of the State’s regular procedures
for determining eligibility, or penalize the State on the
basis of such error rate in any manner other than the re-
duction of payments provided for under clause (i)(V).
(iii) RULE OF CONSTRUCTION.—Nothing in this paragraph
shall be construed as relieving a State that elects to apply
this paragraph from being subject to a penalty under sec-
tion 1903(u), for payments made under the State Medicaid
plan with respect to ineligible individuals and families
that are determined to exceed the error rate permitted
under that section (as determined without regard to the
error rate determined under clause (i)(II)).
(iv) ERROR RATE DEFINED.—In this subparagraph, the
term ‘‘error rate’’ means the rate of erroneous excess pay-
ments for medical assistance (as defined in section
1903(u)(1)(D)) for the period involved, except that such
payments shall be limited to individuals for which eligi-
bility determinations are made under this paragraph and
except that in applying this paragraph under title XXI,
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there shall be substituted for references to provisions of
this title corresponding provisions within title XXI.
(F) EXPRESS LANE AGENCY.—
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56
(i) IN GENERAL.—In this paragraph, the term ‘‘Express
Lane agency’’ means a public agency that—
(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 in-
formation disclosed for such purposes; and
(IV) enters into, or is subject to, an interagency
agreement to limit the disclosure and use of the infor-
mation disclosed.
(ii) INCLUSION OF SPECIFIC PUBLIC AGENCIES AND INDIAN
TRIBES AND TRIBAL ORGANIZATIONS.—Such term includes
the following:
(I) A public agency that determines eligibility for as-
sistance under any of the following:
(aa) The temporary assistance for needy fami-
lies program funded under part A of title IV.
(bb) A State program funded under part D of
title IV.
(cc) The State Medicaid plan.
(dd) The State CHIP plan.
(ee) The Food and Nutrition Act of 2008 (7
U.S.C. 2011 et seq.).
(ff) The Head Start Act (42 U.S.C. 9801 et seq.).
(gg) The Richard B. Russell National School
Lunch Act (42 U.S.C. 1751 et seq.).
(hh) The Child Nutrition Act of 1966 (42 U.S.C.
1771 et seq.).
(ii) The Child Care and Development Block
Grant Act of 1990 (42 U.S.C. 9858 et seq.).
(jj) The Stewart B. McKinney Homeless Assist-
ance Act (42 U.S.C. 11301 et seq.).
(kk) The United States Housing Act of 1937 (42
U.S.C. 1437 et seq.).
(ll) The Native American Housing Assistance
and Self-Determination Act of 1996 (25 U.S.C.
4101 et seq.).
(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.
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(III) A public agency that is subject to an inter-
agency agreement limiting the disclosure and use of
the information disclosed for purposes of determining
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57
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 section 1139(c)).
(iii) EXCLUSIONS.—Such term does not include an agency
that determines eligibility for a program established under
the Social Services Block Grant established under title XX
or a private, for-profit organization.
(iv) RULES OF CONSTRUCTION.—Nothing in this para-
graph shall be construed as—
(I) exempting a State Medicaid agency from com-
plying with the requirements of section 1902(a)(4) re-
lating to merit-based personnel standards for employ-
ees of the State Medicaid agency and safeguards
against conflicts of interest); or
(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 eligi-
bility determinations under the State Medicaid plan.
(v) ADDITIONAL DEFINITIONS.—In this paragraph:
(I) STATE.—The term ‘‘State’’ means 1 of the 50
States or the District of Columbia.
(II) STATE CHIP AGENCY.—The term ‘‘State CHIP
agency’’ means the State agency responsible for ad-
ministering the State CHIP plan.
(III) STATE CHIP PLAN.—The term ‘‘State CHIP plan’’
means the State child health plan established under
title XXI and includes any waiver of such plan.
(IV) STATE MEDICAID AGENCY.—The term ‘‘State
Medicaid agency’’ means the State agency responsible
for administering the State Medicaid plan.
(V) STATE MEDICAID PLAN.—The term ‘‘State Med-
icaid plan’’ means the State plan established under
title XIX and includes any waiver of such plan.
(G) CHILD DEFINED.—For purposes of this paragraph, the
term ‘‘child’’ means an individual under 19 years of age, or, at
the option of a State, such higher age, not to exceed 21 years
of age, as the State may elect.
(H) STATE OPTION TO RELY ON STATE INCOME TAX DATA OR
RETURN.—At the option of the State, a finding from an Express
Lane agency may include gross income or adjusted gross in-
come shown by State income tax records or returns.
(I) APPLICATION.—This paragraph shall not apply with re-
spect to eligibility determinations made after September 30,
2027.
(14) INCOME DETERMINED USING MODIFIED ADJUSTED GROSS
INCOME.—
(A) IN GENERAL.—Notwithstanding subsection (r) or any
other provision of this title, except as provided in subpara-
graph (D), for purposes of determining income eligibility
SSpencer on DSK126QN23PROD with REPORTS
for medical assistance under the State plan or under any
waiver of such plan and for any other purpose applicable
under the plan or waiver for which a determination of in-
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58
come is required, including with respect to the imposition
of premiums and cost-sharing, a State shall use the modi-
fied adjusted gross income of an individual and, in the case
of an individual in a family greater than 1, the household
income of such family. A State shall establish income eligi-
bility thresholds for populations to be eligible for medical
assistance under the State plan or a waiver of the plan
using modified adjusted gross income and household in-
come that are not less than the effective income eligibility
levels that applied under the State plan or waiver on the
date of enactment of the Patient Protection and Affordable
Care Act. For purposes of complying with the maintenance
of effort requirements under subsection (gg) during the
transition to modified adjusted gross income and house-
hold income, a State shall, working with the Secretary, es-
tablish an equivalent income test that ensures individuals
eligible for medical assistance under the State plan or
under a waiver of the plan on the date of enactment of the
Patient Protection and Affordable Care Act, do not lose
coverage under the State plan or under a waiver of the
plan. The Secretary may waive such provisions of this title
and title XXI as are necessary to ensure that States estab-
lish income and eligibility determination systems that pro-
tect beneficiaries.
(B) NO INCOME OR EXPENSE DISREGARDS.—Subject to
subparagraph (I), no type of expense, block, or other in-
come disregard shall be applied by a State to determine in-
come eligibility for medical assistance under the State plan
or under any waiver of such plan or for any other purpose
applicable under the plan or waiver for which a determina-
tion of income is required.
(C) NO ASSETS TEST.—A State shall not apply any assets
or resources test for purposes of determining eligibility for
medical assistance under the State plan or under a waiver
of the plan.
(D) EXCEPTIONS.—
(i) INDIVIDUALS ELIGIBLE BECAUSE OF OTHER AID OR
ASSISTANCE, ELDERLY INDIVIDUALS, MEDICALLY NEEDY
INDIVIDUALS, AND INDIVIDUALS ELIGIBLE FOR MEDICARE
COST-SHARING.—Subparagraphs (A), (B), and (C) shall
not apply to the determination of eligibility under the
State plan or under a waiver for medical assistance for
the following:
(I) Individuals who are eligible for medical as-
sistance under the State plan or under a waiver
of the plan on a basis that does not require a de-
termination of income by the State agency admin-
istering 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 eli-
gible on the basis of receiving (or being treated as
if receiving) supplemental security income benefits
SSpencer on DSK126QN23PROD with REPORTS
under title 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.
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59
(II) Individuals who have attained age 65.
(III) Individuals who qualify for medical assist-
ance 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) with-
out regard to whether the individual is eligible for
supplemental security income benefits under title
XVI on the basis of being blind or disabled and in-
cluding an individual who is eligible for medical
assistance on the basis of section 1902(e)(3).
(IV) Individuals described in subsection
(a)(10)(C).
(V) Individuals described in any clause of sub-
section (a)(10)(E).
(ii) EXPRESS LANE AGENCY FINDINGS.—In the case of
a State that elects the Express Lane option under
paragraph (13), notwithstanding subparagraphs (A),
(B), and (C), the State may rely on a finding made by
an Express Lane agency in accordance with that para-
graph relating to the income of an individual for pur-
poses of determining the individual’s eligibility for
medical assistance under the State plan or under a
waiver of the plan.
(iii) MEDICARE PRESCRIPTION DRUG SUBSIDIES DETER-
MINATIONS.—Subparagraphs (A), (B), and (C) shall not
apply to any determinations of eligibility for premium
and cost-sharing subsidies under and in accordance
with section 1860D–14 made by the State pursuant to
section 1935(a)(2).
(iv) LONG-TERM CARE.—Subparagraphs (A), (B), and
(C) shall not apply to any determinations of eligibility
of individuals for purposes of medical assistance for
nursing facility services, a level of care in any institu-
tion equivalent to that of nursing facility services,
home or community-based services furnished under a
waiver or State plan amendment under section 1915
or a waiver under section 1115, and services described
in section 1917(c)(1)(C)(ii).
(v) GRANDFATHER OF CURRENT ENROLLEES UNTIL
DATE OF NEXT REGULAR REDETERMINATION.—An indi-
vidual who, on January 1, 2014, is enrolled in the
State plan or under a waiver of the plan and who
would be determined ineligible for medical assistance
solely because of the application of the modified ad-
justed gross income or household income standard de-
scribed in subparagraph (A), shall remain eligible for
medical assistance under the State plan or waiver
(and subject to the same premiums and cost-sharing
as applied to the individual on that date) through
March 31, 2014, or the date on which the individual’s
next regularly scheduled redetermination of eligibility
is to occur, whichever is later.
SSpencer on DSK126QN23PROD with REPORTS
(E) TRANSITION PLANNING AND OVERSIGHT.—Each State
shall submit to the Secretary for the Secretary’s approval
the income eligibility thresholds proposed to be established
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60
using modified adjusted gross income and household in-
come, the methodologies and procedures to be used to de-
termine income eligibility using modified adjusted gross in-
come and household income and, if applicable, a State plan
amendment establishing an optional eligibility category
under subsection (a)(10)(A)(ii)(XX). To the extent prac-
ticable, the State shall use the same methodologies and
procedures for purposes of making such determinations as
the State used on the date of enactment of the Patient Pro-
tection and Affordable Care Act. The Secretary shall en-
sure that the income eligibility thresholds proposed to be
established using modified adjusted gross income and
household income, including under the eligibility category
established under subsection (a)(10)(A)(ii)(XX), and the
methodologies and procedures proposed to be used to de-
termine income eligibility, will not result in children who
would have been eligible for medical assistance under the
State plan or under a waiver of the plan on the date of en-
actment of the Patient Protection and Affordable Care Act
no longer being eligible for such assistance.
(F) LIMITATION ON SECRETARIAL AUTHORITY.—The Sec-
retary shall not waive compliance with the requirements of
this paragraph except to the extent necessary to permit a
State to coordinate eligibility requirements for dual eligi-
ble individuals (as defined in section 1915(h)(2)(B)) under
the State plan or under a waiver of the plan and under
title XVIII and individuals who require the level of care
provided in a hospital, a nursing facility, or an inter-
mediate care facility for the mentally retarded.
(G) DEFINITIONS OF MODIFIED ADJUSTED GROSS INCOME
AND HOUSEHOLD INCOME.—In this paragraph, the terms
‘‘modified adjusted gross income’’ and ‘‘household income’’
have the meanings given such terms in section 36B(d)(2)
of the Internal Revenue Code of 1986.
(H) CONTINUED APPLICATION OF MEDICAID RULES RE-
GARDING POINT-IN-TIME INCOME AND SOURCES OF IN-
COME.—The requirement under this paragraph for States
to use modified adjusted gross income and household in-
come to determine income eligibility for medical assistance
under the State plan or under any waiver of such plan and
for any other purpose applicable under the plan or waiver
for which a determination of income is required shall not
be construed as affecting or limiting the application of—
(i) the requirement under this title and under the
State plan or a waiver of the plan to determine an in-
dividual’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 title or under
the State plan or a waiver of the plan regarding
sources of countable income.
(I) TREATMENT OF PORTION OF MODIFIED ADJUSTED GROSS
SSpencer on DSK126QN23PROD with REPORTS
INCOME.—For purposes of determining the income eligi-
bility of an individual for medical assistance whose eligi-
bility is determined based on the application of modified
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61
adjusted gross income under subparagraph (A), the State
shall—
(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 pov-
erty line) and such upper income limit increased by 5
percentage points; and
(ii) notwithstanding the requirement in subpara-
graph (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) EXCLUSION OF PARENT MENTOR COMPENSATION FROM
INCOME DETERMINATION.—Any nominal amount received
by an individual as compensation, including a stipend, for
participation as a parent mentor (as defined in paragraph
(5) of section 2113(f)) in an activity or program funded
through a grant under such section shall be disregarded
for purposes of determining the income eligibility of such
individual for medical assistance under the State plan or
any waiver of such plan.
(K) TREATMENT OF CERTAIN LOTTERY WINNINGS AND IN-
COME RECEIVED AS A LUMP SUM.—
(i) IN GENERAL.—In the case of an individual who is
the recipient of qualified lottery winnings (pursuant to
lotteries occurring on or after January 1, 2018) or
qualified lump sum income (received on or after such
date) and whose eligibility for medical assistance is
determined based on the application of modified ad-
justed gross income under subparagraph (A), a State
shall, in determining such eligibility, include such
winnings or income (as applicable) as income re-
ceived—
(I) in the month in which such winnings or in-
come (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 in-
come of $1,260,000 or more), if the amount of such
winnings or income is greater than or equal to
$100,000.
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(ii) COUNTING IN EQUAL INSTALLMENTS.—For pur-
poses of subclauses (II), (III), and (IV) of clause (i),
winnings or income to which such subclause applies
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62
shall be counted in equal monthly installments over
the period of months specified under such subclause.
(iii) HARDSHIP EXEMPTION.—An individual whose in-
come, by application of clause (i), exceeds the applica-
ble eligibility threshold established by the State, shall
continue to be eligible for medical assistance to the ex-
tent that the State determines, under procedures es-
tablished by the State (in accordance with standards
specified by the Secretary), that the denial of eligi-
bility of the individual would cause an undue medical
or financial hardship as determined on the basis of cri-
teria established by the Secretary.
(iv) NOTIFICATIONS AND ASSISTANCE REQUIRED IN
CASE OF LOSS OF ELIGIBILITY.—A State shall, with re-
spect to an individual who loses eligibility for medical
assistance under the State plan (or a waiver of such
plan) by reason of clause (i)—
(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 Pa-
tient Protection and Affordable Care Act dur-
ing 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 assist-
ance under the State plan or under any waiv-
er of such plan and be eligible to reapply to
receive such medical assistance; and
(II) provide technical assistance to the indi-
vidual seeking to enroll in such a qualified health
plan.
(v) QUALIFIED LOTTERY WINNINGS DEFINED.—In this
subparagraph, the term ‘‘qualified lottery winnings’’
means winnings from a sweepstakes, lottery, or pool
described in paragraph (3) of section 4402 of the Inter-
nal Revenue Code of 1986 or a lottery operated by a
multistate or multijurisdictional lottery association, in-
cluding amounts awarded as a lump sum payment.
(vi) QUALIFIED LUMP SUM INCOME DEFINED.—In this
subparagraph, the term ‘‘qualified lump sum income’’
means income that is received as a lump sum from
monetary winnings from gambling (as defined by the
Secretary and including gambling activities described
in section 1955(b)(4) of title 18, United States Code).
(15) EXCLUSION OF COMPENSATION FOR PARTICIPATION IN A
CLINICAL TRIAL FOR TESTING OF TREATMENTS FOR A RARE DIS-
EASE OR CONDITION.—The first $2,000 received by an indi-
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vidual (who has attained 19 years of age) as compensation for
participation in a clinical trial meeting the requirements of sec-
tion 1612(b)(26) shall be disregarded for purposes of deter-
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63
mining the income eligibility of such individual for medical as-
sistance under the State plan or any waiver of such plan.
(16) EXTENDING CERTAIN COVERAGE FOR PREGNANT AND
POSTPARTUM WOMEN.—
(A) IN GENERAL.—At the option of the State, the State
plan (or waiver of such State plan) may provide, that an
individual who, while pregnant, is eligible for and has re-
ceived medical assistance under the State plan approved
under this title (or a waiver of such plan) (including during
a period of retroactive eligibility under subsection (a)(34))
shall, in addition to remaining eligible under paragraph (5)
for all pregnancy-related and postpartum medical assist-
ance available under the State plan (or waiver) through
the last day of the month in which the 60-day period (be-
ginning on the last day of her pregnancy) ends, remain eli-
gible under the State plan (or waiver) for medical assist-
ance for the period beginning on the first day occurring
after the end of such 60-day period and ending on the last
day of the month in which the 12-month period (beginning
on the last day of her pregnancy) ends.
(B) FULL BENEFITS DURING PREGNANCY AND THROUGH-
OUT THE 12-MONTH POSTPARTUM PERIOD.—The medical as-
sistance provided for a pregnant or postpartum individual
by a State making an election under this paragraph, with-
out regard to the basis on which the individual is eligible
for medical assistance under the State plan (or waiver),
shall—
(i) include all items and services covered under the
State plan (or waiver) that are not less in amount, du-
ration, 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) COVERAGE UNDER CHIP.—A State making an election
under this paragraph that covers under title XXI child
health assistance for targeted low-income children who are
pregnant or targeted low-income pregnant women, as ap-
plicable, shall also make the election under section
2107(e)(1)(J) of such title.
(f) Notwithstanding any other provision of this title, except as
provided in subsection (e) and section 1619(b)(3) and section 1924,
except with respect to qualified disabled and working individuals
(described in section 1905(s)), and except with respect to qualified
medicare beneficiaries, qualified severely impaired individuals, and
individuals described in subsection (m)(1), no State not eligible to
participate in the State plan program established under title XVI
shall be required to provide medical assistance to any aged, blind,
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or disabled individual (within the meaning of title XVI) for any
month unless such State would be (or would have been) required
to provide medical assistance to such individual for such month
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64
had its plan for medical assistance approved under this title and
in effect on January 1, 1972, been in effect in such month, except
that for this purpose any such individual shall be deemed eligible
for medical assistance under such State plan if (in addition to
meeting such other requirements as are or may be imposed under
the State plan) the income of any such individual as determined in
accordance with section 1903(f) (after deducting any supplemental
security income payment and State supplementary payment made
with respect to such individual, and incurred expenses for medical
care as recognized under State law regardless of whether such ex-
penses are reimbursed under another public program of the State
or political subdivision thereof) is not in excess of the standard for
medical assistance established under the State plan as in effect on
January 1, 1972. In States which provide medical assistance to in-
dividuals pursuant to paragraph (10)(C) of subsection (a) of this
section, an individual who is eligible for medical assistance by rea-
son of the requirements of this section concerning the deduction of
incurred medical expenses from income shall be considered an indi-
vidual eligible for medical assistance under paragraph (10)(A) of
that subsection if that individual is, or is eligible to be (1) an indi-
vidual with respect to whom there is payable a State supple-
mentary payment on the basis of which similarly situated individ-
uals are eligible to receive medical assistance equal in amount, du-
ration, and scope to that provided to individuals eligible under
paragraph (10)(A), or (2) an eligible individual or eligible spouse,
as defined in title XVI, with respect to whom supplemental security
income benefits are payable; otherwise that individual shall be con-
sidered to be an individual eligible for medical assistance under
paragraph (10)(C) of that subsection. In States which do not pro-
vide medical assistance to individuals pursuant to paragraph
(10)(C) of that subsection, an individual who is eligible for medical
assistance by reason of the requirements of this section concerning
the deduction of incurred medical expenses from income shall be
considered an individual eligible for medical assistance under para-
graph (10)(A) of that subsection.
(g) 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)(1) Nothing in this title (including subsections (a)(13) and
(a)(30) of this section) shall be construed as authorizing the Sec-
retary to limit the amount of payment that may be made under a
plan under this title for home and community care, home and com-
munity-based services provided under subsection (c), (d), or (i) of
section 1915 or under a waiver or demonstration project under sec-
tion 1115, self-directed personal assistance services provided pursu-
ant to a written plan of care under section 1915(j), and home and
community-based attendant services and supports under section
1915(k).
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(2) Nothing in this title, title XVIII, or title XI shall be construed
as prohibiting receipt of any care or services specified in paragraph
(1) in an acute care hospital that are—
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65
(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 Fed-
eral 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)(1) In addition to any other authority under State law, where
a State determines that a intermediate care facility for the men-
tally retarded which is certified for participation under its plan no
longer substantially meets the requirements for such a facility
under this title and further determines that the facility’s defi-
ciencies—
(A) immediately jeopardize the health and safety of its pa-
tients, the State shall provide for the termination of the facili-
ty’s certification for participation under the plan and may pro-
vide, 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, es-
tablish alternative remedies if the State demonstrates to the
Secretary’s satisfaction that the alternative remedies are effec-
tive 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, fol-
lowing the initial determination that it no longer substantially
meets the requirements for such a facility under this title, to cor-
rect its deficiencies, and, following this period, has been given rea-
sonable 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 title, 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, which-
ever 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 fol-
lowing the month specified in such clause.
(j) Notwithstanding any other requirement of this title, the Sec-
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retary may waive or modify any requirement of this title with re-
spect to the medical assistance program in American Samoa and
the Northern Mariana Islands, other than a waiver of the Federal
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66
medical assistance percentage, the limitation in section 1108(f),,
the requirement that payment may be made for medical assistance
only with respect to amounts expended by American Samoa or the
Northern Mariana Islands for care and services described in a
numbered paragraph of section 1905(a), or the requirement under
subsection (qq)(1) (relating to data reporting).
(k)(1) The medical assistance provided to an individual described
in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of bench-
mark coverage described in section 1937(b)(1) or benchmark equiv-
alent coverage described in section 1937(b)(2). Such medical assist-
ance shall be provided subject to the requirements of section 1937,
without regard to whether a State otherwise has elected the option
to provide medical assistance through coverage under that section,
unless an individual described in subclause (VIII) of subsection
(a)(10)(A)(i) is also an individual for whom, under subparagraph (B)
of section 1937(a)(2), the State may not require enrollment in
benchmark coverage described in subsection (b)(1) of section 1937
or benchmark equivalent coverage described in subsection (b)(2) of
that section.
(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 med-
ical assistance to individuals who would be described in subclause
(VIII) of subsection (a)(10)(A)(i) if that subclause were effective be-
fore January 1, 2014. A State may elect to phase-in the extension
of eligibility for medical assistance to such individuals based on in-
come, so long as the State does not extend such eligibility to indi-
viduals 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), 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 section 1931.
(l)(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 sub-
section (a)(10)(A)(i) and whose family income does not exceed the
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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.
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67
(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 section 673(2) of the Omnibus Budget Reconciliation Act of
1981) applicable to a family of the size involved.
(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 the date of the enactment
of this clause, has elected to provide, and provides, medical assist-
ance to individuals described in this subsection or has enacted leg-
islation authorizing, or appropriating funds, to provide such assist-
ance to such individuals before July 1, 1989, the percentage pro-
vided 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 the date of the
enactment of this clause, or
(II) if no such percentage is specified as of the date of the
enactment of this clause, 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 the date of the enactment
of this clause, has established under clause (i), or has enacted legis-
lation authorizing, or appropriating funds, to provide for, a percent-
age (of the income official poverty line) that is greater than 133
percent, the percentage provided under clause (ii) for medical as-
sistance 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 the date of the
enactment of this clause, or
(II) if no such percentage is specified as of the date of the
enactment of this clause, 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 de-
scribed in subparagraph (C) of such paragraph, the State shall es-
tablish 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 de-
scribed in subparagraph (D) of that paragraph, the State shall es-
tablish an income level which is equal to 100 percent (or, beginning
January 1, 2014, 133 percent) of the income official poverty line de-
scribed in subparagraph (A) applicable to a family of the size in-
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volved.
(3) Notwithstanding subsection (a)(17), for individuals who are
eligible for medical assistance because of subsection
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68
(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 title 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 title IV;
(D) the income standard to be applied is the appropriate in-
come 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 title IV (except to the extent such methodology is incon-
sistent 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 in-
dividuals 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 assist-
ance to its residents under a waiver granted under section 1115,
the Secretary shall require the State to provide medical assistance
for pregnant women and infants under age 1 described in sub-
section (a)(10)(A)(i)(IV) and for children described in subsection
(a)(10)(A)(i)(VI) or subsection (a)(10)(A)(i)(VII) in the same manner
as the State would be required to provide such assistance for such
individuals if the State had in effect a plan approved under this
title.
(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)(1) Individuals described in this paragraph are individuals—
(A) who are 65 years of age or older or are disabled individ-
uals (as determined under section 1614(a)(3)),
(B) whose income (as determined under section 1612 for pur-
poses of the supplemental security income program, except as
provided in paragraph (2)(C)) does not exceed an income level
established by the State consistent with paragraph (2)(A), and
(C) whose resources (as determined under section 1613 for
purposes of the supplemental security income program) do not
exceed (except as provided in paragraph (2)(B)) the maximum
amount of resources that an individual may have and obtain
benefits under that program.
(2)(A) The income level established under paragraph (1)(B) may
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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 section 673(2) of the Om-
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69
nibus Budget Reconciliation Act of 1981) applicable to a family of
the size involved.
(B) In the case of a State that provides medical assistance to in-
dividuals 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 para-
graph (1)(A) who are not described in subsection (a)(10)(A).
(C) The provisions of section 1905(p)(2)(D) shall apply to deter-
minations of income under this subsection in the same manner as
they apply to determinations of income under section 1905(p).
(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 section 1612(b)(4)(B)(ii), costs in-
curred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such in-
dividuals 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 section 1905(p)(1)—
(A) the income standard to be applied is the income standard
described in section 1905(p)(1)(B), and
(B) except as provided in section 1612(b)(4)(B)(ii), costs in-
curred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such in-
dividuals shall not, because of subsection (a)(17), require or permit
such treatment for other individuals.
(n)(1) In the case of medical assistance furnished under this title
for medicare cost-sharing respecting the furnishing of a service or
item to a qualified medicare beneficiary, the State plan may pro-
vide 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 title 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 pro-
vide any payment for any expenses incurred relating to payment
for deductibles, coinsurance, or copayments for medicare cost-shar-
ing to the extent that payment under title XVIII for the service
would exceed the payment amount that otherwise would be made
under the State plan under this title 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-shar-
ing for a qualified medicare beneficiary with respect to an item or
service is reduced or eliminated through the application of para-
graph (2)—
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(A) for purposes of applying any limitation under title XVIII
on the amount that the beneficiary may be billed or charged
for the service, the amount of payment made under title XVIII
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70
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 sec-
tion 1903(m)(1)(A) for the service; and
(C) any lawful sanction that may be imposed upon a provider
or such an organization for excess charges under this title or
title 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) Notwithstanding any provision of subsection (a) to the con-
trary, a State plan under this title shall provide that any supple-
mental security income benefits paid by reason of subparagraph (E)
or (G) of section 1611(e)(1) to an individual who—
(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 in-
termediate care facility.
(p)(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 title for any reason for which the Secretary could
exclude the individual or entity from participation in a program
under title XVIII under section 1128, 1128A, or 1866(b)(2).
(2) In order for a State to receive payments for medical assist-
ance under section 1903(a), with respect to payments the State
makes to a medicaid managed care organization (as defined in sec-
tion 1903(m)) or to an entity furnishing services under a waiver ap-
proved under section 1915(b)(1), the State must provide that it will
exclude from participation, as such an organization or entity, any
organization or entity that—
(A) could be excluded under section 1128(b)(8) (relating to
owners and managing employees who have been convicted of
certain crimes or received other sanctions),
(B) has, directly or indirectly, a substantial contractual rela-
tionship (as defined by the Secretary) with an individual or en-
tity that is described in section 1128(b)(8)(B), or
(C) employs or contracts with any individual or entity that
is excluded from participation under this title under section
1128 or 1128A for the provision of health care, utilization re-
view, medical social work, or administrative services or em-
ploys or contracts with any entity for the provision (directly or
indirectly) through such an excluded individual or entity of
such services.
(3) As used in this subsection, the term ‘‘exclude’’ includes the re-
fusal to enter into or renew a participation agreement or the termi-
nation of such an agreement.
(q)(1)(A) In order to meet the requirement of subsection (a)(50),
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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
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71
monthly to payment for the cost of care in an institution, there
shall be deducted from the monthly income (in addition to other al-
lowances otherwise provided under the State plan) a monthly per-
sonal needs allowance—
(i) which is reasonable in amount for clothing and other per-
sonal 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 title throughout a month, and
(ii) who is or are determined to be eligible for medical assist-
ance under the State plan.
(2) The minimum monthly personal needs allowance described in
this paragraph 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 deter-
mining eligibility).
(r)(1)(A) For purposes of sections 1902(a)(17) and 1924(d)(1)(D)
and for purposes of a waiver under section 1915, with respect to
the post-eligibility treatment of income of individuals who are insti-
tutionalized or receiving home or community-based services under
such a waiver, the treatment described in subparagraph (B) shall
apply, there shall be disregarded reparation payments made by the
Federal Republic of Germany, and there shall be taken into ac-
count amounts for incurred expenses for medical or remedial care
that are not subject to payment by a third party, including—
(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 title,
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 eli-
gible for medical assistance under the State plan under this
title, 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 section 1741(a) of title 38,
United States Code,
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 vet-
erans home’s cost of providing nursing home care to the veteran.
(ii) The provisions of clause (i) shall apply with respect to a sur-
viving spouse of a veteran who does not have a child in the same
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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
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72
(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 section 1905(p) may
be less restrictive, and shall be no more restrictive, than the meth-
odology—
(i) in the case of groups consisting of aged, blind, or disabled
individuals, under the supplemental security income program
under title 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), meth-
odology is considered to be ‘‘no more restrictive’’ if, using the meth-
odology, additional individuals may be eligible for medical assist-
ance and no individuals who are otherwise eligible are made ineli-
gible for such assistance.
(s) In order to meet the requirements of subsection (a)(55), the
State plan must provide that payments to hospitals under the plan
for inpatient hospital services furnished to infants who have not at-
tained 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 section 1923(b)(1), shall—
(1) if made on a prospective basis (whether per diem, per
case, or otherwise) provide for an outlier adjustment in pay-
ment amounts for medically necessary inpatient hospital serv-
ices 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 ad-
justed 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) Nothing in this title (including sections 1903(a) and 1905(a))
shall be construed as authorizing the Secretary to deny or limit
payments to a State for expenditures, for medical assistance for
items or services, attributable to taxes of general applicability im-
posed with respect to the provision of such items or services.
(u)(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 section 1612 for pur-
poses of the supplemental security income program) does not
exceed 100 percent of the official poverty line (as defined by
the Office of Management and Budget, and revised annually in
accordance with section 673(2) of the Omnibus Budget Rec-
onciliation Act of 1981) applicable to a family of the size in-
volved,
(C) whose resources (as determined under section 1613 for
purposes of the supplemental security income program) do not
exceed twice the maximum amount of resources that an indi-
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vidual may have and obtain benefits under that program, and
(D) with respect to whose enrollment for COBRA continu-
ation coverage the State has determined that the savings in ex-
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73
penditures under this title 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 em-
ployer with 75 or more employees provided pursuant to title XXII
of the Public Health Service Act, section 4980B of the Internal Rev-
enue Code of 1986, or title VI of the Employee Retirement Income
Security Act of 1974.
(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 section 1612(b)(4)(B)(ii), costs in-
curred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such in-
dividuals shall not, because of subsection (a)(10)(B) or (a)(17), re-
quire or permit such treatment for other individuals.
(v) 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 de-
termined 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 section
1614(a) of the Social Security Act.
(w)(1) For purposes of subsection (a)(57) and sections
1903(m)(1)(A) and 1919(c)(2)(E), the requirement of this subsection
is that a provider or organization (as the case may be) maintain
written policies and procedures with respect to all adult individuals
receiving medical care by or through the provider or organization—
(A) to provide written information to each such individual
concerning—
(i) an individual’s rights under State law (whether statu-
tory 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 para-
graph (3)), and
(ii) the provider’s or organization’s written policies re-
specting the implementation of such rights;
(B) to document in the individual’s medical record whether
or not the individual has executed an advance directive;
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(C) not to condition the provision of care or otherwise dis-
criminate against an individual based on whether or not the
individual has executed an advance directive;
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74
(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 direc-
tives.
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 indi-
vidual’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 ap-
plication of a State law which allows for an objection on the basis
of conscience for any health care provider or any agent of such pro-
vider which as a matter of conscience cannot implement an ad-
vance directive.
(4) In this subsection, the term ‘‘advance directive’’ means a writ-
ten 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 provi-
sion of such care when the individual is incapacitated.
(5) For construction relating to this subsection, see section 7 of
the Assisted Suicide Funding Restriction Act of 1997 (relating to
clarification respecting assisted suicide, euthanasia, and mercy kill-
ing).
(x) 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 title.
(y)(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 section 1905(h)) and further
finds that the hospital’s deficiencies—
(A) immediately jeopardize the health and safety of its pa-
tients, 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.
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(2) Except as provided in paragraph (3), if a psychiatric hospital
described in paragraph (1)(B) has not complied with the require-
ments for a psychiatric hospital under this title—
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75
(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 finan-
cial participation shall be provided under section 1903(a) with
respect to further services provided in the hospital until the
State finds that the hospital is in compliance with the require-
ments of this title.
(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 alter-
native action to assure compliance of the hospital with the re-
quirements than to terminate the certification of the hospital,
(B) the State has submitted a plan and timetable for correc-
tive action to the Secretary for approval and the Secretary ap-
proves the plan of corrective action, and
(C) the State agrees to repay to the Federal Government
payments received under this paragraph if the corrective ac-
tion is not taken in accordance with the approved plan and
timetable.
(z)(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 title with respect to disabled individuals) does not exceed
the maximum amount of income a disabled individual de-
scribed 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 title with respect to disabled individuals) do not ex-
ceed the maximum amount of resources a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain med-
ical assistance under the plan.
(2) For purposes of subsection (a)(10), the term ‘‘TB-related serv-
ices’’ means each of the following services relating to treatment of
infection with tuberculosis:
(A) Prescribed drugs.
(B) Physicians’ services and services described in section
1905(a)(2).
(C) Laboratory and X-ray services (including services to con-
firm the presence of infection).
(D) Clinic services and Federally-qualified health center
services.
(E) Case management services (as defined in section
1915(g)(2)).
(F) Services (other than room and board) designed to encour-
age completion of regimens of prescribed drugs by outpatients,
including services to observe directly the intake of prescribed
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drugs.
(aa) Individuals described in this subsection are individuals
who—
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76
(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 cer-
vical cancer early detection program established under title XV
of the Public Health Service Act (42 U.S.C. 300k et seq.) in ac-
cordance with the requirements of section 1504 of that Act (42
U.S.C. 300n) and need treatment for breast or cervical cancer;
and
(4) are not otherwise covered under creditable coverage, as
defined in section 2701(c) of the Public Health Service Act (42
U.S.C. 300gg(c)), but applied without regard to paragraph
(1)(F) of such section.
(bb) PAYMENT FOR SERVICES PROVIDED BY FEDERALLY-QUALIFIED
HEALTH CENTERS AND RURAL HEALTH CLINICS.—
(1) IN GENERAL.—Beginning with fiscal year 2001 with re-
spect 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 section 1905(a)(2)(C) fur-
nished by a Federally-qualified health center and services de-
scribed in section 1905(a)(2)(B) furnished by a rural health
clinic in accordance with the provisions of this subsection.
(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 serv-
ices 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 section 1833(a)(3), or,
in the case of services to which such regulations do not apply,
the same methodology used under section 1833(a)(3), adjusted
to take into account any increase or decrease in the scope of
such services furnished by the center or clinic during fiscal
year 2001.
(3) FISCAL YEAR 2002 AND SUCCEEDING FISCAL YEARS.—Sub-
ject 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 section 1842(i)(3)) applicable to primary care
services (as defined in section 1842(i)(4)) for that fiscal
year; and
(B) adjusted to take into account any increase or de-
crease 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
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clinic after fiscal year 2000, the State plan shall provide for
payment for services described in section 1905(a)(2)(C) fur-
nished by the center or services described in section
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77
1905(a)(2)(B) furnished by the clinic in the first fiscal year in
which the center or clinic so qualifies in an amount (calculated
on a per visit basis) that is equal to 100 percent of the costs
of furnishing such services during such fiscal year based on the
rates established under this subsection for the fiscal year for
other such centers or clinics located in the same or adjacent
area with a similar case load or, in the absence of such a cen-
ter or clinic, in accordance with the regulations and method-
ology referred to in paragraph (2) or based on such other tests
of reasonableness as the Secretary may specify. For each fiscal
year following the fiscal year in which the entity first qualifies
as a Federally-qualified health center or rural health clinic, the
State plan shall provide for the payment amount to be cal-
culated in accordance with paragraph (3).
(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 pur-
suant to a contract between the center or clinic and a man-
aged care entity (as defined in section 1932(a)(1)(B)), the
State plan shall provide for payment to the center or clinic
by the State of a supplemental payment equal to the
amount (if any) by which the amount determined under
paragraphs (2), (3), and (4) of this subsection exceeds the
amount of the payments provided under the contract.
(B) PAYMENT SCHEDULE.—The supplemental payment re-
quired under subparagraph (A) shall be made pursuant to
a payment schedule agreed to by the State and the Feder-
ally-qualified health center or rural health clinic, but in no
case less frequently than every 4 months.
(6) ALTERNATIVE PAYMENT METHODOLOGIES.—Notwith-
standing 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 section
1905(a)(2)(C) or to a rural health clinic for services described
in section 1905(a)(2)(B) in an amount which is determined
under an alternative payment methodology that—
(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 sec-
tion.
(cc)(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 sec-
ond, 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 quar-
ter 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 there-
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after;
(B) who would be considered disabled under section
1614(a)(3)(C) (as determined under title XVI for children but
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78
without regard to any income or asset eligibility requirements
that apply under such title with respect to children); and
(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 section
2110(c)(5)) applicable to a family of the size involved; or
(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 pov-
erty line may only be provided with State funds; and
(II) no Federal financial participation shall be pro-
vided under section 1903(a) for any medical assistance
provided to such an individual.
(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), the
State shall—
(i) notwithstanding section 1906, require such parent to
apply for, enroll in, and pay premiums for such coverage as a
condition of such parent’s child being or remaining eligible for
medical assistance under subsection (a)(10)(A)(ii)(XIX) if the
parent is determined eligible for such coverage and the em-
ployer contributes at least 50 percent of the total cost of an-
nual premiums for such coverage; and
(ii) if such coverage is obtained—
(I) subject to paragraph (2) of section 1916(h), 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 section 1906 but subject to paragraph
(1)(C)(ii), may provide for payment of any portion of the annual
premium for such family coverage that the parent is required to
pay. Any payments made by the State under this subparagraph
shall be considered, for purposes of section 1903(a), to be payments
for medical assistance.
(dd) ELECTRONIC TRANSMISSION OF INFORMATION.—If the State
agency determining eligibility for medical assistance under this
title or child health assistance under title XXI verifies an element
of eligibility based on information from an Express Lane Agency
(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 ap-
plication for medical assistance may be satisfied through an elec-
tronic signature, as defined in section 1710(1) of the Government
Paperwork Elimination Act (44 U.S.C. 3504 note). The require-
ments of subparagraphs (A) and (B) of section 1137(d)(2) may be
met through evidence in digital or electronic form.
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(ee)(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
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79
eligibility under this title, are, in lieu of requiring the individual
to present satisfactory documentary evidence of citizenship or na-
tionality under section 1903(x) (if the individual is not described in
paragraph (2) of that section), as follows:
(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 So-
cial Security that the name or social security number, or the
declaration of citizenship or nationality, of the individual is in-
consistent 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 con-
tacting the individual to confirm the accuracy of the name
or social security number submitted or declaration of citi-
zenship or nationality and by taking such additional ac-
tions as the Secretary, through regulation or other guid-
ance, 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 sub-
clause (I) is received by the individual to either
present satisfactory documentary evidence of citizen-
ship or nationality (as defined in section 1903(x)(3)) or
resolve the inconsistency with the Commissioner of So-
cial Security (and continues to provide the individual
with medical assistance during such 90-day period);
and
(III) disenrolls the individual from the State plan
under this title within 30 days after the end of such
90-day period if no such documentary evidence is pre-
sented or if such inconsistency is not resolved.
(2)(A) Each State electing to satisfy the requirements of this sub-
section for purposes of section 1902(a)(46)(B) shall establish a pro-
gram under which the State submits at least monthly to the Com-
missioner of Social Security for comparison of the name and social
security number, of each individual newly enrolled in the State
plan under this title that month who is not described in section
1903(x)(2) and who declares to be a United States citizen or na-
tional, with information in records maintained by the Commis-
sioner.
(B) In establishing the State program under this paragraph, the
State may enter into an agreement with the Commissioner of So-
cial Security—
(i) to provide, through an on-line system or otherwise, for the
electronic submission of, and response to, the information sub-
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mitted under subparagraph (A) for an individual enrolled in
the State plan under this title who declares to be citizen or na-
tional on at least a monthly basis; or
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80
(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 burden-
some 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 so-
cial 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 doc-
umentary evidence of citizenship or nationality (as defined in sec-
tion 1903(x)(3)) as is provided under clauses (i) and (ii) of section
1137(d)(4)(A) to an individual for the submittal to the State of evi-
dence indicating a satisfactory immigration status.
(3)(A) The State agency implementing the plan approved under
this title 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 subpara-
graph, 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 con-
sistent with information in records maintained by the Commis-
sioner 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 So-
cial Security or provide satisfactory documentation of citizen-
ship 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 title.
(B) If, for any fiscal year, the average monthly percentage deter-
mined under subparagraph (A) is greater than 3 percent—
(i) the State shall develop and adopt a corrective plan to re-
view its procedures for verifying the identities of individuals
seeking to enroll in the State plan under this title and to iden-
tify 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
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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)
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81
in effect as of the close of the fiscal year that provides for the sub-
mission on a real-time basis of the information described in such
paragraph.
(4) Nothing in this subsection shall affect the rights of any indi-
vidual under this title to appeal any disenrollment from a State
plan.
(ff) Notwithstanding any other requirement of this title 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 title:
(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 reserva-
tions in Oklahoma, Alaska Native regions established by the
Alaska Native Claims Settlement Act, and Indian allotments
on or near a reservation as designated and approved by the
Bureau of Indian Affairs of the Department of the Interior.
(2) For any federally recognized Tribe not described in para-
graph (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 nat-
ural resources or harvesting of timber, other plants and plant
products, animals, fish, and shellfish) resulting from the exer-
cise of federally protected rights.
(4) Ownership interests in or usage rights to items not cov-
ered 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 appli-
cable tribal law or custom.
(gg) MAINTENANCE OF EFFORT.—
(1) GENERAL REQUIREMENT TO MAINTAIN ELIGIBILITY STAND-
ARDS UNTIL STATE EXCHANGE IS FULLY OPERATIONAL.—Subject
to the succeeding paragraphs of this subsection, during the pe-
riod that begins on the date of enactment of the Patient Protec-
tion and Affordable Care Act and ends on the date on which
the Secretary determines that an Exchange established by the
State under section 1311 of the Patient Protection and Afford-
able Care Act is fully operational, as a condition for receiving
any Federal payments under section 1903(a) for calendar quar-
ters occurring during such period, a State shall not have in ef-
fect eligibility standards, methodologies, or procedures under
the State plan under this title or under any waiver of such
plan that is in effect during that period, that are more restric-
tive than the eligibility standards, methodologies, or proce-
dures, respectively, under the plan or waiver that are in effect
on the date of enactment of the Patient Protection and Afford-
able Care Act.
(2) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHILDREN
SSpencer on DSK126QN23PROD with REPORTS
THROUGH SEPTEMBER 30, 2027.—The requirement under para-
graph (1) shall continue to apply to a State through September
30, 2027 (but during the period that begins on October 1, 2019,
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82
and ends on September 30, 2027 only with respect to children
in families whose income does not exceed 300 percent of the
poverty line (as defined in section 2110(c)(5)) applicable to a
family of the size involved) with respect to the eligibility stand-
ards, methodologies, and procedures under the State plan
under this title or under any waiver of such plan that are ap-
plicable to determining the eligibility for medical assistance of
any child who is under 19 years of age (or such higher age as
the State may have elected).
(3) NONAPPLICATION.—During the period that begins on Jan-
uary 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 per-
cent of the poverty line (as defined in section 2110(c)(5)) appli-
cable to a family of the size involved if, on or after December
31, 2010, the State certifies to the Secretary that, with respect
to the State fiscal year during which the certification is made,
the State has a budget deficit, or with respect to the suc-
ceeding State fiscal year, the State is projected to have a budg-
et deficit. Upon submission of such a certification to the Sec-
retary, the requirement under paragraph (1) shall not apply to
the State with respect to any remaining portion of the period
described in the preceding sentence.
(4) DETERMINATION OF COMPLIANCE.—
(A) STATES SHALL APPLY MODIFIED ADJUSTED GROSS IN-
COME.—A State’s determination of income in accordance
with subsection (e)(14) shall not be considered to be eligi-
bility standards, methodologies, or procedures that are
more restrictive than the standards, methodologies, or pro-
cedures in effect under the State plan or under a waiver
of the plan on the date of enactment of the Patient Protec-
tion and Affordable Care Act 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, meth-
odologies, or procedures under the State plan under this
title or under any waiver of the plan that are less restric-
tive than the eligibility standards, methodologies, or proce-
dures, applied under the State plan or under a waiver of
the plan on the date of enactment of the Patient Protection
and Affordable Care Act, or that makes individuals who,
on such date of enactment, are eligible for medical assist-
ance under a waiver of the State plan, after such date of
enactment 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
SSpencer on DSK126QN23PROD with REPORTS
(VIII) of section 1902(a)(10)(A)(i), shall not be considered to
have in effect eligibility standards, methodologies, or pro-
cedures that are more restrictive than the standards,
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83
methodologies, or procedures in effect under the State plan
or under a waiver of the plan on the date of enactment of
the Patient Protection and Affordable Care Act for pur-
poses of determining compliance with the requirements of
paragraph (1), (2), or (3).
(hh)(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 sub-
clause 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 section 1931.
(ii)(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 title (or under its State child health plan
under title XXI) for pregnant women; and
(B) who are not pregnant.
(2) At the option of a State, individuals described in this sub-
section 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 subsection (a)(10) pursuant to a
waiver granted under section 1115.
(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under this sub-
section, the State may consider only the income of the appli-
cant or recipient.
(jj) PRIMARY CARE SERVICES DEFINED.—For purposes of sub-
section (a)(13)(C), the term ‘‘primary care services’’ means—
(1) evaluation and management services that are procedure
codes (for services covered under title XVIII) for services in the
category designated Evaluation and Management in the
Healthcare Common Procedure Coding System (established by
the Secretary under section 1848(c)(5) as of December 31, 2009,
and as subsequently modified); and
(2) services related to immunization administration for vac-
cines and toxoids for which CPT codes 90465, 90466, 90467,
90468, 90471, 90472, 90473, or 90474 (as subsequently modi-
fied) apply under such System.
SSpencer on DSK126QN23PROD with REPORTS
(kk) PROVIDER AND SUPPLIER SCREENING, OVERSIGHT, AND RE-
PORTING REQUIREMENTS.—For purposes of subsection (a)(77), the
requirements of this subsection are the following:
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84
(1) SCREENING.—The State complies with the process for
screening providers and suppliers under this title, as estab-
lished by the Secretary under section 1866(j)(2).
(2) PROVISIONAL PERIOD OF ENHANCED OVERSIGHT FOR NEW
PROVIDERS AND SUPPLIERS.—The State complies with proce-
dures to provide for a provisional period of enhanced oversight
for new providers and suppliers under this title, as established
by the Secretary under section 1866(j)(3).
(3) DISCLOSURE REQUIREMENTS.—The State requires pro-
viders and suppliers under the State plan or under a waiver
of the plan to comply with the disclosure requirements estab-
lished by the Secretary under section 1866(j)(5).
(4) TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PRO-
VIDERS OR SUPPLIERS.—
(A) TEMPORARY MORATORIUM IMPOSED BY THE SEC-
RETARY.—
(i) IN GENERAL.—Subject to clause (ii), the State
complies with any temporary moratorium on the en-
rollment of new providers or suppliers imposed by the
Secretary under section 1866(j)(7).
(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 de-
termines that the imposition of such temporary
moratorium would adversely impact beneficiaries’
access to medical assistance.
(II) FFP AVAILABLE.—Notwithstanding section
1903(i)(2)(E), payment may be made to a State
under this title with respect to amounts expended
for items and services described in such section if
the Secretary, in consultation with the State agen-
cy administering the State plan under this title
(or a waiver of the plan), determines that denying
payment to the State pursuant to such section
would adversely impact beneficiaries’ access to
medical assistance.
(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 speci-
fied in subparagraph (C)(iii) of section 1866(j)(7) from
charging an individual or other person eligible to re-
ceive medical assistance under the State plan under
this title (or a waiver of the plan) for an item or serv-
ice described in section 1903(i)(2)(E) furnished to such
an individual.
(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
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providers or suppliers under the State plan or under a
waiver of the plan, periods of enrollment moratoria, or nu-
merical caps or other limits, for providers or suppliers
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85
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 sec-
tion 1866(j)(7), a compliance program that contains the core
elements established under subparagraph (B) of that section
1866(j)(7) for providers or suppliers within a particular indus-
try 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 Serv-
ices, in accordance with regulations of the Secretary.
(7) ENROLLMENT AND NPI OF ORDERING OR REFERRING PRO-
VIDERS.—The State requires—
(A) all ordering or referring physicians or other profes-
sionals 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 re-
ferring 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 No-
vember 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 ef-
fective date of such termination, submits to the Secretary
with respect to any such provider or person, as appro-
priate—
(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 prac-
tice;
(iv) the date of birth, Social Security number, na-
tional provider identifier (if applicable), Federal tax-
payer identification number, and the State license or
certification number of such provider or person (if ap-
plicable);
(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,
SSpencer on DSK126QN23PROD with REPORTS
as specified in the notice; and
(viii) any other information required by the Sec-
retary.
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86
(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 pro-
vider and supplier oversight activities beyond those required
by the Secretary.
(ll) TERMINATION NOTIFICATION DATABASE.—In the case of a pro-
vider of services or any other person whose participation under this
title or title 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 Sec-
retary 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 (42
U.S.C. 1395cc note; Public Law 111–148).
(mm) DIRECTORY PHYSICIAN OR PROVIDER DESCRIBED.—A physi-
cian 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 pay-
ment for items and services furnished by the physician or pro-
vider to individuals eligible to receive medical assistance under
the State plan, requires the enrollment of the physician or pro-
vider 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 ap-
plicable) 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 immediately before becoming an inmate of
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such a public institution; or
(B) is determined eligible for such medical assistance
while an inmate of a public institution.
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87
(3) INMATE OF A PUBLIC INSTITUTION.—The term ‘‘inmate of
a public institution’’ has the meaning given such term for pur-
poses of applying the subdivision (A) following paragraph
ø(30)¿ (31) of section 1905(a), taking into account the exception
in such subdivision for a patient of a medical institution.
(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 fol-
lowing:
(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 ex-
cess of any limitation that may be identified by
the State; and
(III) a claims review automated process (as de-
signed and implemented by the State) that mon-
itors when an individual enrolled under the State
plan (or under a waiver of the State plan) is con-
currently prescribed opioids and—
(aa) benzodiazepines; or
(bb) antipsychotics.
(ii) MANAGED CARE ENTITIES.—The State requires
each managed care entity (as defined in section
1932(a)(1)(B)) with respect to which the State has a
contract under section 1903(m) or under section
1905(t)(3) to have in place, subject to paragraph (3),
with respect to individuals who are eligible for medical
assistance under the State plan (or under a waiver of
the State plan) and who are enrolled with the entity,
the limitations described in subclauses (I) and (II) of
clause (i) and a claims review automated process de-
scribed in subclause (III) of such clause.
(iii) RULES OF CONSTRUCTION.—Nothing in this sub-
paragraph may be construed as prohibiting a State or
managed care entity from designing and implementing
SSpencer on DSK126QN23PROD with REPORTS
a claims review automated process under this sub-
paragraph that provides for prospective or retrospec-
tive reviews of claims. Nothing in this subparagraph
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88
shall be understood as prohibiting the exercise of clin-
ical judgment from a provider enrolled as a partici-
pating provider in a State plan (or waiver of the State
plan) or contracting with a managed care entity re-
garding 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 de-
signed 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 Sec-
retary 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 phar-
macies dispensing drugs to individuals so enrolled.
(D) REPORTS.—The State shall include in the annual re-
port submitted to the Secretary under section 1927(g)(3)(D)
information on the limitations, requirement, program, and
processes applied by the State under subparagraphs (A)
through (C) in accordance with such manner and time as
specified by the Secretary.
(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 pro-
gram described in such subparagraph that was in
place before such date; or
(iii) described in subparagraph (C) by having a proc-
ess described in such subparagraph that was in place
before such date.
(2) ANNUAL REPORT BY SECRETARY.—For each fiscal year be-
ginning 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;
SSpencer on DSK126QN23PROD with REPORTS
(ii) is a resident of a long-term care facility, of a fa-
cility described in section 1905(d), or of another facil-
ity for which frequently abused drugs are dispensed
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89
for residents through a contract with a single phar-
macy; or
(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 pur-
poses of section 1860D–4(c)(5)(D)(ii)(II)).
(pp) RESIDENTIAL PEDIATRIC RECOVERY CENTER DEFINED.—
(1) IN GENERAL.—For purposes of section 1902(a)(86), the
term ‘‘residential pediatric recovery center’’ means a center or
facility that furnishes items and services for which medical as-
sistance is available under the State plan to infants with the
diagnosis of neonatal abstinence syndrome without any other
significant medical risk factors.
(2) COUNSELING AND SERVICES.—A residential pediatric re-
covery center may offer counseling and other services to moth-
ers (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 title 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 IN-
TEGRITY REQUIREMENTS TO NORTHERN MARIANA ISLANDS, AMER-
ICAN SAMOA, AND GUAM.—
(1) IN GENERAL.—Not later than October 1, 2021, the North-
ern Mariana Islands, American Samoa, and Guam shall—
(A) demonstrate progress in implementing methods, sat-
isfactory to the Secretary, for the collection and reporting
of reliable data to the Transformed Medicaid Statistical In-
formation System (T–MSIS) (or a successor system); and
(B) demonstrate progress in establishing a State med-
icaid fraud control unit described in section 1903(q).
(2) DETERMINATION OF PROGRESS.—For purposes of para-
graph (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 reli-
able 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 PRO-
VIDED TO PUERTO RICO.—
(A) IN GENERAL.—Puerto Rico shall establish and main-
tain a system, which may include the use of a quarterly
SSpencer on DSK126QN23PROD with REPORTS
Form CMS–64, for tracking any amounts paid by the Fed-
eral Government to Puerto Rico with respect to the State
plan of Puerto Rico (or a waiver of such plan). Under such
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90
system, Puerto Rico shall ensure that information is avail-
able, with respect to each quarter in a fiscal year (begin-
ning with the first quarter beginning on or after the date
that is 1 year after the date of the enactment of this sub-
section), on the following:
(i) In the case of a quarter other than the first quar-
ter 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 ex-
pended.
(ii) The total amount that Puerto Rico expects to ex-
pend during the quarter under the State plan of Puer-
to 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 RE-
QUEST.—Puerto Rico shall, upon request, submit to the Admin-
istrator 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 MEAS-
URES.—Beginning 12 months after the date of enactment of
this subsection, Puerto Rico shall begin to report to the Admin-
istrator of the Centers for Medicare & Medicaid Services on se-
lected measures included in the Medicaid and CHIP Scorecard
developed by the Centers for Medicare & Medicaid Services.
(ss) UNINSURED INDIVIDUAL DEFINED.—For purposes of this sec-
tion, the term ‘‘uninsured individual’’ means, notwithstanding any
other provision of this title, any individual who is—
(1) not described in subsection (a)(10)(A)(i) (excluding sub-
clause (VIII) of such subsection if the individual is a resident
of a State which does not furnish medical assistance to individ-
uals described in such subclause); and
(2) not enrolled in a Federal health care program (as defined
in section 1128B(f)), a group health plan, group or individual
health insurance coverage offered by a health insurance issuer
(as such terms are defined in section 2791 of the Public Health
Service Act), or a health plan offered under chapter 89 of title
5, United States Code, except that individuals who are eligible
for medical assistance under subsection (a)(10)(A)(ii)(XII), sub-
section (a)(10)(A)(ii)(XVIII), subsection (a)(10)(A)(ii)(XXI), or
subsection (a)(10)(C) (but only to the extent such an individual
is considered to not have minimum essential coverage under
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section 5000A(f)(1) of the Internal Revenue Code of 1986), or
who are described in subsection (l)(1)(A) and are eligible for
medical assistance only because of subsection (a)(10)(A)(i)(IV)
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91
or (a)(10)(A)(ii)(IX) and whose eligibility for such assistance is
limited by the State under clause (VII) in the matter following
subsection (a)(10)(G), shall not be treated as enrolled in a Fed-
eral health care program for purposes of this paragraph.
* * * * * * *
DEFINITIONS
SEC. 1905. For purposes of this title—
(a) The term ‘‘medical assistance’’ means payment of part or all
of the cost of the following care and services or the care and serv-
ices themselves, or both (if provided in or after the third month be-
fore the month in which the recipient makes application for assist-
ance or, in the case of medicare cost-sharing with respect to a
qualified medicare beneficiary described in subsection (p)(1), if pro-
vided after the month in which the individual becomes such a bene-
ficiary) for individuals, and, with respect to physicians’ or dentists’
services, at the option of the State, to individuals (other than indi-
viduals with respect to whom there is being paid, or who are eligi-
ble, 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 section 1902(a)(10)(A)) not receiving aid or assistance
under any plan of the State approved under title I, X, XIV, or XVI,
or part A of title IV, and with respect to whom supplemental secu-
rity income benefits are not being paid under title XVI, who are—
(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 406(b)(1) with whom a child
is living if such child is (or would, if needy, be) a dependent
child under part A of title IV,
(iii) 65 years of age or older,
(iv) blind, with respect to States eligible to participate in the
State plan program established under title XVI,
(v) 18 years of age or older and permanently and totally dis-
abled, with respect to States eligible to participate in the State
plan program established under title XVI,
(vi) persons essential (as described in the second sentence of
this subsection) to individuals receiving aid or assistance under
State plans approved under title I, X, XIV, or XVI,
(vii) blind or disabled as defined in section 1614, with respect
to States not eligible to participate in the State plan program
established under title XVI,
(viii) pregnant women,
(ix) individuals provided extended benefits under section
1925,
(x) individuals described in section 1902(u)(1),
(xi) individuals described in section 1902(z)(1),
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(xii) employed individuals with a medically improved dis-
ability (as defined in subsection (v)),
(xiii) individuals described in section 1902(aa),
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92
(xiv) individuals described in section 1902(a)(10)(A)(i)(VIII)
or 1902(a)(10)(A)(i)(IX),
(xv) individuals described in section 1902(a)(10)(A)(ii)(XX),
(xvi) individuals described in section 1902(ii), or
(xvii) individuals who are eligible for home and community-
based services under needs-based criteria established under
paragraph (1)(A) of section 1915(i), or who are eligible for home
and community-based services under paragraph (6) of such sec-
tion, and who will receive home and community-based services
pursuant to a State plan amendment under such subsection,
but whose income and resources are insufficient to meet all of such
cost—
(1) inpatient hospital services (other than services in an in-
stitution 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 sub-
section (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 section 1135(g) beginning on or after the date of the
enactment of this subparagraph for the detection of SARS–
CoV–2 or the diagnosis of the virus that causes COVID–19,
and the administration of such in vitro diagnostic products;
(4)(A) nursing facility services (other than services in an in-
stitution for mental diseases) for individuals 21 years of age or
older; (B) early and periodic screening, diagnostic, and treat-
ment 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-bear-
ing 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 (D) counseling and
pharmacotherapy for cessation of tobacco use by pregnant
women (as defined in subsection (bb)); and (E) during the pe-
riod beginning on the date of the enactment of the American
Rescue Plan Act of 2021 and ending on the last day of the first
calendar quarter that begins one year after the last day of the
period at the end of the emergency sentence described in sec-
tion 1135(g)(1)(B), a COVID–19 vaccine and administration of
the vaccine; and (F) during the period beginning on the date
of the enactment of the American Rescue Plan Act of 2021 and
ending on the last day of the first calendar quarter that begins
one year after the last day of the period at the end of the emer-
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gency sentence described in section 1135(g)(1)(B), testing and
treatments for COVID–19, including specialized equipment and
therapies (including preventive therapies), and, without regard
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93
to the requirements of section 1902(a)(10)(B) (relating to com-
parability), in the case of an individual who is diagnosed with
or presumed to have COVID–19, during the period such indi-
vidual 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 waiv-
er of such plan);
(5)(A) physicians’ services furnished by a physician (as de-
fined in section 1861(r)(1)), whether furnished in the office, the
patient’s home, a hospital, or a nursing facility, or elsewhere,
and (B) medical and surgical services furnished by a dentist
(described in section 1861(r)(2)) to the extent such services may
be performed under State law either by a doctor of medicine
or by a doctor of dental surgery or dental medicine and would
be described in clause (A) if furnished by a physician (as de-
fined in section 1861(r)(1));
(6) medical care, or any other type of remedial care recog-
nized 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 admin-
istered by a physician, including such services furnished out-
side 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 rehabilita-
tive 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 vac-
cines recommended by the Advisory Committee on Immu-
nization Practices (an advisory committee established by
the Secretary, acting through the Director of the Centers
for Disease Control and Prevention) and their administra-
tion; and
(C) any medical or remedial services (provided in a facil-
ity, 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
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mental diseases;
(15) services in an intermediate care facility for the mentally
retarded (other than in an institution for mental diseases) for
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individuals who are determined, in accordance with section
1902(a)(31), to be in need of such care;
(16) (A) effective January 1, 1973, inpatient psychiatric hos-
pital services for individuals under age 21, as defined in sub-
section (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 sub-
paragraph;
(17) services furnished by a nurse-midwife (as defined in sec-
tion 1861(gg)) which the nurse-midwife is legally authorized to
perform under State law (or the State regulatory mechanism
provided by State law), whether or not the nurse-midwife is
under the supervision of, or associated with, a physician or
other health care provider, and without regard to whether or
not the services are performed in the area of management of
the care of mothers and babies throughout the maternity cycle;
(18) hospice care (as defined in subsection (o));
(19) case management services (as defined in section
1915(g)(2)) and TB-related services described in section
1902(z)(2)(F);
(20) respiratory care services (as defined in section
1902(e)(9)(C));
(21) services furnished by a certified pediatric nurse practi-
tioner 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 per-
form under State law (or the State regulatory mechanism pro-
vided 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 section 1929) for functionally disabled elderly indi-
viduals;
(23) community supported living arrangements services (to
the extent allowed and as defined in section 1930);
(24) personal care services furnished to an individual who is
not an inpatient or resident of a hospital, nursing facility, in-
termediate care facility for the mentally retarded, or institu-
tion for mental disease that are (A) authorized for the indi-
vidual by a physician in accordance with a plan of treatment
or (at the option of the State) otherwise authorized for the indi-
vidual 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));
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(26) services furnished under a PACE program under section
1934 to PACE program eligible individuals enrolled under the
program under such section;
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95
(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 sub-
section (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), for
the period beginning October 1, 2020, and ending September
30, 2025, medication-assisted treatment (as defined in para-
graph (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); and
(31) 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 ø(except
as a patient in a medical institution)¿ (except in the case of eli-
gible juveniles described in section 1902(a)(84)(D), individuals
as a patient in a medical institution, or, at the option of the
State, for an individual who is a juvenile, while such indi-
vidual is an inmate of a public institution pending disposition
of charges); or
(B) any such payments with respect to care or services for
any individual who has not attained 65 years of age and who
is a patient in an institution for mental diseases (except in the
case of services provided under a State plan amendment de-
scribed in section 1915(l)).
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 per-
son are taken into account in determining the amount of aid or as-
sistance furnished to such individual (under a State plan approved
under title 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 in-
clude expenditures for medicare cost-sharing and for premiums
under part B of title XVIII for individuals who are eligible for med-
ical assistance under the plan and (A) are receiving aid or assist-
ance under any plan of the State approved under title I, X, XIV,
or XVI, or part A of title IV, or with respect to whom supplemental
security income benefits are being paid under title XVI, or (B) with
respect to whom there is being paid a State supplementary pay-
ment and are eligible for medical assistance equal in amount, dura-
tion, and scope to the medical assistance made available to individ-
uals described in section 1902(a)(10)(A), and, except in the case of
individuals 65 years of age or older and disabled individuals enti-
tled to health insurance benefits under title XVIII who are not en-
rolled under part B of title XVIII, other insurance premiums for
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medical or any other type of remedial care or the cost thereof. No
service (including counseling) shall be excluded from the definition
of ‘‘medical assistance’’ solely because it is provided as a treatment
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96
service for alcoholism or drug dependency. In the case of a woman
who is eligible for medical assistance on the basis of being preg-
nant (including through the end of the month in which the 60-day
period beginning on the last day of her pregnancy ends), who is a
patient in an institution for mental diseases for purposes of receiv-
ing treatment for a substance use disorder, and who was enrolled
for medical assistance under the State plan immediately before be-
coming a patient in an institution for mental diseases or who be-
comes eligible to enroll for such medical assistance while such a pa-
tient, the exclusion from the definition of ‘‘medical assistance’’ set
forth in the subdivision (B) following paragraph (30) of the first
sentence of this subsection shall not be construed as prohibiting
Federal financial participation for medical assistance for items or
services that are provided to the woman outside of the institution.
(b) Subject to subsections (y), (z), (aa), (ff), (hh), and (ii) and sec-
tion 1933(d), the term ‘‘Federal medical assistance percentage’’ for
any State shall be 100 per centum less the State percentage; and
the State percentage shall be that percentage which bears the
same ratio to 45 per centum as the square of the per capita income
of such State bears to the square of the per capita income of the
continental United States (including Alaska) and Hawaii; except
that (1) the Federal medical assistance percentage shall in no case
be less than 50 per centum or more than 83 per centum, (2) the
Federal medical assistance percentage for Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, and American
Samoa shall be 55 percent, (3) for purposes of this title and title
XXI, the Federal medical assistance percentage for the District of
Columbia shall be 70 percent, (4) the Federal medical assistance
percentage shall be equal to the enhanced FMAP described in sec-
tion 2105(b) with respect to medical assistance provided to individ-
uals who are eligible for such assistance only on the basis of section
1902(a)(10)(A)(ii)(XVIII), and (5) in the case of a State that pro-
vides medical assistance for services and vaccines described in sub-
paragraphs (A) and (B) of subsection (a)(13), and prohibits cost-
sharing for such services and vaccines, the Federal medical assist-
ance percentage, as determined under this subsection and sub-
section (y) (without regard to paragraph (1)(C) of such subsection),
shall be increased by 1 percentage point with respect to medical as-
sistance for such services and vaccines and for items and services
described in subsection (a)(4)(D). The Federal medical assistance
percentage for any State shall be determined and promulgated in
accordance with the provisions of section 1101(a)(8)(B). Notwith-
standing the first sentence of this section, the Federal medical as-
sistance percentage shall be 100 per centum with respect to
amounts expended as medical assistance for services which are re-
ceived through an Indian Health Service facility whether operated
by the Indian Health Service or by an Indian tribe or tribal organi-
zation (as defined in section 4 of the Indian Health Care Improve-
ment Act); for the 8 fiscal year quarters beginning with the first
fiscal year quarter beginning after the date of the enactment of the
American Rescue Plan Act of 2021, the Federal medical assistance
percentage shall also be 100 per centum with respect to amounts
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expended as medical assistance for services which are received
through an Urban Indian organization (as defined in paragraph
(29) of section 4 of the Indian Health Care Improvement Act) that
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97
has a grant or contract with the Indian Health Service under title
V of such Act; and, for such 8 fiscal year quarters, the Federal
medical assistance percentage shall also be 100 per centum with
respect to amounts expended as medical assistance for services
which are received through a Native Hawaiian Health Center (as
defined in section 12(4) of the Native Hawaiian Health Care Im-
provement Act) or a qualified entity (as defined in section 6(b) of
such Act) that has a grant or contract with the Papa Ola Lokahi
under section 8 of such Act. Notwithstanding the first sentence of
this subsection, in the case of a State plan that meets the condition
described in subsection (u)(1), with respect to expenditures (other
than expenditures under section 1923) described in subsection
(u)(2)(A) or subsection (u)(3) for the State for a fiscal year, and that
do not exceed the amount of the State’s available allotment under
section 2104, the Federal medical assistance percentage is equal to
the enhanced FMAP described in section 2105(b). Notwithstanding
the first sentence of this subsection, the Federal medical assistance
percentage shall be 100 per centum with respect to (and, notwith-
standing any other provision of this title, available for) medical as-
sistance provided to uninsured individuals (as defined in section
1902(ss)) who are eligible for such assistance only on the basis of
section 1902(a)(10)(A)(ii)(XXIII) and with respect to expenditures
described in section 1903(a)(7) that a State demonstrates to the
satisfaction of the Secretary are attributable to administrative
costs related to providing for such medical assistance to such indi-
viduals under the State plan.
(c) For definition of the term ‘‘nursing facility’’, see section
1919(a).
(d) The term ‘‘intermediate care facility for the mentally re-
tarded’’ means an institution (or distinct part thereof) for the men-
tally 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 men-
tally 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
title 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 fur-
nished to patients in such institution (or distinct part thereof)
in the State will not, because of payments made under this
title, 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 institu-
tion is located elected to make such services available under its
plan approved under this title.
(e) In the case of any State the State plan of which (as approved
under this title)—
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(1) does not provide for the payment of services (other than
services covered under section 1902(a)(12)) provided by an op-
tometrist; but
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98
(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 author-
ized 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) For purposes of this title, the term ‘‘nursing facility services’’
means services which are or were required to be given an indi-
vidual 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) 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 stand-
ards promulgated by the Secretary under section 1861(r)(5);
and
(2) services which consist of treatment by means of manual
manipulation of the spine which the chiropractor is legally au-
thorized to perform by the State.
(h)(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 de-
fined in section 1861(f) or in another inpatient setting that the
Secretary has specified in regulations;
(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 in-
patient 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 nec-
essary; 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 re-
quires such services, or (II) if earlier, the date such individual
attains age 22;
(2) Such term does not include services provided during any cal-
endar 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
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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
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99
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) 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 per-
sons with mental diseases, including medical attention, nursing
care, and related services.
(j) 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 title 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 title XVI, or would but for his income be payable
under that title.
(k) Increased supplemental security income benefits payable pur-
suant to section 211 of Public Law 93-66 shall not be considered
supplemental security income benefits payable under title XVI.
(l)(1) The terms ‘‘rural health clinic services’’ and ‘‘rural health
clinic’’ have the meanings given such terms in section 1861(aa), ex-
cept that (A) clause (ii) of section 1861(aa)(2) shall not apply to
such terms, and (B) the physician arrangement required under sec-
tion 1861(aa)(2)(B) shall only apply with respect to rural health
clinic services and, with respect to other ambulatory care services,
the physician arrangement required shall be only such as may be
required under the State plan for those services.
(2)(A) The term ‘‘Federally-qualified health center services’’
means services of the type described in subparagraphs (A) through
(C) of section 1861(aa)(1) when furnished to an individual as an pa-
tient of a Federally-qualified health center and, for this purpose,
any reference to a rural health clinic or a physician described in
section 1861(aa)(2)(B) is deemed a reference to a Federally-quali-
fied health center or a physician at the center, respectively.
(B) The term ‘‘Federally-qualified health center’’ means an entity
which—
(i) is receiving a grant under section 330 of the Public Health
Service Act,
(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 section
330 of such Act,
(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 an-
other entity, or
(iv) was treated by the Secretary, for purposes of part B of
title XVIII, as a comprehensive Federally funded health center
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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
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100
Act (Public Law 93-638) or by an urban Indian organization receiv-
ing funds under title V of the Indian Health Care Improvement Act
for the provision of primary health services. In applying clause (ii),
the Secretary may waive any requirement referred to in such
clause for up to 2 years for good cause shown.
(3)(A) The term ‘‘freestanding birth center services’’ means serv-
ices 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 facil-
ity—
(i) that is not a hospital;
(ii) where childbirth is planned to occur away from the preg-
nant 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 admin-
istering prenatal labor and delivery or postpartum care in a free-
standing birth center (as defined in subparagraph (B)), such as
nurse midwives and other providers of services such as birth at-
tendants 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 reg-
istered 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 super-
vision of, or associated with, a physician or other health care pro-
vider. Nothing in this subparagraph shall be construed as changing
State law requirements applicable to a birth attendant.
(m)(1) Subject to paragraph (2), the term ‘‘qualified family mem-
ber’’ 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
title IV pursuant to section 407 if the State had not exercised the
option under section 407(b)(2)(B)(i).
(2) No individual shall be a qualified family member for any pe-
riod after September 30, 1998.
(n) 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 title IV (or would be eligible for
such aid if coverage under the State plan under part A of
title IV included aid to families with dependent children of
unemployed parents pursuant to section 407) if her child
had been born and was living with her in the month such
aid would be paid, and such pregnancy has been medically
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verified;
(B) is a member of a family which would be eligible for
aid under the State plan under part A of title IV pursuant
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101
to section 407 if the plan required the payment of aid pur-
suant to such section; or
(C) otherwise meets the income and resources require-
ments of a State plan under part A of title 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 re-
quirements of the State plan under part A of title IV.
(o)(1)(A) Subject to subparagraphs (B) and (C), the term ‘‘hospice
care’’ means the care described in section 1861(dd)(1) furnished by
a hospice program (as defined in section 1861(dd)(2)) to a termi-
nally ill individual who has voluntarily elected (in accordance with
paragraph (2)) to have payment made for hospice care instead of
having payment made for certain benefits described in section
1812(d)(2)(A) and for which payment may otherwise be made under
title XVIII and intermediate care facility services under the plan.
For purposes of such election, hospice care may be provided to an
individual while such individual is a resident of a skilled nursing
facility or intermediate care facility, but the only payment made
under the State plan shall be for the hospice care.
(B) For purposes of this title, with respect to the definition of
hospice program under section 1861(dd)(2), the Secretary may
allow an agency or organization to make the assurance under sub-
paragraph (A)(iii) of such section without taking into account any
individual who is afflicted with acquired immune deficiency syn-
drome (AIDS).
(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 title 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 es-
tablished by the State and that are consistent with the proce-
dures established under section 1812(d)(2);
(B) shall be for such a period or periods (which need not be
the same periods described in section 1812(d)(1)) as the State
may establish; and
(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 as-
sistance for services in such facility under the plan,
(B) who is entitled to benefits under part A of title XVIII and
has elected, under section 1812(d), to receive hospice care
under such part, and
(C) with respect to whom the hospice program under such
title and the nursing facility or intermediate care facility for
the mentally retarded have entered into a written agreement
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under which the program takes full responsibility for the pro-
fessional management of the individual’s hospice care and the
facility agrees to provide room and board to the individual,
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102
instead of any payment otherwise made under the plan with re-
spect 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 section 1902(a)(13)(B) and, if the individual
is an individual described in section 1902(a)(10)(A), shall provide
for payment of any coinsurance amounts imposed under section
1813(a)(4).
(p)(1) The term ‘‘qualified medicare beneficiary’’ means an indi-
vidual—
(A) who is entitled to hospital insurance benefits under part
A of title XVIII (including an individual entitled to such bene-
fits pursuant to an enrollment under section 1818, but not in-
cluding an individual entitled to such benefits only pursuant to
an enrollment under section 1818A) or who is enrolled under
part B for the purpose of coverage of immunosuppressive drugs
under section 1836(b),
(B) whose income (as determined under section 1612 for pur-
poses of the supplemental security income program, except as
provided in paragraph (2)(D)) does not exceed an income level
established by the State consistent with paragraph (2), and
(C) whose resources (as determined under section 1613 for
purposes of the supplemental security income program) do not
exceed twice the maximum amount of resources that an indi-
vidual may have and obtain benefits under that program or, ef-
fective beginning with January 1, 2010, whose resources (as so
determined) do not exceed the maximum resource level applied
for the year under subparagraph (D) of section 1860D–14(a)(3)
(determined without regard to the life insurance policy exclu-
sion provided under subparagraph (G) of such section) applica-
ble to an individual or to the individual and the individual’s
spouse (as the case may be).
(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 ac-
cordance with section 673(2) of the Omnibus Budget Reconciliation
Act of 1981) applicable to a family of the size involved.
(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 sec-
tion 1902(f) and which, as of January 1, 1987, used an income
standard for individuals age 65 or older which was more restrictive
than the income standard established under the supplemental se-
curity income program under title XVI, the percent provided under
subparagraph (B), with respect to eligibility for medical assistance
on or after—
(i) January 1, 1989, is 80 percent,
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(ii) January 1, 1990, is 85 percent,
(iii) January 1, 1991, is 95 percent, and
(iv) January 1, 1992, is 100 percent.
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103
(D)(i) In determining under this subsection the income of an indi-
vidual who is entitled to monthly insurance benefits under title II
for a transition month (as defined in clause (ii)) in a year, such in-
come shall not include any amounts attributable to an increase in
the level of monthly insurance benefits payable under such title
which have occurred pursuant to section 215(i) for benefits payable
for months beginning with December of the previous year.
(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 section
1902(n)(2)) the following costs incurred with respect to a qualified
medicare beneficiary, without regard to whether the costs incurred
were for items and services for which medical assistance is other-
wise available under the plan:
(A)(i) premiums under section 1818 or 1818A, and
(ii) premiums under section 1839,
(B) Coinsurance under title XVIII (including coinsurance de-
scribed in section 1813).
(C) Deductibles established under title XVIII (including
those described in section 1813 and section 1833(b)).
(D) The difference between the amount that is paid under
section 1833(a) and the amount that would be paid under such
section if any reference to ‘‘80 percent’’ therein were deemed a
reference to ‘‘100 percent’’.
Such term also may include, at the option of a State, premiums for
enrollment of a qualified medicare beneficiary with an eligible or-
ganization under section 1876.
(4) Notwithstanding any other provision of this title, in the case
of a State (other than the 50 States and the District of Columbia)—
(A) the requirement stated in section 1902(a)(10)(E) shall be
optional, and
(B) for purposes of paragraph (2), the State may substitute
for the percent provided under subparagraph (B) of such para-
graph or 1902(a)(10)(E)(iii) any percent.
In the case of any State which is providing medical assistance to
its residents under a waiver granted under section 1115, the Sec-
retary shall require the State to meet the requirement of section
1902(a)(10)(E) in the same manner as the State would be required
to meet such requirement if the State had in effect a plan approved
under this title.
(5)(A) The Secretary shall develop and distribute to States a sim-
plified application form for use by individuals (including both quali-
fied medicare beneficiaries and specified low-income medicare bene-
ficiaries) in applying for medical assistance for medicare cost-shar-
ing under this title 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 ben-
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efits under section 226 or 226A and shall make the translated
forms available to the States and to the Commissioner of Social Se-
curity.
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104
(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
(6) For provisions relating to outreach efforts to increase aware-
ness of the availability of medicare cost-sharing, see section 1144.
(q) 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 in-
come benefits under section 1611(b) on the basis of blind-
ness or disability, (ii) a supplementary payment under sec-
tion 1616 of this Act or under section 212 of Public Law
93-66 on such basis, (iii) a payment of monthly benefits
under section 1619(a), or (iv) a supplementary payment
under section 1616(c)(3), and
(B) was eligible for medical assistance under the State
plan approved under this title; and
(2) with respect to whom the Commissioner of Social Secu-
rity 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-dis-
ability-related requirements for eligibility for benefits
under title 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 sec-
tion 1611(b) (if he were otherwise eligible for such pay-
ments),
(C) the lack of eligibility for benefits under this title
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 title XVI (including any federally adminis-
tered State supplementary payments), this title, and pub-
licly funded attendant care services (including personal
care assistance) that would be available to him in the ab-
sence of such earnings.
In the case of an individual who is eligible for medical assist-
ance pursuant to section 1619(b) in June, 1987, the individual
shall be a qualified severely impaired individual for so long as
such individual meets the requirements of paragraph (2).
(r) The term ‘‘early and periodic screening, diagnostic, and treat-
ment 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,
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with respect to immunizations under subparagraph
(B)(iii), in accordance with the schedule referred to in
section 1928(c)(2)(B)(i) for pediatric vaccines, and
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105
(ii) at such other intervals, indicated as medically
necessary, to determine the existence of certain phys-
ical or mental illnesses or conditions; and
(B) which shall at a minimum include—
(i) a comprehensive health and developmental his-
tory (including assessment of both physical and men-
tal health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the
schedule referred to in section 1928(c)(2)(B)(i) for pedi-
atric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level as-
sessment appropriate for age and risk factors), and
(v) health education (including anticipatory guid-
ance).
(2) Vision services—
(A) which are provided—
(i) at intervals which meet reasonable standards of
medical practice, as determined by the State after con-
sultation with recognized medical organizations in-
volved 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 con-
sultation with recognized dental organizations in-
volved 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 con-
sultation with recognized medical organizations in-
volved 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 section 1905(a) to
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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.
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106
Nothing in this title 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 par-
ticipation goals for each State for participation of individuals who
are covered under the State plan under this title in early and peri-
odic screening, diagnostic, and treatment services. Not later than
January 1, 2025, and not later than each January 1 thereafter, the
Secretary shall review implementation of the requirements of this
subsection by States, including such requirements relating to serv-
ices provided by a managed care entity, identify and disseminate
best practices for ensuring comprehensive coverage of services, iden-
tify gaps and deficiencies in meeting Federal requirements, and pro-
vide guidance to States on addressing identified gaps and dispari-
ties and meeting Federal coverage requirements in order to ensure
children have access to behavioral health services.
(s) The term ‘‘qualified disabled and working individual’’ means
an individual—
(1) who is entitled to enroll for hospital insurance benefits
under part A of title XVIII under section 1818A (as added by
6012 of the Omnibus Budget Reconciliation Act of 1989);
(2) whose income (as determined under section 1612 for pur-
poses of the supplemental security income program) does not
exceed 200 percent of the official poverty line (as defined by
the Office of Management and Budget and revised annually in
accordance with section 673(2) of the Omnibus Budget Rec-
onciliation Act of 1981) applicable to a family of the size in-
volved;
(3) whose resources (as determined under section 1613 for
purposes of the supplemental security income program) do not
exceed twice the maximum amount of resources that an indi-
vidual or a couple (in the case of an individual with a spouse)
may have and obtain benefits for supplemental security income
benefits under title XVI; and
(4) who is not otherwise eligible for medical assistance under
this title.
(t)(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 fol-
lowing 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 em-
ploying or having other arrangements with physicians to pro-
vide such services.
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(B) At State option—
(i) a nurse practitioner (as described in section
1905(a)(21));
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107
(ii) a certified nurse-midwife (as defined in section
1861(gg)); or
(iii) a physician assistant (as defined in section
1861(aa)(5)).
(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 afford-
able modes of transportation;
(C) provides for arrangements with, or referrals to, sufficient
numbers of physicians and other appropriate health care pro-
fessionals 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 med-
ical assistance under this title;
(E) provides for a right for an enrollee to terminate enroll-
ment in accordance with section 1932(a)(4); and
(F) complies with the other applicable provisions of section
1932.
(4) For purposes of this subsection, the term ‘‘primary care’’ in-
cludes 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 physi-
cian, obstetrician/gynecologist, or pediatrician.
(u)(1) The conditions described in this paragraph for a State plan
are as follows:
(A) The State is complying with the requirement of section
2105(d)(1).
(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
section 2110(b)(1) (determined without regard to that portion of
subparagraph (C) of such section concerning eligibility for medical
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assistance under this title) who would not qualify for medical as-
sistance under the State plan under this title as in effect on March
31, 1997 (but taking into account the expansion of age of eligibility
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108
effected through the operation of section 1902(l)(1)(D)). Such term
excludes any child eligible for medical assistance only by reason of
section 1902(a)(10)(A)(ii)(XIX).
(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 section 1902(l)(1)(D) if they had been born on or after such date,
and who are not eligible for such assistance under the State plan
under this title based on such State plan as in effect as of March
31, 1997.
(4) The limitations on payment under subsections (f) and (g) of
section 1108 shall not apply to Federal payments made under sec-
tion 1903(a)(1) based on an enhanced FMAP described in section
2105(b).
(v)(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 section
1902(a)(10)(A)(ii)(XV) because the individual, by reason of med-
ical improvement, is determined at the time of a regularly
scheduled continuing disability review to no longer be eligible
for benefits under section 223(d) or 1614(a)(3); and
(D) continues to have a severe medically determinable im-
pairment, 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 require-
ment under section 6 of the Fair Labor Standards Act (29
U.S.C. 206) and working at least 40 hours per month; or
(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 Sec-
retary.’
(w)(1) For purposes of this title, 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 para-
graph (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 section 1931(b).
(3) A State may limit the eligibility of independent foster care
adolescents under section 1902(a)(10)(A)(ii)(XVII) to those individ-
uals with respect to whom foster care maintenance payments or
independent living services were furnished under a program fund-
ed under part E of title IV before the date the individuals attained
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18 years of age.
(x) For purposes of subsection (a)(27), the strategies, treatment,
and services described in that subsection include the following:
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109
(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 profes-
sionals 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 hav-
ing another stroke.
(y) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR NEWLY ELI-
GIBLE 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 sec-
tion 1902(a)(10)(A)(i), shall be equal to—
(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 section 1902(a)(10)(A)(i), an individual who is not under
19 years of age (or such higher age as the State may have
elected) and who, as of December 1, 2009, is not eligible
under the State plan or under a waiver of the plan for full
benefits or for benchmark coverage described in subpara-
graph (A), (B), or (C) of section 1937(b)(1) or benchmark
equivalent coverage described in section 1937(b)(2) that
has an aggregate actuarial value that is at least actuari-
ally equivalent to benchmark coverage described in sub-
paragraph (A), (B), or (C) of section 1937(b)(1), or is eligi-
ble but not enrolled (or is on a waiting list) for such bene-
fits or coverage through a waiver under the plan that has
a capped or limited enrollment that is full.
(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 title 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
section 1902(a)(10)(A)(i).
(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 deter-
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mined under subsection (b) with respect to a fiscal year occur-
ring during that period shall be increased by 2.2 percentage
points for any State described in subparagraph (B) for amounts
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110
expended for medical assistance for individuals who are not
newly eligible (as defined in subsection (y)(2)) individuals de-
scribed in subclause (VIII) of section 1902(a)(10)(A)(i).
(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 pay-
ments under this title on the basis of an increased Federal
medical assistance percentage under subsection (y) for ex-
penditures for medical assistance for newly eligible indi-
viduals (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 cov-
erage under a waiver that is in effect on July 2009.
(2)(A) For calendar quarters in 2014 and each year there-
after, the Federal medical assistance percentage otherwise de-
termined under subsection (b) for an expansion State described
in paragraph (3) with respect to medical assistance for individ-
uals described in section 1902(a)(10)(A)(i)(VIII) who are non-
pregnant childless adults with respect to whom the State may
require enrollment in benchmark coverage under section 1937
shall be equal to the percent specified in subparagraph (B)(i)
for such year.
(B)(i) The percent specified in this subparagraph for a State
for a year is equal to the Federal medical assistance percent-
age (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 the date of the enact-
ment of the Patient Protection and Affordable Care Act, the
State offers health benefits coverage statewide to parents and
nonpregnant, childless adults whose income is at least 100 per-
cent of the poverty line, that includes inpatient hospital serv-
ices, is not dependent on access to employer coverage, employer
contribution, or employment and is not limited to premium as-
sistance, hospital-only benefits, a high deductible health plan,
or alternative benefits under a demonstration program author-
ized under section 1938. A State that offers health benefits cov-
erage to only parents or only nonpregnant childless adults de-
scribed in the preceding sentence shall not be considered to be
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an expansion State.
(aa)(1) Notwithstanding subsection (b), beginning January 1,
2011, the Federal medical assistance percentage for a fiscal year
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111
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 reg-
ular 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 percent-
age determined for the State for the preceding fiscal year after
the application of only subsection (a) of section 5001 of Public
Law 111–5 (if applicable to the preceding fiscal year) and with-
out regard to this subsection, subsections (y) and (z), and sub-
sections (b) and (c) of section 5001 of Public Law 111–5.
(B) In the case of the second or any succeeding fiscal year
for which this subsection applies to the State, the State’s reg-
ular FMAP for such fiscal year shall be increased by 25 per-
cent (or 50 percent in the case of fiscal year 2013) of the num-
ber 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 adjust-
ment State’’ means a State that is one of the 50 States or the Dis-
trict of Columbia, for which, at any time during the preceding 7 fis-
cal years, the President has declared a major disaster under section
401 of the Robert T. Stafford Disaster Relief and Emergency Assist-
ance Act and determined as a result of such disaster that every
county or parish in the State warrant individual and public assist-
ance or public assistance from the Federal Government under such
Act and for which—
(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 reg-
ular FMAP for the fiscal year is less than the Federal medical
assistance percentage determined for the State for the pre-
ceding fiscal year after the application of only subsection (a) of
section 5001 of Public Law 111–5 (if applicable to the pre-
ceding fiscal year) and without regard to this subsection, sub-
sections (y) and (z), and subsections (b) and (c) of section 5001
of Public Law 111–5, by at least 3 percentage points; and
(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 as-
sistance 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 sec-
tion 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)
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shall apply for purposes of this title (other than with respect to dis-
proportionate share hospital payments described in section 1923
and payments under this title that are based on the enhanced
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112
FMAP described in 2105(b)) and shall not apply with respect to
payments under title IV (other than under part E of title IV) or
payments under title XXI.
(bb)(1) For purposes of this title, 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 non-
prescription 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 to-
bacco 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 title 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 ef-
fective 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 title.
(cc) REQUIREMENT FOR CERTAIN STATES.—Notwithstanding sub-
sections (y), (z), and (aa), in the case of a State that requires polit-
ical subdivisions within the State to contribute toward the non-
Federal share of expenditures required under the State plan under
section 1902(a)(2), the State shall not be eligible for an increase in
its Federal medical assistance percentage under such subsections if
it requires that political subdivisions pay a greater percentage of
the non-Federal share of such expenditures, or a greater percent-
age of the non-Federal share of payments under section 1923, than
the respective percentages that would have been required by the
State under the State plan under this title, State law, or both, as
in effect on December 31, 2009, and without regard to any such in-
crease. Voluntary contributions by a political subdivision to the
non-Federal share of expenditures under the State plan under this
title or to the non-Federal share of payments under section 1923,
shall not be considered to be required contributions for purposes of
this subsection. The treatment of voluntary contributions, and the
treatment of contributions required by a State under the State plan
under this title, or State law, as provided by this subsection, shall
also apply to the increases in the Federal medical assistance per-
centage under section 5001 of the American Recovery and Reinvest-
ment Act of 2009 and section 6008 of the Families First
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Coronavirus Response Act, except that in applying such treatments
to the increases in the Federal medical assistance percentage under
section 6008 of the Families First Coronavirus Response Act, the
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113
reference to ‘‘December 31, 2009’’ shall be deemed to be a reference
to ‘‘March 11, 2020’’.
(dd) INCREASED FMAP FOR ADDITIONAL EXPENDITURES FOR PRI-
MARY CARE SERVICES.—Notwithstanding subsection (b), with re-
spect to the portion of the amounts expended for medical assistance
for services described in section 1902(a)(13)(C) furnished on or after
January 1, 2013, and before January 1, 2015, that is attributable
to the amount by which the minimum payment rate required under
such section (or, by application, section 1932(f)) exceeds the pay-
ment rate applicable to such services under the State plan as of
July 1, 2009, the Federal medical assistance percentage for a State
that is one of the 50 States or the District of Columbia shall be
equal to 100 percent. The preceding sentence does not prohibit the
payment of Federal financial participation based on the Federal
medical assistance percentage for amounts in excess of those speci-
fied in such sentence.
(ee) MEDICATION-ASSISTED TREATMENT.—
(1) DEFINITION.—For purposes of subsection (a)(29), the term
‘‘medication-assisted treatment’’—
(A) means all drugs approved under section 505 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), in-
cluding methadone, and all biological products licensed
under section 351 of the Public Health Service Act (42
U.S.C. 262) to treat opioid use disorders; and
(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 sub-
section (a) shall not apply with respect to a State for the period
specified in such paragraph, if before the beginning of such pe-
riod the State certifies to the satisfaction of the Secretary that
implementing such provisions statewide for all individuals eli-
gible to enroll in the State plan (or waiver of the State plan)
would not be feasible by reason of a shortage of qualified pro-
viders 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 section
1903(m) or under section 1905(t)(3).
(3) APPLICATION OF REBATE REQUIREMENTS.—The require-
ments of section 1927 shall apply to any drug or biological
product described in paragraph (1)(A) that is—
(A) furnished as medical assistance in accordance with
subsection (a)(29) and section 1902(a)(10)(A); and
(B) a covered outpatient drug (as defined in section
1927(k), except that, in applying paragraph (2)(A) of such
section to a drug described in paragraph (1)(A), such drug
shall be deemed a prescribed drug for purposes of sub-
section (a)(12)).
(ff) TEMPORARY INCREASE IN FMAP FOR TERRITORIES FOR CER-
TAIN FISCAL YEARS.—Notwithstanding subsection (b) or (z)(2), sub-
ject to subsections (hh) and (ii)—
(1) for the period beginning October 1, 2019, and ending De-
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cember 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;
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114
(2) subject to section 1108(g)(7)(C), for the period beginning
December 21, 2019, and ending December 3, 2021, and for the
period beginning January 1, 2022, and ending December 13,
2022 the Federal medical assistance percentage for Puerto Rico
shall be equal to 76 percent; and
(3) subject to section 1108(g)(8)(B), for the period beginning
December 21, 2019, and ending December 13, 2022, the Fed-
eral medical assistance percentage for the Virgin Islands,
Guam, the Northern Mariana Islands, and American Samoa
shall be equal to 83 percent.
(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 partici-
pation, to the extent that the provision of such an item or
service to the individual outside the course of such partici-
pation 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 investiga-
tional 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 sub-
section (a)(30), the term ‘‘qualifying clinical trial’’ means a clin-
ical trial (in any clinical phase of development) that is con-
ducted in relation to the prevention, detection, or treatment of
any serious or life-threatening disease or condition and is de-
scribed 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.
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(III) The Agency for Healthcare Research and Qual-
ity.
(IV) The Centers for Medicare & Medicaid Services.
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115
(V) A cooperative group or center of any of the enti-
ties described in subclauses (I) through (IV) or the De-
partment of Defense or the Department of Veterans
Affairs.
(VI) A qualified non-governmental research entity
identified in the guidelines issued by the National In-
stitutes 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 inves-
tigational new drug exemption under section 505(i) of the
Federal Food, Drug, and Cosmetic Act or an exemption for
a biological product undergoing investigation under section
351(a)(3) of the Public Health Service Act.
(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 stud-
ies 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 loca-
tion 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 appropriate-
ness 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 devel-
oped for State use by the Secretary and that includes the op-
tion 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 quali-
fying clinical trial, or any other documentation that may be
proprietary or determined by the Secretary to be burdensome
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to provide.
(hh) TEMPORARY INCREASED FMAP FOR MEDICAL ASSISTANCE
FOR COVERAGE AND ADMINISTRATION OF COVID–19 VACCINES.—
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116
(1) IN GENERAL.—Notwithstanding any other provision of
this title, 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 administra-
tion of such a vaccine), shall be equal to 100 percent.
(2) PERIOD DESCRIBED.—The period described in this para-
graph is the period that—
(A) begins on the first day of the first quarter beginning
after the date of the enactment of this subsection; and
(B) ends on the last day of the first quarter that begins
one year after the last day of the emergency period de-
scribed in section 1135(g)(1)(B).
(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 para-
graph (1) shall not be taken into account for purposes of apply-
ing payment limits under subsections (f) and (g) of section
1108.
(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 section
1902(a)(10)(A)(i)(VIII) under the State plan (or waiver of such
plan), the Federal medical assistance percentage determined
under subsection (b) for such State shall, after application of
any increase, if applicable, under section 6008 of the Families
First Coronavirus Response Act, be increased by 5 percentage
points, except for any quarter (and each subsequent quarter)
during such period during which the State ceases to provide
medical assistance to any such individual under the State plan
(or waiver of such plan).
(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 section 1923;
(B) shall not be taken into account in calculating the en-
hanced FMAP of a State under section 2105;
(C) shall not be taken into account for purposes of part
A, D, or E of title IV; and
(D) shall not be taken into account for purposes of apply-
ing payment limits under subsections (f) and (g) of section
1108.
(3) DEFINITION.—For purposes of this subsection, the term
‘‘qualifying State’’ means a State which has not expended
amounts for all individuals described in section
1902(a)(10)(A)(i)(VIII) before the date of the enactment of this
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subsection.
* * * * * * *
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117
TITLE XXI—STATE CHILDREN’S HEALTH INSURANCE
PROGRAM
* * * * * * *
SEC. 2107. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN
ADMINISTRATION.
(a) STRATEGIC OBJECTIVES AND PERFORMANCE GOALS.—
(1) DESCRIPTION.—A State child health plan shall include a
description of—
(A) the strategic objectives,
(B) the performance goals, and
(C) the performance measures,
the State has established for providing child health assistance
to targeted low-income children under the plan and otherwise
for maximizing health benefits coverage for other low-income
children and children generally in the State.
(2) STRATEGIC OBJECTIVES.—Such plan shall identify specific
strategic objectives relating to increasing the extent of cred-
itable health coverage among targeted low-income children and
other low-income children.
(3) PERFORMANCE GOALS.—Such plan shall specify one or
more performance goals for each such strategic objective so
identified.
(4) PERFORMANCE MEASURES.—Such plan shall describe how
performance under the plan will be—
(A) measured through objective, independently verifiable
means, and
(B) compared against performance goals, in order to de-
termine the State’s performance under this title.
(b) RECORDS, REPORTS, AUDITS, AND EVALUATION.—
(1) DATA COLLECTION, RECORDS, AND REPORTS.—A State child
health plan shall include an assurance that the State will col-
lect the data, maintain the records, and furnish the reports to
the Secretary, at the times and in the standardized format the
Secretary may require in order to enable the Secretary to mon-
itor State program administration and compliance and to
evaluate and compare the effectiveness of State plans under
this title.
(2) STATE ASSESSMENT AND STUDY.—A State child health
plan shall include a description of the State’s plan for the an-
nual assessments and reports under section 2108(a) and the
evaluation required by section 2108(b).
(3) AUDITS.—A State child health plan shall include an as-
surance that the State will afford the Secretary access to any
records or information relating to the plan for the purposes of
review or audit.
(c) PROGRAM DEVELOPMENT PROCESS.—A State child health plan
shall include a description of the process used to involve the public
in the design and implementation of the plan and the method for
ensuring ongoing public involvement.
(d) PROGRAM BUDGET.—A State child health plan shall include a
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description of the budget for the plan. The description shall be up-
dated periodically as necessary and shall include details on the
planned use of funds and the sources of the non-Federal share of
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118
plan expenditures, including any requirements for cost-sharing by
beneficiaries.
(e) APPLICATION OF CERTAIN GENERAL PROVISIONS.—The fol-
lowing sections of this Act shall apply to States under this title in
the same manner as they apply to a State under title XIX:
(1) TITLE XIX PROVISIONS.—
(A) Section 1902(a)(4)(C) (relating to conflict of interest
standards).
(B) Section 1902(a)(25) (relating to third party liability).
(C) Section 1902(a)(39) (relating to termination of par-
ticipation of certain providers).
(D) Section 1902(a)(78) (relating to enrollment of pro-
viders participating in State plans providing medical as-
sistance on a fee-for-service basis).
(E) Section 1902(a)(72) (relating to limiting FQHC con-
tracting for provision of dental services).
(F) Section 1902(a)(73) (relating to requiring certain
States to seek advice from designees of Indian Health Pro-
grams and Urban Indian Organizations).
(G) Subsections (a)(77) and (kk) of section 1902 (relating
to provider and supplier screening, oversight, and report-
ing requirements).
(H) Section 1902(e)(13) (relating to the State option to
rely on findings from an Express Lane agency to help
evaluate a child’s eligibility for medical assistance).
(I) Section 1902(e)(14) (relating to income determined
using modified adjusted gross income and household in-
come).
(J) Paragraphs (5) and (16) of section 1902(e) (relating to
the State option to provide medical assistance consisting of
full benefits during pregnancy and throughout the 12-
month postpartum period under title XIX), if the State pro-
vides child health assistance for targeted low-income chil-
dren who are pregnant or to targeted low-income pregnant
women and the State has elected to apply such paragraph
(16) with respect to pregnant women under title XIX, the
provision of assistance under the State child health plan
or waiver for targeted low-income children or targeted low-
income pregnant women during pregnancy and the 12-
month postpartum period shall be required and not at the
option of the State and shall include coverage of all items
or services provided to a targeted low-income child or tar-
geted low-income pregnant woman (as applicable) under
the State child health plan or waiver).
(K) Section 1902(bb) (relating to payment for services
provided by Federally-qualified health centers and rural
health clinics).
(L) Section 1902(ff) (relating to disregard of certain prop-
erty for purposes of making eligibility determinations).
(M) Paragraphs (2), (16), and (17) of section 1903(i) (re-
lating to limitations on payment).
(N) Section 1903(m)(3) (relating to limitation on pay-
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ment with respect to managed care).
(O) Paragraph (4) of section 1903(v) (relating to optional
coverage of categories of lawfully residing immigrant chil-
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119
dren or pregnant women), but only if the State has elected
to apply such paragraph with respect to such category of
children or pregnant women under title XIX.
(P) Section 1903(w) (relating to limitations on provider
taxes and donations).
(Q) Section 1920A (relating to presumptive eligibility for
children).
(R) Subsections (a)(2)(C) (relating to Indian enrollment),
(d)(5) (relating to contract requirement for managed care
entities), (d)(6) (relating to enrollment of providers partici-
pating with a managed care entity), and (h) (relating to
special rules with respect to Indian enrollees, Indian
health care providers, and Indian managed care entities)
of section 1932.
(S) Section 1942 (relating to authorization to receive
data directly relevant to eligibility determinations).
(T) Section 1943(b) (relating to coordination with State
Exchanges and the State Medicaid agency).
(U) Section 1902(a)(84)(D) (relating to eligible juveniles
scheduled to be released from placement in a public institu-
tion following adjudication).
(2) TITLE XI PROVISIONS.—
(A) Section 1115 (relating to waiver authority).
(B) Section 1116 (relating to administrative and judicial
review), but only insofar as consistent with this title.
(C) Section 1124 (relating to disclosure of ownership and
related information).
(D) Section 1126 (relating to disclosure of information
about certain convicted individuals).
(E) Section 1128A (relating to civil monetary penalties).
(F) Section 1128B(d) (relating to criminal penalties for
certain additional charges).
(G) Section 1132 (relating to periods within which claims
must be filed).
(f) LIMITATION OF WAIVER AUTHORITY.—Notwithstanding sub-
section (e)(2)(A) and section 1115(a)(1):
(1) The Secretary may not approve a waiver, experimental,
pilot, or demonstration project that would allow funds made
available under this title to be used to provide child health as-
sistance or other health benefits coverage to a nonpregnant
childless adult or a parent (as defined in section 2111(c)(2)(A)),
who is not pregnant, of a targeted low-income child.
(2) The Secretary may not approve, extend, renew, or amend
a waiver, experimental, pilot, or demonstration project with re-
spect to a State after the date of enactment of the Children’s
Health Insurance Program Reauthorization Act of 2009 that
would waive or modify the requirements of section 2111.
(g) USE OF BLENDED RISK POOLS.—
(1) IN GENERAL.—Nothing in this title (or any other provision
of Federal law) shall be construed as preventing a State from
considering children enrolled in a qualified CHIP look-alike
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program and children enrolled in a State child health plan
under this title (or a waiver of such plan) as members of a sin-
gle risk pool.
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120
(2) QUALIFIED CHIP LOOK-ALIKE PROGRAM.—In this sub-
section, the term ‘‘qualified CHIP look-alike program’’ means a
State program—
(A) under which children who are under the age of 19
and are not eligible to receive medical assistance under
title XIX or child health assistance under this title may
purchase coverage through the State that provides benefits
that are at least identical to the benefits provided under
the State child health plan under this title (or a waiver of
such plan); and
(B) that is funded exclusively through non-Federal
funds, including funds received by the State in the form of
premiums for the purchase of such coverage.
* * * * * * *
Æ
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