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116th Congress    }                                  {   Rept. 116-381
                        HOUSE OF REPRESENTATIVES
 2d Session       }                                  {          Part 1

======================================================================



 
                 HELPING SENIORS AFFORD HEALTH CARE ACT

                                _______
                                

January 24, 2020.--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

                             together with

                             MINORITY VIEWS

                        [To accompany H.R. 4671]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 4671) to amend titles XVIII and XIX of the 
Social Security Act to reduce cost-sharing, align income and 
resource eligibility tests, simplify enrollment, and provide 
for other program improvements for low-income Medicare 
beneficiaries, having considered the same, report favorably 
thereon without amendment and recommend that the bill do pass.

                                CONTENTS

                                                                   Page
   I. Purpose and Summary.............................................2
  II. Background and Need for Legislation.............................2
 III. Committee Hearings..............................................3
  IV. Committee Consideration.........................................3
   V. Committee Votes.................................................4
  VI. Oversight Findings..............................................4
 VII. New Budget Authority, Entitlement Authority, and Tax Expenditure4
VIII. Federal Mandates Statement......................................4
  IX. Statement of General Performance Goals and Objectives...........4
   X. Duplication of Federal Programs.................................4
  XI. Committee Cost Estimate.........................................5
 XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits.....5
XIII. Advisory Committee Statement....................................5
 XIV. Applicability to Legislative Branch.............................5
  XV. Section-by-Section Analysis of the Legislation..................5
 XVI. Changes in Existing Law Made by the Bill, as Reported...........6
XVII. Minority Views................................................139

                         I. Purpose and Summary

    H.R. 4671, the ``Helping Seniors Afford Health Care Act'', 
was introduced on October 15, 2019, by Reps. Kim (D-NJ), Blunt 
Rochester (D-DE), and Evans (D-PA), and referred to the 
Committee on Energy and Commerce.
    The goal of H.R. 4671 is to improve access and 
affordability of underlying health care services by enhancing 
the Medicare Savings Program (MSP). H.R. 4671 increases the 
income eligibility levels to 135 percent of Federal Poverty 
Level (FPL) for the MSP's Qualified Medicare Beneficiary (QMB) 
program, and up to 200 percent of FPL for the Specified Low-
Income Medicare Beneficiary (SLMB) program. H.R. 4671 also 
simplifies MSP enrollment by giving states the option to use 
Express Lane and 12-month continuous eligibility for the MSP 
program. The legislation provides additional funding to states 
for the newly eligible population at a 100 percent Federal 
Medical Assistance Percentage (FMAP) rate and provides $50 
million annually in grants to states to conduct outreach 
regarding Medicare enrollment assistance and benefit 
availability for fiscal years 2021 through 2025. Additionally, 
H.R. 4671 aligns the Low-Income Subsidy (LIS) program and MSP 
eligibility and resource tests by increasing the MSP resource 
standards to the Medicaid spousal impoverishment resource 
allowance standard.

                II. Background and Need for Legislation

    The MSP provides financial assistance for Medicare premiums 
and cost-sharing to eligible low-income adults over age 65 and 
adults with disabilities. The QMB program is the most expansive 
program under MSP, and helps pay for Medicare Part A premiums, 
Part B premiums, coinsurance, deductibles and copayments for 
individuals at or below 100 percent of the FPL. The Specified 
Low-Income Medicare Beneficiary (SLMB) program provides 
financial assistance with Part B premiums for individuals with 
incomes of at least 100 percent but less than 120 percent of 
the FPL. The Qualifying Individual (QI) program provides 
assistance with Part B premiums for individuals with incomes 
between 120 and 135 percent of the FPL. State Medicaid programs 
pay the full amount for the Medicare premium under MSP, and 
receive federal matching funds at the regular Medicaid match 
rate for those expenditures for the QMB and SLMB programs. For 
the QI program, states receive a federal allotment that is set 
at a specific amount each year. States receive 100 percent 
federal match up to the amount of the allotment.
    Participation in MSP has been low, and studies have shown 
that many eligible beneficiaries are not enrolling in the 
program.\1\ One study found that only 53 percent of eligible 
individuals had enrolled in the QMB program, and only 32 
percent of eligible individuals in the SLMB program.\2\ The 
same study found that 85 percent of individuals who qualify for 
the QI program were not receiving financial assistance with 
their Medicare premiums. Burdensome enrollment processes and 
lack of program awareness have been barriers contributing to 
low participation.
---------------------------------------------------------------------------
    \1\Medicaid and CHIP Payment Access Commission, Medicare Savings 
Programs: New Estimates Continue to Show Many Eligible Individuals Not 
Enrolled (Aug. 2017) (www.macpac.gov/wp-content/uploads/2017/08/
Medicare-Savings-Programs-New-Estimates-Continue-to-Show-Many-Eligible-
Individuals-Not-Enrolled.pdf).
    \2\Id.
---------------------------------------------------------------------------
    Low-income beneficiaries who receive financial assistance 
under MSP have experienced increased access to health care 
services.\3\ Out-of-pocket costs place significant financial 
burden on low-income elderly beneficiaries.\4\ For instance, 
one study found that MSP enrollees are less likely to delay 
seeking medical care because of costs.\5\ Extending eligibility 
to more low-income individuals, and thereby improving 
availability of these programs, will improve access to care and 
help lower out-of-pocket costs.
---------------------------------------------------------------------------
    \3\Center on Budget and Policy Priorities, Improving the Medicare 
Savings Programs Would Help Low-Income Seniors Cope With Higher Medical 
Expenses (May 20, 2009) (www.cbpp.org/research/improving-the-medicare-
savings-programs-would-help-low-income-seniors-cope-with-higher#_ftn6).
    \4\Id.
    \5\Health Affairs, Avoidance of Health Care Services Because of 
Cost: Impact of the Medicare Savings Program (Feb. 2005) 
(www.healthaffairs.org/doi/full/10.1377/hlthaff.24.1.263).
---------------------------------------------------------------------------
    H.R. 4671 increases the number of low-income Americans who 
qualify for financial assistance under the MSP program. H.R. 
4671 increases the income eligibility level to 135 percent of 
FPL for the QMB Program, and up to 200 percent of FPL for the 
SLMB Program beginning plan year 2021. The bill provides 
additional funding to states at a 100 percent FMAP rate for the 
newly eligible population. The legislation simplifies the 
enrollment process for beneficiaries, and eliminates barriers 
to enrollment by refining asset verification standards.

                        III. Committee Hearings

    For the purposes of section 103(i) of H. Res. 6 of the 
116th Congress, the following hearing was used to develop or 
consider H.R. 4671:
    On September 25, 2019, the Subcommittee on Health held a 
legislative hearing entitled ``Making Prescription Drugs More 
Affordable: Legislation to Negotiate a Better Deal for 
Americans.'' The hearing focused on H.R. 3 and other bills to 
improve the Medicare program. The Subcommittee received 
testimony from the following witnesses:
           Robert Fowler, Professor Emeritus, Baldwin 
        Wallace University;
           Gerard Anderson, Professor, Johns Hopkins 
        Bloomberg School of Public Health; and
           Benedic Ippolito, Research Fellow in 
        Economic Policy Studies, American Enterprise Institute.

                      IV. Committee Consideration

    H.R. 4671, the ``Helping Seniors Afford Health Care Act'', 
was introduced on October 15, 2019, by Reps. Kim (D-NJ), Blunt 
Rochester (D-DE), and Evans (D-PA), and referred to the 
Committee on Energy and Commerce, in addition to the Committee 
on Ways and Means. The bill was referred to the Subcommittee on 
Health on October 16, 2019. The legislative hearing was held 
prior to the bill's introduction, and subsequently the 
Subcommittee on Health was discharged from further 
consideration of the bill on October 17, 2019, when it was 
taken up for consideration by the full Committee.
    The full Committee met in open markup session, pursuant to 
notice, on October 17, 2019, to consider H.R. 4671. During 
consideration, no amendments were offered to the bill. 
Whereupon, the Committee on Energy and Commerce agreed to a 
motion by Mr. Pallone, Chairman of the committee, to order H.R. 
4671 reported favorably to the House, without amendment, by a 
voice vote, a quorum being present.

                           V. Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list each record vote 
on the motion to report legislation and amendments thereto. The 
Committee advises that there were no record votes taken on H.R. 
4671.

                         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 findings 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 Representatives, the Committee adopts as its own the 
estimate of new budget authority, entitlement authority, or tax 
expenditures or revenues 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 expenditures.

                    VIII. Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates 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 extend 
Medicare Savings Program (MSP) eligibility to more low-income 
individuals and improve access to health care. The legislation 
increases the income eligibility levels for MSP, simplifies the 
enrollment process for beneficiaries, and eliminates barriers 
to enrollment by refining asset verification standards.

                   X. Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 4671 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 Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974.

    XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits

    Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 4671 contains no earmarks, limited 
tax benefits, or limited tariff benefits.

                   XIII. Advisory Committee Statement

    The legislation does not create any new Federal advisory 
committee within the meaning of section 5(b) of the Federal 
Advisory Committee Act.

                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 Congressional 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 ``Helping Seniors Afford Health Care Act''.

Sec. 2. Federal exchange outreach and educational activities

    Section 2 amends section 1905 of the Social Security Act 
and increases the income eligibility level to 135 percent of 
FPL for the QMB program, and up to 200 percent of FPL for the 
SLMB program beginning plan year 2021. The section repeals the 
QI program. The section provides additional funding to states 
for the newly eligible population at a 100 percent FMAP. The 
section amends section 1902 of the Social Security Act and 
applies three-month retroactive eligibility to the QMB program. 
The section provides states the option to use Express Lane and 
12-month continuous eligibility for the MSP Program. The 
section prohibits any assistance under the MSP program from 
being considered income or resources in determining eligibility 
for any other federal, state, or local public benefit program.
    The section also amends section 1860D-14 of the Social 
Security Act and aligns the LIS program and MSP eligibility and 
resources tests. The section increases the MSP resources 
standards to the Medicaid spousal impoverishment resource 
allowance standards.
    The section provides $50 million annually in grants to 
states to conduct outreach regarding Medicare enrollment 
assistance and benefit availability for fiscal years 2021 
through 2025. The section requires the state allocation to be 
based on the percentage of low-income and rural beneficiaries 
in each state.

       XVI. Changes in Existing Law Made by the Bill, as Reported


         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 omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                          SOCIAL SECURITY ACT




           *       *       *       *       *       *       *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

           *       *       *       *       *       *       *



Part D--Voluntary Prescription Drug Benefit Program

           *       *       *       *       *       *       *



Subpart 2--Prescription Drug Plans; PDP Sponsors; Financing

           *       *       *       *       *       *       *



     premium and cost-sharing subsidies for low-income individuals

  Sec. 1860D-14. (a) Income-Related Subsidies for Individuals 
With Income Up to 150 Percent of Poverty Line.--
          (1) Individuals with income below 135 percent of 
        poverty line.--In the case of a subsidy eligible 
        individual (as defined in paragraph (3)) who is 
        determined to have income that is below 135 percent of 
        the poverty line applicable to a family of the size 
        involved (as determined under paragraph (3)(G)) and who 
        meets the resources requirement described in paragraph 
        (3)(D) or who is covered under this paragraph under 
        paragraph (3)(B)(i), the individual is entitled under 
        this section to the following:
                  (A) Full premium subsidy.--An income-related 
                premium subsidy equal to 100 percent of the 
                amount described in subsection (b)(1), but not 
                to exceed the premium amount specified in 
                subsection (b)(2)(B).
                  (B) Elimination of deductible.--A reduction 
                in the annual deductible applicable under 
                section 1860D-2(b)(1) to $0.
                  (C) Continuation of coverage above the 
                initial coverage limit.--The continuation of 
                coverage from the initial coverage limit (under 
                paragraph (3) of section 1860D-2(b)) for 
                expenditures incurred through the total amount 
                of expenditures at which benefits are available 
                under paragraph (4) of such section, subject to 
                the reduced cost-sharing described in 
                subparagraph (D).
                  (D) Reduction in cost-sharing below out-of-
                pocket threshold.--
                          (i) Institutionalized individuals.--
                        In the case of an individual who is a 
                        full-benefit dual eligible individual 
                        and who is an institutionalized 
                        individual or couple (as defined in 
                        section 1902(q)(1)(B)) or, effective on 
                        a date specified by the Secretary (but 
                        in no case earlier than January 1, 
                        2012), who would be such an 
                        institutionalized individual or couple, 
                        if the full-benefit dual eligible 
                        individual were not receiving services 
                        under a home and community-based waiver 
                        authorized for a State under section 
                        1115 or subsection (c) or (d) of 
                        section 1915 or under a State plan 
                        amendment under subsection (i) of such 
                        section or services provided through 
                        enrollment in a medicaid managed care 
                        organization with a contract under 
                        section 1903(m) or under section 1932, 
                        the elimination of any beneficiary 
                        coinsurance described in section 1860D-
                        2(b)(2) (for all amounts through the 
                        total amount of expenditures at which 
                        benefits are available under section 
                        1860D-2(b)(4)).
                          (ii) Lowest income dual eligible 
                        individuals.--In the case of an 
                        individual not described in clause (i) 
                        who is a full-benefit dual eligible 
                        individual and whose income does not 
                        exceed 100 percent of the poverty line 
                        applicable to a family of the size 
                        involved, the substitution for the 
                        beneficiary coinsurance described in 
                        section 1860D-2(b)(2) (for all amounts 
                        through the total amount of 
                        expenditures at which benefits are 
                        available under section 1860D-2(b)(4)) 
                        of a copayment amount that does not 
                        exceed $1 for a generic drug or a 
                        preferred drug that is a multiple 
                        source drug (as defined in section 
                        1927(k)(7)(A)(i)) and $3 for any other 
                        drug, or, if less, the copayment amount 
                        applicable to an individual under 
                        clause (iii).
                          (iii) Other individuals.--In the case 
                        of an individual not described in 
                        clause (i) or (ii), the substitution 
                        for the beneficiary coinsurance 
                        described in section 1860D-2(b)(2) (for 
                        all amounts through the total amount of 
                        expenditures at which benefits are 
                        available under section 1860D-2(b)(4)) 
                        of a copayment amount that does not 
                        exceed the copayment amount specified 
                        under section 1860D-2(b)(4)(A)(i)(I) 
                        for the drug and year involved.
                  (E) Elimination of cost-sharing above annual 
                out-of-pocket threshold.--The elimination of 
                any cost-sharing imposed under section 1860D-
                2(b)(4)(A).
          (2) Other individuals with income below 150 percent 
        of poverty line.--In the case of a subsidy eligible 
        individual who is not described in paragraph (1), the 
        individual is entitled under this section to the 
        following:
                  (A) Sliding scale premium subsidy.--An 
                income-related premium subsidy determined on a 
                linear sliding scale ranging from 100 percent 
                of the amount described in paragraph (1)(A) for 
                individuals with incomes at or below 135 
                percent of such level to 0 percent of such 
                amount for individuals with incomes at 150 
                percent of such level.
                  (B) Reduction of deductible.--A reduction in 
                the annual deductible applicable under section 
                1860D-2(b)(1) to $50.
                  (C) Continuation of coverage above the 
                initial coverage limit.--The continuation of 
                coverage from the initial coverage limit (under 
                paragraph (3) of section 1860D-2(b)) for 
                expenditures incurred through the total amount 
                of expenditures at which benefits are available 
                under paragraph (4) of such section, subject to 
                the reduced coinsurance described in 
                subparagraph (D).
                  (D) Reduction in cost-sharing below out-of-
                pocket threshold.--The substitution for the 
                beneficiary coinsurance described in section 
                1860D-2(b)(2) (for all amounts above the 
                deductible under subparagraph (B) through the 
                total amount of expenditures at which benefits 
                are available under section 1860D-2(b)(4)) of 
                coinsurance of ``15 percent'' instead of 
                coinsurance of ``25 percent'' in section 1860D-
                2(b)(2).
                  (E) Reduction of cost-sharing above annual 
                out-of-pocket threshold.--Subject to subsection 
                (c), the substitution for the cost-sharing 
                imposed under section 1860D-2(b)(4)(A) of a 
                copayment or coinsurance not to exceed the 
                copayment or coinsurance amount specified under 
                section 1860D-2(b)(4)(A)(i)(I) for the drug and 
                year involved.
          (3) Determination of eligibility.--
                  (A) Subsidy eligible individual defined.--For 
                purposes of this part, subject to [subparagraph 
                (F)] subparagraph (E), the term ``subsidy 
                eligible individual'' means a part D eligible 
                individual who--
                          (i) is enrolled in a prescription 
                        drug plan or MA-PD plan;
                          (ii) has income below 150 percent of 
                        the poverty line applicable to a family 
                        of the size involved (as determined 
                        under subparagraph (G)); and
                          (iii) meets the resources requirement 
                        described in subparagraph (D) [or (E)].
                  (B) Determinations.--
                          (i) In general.--The determination of 
                        whether a part D eligible individual 
                        residing in a State is a subsidy 
                        eligible individual and whether the 
                        individual is described in paragraph 
                        (1) shall be determined under the State 
                        plan under title XIX for the State 
                        under section 1935(a) or by the 
                        Commissioner of Social Security. There 
                        are authorized to be appropriated to 
                        the Social Security Administration such 
                        sums as may be necessary for the 
                        determination of eligibility under this 
                        subparagraph.
                          (ii) Effective period.--
                        Determinations under this subparagraph 
                        shall be effective beginning with the 
                        month in which the individual applies 
                        for a determination that the individual 
                        is a subsidy eligible individual and 
                        shall remain in effect for a period 
                        specified by the Secretary, but not to 
                        exceed 1 year.
                          (iii) Redeterminations and appeals 
                        through medicaid.--Redeterminations and 
                        appeals, with respect to eligibility 
                        determinations under clause (i) made 
                        under a State plan under title XIX, 
                        shall be made in accordance with the 
                        frequency of, and manner in which, 
                        redeterminations and appeals of 
                        eligibility are made under such plan 
                        for purposes of medical assistance 
                        under such title.
                          (iv) Redeterminations and appeals 
                        through commissioner.--With respect to 
                        eligibility determinations under clause 
                        (i) made by the Commissioner of Social 
                        Security--
                                  (I) redeterminations shall be 
                                made at such time or times as 
                                may be provided by the 
                                Commissioner;
                                  (II) the Commissioner shall 
                                establish procedures for 
                                appeals of such determinations 
                                that are similar to the 
                                procedures described in the 
                                third sentence of section 
                                1631(c)(1)(A); and
                                  (III) judicial review of the 
                                final decision of the 
                                Commissioner made after a 
                                hearing shall be available to 
                                the same extent, and with the 
                                same limitations, as provided 
                                in subsections (g) and (h) of 
                                section 205.
                          (v) Treatment of medicaid 
                        beneficiaries.--Subject to 
                        [subparagraph (F)] subparagraph (E), 
                        the Secretary--
                                  (I) shall provide that part D 
                                eligible individuals who are 
                                full-benefit dual eligible 
                                individuals (as defined in 
                                section 1935(c)(6)) or who are 
                                recipients of supplemental 
                                security income benefits under 
                                title XVI shall be treated as 
                                subsidy eligible individuals 
                                described in paragraph (1); and
                                  (II) may provide that part D 
                                eligible individuals not 
                                described in subclause (I) who 
                                are determined for purposes of 
                                the State plan under title XIX 
                                to be eligible for medical 
                                assistance under clause (i), 
                                (iii), or (iv) of section 
                                1902(a)(10)(E) are treated as 
                                being determined to be subsidy 
                                eligible individuals described 
                                in paragraph (1).
                        Insofar as the Secretary determines 
                        that the eligibility requirements under 
                        the State plan for medical assistance 
                        referred to in subclause (II) are 
                        substantially the same as the 
                        requirements for being treated as a 
                        subsidy eligible individual described 
                        in paragraph (1), the Secretary shall 
                        provide for the treatment described in 
                        such subclause.
                          (vi) Special rule for widows and 
                        widowers.--Notwithstanding the 
                        preceding provisions of this 
                        subparagraph, in the case of an 
                        individual whose spouse dies during the 
                        effective period for a determination or 
                        redetermination that has been made 
                        under this subparagraph, such effective 
                        period shall be extended through the 
                        date that is 1 year after the date on 
                        which the determination or 
                        redetermination would (but for the 
                        application of this clause) otherwise 
                        cease to be effective.
                  (C) Income determinations.--For purposes of 
                applying this section--
                          (i) in the case of a part D eligible 
                        individual who is not treated as a 
                        subsidy eligible individual under 
                        subparagraph (B)(v), income shall be 
                        determined in the manner described in 
                        section 1905(p)(1)(B), without regard 
                        to the application of section 
                        1902(r)(2) and except that support and 
                        maintenance furnished in kind shall not 
                        be counted as income; and
                          (ii) the term ``poverty line'' has 
                        the meaning given such term in section 
                        673(2) of the Community Services Block 
                        Grant Act (42 U.S.C. 9902(2)), 
                        including any revision required by such 
                        section.
                Nothing in clause (i) shall be construed to 
                affect the application of section 1902(r)(2) 
                for the determination of eligibility for 
                medical assistance under title XIX.
                  [(D) Resource standard applied to full low-
                income subsidy to be based on three times ssi 
                resource standard.--The resources requirement 
                of this subparagraph is that an individual's 
                resources (as determined under section 1613 for 
                purposes of the supplemental security income 
                program subject to the life insurance policy 
                exclusion provided under subparagraph (G)) do 
                not exceed--
                          [(i) for 2006 three times the maximum 
                        amount of resources that an individual 
                        may have and obtain benefits under that 
                        program; and
                          [(ii) for a subsequent year the 
                        resource limitation established under 
                        this clause for the previous year 
                        increased by the annual percentage 
                        increase in the consumer price index 
                        (all items; U.S. city average) as of 
                        September of such previous year.
                Any resource limitation established under 
                clause (ii) that is not a multiple of $10 shall 
                be rounded to the nearest multiple of $10.]
                  [(E) Alternative.--] (D)  resource 
                standard.--
                          (i) In general.--The resources 
                        requirement of this subparagraph is 
                        that an individual's resources (as 
                        determined under section 1613 for 
                        purposes of the supplemental security 
                        income program [subject to the life 
                        insurance policy exclusion provided 
                        under subparagraph (G)] subject to the 
                        resource exclusions provided under 
                        subparagraph (F)) do not exceed--
                                  (I) for 2006, $10,000 (or 
                                $20,000 in the case of the 
                                combined value of the 
                                individual's assets or 
                                resources and the assets or 
                                resources of the individual's 
                                spouse); and
                                  (II) for a subsequent year 
                                the dollar amounts specified in 
                                this subclause (or subclause 
                                (I)) for the previous year 
                                increased by the annual 
                                percentage increase in the 
                                consumer price index (all 
                                items; U.S. city average) as of 
                                September of such previous 
                                year.
                        Any dollar amount established under 
                        subclause (II) that is not a multiple 
                        of $10 shall be rounded to the nearest 
                        multiple of $10.
                          (ii) Use of simplified application 
                        form and process.--The Secretary, 
                        jointly with the Commissioner of Social 
                        Security, shall--
                                  (I) develop a model, 
                                simplified application form and 
                                process consistent with clause 
                                (iii) for the determination and 
                                verification of a part D 
                                eligible individual's assets or 
                                resources under this 
                                subparagraph; and
                                  (II) provide such form to 
                                States.
                          (iii) Documentation and safeguards.--
                        Under such process--
                                  (I) the application form 
                                shall consist of an attestation 
                                under penalty of perjury 
                                regarding the level of assets 
                                or resources (or combined 
                                assets and resources in the 
                                case of a married part D 
                                eligible individual) and 
                                valuations of general classes 
                                of assets or resources;
                                  (II) such form shall be 
                                accompanied by copies of recent 
                                statements (if any) from 
                                financial institutions in 
                                support of the application; and
                                  (III) matters attested to in 
                                the application shall be 
                                subject to appropriate methods 
                                of verification.
                          (iv) Methodology flexibility.--The 
                        Secretary may permit a State in making 
                        eligibility determinations for premium 
                        and cost-sharing subsidies under this 
                        section to use the same asset or 
                        resource methodologies that are used 
                        with respect to eligibility for medical 
                        assistance for medicare cost-sharing 
                        described in section 1905(p) so long as 
                        the Secretary determines that the use 
                        of such methodologies will not result 
                        in any significant differences in the 
                        number of individuals determined to be 
                        subsidy eligible individuals.
                  [(F)] (E) Treatment of territorial 
                residents.--In the case of a part D eligible 
                individual who is not a resident of the 50 
                States or the District of Columbia, the 
                individual is not eligible to be a subsidy 
                eligible individual under this section but may 
                be eligible for financial assistance with 
                prescription drug expenses under section 
                1935(e).
                  [(G) Life insurance policy exclusion.--In 
                determining the resources of an individual (and 
                the eligible spouse of the individual, if any) 
                under section 1613 for purposes of 
                subparagraphs (D) and (E) no part of the value 
                of any life insurance policy shall be taken 
                into account.]
                  (F) Resource exclusions.--In determining the 
                resources of an individual (and the eligible 
                spouse of the individual, if any) under section 
                1613 for purposes of subparagraph (D)--
                          (i) no part of the value of any life 
                        insurance policy shall be taken into 
                        account;
                          (ii) no part of the value of any 
                        vehicle shall be taken into account;
                          (iii) there shall be excluded an 
                        amount equal to $1,500 each with 
                        respect to any individual or eligible 
                        spouse of an individual who attests 
                        that some of the resources of such 
                        individual or spouse will be used to 
                        meet the burial and related expenses of 
                        such individual or spouse; and
                          (iv) no balance in, or benefits 
                        received under, an employee pension 
                        benefit plan (as defined in section 3 
                        of the Employee Retirement Income 
                        Security Act of 1974) shall be taken 
                        into account.
                  (G) Family size.--In determining the size of 
                the family of an individual for purposes of 
                determining the income eligibility of such 
                individual under this section, an individual's 
                family shall consist of--
                          (i) the individual;
                          (ii) the individual's spouse who 
                        lives in the same household as the 
                        individual (if any); and
                          (iii) any other individuals who--
                                  (I) are related to the 
                                individual whose income 
                                eligibility is in question or 
                                such individual's spouse who 
                                lives in the same household;
                                  (II) are living in the same 
                                household as such individual; 
                                and
                                  (III) are dependent on such 
                                individual or such individual's 
                                spouse who is living in the 
                                same household for at least 
                                one-half of their financial 
                                support.
          (4) Indexing dollar amounts.--
                  (A) Copayment for lowest income dual eligible 
                individuals.--The dollar amounts applied under 
                paragraph (1)(D)(ii)--
                          (i) for 2007 shall be the dollar 
                        amounts specified in such paragraph 
                        increased by the annual percentage 
                        increase in the consumer price index 
                        (all items; U.S. city average) as of 
                        September of such previous year; or
                          (ii) for a subsequent year shall be 
                        the dollar amounts specified in this 
                        clause (or clause (i)) for the previous 
                        year increased by the annual percentage 
                        increase in the consumer price index 
                        (all items; U.S. city average) as of 
                        September of such previous year.
                Any amount established under clause (i) or 
                (ii), that is based on an increase of $1 or $3, 
                that is not a multiple of 5 cents or 10 cents, 
                respectively, shall be rounded to the nearest 
                multiple of 5 cents or 10 cents, respectively.
                  (B) Reduced deductible.--The dollar amount 
                applied under paragraph (2)(B)--
                          (i) for 2007 shall be the dollar 
                        amount specified in such paragraph 
                        increased by the annual percentage 
                        increase described in section 1860D-
                        2(b)(6) for 2007; or
                          (ii) for a subsequent year shall be 
                        the dollar amount specified in this 
                        clause (or clause (i)) for the previous 
                        year increased by the annual percentage 
                        increase described in section 1860D-
                        2(b)(6) for the year involved.
                Any amount established under clause (i) or (ii) 
                that is not a multiple of $1 shall be rounded 
                to the nearest multiple of $1.
          (5) Waiver of de minimis premiums.--The Secretary 
        shall, under procedures established by the Secretary, 
        permit a prescription drug plan or an MA-PD plan to 
        waive the monthly beneficiary premium for a subsidy 
        eligible individual if the amount of such premium is de 
        minimis. If such premium is waived under the plan, the 
        Secretary shall not reassign subsidy eligible 
        individuals enrolled in the plan to other plans based 
        on the fact that the monthly beneficiary premium under 
        the plan was greater than the low-income benchmark 
        premium amount.
  (b) Premium Subsidy Amount.--
          (1) In general.--The premium subsidy amount described 
        in this subsection for a subsidy eligible individual 
        residing in a PDP region and enrolled in a prescription 
        drug plan or MA-PD plan is the low-income benchmark 
        premium amount (as defined in paragraph (2)) for the 
        PDP region in which the individual resides or, if 
        greater, the amount specified in paragraph (3).
          (2) Low-income benchmark premium amount defined.--
                  (A) In general.--For purposes of this 
                subsection, the term ``low-income benchmark 
                premium amount'' means, with respect to a PDP 
                region in which--
                          (i) all prescription drug plans are 
                        offered by the same PDP sponsor, the 
                        weighted average of the amounts 
                        described in subparagraph (B)(i) for 
                        such plans; or
                          (ii) there are prescription drug 
                        plans offered by more than one PDP 
                        sponsor, the weighted average of 
                        amounts described in subparagraph (B) 
                        for prescription drug plans and MA-PD 
                        plans described in section 
                        1851(a)(2)(A)(i) offered in such 
                        region.
                  (B) Premium amounts described.--The premium 
                amounts described in this subparagraph are, in 
                the case of--
                          (i) a prescription drug plan that is 
                        a basic prescription drug plan, the 
                        monthly beneficiary premium for such 
                        plan;
                          (ii) a prescription drug plan that 
                        provides alternative prescription drug 
                        coverage the actuarial value of which 
                        is greater than that of standard 
                        prescription drug coverage, the portion 
                        of the monthly beneficiary premium that 
                        is attributable to basic prescription 
                        drug coverage; and
                          (iii) an MA-PD plan, the portion of 
                        the MA monthly prescription drug 
                        beneficiary premium that is 
                        attributable to basic prescription drug 
                        benefits (described in section 
                        1852(a)(6)(B)(ii)) and determined 
                        before the application of the monthly 
                        rebate computed under section 
                        1854(b)(1)(C)(i) for that plan and year 
                        involved and, in the case of a 
                        qualifying plan, before the application 
                        of the increase under section 1853(o) 
                        for that plan and year involved.
                The premium amounts described in this 
                subparagraph do not include any amounts 
                attributable to late enrollment penalties under 
                section 1860D-13(b).
          (3) Access to 0 premium plan.--In no case shall the 
        premium subsidy amount under this subsection for a PDP 
        region be less than the lowest monthly beneficiary 
        premium for a prescription drug plan that offers basic 
        prescription drug coverage in the region.
  (c) Administration of Subsidy Program.--
          (1) In general.--The Secretary shall provide a 
        process whereby, in the case of a part D eligible 
        individual who is determined to be a subsidy eligible 
        individual and who is enrolled in a prescription drug 
        plan or is enrolled in an MA-PD plan--
                  (A) the Secretary provides for a notification 
                of the PDP sponsor or the MA organization 
                offering the plan involved that the individual 
                is eligible for a subsidy and the amount of the 
                subsidy under subsection (a);
                  (B) the sponsor or organization involved 
                reduces the premiums or cost-sharing otherwise 
                imposed by the amount of the applicable subsidy 
                and submits to the Secretary information on the 
                amount of such reduction;
                  (C) the Secretary periodically and on a 
                timely basis reimburses the sponsor or 
                organization for the amount of such reductions; 
                and
                  (D) the Secretary ensures the confidentiality 
                of individually identifiable information.
        In applying subparagraph (C), the Secretary shall 
        compute reductions based upon imposition under 
        subsections (a)(1)(D) and (a)(2)(E) of unreduced 
        copayment amounts applied under such subsections.
          (2) Use of capitated form of payment.--The 
        reimbursement under this section with respect to cost-
        sharing subsidies may be computed on a capitated basis, 
        taking into account the actuarial value of the 
        subsidies and with appropriate adjustments to reflect 
        differences in the risks actually involved.
  (d) Facilitation of Reassignments.--Beginning not later than 
January 1, 2011, the Secretary shall, in the case of a subsidy 
eligible individual who is enrolled in one prescription drug 
plan and is subsequently reassigned by the Secretary to a new 
prescription drug plan, provide the individual, within 30 days 
of such reassignment, with--
          (1) information on formulary differences between the 
        individual's former plan and the plan to which the 
        individual is reassigned with respect to the 
        individual's drug regimens; and
          (2) a description of the individual's right to 
        request a coverage determination, exception, or 
        reconsideration under section 1860D-4(g), bring an 
        appeal under section 1860D-4(h), or resolve a grievance 
        under section 1860D-4(f).
  (e) Relation to Medicaid Program.--For special provisions 
under the medicaid program relating to medicare prescription 
drug benefits, see section 1935.

           *       *       *       *       *       *       *


Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *


        exclusions from coverage and medicare as secondary payer

  Sec. 1862. (a) Notwithstanding any other provision of this 
title, no payment may be made under part A or part B for any 
expenses incurred for items or services--
          (1)(A) which, except for items and services described 
        in a succeeding subparagraph or additional preventive 
        services (as described in section 1861(ddd)(1)), are 
        not reasonable and necessary for the diagnosis or 
        treatment of illness or injury or to improve the 
        functioning of a malformed body member,
          (B) in the case of items and services described in 
        section 1861(s)(10), which are not reasonable and 
        necessary for the prevention of illness,
          (C) in the case of hospice care, which are not 
        reasonable and necessary for the palliation or 
        management of terminal illness,
          (D) in the case of clinical care items and services 
        provided with the concurrence of the Secretary and with 
        respect to research and experimentation conducted by, 
        or under contract with, the Medicare Payment Advisory 
        Commission or the Secretary, which are not reasonable 
        and necessary to carry out the purposes of section 
        1886(e)(6),
          (E) in the case of research conducted pursuant to 
        section 1142, which is not reasonable and necessary to 
        carry out the purposes of that section,
          (F) in the case of screening mammography, which is 
        performed more frequently than is covered under section 
        1834(c)(2) or which is not conducted by a facility 
        described in section 1834(c)(1)(B), in the case of 
        screening pap smear and screening pelvic exam, which is 
        performed more frequently than is provided under 
        section 1861(nn), and, in the case of screening for 
        glaucoma, which is performed more frequently than is 
        provided under section 1861(uu),
          (G) in the case of prostate cancer screening tests 
        (as defined in section 1861(oo)), which are performed 
        more frequently than is covered under such section,
          (H) in the case of colorectal cancer screening tests, 
        which are performed more frequently than is covered 
        under section 1834(d),
          (I) the frequency and duration of home health 
        services which are in excess of normative guidelines 
        that the Secretary shall establish by regulation,
          (J) in the case of a drug or biological specified in 
        section 1847A(c)(6)(C) for which payment is made under 
        part B that is furnished in a competitive area under 
        section 1847B, that is not furnished by an entity under 
        a contract under such section,
          (K) in the case of an initial preventive physical 
        examination, which is performed more than 1 year after 
        the date the individual's first coverage period begins 
        under part B,
          (L) in the case of cardiovascular screening blood 
        tests (as defined in section 1861(xx)(1)), which are 
        performed more frequently than is covered under section 
        1861(xx)(2),
          (M) in the case of a diabetes screening test (as 
        defined in section 1861(yy)(1)), which is performed 
        more frequently than is covered under section 
        1861(yy)(3),
          (N) in the case of ultrasound screening for abdominal 
        aortic aneurysm which is performed more frequently than 
        is provided for under section 1861(s)(2)(AA),
          (O) in the case of kidney disease education services 
        (as defined in paragraph (1) of section 1861(ggg)), 
        which are furnished in excess of the number of sessions 
        covered under paragraph (4) of such section, and
          (P) in the case of personalized prevention plan 
        services (as defined in section 1861(hhh)(1)), which 
        are performed more frequently than is covered under 
        such section;
          (2) for which the individual furnished such items or 
        services has no legal obligation to pay, and which no 
        other person (by reason of such individual's membership 
        in a prepayment plan or otherwise) has a legal 
        obligation to provide or pay for, except in the case of 
        Federally qualified health center services;
          (3) which are paid for directly or indirectly by a 
        governmental entity (other than under this Act and 
        other than under a health benefits or insurance plan 
        established for employees of such an entity), except in 
        the case of rural health clinic services, as defined in 
        section 1861(aa)(1), in the case of Federally qualified 
        health center services, as defined in section 
        1861(aa)(3), in the case of services for which payment 
        may be made under section 1880(e), and in such other 
        cases as the Secretary may specify;
          (4) which are not provided within the United States 
        (except for inpatient hospital services furnished 
        outside the United States under the conditions 
        described in section 1814(f) and, subject to such 
        conditions, limitations, and requirements as are 
        provided under or pursuant to this title, physicians' 
        services and ambulance services furnished an individual 
        in conjunction with such inpatient hospital services 
        but only for the period during which such inpatient 
        hospital services were furnished);
          (5) which are required as a result of war, or of an 
        act of war, occurring after the effective date of such 
        individual's current coverage under such part;
          (6) which constitute personal comfort items (except, 
        in the case of hospice care, as is otherwise permitted 
        under paragraph (1)(C));
          (7) where such expenses are for routine physical 
        checkups, eyeglasses (other than eyewear described in 
        section 1861(s)(8)) or eye examinations for the purpose 
        of prescribing, fitting, or changing eyeglasses, 
        procedures performed (during the course of any eye 
        examination) to determine the refractive state of the 
        eyes, hearing aids or examinations therefor, or 
        immunizations (except as otherwise allowed under 
        section 1861(s)(10) and subparagraph (B), (F), (G), 
        (H), (K), or (P) of paragraph (1));
          (8) where such expenses are for orthopedic shoes or 
        other supportive devices for the feet, other than shoes 
        furnished pursuant to section 1861(s)(12);
          (9) where such expenses are for custodial care 
        (except, in the case of hospice care, as is otherwise 
        permitted under paragraph (1)(C));
          (10) where such expenses are for cosmetic surgery or 
        are incurred in connection therewith, except as 
        required for the prompt repair of accidental injury or 
        for improvement of the functioning of a malformed body 
        member;
          (11) where such expenses constitute charges imposed 
        by immediate relatives of such individual or members of 
        his household;
          (12) where such expenses are for services in 
        connection with the care, treatment, filling, removal, 
        or replacement of teeth or structures directly 
        supporting teeth, except that payment may be made under 
        part A in the case of inpatient hospital services in 
        connection with the provision of such dental services 
        if the individual, because of his underlying medical 
        condition and clinical status or because of the 
        severity of the dental procedure, requires 
        hospitalization in connection with the provision of 
        such services;
          (13) where such expenses are for--
                  (A) the treatment of flat foot conditions and 
                the prescription of supportive devices 
                therefor,
                  (B) the treatment of subluxations of the 
                foot, or
                  (C) routine foot care (including the cutting 
                or removal of corns or calluses, the trimming 
                of nails, and other routine hygienic care);
          (14) which are other than physicians' services (as 
        defined in regulations promulgated specifically for 
        purposes of this paragraph), services described by 
        section 1861(s)(2)(K), certified nurse-midwife 
        services, qualified psychologist services, and services 
        of a certified registered nurse anesthetist, and which 
        are furnished to an individual who is a patient of a 
        hospital or critical access hospital by an entity other 
        than the hospital or critical access hospital, unless 
        the services are furnished under arrangements (as 
        defined in section 1861(w)(1)) with the entity made by 
        the hospital or critical access hospital;
          (15)(A) which are for services of an assistant at 
        surgery in a cataract operation (including subsequent 
        insertion of an intraocular lens) unless, before the 
        surgery is performed, the appropriate quality 
        improvement organization (under part B of title XI) or 
        a carrier under section 1842 has approved of the use of 
        such an assistant in the surgical procedure based on 
        the existence of a complicating medical condition, or
          (B) which are for services of an assistant at surgery 
        to which section 1848(i)(2)(B) applies;
          (16) in the case in which funds may not be used for 
        such items and services under the Assisted Suicide 
        Funding Restriction Act of 1997;
          (17) where the expenses are for an item or service 
        furnished in a competitive acquisition area (as 
        established by the Secretary under section 1847(a)) by 
        an entity other than an entity with which the Secretary 
        has entered into a contract under section 1847(b) for 
        the furnishing of such an item or service in that area, 
        unless the Secretary finds that the expenses were 
        incurred in a case of urgent need, or in other 
        circumstances specified by the Secretary;
          (18) which are covered skilled nursing facility 
        services described in section 1888(e)(2)(A)(i) and 
        which are furnished to an individual who is a resident 
        of a skilled nursing facility during a period in which 
        the resident is provided covered post-hospital extended 
        care services (or, for services described in section 
        1861(s)(2)(D), which are furnished to such an 
        individual without regard to such period), by an entity 
        other than the skilled nursing facility, unless the 
        services are furnished under arrangements (as defined 
        in section 1861(w)(1)) with the entity made by the 
        skilled nursing facility;
          (19) which are for items or services which are 
        furnished pursuant to a private contract described in 
        section 1802(b);
          (20) in the case of outpatient physical therapy 
        services, outpatient speech-language pathology 
        services, or outpatient occupational therapy services 
        furnished as an incident to a physician's professional 
        services (as described in section 1861(s)(2)(A)), that 
        do not meet the standards and conditions (other than 
        any licensing requirement specified by the Secretary) 
        under the second sentence of section 1861(p) (or under 
        such sentence through the operation of subsection (g) 
        or (ll)(2) of section 1861) as such standards and 
        conditions would apply to such therapy services if 
        furnished by a therapist;
          (21) where such expenses are for home health services 
        (including medical supplies described in section 
        1861(m)(5), but excluding durable medical equipment to 
        the extent provided for in such section) furnished to 
        an individual who is under a plan of care of the home 
        health agency if the claim for payment for such 
        services is not submitted by the agency;
          (22) subject to subsection (h), for which a claim is 
        submitted other than in an electronic form specified by 
        the Secretary;
          (23) which are the technical component of advanced 
        diagnostic imaging services described in section 
        1834(e)(1)(B) for which payment is made under the fee 
        schedule established under section 1848(b) and that are 
        furnished by a supplier (as defined in section 
        1861(d)), if such supplier is not accredited by an 
        accreditation organization designated by the Secretary 
        under section 1834(e)(2)(B);
          (24) where such expenses are for renal dialysis 
        services (as defined in subparagraph (B) of section 
        1881(b)(14)) for which payment is made under such 
        section unless such payment is made under such section 
        to a provider of services or a renal dialysis facility 
        for such services; or
          (25) not later than January 1, 2014, for which the 
        payment is other than by electronic funds transfer 
        (EFT) or an electronic remittance in a form as 
        specified in ASC X12 835 Health Care Payment and 
        Remittance Advice or subsequent standard.
Paragraph (7) shall not apply to Federally qualified health 
center services described in section 1861(aa)(3)(B). In making 
a national coverage determination (as defined in paragraph 
(1)(B) of section 1869(f)) the Secretary shall ensure 
consistent with subsection (l) that the public is afforded 
notice and opportunity to comment prior to implementation by 
the Secretary of the determination; meetings of advisory 
committees with respect to the determination are made on the 
record; in making the determination, the Secretary has 
considered applicable information (including clinical 
experience and medical, technical, and scientific evidence) 
with respect to the subject matter of the determination; and in 
the determination, provide a clear statement of the basis for 
the determination (including responses to comments received 
from the public), the assumptions underlying that basis, and 
make available to the public the data (other than proprietary 
data) considered in making the determination.
  (b) Medicare as Secondary Payer.--
          (1) Requirements of group health plans.--
                  (A) Working aged under group health plans.--
                          (i) In general.--A group health 
                        plan--
                                  (I) may not take into account 
                                that an individual (or the 
                                individual's spouse) who is 
                                covered under the plan by 
                                virtue of the individual's 
                                current employment status with 
                                an employer is entitled to 
                                benefits under this title under 
                                section 226(a), and
                                  (II) shall provide that any 
                                individual age 65 or older (and 
                                the spouse age 65 or older of 
                                any individual) who has current 
                                employment status with an 
                                employer shall be entitled to 
                                the same benefits under the 
                                plan under the same conditions 
                                as any such individual (or 
                                spouse) under age 65.
                          (ii) Exclusion of group health plan 
                        of a small employer.--Clause (i) shall 
                        not apply to a group health plan unless 
                        the plan is a plan of, or contributed 
                        to by, an employer that has 20 or more 
                        employees for each working day in each 
                        of 20 or more calendar weeks in the 
                        current calendar year or the preceding 
                        calendar year.
                          (iii) Exception for small employers 
                        in multiemployer or multiple employer 
                        group health plans.--Clause (i) also 
                        shall not apply with respect to 
                        individuals enrolled in a multiemployer 
                        or multiple employer group health plan 
                        if the coverage of the individuals 
                        under the plan is by virtue of current 
                        employment status with an employer that 
                        does not have 20 or more individuals in 
                        current employment status for each 
                        working day in each of 20 or more 
                        calendar weeks in the current calendar 
                        year and the preceding calendar year; 
                        except that the exception provided in 
                        this clause shall only apply if the 
                        plan elects treatment under this 
                        clause.
                          (iv) Exception for individuals with 
                        end stage renal disease.--Subparagraph 
                        (C) shall apply instead of clause (i) 
                        to an item or service furnished in a 
                        month to an individual if for the month 
                        the individual is, or (without regard 
                        to entitlement under section 226) would 
                        upon application be, entitled to 
                        benefits under section 226A.
                          (v) Group health plan defined.--In 
                        this subparagraph, and subparagraph 
                        (C), the term ``group health plan'' has 
                        the meaning given such term in section 
                        5000(b)(1) of the Internal Revenue Code 
                        of 1986, without regard to section 
                        5000(d) of such Code
                  (B) Disabled individuals in large group 
                health plans.--
                          (i) In general.--A large group health 
                        plan (as defined in clause (iii)) may 
                        not take into account that an 
                        individual (or a member of the 
                        individual's family) who is covered 
                        under the plan by virtue of the 
                        individual's current employment status 
                        with an employer is entitled to 
                        benefits under this title under section 
                        226(b).
                          (ii) Exception for individuals with 
                        end stage renal disease.--Subparagraph 
                        (C) shall apply instead of clause (i) 
                        to an item or service furnished in a 
                        month to an individual if for the month 
                        the individual is, or (without regard 
                        to entitlement under section 226) would 
                        upon application be, entitled to 
                        benefits under section 226A.
                          (iii) Large Group Health Plan 
                        Defined.--In this subparagraph, the 
                        term ``large group health plan'' has 
                        the meaning given such term in section 
                        5000(b)(2) of the Internal Revenue Code 
                        of 1986, without regard to section 
                        5000(d) of such Code.
                  (C) Individuals with end stage renal 
                disease.--A group health plan (as defined in 
                subparagraph (A)(v))--
                          (i) may not take into account that an 
                        individual is entitled to or eligible 
                        for benefits under this title under 
                        section 226A during the 12-month period 
                        which begins with the first month in 
                        which the individual becomes entitled 
                        to benefits under part A under the 
                        provisions of section 226A, or, if 
                        earlier, the first month in which the 
                        individual would have been entitled to 
                        benefits under such part under the 
                        provisions of section 226A if the 
                        individual had filed an application for 
                        such benefits; and
                          (ii) may not differentiate in the 
                        benefits it provides between 
                        individuals having end stage renal 
                        disease and other individuals covered 
                        by such plan on the basis of the 
                        existence of end stage renal disease, 
                        the need for renal dialysis, or in any 
                        other manner;
                except that clause (ii) shall not prohibit a 
                plan from paying benefits secondary to this 
                title when an individual is entitled to or 
                eligible for benefits under this title under 
                section 226A after the end of the 12-month 
                period described in clause (i). Effective for 
                items and services furnished on or after 
                February 1, 1991, and before the date of 
                enactment of the Balanced Budget Act of 1997 
                (with respect to periods beginning on or after 
                February 1, 1990), this subparagraph shall be 
                applied by substituting ``18- month'' for ``12-
                month'' each place it appears. Effective for 
                items and services furnished on or after the 
                date of enactment of the Balanced Budget Act of 
                1997, (with respect to periods beginning on or 
                after the date that is 18 months prior to such 
                date), clauses (i) and (ii) shall be applied by 
                substituting ``30-month'' for ``12-month'' each 
                place it appears.
                  (D) Treatment of certain members of religious 
                orders.--In this subsection, an individual 
                shall not be considered to be employed, or an 
                employee, with respect to the performance of 
                services as a member of a religious order which 
                are considered employment only by virtue of an 
                election made by the religious order under 
                section 3121(r) of the Internal Revenue Code of 
                1986.
                  (E) General Provisions.--For purposes of this 
                subsection:
                          (i) Aggregation Rules.--
                                  (I) All employers treated as 
                                a single employer under 
                                subsection (a) or (b) of 
                                section 52 of the Internal 
                                Revenue Code of 1986 shall be 
                                treated as a single employer.
                                  (II) All employees of the 
                                members of an affiliated 
                                service group (as defined in 
                                section 414(m) of such Code) 
                                shall be treated as employed by 
                                a single employer.
                                  (III) Leased employees (as 
                                defined in section 414(n)(2) of 
                                such Code) shall be treated as 
                                employees of the person for 
                                whom they perform services to 
                                the extent they are so treated 
                                under section 414(n) of such 
                                Code.
                        In applying sections of the Internal 
                        Revenue Code of 1986 under this clause, 
                        the Secretary shall rely upon 
                        regulations and decisions of the 
                        Secretary of the Treasury respecting 
                        such sections.
                          (ii) Current employment status 
                        defined.--An individual has ``current 
                        employment status'' with an employer if 
                        the individual is an employee, is the 
                        employer, or is associated with the 
                        employer in a business relationship.
                          (iii) Treatment of self-employed 
                        persons as employers.--The term 
                        ``employer'' includes a self-employed 
                        person.
                  (F) Limitation on beneficiary liability.--An 
                individual who is entitled to benefits under 
                this title and is furnished an item or service 
                for which such benefits are incorrectly paid is 
                not liable for repayment of such benefits under 
                this paragraph unless payment of such benefits 
                was made to the individual.
          (2) Medicare secondary payer.--
                  (A) In general.--Payment under this title may 
                not be made, except as provided in subparagraph 
                (B), with respect to any item or service to the 
                extent that--
                          (i) payment has been made, or can 
                        reasonably be expected to be made, with 
                        respect to the item or service as 
                        required under paragraph (1), or
                          (ii) payment has been made or can 
                        reasonably be expected to be made under 
                        a workmen's compensation law or plan of 
                        the United States or a State or under 
                        an automobile or liability insurance 
                        policy or plan (including a self-
                        insured plan) or under no fault 
                        insurance.
                In the subsection, the term ``primary plan'' 
                means a group health plan or large group health 
                plan, to the extent that clause (i) applies, 
                and a workmen's compensation law or plan, an 
                automobile or liability insurance policy or 
                plan (including a self-insured plan) or no 
                fault insurance, to the extent that clause (ii) 
                applies. An entity that engages in a business, 
                trade, or profession shall be deemed to have a 
                self-insured plan if it carries its own risk 
                (whether by a failure to obtain insurance, or 
                otherwise) in whole or in part.
                  (B) Conditional payment.--
                          (i) Authority to make conditional 
                        payment.--The Secretary may make 
                        payment under this title with respect 
                        to an item or service if a primary plan 
                        described in subparagraph (A)(ii) has 
                        not made or cannot reasonably be 
                        expected to make payment with respect 
                        to such item or service promptly (as 
                        determined in accordance with 
                        regulations). Any such payment by the 
                        Secretary shall be conditioned on 
                        reimbursement to the appropriate Trust 
                        Fund in accordance with the succeeding 
                        provisions of this subsection.
                          (ii) Repayment required.--Subject to 
                        paragraph (9), a primary plan, and an 
                        entity that receives payment from a 
                        primary plan, shall reimburse the 
                        appropriate Trust Fund for any payment 
                        made by the Secretary under this title 
                        with respect to an item or service if 
                        it is demonstrated that such primary 
                        plan has or had a responsibility to 
                        make payment with respect to such item 
                        or service. A primary plan's 
                        responsibility for such payment may be 
                        demonstrated by a judgment, a payment 
                        conditioned upon the recipient's 
                        compromise, waiver, or release (whether 
                        or not there is a determination or 
                        admission of liability) of payment for 
                        items or services included in a claim 
                        against the primary plan or the primary 
                        plan's insured, or by other means. If 
                        reimbursement is not made to the 
                        appropriate Trust Fund before the 
                        expiration of the 60-day period that 
                        begins on the date notice of, or 
                        information related to, a primary 
                        plan's responsibility for such payment 
                        or other information is received, the 
                        Secretary may charge interest 
                        (beginning with the date on which the 
                        notice or other information is 
                        received) on the amount of the 
                        reimbursement until reimbursement is 
                        made (at a rate determined by the 
                        Secretary in accordance with 
                        regulations of the Secretary of the 
                        Treasury applicable to charges for late 
                        payments).
                          (iii) Action by united states.--In 
                        order to recover payment made under 
                        this title for an item or service, the 
                        United States may bring an action 
                        against any or all entities that are or 
                        were required or responsible (directly, 
                        as an insurer or self-insurer, as a 
                        third-party administrator, as an 
                        employer that sponsors or contributes 
                        to a group health plan, or large group 
                        health plan, or otherwise) to make 
                        payment with respect to the same item 
                        or service (or any portion thereof) 
                        under a primary plan. The United States 
                        may, in accordance with paragraph 
                        (3)(A) collect double damages against 
                        any such entity. In addition, the 
                        United States may recover under this 
                        clause from any entity that has 
                        received payment from a primary plan or 
                        from the proceeds of a primary plan's 
                        payment to any entity. The United 
                        States may not recover from a third-
                        party administrator under this clause 
                        in cases where the third-party 
                        administrator would not be able to 
                        recover the amount at issue from the 
                        employer or group health plan and is 
                        not employed by or under contract with 
                        the employer or group health plan at 
                        the time the action for recovery is 
                        initiated by the United States or for 
                        whom it provides administrative 
                        services due to the insolvency or 
                        bankruptcy of the employer or plan. An 
                        action may not be brought by the United 
                        States under this clause with respect 
                        to payment owed unless the complaint is 
                        filed not later than 3 years after the 
                        date of the receipt of notice of a 
                        settlement, judgment, award, or other 
                        payment made pursuant to paragraph (8) 
                        relating to such payment owed.
                          (iv) Subrogation rights.--The United 
                        States shall be subrogated (to the 
                        extent of payment made under this title 
                        for such an item or service) to any 
                        right under this subsection of an 
                        individual or any other entity to 
                        payment with respect to such item or 
                        service under a primary plan.
                          (v) Waiver of rights.--The Secretary 
                        may waive (in whole or in part) the 
                        provisions of this subparagraph in the 
                        case of an individual claim if the 
                        Secretary determines that the waiver is 
                        in the best interests of the program 
                        established under this title.
                          (vi) Claims-filing period.--
                        Notwithstanding any other time limits 
                        that may exist for filing a claim under 
                        an employer group health plan, the 
                        United States may seek to recover 
                        conditional payments in accordance with 
                        this subparagraph where the request for 
                        payment is submitted to the entity 
                        required or responsible under this 
                        subsection to pay with respect to the 
                        item or service (or any portion 
                        thereof) under a primary plan within 
                        the 3-year period beginning on the date 
                        on which the item or service was 
                        furnished.
                          (vii) Use of website to determine 
                        final conditional reimbursement 
                        amount.--
                                  (I) Notice to secretary of 
                                expected date of a settlement, 
                                judgment, etc.--In the case of 
                                a payment made by the Secretary 
                                pursuant to clause (i) for 
                                items and services provided to 
                                the claimant, the claimant or 
                                applicable plan (as defined in 
                                paragraph (8)(F)) may at any 
                                time beginning 120 days before 
                                the reasonably expected date of 
                                a settlement, judgment, award, 
                                or other payment, notify the 
                                Secretary that a payment is 
                                reasonably expected and the 
                                expected date of such payment.
                                  (II) Secretarial providing 
                                access to claims information 
                                through a website.--The 
                                Secretary shall maintain and 
                                make available to individuals 
                                to whom items and services are 
                                furnished under this title (and 
                                to authorized family or other 
                                representatives recognized 
                                under regulations and to an 
                                applicable plan which has 
                                obtained the consent of the 
                                individual) access to 
                                information on the claims for 
                                such items and services 
                                (including payment amounts for 
                                such claims), including those 
                                claims that relate to a 
                                potential settlement, judgment, 
                                award, or other payment. Such 
                                access shall be provided to an 
                                individual, representative, or 
                                plan through a website that 
                                requires a password to gain 
                                access to the information. The 
                                Secretary shall update the 
                                information on claims and 
                                payments on such website in as 
                                timely a manner as possible but 
                                not later than 15 days after 
                                the date that payment is made. 
                                Information related to claims 
                                and payments subject to the 
                                notice under subclause (I) 
                                shall be maintained and made 
                                available consistent with the 
                                following:
                                          (aa) The information 
                                        shall be as complete as 
                                        possible and shall 
                                        include provider or 
                                        supplier name, 
                                        diagnosis codes (if 
                                        any), dates of service, 
                                        and conditional payment 
                                        amounts.
                                          (bb) The information 
                                        accurately identifies 
                                        those claims and 
                                        payments that are 
                                        related to a potential 
                                        settlement, judgment, 
                                        award, or other payment 
                                        to which the provisions 
                                        of this subsection 
                                        apply.
                                          (cc) The website 
                                        provides a method for 
                                        the receipt of secure 
                                        electronic 
                                        communications with the 
                                        individual, 
                                        representative, or plan 
                                        involved.
                                          (dd) The website 
                                        provides that 
                                        information is 
                                        transmitted from the 
                                        website in a form that 
                                        includes an official 
                                        time and date that the 
                                        information is 
                                        transmitted.
                                          (ee) The website 
                                        shall permit the 
                                        individual, 
                                        representative, or plan 
                                        to download a statement 
                                        of reimbursement 
                                        amounts (in this clause 
                                        referred to as a 
                                        ``statement of 
                                        reimbursement amount'') 
                                        on payments for claims 
                                        under this title 
                                        relating to a potential 
                                        settlement, judgment, 
                                        award, or other 
                                        payment.
                                  (III) Use of timely web 
                                download as basis for final 
                                conditional amount.--If an 
                                individual (or other claimant 
                                or applicable plan with the 
                                consent of the individual) 
                                obtains a statement of 
                                reimbursement amount from the 
                                website during the protected 
                                period as defined in subclause 
                                (V) and the related settlement, 
                                judgment, award or other 
                                payment is made during such 
                                period, then the last statement 
                                of reimbursement amount that is 
                                downloaded during such period 
                                and within 3 business days 
                                before the date of the 
                                settlement, judgment, award, or 
                                other payment shall constitute 
                                the final conditional amount 
                                subject to recovery under 
                                clause (ii) related to such 
                                settlement, judgment, award, or 
                                other payment.
                                  (IV) Resolution of 
                                discrepancies.--If the 
                                individual (or authorized 
                                representative) believes there 
                                is a discrepancy with the 
                                statement of reimbursement 
                                amount, the Secretary shall 
                                provide a timely process to 
                                resolve the discrepancy. Under 
                                such process the individual (or 
                                representative) must provide 
                                documentation explaining the 
                                discrepancy and a proposal to 
                                resolve such discrepancy. 
                                Within 11 business days after 
                                the date of receipt of such 
                                documentation, the Secretary 
                                shall determine whether there 
                                is a reasonable basis to 
                                include or remove claims on the 
                                statement of reimbursement. If 
                                the Secretary does not make 
                                such determination within the 
                                11 business-day period, then 
                                the proposal to resolve the 
                                discrepancy shall be accepted. 
                                If the Secretary determines 
                                within such period that there 
                                is not a reasonable basis to 
                                include or remove claims on the 
                                statement of reimbursement, the 
                                proposal shall be rejected. If 
                                the Secretary determines within 
                                such period that there is a 
                                reasonable basis to conclude 
                                there is a discrepancy, the 
                                Secretary must respond in a 
                                timely manner by agreeing to 
                                the proposal to resolve the 
                                discrepancy or by providing 
                                documentation showing with good 
                                cause why the Secretary is not 
                                agreeing to such proposal and 
                                establishing an alternate 
                                discrepancy resolution. In no 
                                case shall the process under 
                                this subclause be treated as an 
                                appeals process or as 
                                establishing a right of appeal 
                                for a statement of 
                                reimbursement amount and there 
                                shall be no administrative or 
                                judicial review of the 
                                Secretary's determinations 
                                under this subclause.
                                  (V) Protected period.--In 
                                subclause (III), the term 
                                ``protected period'' means, 
                                with respect to a settlement, 
                                judgment, award or other 
                                payment relating to an injury 
                                or incident, the portion (if 
                                any) of the period beginning on 
                                the date of notice under 
                                subclause (I) with respect to 
                                such settlement, judgment, 
                                award, or other payment that is 
                                after the end of a Secretarial 
                                response period beginning on 
                                the date of such notice to the 
                                Secretary. Such Secretarial 
                                response period shall be a 
                                period of 65 days, except that 
                                such period may be extended by 
                                the Secretary for a period of 
                                an additional 30 days if the 
                                Secretary determines that 
                                additional time is required to 
                                address claims for which 
                                payment has been made. Such 
                                Secretarial response period 
                                shall be extended and shall not 
                                include any days for any part 
                                of which the Secretary 
                                determines (in accordance with 
                                regulations) that there was a 
                                failure in the claims and 
                                payment posting system and the 
                                failure was justified due to 
                                exceptional circumstances (as 
                                defined in such regulations). 
                                Such regulations shall define 
                                exceptional circumstances in a 
                                manner so that not more than 1 
                                percent of the repayment 
                                obligations under this 
                                subclause would qualify as 
                                exceptional circumstances.
                                  (VI) Effective date.--The 
                                Secretary shall promulgate 
                                final regulations to carry out 
                                this clause not later than 9 
                                months after the date of the 
                                enactment of this clause.
                                  (VII) Website including 
                                successor technology.--In this 
                                clause, the term ``website'' 
                                includes any successor 
                                technology.
                          (viii) Right of appeal for secondary 
                        payer determinations relating to 
                        liability insurance (including self-
                        insurance), no fault insurance, and 
                        workers' compensation laws and plans.--
                        The Secretary shall promulgate 
                        regulations establishing a right of 
                        appeal and appeals process, with 
                        respect to any determination under this 
                        subsection for a payment made under 
                        this title for an item or service for 
                        which the Secretary is seeking to 
                        recover conditional payments from an 
                        applicable plan (as defined in 
                        paragraph (8)(F)) that is a primary 
                        plan under subsection (A)(ii), under 
                        which the applicable plan involved, or 
                        an attorney, agent, or third party 
                        administrator on behalf of such plan, 
                        may appeal such determination. The 
                        individual furnished such an item or 
                        service shall be notified of the plan's 
                        intent to appeal such determination
                  (C) Treatment of questionnaires.--The 
                Secretary may not fail to make payment under 
                subparagraph (A) solely on the ground that an 
                individual failed to complete a questionnaire 
                concerning the existence of a primary plan.
          (3) Enforcement.--
                  (A) Private cause of action.--There is 
                established a private cause of action for 
                damages (which shall be in an amount double the 
                amount otherwise provided) in the case of a 
                primary plan which fails to provide for primary 
                payment (or appropriate reimbursement) in 
                accordance with paragraphs (1) and (2)(A).
                  (B) Reference to excise tax with respect to 
                nonconforming group health plans.--For 
                provision imposing an excise tax with respect 
                to nonconforming group health plans, see 
                section 5000 of the Internal Revenue Code of 
                1986.
                  (C) Prohibition of financial incentives not 
                to enroll in a group health plan or a large 
                group health plan.--It is unlawful for an 
                employer or other entity to offer any financial 
                or other incentive for an individual entitled 
                to benefits under this title not to enroll (or 
                to terminate enrollment) under a group health 
                plan or a large group health plan which would 
                (in the case of such enrollment) be a primary 
                plan (as defined in paragraph (2)(A)). Any 
                entity that violates the previous sentence is 
                subject to a civil money penalty of not to 
                exceed $5,000 for each such violation. The 
                provisions of section 1128A (other than 
                subsections (a) and (b)) shall apply to a civil 
                money penalty under the previous sentence in 
                the same manner as such provisions apply to a 
                penalty or proceeding under section 1128A(a).
          (4) Coordination of benefits.--Where payment for an 
        item or service by a primary plan is less than the 
        amount of the charge for such item or service and is 
        not payment in full, payment may be made under this 
        title (without regard to deductibles and coinsurance 
        under this title) for the remainder of such charge, 
        but--
                  (A) payment under this title may not exceed 
                an amount which would be payable under this 
                title for such item or service if paragraph 
                (2)(A) did not apply; and
                  (B) payment under this title, when combined 
                with the amount payable under the primary plan, 
                may not exceed--
                          (i) in the case of an item or service 
                        payment for which is determined under 
                        this title on the basis of reasonable 
                        cost (or other cost-related basis) or 
                        under section 1886, the amount which 
                        would be payable under this title on 
                        such basis, and
                          (ii) in the case of an item or 
                        service for which payment is authorized 
                        under this title on another basis--
                                  (I) the amount which would be 
                                payable under the primary plan 
                                (without regard to deductibles 
                                and coinsurance under such 
                                plan), or
                                  (II) the reasonable charge or 
                                other amount which would be 
                                payable under this title 
                                (without regard to deductibles 
                                and coinsurance under this 
                                title),
                        whichever is greater.
          (5) Identification of secondary payer situations.--
                  (A) Requesting matching information.--
                          (i) Commissioner of social 
                        security.--The Commissioner of Social 
                        Security shall, not less often that 
                        annually, transmit to the Secretary of 
                        the Treasury a list of the names and 
                        TINs of medicare beneficiaries (as 
                        defined in section 6103(l)(12) of the 
                        Internal Revenue Code of 1986) and 
                        request that the Secretary disclose to 
                        the Commissioner the information 
                        described in subparagraph (A) of such 
                        section.
                          (ii) Administrator.--The 
                        Administrator of the Centers for 
                        Medicare & Medicaid Services shall 
                        request, not less often than annually, 
                        the Commissioner of the Social Security 
                        Administration to disclose to the 
                        Administrator the information described 
                        in subparagraph (B) of section 
                        6103(l)(12) of the Internal Revenue 
                        Code of 1986.
                  (B) Disclosure to fiscal intermediaries and 
                carriers.--In addition to any other information 
                provided under this title to fiscal 
                intermediaries and carriers, the Administrator 
                shall disclose to such intermediaries and 
                carriers (or to such a single intermediary or 
                carrier as the Secretary may designate) the 
                information received under subparagraph (A) for 
                purposes of carrying out this subsection.
                  (C) Contacting employers.--
                          (i) In general.--With respect to each 
                        individual (in this subparagraph 
                        referred to as an ``employee'') who was 
                        furnished a written statement under 
                        section 6051 of the Internal Revenue 
                        Code of 1986 by a qualified employer 
                        (as defined in section 
                        6103(l)(12)(E)(iii) of such Code), as 
                        disclosed under subparagraph (B), the 
                        appropriate fiscal intermediary or 
                        carrier shall contact the employer in 
                        order to determine during what period 
                        the employee or employee's spouse may 
                        be (or have been) covered under a group 
                        health plan of the employer and the 
                        nature of the coverage that is or was 
                        provided under the plan (including the 
                        name, address, and identifying number 
                        of the plan).
                          (ii) Employer response.--Within 30 
                        days of the date of receipt of the 
                        inquiry, the employer shall notify the 
                        intermediary or carrier making the 
                        inquiry as to the determinations 
                        described in clause (i). An employer 
                        (other than a Federal or other 
                        governmental entity) who willfully or 
                        repeatedly fails to provide timely and 
                        accurate notice in accordance with the 
                        previous sentence shall be subject to a 
                        civil money penalty of not to exceed 
                        $1,000 for each individual with respect 
                        to which such an inquiry is made. The 
                        provision of section 1128A (other than 
                        subsections (a) and (b)) shall apply to 
                        a civil money penalty under the 
                        previous sentence in the same manner as 
                        such provisions apply to a penalty or 
                        proceeding under section 1128A(a).
                  (D) Obtaining information from 
                beneficiaries.--Before an individual applies 
                for benefits under part A or enrolls under part 
                B, the Administrator shall mail the individual 
                a questionnaire to obtain information on 
                whether the individual is covered under a 
                primary plan and the nature of the coverage 
                provided under the plan, including the name, 
                address, and identifying number of the plan.
                  (E) End date.--The provisions of this 
                paragraph shall not apply to information 
                required to be provided on or after July 1, 
                2016.
          (6) Screening requirements for providers and 
        suppliers.--
                  (A) In general.--Notwithstanding any other 
                provision of this title, no payment may be made 
                for any item or service furnished under part B 
                unless the entity furnishing such item or 
                service completes (to the best of its knowledge 
                and on the basis of information obtained from 
                the individual to whom the item or service is 
                furnished) the portion of the claim form 
                relating to the availability of other health 
                benefit plans.
                  (B) Penalties.--An entity that knowingly, 
                willfully, and repeatedly fails to complete a 
                claim form in accordance with subparagraph (A) 
                or provides inaccurate information relating to 
                the availability of other health benefit plans 
                on a claim form under such subparagraph shall 
                be subject to a civil money penalty of not to 
                exceed $2,000 for each such incident. The 
                provisions of section 1128A (other than 
                subsections (a) and (b)) shall apply to a civil 
                money penalty under the previous sentence in 
                the same manner as such provisions apply to a 
                penalty or proceeding under section 1128A(a).
          (7) Required submission of information by group 
        health plans.--
                  (A) Requirement.--On and after the first day 
                of the first calendar quarter beginning after 
                the date that is 1 year after the date of the 
                enactment of this paragraph, an entity serving 
                as an insurer or third party administrator for 
                a group health plan, as defined in paragraph 
                (1)(A)(v), and, in the case of a group health 
                plan that is self-insured and self-
                administered, a plan administrator or 
                fiduciary, shall--
                          (i) secure from the plan sponsor and 
                        plan participants such information as 
                        the Secretary shall specify for the 
                        purpose of identifying situations where 
                        the group health plan is or has been--
                                  (I) a primary plan to the 
                                program under this title; or
                                  (II) for calendar quarters 
                                beginning on or after January 
                                1, 2020, a primary payer with 
                                respect to benefits relating to 
                                prescription drug coverage 
                                under part D; and
                          (ii) submit such information to the 
                        Secretary in a form and manner 
                        (including frequency) specified by the 
                        Secretary.
                  (B) Enforcement.--
                          (i) In general.--An entity, a plan 
                        administrator, or a fiduciary described 
                        in subparagraph (A) that fails to 
                        comply with the requirements under such 
                        subparagraph shall be subject to a 
                        civil money penalty of $1,000 for each 
                        day of noncompliance for each 
                        individual for which the information 
                        under such subparagraph should have 
                        been submitted. The provisions of 
                        subsections (e) and (k) of section 
                        1128A shall apply to a civil money 
                        penalty under the previous sentence in 
                        the same manner as such provisions 
                        apply to a penalty or proceeding under 
                        section 1128A(a). A civil money penalty 
                        under this clause shall be in addition 
                        to any other penalties prescribed by 
                        law and in addition to any Medicare 
                        secondary payer claim under this title 
                        with respect to an individual.
                          (ii) Deposit of amounts collected.--
                        Any amounts collected pursuant to 
                        clause (i) shall be deposited in the 
                        Federal Hospital Insurance Trust Fund 
                        under section 1817.
                  (C) Sharing of information.--Notwithstanding 
                any other provision of law, under terms and 
                conditions established by the Secretary, the 
                Secretary--
                          (i) shall share information on 
                        entitlement under Part A and enrollment 
                        under Part B under this title with 
                        entities, plan administrators, and 
                        fiduciaries described in subparagraph 
                        (A);
                          (ii) may share the entitlement and 
                        enrollment information described in 
                        clause (i) with entities and persons 
                        not described in such clause; and
                          (iii) may share information collected 
                        under this paragraph as necessary for 
                        purposes of the proper coordination of 
                        benefits.
                  (D) Implementation.--Notwithstanding any 
                other provision of law, the Secretary may 
                implement this paragraph by program instruction 
                or otherwise.
          (8) Required submission of information by or on 
        behalf of liability insurance (including self-
        insurance), no fault insurance, and workers' 
        compensation laws and plans.--
                  (A) Requirement.--On and after the first day 
                of the first calendar quarter beginning after 
                the date that is 18 months after the date of 
                the enactment of this paragraph, an applicable 
                plan shall--
                          (i) determine whether a claimant 
                        (including an individual whose claim is 
                        unresolved) is entitled to benefits 
                        under the program under this title on 
                        any basis; and
                          (ii) if the claimant is determined to 
                        be so entitled, submit the information 
                        described in subparagraph (B) with 
                        respect to the claimant to the 
                        Secretary in a form and manner 
                        (including frequency) specified by the 
                        Secretary.
                  (B) Required information.--The information 
                described in this subparagraph is--
                          (i) the identity of the claimant for 
                        which the determination under 
                        subparagraph (A) was made; and
                          (ii) such other information as the 
                        Secretary shall specify in order to 
                        enable the Secretary to make an 
                        appropriate determination concerning 
                        coordination of benefits, including any 
                        applicable recovery claim.
                Not later than 18 months after the date of 
                enactment of this sentence, the Secretary shall 
                modify the reporting requirements under this 
                paragraph so that an applicable plan in 
                complying with such requirements is permitted 
                but not required to access or report to the 
                Secretary beneficiary social security account 
                numbers or health identification claim numbers, 
                except that the deadline for such modification 
                shall be extended by one or more periods 
                (specified by the Secretary) of up to 1 year 
                each if the Secretary notifies the committees 
                of jurisdiction of the House of Representatives 
                and of the Senate that the prior deadline for 
                such modification, without such extension, 
                threatens patient privacy or the integrity of 
                the secondary payer program under this 
                subsection. Any such deadline extension notice 
                shall include information on the progress being 
                made in implementing such modification and the 
                anticipated implementation date for such 
                modification.
                  (C) Timing.--Information shall be submitted 
                under subparagraph (A)(ii) within a time 
                specified by the Secretary after the claim is 
                resolved through a settlement, judgment, award, 
                or other payment (regardless of whether or not 
                there is a determination or admission of 
                liability).
                  (D) Claimant.--For purposes of subparagraph 
                (A), the term ``claimant'' includes--
                          (i) an individual filing a claim 
                        directly against the applicable plan; 
                        and
                          (ii) an individual filing a claim 
                        against an individual or entity insured 
                        or covered by the applicable plan.
                  (E) Enforcement.--
                          (i) In general.--An applicable plan 
                        that fails to comply with the 
                        requirements under subparagraph (A) 
                        with respect to any claimant may be 
                        subject to a civil money penalty of up 
                        to $1,000 for each day of noncompliance 
                        with respect to each claimant. The 
                        provisions of subsections (e) and (k) 
                        of section 1128A shall apply to a civil 
                        money penalty under the previous 
                        sentence in the same manner as such 
                        provisions apply to a penalty or 
                        proceeding under section 1128A(a). A 
                        civil money penalty under this clause 
                        shall be in addition to any other 
                        penalties prescribed by law and in 
                        addition to any Medicare secondary 
                        payer claim under this title with 
                        respect to an individual.
                          (ii) Deposit of amounts collected.--
                        Any amounts collected pursuant to 
                        clause (i) shall be deposited in the 
                        Federal Hospital Insurance Trust Fund.
                  (F) Applicable plan.--In this paragraph, the 
                term ``applicable plan'' means the following 
                laws, plans, or other arrangements, including 
                the fiduciary or administrator for such law, 
                plan, or arrangement:
                          (i) Liability insurance (including 
                        self-insurance).
                          (ii) No fault insurance.
                          (iii) Workers' compensation laws or 
                        plans.
                  (G) Sharing of information.--The Secretary 
                may share information collected under this 
                paragraph as necessary for purposes of the 
                proper coordination of benefits.
                  (H) Implementation.--Notwithstanding any 
                other provision of law, the Secretary may 
                implement this paragraph by program instruction 
                or otherwise.
                  (I) Regulations.--Not later than 60 days 
                after the date of the enactment of this 
                subparagraph, the Secretary shall publish a 
                notice in the Federal Register soliciting 
                proposals, which will be accepted during a 60-
                day period, for the specification of practices 
                for which sanctions will and will not be 
                imposed under subparagraph (E), including not 
                imposing sanctions for good faith efforts to 
                identify a beneficiary pursuant to this 
                paragraph under an applicable entity 
                responsible for reporting information. After 
                considering the proposals so submitted, the 
                Secretary, in consultation with the Attorney 
                General, shall publish in the Federal Register, 
                including a 60-day period for comment, proposed 
                specified practices for which such sanctions 
                will and will not be imposed. After considering 
                any public comments received during such 
                period, the Secretary shall issue final rules 
                specifying such practices.
          (9) Exception.--
                  (A) In general.--Clause (ii) of paragraph 
                (2)(B) and any reporting required by paragraph 
                (8) shall not apply with respect to any 
                settlement, judgment, award, or other payment 
                by an applicable plan arising from liability 
                insurance (including self-insurance) and from 
                alleged physical trauma-based incidents 
                (excluding alleged ingestion, implantation, or 
                exposure cases) constituting a total payment 
                obligation to a claimant of not more than the 
                single threshold amount calculated by the 
                Secretary under subparagraph (B) for the year 
                involved.
                  (B) Annual computation of threshold.--
                          (i) In general.--Not later than 
                        November 15 before each year, the 
                        Secretary shall calculate and publish a 
                        single threshold amount for 
                        settlements, judgments, awards, or 
                        other payments for obligations arising 
                        from liability insurance (including 
                        self-insurance) and for alleged 
                        physical trauma-based incidents 
                        (excluding alleged ingestion, 
                        implantation, or exposure cases) 
                        subject to this section for that year. 
                        The annual single threshold amount for 
                        a year shall be set such that the 
                        estimated average amount to be credited 
                        to the Medicare trust funds of 
                        collections of conditional payments 
                        from such settlements, judgments, 
                        awards, or other payments arising from 
                        liability insurance (including self-
                        insurance) and for such alleged 
                        incidents subject to this section shall 
                        equal the estimated cost of collection 
                        incurred by the United States 
                        (including payments made to 
                        contractors) for a conditional payment 
                        arising from liability insurance 
                        (including self-insurance) and for such 
                        alleged incidents subject to this 
                        section for the year. At the time of 
                        calculating, but before publishing, the 
                        single threshold amount for 2014, the 
                        Secretary shall inform, and seek review 
                        of, the Comptroller General of the 
                        United States with regard to such 
                        amount.
                          (ii) Publication.--The Secretary 
                        shall include, as part of such 
                        publication for a year--
                                  (I) the estimated cost of 
                                collection incurred by the 
                                United States (including 
                                payments made to contractors) 
                                for a conditional payment 
                                arising from liability 
                                insurance (including self-
                                insurance) and for such alleged 
                                incidents; and
                                  (II) a summary of the 
                                methodology and data used by 
                                the Secretary in computing such 
                                threshold amount and such cost 
                                of collection.
                  (C) Exclusion of ongoing expenses.--For 
                purposes of this paragraph and with respect to 
                a settlement, judgment, award, or other payment 
                not otherwise addressed in clause (ii) of 
                paragraph (2)(B) that includes ongoing 
                responsibility for medical payments (excluding 
                settlements, judgments, awards, or other 
                payments made by a workers' compensation law or 
                plan or no fault insurance), the amount 
                utilized for calculation of the threshold 
                described in subparagraph (A) shall include 
                only the cumulative value of the medical 
                payments made under this title.
                  (D) Report to congress.--Not later than 
                November 15 before each year, the Secretary 
                shall submit to the Congress a report on the 
                single threshold amount for settlements, 
                judgments, awards, or other payments for 
                conditional payment obligations arising from 
                liability insurance (including self-insurance) 
                and alleged incidents described in subparagraph 
                (A) for that year and on the establishment and 
                application of similar thresholds for such 
                payments for conditional payment obligations 
                arising from worker compensation cases and from 
                no fault insurance cases subject to this 
                section for the year. For each such report, the 
                Secretary shall--
                          (i) calculate the threshold amount by 
                        using the methodology applicable to 
                        certain liability claims described in 
                        subparagraph (B); and
                          (ii) include a summary of the 
                        methodology and data used in 
                        calculating each threshold amount and 
                        the amount of estimated savings under 
                        this title achieved by the Secretary 
                        implementing each such threshold.
  (c) No payment may be made under part B for any expenses 
incurred for--
          (1) a drug product--
                  (A) which is described in section 107(c)(3) 
                of the Drug Amendments of 1962,
                  (B) which may be dispensed only upon 
                prescription,
                  (C) for which the Secretary has issued a 
                notice of an opportunity for a hearing under 
                subsection (e) of section 505 of the Federal 
                Food, Drug, and Cosmetic Act on a proposed 
                order of the Secretary to withdraw approval of 
                an application for such drug product under such 
                section because the Secretary has determined 
                that the drug is less than effective for all 
                conditions of use prescribed, recommended, or 
                suggested in its labeling, and
                  (D) for which the Secretary has not 
                determined there is a compelling justification 
                for its medical need; and
          (2) any other drug product--
                  (A) which is identical, related, or similar 
                (as determined in accordance with section 310.6 
                of title 21 of the Code of Federal Regulations) 
                to a drug product described in paragraph (1), 
                and
                  (B) for which the Secretary has not 
                determined there is a compelling justification 
                for its medical need,
until such time as the Secretary withdraws such proposed order.
  (d) For purposes of subsection (a)(1)(A), in the case of any 
item or service that is required to be provided pursuant to 
section 1867 to an individual who is entitled to benefits under 
this title, determinations as to whether the item or service is 
reasonable and necessary shall be made on the basis of the 
information available to the treating physician or practitioner 
(including the patient's presenting symptoms or complaint) at 
the time the item or service was ordered or furnished by the 
physician or practitioner (and not on the patient's principal 
diagnosis). When making such determinations with respect to 
such an item or service, the Secretary shall not consider the 
frequency with which the item or service was provided to the 
patient before or after the time of the admission or visit.
  (e)(1) No payment may be made under this title with respect 
to any item or service (other than an emergency item or 
service, not including items or services furnished in an 
emergency room of a hospital) furnished--
          (A) by an individual or entity during the period when 
        such individual or entity is excluded pursuant to 
        section 1128, 1128A, 1156 or 1842(j)(2) from 
        participation in the program under this title; or
          (B) at the medical direction or on the prescription 
        of a physician during the period when he is excluded 
        pursuant to section 1128, 1128A, 1156 or 1842(j)(2) 
        from participation in the program under this title and 
        when the person furnishing such item or service knew or 
        had reason to know of the exclusion (after a reasonable 
        time period after reasonable notice has been furnished 
        to the person).
  (2) Where an individual eligible for benefits under this 
title submits a claim for payment for items or services 
furnished by an individual or entity excluded from 
participation in the programs under this title, pursuant to 
section 1128, 1128A, 1156, 1160 (as in effect on September 2, 
1982), 1842(j)(2), 1862(d) (as in effect on the date of the 
enactment of the Medicare and Medicaid Patient and Program 
Protection Act of 1987), or l866, and such beneficiary did not 
know or have reason to know that such individual or entity was 
so excluded, then, to the extent permitted by this title, and 
notwithstanding such exclusion, payment shall be made for such 
items or services. In each such case the Secretary shall notify 
the beneficiary of the exclusion of the individual or entity 
furnishing the items or services. Payment shall not be made for 
items or services furnished by an excluded individual or entity 
to a beneficiary after a reasonable time (as determined by the 
Secretary in regulations) after the Secretary has notified the 
beneficiary of the exclusion of that individual or entity.
  (f) The Secretary shall establish utilization guidelines for 
the determination of whether or not payment may be made, 
consistent with paragraph (1)(A) of subsection (a), under part 
A or part B for expenses incurred with respect to the provision 
of home health services, and shall provide for the 
implementation of such guidelines through a process of 
selective postpayment coverage review by intermediaries or 
otherwise.
  (g) The Secretary shall, in making the determinations under 
paragraphs (1) and (9) of subsection (a), and for the purposes 
of promoting the effective, efficient, and economical delivery 
of health care services, and of promoting the quality of 
services of the type for which payment may be made under this 
title, enter into contracts with quality improvement 
organizations pursuant to part B of title XI of this Act.
  (h)(1) The Secretary--
          (A) shall waive the application of subsection (a)(22) 
        in cases in which--
                  (i) there is no method available for the 
                submission of claims in an electronic form; or
                  (ii) the entity submitting the claim is a 
                small provider of services or supplier; and
          (B) may waive the application of such subsection in 
        such unusual cases as the Secretary finds appropriate.
  (2) For purposes of this subsection, the term ``small 
provider of services or supplier'' means--
          (A) a provider of services with fewer than 25 full-
        time equivalent employees; or
          (B) a physician, practitioner, facility, or supplier 
        (other than provider of services) with fewer than 10 
        full-time equivalent employees.
  (i) In order to supplement the activities of the Medicare 
Payment Advisory Commission under section 1886(e) in assessing 
the safety, efficacy, and cost-effectiveness of new and 
existing medical procedures, the Secretary may carry out, or 
award grants or contracts for, original research and 
experimentation of the type described in clause (ii) of section 
1886(e)(6)(E) with respect to such a procedure if the Secretary 
finds that--
          (1) such procedure is not of sufficient commercial 
        value to justify research and experimentation by a 
        commercial organization;
          (2) research and experimentation with respect to such 
        procedure is not of a type that may appropriately be 
        carried out by an institute, division, or bureau of the 
        National Institutes of Health; and
          (3) such procedure has the potential to be more cost-
        effective in the treatment of a condition than 
        procedures currently in use with respect to such 
        condition.
  (j)(1) Any advisory committee appointed to advise the 
Secretary on matters relating to the interpretation, 
application, or implementation of subsection (a)(1) shall 
assure the full participation of a nonvoting member in the 
deliberations of the advisory committee, and shall provide such 
nonvoting member access to all information and data made 
available to voting members of the advisory committee, other 
than information that--
          (A) is exempt from disclosure pursuant to subsection 
        (a) of section 552 of title 5, United States Code, by 
        reason of subsection (b)(4) of such section (relating 
        to trade secrets); or
          (B) the Secretary determines would present a conflict 
        of interest relating to such nonvoting member.
  (2) If an advisory committee described in paragraph (1) 
organizes into panels of experts according to types of items or 
services considered by the advisory committee, any such panel 
of experts may report any recommendation with respect to such 
items or services directly to the Secretary without the prior 
approval of the advisory committee or an executive committee 
thereof.
  (k)(1) Subject to paragraph (2), a group health plan (as 
defined in subsection (a)(1)(A)(v)) providing supplemental or 
secondary coverage to individuals also entitled to services 
under this title shall not require a medicare claims 
determination under this title for dental benefits specifically 
excluded under subsection (a)(12) as a condition of making a 
claims determination for such benefits under the group health 
plan.
  (2) A group health plan may require a claims determination 
under this title in cases involving or appearing to involve 
inpatient dental hospital services or dental services expressly 
covered under this title pursuant to actions taken by the 
Secretary.
  (l) National and Local Coverage Determination Process.--
          (1) Factors and evidence used in making national 
        coverage determinations.--The Secretary shall make 
        available to the public the factors considered in 
        making national coverage determinations of whether an 
        item or service is reasonable and necessary. The 
        Secretary shall develop guidance documents to carry out 
        this paragraph in a manner similar to the development 
        of guidance documents under section 701(h) of the 
        Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
        371(h)).
          (2) Timeframe for decisions on requests for national 
        coverage determinations.--In the case of a request for 
        a national coverage determination that--
                  (A) does not require a technology assessment 
                from an outside entity or deliberation from the 
                Medicare Coverage Advisory Committee, the 
                decision on the request shall be made not later 
                than 6 months after the date of the request; or
                  (B) requires such an assessment or 
                deliberation and in which a clinical trial is 
                not requested, the decision on the request 
                shall be made not later than 9 months after the 
                date of the request.
          (3) Process for public comment in national coverage 
        determinations.--
                  (A) Period for proposed decision.--Not later 
                than the end of the 6-month period (or 9-month 
                period for requests described in paragraph 
                (2)(B)) that begins on the date a request for a 
                national coverage determination is made, the 
                Secretary shall make a draft of proposed 
                decision on the request available to the public 
                through the Internet website of the Centers for 
                Medicare & Medicaid Services or other 
                appropriate means.
                  (B)  30-day period for public comment.--
                Beginning on the date the Secretary makes a 
                draft of the proposed decision available under 
                subparagraph (A), the Secretary shall provide a 
                30-day period for public comment on such draft.
                  (C)  60-day period for final decision.--Not 
                later than 60 days after the conclusion of the 
                30-day period referred to under subparagraph 
                (B), the Secretary shall--
                          (i) make a final decision on the 
                        request;
                          (ii) include in such final decision 
                        summaries of the public comments 
                        received and responses to such 
                        comments;
                          (iii) make available to the public 
                        the clinical evidence and other data 
                        used in making such a decision when the 
                        decision differs from the 
                        recommendations of the Medicare 
                        Coverage Advisory Committee; and
                          (iv) in the case of a final decision 
                        under clause (i) to grant the request 
                        for the national coverage 
                        determination, the Secretary shall 
                        assign a temporary or permanent code 
                        (whether existing or unclassified) and 
                        implement the coding change.
          (4) Consultation with outside experts in certain 
        national coverage determinations.--With respect to a 
        request for a national coverage determination for which 
        there is not a review by the Medicare Coverage Advisory 
        Committee, the Secretary shall consult with appropriate 
        outside clinical experts.
          (5) Local coverage determination process.--
                  (A) Plan to promote consistency of coverage 
                determinations.--The Secretary shall develop a 
                plan to evaluate new local coverage 
                determinations to determine which 
                determinations should be adopted nationally and 
                to what extent greater consistency can be 
                achieved among local coverage determinations.
                  (B) Consultation.--The Secretary shall 
                require the fiscal intermediaries or carriers 
                providing services within the same area to 
                consult on all new local coverage 
                determinations within the area.
                  (C) Dissemination of information.--The 
                Secretary should serve as a center to 
                disseminate information on local coverage 
                determinations among fiscal intermediaries and 
                carriers to reduce duplication of effort.
                  (D) Local coverage determinations.--The 
                Secretary shall require each Medicare 
                administrative contractor that develops a local 
                coverage determination to make available on the 
                Internet website of such contractor and on the 
                Medicare Internet website, at least 45 days 
                before the effective date of such 
                determination, the following information:
                          (i) Such determination in its 
                        entirety.
                          (ii) Where and when the proposed 
                        determination was first made public.
                          (iii) Hyperlinks to the proposed 
                        determination and a response to 
                        comments submitted to the contractor 
                        with respect to such proposed 
                        determination.
                          (iv) A summary of evidence that was 
                        considered by the contractor during the 
                        development of such determination and a 
                        list of the sources of such evidence.
                          (v) An explanation of the rationale 
                        that supports such determination.
          (6) National and local coverage determination 
        defined.--For purposes of this subsection--
                  (A) National coverage determination.--The 
                term ``national coverage determination'' means 
                a determination by the Secretary with respect 
                to whether or not a particular item or service 
                is covered nationally under this title.
                  (B) Local coverage determination.--The term 
                ``local coverage determination'' has the 
                meaning given that in section 1869(f)(2)(B).
  (m) Coverage of Routine Costs Associated With Certain 
Clinical Trials of Category A Devices.--
          (1) In general.--In the case of an individual 
        entitled to benefits under part A, or enrolled under 
        part B, or both who participates in a category A 
        clinical trial, the Secretary shall not exclude under 
        subsection (a)(1) payment for coverage of routine costs 
        of care (as defined by the Secretary) furnished to such 
        individual in the trial.
          (2) Category a clinical trial.--For purposes of 
        paragraph (1), a ``category A clinical trial'' means a 
        trial of a medical device if--
                  (A) the trial is of an experimental/
                investigational (category A) medical device (as 
                defined in regulations under section 405.201(b) 
                of title 42, Code of Federal Regulations (as in 
                effect as of September 1, 2003));
                  (B) the trial meets criteria established by 
                the Secretary to ensure that the trial conforms 
                to appropriate scientific and ethical 
                standards; and
                  (C) in the case of a trial initiated before 
                January 1, 2010, the device involved in the 
                trial has been determined by the Secretary to 
                be intended for use in the diagnosis, 
                monitoring, or treatment of an immediately 
                life-threatening disease or condition.
  (n) Requirement of a Surety Bond for Certain Providers of 
Services and Suppliers.--
          (1) In general.--The Secretary may require a provider 
        of services or supplier described in paragraph (2) to 
        provide the Secretary on a continuing basis with a 
        surety bond in a form specified by the Secretary in an 
        amount (not less than $50,000) that the Secretary 
        determines is commensurate with the volume of the 
        billing of the provider of services or supplier. The 
        Secretary may waive the requirement of a bond under the 
        preceding sentence in the case of a provider of 
        services or supplier that provides a comparable surety 
        bond under State law.
          (2) Provider of services or supplier described.--A 
        provider of services or supplier described in this 
        paragraph is a provider of services or supplier the 
        Secretary determines appropriate based on the level of 
        risk involved with respect to the provider of services 
        or supplier, and consistent with the surety bond 
        requirements under sections 1834(a)(16)(B) and 
        1861(o)(7)(C).
  (o) Suspension of Payments Pending Investigation of Credible 
Allegations of Fraud.--
          (1) In general.--The Secretary may suspend payments 
        to a provider of services or supplier under this title 
        pending an investigation of a credible allegation of 
        fraud against the provider of services or supplier, 
        unless the Secretary determines there is good cause not 
        to suspend such payments.
          (2) Consultation.--The Secretary shall consult with 
        the Inspector General of the Department of Health and 
        Human Services in determining whether there is a 
        credible allegation of fraud against a provider of 
        services or supplier.
          (3) Promulgation of regulations.--The Secretary shall 
        promulgate regulations to carry out this subsection, 
        section 1860D-12(b)(7) (including as applied pursuant 
        to section 1857(f)(3)(D)), and section 1903(i)(2)(C).
          (4) Credible allegation of fraud.--In carrying out 
        this subsection, section 1860D-12(b)(7) (including as 
        applied pursuant to section 1857(f)(3)(D)), and section 
        1903(i)(2)(C), a fraud hotline tip (as defined by the 
        Secretary) without further evidence shall not be 
        treated as sufficient evidence for a credible 
        allegation of fraud.
  (p) Treatment of Qualified Medicare Beneficiaries (QMBS), 
Specified Low-income Medicare Beneficiaries (SLMBS), and Other 
Dual Eligibles.--Nothing in this title shall be construed as 
authorizing a provider of services or supplier to discriminate 
(through a private contractual arrangement or otherwise) 
against an individual who is otherwise entitled to services 
under this title on the basis that the individual is a 
qualified medicare beneficiary (as defined in section 
1905(p)(1)), a specified low-income medicare beneficiary, or is 
otherwise eligible for medical assistance for medicare cost-
sharing or other benefits under title XIX.

           *       *       *       *       *       *       *


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 subdivisions of the State, and, if 
        administered by them, be mandatory upon them;
          (2) provide for financial participation by the State 
        equal to not less than 40 per centum of the non-Federal 
        share of the expenditures under the plan with respect 
        to which payments under 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 distribution of 
        funds from Federal or State sources, for carrying out 
        the State plan, on an equalization or other basis which 
        will assure 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 before the State agency to any individual whose 
        claim for medical assistance under the plan is denied 
        or is not acted upon with reasonable promptness;
          (4) provide (A) such methods of administration 
        (including methods relating to the establishment and 
        maintenance of personnel standards on a merit basis, 
        except that the Secretary shall exercise no authority 
        with respect to the selection, tenure of office, and 
        compensation of any individual employed in accordance 
        with such methods, and including provision for 
        utilization of professional medical personnel in the 
        administration and, where administered locally, 
        supervision of administration of the plan) as are found 
        by the Secretary to be necessary for the proper and 
        efficient operation of the plan, (B) for the training 
        and effective use of paid subprofessional staff, with 
        particular emphasis on the full-time or part-time 
        employment of recipients and other persons of low 
        income, as community service aides, in the 
        administration of the plan and for the use of nonpaid 
        or partially paid volunteers in a social service 
        volunteer program in providing services to applicants 
        and recipients and in assisting any advisory committees 
        established by the State agency, (C) that each State or 
        local officer, employee, or independent contractor who 
        is responsible for the expenditure of substantial 
        amounts of funds under the State plan, each individual 
        who formerly was such an officer, employee, or 
        contractor, and each partner of such an officer, 
        employee, or contractor shall be prohibited from 
        committing any act, in relation to any activity under 
        the plan, the commission of which, in connection with 
        any activity concerning the United States Government, 
        by an officer or employee of the United States 
        Government, an individual who was such an officer or 
        employee, or a partner of such an officer or employee 
        is prohibited by 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 services under the State plan shall be subject to 
        safeguards against conflicts of interest that are at 
        least as stringent as the safeguards that apply under 
        section 27 of the Office of Federal Procurement 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 administration of the plan; or provide 
        for the establishment or designation of a single State 
        agency to administer or to supervise the administration 
        of the plan, except that the determination of 
        eligibility for medical assistance under the plan shall 
        be made by the State or local agency administering the 
        State plan approved under 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 administering 
        the supplemental security income program established 
        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 provisions as the Secretary may from 
        time to time find necessary to assure the correctness 
        and verification of such reports;
          (7) provide--
                  (A) safeguards which restrict the use or 
                disclosure of information concerning applicants 
                and recipients to purposes directly connected 
                with--
                          (i) the administration of the plan; 
                        and
                          (ii) the exchange of information 
                        necessary to certify or verify the 
                        certification of eligibility of 
                        children for free or reduced price 
                        breakfasts under the Child Nutrition 
                        Act of 1966 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 program 
                established under the Richard B. Russell 
                National School Lunch Act under which the State 
                shall establish procedures to ensure that--
                          (i) a child receiving medical 
                        assistance under the State plan under 
                        this 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 Richard B. Russell National School 
                        Lunch Act (42 U.S.C. 1751 et seq.) or 
                        the school breakfast program 
                        established 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 reasonable promptness to all 
        eligible individuals;
          (9) provide--
                  (A) that the State health agency, or other 
                appropriate State medical agency (whichever is 
                utilized by the Secretary for the purpose 
                specified in the first sentence of section 
                1864(a)), shall be responsible for establishing 
                and maintaining health standards for private or 
                public institutions in which recipients of 
                medical assistance under the plan may receive 
                care or services,
                  (B) for the establishment or designation of a 
                State authority or authorities which shall be 
                responsible for establishing and maintaining 
                standards, other than those relating to health, 
                for such institutions,
                  (C) that any laboratory services paid for 
                under such plan must be provided by a 
                laboratory which meets the applicable 
                requirements of 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 inspection reports (or a successor form), 
                complaint investigation reports, the facility's 
                plan of correction, and such other information 
                that the State or the Secretary considers 
                useful in assisting the public to assess the 
                quality of long term care options and the 
                quality of care provided by individual 
                facilities;
          (10) provide--
                  (A) for making medical assistance available, 
                including at least the care and services listed 
                in paragraphs (1) through (5), (17), (21), 
                (28), and (29) 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 (including 
                                individuals eligible under this 
                                title by reason of section 
                                402(a)(37), 406(h), or 473(b), 
                                or considered by the State to 
                                be receiving such aid as 
                                authorized under section 
                                482(e)(6)),
                                  (II)(aa) with respect to whom 
                                supplemental security income 
                                benefits are being paid under 
                                title XVI (or were being paid 
                                as of the date of the enactment 
                                of section 211(a) of the 
                                Personal Responsibility and 
                                Work Opportunity Reconciliation 
                                Act of 1996 (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 following'',
                                  (III) who are qualified 
                                pregnant women or children 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 exceed the income 
                                level the State is required to 
                                establish under subsection 
                                (l)(2)(B) for such a family,
                                  (VII) who are described in 
                                subparagraph (D) of subsection 
                                (l)(1) and whose family income 
                                does not exceed the income 
                                level the State is required to 
                                establish under subsection 
                                (l)(2)(C) for such a family;
                                  (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 
                                subclause of this clause, and 
                                whose income (as determined 
                                under subsection (e)(14)) does 
                                not exceed 133 percent of the 
                                poverty line (as defined in 
                                section 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 subclauses but 
                                        have income that 
                                        exceeds the level of 
                                        income applicable under 
                                        the State plan for 
                                        eligibility to enroll 
                                        for medical assistance 
                                        under such subclause;
                                          (cc) were in foster 
                                        care under the 
                                        responsibility of 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 subparagraph but--
                                  (I) who meet the income and 
                                resources requirements of the 
                                appropriate State plan 
                                described in clause (i) or the 
                                supplemental security income 
                                program (as the case may be),
                                  (II) who would meet the 
                                income and resources 
                                requirements of the appropriate 
                                State plan described in clause 
                                (i) if their work-related child 
                                care costs were paid from their 
                                earnings rather than by a State 
                                agency as a service 
                                expenditure,
                                  (III) who would be eligible 
                                to receive aid under the 
                                appropriate State plan 
                                described in clause (i) if 
                                coverage under such plan was as 
                                broad as allowed under Federal 
                                law,
                                  (IV) with respect to whom 
                                there is being paid, or who are 
                                eligible, or would be eligible 
                                if they were not in a medical 
                                institution, to have paid with 
                                respect to them, aid or 
                                assistance under the 
                                appropriate State plan 
                                described in clause (i), 
                                supplemental security income 
                                benefits under 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 eligibility by reason of 
                                this subclause beginning on the 
                                first day of such period), who 
                                meet the resource requirements 
                                of the appropriate State plan 
                                described in clause (i) or the 
                                supplemental security income 
                                program, and whose income does 
                                not exceed a separate income 
                                standard established by the 
                                State which is consistent with 
                                the limit established under 
                                section 1903(f)(4)(C),
                                  (VI) who would be eligible 
                                under the State plan under this 
                                title if they were in a medical 
                                institution, with respect to 
                                whom there has been a 
                                determination that but for the 
                                provision of home or community-
                                based services described in 
                                subsection (c), (d), or (e) of 
                                section 1915 they would require 
                                the level of care provided in a 
                                hospital, nursing facility 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 
                                institution, who are terminally 
                                ill, and who will receive 
                                hospice care pursuant to a 
                                voluntary election described 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 agreement 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 
                                        assistance agreement 
                                        being entered into, or 
                                        who would have been 
                                        eligible for medical 
                                        assistance at such time 
                                        if the eligibility 
                                        standards and 
                                        methodologies of the 
                                        State's foster care 
                                        program under part E of 
                                        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;
                                  (IX) who are described in 
                                subsection (l)(1) and are not 
                                described in clause (i)(IV), 
                                clause (i)(VI), or clause 
                                (i)(VII);
                                  (X) who are described in 
                                subsection (m)(1);
                                  (XI) who receive only an 
                                optional State supplementary 
                                payment based on need and paid 
                                on a regular basis, equal to 
                                the difference between the 
                                individual's countable income 
                                and the income standard used to 
                                determine eligibility for such 
                                supplementary payment (with 
                                countable income being the 
                                income remaining after 
                                deductions as established by 
                                the State pursuant to standards 
                                that may be more restrictive 
                                than the standards for 
                                supplementary security income 
                                benefits under title XVI), 
                                which are available to all 
                                individuals in the State (but 
                                which may be based on different 
                                income standards by political 
                                subdivision according to cost 
                                of living differences), and 
                                which are paid by a State that 
                                does not have an agreement with 
                                the Commissioner of Social 
                                Security under section 1616 or 
                                1634;
                                  (XII) who are described in 
                                subsection (z)(1) (relating 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 
                                Reconciliation 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-sharing 
                                charges (set on a sliding scale 
                                based on income) that the State 
                                may determine);
                                  (XIV) who are optional 
                                targeted low-income children 
                                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 
                                limitations (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 
                                establish, but only if the 
                                State provides medical 
                                assistance to individuals 
                                described in subclause (XV);
                                  (XVII) who are independent 
                                foster care adolescents (as 
                                defined in section 1905(w)(1)), 
                                or who are within any 
                                reasonable categories of such 
                                adolescents specified by the 
                                State;
                                  (XVIII) who are described in 
                                subsection (aa) (relating to 
                                certain breast or cervical 
                                cancer patients);
                                  (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 
                                enrolled under a previous 
                                subclause of this clause, and 
                                whose income (as determined 
                                under subsection (e)(14)) 
                                exceeds 133 percent of the 
                                poverty line (as defined in 
                                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) (relating to 
                                individuals who meet certain 
                                income standards); or
                                  (XXII) 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 section, and who will 
                                receive home and community-
                                based services pursuant to a 
                                State plan amendment under such 
                                subsection;
                  (B) that the medical assistance made 
                available to any individual described in 
                subparagraph (A)--
                          (i) shall not be less in amount, 
                        duration, or scope than the medical 
                        assistance made available to any other 
                        such individual, and
                          (ii) shall not be less in amount, 
                        duration, or scope than the medical 
                        assistance made available to 
                        individuals not described in 
                        subparagraph (A);
                  (C) that if medical assistance is included 
                for any group of individuals described in 
                section 1905(a) who are not described in 
                subparagraph (A) or (E), then--
                          (i) the plan must include a 
                        description of (I) the criteria for 
                        determining eligibility of individuals 
                        in the group for such medical 
                        assistance, (II) the amount, duration, 
                        and scope of medical assistance made 
                        available to individuals in the group, 
                        and (III) the single standard to be 
                        employed in determining income and 
                        resource eligibility for all such 
                        groups, and the methodology to be 
                        employed in determining such 
                        eligibility, which shall be no more 
                        restrictive than the methodology which 
                        would be employed under the 
                        supplemental security income program in 
                        the case of groups consisting of aged, 
                        blind, or disabled individuals in a 
                        State in which such program is in 
                        effect, and which shall be no more 
                        restrictive than the methodology which 
                        would be employed under the appropriate 
                        State plan (described in subparagraph 
                        (A)(i)) to which such group is most 
                        closely categorically related in the 
                        case of other groups;
                          (ii) the plan must make available 
                        medical assistance--
                                  (I) to individuals under the 
                                age of 18 who (but for income 
                                and resources) would be 
                                eligible for medical assistance 
                                as an individual described in 
                                subparagraph (A)(i), and
                                  (II) to pregnant women, 
                                during the course of their 
                                pregnancy, who (but for income 
                                and resources) would be 
                                eligible for medical assistance 
                                as an individual described in 
                                subparagraph (A);
                          (iii) such medical assistance must 
                        include (I) with respect to children 
                        under 18 and individuals entitled to 
                        institutional services, ambulatory 
                        services, and (II) with respect to 
                        pregnant women, prenatal care and 
                        delivery services; and
                          (iv) if such medical assistance 
                        includes services in institutions for 
                        mental diseases or in an intermediate 
                        care facility for the mentally retarded 
                        (or both) for any such group, it also 
                        must include for all groups covered at 
                        least the care and services listed in 
                        paragraphs (1) through (5) and (17) of 
                        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 individual who, under the State plan, 
                is entitled to nursing facility services;
                  (E)(i) for making medical assistance 
                available for medicare cost-sharing (as defined 
                in 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 individuals described in 
                section 1905(s); and
                  (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) 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] 120 
                percent in 1995 and years thereafter before 
                2021, and 200 percent in 2021 and years 
                thereafter of the official poverty line 
                (referred 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 described 
                in section 1905(p)(3)(A)(ii) for individuals 
                who would be qualified medicare beneficiaries 
                described in section 1905(p)(1) 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 section) for a family 
                of the size involved and who are not otherwise 
                eligible for medical assistance under the State 
                plan;]
                  (F) at the option of a State, for making 
                medical assistance available for COBRA premiums 
                (as defined in subsection (u)(2)) for qualified 
                COBRA continuation beneficiaries described in 
                section 1902(u)(1); and
                  (G) that, in applying eligibility criteria of 
                the supplemental security income program under 
                title XVI for purposes of determining 
                eligibility for medical assistance under the 
                State plan of an individual who is not 
                receiving supplemental security income, the 
                State will disregard the provisions of 
                subsections (c) and (e) of 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 eligible 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 
        individuals), 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 services of the same amount, duration, and scope, to 
        any other individuals, (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 respect to 
        whom there is being paid, or who are eligible, or would 
        be eligible if they were not in a medical institution, 
        to have paid with respect to them, a State 
        supplementary payment 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 imposition 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 pregnant women covered under the plan of 
        services relating to pregnancy (including prenatal, 
        delivery, and postpartum services) 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 services of the same amount, duration, and scope, 
        to any other individuals, provided such services are 
        made available (in the same amount, duration, and 
        scope) to all pregnant women covered 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 assistance 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 (including prenatal, 
        delivery, postpartum, and family planning services) and 
        to other conditions which may complicate pregnancy, 
        (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 making 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 condition or diagnosis), the 
        plan must establish exceptions to such a limit for 
        medically necessary inpatient hospital services 
        furnished 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 subparagraph (B) 
        (relating to comparability) shall not be construed as 
        requiring such an exception for other individuals, 
        services, or hospitals, (XI) the making available of 
        medical assistance to cover the costs of premiums, 
        deductibles, coinsurance, 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 same amount, duration, and scope of 
        such private coverage to any other individuals, (XII) 
        the medical assistance made available to an individual 
        described in subsection (u)(1) who is eligible 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 subsection (z)(1) who is 
        eligible for medical assistance only because of 
        subparagraph (A)(ii)(XII) shall be limited to medical 
        assistance for TB-related services (described in 
        subsection (z)(2)), (XIV) the medical assistance made 
        available to an individual described in subsection (aa) 
        who is eligible for medical assistance only because of 
        subparagraph (A)(10)(ii)(XVIII) shall be limited to 
        medical assistance provided during the period in which 
        such an individual requires treatment for breast or 
        cervical cancer (XV) the medical assistance made 
        available to an individual described in subparagraph 
        (A)(i)(VIII) shall be limited to medical assistance 
        described in subsection (k)(1), (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) including medical diagnosis and treatment 
        services that are provided pursuant to a family 
        planning service in a family planning setting and 
        (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);
          (11)(A) provide for entering into cooperative 
        arrangements with the State agencies responsible for 
        administering or supervising the administration of 
        health services and vocational rehabilitation services 
        in the State looking toward maximum utilization of such 
        services in the provision of medical assistance under 
        the plan, (B) provide, to the extent prescribed by the 
        Secretary, for entering into agreements, with any 
        agency, institution, or organization receiving payments 
        under (or through an allotment under) title V, (i) 
        providing for utilizing such agency, institution, or 
        organization in furnishing care and services which are 
        available under such title or allotment and which are 
        included in the State plan approved under this section 
        (ii) making such provision as may be appropriate for 
        reimbursing such agency, institution, or organization 
        for the cost of any such care and services furnished 
        any individual for which payment would otherwise be 
        made to the State with respect to the individual under 
        section 1903, and (iii) providing for coordination of 
        information and education on pediatric vaccinations and 
        delivery of immunization services, and (C) provide for 
        coordination of the operations under this title, 
        including the provision of information and education on 
        pediatric vaccinations and the delivery of immunization 
        services, with the State's operations under the special 
        supplemental nutrition program for women, infants, and 
        children under section 17 of the Child Nutrition 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 individual may select;
          (13) provide--
                  (A) for a public process for determination of 
                rates of payment under the plan for hospital 
                services, nursing facility services, and 
                services of intermediate care facilities for 
                the mentally retarded under which--
                          (i) proposed rates, the methodologies 
                        underlying the establishment of such 
                        rates, and justifications for the 
                        proposed rates are published,
                          (ii) providers, beneficiaries and 
                        their representatives, and other 
                        concerned State residents are given a 
                        reasonable opportunity for review and 
                        comment on the proposed rates, 
                        methodologies, and justifications,
                          (iii) final rates, the methodologies 
                        underlying the establishment of such 
                        rates, and justifications for such 
                        final rates are published, and
                          (iv) in the case of hospitals, such 
                        rates take into account (in a manner 
                        consistent with section 1923) the 
                        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 intermediate 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 
                individual; and
                  (C) payment for primary care services (as 
                defined in subsection (jj)) furnished in 2013 
                and 2014 by a physician with a primary 
                specialty designation of family medicine, 
                general internal medicine, or pediatric 
                medicine at a rate not less than 100 percent of 
                the payment rate that applies to such services 
                and physician under part B of 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 
        regulations prescribed by the Secretary, of provisions 
        (conforming to such regulations) with respect to the 
        furnishing of medical assistance under the plan to 
        individuals who are residents of the State but are 
        absent therefrom;
          (17) except as provided in subsections (e)(14), 
        (e)(15), (l)(3), (m)(3), and (m)(4), include reasonable 
        standards (which shall be comparable for all groups and 
        may, in accordance with standards prescribed by the 
        Secretary, differ with respect to income levels, but 
        only in the case of applicants or recipients of 
        assistance under the plan who are not receiving aid or 
        assistance under any plan of the State approved under 
        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, as determined in accordance with 
        standards prescribed by the Secretary, available to the 
        applicant or recipient and (in the case of any 
        applicant or recipient who would, except for income and 
        resources, be eligible for aid or assistance in the 
        form of money payments under any plan of the State 
        approved under 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, 
        assistance, or benefits, (C) provide for reasonable 
        evaluation of any such income or resources, and (D) do 
        not take into account the financial responsibility of 
        any individual for any applicant or recipient of 
        assistance under the plan unless such applicant or 
        recipient is such individual's spouse or such 
        individual's child who is under age 21 or (with respect 
        to States eligible to participate in the State program 
        established under title XVI), is blind or permanently 
        and totally disabled, or is blind or disabled 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 correctly 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 determined, and such care and services 
        will be provided, in a manner consistent with 
        simplicity of administration and the best interests of 
        the recipients;
          (20) if the State plan includes medical assistance in 
        behalf of individuals 65 years of age or older who are 
        patients in institutions for mental diseases--
                  (A) provide for having in effect such 
                agreements or other arrangements with State 
                authorities concerned with mental diseases, 
                and, where appropriate, with such institutions, 
                as may be necessary for carrying out the State 
                plan, including arrangements for joint planning 
                and for development of alternate methods of 
                care, arrangements providing assurance of 
                immediate readmittance to institutions where 
                needed for individuals under alternate plans of 
                care, and arrangements providing for access to 
                patients and facilities, for furnishing 
                information, and for making reports;
                  (B) provide for an individual plan for each 
                such patient to assure that the institutional 
                care provided to him is in his best interests, 
                including, to that end, assurances that there 
                will be initial and periodic review of his 
                medical and other needs, that he will be given 
                appropriate medical treatment within the 
                institution, and that there will be a periodic 
                determination of his need for continued 
                treatment in the institution; and
                  (C) provide for the development of alternate 
                plans of care, making maximum utilization of 
                available resources, for recipients 65 years of 
                age or older who would otherwise need care in 
                such institutions, including appropriate 
                medical treatment and other aid or assistance; 
                for services referred to in section 
                3(a)(4)(A)(i) and (ii) or section 
                1603(a)(4)(A)(i) and (ii) which are appropriate 
                for such recipients and for such patients; and 
                for methods of administration necessary to 
                assure that the responsibilities of the State 
                agency under the State plan with respect to 
                such recipients and such patients will be 
                effectively carried out;
          (21) if the State plan includes medical assistance in 
        behalf of individuals 65 years of age or older who are 
        patients in public institutions for mental diseases, 
        show that the State is making satisfactory progress 
        toward developing and implementing a comprehensive 
        mental health program, including provision for 
        utilization of community mental health centers, nursing 
        facilities, and other alternatives to care in public 
        institutions for mental diseases;
          (22) include descriptions of (A) the kinds and 
        numbers of professional medical personnel and 
        supporting staff that will be used in the 
        administration of the plan and of the responsibilities 
        they will have, (B) the standards, for private or 
        public institutions in which recipients of medical 
        assistance under the plan may receive care or services, 
        that will be utilized by the State authority or 
        authorities responsible for establishing and 
        maintaining such standards, (C) the cooperative 
        arrangements with State health agencies and State 
        vocational rehabilitation agencies entered into with a 
        view to maximum utilization of and coordination of the 
        provision of medical assistance with the services 
        administered or supervised by such agencies, and (D) 
        other standards and methods that the State will use to 
        assure that medical or remedial care and services 
        provided to recipients of medical assistance are of 
        high quality;
          (23) provide that (A) any individual eligible for 
        medical assistance (including drugs) may obtain such 
        assistance from any institution, agency, community 
        pharmacy, or person, qualified to perform the service 
        or services required (including an organization which 
        provides such services, or arranges for their 
        availability, on a prepayment basis), who undertakes to 
        provide him such services, and (B) an enrollment of an 
        individual eligible for medical assistance in a primary 
        care case-management system (described in section 
        1915(b)(1)), a medicaid managed 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 paragraph shall not apply in the case of 
        Puerto Rico, the Virgin Islands, and Guam, and except 
        that nothing in this paragraph shall be construed as 
        requiring a State to provide medical assistance for 
        such services furnished by a person or entity convicted 
        of a felony under Federal or State law for an offense 
        which the State agency determines is inconsistent with 
        the best interests of beneficiaries under the State 
        plan or by a provider or supplier to which a moratorium 
        under subsection (kk)(4) is applied during the period 
        of such moratorium';
          (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 administration 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 section 607(1) of the 
                Employee Retirement Income Security Act of 
                1974), service benefit plans, managed care 
                organizations, 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, including--
                          (i) the collection of sufficient 
                        information (as specified by the 
                        Secretary in regulations) to enable the 
                        State to pursue claims against such 
                        third parties, with such information 
                        being collected at the time of any 
                        determination or redetermination of 
                        eligibility for medical assistance, and
                          (ii) the submission to the Secretary 
                        of a plan (subject to approval by the 
                        Secretary) for pursuing claims against 
                        such third parties, which plan shall be 
                        integrated with, and be monitored as a 
                        part of the Secretary's review of, the 
                        State's mechanized claims processing 
                        and information retrieval systems 
                        required under 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 
                reimbursement the State can reasonably expect 
                to recover exceeds the costs of such recovery, 
                the State or local agency will seek 
                reimbursement for such assistance to the extent 
                of such legal liability;
                  (C) that in the case of an individual who is 
                entitled to medical assistance under the State 
                plan with respect to a service for which a 
                third party is liable for payment, the person 
                furnishing the service may not seek to collect 
                from the individual (or any financially 
                responsible relative or representative of that 
                individual) payment of an amount for that 
                service (i) if the total of the amount of the 
                liabilities of third parties for that service 
                is at least equal to the amount payable for 
                that service under the plan (disregarding 
                section 1916), or (ii) in an amount which 
                exceeds the lesser of (I) the amount which may 
                be collected under section 1916, or (II) the 
                amount by which the amount payable for that 
                service under the plan (disregarding section 
                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 participating under the plan may not refuse 
                to furnish services to an individual (who is 
                entitled to have payment made under the plan 
                for the services the person furnishes) because 
                of a third party's potential liability for 
                payment for the service;
                  (E) that in the case of preventive pediatric 
                care (including early and periodic screening 
                and diagnosis services under 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, except that the 
                        State may, if the State determines 
                        doing so is cost-effective and will not 
                        adversely affect access to care, only 
                        make such payment if a third party so 
                        liable has not made payment within 90 
                        days after the date the provider of 
                        such services has initially submitted a 
                        claim to such third party for payment 
                        for such services; and
                          (ii) seek reimbursement from such 
                        third party in accordance with 
                        subparagraph (B);
                  (F) that in the case of any services covered 
                under such plan which are provided to an 
                individual on whose behalf child support 
                enforcement is being carried out by the State 
                agency under part D of 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 liability for payment for such 
                        services, if such third-party liability 
                        is derived (through insurance or 
                        otherwise) from the parent whose 
                        obligation to pay support is being 
                        enforced by such agency, if payment has 
                        not been made by such third party 
                        within 100 days after the date the 
                        provider of such services has initially 
                        submitted a claim to such third party 
                        for payment for such services, except 
                        that the State may make such payment 
                        within 30 days after such date if the 
                        State determines doing so is cost-
                        effective and necessary to ensure 
                        access to care.;
                          (ii) seek reimbursement from such 
                        third party in accordance with 
                        subparagraph (B);
                  (G) that the State prohibits any health 
                insurer (including a group health plan, as 
                defined in section 607(1) of the Employee 
                Retirement Income Security Act of 1974, a self-
                insured plan, a service benefit plan, a managed 
                care organization, 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 considered to have 
                acquired the rights of such individual to 
                payment by any other party for such health care 
                items or services; and
                  (I) that the State shall provide assurances 
                satisfactory to the Secretary that the State 
                has in effect laws requiring health insurers, 
                including self-insured plans, group health 
                plans (as defined in section 607(1) of the 
                Employee Retirement Income Security Act of 
                1974), service benefit plans, managed care 
                organizations, 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, 
                as a condition of doing business in the State, 
                to--
                          (i) provide, with respect to 
                        individuals who are eligible (and, at 
                        State option, individuals who apply or 
                        whose eligibility for medical 
                        assistance is being evaluated in 
                        accordance with 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 request 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) accept the State's right of 
                        recovery and the assignment to the 
                        State of any right of an individual or 
                        other entity to payment from the party 
                        for an item or service for which 
                        payment has been made under the State 
                        plan;
                          (iii) respond to any inquiry by the 
                        State regarding a claim for payment for 
                        any health care item or service that is 
                        submitted not later than 3 years after 
                        the date of the provision of such 
                        health care item or service; 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, or a failure to present proper 
                        documentation at the point-of-sale that 
                        is the basis of the claim, 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 inpatient mental hospital services, provide, with 
        respect to each patient receiving such services, for a 
        regular program of medical review (including medical 
        evaluation) of his need for such services, and for a 
        written plan of care;
          (27) provide for agreements with every person or 
        institution providing services under the State plan 
        under which such person or institution agrees (A) to 
        keep such records as are necessary fully to disclose 
        the extent of the services provided to individuals 
        receiving assistance under the State plan, and (B) to 
        furnish the State agency or the Secretary with such 
        information, regarding any payments claimed by such 
        person or institution for providing services under the 
        State plan, as the State agency or the Secretary may 
        from time to time request;
          (28) provide--
                  (A) that any nursing facility receiving 
                payments under such plan must satisfy all the 
                requirements of subsections (b) through (d) of 
                section 1919 as they apply to such facilities;
                  (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 services 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 respective sections) with the requirements 
                of--
                          (i) section 1919(e);
                          (ii) section 1919(g) (relating to 
                        responsibility for survey and 
                        certification of nursing facilities); 
                        and
                          (iii) sections 1919(h)(2)(B) and 
                        1919(h)(2)(D) (relating 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 efficiency, 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 facility for the mentally 
                retarded, or hospital for mental diseases is 
                reviewed or screened in accordance with 
                criteria established by medical and other 
                professional personnel who are not themselves 
                directly responsible for the care of the 
                patient involved, and who do not have a 
                significant financial interest in any such 
                institution and are not, except in the case of 
                a hospital, employed by the institution 
                providing the care involved, and
                  (ii) the information developed from such 
                review or screening, along with the data 
                obtained from prior reviews of the necessity 
                for admission and continued stay of patients by 
                such professional personnel, shall be used as 
                the basis for establishing the size and 
                composition of the sample of admissions to be 
                subject to review and evaluation by such 
                personnel, and any such sample may be of any 
                size up to 100 percent of all admissions and 
                must be of sufficient size to serve the purpose 
                of (I) identifying the patterns of care being 
                provided and the changes occurring over time in 
                such patterns so that the need for modification 
                may be ascertained, and (II) subjecting 
                admissions to early or more extensive review 
                where information indicates that such 
                consideration is warranted to a hospital, 
                intermediate care facility for the mentally 
                retarded, or hospital for mental diseases;
          (31) with respect to services in an intermediate care 
        facility for the mentally retarded (where the State 
        plan includes medical assistance for such services) 
        provide, with respect to each patient receiving such 
        services, for a written plan of care, prior to 
        admission to or authorization of benefits in such 
        facility, in accordance with regulations of the 
        Secretary, and for a regular program of independent 
        professional review (including medical evaluation) 
        which shall periodically review his need for such 
        services;
          (32) provide that no payment under the plan for any 
        care or service provided to an individual shall be made 
        to anyone other than such individual or the person or 
        institution providing such care or service, under an 
        assignment or power of attorney or otherwise; except 
        that--
                  (A) in the case of any care or service 
                provided by a physician, dentist, or other 
                individual practitioner, such payment may be 
                made (i) to the employer of such physician, 
                dentist, or other practitioner if such 
                physician, dentist, or practitioner is required 
                as a condition of his employment to turn over 
                his fee for such care or service to his 
                employer, or (ii) (where the care or service 
                was provided in a hospital, clinic, or other 
                facility) to the facility in which the care or 
                service was provided if there is a contractual 
                arrangement between such physician, dentist, or 
                practitioner and such facility under which such 
                facility submits the bill for such care or 
                service;
                  (B) nothing in this paragraph shall be 
                construed (i) to prevent the making of such a 
                payment in accordance with an assignment from 
                the person or institution providing the care or 
                service involved if such assignment is made to 
                a governmental agency or entity or is 
                established by or pursuant to the order of a 
                court of competent jurisdiction, or (ii) to 
                preclude an agent of such person or institution 
                from receiving any such payment if (but only 
                if) such agent does so pursuant to an agency 
                agreement under which the compensation to be 
                paid to the agent for his services for or in 
                connection with the billing or collection of 
                payments due such person or institution under 
                the plan is unrelated (directly or indirectly) 
                to the amount of such payments or the billings 
                therefor, and is not dependent upon the actual 
                collection of any such payment;
                  (C) in the case of services furnished (during 
                a period that does not exceed 14 continuous 
                days in the case of an informal reciprocal 
                arrangement or 90 continuous days (or such 
                longer period as the Secretary may provide) in 
                the case of an arrangement involving per diem 
                or other fee-for-time compensation) by, or 
                incident to the services of, one physician to 
                the patients of another physician who submits 
                the claim for such services, payment shall be 
                made to the physician submitting the claim (as 
                if the services were furnished by, or incident 
                to, the physician's services), but only if the 
                claim identifies (in a manner specified by the 
                Secretary) the physician who furnished the 
                services; and
                  (D) in the case of payment for a childhood 
                vaccine administered before October 1, 1994, to 
                individuals entitled to medical assistance 
                under the State plan, the State plan may make 
                payment directly to the manufacturer of the 
                vaccine under a voluntary replacement program 
                agreed to by the State pursuant to which the 
                manufacturer (i) supplies doses of the vaccine 
                to providers administering the vaccine, (ii) 
                periodically replaces the supply of the 
                vaccine, and (iii) charges the State the 
                manufacturer's price to the Centers for Disease 
                Control and Prevention for the vaccine so 
                administered (which price includes a reasonable 
                amount to cover shipping and the handling of 
                returns);
          (33) provide--
                  (A) that the State health agency, or other 
                appropriate State medical agency, shall be 
                responsible for establishing a plan, consistent 
                with regulations prescribed by the Secretary, 
                for the review by appropriate professional 
                health personnel of the appropriateness and 
                quality of care and services furnished to 
                recipients of medical assistance under the plan 
                in order to provide guidance with respect 
                thereto in the administration of the plan to 
                the State agency established or designated 
                pursuant to paragraph (5) and, where 
                applicable, to the State agency described in 
                the second sentence of this subsection; and
                  (B) that, except as provided in 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 licensing health institutions, 
                the State agency responsible for such 
                licensing, will perform for the State agency 
                administering 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 validate State 
                determinations and, on that basis, make 
                independent and binding determinations 
                concerning the extent to which individual 
                institutions and agencies meet the requirements 
                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 individual) for such assistance if such 
        individual was (or upon application would have been) 
        eligible for such assistance at the time such care and 
        services were furnished;
          (35) provide that any disclosing entity (as defined 
        in 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, clinic, or organization, by the 
        appropriate State agency described in paragraph (9), 
        such agency shall (in accordance with regulations of 
        the Secretary) make public in readily available form 
        and place the pertinent findings of each such survey 
        relating to the compliance of each such health care 
        facility, laboratory, clinic, agency, or organization 
        with (A) the statutory conditions of participation 
        imposed under this title, and (B) the major additional 
        conditions which the Secretary finds necessary in the 
        interest of health and safety of individuals who are 
        furnished care or services by any such facility, 
        laboratory, clinic, agency, or organization;
          (37) provide for claims payment procedures which (A) 
        ensure that 90 per centum of claims for payment (for 
        which no further written information or substantiation 
        is required in order to make payment) made for services 
        covered under the plan and furnished by health care 
        practitioners through individual or group practices or 
        through shared health facilities are paid within 30 
        days of the date of receipt of such claims and that 99 
        per centum of such claims are paid within 90 days of 
        the date of receipt of such claims, and (B) provide for 
        procedures of prepayment and postpayment claims review, 
        including review of appropriate data with respect to 
        the recipient and provider of a service and the nature 
        of the service for which payment is claimed, to ensure 
        the proper and efficient payment of claims and 
        management of the program;
          (38) require that an entity (other than an individual 
        practitioner or a group of practitioners) that 
        furnishes, or arranges for the furnishing of, items or 
        services under the plan, shall supply (within such 
        period as may be specified in regulations by the 
        Secretary or by the single State agency which 
        administers or supervises the administration of the 
        plan) upon request specifically addressed to such 
        entity by the Secretary or such State agency, the 
        information described in 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 terminated 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 included by the 
        Secretary in any database or similar system developed 
        pursuant to section 6401(b)(2) of the Patient 
        Protection and Affordable Care Act, and provide that no 
        payment may be made under the plan with respect to any 
        item or service furnished by such individual or entity 
        during such period;
          (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 reporting system 
        (established under such section) for that type of 
        facility or organization;
          (41) provide, in accordance with subsection (kk)(8) 
        (as applicable), that whenever a provider of services 
        or any other person is terminated, suspended, or 
        otherwise sanctioned or prohibited from participating 
        under the State plan, the State agency shall promptly 
        notify the Secretary and, in the case of a physician 
        and notwithstanding paragraph (7), the State medical 
        licensing board of such action;
          (42) provide that--
                  (A) the records of any entity participating 
                in the plan and providing services reimbursable 
                on a cost-related basis will be audited as the 
                Secretary determines to be necessary to insure 
                that proper payments are made under the plan; 
                and
                  (B) not later than December 31, 2010, the 
                State shall--
                          (i) establish a program under which 
                        the State contracts (consistent with 
                        State law and in the same manner as the 
                        Secretary enters into contracts with 
                        recovery audit contractors under 
                        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 overpayments 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 
                                        underpayments;
                                  (III) the State has an 
                                adequate process for entities 
                                to appeal any adverse 
                                determination made by such 
                                contractors; and
                                  (IV) such program is carried 
                                out in accordance with such 
                                requirements as the Secretary 
                                shall specify, including--
                                          (aa) for purposes of 
                                        section 1903(a)(7), 
                                        that amounts expended 
                                        by the State to carry 
                                        out the program shall 
                                        be considered amounts 
                                        expended as necessary 
                                        for the proper and 
                                        efficient 
                                        administration of the 
                                        State plan or a waiver 
                                        of the plan;
                                          (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 contractors 
                                        or entities performing 
                                        audits of entities 
                                        receiving payments 
                                        under the State plan or 
                                        waiver in the State, 
                                        including efforts with 
                                        Federal and State law 
                                        enforcement with 
                                        respect to the 
                                        Department of Justice, 
                                        including the Federal 
                                        Bureau of 
                                        Investigations, the 
                                        Inspector General of 
                                        the Department of 
                                        Health and Human 
                                        Services, and the State 
                                        medicaid fraud control 
                                        unit; and
          (43) provide for--
                  (A) informing all persons in the State who 
                are under the age of 21 and who have been 
                determined to be eligible for medical 
                assistance including services described in 
                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 
                immunizations 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 appropriate agencies, 
                organizations, or individuals) corrective 
                treatment the need for which is disclosed by 
                such child health screening services, and
                  (D) reporting to the Secretary (in a uniform 
                form and manner established by the Secretary, 
                by age group and by basis of eligibility for 
                medical assistance, and by not later than April 
                1 after the end of each fiscal year, beginning 
                with fiscal year 1990) the following 
                information relating to early and periodic 
                screening, diagnostic, and treatment services 
                provided under the plan during each fiscal 
                year:
                          (i) the number of children provided 
                        child health screening services,
                          (ii) the number of children referred 
                        for corrective treatment (the need for 
                        which is disclosed by such child health 
                        screening services),
                          (iii) the number of children 
                        receiving dental services, and other 
                        information relating to the provision 
                        of dental services to such children 
                        described in section 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 mentally retarded, or inpatient mental 
        hospital services is made under the State plan--
                  (A) a physician (or, in the case of skilled 
                nursing facility services or intermediate care 
                facility services, a physician, or a nurse 
                practitioner or clinical nurse specialist who 
                is not an employee of the facility but is 
                working in collaboration with a physician) 
                certifies at the time of admission, or, if 
                later, the time the individual applies for 
                medical assistance under the State plan (and a 
                physician, a physician assistant under the 
                supervision of a physician, or, in the case of 
                skilled nursing facility services or 
                intermediate care facility services, a 
                physician, or a nurse practitioner or clinical 
                nurse specialist who is not an employee of the 
                facility but is working in collaboration with a 
                physician, recertifies, where such services are 
                furnished over a period of time, in such cases, 
                at least as often as required under section 
                1903(g)(6) (or, in the case of services that 
                are services provided in an intermediate care 
                facility for the mentally retarded, every 
                year), and accompanied by such supporting 
                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 
                established and periodically reviewed and 
                evaluated by a physician, or, in the case of 
                skilled nursing facility services or 
                intermediate care facility services, a 
                physician, or a nurse practitioner or clinical 
                nurse specialist who is not an employee of the 
                facility but is working in collaboration with a 
                physician;
          (45) provide for mandatory assignment of rights of 
        payment for medical support and other medical care owed 
        to recipients, in accordance with 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 establishing 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 presumptive eligibility period 
                in accordance with section 1920 and provide for 
                making medical assistance for items and 
                services described in subsection (a) of section 
                1920A available to children during a 
                presumptive eligibility period in accordance 
                with such section and provide for making 
                medical assistance available to individuals 
                described in subsection (a) of section 1920B 
                during a presumptive eligibility period in 
                accordance with such section and provide for 
                making medical assistance available to 
                individuals described in subsection (a) of 
                section 1920C during a presumptive eligibility 
                period in accordance with such section; and
                  (B) that any hospital that is a participating 
                provider under the State plan may elect to be a 
                qualified entity for purposes of determining, 
                on the basis of preliminary information, 
                whether any individual is eligible for medical 
                assistance under the State plan or under a 
                waiver of the plan for purposes of providing 
                the individual with medical assistance during a 
                presumptive eligibility period, in the same 
                manner, and subject to the same requirements, 
                as apply to the State options with respect to 
                populations described in section 1920, 1920A, 
                1920B, or 1920C (but without 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 access to certain information respecting sanctions 
        taken against health care practitioners and providers 
        by State licensing authorities in accordance with 
        section 1921;
          (50) provide, in accordance with subsection (q), for 
        a monthly personal needs allowance for certain 
        institutionalized individuals and couples;
          (51) meet the requirements of section 1924 (relating 
        to protection of community spouses);
          (52) meet the requirements of section 1925 (relating 
        to extension 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 assistance 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 supplemental 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 assistance 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), or (a)(10)(A)(ii)(IX)--
                  (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 
                disproportionate 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 payments for certain inpatient hospital 
        services;
          (57) provide that each hospital, nursing facility, 
        provider of home health care or personal care services, 
        hospice program, or medicaid managed care organization 
        (as defined in 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 recognized by the courts of 
        the State) concerning advance directives that would be 
        distributed by providers or organizations under the 
        requirements of subsection (w);
          (59) maintain a list (updated not less often than 
        monthly, and containing each physician's unique 
        identifier provided under the system established under 
        subsection (x)) of all physicians who are certified to 
        participate under the State plan;
          (60) provide that the State agency shall provide 
        assurances satisfactory to the Secretary that the State 
        has in effect the laws relating to medical child 
        support required under section 1908A;
          (61) provide that the State must demonstrate that it 
        operates a medicaid fraud and abuse control unit 
        described in section 1903(q) that effectively carries 
        out the functions and requirements described in such 
        section, as determined in accordance 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 provision 
        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 
        eligibility with respect to individuals who are (or 
        seek to be) eligible for medical assistance based on 
        the application of section 1931;
          (64) provide, not later than 1 year after the date of 
        the enactment of this paragraph, a mechanism to receive 
        reports from beneficiaries and others and compile data 
        concerning alleged instances of waste, fraud, and abuse 
        relating to the operation of this title;
          (65) provide that the State shall issue provider 
        numbers for all suppliers of medical assistance 
        consisting of durable medical 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 defined in section 
                1124(a)(3)) in the supplier or in any 
                subcontractor (as defined by the Secretary in 
                regulations) in which the supplier directly or 
                indirectly has a 5 percent or more ownership 
                interest; and
                  (ii) to the extent determined to be feasible 
                under regulations of the Secretary, the name of 
                any disclosing entity (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 interest 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 section 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 condition of receiving such payments, 
        shall--
                  (A) establish written policies for all 
                employees of the entity (including management), 
                and of any contractor or agent of the entity, 
                that provide detailed information about the 
                False Claims Act established under sections 
                3729 through 3733 of title 31, United States 
                Code, administrative 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 Federal 
                health care programs (as defined in section 
                1128B(f));
                  (B) include as part of such written policies, 
                detailed provisions regarding the entity's 
                policies and procedures for detecting and 
                preventing fraud, waste, and abuse; and
                  (C) include in any employee handbook for the 
                entity, a specific discussion of the laws 
                described in subparagraph (A), the rights of 
                employees to be protected as whistleblowers, 
                and the entity's policies and procedures for 
                detecting and preventing fraud, waste, and 
                abuse;
          (69) provide that the State must comply with any 
        requirements determined by the Secretary to be 
        necessary for carrying out the Medicaid Integrity 
        Program established under section 1936;
          (70) at the option of the State and notwithstanding 
        paragraphs (1), (10)(B), and (23), provide for the 
        establishment of a non-emergency medical transportation 
        brokerage program in order to more cost-effectively 
        provide transportation for individuals eligible for 
        medical assistance under the State plan who need access 
        to medical care or services and have no other means of 
        transportation which--
                  (A) may include a wheelchair van, taxi, 
                stretcher car, bus passes and tickets, secured 
                transportation, and such other transportation 
                as the Secretary determines appropriate; and
                  (B) may be conducted under contract with a 
                broker who--
                          (i) is selected through a competitive 
                        bidding process based on the State's 
                        evaluation of the broker's experience, 
                        performance, references, resources, 
                        qualifications, and costs;
                          (ii) has oversight procedures to 
                        monitor beneficiary access and 
                        complaints and ensure that transport 
                        personnel are licensed, qualified, 
                        competent, and courteous;
                          (iii) is subject to regular auditing 
                        and oversight by the State in order to 
                        ensure the quality of the 
                        transportation services provided and 
                        the adequacy of beneficiary access to 
                        medical care and services; and
                          (iv) complies with such requirements 
                        related to prohibitions on referrals 
                        and conflict of interest as the 
                        Secretary shall establish (based on the 
                        prohibitions on physician referrals 
                        under section 1877 and such other 
                        prohibitions and requirements as the 
                        Secretary determines 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 relationships with private practice dental 
        providers in the provision of Federally-qualified 
        health center services;
          (73) in the case of any State in which 1 or more 
        Indian Health Programs or Urban Indian Organizations 
        furnishes health care services, provide for a process 
        under which the State seeks advice on a regular, 
        ongoing basis from designees of such Indian Health 
        Programs and Urban Indian Organizations on matters 
        relating to the application of this title that are 
        likely to have a direct effect on such Indian Health 
        Programs and Urban Indian Organizations and that--
                  (A) shall include solicitation of advice 
                prior to submission of any plan amendments, 
                waiver requests, and proposals for 
                demonstration projects likely to have a direct 
                effect on Indians, Indian Health Programs, or 
                Urban Indian Organizations; and
                  (B) may include appointment of an advisory 
                committee and of a designee of such Indian 
                Health Programs and Urban Indian Organizations 
                to the medical care advisory committee advising 
                the State on its State plan under this title;
          (74) provide for maintenance of effort under the 
        State plan or under any waiver of the plan in 
        accordance with subsection (gg); and
          (75) provide that, beginning January 2015, and 
        annually thereafter, the State shall submit a report to 
        the Secretary that contains--
                  (A) the total number of enrolled and newly 
                enrolled individuals in the State plan or under 
                a waiver of the plan for the fiscal year ending 
                on September 30 of the preceding calendar year, 
                disaggregated by population, including 
                children, parents, nonpregnant childless 
                adults, disabled individuals, elderly 
                individuals, and such other categories or sub-
                categories of individuals eligible for medical 
                assistance under the State plan or under a 
                waiver of the plan as the Secretary may 
                require;
                  (B) a description, which may be specified by 
                population, of the outreach and enrollment 
                processes used by the State during such fiscal 
                year; and
                  (C) any other data reporting determined 
                necessary by the Secretary to monitor 
                enrollment and retention of individuals 
                eligible for medical assistance under the State 
                plan or under a waiver of the plan;
          (76) provide that any data collected under the State 
        plan meets the requirements of section 3101 of the 
        Public Health Service Act;
          (77) provide that the State shall comply with 
        provider and supplier screening, oversight, and 
        reporting requirements in accordance with subsection 
        (kk);
          (78) provide that, not later than January 1, 2017, in 
        the case of a State that pursuant to its State plan or 
        waiver of the plan for medical assistance pays for 
        medical assistance on a fee-for-service basis, the 
        State shall require each provider furnishing items and 
        services to, or ordering, prescribing, referring, or 
        certifying eligibility for, services for individuals 
        eligible to receive medical assistance under such plan 
        to enroll with the State agency and provide to the 
        State agency the provider's identifying information, 
        including the name, specialty, date of birth, Social 
        Security number, national provider identifier (if 
        applicable), Federal taxpayer identification number, 
        and the State license or certification number of the 
        provider (if applicable);
          (79) provide that any agent, clearinghouse, or other 
        alternate payee (as defined by the Secretary) that 
        submits claims on behalf of a health care provider must 
        register with the State and the Secretary in a form and 
        manner specified by the Secretary;
          (80) provide that the State shall not provide any 
        payments for items or services provided under the State 
        plan or under a waiver to any financial institution or 
        entity located outside of the United States;
          (81) provide for implementation of the payment models 
        specified by the Secretary under section 1115A(c) for 
        implementation 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 
        administering the State plan under this title provides 
        assurances to the Secretary that the State agency is in 
        compliance with subparagraphs (A), (B), and (C) of 
        section 1128K(b)(2);
          (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 administering the State plan, a directory 
        of the physicians described in subsection (mm) and, at 
        State option, other providers 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 provider 
                                provides services; and
                                  (IV) the telephone number of 
                                the physician or provider; and
                          (ii) with respect to any such 
                        physician or provider participating in 
                        such a primary care case-management 
                        system, information regarding--
                                  (I) whether the physician or 
                                provider is accepting as new 
                                patients individuals who 
                                receive medical assistance 
                                under this 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 
                                interpretation services at the 
                                physician's or provider's 
                                office; and
                  (B) may include, at State option, with 
                respect to each such physician or provider--
                          (i) the Internet website of such 
                        physician or provider; or
                          (ii) whether the physician or 
                        provider is accepting as new patients 
                        individuals who receive medical 
                        assistance under this 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)) because 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 juvenile described in paragraph (2)(A) 
                of subsection (nn), the State shall, prior to 
                the individual's release from such a public 
                institution, conduct a redetermination of 
                eligibility for such individual with respect to 
                such medical assistance (without requiring a 
                new application from the individual) and, if 
                the State determines pursuant to such 
                redetermination that the individual continues 
                to meet the eligibility requirements for such 
                medical assistance, the State shall restore 
                coverage for such medical assistance to such an 
                individual upon the individual's release from 
                such public institution; and
                  (C) in the case of an individual who is an 
                eligible juvenile described in paragraph (2)(B) 
                of subsection (nn), the State shall process any 
                application for medical assistance submitted 
                by, or on behalf of, such individual such that 
                the State makes a determination of eligibility 
                for such individual with respect to such 
                medical assistance upon release of such 
                individual from such public institution;
          (85) provide that the State is in compliance with the 
        drug review and utilization requirements under 
        subsection (oo)(1); and
          (86) provide, at the option of the State, for making 
        medical assistance available on an inpatient or 
        outpatient basis at a residential pediatric recovery 
        center (as defined in subsection (pp)) to infants with 
        neonatal abstinence syndrome.
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 administration 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 supervised 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 section 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 insurance 
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 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 dependent 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 
permanently 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 
conditions specified in subsection (a) of this section, except 
that he shall not approve any plan which imposes, as a 
condition of eligibility for medical assistance under the 
plan--
          (1) an age requirement of more than 65 years; or
          (2) any residence requirement which excludes any 
        individual who resides in the State, regardless of 
        whether or not the residence is maintained permanently 
        or at a fixed address; or
          (3) any citizenship requirement which excludes any 
        citizen of the United States.
  (c) Notwithstanding subsection (b), the Secretary shall not 
approve any State plan for medical assistance if the State 
requires individuals described in subsection (l)(1) to apply 
for assistance under the State program funded under part A of 
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 
requirements of section 1152, as determined by the Secretary, 
or a utilization 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 requirements 
shall be deemed to be met for those services or providers (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 extension 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 
medicaid 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 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 eligible for such benefits until the 
end of such minimum period, but, except for benefits furnished 
under section 1905(a)(4)(C), only with respect to such benefits 
provided to the individual as an enrollee of such organization 
or entity or by or through the case manager.
  (B) For purposes of subparagraph (A), the term ``minimum 
enrollment period'' means, with respect to an individual's 
enrollment with an organization or entity under a State plan, a 
period, established by the State, of not more than six months 
beginning on the date the individual's enrollment with the 
organization or entity becomes effective.
  (3) At the option of the State, any individual who--
          (A) is 18 years of age or younger and qualifies as a 
        disabled individual under 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 individual outside such an institution, 
                and
                  (iii) the estimated amount which would be 
                expended for medical assistance for the 
                individual for such care outside an institution 
                is not greater than the estimated amount which 
                would otherwise be expended for medical 
                assistance for the individual within an 
                appropriate institution; and
          (C) if the individual were in a medical institution, 
        would be eligible for medical assistance under the 
        State plan under this title,
        shall be deemed, for purposes of this title only, to be 
        an individual 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 assistance under a State plan on the date of the 
child's birth shall be deemed to have applied for medical 
assistance and to have been found eligible for such assistance 
under such plan on the date of such birth and to remain 
eligible for such assistance for a period of one year. During 
the period in which a child is deemed under the preceding 
sentence to be eligible for medical assistance, the medical 
assistance eligibility identification number of the mother 
shall also serve as the identification number of the child, and 
all claims shall be submitted and paid under such number 
(unless the State issues a separate identification number for 
the child before such period expires). Notwithstanding the 
preceding sentence, in the case of a child who is born in the 
United States to an alien mother for whom medical assistance 
for the delivery of the child is made available pursuant to 
section 1903(v), the State immediately shall issue a separate 
identification number for the child upon notification 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 pregnant, for all pregnancy-related and postpartum medical 
assistance under the plan, through the end of the month in 
which the 60-day period (beginning on the last day of her 
pregnancy) ends.
  (6) In the case of a pregnant woman described in subsection 
(a)(10) who, because of a change in income of the family of 
which she is a member, would not otherwise continue to be 
described in such subsection, the woman shall be deemed to 
continue to be an individual described in subsection 
(a)(10)(A)(i)(IV) and subsection (l)(1)(A) without regard to 
such change of income through the end of the month in which the 
60-day period (beginning on the last day of her pregnancy) 
ends. The preceding sentence shall not apply in the case of a 
woman who has been provided ambulatory prenatal care pursuant 
to section 1920 during a presumptive eligibility period 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 assistance is provided on the date the infant 
        or child attains the maximum age with respect to which 
        coverage is provided under the State plan for such 
        individuals, and
          (B) who, but for attaining such age, would remain 
        eligible for medical assistance under such subsection,
the infant or child shall continue to be treated as an 
individual described in such respective provision until the end 
of the stay for which the inpatient services are furnished.
  (8) If an individual is determined to be a qualified medicare 
beneficiary (as defined in section 1905(p)(1)), such 
determination shall apply to services furnished [after the end 
of the month in which the determination first occurs] in or 
after the third month before the month in which the individual 
makes application for assistance. 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. The Secretary shall provide for a 
process under which claims for medical assistance under the 
State plan may be submitted for services furnished to such an 
individual during such 3-month period before the month in which 
the individual made application for assistance.
  (9)(A) At the option of the State, the plan may include as 
medical assistance respiratory care services for any individual 
who--
          (i) is medically dependent on a ventilator for life 
        support at least six hours per day;
          (ii) has been so dependent for at least 30 
        consecutive days (or the maximum number of days 
        authorized under the State plan, whichever is less) as 
        an inpatient;
          (iii) but for the availability of respiratory care 
        services, would require respiratory care as an 
        inpatient in a hospital, nursing facility, or 
        intermediate care facility for the mentally retarded 
        and would be eligible to have payment made for such 
        inpatient care under the State plan;
          (iv) has adequate social support services to be cared 
        for at home; and
          (v) wishes to be cared for at home.
  (B) The requirements of subparagraph (A)(ii) may be satisfied 
by a continuous stay in one or more hospitals, nursing 
facilities, or intermediate care facilities for the mentally 
retarded.
  (C) For purposes of this paragraph, respiratory care services 
means services provided on a part-time basis in the home of the 
individual by a respiratory therapist or other health care 
professional trained in respiratory therapy (as determined by 
the State), payment for which is not otherwise included within 
other items and services furnished to such individual as 
medical assistance under the plan.
  (10)(A) The fact that an individual, child, or pregnant woman 
may be denied aid under part A of 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 section 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 paragraph) 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 eligible 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 
enrollment period'' means, with respect to an individual's 
enrollment with a group health plan, a period established by 
the State, of not more than 6 months beginning on the date the 
individual's enrollment under the plan becomes effective.
  (12) (A) At the option of the State, the plan may provide 
that an individual who is under an age specified by the State 
(not to exceed 19 years of age) and who is determined to be 
eligible for benefits under a State plan approved under this 
title under subsection (a)(10)(A) shall remain eligible for 
those benefits until the earlier of--
          [(A)] (i) the end of a period (not to exceed 12 
        months) following the determination; or
          [(B)] (ii) the time that the individual exceeds that 
        age.
  (B) At the option of the State, the plan may provide that an 
individual who is determined to be eligible for benefits under 
a State plan approved under this title under any of the 
following eligibility categories, or who is redetermined to be 
eligible for such benefits under any of such categories, shall 
be considered to meet the eligibility requirements met on the 
date of application and shall remain eligible for those 
benefits until the end of the 12-month period following the 
date of the determination or redetermination of eligibility, 
except that a State may provide for such determinations more 
frequently, but not more frequently than once every 6 months 
for an individual:
          (i) A specified low-income medicare beneficiary 
        described in subsection (a)(10)(E)(iii) of this section 
        who is determined eligible for medicare cost sharing 
        described in section 1905(p)(3)(A)(ii).
          (ii) A qualified disabled and working individual 
        described in section 1905(s) who is determined eligible 
        for medicare cost-sharing described in section 
        1905(p)(3)(A)(i).
  (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 determined 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 ineligible 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 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 procedures for requesting such an 
                        evaluation.
                          (III) Compliance with screen and 
                        enroll requirement.--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 option, the State may 
                        fulfill such requirements in accordance 
                        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 
                redeterminations.--The State may apply the 
                provisions of this paragraph when conducting 
                initial determinations of eligibility, 
                redeterminations of eligibility, or both, as 
                described in the State plan.
                  (iii) State option to extend express lane 
                eligibility to other populations.--
                          (I) In general.--At the option of the 
                        State, the State may apply the 
                        provisions of this paragraph with 
                        respect to determining eligibility 
                        under this title for an eligible 
                        individual (as defined in subclause 
                        (II)). In applying this paragraph in 
                        the case of a State making such an 
                        option, any reference in this paragraph 
                        to a child with respect to this title 
                        (other than a reference to child health 
                        assistance) shall be deemed to be a 
                        reference to an eligible individual.
                          (II) Eligible individual defined.--In 
                        this clause, the term ``eligible 
                        individual'' means any of the 
                        following:
                                  (aa) A qualified medicare 
                                beneficiary described in 
                                section 1905(p)(1) for purposes 
                                of determining eligibility for 
                                medicare cost-sharing (as 
                                defined in section 1905(p)(3)).
                                  (bb) A specified low-income 
                                medicare beneficiary described 
                                in subsection (a)(10)(E)(iii) 
                                of this section for purposes of 
                                determining eligibility for 
                                medicare cost-sharing described 
                                in section 1905(p)(3)(A)(ii).
                                  (cc) A qualified disabled and 
                                working individual described in 
                                section 1905(s) for purposes of 
                                determining eligibility for 
                                medicare cost-sharing described 
                                in section 1905(p)(3)(A)(i).
          (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 determining eligibility 
                for or enrolling children into medical 
                assistance under this title or child health 
                assistance under title XXI; or
                  (ii) to modify the limitations in section 
                1902(a)(5) concerning the agencies that may 
                make a determination of eligibility for medical 
                assistance under this title.
          (C) Options for satisfying the screen and enroll 
        requirement.--
                  (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 
                subparagraphs (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.--
                          (I) In general.--Under this clause, 
                        the State establishes a screening 
                        threshold set as a percentage of the 
                        Federal poverty level that exceeds the 
                        highest income 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 
                        methodologies used by the program 
                        administered by the Express Lane agency 
                        and the methodologies used by the State 
                        in determining eligibility for medical 
                        assistance under this title.
                          (II) Children with income not above 
                        threshold.--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 
                        otherwise 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 section 
                        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 eligible for Medicaid). If 
                        such a child is enrolled in child 
                        health assistance under title XXI, the 
                        State shall provide the parent, 
                        guardian, or custodial relative with 
                        the following:
                                  (aa) Notice that the child 
                                may be eligible to receive 
                                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 
                                assistance under this title 
                                using such regular procedures.
                                  (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 
                                covered 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 Express Lane 
                        agency.
                          (II) Determination of eligibility.--
                        During such temporary enrollment 
                        period, the State shall determine the 
                        child's eligibility for child health 
                        assistance under title XXI or for 
                        medical assistance under this title in 
                        accordance with this clause.
                          (III) Prompt follow up.--In making 
                        such a determination, the State shall 
                        take prompt action to determine whether 
                        the child should be enrolled in medical 
                        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 
                        determination.--In making such a 
                        determination, the State shall use 
                        procedures that, to the maximum 
                        feasible extent, 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 enrolled in title XXI during a 
                        temporary enrollment period 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 requirement 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 duration of 
                        the State's election under this 
                        paragraph;
                          (II) annually provide the Secretary 
                        with a statistically valid sample (that 
                        is approved by Secretary) of the 
                        children enrolled in such plans through 
                        reliance on such a finding by 
                        conducting a full Medicaid eligibility 
                        review of the children identified for 
                        such sample for purposes of determining 
                        an eligibility error rate (as described 
                        in clause (iv)) with respect to the 
                        enrollment of such children (and shall 
                        not include such children in any data 
                        or samples used for purposes of 
                        complying with a Medicaid Eligibility 
                        Quality Control (MEQC) review or a 
                        payment error rate measurement (PERM) 
                        requirement);
                          (III) submit the error rate 
                        determined under subclause (II) to the 
                        Secretary;
                          (IV) if such error rate exceeds 3 
                        percent for either of the first 2 
                        fiscal years in which the State elects 
                        to apply this paragraph, demonstrate to 
                        the satisfaction of the Secretary the 
                        specific corrective actions implemented 
                        by the State to improve upon such error 
                        rate; and
                          (V) if such error rate exceeds 3 
                        percent for any fiscal year in which 
                        the State elects to apply this 
                        paragraph, a reduction in the amount 
                        otherwise payable to the State under 
                        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 respect 
                        to the children included in the sample 
                        for the fiscal 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 
                reduction 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 section 
                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 payments 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 eligibility 
                determinations are made under this paragraph 
                and except that in applying this paragraph 
                under title XXI, there shall be substituted for 
                references to provisions of this title 
                corresponding provisions within title XXI.
          (F) Express lane agency.--
                  (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 
                                information disclosed for such 
                                purposes; and
                          (IV) enters into, or is subject to, 
                        an interagency agreement to limit the 
                        disclosure and use of the information 
                        disclosed.
                  (ii) Inclusion of specific public agencies 
                and indian tribes and tribal organizations.--
                Such term includes the following:
                          (I) A public agency that determines 
                        eligibility for assistance under any of 
                        the following:
                                  (aa) The temporary assistance 
                                for needy families program 
                                funded under part A of 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 Assistance 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.
                          (III) A public agency that is subject 
                        to an interagency agreement limiting 
                        the disclosure and use of the 
                        information disclosed for purposes of 
                        determining eligibility under the State 
                        Medicaid plan or the State CHIP plan.
                          (IV) The Indian Health Service, an 
                        Indian Tribe, Tribal Organization, or 
                        Urban Indian Organization (as defined 
                        in 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 
                paragraph shall be construed as--
                          (I) exempting a State Medicaid agency 
                        from complying with the requirements of 
                        section 1902(a)(4) relating to merit-
                        based personnel standards for employees 
                        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 eligibility 
                        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 administering 
                        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 Medicaid 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 income shown by State income tax records 
        or returns.
          (I) Application.--This paragraph shall not apply with 
        respect 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 subparagraph (D), for 
                purposes of determining 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, 
                including with respect to the imposition of 
                premiums and cost-sharing, a State shall use 
                the modified 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 
                eligibility 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 income 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 household income, a State 
                shall, working with the Secretary, establish 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 establish income and eligibility 
                determination systems that protect 
                beneficiaries.
                  (B) No income or expense disregards.--Subject 
                to subparagraph (I), no type of expense, block, 
                or other income disregard shall be applied by a 
                State to determine income 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 determination 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 assistance 
                                under the State plan or under a 
                                waiver of the plan on a basis 
                                that does not require a 
                                determination of income by the 
                                State agency administering the 
                                State plan or waiver, including 
                                as a result of eligibility for, 
                                or receipt of, other Federal or 
                                State aid or assistance, 
                                individuals who are eligible on 
                                the basis of receiving (or 
                                being treated as if receiving) 
                                supplemental security income 
                                benefits under 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.
                                  (II) Individuals who have 
                                attained age 65.
                                  (III) Individuals who qualify 
                                for medical assistance under 
                                the State plan or under any 
                                waiver of such plan on the 
                                basis of being blind or 
                                disabled (or being treated as 
                                being blind or disabled) 
                                without regard to whether the 
                                individual is eligible for 
                                supplemental security income 
                                benefits under title XVI on the 
                                basis of being blind or 
                                disabled and including 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 subsection 
                                (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 
                        paragraph relating to the income of an 
                        individual for purposes 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 determinations.--
                        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 
                        institution 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 individual 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 adjusted gross income or 
                        household income standard described 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.
                  (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 using 
                modified adjusted gross income and household 
                income, the methodologies and procedures to be 
                used to determine income eligibility using 
                modified adjusted gross income 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 practicable, 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 Protection and Affordable Care Act. The 
                Secretary shall ensure 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 determine 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 
                enactment of the Patient Protection and 
                Affordable Care Act no longer being eligible 
                for such assistance.
                  (F) Limitation on secretarial authority.--The 
                Secretary 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 
                eligible 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 intermediate 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 
                regarding point-in-time income and sources of 
                income.--The requirement under this paragraph 
                for States to use modified adjusted gross 
                income and household income 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 individual's 
                        income as of the point in time at which 
                        an application for medical assistance 
                        under the State plan or a waiver of the 
                        plan is processed; or
                          (ii) any rules established under this 
                        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 income.--For purposes of determining the 
                income eligibility of an individual for medical 
                assistance whose eligibility is determined 
                based on the application of modified 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 poverty line) and such upper 
                        income limit increased by 5 percentage 
                        points; and
                          (ii) notwithstanding the requirement 
                        in subparagraph (A) with respect to use 
                        of modified adjusted gross income, 
                        utilize as the applicable income of 
                        such individual, in determining such 
                        income eligibility, an amount equal to 
                        the modified adjusted gross income 
                        applicable to such individual reduced 
                        by such dollar equivalent amount.
                  (J) 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 
                income 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 adjusted gross 
                        income under subparagraph (A), a State 
                        shall, in determining such eligibility, 
                        include such winnings or income (as 
                        applicable) as income received--
                                  (I) in the month in which 
                                such winnings or income (as 
                                applicable) is received if the 
                                amount of such winnings or 
                                income is less than $80,000;
                                  (II) over a period of 2 
                                months if the amount of such 
                                winnings or income (as 
                                applicable) is greater than or 
                                equal to $80,000 but less than 
                                $90,000;
                                  (III) over a period of 3 
                                months if the amount of such 
                                winnings or income (as 
                                applicable) is greater than or 
                                equal to $90,000 but less than 
                                $100,000; and
                                  (IV) over a period of 3 
                                months plus 1 additional month 
                                for each increment of $10,000 
                                of such winnings or income (as 
                                applicable) received, not to 
                                exceed a period of 120 months 
                                (for winnings or income of 
                                $1,260,000 or more), if the 
                                amount of such winnings or 
                                income is greater than or equal 
                                to $100,000.
                          (ii) Counting in equal 
                        installments.--For purposes of 
                        subclauses (II), (III), and (IV) of 
                        clause (i), winnings or income to which 
                        such subclause applies shall be counted 
                        in equal monthly installments over the 
                        period of months specified under such 
                        subclause.
                          (iii) Hardship exemption.--An 
                        individual whose income, by application 
                        of clause (i), exceeds the applicable 
                        eligibility threshold established by 
                        the State, shall continue to be 
                        eligible for medical assistance to the 
                        extent that the State determines, under 
                        procedures established by the State (in 
                        accordance with standards specified by 
                        the Secretary), that the denial of 
                        eligibility of the individual would 
                        cause an undue medical or financial 
                        hardship as determined on the basis of 
                        criteria established by the Secretary.
                          (iv) Notifications and assistance 
                        required in case of loss of 
                        eligibility.--A State shall, with 
                        respect 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 
                                        Patient Protection and 
                                        Affordable Care Act 
                                        during the special 
                                        enrollment period 
                                        specified in section 
                                        9801(f)(3) of the 
                                        Internal Revenue Code 
                                        of 1986 (relating to 
                                        loss of Medicaid or 
                                        CHIP coverage); and
                                          (bb) of the date on 
                                        which the individual 
                                        would no longer be 
                                        considered ineligible 
                                        by reason of clause (i) 
                                        to receive medical 
                                        assistance under the 
                                        State plan or under any 
                                        waiver of such plan and 
                                        be eligible to reapply 
                                        to receive such medical 
                                        assistance; and
                                  (II) provide technical 
                                assistance to the individual 
                                seeking to enroll in such a 
                                qualified health plan.
                          (v) 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 Internal 
                        Revenue Code of 1986 or a lottery 
                        operated by a multistate or 
                        multijurisdictional lottery 
                        association, including 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 
        disease or condition.--The first $2,000 received by an 
        individual (who has attained 19 years of age) as 
        compensation for participation in a clinical trial 
        meeting the requirements of section 1612(b)(26) 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.
  (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, 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 
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 expenses 
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 individuals pursuant to paragraph (10)(C) of 
subsection (a) of this section, 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 paragraph (10)(A) of that subsection 
if that individual is, or is eligible to be (1) an individual 
with respect to whom there is payable a State supplementary 
payment on the basis of which similarly situated individuals 
are eligible to receive medical assistance equal in amount, 
duration, 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 considered to be an individual 
eligible for medical assistance under paragraph (10)(C) of that 
subsection. In States which do not provide 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 paragraph (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) Nothing in this title (including subsections (a)(13) and 
(a)(30) of this section) shall be construed as authorizing the 
Secretary to limit the amount of payment that may be made under 
a plan under this title for home and community care.
  (i)(1) In addition to any other authority under State law, 
where a State determines that a intermediate care facility for 
the mentally retarded which is certified for participation 
under its plan no longer substantially meets the requirements 
for such a facility under this title and further determines 
that the facility's deficiencies--
          (A) immediately jeopardize the health and safety of 
        its patients, the State shall provide for the 
        termination of the facility's certification for 
        participation under the plan and may provide, or
          (B) do not immediately jeopardize the health and 
        safety of its patients, the State may, in lieu of 
        providing for terminating the facility's certification 
        for participation under the plan, establish alternative 
        remedies if the State demonstrates to the Secretary's 
        satisfaction that the alternative remedies are 
        effective in deterring noncompliance and correcting 
        deficiencies, and may provide
that no payment will be made under the State plan with respect 
to any individual admitted to such facility after a date 
specified by the State.
  (2) The State shall not make such a decision with respect to 
a facility until the facility has had a reasonable opportunity, 
following the initial determination that it no longer 
substantially meets the requirements for such a facility under 
this title, to correct its deficiencies, and, following this 
period, has been given reasonable notice and opportunity for a 
hearing.
  (3) The State's decision to deny payment may be made 
effective only after such notice to the public and to the 
facility as may be provided for by the State, and its 
effectiveness shall terminate (A) when the State finds that the 
facility is in substantial compliance (or is making good faith 
efforts to achieve substantial compliance) with the 
requirements for such a facility under this 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, whichever occurs first. If a facility to which 
clause (B) of the previous sentence applies still fails to 
substantially meet the provisions of the respective section on 
the date specified in such clause, the State shall terminate 
such facility's certification for participation under the plan 
effective with the first day of the first month following the 
month specified in such clause.
  (j) Notwithstanding any other requirement of this title, the 
Secretary may waive or modify any requirement of this title 
with respect to the medical assistance program in American 
Samoa and the Northern Mariana Islands, other than a waiver of 
the Federal medical assistance percentage, the limitation in 
section 1108(f), or 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).
  (k)(1) The medical assistance provided to an individual 
described in subclause (VIII) of subsection (a)(10)(A)(i) shall 
consist of benchmark coverage described in section 1937(b)(1) 
or benchmark equivalent coverage described in section 
1937(b)(2). Such medical assistance 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 medical assistance to individuals who would be 
described in subclause (VIII) of subsection (a)(10)(A)(i) if 
that subclause were effective before January 1, 2014. A State 
may elect to phase-in the extension of eligibility for medical 
assistance to such individuals based on income, so long as the 
State does not extend such eligibility to individuals described 
in such subclause with higher income before making individuals 
described in such subclause with lower income eligible for 
medical assistance.
  (3) If an individual described in subclause (VIII) of 
subsection (a)(10)(A)(i) is the parent of a child who is under 
19 years of age (or such higher age as the State may have 
elected) who is eligible for medical assistance under the State 
plan or under a waiver of such plan (under that subclause or 
under a State plan amendment under paragraph (2), 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 
subsection (a)(10)(A)(i) and whose family income does not 
exceed the income level established by the State under 
paragraph (2) for a family size equal to the size of the 
family, including the woman, infant, or child.
  (2)(A)(i) For purposes of paragraph (1) with respect to 
individuals described in subparagraph (A) or (B) of that 
paragraph, the State shall establish an income level which is a 
percentage (not less than the percentage provided under clause 
(ii) and not more than 185 percent) of the income official 
poverty line (as defined by the Office of Management and 
Budget, and revised annually in accordance with 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 assistance to individuals described in this subsection 
or has enacted legislation authorizing, or appropriating funds, 
to provide such assistance to such individuals before July 1, 
1989, the percentage provided under clause (ii)(I) shall not be 
less than--
          (I) the percentage specified by the State in an 
        amendment to its State plan (whether approved or not) 
        as of 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 legislation authorizing, or appropriating funds, to 
provide for, a percentage (of the income official poverty line) 
that is greater than 133 percent, the percentage provided under 
clause (ii) for medical assistance on or after April 1, 1990, 
shall not be less than--
          (I) the percentage specified by the State in an 
        amendment to its State plan (whether approved or not) 
        as of 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 
described in subparagraph (C) of such paragraph, the State 
shall establish an income level which is equal to 133 percent 
of the income official poverty line described in subparagraph 
(A) applicable to a family of the size involved.
  (C) For purposes of paragraph (1) with respect to individuals 
described in subparagraph (D) of that paragraph, the State 
shall establish an income level which is equal to 100 percent 
(or, beginning January 1, 2014, 133 percent) of the income 
official poverty line described in subparagraph (A) applicable 
to a family of the size involved.
  (3) Notwithstanding subsection (a)(17), for individuals who 
are eligible for medical assistance because of subsection 
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or 
(a)(10)(A)(ii)(IX)--
          (A) application of a resource standard shall be at 
        the option of the State;
          (B) any resource standard or methodology that is 
        applied with respect to an individual described in 
        subparagraph (A) of paragraph (1) may not be more 
        restrictive than the resource standard or methodology 
        that is applied under 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 income standard established under paragraph 
        (2); and
          (E) family income shall be determined in accordance 
        with the methodology employed under the State plan 
        under part A or E of title IV (except to the extent 
        such methodology is inconsistent with clause (D) of 
        subsection (a)(17)), and costs incurred for medical 
        care or for any other type of remedial care shall not 
        be taken into account.
Any different treatment provided under this paragraph for such 
individuals shall not, because of subsection (a)(17), require 
or permit such treatment for other individuals.
  (4)(A) In the case of any State which is providing medical 
assistance to its residents under a waiver granted under 
section 1115, the Secretary shall require the State to provide 
medical assistance for pregnant women and infants under age 1 
described in subsection (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 
        individuals (as determined under section 1614(a)(3)),
          (B) whose income (as determined under section 1612 
        for purposes 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 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 Omnibus 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 individuals not described in subsection (a)(10)(A) and at 
the State's option, the State may use under paragraph (1)(C) 
such resource level (which is higher than the level described 
in that paragraph) as may be applicable with respect to 
individuals described in paragraph (1)(A) who are not described 
in subsection (a)(10)(A).
  (C) The provisions of section 1905(p)(2)(D) shall apply to 
determinations 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 incurred 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 
individuals shall not, because of subsection (a)(17), require 
or permit such treatment for other individuals.
  (4) Notwithstanding subsection (a)(17), for qualified 
medicare beneficiaries described in 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 incurred 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 
individuals 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 provide payment in an amount with respect to the 
service or item that results in the sum of such payment amount 
and any amount of payment made under 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 
provide any payment for any expenses incurred relating to 
payment for deductibles, coinsurance, or copayments for 
medicare cost-sharing to the extent that payment under 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-
sharing for a qualified medicare beneficiary with respect to an 
item or service is reduced or eliminated through the 
application of paragraph (2)--
          (A) for purposes of applying any limitation under 
        title XVIII on the amount that the beneficiary may be 
        billed or charged for the service, the amount of 
        payment made under title XVIII plus the amount of 
        payment (if any) under the State plan shall be 
        considered to be payment in full for the service;
          (B) the beneficiary shall not have any legal 
        liability to make payment to a provider or to an 
        organization described in section 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.
  (4) A State plan shall not deny a claim from a provider or 
supplier with respect to medicare cost-sharing described in 
subparagraph (B), (C), or (D) of section 1905(p)(3) for an item 
or service which is eligible for payment under title XVIII on 
the basis that the provider or supplier does not have a 
provider agreement in effect under this title or does not 
otherwise serve all individuals entitled to medical assistance 
under this title. The State shall create a mechanism through 
which provider or suppliers that do not otherwise have provider 
agreements with the State can bill the State for medicare cost-
sharing for qualified medicare beneficiaries.
  (o) Notwithstanding any provision of subsection (a) to the 
contrary, a State plan under this title shall provide that any 
supplemental 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 intermediate 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 
assistance under section 1903(a), with respect to payments the 
State makes to a medicaid managed care organization (as defined 
in section 1903(m)) or to an entity furnishing services under a 
waiver approved 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 relationship (as defined by the Secretary) 
        with an individual or entity 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 review, medical social work, 
        or administrative services or employs 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 refusal to enter into or renew a participation agreement or 
the termination of such an agreement.
  (q)(1)(A) In order to meet the requirement of subsection 
(a)(50), the State plan must provide that, in the case of an 
institutionalized individual or couple described in 
subparagraph (B), in determining the amount of the individual's 
or couple's income to be applied monthly to payment for the 
cost of care in an institution, there shall be deducted from 
the monthly income (in addition to other allowances otherwise 
provided under the State plan) a monthly personal needs 
allowance--
          (i) which is reasonable in amount for clothing and 
        other personal needs of the individual (or couple) 
        while in an institution, and
          (ii) which is not less (and may be greater) than the 
        minimum monthly personal needs allowance described in 
        paragraph (2).
  (B) In this subsection, the term ``institutionalized 
individual or couple'' means an individual or married couple--
          (i) who is an inpatient (or who are inpatients) in a 
        medical institution or nursing facility for which 
        payments are made under this title throughout a month, 
        and
          (ii) who is or are determined to be eligible for 
        medical assistance under the State plan.
  (2) The minimum monthly personal needs allowance described in 
this paragraph is $30 for an institutionalized individual and 
$60 for an institutionalized couple (if both are aged, blind, 
or disabled, and their incomes are considered available to each 
other in determining eligibility).
  (r)(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 institutionalized 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 account 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 eligible 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 veterans home's cost of providing nursing home 
care to the veteran.
  (ii) The provisions of clause (i) shall apply with respect to 
a surviving spouse of a veteran who does not have a child in 
the same manner as they apply to a veteran described in such 
clause.
  (2)(A) The methodology to be employed in determining income 
and resource eligibility for individuals under subsection 
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), 
(a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) 
or under section 1905(p) may be less restrictive, and shall be 
no more restrictive, than the methodology--
          (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), 
methodology is considered to be ``no more restrictive'' if, 
using the methodology, additional individuals may be eligible 
for medical assistance and no individuals who are otherwise 
eligible are made ineligible for such assistance.
  (s) 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 attained the age of 1 year, and to children who 
have not attained the age of 6 years and who receive such 
services in a disproportionate share hospital described in 
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 payment amounts for medically necessary 
        inpatient hospital services involving exceptionally 
        high costs or exceptionally long lengths of stay,
          (2) not be limited by the imposition of day limits 
        with respect to the delivery of such services to such 
        individuals, and
          (3) not be limited by the imposition of dollar limits 
        (other than such limits resulting from prospective 
        payments as adjusted pursuant to paragraph (1)) with 
        respect to the delivery of such services to any such 
        individual who has not attained their first birthday 
        (or in the case of such an individual who is an 
        inpatient on his first birthday until such individual 
        is discharged).
  (t) 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 imposed 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 purposes 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 Reconciliation Act 
        of 1981) applicable to a family of the size involved,
          (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 individual may have and obtain 
        benefits under that program, and
          (D) with respect to whose enrollment for COBRA 
        continuation coverage the State has determined that the 
        savings in expenditures 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 employer with 75 or more employees provided pursuant to 
title XXII of the Public Health Service Act, section 4980B of 
the Internal Revenue 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 incurred 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 
individuals shall not, because of subsection (a)(10)(B) or 
(a)(17), require 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 determined otherwise eligible for such 
assistance during the period of time prior to which a final 
determination of disability or blindness is made by the Social 
Security Administration with respect to such an individual. In 
making such determinations, the State must apply the 
definitions of disability and blindness found in 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 statutory or as recognized by the 
                courts of the State) to make decisions 
                concerning such medical care, including the 
                right to accept or refuse medical or surgical 
                treatment and the right to formulate advance 
                directives (as defined in paragraph (3)), and
                  (ii) the provider's or organization's written 
                policies respecting the implementation of such 
                rights;
          (B) to document in the individual's medical record 
        whether or not the individual has executed an advance 
        directive;
          (C) not to condition the provision of care or 
        otherwise discriminate against an individual based on 
        whether or not the individual has executed an advance 
        directive;
          (D) to ensure compliance with requirements of State 
        law (whether statutory or as recognized by the courts 
        of the State) respecting advance directives; and
          (E) to provide (individually or with others) for 
        education for staff and the community on issues 
        concerning advance directives.
Subparagraph (C) shall not be construed as requiring the 
provision of care which conflicts with an advance directive.
  (2) The written information described in paragraph (1)(A) 
shall be provided to an adult individual--
          (A) in the case of a hospital, at the time of the 
        individual's admission as an inpatient,
          (B) in the case of a nursing facility, at the time of 
        the individual's admission as a resident,
          (C) in the case of a provider of home health care or 
        personal care services, in advance of the individual 
        coming under the care of the provider,
          (D) in the case of a hospice program, at the time of 
        initial receipt of hospice care by the individual from 
        the program, and
          (E) in the case of a medicaid managed care 
        organization, at the time of enrollment of the 
        individual with the organization.
  (3) Nothing in this section shall be construed to prohibit 
the application of a State law which allows for an objection on 
the basis of conscience for any health care provider or any 
agent of such provider which as a matter of conscience cannot 
implement an advance directive.
  (4) In this subsection, the term ``advance directive'' means 
a written instruction, such as a living will or durable power 
of attorney for health care, recognized under State law 
(whether statutory or as recognized by the courts of the State) 
and relating to the provision of such care when the individual 
is incapacitated.
  (5) For construction relating to this subsection, see section 
7 of the Assisted Suicide Funding Restriction Act of 1997 
(relating to clarification respecting assisted suicide, 
euthanasia, and mercy killing).
  (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 patients, the State shall terminate the hospital's 
        participation under the State plan; or
          (B) do not immediately jeopardize the health and 
        safety of its patients, the State may terminate the 
        hospital's participation under the State plan, or 
        provide that no payment will be made under the State 
        plan with respect to any individual admitted to such 
        hospital after the effective date of the finding, or 
        both.
  (2) Except as provided in paragraph (3), if a psychiatric 
hospital described in paragraph (1)(B) has not complied with 
the requirements for a psychiatric hospital under this title--
          (A) within 3 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        the State shall provide that no payment will be made 
        under the State plan with respect to any individual 
        admitted to such hospital after the end of such 3-month 
        period, or
          (B) within 6 months after the date the hospital is 
        found to be out of compliance with such requirements, 
        no Federal financial participation shall be provided 
        under section 1903(a) with respect to further services 
        provided in the hospital until the State finds that the 
        hospital is in compliance with the requirements 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 alternative action to assure compliance of the 
        hospital with the requirements than to terminate the 
        certification of the hospital,
          (B) the State has submitted a plan and timetable for 
        corrective action to the Secretary for approval and the 
        Secretary approves the plan of corrective action, and
          (C) the State agrees to repay to the Federal 
        Government payments received under this paragraph if 
        the corrective action is not taken in accordance with 
        the approved plan and timetable.
  (z)(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 described in subsection (a)(10)(A)(i) may 
        have and obtain medical assistance under the plan; and
          (C) whose resources (as determined under the State 
        plan under this title with respect to disabled 
        individuals) do not exceed the maximum amount of 
        resources a disabled individual described in subsection 
        (a)(10)(A)(i) may have and obtain medical assistance 
        under the plan.
  (2) For purposes of subsection (a)(10), the term ``TB-related 
services'' means each of the following services relating to 
treatment of infection with tuberculosis:
          (A) Prescribed drugs.
          (B) Physicians' services and services described in 
        section 1905(a)(2).
          (C) Laboratory and X-ray services (including services 
        to confirm the presence of infection).
          (D) Clinic services and Federally-qualified health 
        center services.
          (E) Case management services (as defined in section 
        1915(g)(2)).
          (F) Services (other than room and board) designed to 
        encourage completion of regimens of prescribed drugs by 
        outpatients, including services to observe directly the 
        intake of prescribed drugs.
  (aa) Individuals described in this subsection are individuals 
who--
          (1) are not described in subsection (a)(10)(A)(i);
          (2) have not attained age 65;
          (3) have been screened for breast and cervical cancer 
        under the Centers for Disease Control and Prevention 
        breast and cervical cancer early detection program 
        established under title XV of the Public Health Service 
        Act (42 U.S.C. 300k et seq.) in accordance 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 
        respect to services furnished on or after January 1, 
        2001, and each succeeding fiscal year, the State plan 
        shall provide for payment for services described in 
        section 1905(a)(2)(C) furnished by a Federally-
        qualified health center and services described 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 services in an amount (calculated on a 
        per visit basis) that is equal to 100 percent of the 
        average of the costs of the center or clinic of 
        furnishing such services during fiscal years 1999 and 
        2000 which are reasonable and related to the cost of 
        furnishing such services, or based on such other tests 
        of reasonableness as the Secretary prescribes in 
        regulations under 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.--
        Subject to paragraph (4), for services furnished during 
        fiscal year 2002 or a succeeding fiscal year, the State 
        plan shall provide for payment for such services in an 
        amount (calculated on a per visit basis) that is equal 
        to the amount calculated for such services under this 
        subsection for the preceding fiscal year--
                  (A) increased by the percentage increase in 
                the MEI (as defined in 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 decrease in the scope of such 
                services furnished by the center or clinic 
                during that fiscal year.
          (4) Establishment of initial year payment amount for 
        new centers or clinics.--In any case in which an entity 
        first qualifies as a Federally-qualified health center 
        or rural health clinic after fiscal year 2000, the 
        State plan shall provide for payment for services 
        described in section 1905(a)(2)(C) furnished by the 
        center or services described in section 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 
        center or clinic, in accordance with the regulations 
        and methodology 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 calculated 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 pursuant to a 
                contract between the center or clinic and a 
                managed 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 required under subparagraph (A) shall 
                be made pursuant to a payment schedule agreed 
                to by the State and the Federally-qualified 
                health center or rural health clinic, but in no 
                case less frequently than every 4 months.
          (6) Alternative payment methodologies.--
        Notwithstanding any other provision of this section, 
        the State plan may provide for payment in any fiscal 
        year to a Federally-qualified health center for 
        services described in 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 section.
  (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 second, third, and 
                fourth quarters of fiscal year 2007;
                  (ii) on or after October 1, 1995 (or, at the 
                option of a State, on or after an earlier 
                date), in the case of each quarter of fiscal 
                year 2008; and
                  (iii) after October 1, 1989, in the case of 
                each quarter of fiscal year 2009 and each 
                quarter of any fiscal year thereafter;
          (B) who would be considered disabled under section 
        1614(a)(3)(C) (as determined under title XVI for 
        children but 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 poverty 
                        line may only be provided with State 
                        funds; and
                          (II) no Federal financial 
                        participation shall be provided 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 employer 
        contributes at least 50 percent of the total cost of 
        annual 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 application for medical 
assistance may be satisfied through an electronic signature, as 
defined in section 1710(1) of the Government Paperwork 
Elimination Act (44 U.S.C. 3504 note). The requirements of 
subparagraphs (A) and (B) of section 1137(d)(2) may be met 
through evidence in digital or electronic form.
  (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 eligibility under this title, are, in 
lieu of requiring the individual to present satisfactory 
documentary evidence of citizenship or nationality 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 Social Security that the name or social 
        security number, or the declaration of citizenship or 
        nationality, of the individual is inconsistent with 
        information in the records maintained by the 
        Commissioner--
                  (i) the State makes a reasonable effort to 
                identify and address the causes of such 
                inconsistency, including through typographical 
                or other clerical errors, by contacting the 
                individual to confirm the accuracy of the name 
                or social security number submitted or 
                declaration of citizenship or nationality and 
                by taking such additional actions as the 
                Secretary, through regulation or other 
                guidance, or the State may identify, and 
                continues to provide the individual with 
                medical assistance while making such effort; 
                and
                  (ii) in the case such inconsistency is not 
                resolved under clause (i), the State--
                          (I) notifies the individual of such 
                        fact;
                          (II) provides the individual with a 
                        period of 90 days from the date on 
                        which the notice required under 
                        subclause (I) is received by the 
                        individual to either present 
                        satisfactory documentary evidence of 
                        citizenship or nationality (as defined 
                        in section 1903(x)(3)) or resolve the 
                        inconsistency with the Commissioner of 
                        Social 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 presented or if such inconsistency 
                        is not resolved.
  (2)(A) Each State electing to satisfy the requirements of 
this subsection for purposes of section 1902(a)(46)(B) shall 
establish a program under which the State submits at least 
monthly to the Commissioner 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 national, with information in 
records maintained by the Commissioner.
  (B) In establishing the State program under this paragraph, 
the State may enter into an agreement with the Commissioner of 
Social Security--
          (i) to provide, through an on-line system or 
        otherwise, for the electronic submission of, and 
        response to, the information submitted under 
        subparagraph (A) for an individual enrolled in the 
        State plan under this title who declares to be citizen 
        or national on at least a monthly basis; or
          (ii) to provide for a determination of the 
        consistency of the information submitted with the 
        information maintained in the records of the 
        Commissioner through such other method as agreed to by 
        the State and the Commissioner and approved by the 
        Secretary, provided that such method is no more 
        burdensome for individuals to comply with than any 
        burdens that may apply under a method described in 
        clause (i).
  (C) The program established under this paragraph shall 
provide that, in the case of any individual who is required to 
submit a social security number to the State under subparagraph 
(A) and who is unable to provide the State with such number, 
shall be provided with at least the reasonable opportunity to 
present satisfactory documentary evidence of citizenship or 
nationality (as defined in section 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 evidence 
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 subparagraph, a name, social security number, or 
declaration of citizenship or nationality of an individual 
shall be treated as inconsistent and included in the 
determination of such percentage only if--
          (i) the information submitted by the individual is 
        not consistent with information in records maintained 
        by the Commissioner of Social Security;
          (ii) the inconsistency is not resolved by the State;
          (iii) the individual was provided with a reasonable 
        period of time to resolve the inconsistency with the 
        Commissioner of Social Security or provide satisfactory 
        documentation of citizenship status and did not 
        successfully resolve such inconsistency; and
          (iv) payment has been made for an item or service 
        furnished to the individual under this title.
  (B) If, for any fiscal year, the average monthly percentage 
determined under subparagraph (A) is greater than 3 percent--
          (i) the State shall develop and adopt a corrective 
        plan to review its procedures for verifying the 
        identities of individuals seeking to enroll in the 
        State plan under this title and to identify and 
        implement changes in such procedures to improve their 
        accuracy; and
          (ii) pay to the Secretary an amount equal to the 
        amount which bears the same ratio to the total payments 
        under the State plan for the fiscal year for providing 
        medical assistance to individuals who provided 
        inconsistent information as the number of individuals 
        with inconsistent information in excess of 3 percent of 
        such total submitted bears to the total number of 
        individuals with inconsistent information.
  (C) The Secretary may waive, in certain limited cases, all or 
part of the payment under subparagraph (B)(ii) if the State is 
unable to reach the allowable error rate despite a good faith 
effort by such State.
  (D) Subparagraphs (A) and (B) shall not apply to a State for 
a fiscal year if there is an agreement described in paragraph 
(2)(B) in effect as of the close of the fiscal year that 
provides for the submission on a real-time basis of the 
information described in such paragraph.
  (4) Nothing in this subsection shall affect the rights of any 
individual under this 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 
        reservations 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 paragraph (1), property located within the most 
        recent boundaries of a prior Federal reservation.
          (3) Ownership interests in rents, leases, royalties, 
        or usage rights related to natural resources (including 
        extraction of natural resources or harvesting of 
        timber, other plants and plant products, animals, fish, 
        and shellfish) resulting from the exercise of federally 
        protected rights.
          (4) Ownership interests in or usage rights to items 
        not covered by paragraphs (1) through (3) that have 
        unique religious, spiritual, traditional, or cultural 
        significance or rights that support subsistence or a 
        traditional lifestyle according to applicable tribal 
        law or custom.
  (gg) Maintenance of Effort.--
          (1) General requirement to maintain eligibility 
        standards until state exchange is fully operational.--
        Subject to the succeeding paragraphs of this 
        subsection, during the period that begins on the date 
        of enactment of the Patient Protection 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 
        Affordable Care Act is fully operational, as a 
        condition for receiving any Federal payments under 
        section 1903(a) for calendar quarters occurring during 
        such period, a State shall not have in effect 
        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 restrictive than the eligibility 
        standards, methodologies, or procedures, respectively, 
        under the plan or waiver that are in effect on the date 
        of enactment of the Patient Protection and Affordable 
        Care Act.
          (2) Continuation of eligibility standards for 
        children through september 30, 2027.--The requirement 
        under paragraph (1) shall continue to apply to a State 
        through September 30, 2027 (but during the period that 
        begins on October 1, 2019, 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 standards, methodologies, and procedures 
        under the State plan under this title or under any 
        waiver of such plan that are applicable 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 
        January 1, 2011, and ends on December 31, 2013, the 
        requirement under paragraph (1) shall not apply to a 
        State with respect to nonpregnant, nondisabled adults 
        who are eligible for medical assistance under the State 
        plan or under a waiver of the plan at the option of the 
        State and whose income exceeds 133 percent of the 
        poverty line (as defined in section 2110(c)(5)) 
        applicable 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 succeeding State 
        fiscal year, the State is projected to have a budget 
        deficit. Upon submission of such a certification to the 
        Secretary, 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 income.--A State's determination of 
                income in accordance with subsection (e)(14) 
                shall not be considered to be eligibility 
                standards, methodologies, or procedures that 
                are more restrictive than the standards, 
                methodologies, or procedures in effect under 
                the State plan or under a waiver of the plan on 
                the date of enactment of the Patient Protection 
                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, 
                methodologies, or procedures under the State 
                plan under this title or under any waiver of 
                the plan that are less restrictive than the 
                eligibility standards, methodologies, or 
                procedures, applied under the State plan or 
                under a waiver of the plan on 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 assistance 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 (VIII) 
                of section 1902(a)(10)(A)(i), shall not be 
                considered to have in effect eligibility 
                standards, methodologies, or procedures that 
                are more restrictive than the standards, 
                methodologies, or procedures in effect under 
                the State plan or under a waiver of the plan on 
                the date of enactment of the Patient Protection 
                and Affordable Care Act for purposes 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 subclause with higher income 
before making individuals described in such subclause with 
lower income eligible for medical assistance.
  (2) If an individual described in subclause (XX) of 
subsection (a)(10)(A)(ii) is the parent of a child who is under 
19 years of age (or such higher age as the State may have 
elected) who is eligible for medical assistance under the State 
plan or under a waiver of such plan, the individual may not be 
enrolled under the State plan unless the individual's child is 
enrolled under the State plan or under a waiver of the plan or 
is enrolled in other health insurance coverage. For purposes of 
the preceding sentence, the term ``parent'' includes an 
individual treated as a caretaker relative for purposes of 
carrying out 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 subsection may include individuals who, had 
        individuals applied on or before January 1, 2007, would 
        have been made eligible pursuant to the standards and 
        processes imposed by that State for benefits described 
        in clause (XVI) of the matter following subparagraph 
        (G) of section 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 subsection, the State may consider 
        only the income of the applicant or recipient.
  (jj) Primary Care Services Defined.--For purposes of 
subsection (a)(13)(C), the term ``primary care services'' 
means--
          (1) evaluation and management services that are 
        procedure codes (for services covered under 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 vaccines and toxoids for which CPT codes 90465, 
        90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as 
        subsequently modified) apply under such System.
  (kk) Provider and Supplier Screening, Oversight, and 
Reporting Requirements.--For purposes of subsection (a)(77), 
the requirements of this subsection are the following:
          (1) Screening.--The State complies with the process 
        for screening providers and suppliers under this title, 
        as established by the Secretary under section 
        1866(j)(2).
          (2) Provisional period of enhanced oversight for new 
        providers and suppliers.--The State complies with 
        procedures to provide for a provisional period of 
        enhanced oversight for new providers and suppliers 
        under this title, as established by the Secretary under 
        section 1866(j)(3).
          (3) Disclosure requirements.--The State requires 
        providers and suppliers under the State plan or under a 
        waiver of the plan to comply with the disclosure 
        requirements established by the Secretary under section 
        1866(j)(5).
          (4) Temporary moratorium on enrollment of new 
        providers or suppliers.--
                  (A) Temporary moratorium imposed by the 
                secretary.--
                          (i) In general.--Subject to clause 
                        (ii), the State complies with any 
                        temporary moratorium on the enrollment 
                        of new providers or suppliers imposed 
                        by the Secretary under 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 
                                determines 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 agency 
                                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 specified in subparagraph 
                        (C)(iii) of section 1866(j)(7) from 
                        charging an individual or other person 
                        eligible to receive medical assistance 
                        under the State plan under this title 
                        (or a waiver of the plan) for an item 
                        or service 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 providers or 
                suppliers under the State plan or under a 
                waiver of the plan, periods of enrollment 
                moratoria, or numerical caps or other limits, 
                for providers or suppliers identified by the 
                Secretary as being at high-risk for fraud, 
                waste, or abuse as necessary to combat fraud, 
                waste, or abuse, but only if the State 
                determines that the imposition of any such 
                period, cap, or other limits would not 
                adversely impact beneficiaries' access to 
                medical assistance.
          (5) Compliance programs.--The State requires 
        providers and suppliers under the State plan or under a 
        waiver of the plan to establish, in accordance with the 
        requirements of section 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 industry or 
        category.
          (6) Reporting of adverse provider actions.--The State 
        complies with the national system for reporting 
        criminal and civil convictions, sanctions, negative 
        licensure actions, and other adverse provider actions 
        to the Secretary, through the Administrator of the 
        Centers for Medicare & Medicaid Services, in accordance 
        with regulations of the Secretary.
          (7) Enrollment and npi of ordering or referring 
        providers.--The State requires--
                  (A) all ordering or referring physicians or 
                other professionals to be enrolled under the 
                State plan or under a waiver of the plan as a 
                participating provider; and
                  (B) the national provider identifier of any 
                ordering or referring physician or other 
                professional to be specified on any claim for 
                payment that is based on an order or referral 
                of the physician or other professional.
          (8) Provider terminations.--
                  (A) In general.--Beginning on July 1, 2018, 
                in the case of a notification under subsection 
                (a)(41) with respect to a termination for a 
                reason specified in section 455.101 of title 
                42, Code of Federal Regulations (as in effect 
                on November 1, 2015) or for any other reason 
                specified by the Secretary, of the 
                participation of a provider of services or any 
                other person under the State plan (or under a 
                waiver of the plan), the State, not later than 
                30 days after the effective date of such 
                termination, submits to the Secretary with 
                respect to any such provider or person, as 
                appropriate--
                          (i) the name of such provider or 
                        person;
                          (ii) the provider type of such 
                        provider or person;
                          (iii) the specialty of such 
                        provider's or person's practice;
                          (iv) the date of birth, Social 
                        Security number, national provider 
                        identifier (if applicable), Federal 
                        taxpayer identification number, and the 
                        State license or certification number 
                        of such provider or person (if 
                        applicable);
                          (v) the reason for the termination;
                          (vi) a copy of the notice of 
                        termination sent to the provider or 
                        person;
                          (vii) the date on which such 
                        termination is effective, as specified 
                        in the notice; and
                          (viii) any other information required 
                        by the Secretary.
                  (B) Effective date defined.--For purposes of 
                this paragraph, the term ``effective date'' 
                means, with respect to a termination described 
                in subparagraph (A), the later of--
                          (i) the date on which such 
                        termination is effective, as specified 
                        in the notice of such termination; or
                          (ii) the date on which all appeal 
                        rights applicable to such termination 
                        have been exhausted or the timeline for 
                        any such appeal has expired.
          (9) Other state oversight.--Nothing in this 
        subsection shall be interpreted to preclude or limit 
        the ability of a State to engage in provider and 
        supplier screening or enhanced provider and supplier 
        oversight activities beyond those required by the 
        Secretary.
  (ll) Termination Notification Database.--In the case of a 
provider of services or any other person whose participation 
under this 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 Secretary determines appropriate, 
include such termination in any database or similar system 
developed pursuant to section 6401(b)(2) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 1395cc note; 
Public Law 111-148).
  (mm) Directory Physician or Provider Described.--A physician 
or provider described in this subsection is--
          (1) in the case of a physician or provider of a 
        provider type for which the State agency, as a 
        condition on receiving payment for items and services 
        furnished by the physician or provider to individuals 
        eligible to receive medical assistance under the State 
        plan, requires the enrollment of the physician or 
        provider with the State agency, a physician or a 
        provider that--
                  (A) is enrolled with the agency as of the 
                date on which the directory is published or 
                updated (as applicable) under subsection 
                (a)(83); and
                  (B) received payment under the State plan in 
                the 12-month period preceding such date; and
          (2) in the case of a physician or provider of a 
        provider type for which the State agency does not 
        require such enrollment, a physician or provider that 
        received payment under the State plan (or a waiver of 
        the plan) in the 12-month period preceding the date on 
        which the directory is published or updated (as 
        applicable) under subsection (a)(83).
  (nn) Juvenile; Eligible Juvenile; Public Institution.--For 
purposes of subsection (a)(84) and this subsection:
          (1) Juvenile.--The term ``juvenile'' means an 
        individual who is--
                  (A) under 21 years of age; or
                  (B) described in subsection 
                (a)(10)(A)(i)(IX).
          (2) Eligible juvenile.--The term ``eligible 
        juvenile'' means a juvenile who is an inmate of a 
        public institution and who--
                  (A) was determined eligible for medical 
                assistance under the State plan immediately 
                before becoming an inmate of such a public 
                institution; or
                  (B) is determined eligible for such medical 
                assistance while an inmate of a public 
                institution.
          (3) Inmate of a public institution.--The term 
        ``inmate of a public institution'' has the meaning 
        given such term for purposes of applying the 
        subdivision (A) following paragraph (30) 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 following:
                  (A) Claims review limitations.--
                          (i) In general.--The State has in 
                        place--
                                  (I) safety edits (as 
                                specified by the State) for 
                                subsequent fills for opioids 
                                and a claims review automated 
                                process (as designed and 
                                implemented by the State) that 
                                indicates when an individual 
                                enrolled under the State plan 
                                (or under a waiver of the State 
                                plan) is prescribed a 
                                subsequent fill of opioids in 
                                excess of any limitation that 
                                may be identified by the State;
                                  (II) safety edits (as 
                                specified by the State) on the 
                                maximum daily morphine 
                                equivalent that can be 
                                prescribed to an individual 
                                enrolled under the State plan 
                                (or under a waiver of the State 
                                plan) for treatment of chronic 
                                pain and a claims review 
                                automated process (as designed 
                                and implemented by the State) 
                                that indicates when an 
                                individual enrolled under the 
                                plan (or waiver) is prescribed 
                                the morphine equivalent for 
                                such treatment in excess of any 
                                limitation that may be 
                                identified by the State; and
                                  (III) a claims review 
                                automated process (as designed 
                                and implemented by the State) 
                                that monitors when an 
                                individual enrolled under the 
                                State plan (or under a waiver 
                                of the State plan) is 
                                concurrently prescribed opioids 
                                and--
                                          (aa) benzodiazepines; 
                                        or
                                          (bb) antipsychotics.
                          (ii) Managed care entities.--The 
                        State requires each managed care entity 
                        (as defined in 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 described in 
                        subclause (III) of such clause.
                          (iii) Rules of construction.--Nothing 
                        in this subparagraph may be construed 
                        as prohibiting a State or managed care 
                        entity from designing and implementing 
                        a claims review automated process under 
                        this subparagraph that provides for 
                        prospective or retrospective reviews of 
                        claims. Nothing in this subparagraph 
                        shall be understood as prohibiting the 
                        exercise of clinical judgment from a 
                        provider enrolled as a participating 
                        provider in a State plan (or waiver of 
                        the State plan) or contracting with a 
                        managed care entity regarding the best 
                        items and services for an individual 
                        enrolled under such State plan (or 
                        waiver).
                  (B) Program to monitor antipsychotic 
                medications by children.--The State has in 
                place a program (as designed and implemented by 
                the State) to monitor and manage the 
                appropriate use of antipsychotic medications by 
                children enrolled under the State plan (or 
                under a waiver of the State plan) and submits 
                annually to the Secretary such information as 
                the Secretary may require on activities carried 
                out under such program for individuals not more 
                than the age of 18 years generally and children 
                in foster care specifically.
                  (C) Fraud and abuse identification.--The 
                State has in place a process (as designed and 
                implemented by the State) that identifies 
                potential fraud or abuse of controlled 
                substances by individuals enrolled under the 
                State plan (or under a waiver of the State 
                plan), health care providers prescribing drugs 
                to individuals so enrolled, and pharmacies 
                dispensing drugs to individuals so enrolled.
                  (D) Reports.--The State shall include in the 
                annual report submitted to the Secretary under 
                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 program described in such 
                        subparagraph that was in place before 
                        such date; or
                          (iii) described in subparagraph (C) 
                        by having a process described in such 
                        subparagraph that was in place before 
                        such date.
          (2) Annual report by secretary.--For each fiscal year 
        beginning with fiscal year 2020, the Secretary shall 
        submit to Congress a report on the most recent 
        information submitted by States under paragraph (1)(D).
          (3) Exceptions.--
                  (A) Certain individuals exempted.--The drug 
                review and utilization requirements under this 
                subsection shall not apply with respect to an 
                individual who--
                          (i) is receiving--
                                  (I) hospice or palliative 
                                care; or
                                  (II) treatment for cancer;
                          (ii) is a resident of a long-term 
                        care facility, of a facility described 
                        in section 1905(d), or of another 
                        facility for which frequently abused 
                        drugs are dispensed for residents 
                        through a contract with a single 
                        pharmacy; 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 purposes 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 assistance 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 
        recovery center may offer counseling and other services 
        to mothers (and other appropriate family members and 
        caretakers) of infants receiving treatment at such 
        centers if such services are otherwise covered under 
        the State plan under this 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.

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                              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 services themselves, or both (if provided in or after the 
third month before the month in which the recipient makes 
application for assistance [or, in the case of medicare cost-
sharing with respect to a qualified medicare beneficiary 
described in subsection (p)(1), if provided after the month in 
which the individual becomes such a beneficiary]) for 
individuals, and, with respect to physicians' or dentists' 
services, at the option of the State, to individuals (other 
than individuals with respect to whom there is being paid, or 
who are eligible, or would be eligible if they were not in a 
medical institution, to have paid with respect to them a State 
supplementary payment and are eligible for medical assistance 
equal in amount, duration, and scope to the medical assistance 
made available to individuals described in 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 security 
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 disabled, 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),
          (xii) employed individuals with a medically improved 
        disability (as defined in subsection (v)),
          (xiii) individuals described in section 1902(aa),
          (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 section, 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 institution for mental diseases);
          (2)(A) outpatient hospital services, (B) consistent 
        with State law permitting such services, rural health 
        clinic services (as defined in subsection (l)(1)) and 
        any other ambulatory services which are offered by a 
        rural health clinic (as defined in subsection (l)(1)) 
        and which are otherwise included in the plan, and (C) 
        Federally-qualified health center services (as defined 
        in subsection (l)(2)) and any other ambulatory services 
        offered by a Federally-qualified health center and 
        which are otherwise included in the plan;
          (3) other laboratory and X-ray services;
          (4)(A) nursing facility services (other than services 
        in an institution for mental diseases) for individuals 
        21 years of age or older; (B) early and periodic 
        screening, diagnostic, and treatment services (as 
        defined in subsection (r)) for individuals who are 
        eligible under the plan and are under the age of 21; 
        (C) family planning services and supplies furnished 
        (directly or under arrangements with others) to 
        individuals of child-bearing age (including minors who 
        can be considered to be sexually active) who are 
        eligible under the State plan and who desire such 
        services and supplies; and (D) counseling and 
        pharmacotherapy for cessation of tobacco use by 
        pregnant women (as defined in subsection (bb));
          (5)(A) physicians' services furnished by a physician 
        (as defined 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 defined in section 
        1861(r)(1));
          (6) medical care, or any other type of remedial care 
        recognized under State law, furnished by licensed 
        practitioners within the scope of their practice as 
        defined by State law;
          (7) home health care services;
          (8) private duty nursing services;
          (9) clinic services furnished by or under the 
        direction of a physician, without regard to whether the 
        clinic itself is administered by a physician, including 
        such services furnished outside the clinic by clinic 
        personnel to an eligible individual who does not reside 
        in a permanent dwelling or does not have a fixed home 
        or mailing address;
          (10) dental services;
          (11) physical therapy and related services;
          (12) prescribed drugs, dentures, and prosthetic 
        devices; and eyeglasses prescribed by a physician 
        skilled in diseases of the eye or by an optometrist, 
        whichever the individual may select;
          (13) other diagnostic, screening, preventive, and 
        rehabilitative services, including--
                  (A) any clinical preventive services that are 
                assigned a grade of A or B by the United States 
                Preventive Services Task Force;
                  (B) with respect to an adult individual, 
                approved vaccines recommended by the Advisory 
                Committee on Immunization Practices (an 
                advisory committee established by the 
                Secretary, acting through the Director of the 
                Centers for Disease Control and Prevention) and 
                their administration; and
                  (C) any medical or remedial services 
                (provided in a facility, a home, or other 
                setting) recommended by a physician or other 
                licensed practitioner of the healing arts 
                within the scope of their practice under State 
                law, for the maximum reduction of physical or 
                mental disability and restoration of an 
                individual to the best possible functional 
                level;
          (14) inpatient hospital services and nursing facility 
        services for individuals 65 years of age or over in an 
        institution for mental diseases;
          (15) services in an intermediate care facility for 
        the mentally retarded (other than in an institution for 
        mental diseases) for individuals who are determined, in 
        accordance with section 1902(a)(31), to be in need of 
        such care;
          (16) (A) effective January 1, 1973, inpatient 
        psychiatric hospital services for individuals under age 
        21, as defined in subsection (h), and, (B) for 
        individuals receiving services described in 
        subparagraph (A), early and periodic screening, 
        diagnostic, and treatment services (as defined in 
        subsection (r)), whether or not such screening, 
        diagnostic, and treatment services are furnished by the 
        provider of the services described in such 
        subparagraph;
          (17) services furnished by a nurse-midwife (as 
        defined in section 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 practitioner or certified family nurse 
        practitioner (as defined by the Secretary) which the 
        certified pediatric nurse practitioner or certified 
        family nurse practitioner is legally authorized to 
        perform under State law (or the State regulatory 
        mechanism provided by State law), whether or not the 
        certified pediatric nurse practitioner or certified 
        family nurse practitioner is under the supervision of, 
        or associated with, a physician or other health care 
        provider;
          (22) home and community care (to the extent allowed 
        and as defined in section 1929) for functionally 
        disabled elderly individuals;
          (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, intermediate care facility 
        for the mentally retarded, or institution for mental 
        disease that are (A) authorized for the individual by a 
        physician in accordance with a plan of treatment or (at 
        the option of the State) otherwise authorized for the 
        individual in accordance with a service plan approved 
        by the State, (B) provided by an individual who is 
        qualified to provide such services and who is not a 
        member of the individual's family, and (C) furnished in 
        a home or other location;
          (25) primary care case management services (as 
        defined in subsection (t));
          (26) services furnished under a PACE program under 
        section 1934 to PACE program eligible individuals 
        enrolled under the program under such section;
          (27) subject to subsection (x), primary and secondary 
        medical strategies and treatment and services for 
        individuals who have Sickle Cell Disease;
          (28) freestanding birth center services (as defined 
        in subsection (l)(3)(A)) and other ambulatory services 
        that are offered by a freestanding birth center (as 
        defined in subsection (l)(3)(B)) and that are otherwise 
        included in the plan;
          (29) subject to paragraph (2) of subsection (ee), for 
        the period beginning October 1, 2020, and ending 
        September 30, 2025, medication-assisted treatment (as 
        defined in paragraph (1) of such subsection); and
          (30) any other medical care, and any other type of 
        remedial care recognized under State law, specified by 
        the Secretary,
except as otherwise provided in paragraph (16), such term does 
not include--
          (A) any such payments with respect to care or 
        services for any individual who is an inmate of a 
        public institution (except as a patient in a medical 
        institution); or
          (B) any such payments with respect to care or 
        services for any individual who has not attained 65 
        years of age and who is a patient in an institution for 
        mental diseases.
For purposes of clause (vi) of the preceding sentence, a person 
shall be considered essential to another individual if such 
person is the spouse of and is living with such individual, the 
needs of such person are taken into account in determining the 
amount of aid or assistance furnished to such individual (under 
a State plan approved under 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 include expenditures for medicare cost-
sharing and for premiums under part B of title XVIII for 
individuals who are eligible for medical assistance under the 
plan and (A) are receiving aid or assistance under any plan of 
the State approved under 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 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), and, except in the case of 
individuals 65 years of age or older and disabled individuals 
entitled to health insurance benefits under title XVIII who are 
not enrolled under part B of title XVIII, other insurance 
premiums for 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 service for alcoholism or 
drug dependency. In the case of a woman who is eligible for 
medical assistance on the basis of being pregnant (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 
receiving treatment for a substance use disorder, and who was 
enrolled for medical assistance under the State plan 
immediately before becoming a patient in an institution for 
mental diseases or who becomes eligible to enroll for such 
medical assistance while such a patient, 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), and (ff) [and 
section 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 section 2105(b) with respect to medical assistance 
provided to individuals 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 provides medical assistance for 
services and vaccines described in subparagraphs (A) and (B) of 
subsection (a)(13), and prohibits cost-sharing for such 
services and vaccines, the Federal medical assistance 
percentage, as determined under this subsection and subsection 
(y) (without regard to paragraph (1)(C) of such subsection), 
shall be increased by 1 percentage point with respect to 
medical assistance 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). Notwithstanding the first sentence of this 
section, the Federal medical assistance percentage shall be 100 
per centum with respect to amounts expended as medical 
assistance for services which are received through an Indian 
Health Service facility whether operated by the Indian Health 
Service or by an Indian tribe or tribal organization (as 
defined in section 4 of the Indian Health Care Improvement 
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).
  (c) For definition of the term ``nursing facility'', see 
section 1919(a).
  (d) The term ``intermediate care facility for the mentally 
retarded'' means an institution (or distinct part thereof) for 
the mentally retarded or persons with related conditions if--
          (1) the primary purpose of such institution (or 
        distinct part thereof) is to provide health or 
        rehabilitative services for mentally retarded 
        individuals and the institution meets such standards as 
        may be prescribed by the Secretary;
          (2) the mentally retarded individual with respect to 
        whom a request for payment is made under a plan 
        approved under this 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 furnished 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 institution 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)--
          (1) does not provide for the payment of services 
        (other than services covered under section 1902(a)(12)) 
        provided by an optometrist; but
          (2) at a prior period did provide for the payment of 
        services referred to in paragraph (1);
the term ``physicians' services'' (as used in subsection 
(a)(5)) shall include services of the type which an optometrist 
is legally authorized to perform where the State plan 
specifically provides that the term ``physicians' services'', 
as employed in such plan, includes services of the type which 
an optometrist is legally authorized to perform, and shall be 
reimbursed whether furnished by a physician or an optometrist.
  (f) For purposes of this title, the term ``nursing facility 
services'' means services which are or were required to be 
given an individual who needs or needed on a daily basis 
nursing care (provided directly by or requiring the supervision 
of nursing personnel) or other rehabilitation services which as 
a practical matter can only be provided in a nursing facility 
on an inpatient basis.
  (g) If the State plan includes provision of chiropractors' 
services, such services include only--
          (1) services provided by a chiropractor (A) who is 
        licensed as such by the State and (B) who meets uniform 
        minimum standards promulgated by the Secretary under 
        section 1861(r)(5); and
          (2) services which consist of treatment by means of 
        manual manipulation of the spine which the chiropractor 
        is legally authorized to perform by the State.
  (h)(1) For purposes of paragraph (16) of subsection (a), the 
term ``inpatient psychiatric hospital services for individuals 
under age 21'' includes only--
          (A) inpatient services which are provided in an 
        institution (or distinct part thereof) which is a 
        psychiatric hospital as defined in 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 inpatient basis and can reasonably be expected to 
        improve the condition, by reason of which such services 
        are necessary, to the extent that eventually such 
        services will no longer be necessary; and
          (C) inpatient services which, in the case of any 
        individual, are provided prior to (i) the date such 
        individual attains age 21, or (ii) in the case of an 
        individual who was receiving such services in the 
        period immediately preceding the date on which he 
        attained age 21, (I) the date such individual no longer 
        requires such services, or (II) if earlier, the date 
        such individual attains age 22;
  (2) Such term does not include services provided during any 
calendar quarter under the State plan of any State if the total 
amount of the funds expended, during such quarter, by the State 
(and the political subdivisions thereof) from non-Federal funds 
for inpatient services included under paragraph (1), and for 
active psychiatric care and treatment provided on an outpatient 
basis for eligible mentally ill children, is less than the 
average quarterly amount of the funds expended, during the 4-
quarter period ending December 31, 1971, by the State (and the 
political subdivisions thereof) from non-Federal funds for such 
services.
  (i) The term ``institution for mental diseases'' means a 
hospital, nursing facility, or other institution of more than 
16 beds, that is primarily engaged in providing diagnosis, 
treatment, or care of persons with mental diseases, including 
medical attention, nursing care, and related services.
  (j) 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 
pursuant 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), except that (A) clause (ii) of section 1861(aa)(2) 
shall not apply to such terms, and (B) the physician 
arrangement required under section 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 patient 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-qualified 
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 another entity, or
          (iv) was treated by the Secretary, for purposes of 
        part B of title XVIII, as a comprehensive Federally 
        funded health center as of January 1, 1990;
and includes an outpatient health program or facility operated 
by a tribe or tribal organization under the Indian Self-
Determination Act (Public Law 93-638) or by an urban Indian 
organization receiving 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 
services furnished to an individual at a freestanding birth 
center (as defined in subparagraph (B)) at such center.
  (B) The term ``freestanding birth center'' means a health 
facility--
          (i) that is not a hospital;
          (ii) where childbirth is planned to occur away from 
        the pregnant woman's residence;
          (iii) that is licensed or otherwise approved by the 
        State to provide prenatal labor and delivery or 
        postpartum care and other ambulatory services that are 
        included in the plan; and
          (iv) that complies with such other requirements 
        relating to the health and safety of individuals 
        furnished services by the facility as the State shall 
        establish.
  (C) A State shall provide separate payments to providers 
administering prenatal labor and delivery or postpartum care in 
a freestanding birth center (as defined in subparagraph (B)), 
such as nurse midwives and other providers of services such as 
birth attendants recognized under State law, as determined 
appropriate by the Secretary. For purposes of the preceding 
sentence, the term ``birth attendant'' means an individual who 
is recognized or registered by the State involved to provide 
health care at childbirth and who provides such care within the 
scope of practice under which the individual is legally 
authorized to perform such care under State law (or the State 
regulatory mechanism provided by State law), regardless of 
whether the individual is under the supervision of, or 
associated with, a physician or other health care provider. 
Nothing in this subparagraph shall be construed as changing 
State law requirements applicable to a birth attendant.
  (m)(1) Subject to paragraph (2), the term ``qualified family 
member'' means an individual (other than a qualified pregnant 
woman or child, as defined in subsection (n)) who is a member 
of a family that would be receiving aid under the State plan 
under part A of 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 
period 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 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 to section 407 if 
                the plan required the payment of aid pursuant 
                to such section; or
                  (C) otherwise meets the income and resources 
                requirements 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 requirements 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 terminally 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 subparagraph (A)(iii) of such section without 
taking into account any individual who is afflicted with 
acquired immune deficiency syndrome (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 established by the State and that are consistent 
        with the procedures 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 assistance 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 under which the program takes 
        full responsibility for the professional management of 
        the individual's hospice care and the facility agrees 
        to provide room and board to the individual,
instead of any payment otherwise made under the plan with 
respect to the facility's services, the State shall provide for 
payment to the hospice program of an amount equal to the 
additional amount determined in 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 
individual--
          (A) who is entitled to hospital insurance benefits 
        under part A of title XVIII (including an individual 
        entitled to such benefits pursuant to an enrollment 
        under section 1818, but not including an individual 
        entitled to such benefits only pursuant to an 
        enrollment under section 1818A),
          (B) whose income (as determined under section 1612 
        for purposes 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 individual may have and obtain 
        benefits under that program or, effective 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 exclusion provided under subparagraph 
        (G) of such section) applicable to an individual or to 
        the individual and the individual's spouse (as the case 
        may be).]
          (C) whose resources (as determined under section 1613 
        for purposes of the supplemental security income 
        program subject to the resource exclusions under 
        subparagraph (G) of section 1860D-14(a)(3)) do not 
        exceed--
                  (i) in the case of an individual with a 
                spouse, an amount equal to the sum of the first 
                amount specified in subsection (f)(2)(A)(i) of 
                section 1924 (as adjusted under subsection (g) 
                of such section) and the amount specified in 
                subsection (f)(2)(A)(ii)(II) of such section 
                (as so adjusted); or
                  (ii) in the case of an individual who does 
                not have a spouse, an amount equal to \1/2\ of 
                the amount described in clause (i).
The term ``specified low-income medicare beneficiary'' means an 
individual described in section 1902(a)(10)(E)(iii).
  (2)(A) The income level established under paragraph (1)(B) 
[shall be at least the percent provided under subparagraph (B) 
(but not more than 100 percent) of the official poverty line 
(as defined by the Office of Management and Budget, and revised 
annually in accordance with section 673(2) of the Omnibus 
Budget Reconciliation Act of 1981) applicable to a family of 
the size involved.] shall be--
                  (i) before January 1, 2021, at least the 
                percent provided under subparagraph (B) (but 
                not more than 100 percent) of the official 
                poverty line (as defined by the Office of 
                Management and Budget, and revised annually in 
                accordance with section 673(2) of the Omnibus 
                Budget Reconciliation Act of 1981) applicable 
                to a family of the size involved; and 
                  (ii) on or after January 1, 2021, equal to 
                135 percent of the official poverty line (as so 
                defined and revised) 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 
section 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 security 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,
          (ii) January 1, 1990, is 85 percent,
          (iii) January 1, 1991, is 95 percent, and
          (iv) January 1, 1992, is 100 percent.
  (D)(i) In determining under this subsection the income of an 
individual who is entitled to monthly insurance benefits under 
title II for a transition month (as defined in clause (ii)) in 
a year, such income shall not include any amounts attributable 
to an increase in the level of monthly insurance benefits 
payable under such 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.
          (iii) In determining income under this subsection, 
        support and maintenance furnished in kind shall not be 
        counted as income.
  (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 otherwise 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 described 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 organization 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 paragraph 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 
Secretary 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 
simplified application form for use by individuals (including 
both qualified medicare beneficiaries and specified low-income 
medicare beneficiaries) in applying for medical assistance for 
medicare cost-sharing under this 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 benefits under 
section 226 or 226A and shall make the translated forms 
available to the States and to the Commissioner of Social 
Security.
  (B) In developing such form, the Secretary shall consult with 
beneficiary groups and the States.
  (6) For provisions relating to outreach efforts to increase 
awareness of the availability of medicare cost-sharing, see 
section 1144.
          (7) Notwithstanding any other provision of law, any 
        medical assistance for some or all medicare cost-
        sharing under this title shall not be considered income 
        or resources in determining eligibility for, or the 
        amount of assistance or benefits provided under, any 
        other public benefit provided under Federal law or the 
        law of any State or political subdivision thereof.
  (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 income benefits under section 1611(b) 
                on the basis of blindness or disability, (ii) a 
                supplementary payment under section 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 
        Security determines that--
                  (A) the individual continues to be blind or 
                continues to have the disabling physical or 
                mental impairment on the basis of which he was 
                found to be under a disability and, except for 
                his earnings, continues to meet all non-
                disability-related requirements for eligibility 
                for benefits under 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 section 
                1611(b) (if he were otherwise eligible for such 
                payments),
                  (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 administered 
                State supplementary payments), this title, and 
                publicly funded attendant care services 
                (including personal care assistance) that would 
                be available to him in the absence of such 
                earnings.
        In the case of an individual who is eligible for 
        medical assistance pursuant to 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 
treatment services'' means the following items and services:
          (1) Screening services--
                  (A) which are provided--
                          (i) at intervals which meet 
                        reasonable standards of medical and 
                        dental practice, as determined by the 
                        State after consultation with 
                        recognized medical and dental 
                        organizations involved in child health 
                        care and, with respect to immunizations 
                        under subparagraph (B)(iii), in 
                        accordance with the schedule referred 
                        to in section 1928(c)(2)(B)(i) for 
                        pediatric vaccines, and
                          (ii) at such other intervals, 
                        indicated as medically necessary, to 
                        determine the existence of certain 
                        physical or mental illnesses or 
                        conditions; and
                  (B) which shall at a minimum include--
                          (i) a comprehensive health and 
                        developmental history (including 
                        assessment of both physical and mental 
                        health development),
                          (ii) a comprehensive unclothed 
                        physical exam,
                          (iii) appropriate immunizations 
                        (according to the schedule referred to 
                        in section 1928(c)(2)(B)(i) for 
                        pediatric vaccines) according to age 
                        and health history,
                          (iv) laboratory tests (including lead 
                        blood level assessment appropriate for 
                        age and risk factors), and
                          (v) health education (including 
                        anticipatory guidance).
          (2) Vision services--
                  (A) which are provided--
                          (i) at intervals which meet 
                        reasonable standards of medical 
                        practice, as determined by the State 
                        after consultation with recognized 
                        medical organizations involved in child 
                        health care, and
                          (ii) at such other intervals, 
                        indicated as medically necessary, to 
                        determine the existence of a suspected 
                        illness or condition; and
                  (B) which shall at a minimum include 
                diagnosis and treatment for defects in vision, 
                including eyeglasses.
          (3) Dental services--
                  (A) which are provided--
                          (i) at intervals which meet 
                        reasonable standards of dental 
                        practice, as determined by the State 
                        after consultation with recognized 
                        dental organizations involved in child 
                        health care, and
                          (ii) at such other intervals, 
                        indicated as medically necessary, to 
                        determine the existence of a suspected 
                        illness or condition; and
                  (B) which shall at a minimum include relief 
                of pain and infections, restoration of teeth, 
                and maintenance of dental health.
          (4) Hearing services--
                  (A) which are provided--
                          (i) at intervals which meet 
                        reasonable standards of medical 
                        practice, as determined by the State 
                        after consultation with recognized 
                        medical organizations involved in child 
                        health care, and
                          (ii) at such other intervals, 
                        indicated as medically necessary, to 
                        determine the existence of a suspected 
                        illness or condition; and
                  (B) which shall at a minimum include 
                diagnosis and treatment for defects in hearing, 
                including hearing aids.
          (5) Such other necessary health care, diagnostic 
        services, treatment, and other measures described in 
        section 1905(a) to correct or ameliorate defects and 
        physical and mental illnesses and conditions discovered 
        by the screening services, whether or not such services 
        are covered under the State plan.
Nothing in this 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 
participation goals for each State for participation of 
individuals who are covered under the State plan under this 
title in early and periodic screening, diagnostic, and 
treatment 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 purposes 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 Reconciliation Act 
        of 1981) applicable to a family of the size involved;
          [(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 individual 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]
          (3) whose resources (as determined under section 1613 
        for purposes of the supplemental security income 
        program subject to the resource exclusions under 
        subparagraph (G) of section 1860D-14(a)(3)) do not 
        exceed--
                  (A) in the case of an individual with a 
                spouse, the amount in effect for the year under 
                clause (i) of subsection (p)(1)(C); and
                  (B) in the case of an individual who does not 
                have a spouse, the amount in effect for the 
                year under clause (ii) of subsection (p)(1)(C); 
                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 
following that provides services of the type described in 
paragraph (1) under a contract referred to in such paragraph:
          (A) A physician, a physician group practice, or an 
        entity employing or having other arrangements with 
        physicians to provide such services.
          (B) At State option--
                  (i) a nurse practitioner (as described in 
                section 1905(a)(21));
                  (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 affordable modes of 
        transportation;
          (C) provides for arrangements with, or referrals to, 
        sufficient numbers of physicians and other appropriate 
        health care professionals to ensure that services under 
        the contract can be furnished to enrollees promptly and 
        without compromise to quality of care;
          (D) prohibits discrimination on the basis of health 
        status or requirements for health care services in 
        enrollment, disenrollment, or reenrollment of 
        individuals eligible for medical assistance under this 
        title;
          (E) provides for a right for an enrollee to terminate 
        enrollment 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'' includes all health care services customarily provided 
in accordance with State licensure and certification laws and 
regulations, and all laboratory services customarily provided 
by or through, a general practitioner, family medicine 
physician, internal medicine physician, obstetrician/
gynecologist, or pediatrician.
  (u)(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 assistance under this title) who would 
not qualify for medical assistance under the State plan under 
this title as in effect on March 31, 1997 (but taking into 
account the expansion of age of eligibility 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 
section 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 medical 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 
        impairment, as determined under regulations of the 
        Secretary.
  (2) For purposes of paragraph (1), an individual is 
considered to be ``employed'' if the individual--
          (A) is earning at least the applicable minimum wage 
        requirement under 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 Secretary.'
  (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 paragraph (2).
  (2) The levels established by a State under paragraph (1)(C) 
may not be less than the corresponding levels applied by the 
State under 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 individuals with respect to whom foster care maintenance 
payments or independent living services were furnished under a 
program funded under part E of title IV before the date the 
individuals attained 18 years of age.
  (x) For purposes of subsection (a)(27), the strategies, 
treatment, and services described in that subsection include 
the following:
          (1) Chronic blood transfusion (with deferoxamine 
        chelation) to prevent stroke in individuals with Sickle 
        Cell Disease who have been identified as being at high 
        risk for stroke.
          (2) Genetic counseling and testing for individuals 
        with Sickle Cell Disease or the sickle cell trait to 
        allow health care professionals to treat such 
        individuals and to prevent symptoms of Sickle Cell 
        Disease.
          (3) Other treatment and services to prevent 
        individuals who have Sickle Cell Disease and who have 
        had a stroke from having another stroke.
  (y) Increased FMAP for Medical Assistance for Newly Eligible 
Mandatory Individuals.--
          (1) Amount of increase.--Notwithstanding subsection 
        (b), the Federal medical assistance percentage for a 
        State that is one of the 50 States or the District of 
        Columbia, with respect to amounts expended by such 
        State for medical assistance for newly eligible 
        individuals described in subclause (VIII) of section 
        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 subparagraph (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 actuarially equivalent to benchmark 
                coverage described in subparagraph (A), (B), or 
                (C) of section 1937(b)(1), or is eligible but 
                not enrolled (or is on a waiting list) for such 
                benefits 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 determined under subsection (b) 
        with respect to a fiscal year occurring during that 
        period shall be increased by 2.2 percentage points for 
        any State described in subparagraph (B) for amounts 
        expended for medical assistance for individuals who are 
        not newly eligible (as defined in subsection (y)(2)) 
        individuals described in subclause (VIII) of 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 payments under this title on the 
                basis of an increased Federal medical 
                assistance percentage under subsection (y) for 
                expenditures for medical assistance for newly 
                eligible individuals (as so defined); and
                  (iii) has not been approved by the Secretary 
                to divert a portion of the DSH allotment for a 
                State to the costs of providing medical 
                assistance or other health benefits coverage 
                under a waiver that is in effect on July 2009.
          (2)(A) For calendar quarters in 2014 and each year 
        thereafter, the Federal medical assistance percentage 
        otherwise determined under subsection (b) for an 
        expansion State described in paragraph (3) with respect 
        to medical assistance for individuals described in 
        section 1902(a)(10)(A)(i)(VIII) who are nonpregnant 
        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 percentage (as defined in the first sentence 
        of subsection (b)) for the State increased by a number 
        of percentage points equal to the transition percentage 
        (specified in clause (ii) for the year) of the number 
        of percentage points by which--
                  (I) such Federal medical assistance 
                percentage for the State, is less than
                  (II) the percent specified in subsection 
                (y)(1) for the year.
          (ii) The transition percentage specified in this 
        clause for--
                  (I) 2014 is 50 percent;
                  (II) 2015 is 60 percent;
                  (III) 2016 is 70 percent;
                  (IV) 2017 is 80 percent;
                  (V) 2018 is 90 percent; and
                  (VI) 2019 and each subsequent year is 100 
                percent.
          (3) A State is an expansion State if, on the date of 
        the enactment 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 percent of the poverty 
        line, that includes inpatient hospital services, is not 
        dependent on access to employer coverage, employer 
        contribution, or employment and is not limited to 
        premium assistance, hospital-only benefits, a high 
        deductible health plan, or alternative benefits under a 
        demonstration program authorized under section 1938. A 
        State that offers health benefits coverage to only 
        parents or only nonpregnant childless adults described 
        in the preceding sentence shall not be considered to be 
        an expansion State.
  (aa)(1) Notwithstanding subsection (b), beginning January 1, 
2011, the Federal medical assistance percentage for a fiscal 
year for a disaster-recovery FMAP adjustment State shall be 
equal to the following:
          (A) In the case of the first fiscal year (or part of 
        a fiscal year) for which this subsection applies to the 
        State, the State's regular FMAP shall be increased by 
        50 percent of the number of percentage points by which 
        the State's regular FMAP for such fiscal year is less 
        than the Federal medical assistance percentage 
        determined for the State for the preceding fiscal year 
        after the application of only subsection (a) of section 
        5001 of Public Law 111-5 (if applicable to the 
        preceding fiscal year) and without regard to this 
        subsection, subsections (y) and (z), and subsections 
        (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 regular FMAP for such fiscal year 
        shall be increased by 25 percent (or 50 percent in the 
        case of fiscal year 2013) of the number of percentage 
        points by which the State's regular FMAP for such 
        fiscal year is less than the Federal medical assistance 
        percentage received by the State during the preceding 
        fiscal year.
  (2) In this subsection, the term ``disaster-recovery FMAP 
adjustment State'' means a State that is one of the 50 States 
or the District of Columbia, for which, at any time during the 
preceding 7 fiscal years, the President has declared a major 
disaster under section 401 of the Robert T. Stafford Disaster 
Relief and Emergency Assistance Act and determined as a result 
of such disaster that every county or parish in the State 
warrant individual and public assistance 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 regular FMAP for the fiscal year is 
        less than the Federal medical assistance percentage 
        determined for the State for the preceding fiscal year 
        after the application of only subsection (a) of section 
        5001 of Public Law 111-5 (if applicable to the 
        preceding fiscal year) and without regard to this 
        subsection, subsections (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 assistance percentage 
        determined for the State for the preceding fiscal year 
        under this subsection by at least 3 percentage points.
  (3) In this subsection, the term ``regular FMAP'' means, for 
each fiscal year for which this subsection applies to a State, 
the Federal medical assistance percentage that would otherwise 
apply to the State for the fiscal year, as determined under 
subsection (b) and without regard to this subsection, 
subsections (y) and (z), and section 10202 of the Patient 
Protection and Affordable Care Act.
  (4) The Federal medical assistance percentage determined for 
a disaster-recovery FMAP adjustment State under paragraph (1) 
shall apply for purposes of this title (other than with respect 
to disproportionate share hospital payments described in 
section 1923 and payments under this title that are based on 
the enhanced 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 
nonprescription tobacco cessation agents approved by the Food 
and Drug Administration) for cessation of tobacco use by 
pregnant women who use tobacco products or who are being 
treated for tobacco use that is furnished--
          (A) by or under the supervision of a physician; or
          (B) by any other health care professional who--
                  (i) is legally authorized to furnish such 
                services under State law (or the State 
                regulatory mechanism provided by State law) of 
                the State in which the services are furnished; 
                and
                  (ii) is authorized to receive payment for 
                other services under this 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 effective for cessation of tobacco use by 
        pregnant women.
  (3) Such term shall not include coverage for drugs or 
biologicals that are not otherwise covered under this title.
  (cc) Requirement for Certain States.--Notwithstanding 
subsections (y), (z), and (aa), in the case of a State that 
requires political subdivisions within the State to contribute 
toward the non-Federal share of expenditures required under the 
State plan under 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 percentage 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 increase. 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 
percentage under section 5001 of the American Recovery and 
Reinvestment Act of 2009.
  (dd) Increased FMAP for Additional Expenditures for Primary 
Care Services.--Notwithstanding subsection (b), with respect to 
the portion of the amounts expended for medical assistance for 
services described in 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 payment 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 specified 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), including 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 
        subsection (a) shall not apply with respect to a State 
        for the period specified in such paragraph, if before 
        the beginning of such period the State certifies to the 
        satisfaction of the Secretary that implementing such 
        provisions statewide for all individuals eligible to 
        enroll in the State plan (or waiver of the State plan) 
        would not be feasible by reason of a shortage of 
        qualified providers of medication-assisted treatment, 
        or facilities providing such treatment, that will 
        contract with the State or a managed care entity with 
        which the State has a contract under section 1903(m) or 
        under section 1905(t)(3).
  (ff) Temporary Increase in FMAP for Territories.--
Notwithstanding subsection (b) or (z)(2), 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 for the period beginning October 1, 2019, 
and ending November 21, 2019.
  (gg) Increased FMAP for Expanded Medicare Cost-Sharing 
Populations.--
          (1) In general.--Notwithstanding subsection (b), with 
        respect to expenditures described in paragraph (2) the 
        Federal medical assistance percentage shall be equal to 
        100 percent.
          (2) Expenditures described.--The expenditures 
        described in this paragraph are expenditures made on or 
        after January 1, 2021, for medical assistance for 
        medicare cost-sharing provided to any individual under 
        clause (i), (ii), or (iii) of section 1902(a)(10)(E) 
        who would not have been eligible for medicare cost-
        sharing under any such clause under the income or 
        resource eligibility standards in effect on October 1, 
        2018.

           *       *       *       *       *       *       *


  [state coverage of medicare cost-sharing for additional low-income 
                         medicare beneficiaries

  [Sec. 1933. (a) In General.--A State plan under this title 
shall provide, under section 1902(a)(10)(E)(iv) and subject to 
the succeeding provisions of this section and through a plan 
amendment, for medical assistance for payment of the cost of 
medicare cost-sharing described in such section on behalf of 
all individuals described in such section (in this section 
referred to as ``qualifying individuals'') who are selected to 
receive such assistance under subsection (b).
  [(b) Selection of Qualifying Individuals.--A State shall 
select qualifying individuals, and provide such individuals 
with assistance, under this section consistent with the 
following:
          [(1) All qualifying individuals may apply.--The State 
        shall permit all qualifying individuals to apply for 
        assistance during a calendar year.
          [(2) Selection on first-come, first-served basis.--
                  [(A) In general.--For each calendar year 
                (beginning with 1998), from (and to the extent 
                of) the amount of the allocation under 
                subsection (c) for the State for the fiscal 
                year ending in such calendar year, the State 
                shall select qualifying individuals who apply 
                for the assistance in the order in which they 
                apply.
                  [(B) Carryover.--For calendar years after 
                1998, the State shall give preference to 
                individuals who were provided such assistance 
                (or other assistance described in section 
                1902(a)(10)(E)) in the last month of the 
                previous year and who continue to be (or 
                become) qualifying individuals.
          [(3) Limit on number of individuals based on 
        allocation.--The State shall limit the number of 
        qualifying individuals selected with respect to 
        assistance in a calendar year so that the aggregate 
        amount of such assistance provided to such individuals 
        in such year is estimated to be equal to (but not 
        exceed) the State's allocation under subsection (c) for 
        the fiscal year ending in such calendar year.
          [(4) Receipt of assistance during duration of year.--
        If a qualifying individual is selected to receive 
        assistance under this section for a month in a year, 
        the individual is entitled to receive such assistance 
        for the remainder of the year if the individual 
        continues to be a qualifying individual. The fact that 
        an individual is selected to receive assistance under 
        this section at any time during a year does not entitle 
        the individual to continued assistance for any 
        succeeding year.
  [(c) Allocation.--
          [(1) Total allocation.--The total amount available 
        for allocation under this section for--
                  [(A) fiscal year 1998 is $200,000,000;
                  [(B) fiscal year 1999 is $250,000,000;
                  [(C) fiscal year 2000 is $300,000,000;
                  [(D) fiscal year 2001 is $350,000,000; and
                  [(E) each of fiscal years 2002 and 2003 is 
                $400,000,000.
          [(2) Allocation to states.--The Secretary shall 
        provide for the allocation of the total amount 
        described in paragraph (1) for a fiscal year, among the 
        States that executed a plan amendment in accordance 
        with subsection (a), based upon the Secretary's 
        estimate of the ratio of--
                  [(A) an amount equal to the the total number 
                of individuals described in section 
                1902(a)(10)(E)(iv) in the State; to
                  [(B) the sum of the amounts computed under 
                subparagraph (A) for all eligible States.
  [(d) Applicable FMAP.--With respect to assistance described 
in section 1902(a)(10)(E)(iv) furnished in a State for calendar 
quarters in a calendar year --
          [(1) to the extent that such assistance does not 
        exceed the State's allocation under subsection (c) for 
        the fiscal year ending in the calendar year, the 
        Federal medical assistance percentage shall be equal to 
        100 percent; and
          [(2) to the extent that such assistance exceeds such 
        allocation, the Federal medical assistance percentage 
        is 0 percent.
  [(e) Limitation on Entitlement.--Except as specifically 
provided under this section, nothing in this title shall be 
construed as establishing any entitlement of individuals 
described in section 1902(a)(10)(E)(iv) to assistance described 
in such section.
  [(f) Coverage of Costs Through Part B of the Medicare 
Program.--For each fiscal year, the Secretary shall provide for 
the transfer from the Federal Supplementary Medical Insurance 
Trust Fund under section 1841 to the appropriate account in the 
Treasury that provides for payments under section 1903(a) with 
respect to medical assistance provided under this section, of 
an amount equivalent to the total of the amount of payments 
made under such section that is attributable to this section 
and such transfer shall be treated as an expenditure from such 
Trust Fund for purposes of section 1839.
  [(g) Special Rules.--
          [(1) In general.--With respect to each period 
        described in paragraph (2), a State shall select 
        qualifying individuals, subject to paragraph (3), and 
        provide such individuals with assistance, in accordance 
        with the provisions of this section as in effect with 
        respect to calendar year 2003, except that for such 
        purpose--
                  [(A) references in the preceding subsections 
                of this section to a year, whether fiscal or 
                calendar, shall be deemed to be references to 
                such period; and
                  [(B) the total allocation amount under 
                subsection (c) for such period shall be the 
                amount described in paragraph (2) for that 
                period.
          [(2) Periods and total allocation amounts 
        described.--For purposes of this subsection--
                  [(A) for the period that begins on January 1, 
                2008, and ends on September 30, 2008, the total 
                allocation amount is $315,000,000;
                  [(B) for the period that begins on October 1, 
                2008, and ends on December 31, 2008, the total 
                allocation amount is $130,000,000;
                  [(C) for the period that begins on January 1, 
                2009, and ends on September 30, 2009, the total 
                allocation amount is $350,000,000;
                  [(D) for the period that begins on October 1, 
                2009, and ends on December 31, 2009, the total 
                allocation amount is $150,000,000;
                  [(E) for the period that begins on January 1, 
                2010, and ends on September 30, 2010, the total 
                allocation amount is $462,500,000;
                  [(F) for the period that begins on October 1, 
                2010, and ends on December 31, 2010, the total 
                allocation amount is $165,000,000;
                  [(G) for the period that begins on January 1, 
                2011, and ends on September 30, 2011, the total 
                allocation amount is $720,000,000;
                  [(H) for the period that begins on October 1, 
                2011, and ends on December 31, 2011, the total 
                allocation amount is $280,000,000;
                  [(I) for the period that begins on January 1, 
                2012, and ends on September 30, 2012, the total 
                allocation amount is $450,000,000;
                  [(J) for the period that begins on October 1, 
                2012, and ends on December 31, 2012, the total 
                allocation amount is $280,000,000;
                  [(K) for the period that begins on January 1, 
                2013, and ends on September 30, 2013, the total 
                allocation amount is $485,000,000;
                  [(L) for the period that begins on October 1, 
                2013, and ends on December 31, 2013, the total 
                allocation amount is $300,000,000;
                  [(M) for the period that begins on January 1, 
                2014, and ends on September 30, 2014, the total 
                allocation amount is $485,000,000;
                  [(N) for the period that begins on October 1, 
                2014, and ends on December 31, 2014, the total 
                allocation amount is $300,000,000;
                  [(O) for the period that begins on January 1, 
                2015, and ends on March 31, 2015, the total 
                allocation amount is $250,000,000;
                  [(P) for the period that begins on April 1, 
                2015, and ends on December 31, 2015, the total 
                allocation amount is $535,000,000; and
                  [(Q) for 2016 and, subject to paragraph (4), 
                for each subsequent year, the total allocation 
                amount is $980,000,000.
          [(3) Rules for periods that begin after january 1.--
        For any specific period described in subparagraph (B), 
        (D), (F), (H), (J), (L), (N), or (P) of paragraph (2), 
        the following applies:
                  [(A) The specific period shall be treated as 
                a continuation of the immediately preceding 
                period in that calendar year for purposes of 
                applying subsection (b)(2) and qualifying 
                individuals who received assistance in the last 
                month of such immediately preceding period 
                shall be deemed to be selected for the specific 
                period (without the need to complete an 
                application for assistance for such period).
                  [(B) The limit to be applied under subsection 
                (b)(3) for the specific period shall be the 
                same as the limit applied under such subsection 
                for the immediately preceding period.
                  [(C) The ratio to be applied under subsection 
                (c)(2) for the specific period shall be the 
                same as the ratio applied under such subsection 
                for the immediately preceding period.
          [(4) Adjustment to allocations.--The Secretary may 
        increase the allocation amount under paragraph (2)(Q) 
        for a year (beginning with 2017) up to an amount that 
        does not exceed the product of the following:
                  [(A) Maximum allocation amount for previous 
                year.--In the case of 2017, the allocation 
                amount for 2016, or in the case of a subsequent 
                year, the maximum allocation amount allowed 
                under this paragraph for the previous year.
                  [(B) Increase in part b premium.--The monthly 
                premium rate determined under section 1839 for 
                the year divided by the monthly premium rate 
                determined under such section for the previous 
                year.
                  [(C) Increase in part b enrollment.--The 
                average number of individuals (as estimated by 
                the Chief Actuary of the Centers for Medicare & 
                Medicaid Services in September of the previous 
                year) to be enrolled under part B of title 
                XVIII for months in the year divided by the 
                average number of such individuals (as so 
                estimated) under this subparagraph with respect 
                to enrollments in months in the previous year.]

           *       *       *       *       *       *       *


                          xvii. minority views

    Providing low-cost, quality health care for seniors has 
continued to be an important issue for Americans. 
Unfortunately, H.R. 4671, the Helping Seniors Afford Health 
Care Act, is a partisan step to increase government spending 
without any thoughtful deliberation on important topics for 
senior health.
    H.R. 4671 represents a significant expansion of the 
Medicare Savings Program (MSP). The bill would increase 
eligibility levels for the Qualified Medical Beneficiary (QMB) 
program to 135% of the Federal Poverty Level (FPL) and up to 
200% of the FPL for the Specified LowIncome Medicare 
Beneficiary (SLMB) program. H.R. 4671 also provides annual 
grants to encourage low-income seniors to participate in these 
programs. These changes to eligible beneficiaries for the 
Medicare Savings Program represent a significant change for the 
structure of the program and requires a detailed examination 
before moving to floor vote.
    The U.S. Census Bureau estimates that 6.8 million Medicare 
beneficiaries already fall within the income threshold for the 
Medicare Savings Program. The expansion of this program could 
result in a 68% increase in covered individual under the 
program. At a time when there are concerns about the financial 
solvency of the Medicare program, we are concerned that an 
expansion of services without any deliberation risks harming 
the greater program.
    Energy & Commerce Republicans recognize the need to provide 
health services for lowincome seniors eligible for both 
Medicare and Medicaid but are concerned that H.R. 4671 has not 
received any substantive discussion or evaluation before moving 
to a vote on the House floor. At no time during the September 
25th legislative hearing on H.R. 3 was there any discussion 
about changes to the Medicare Savings Program. In fact, a word 
search of the hearing transcript for `Medicare Savings Program' 
yields no results. Energy & Commerce Republicans are concerned 
that such important changes to the Medicare Savings Program 
would be considered without any discussion. The Congressional 
Budget Office has not made any scoring determination on H.R. 
4671's budgetary impact nor have we heard from any witnesses 
from the Centers for Medicare and Medicaid Services to discuss 
their evaluation of the bill's proposals.
    The Committee prides itself on a process of regular order, 
allowing thoughtful and substantive deliberation on legislation 
that comes before us. Unfortunately, H.R. 4671 does not meet 
that standard. The bill was only introduced on October 15th and 
we were given no indication the bill would be considered until 
48 hours prior to the October 17th markup. Given the 
implications H.R. 4671 has on the structure of the Medicare 
Savings Program, we feel that further consideration of the 
bill, including a committee hearing is warranted.

                                   Greg Walden,
                                           Republican Leader, Committee 
                                               on Energy and Commerce.
                                   Michael C. Burgess, M.D.,
                                           Republican Leader, 
                                               Subcommittee on Health, 
                                               Committee on Energy and 
                                               Commerce.

                                  [all]