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116th Congress } { Report
HOUSE OF REPRESENTATIVES
2d Session } { 116-527
======================================================================
HELPING MEDICAID OFFER MATERNITY SERVICES ACT OF 2019
_______
September 21, 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
[To accompany H.R. 4996]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 4996) to amend title XIX of the Social Security
Act to provide for a State option under the Medicaid program to
provide for and extend continuous coverage for certain
individuals, and for other purposes, having considered the
same, reports favorably thereon with an amendment and
recommends that the bill as amended do pass.
CONTENTS
Page
I. Purpose and Summary.............................................4
II. Background and Need for the Legislation.........................4
III. Committee Hearings..............................................5
IV. Committee Consideration.........................................5
V. Committee Votes.................................................6
VI. Oversight Findings..............................................6
VII. New Budget Authority, Entitlement Authority, and Tax Expenditure6
VIII. Federal Mandates Statement......................................6
IX. Statement of General Performance Goals and Objectives...........6
X. Duplication of Federal Programs.................................7
XI. Committee Cost Estimate.........................................7
XII. Earmarks, Limited Tax Benefits, and Limited Tariff Benefits.....7
XIII. Advisory Committee Statement....................................7
XIV. Applicability to Legislative Branch.............................7
XV. Section-by-Section Analysis of the Legislation..................7
XVI. Changes in Existing Law Made by the Bill, as Reported...........8
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Helping Medicaid Offer Maternity
Services Act of 2019'' or the ``Helping MOMS Act of 2019''.
SEC. 2. STATE OPTION UNDER MEDICAID PROGRAM TO PROVIDE FOR AND EXTEND
CONTINUOUS COVERAGE FOR CERTAIN INDIVIDUALS.
(a) State Option To Extend Continuous Coverage for Pregnant and
Postpartum Individuals.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended--
(1) in section 1902(e)(5), by inserting after ``60-day
period'' the following: ``or, at the option of the State, 1-
year period'';
(2) in section 1902(e)(6), by inserting after ``60-day
period'' the following: ``or, at the option of the State, 1-
year period'';
(3) in section 1902(l)(1)(A), by inserting after ``60-day
period'' the following: ``, or, at the option of the State, 1-
year period,'';
(4) in section 1903(v)(4)(A)(i), by inserting after ``60-day
period'' the following: ``, or, at the option of the State, 1-
year period,''; and
(5) in section 1905(a), in the fourth sentence in the matter
following paragraph (30), by inserting after ``60-day period''
the following: ``, or, at the option of the State, 1-year
period,''.
(b) State Option To Provide Continuous Coverage for Full Benefits for
Individuals Who Are or Become Pregnant.--Section 1902(e)(6) of the
Social Security Act (42 U.S.C. 1396a(e)(6)), as amended by subsection
(a), is further amended--
(1) by striking ``(6) In the case of a pregnant woman'' and
inserting
``(6)(A) In the case of a pregnant woman''; and
(2) by adding at the end the following:
``(B)(i) At the option of the State, the State plan may provide that
an individual who is eligible for medical assistance under the State
plan (or a waiver of such plan) or for child health assistance under
title XXI and who is, or who while so eligible becomes, pregnant shall
continue to be eligible for such medical assistance or child health
assistance, respectively, through the end of the month in which the 1-
year period (beginning on the last day of such pregnancy) ends,
regardless of the basis for the individual's eligibility for such
medical assistance.''.
(c) Increase of FMAP.--Section 1905 of the Social Security Act (42
U.S.C. 1396d) is amended--
(1) in subsection (b), in the first sentence, by striking
``and (ff)'' and inserting ``(ff), and (gg)''; and
(2) by adding at the end the following new subsection:
``(gg) Specified Coverage Extension States.--
``(1) In general.--Notwithstanding subsection (b), beginning
January 1, 2020, in the case of a specified coverage extension
State, for the initial extension calendar quarters with respect
to such State, the Federal medical assistance percentage that
would otherwise apply to the State without application of this
subsection, shall be increased by 5 percentage points.
``(2) Specified coverage extension state.--For purposes of
this subsection, the term `specified coverage extension State'
means a State, the State plan of which has in effect the
application of the 1-year period of continuous medical
assistance pursuant to each of paragraphs (5) and (6) of
section 1902(e).
``(3) Initial extension calendar quarter.--For purposes of
this subsection, the term `initial extension calendar quarter'
means, with respect to a State, each calendar quarter occurring
in the first fiscal year that the State is a specified coverage
extension State.''.
(d) Application to CHIP Optional Coverage of Targeted Low-Income
Pregnant Women.--Section 2112 of the Social Security Act (42 U.S.C.
1397ll) is amended--
(1) in subsection (d)(2)(A), by inserting after ``60-day
period'' the following: ``, or, at the option of the State, 1-
year period''; and
(2) in subsection (f)(2), by inserting after ``60-day
period'' the following: ``, or, at the option of the State, 1-
year period''.
(e) Effective Date.--The amendments made by this section shall apply
with respect to eligibility determinations for items and services under
State plans under title XIX of the Social Security Act (or a waiver of
such a plan) (42 U.S.C. 1396 et seq.) and under State child health
plans under title XXI (or waiver of such a plan) made on or after
January 1, 2020.
SEC. 3. MACPAC REPORT.
(a) In General.--Not later than 1 year after the date of the
enactment of this Act, the Medicaid and CHIP Payment and Access
Commission (referred to in this section as ``MACPAC'') shall publish a
report on the coverage of doula services under State Medicaid programs,
which shall at a minimum include the following:
(1) Information about coverage for doula services under State
Medicaid programs that currently provide coverage for such
services, including the type of doula services offered (such as
prenatal, labor and delivery, postpartum support, and also
community-based and traditional doula services).
(2) An analysis of barriers to covering doula services under
State Medicaid programs.
(3) An identification of effective strategies to increase the
use of doula services in order to provide better care and
achieve better maternal and infant health outcomes, including
strategies that States may use to recruit, train, and certify a
diverse doula workforce, particularly from underserved
communities, communities of color, and communities facing
linguistic or cultural barriers.
(4) Recommendations for legislative and administrative
actions to increase access to doula services in State Medicaid
programs, including actions that ensure doulas may earn a
living wage that accounts for their time and costs associated
with providing care.
(b) Stakeholder Consultation.--In developing the report required
under subsection (a), MACPAC shall consult with relevant stakeholders,
including--
(1) States;
(2) organizations representing consumers, including those
that are disproportionately impacted by poor maternal health
outcomes;
(3) organizations and individuals representing doula services
providers, including community-based doula programs and those
who serve underserved communities, including communities of
color, and communities facing linguistic or cultural barriers;
and
(4) organizations representing health care providers.
SEC. 4. GAO REPORT.
(a) In General.--Not later than 2 years after the date of the
enactment of this Act and every five years thereafter, the Comptroller
General of the United States shall submit to Congress a report on the
State adoption, under the Medicaid program under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) and the Children's Health
Insurance Program under title XXI of such Act, of extending coverage to
365 days postpartum pursuant to the provisions of (and amendments made
by this Act). Such report shall include the information and
recommendations described in subsection (b) and shall also identify
ongoing gaps in coverage for--
(1) pregnant women under the Medicaid program and the
Children's Health Insurance Program; and
(2) postpartum women under the Medicaid program and the
Children's Health Insurance Program who received assistance
under either such program during their pregnancy.
(b) Content of Report.--The report under subsection (a) shall include
the following:
(1) Information regarding the extent to which States have
elected to extend coverage to 365 days postpartum pursuant to
the provisions of (and amendments made by this Act), including
which States make the election and when, impacts on perinatal
insurance churn in those States compared to States that did not
make such election, other health impacts of such election
including regarding maternal mortality and morbidity rates, and
impacts on State and Federal Medicaid spending.
(2) Information about the abilities, successes, and
challenges of State Medicaid agencies in--
(A) transitioning their eligibility systems to
incorporate such an election by a State and in
determining whether pregnant and postpartum women are
eligible under another insurance affordability program;
and
(B) transitioning any such women who are so eligible
to coverage under such a program, pursuant to section
1943(b)(3) of the Social Security Act (42 U.S.C 1396w-
3(b)(3)).
(3) Information on factors contributing to ongoing gaps in
coverage resulting from women transitioning from coverage under
the Medicaid program or Children's Health Insurance Program
that disproportionately impact underserved populations,
including low-income women, women of color, women who reside in
a health professional shortage area (as defined in section
332(a)(1)(A) of the Public Health Service Act (42 U.S.C.
254e(a)(1)(A))), or who are members of a medically underserved
population (as defined by section 330(b)(3) of such Act (42
U.S.C. 254b(b)(3)(A))).
(4) Recommendations for addressing and reducing such gaps in
coverage.
(5) Such other information as the Comptroller General
determines appropriate.
SEC. 5. REPORT ON MEDICAID BUNDLED PAYMENTS FOR PREGNANCY-RELATED
SERVICES.
Not later than 2 years after the date of the enactment of this Act,
the Medicaid and CHIP Payment Advisory Commission shall submit to
Congress a report containing an analysis of the use of bundled payments
for reimbursing health care providers with respect to pregnancy-related
services furnished under State plans (or waivers of such plans) under
title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
I. Purpose and Summary
H.R. 4996, the ``Helping Medicaid Offer Maternal Services
Act of 2019'' or the ``Helping MOMS Act of 2019'', was
introduced on November 19, 2019, by Representatives Robin Kelly
(D-IL), Michael Burgess (R-TX), Lauren Underwood (D-IL), Cathy
McMorris Rodgers (R-WA), Ayanna Pressley (D-MA0, and Earl L.
``Buddy'' Carter (R-GA). It would amend title XIX and title XXI
of the Social Security Act to provide States with the option to
extend postpartum Medicaid eligibility and postpartum CHIP
eligibility to one year. For States that adopt the option, the
legislation would increase the Federal medical assistance
percentage (FMAP) by five percentage points. It would also
require a report by the Medicaid and CHIP Payment and Access
Commission (MACPAC) on Medicaid coverage of doula services.
Finally, the bill would also require the Comptroller General to
conduct regular reports on State adoption of the option, and to
identify ongoing gaps in coverage.
II. Background and Need for Legislation
According to the Centers for Disease Control and Prevention
(CDC), women in the United States are more likely to die from
childbirth or pregnancy-related causes than other women in the
developed world.\1\ Although approximately 60 percent of
pregnancy-related deaths are preventable, about 700 women in
the United States die every year from complications of
pregnancy.\2\ The deaths are roughly evenly split between those
that occur during pregnancy (31 percent of deaths), during
delivery or in the week after (36 percent of deaths), and
between one week and one year postpartum (33 percent of
deaths).\3\ There are significant disparities in maternal
health and mortality; Black and American Indian/Alaska Native
women are about three times more likely to die from pregnancy-
related causes than White women.\4\
---------------------------------------------------------------------------
\1\Centers for Disease Control and Prevention, Pregnancy Related
Deaths (accessed Aug. 26, 2019) (www.cdc.gov/reproductivehealth/
maternalinfanthealth/pregnancyrelatedmortality.htm).
\2\Centers for Disease Control and Prevention, Vital Signs:
Pregnancy-related Deaths: Saving Women's Lives Before, During and After
Delivery (May 7, 2019) (www.cdc.gov/vitalsigns/maternal-deaths/
index.html).
\3\Id.
\4\Id.
---------------------------------------------------------------------------
Causes of pregnancy-related deaths differ. While heart
disease and stroke cause most deaths overall, obstetric
emergencies, such as severe bleeding and amniotic fluid
embolism, cause the most deaths at delivery. Severe bleeding,
high blood pressure, and infection are the leading causes in
the week after delivery and weakened heart muscle is the
leading cause in deaths one week to one year postpartum.\5\
---------------------------------------------------------------------------
\5\Id.
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Medicaid pays for over 40 percent of all births in the
United States.\6\ Federal law requires State Medicaid programs
to provide coverage to pregnant women with incomes up to 138
percent of the Federal poverty level (FPL), and to continue to
provide such coverage for 60 days postpartum.\7\ After this
period, a woman may transition to a different Medicaid
eligibility category, but many lose coverage. Access to health
insurance through the pregnancy and postpartum period has been
shown to reduce maternal death rates and can help to prevent,
detect, and treat conditions that increase a woman's risk for
pregnancy complications, including heart disease and diabetes.
However, 30 percent of women will experience a disruption in
their insurance coverage postpartum.\8\
---------------------------------------------------------------------------
\6\MACPAC, Medicaid's Role in Financing Maternity Care (January
2020) (https://www.macpac.gov/wp-content/uploads/2020/01/
Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf).
\7\http://files.kff.org/attachment/Issue-Brief-Expanding-
Postpartum-Medicaid-Coverage.
\8\https://www.acog.org/About-ACOG/ACOG-Departments/State-
Legislative-Activities/Giving-Medicaid-Insured-Women-12-Months-of-
Coverage-After-Delivery?IsMobileSet=false.
---------------------------------------------------------------------------
Extending Medicaid coverage to one year postpartum will
ensure that low-income women have access to comprehensive
health insurance coverage during the postpartum period when
they are at risk of serious health complications.
III. Committee Hearings
For the purposes of section 103(i) of H. Res. 6 of the
116th Congress, the following hearings were used to develop or
consider H.R. 4996:
The Subcommittee on Health on September 6, 2019 held a
legislative hearing on ``Improving Maternal Health: Legislation
to Advance Prevention Efforts and Access to Care.'' Witnesses
included:
Wanda Irving, Mother of Dr. Shalon Irving;
Patrice Harris, M.D., President, Board of
Trustees, American Medical Association;
Elizabeth Howell, M.D., M.P.P., Director,
Blavatnik Family Women's Health Research Institute,
Icahn School of Medicine at Mount Sinai;
David Nelson, M.D., Assistant Professor of
Obstetrics and Gynecology, Division of Maternal-Fetal
Medicine, University of Texas Southwestern Medical
Center;
Usha Ranji, Associate Director, Women's
Health Policy, Kaiser Family Foundation.
IV. Committee Consideration
Representatives Kelly (D-IL), Burgess (R-TX), Underwood (D-
IL), Rodgers (R-WA), Pressley (D-MA), and Carter (R-GA)
introduced H.R. 4996, the ``Helping Medicaid Offer Maternity
Services (MOMS) Act of 2019'', on November 8, 2019, and the
bill was referred to the Committee on Energy and Commerce.
Subsequently, the bill was referred to the Subcommittee on
Health on November 12, 2019. A hearing was held by the
Subcommittee prior to the bill's introduction on September 6,
2019.
The Subcommittee on Health met in open markup session on
November 13, 2019, pursuant to notice, to consider H.R. 4996.
During consideration of the bill, an amendment offered by Mr.
Burgess was agreed to by a voice vote. A motion by Ms. Eshoo,
Chairwoman of the subcommittee, to forward favorably H.R. 4996
to the full Committee, amended, was agreed to by a voice vote.
On November 20, 2019, the full Committee met in open markup
session, pursuant to notice, to consider a committee print of
the bill H.R. 4996, as amended by the Subcommittee on Health on
November 13, 2019. During consideration of the bill, an
amendment offered by Mr. Kennedy of Massachusetts was agreed to
by a voice vote. At the conclusion of markup of the bill, Mr.
Pallone, Chairman of the committee, moved that H.R. 4996 be
ordered reported favorably to the House, amended. The Pallone
motion on final passage was agreed to by the Committee 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.
4996, including the motion for final passage of the bill.
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 provide
State Medicaid programs with the option to offer Medicaid
eligibility for 12 months postpartum.
X. Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII, no provision of
H.R. 4996 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. 4996 contains no earmarks, limited
tax benefits, or limited tariff benefits.
XIII. Advisory Committee Statement
No advisory committee within the meaning of section 5(b) of
the Federal Advisory Committee Act was created by this
legislation.
XIV. Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the 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 Medicaid Offer Maternity Services Act'' or the
``Helping MOMS Act''.
Sec. 2. State option under Medicaid program to provide for and extend
continuous coverage for certain individuals
Section 2 authorizes a State plan option for Medicaid
programs to provide 12 months of eligibility postpartum.
Authorizes a temporary five percent increase to a State's
Federal medical assistance percentage (FMAP) for States that
adopt the option.
Sec. 3. MACPAC report
Section 3 requires a report by the Medicaid and CHIP
Payment and Access Commission (MACPAC) on the coverage of doula
care services by State Medicaid programs.
Sec. 4. GAO report
Section 4 requires a report by the Comptroller General not
later than two years after the date of enactment, and every
five years thereafter, on State adoption of the 12 months
postpartum coverage option and ongoing gaps in coverage for
pregnant women.
Sec. 5. Report on Medicaid bundled payments for pregnancy-related
services
Section 5 requires a report by the Medicaid and CHIP
Payment and Access Commission no later than two years after the
date of enactment on State Medicaid programs use of bundled
payments to reimburse providers for pregnancy-related services.
XVI. Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italics, and existing law in which no
change is proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
* * * * * * *
STATE PLANS FOR MEDICAL ASSISTANCE
Sec. 1902. (a) A State plan for medical assistance must--
(1) provide that it shall be in effect in all
political 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);
(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 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 or, at the option of the State, 1-year
period (beginning on the last day of her pregnancy) ends.
[(6) In the case of a pregnant woman]
(6)(A) 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 or, at the option of the State, 1-year 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.
(B)(i) At the option of the State, the State plan may provide
that an individual who is eligible for medical assistance under
the State plan (or a waiver of such plan) or for child health
assistance under title XXI and who is, or who while so eligible
becomes, pregnant shall continue to be eligible for such
medical assistance or child health assistance, respectively,
through the end of the month in which the 1-year period
(beginning on the last day of such pregnancy) ends, regardless
of the basis for the individual's eligibility for such medical
assistance.
(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. For
purposes of payment to a State under section 1903(a), such
determination shall be considered to be valid for an individual
for a period of 12 months, except that a State may provide for
such determinations more frequently, but not more frequently
than once every 6 months for an individual.
(9)(A) At the option of the State, the plan may include as
medical assistance respiratory care services for any individual
who--
(i) is medically dependent on a ventilator for life
support at least six hours per day;
(ii) has been so dependent for at least 30
consecutive days (or the maximum number of days
authorized under the State plan, whichever is less) as
an inpatient;
(iii) but for the availability of respiratory care
services, would require respiratory care as an
inpatient in a hospital, nursing facility, or
intermediate care facility for the mentally retarded
and would be eligible to have payment made for such
inpatient care under the State plan;
(iv) has adequate social support services to be cared
for at home; and
(v) wishes to be cared for at home.
(B) The requirements of subparagraph (A)(ii) may be satisfied
by a continuous stay in one or more hospitals, nursing
facilities, or 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) 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) the end of a period (not to exceed 12 months)
following the determination; or
(B) the time that the individual exceeds that age.
(13) Express Lane Option.--
(A) In general.--
(i) Option to use a finding from an express
lane agency.--At the option of the State, the
State plan may provide that in determining
eligibility under this title for a child (as
defined in subparagraph (G)), the State may
rely on a finding made within a reasonable
period (as 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.
(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, or, at the option of the State, 1-year 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.
(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.
PAYMENT TO STATES
Sec. 1903. (a) From the sums appropriated therefor, the
Secretary (except as otherwise provided in this section) shall
pay to each State which has a plan approved under this title,
for each quarter, beginning with the quarter commencing January
1, 1966--
(1) an amount equal to the Federal medical assistance
percentage (as defined in section 1905(b), subject to
subsections (g) and (j) of this section and subsection
1923(f)) of the total amount expended during such
quarter as medical assistance under the State plan;
plus
(2)(A) an amount equal to 75 per centum of so much of
the sums expended during such quarter (as found
necessary by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to compensation or training of skilled professional
medical personnel, and staff directly supporting such
personnel, of the State agency or any other public
agency; plus
(B) notwithstanding paragraph (1) or subparagraph
(A), with respect to amounts expended for nursing aide
training and competency evaluation programs, and
competency evaluation programs, described in section
1919(e)(1) (including the costs for nurse aides to
complete such competency evaluation programs),
regardless of whether the programs are provided in or
outside nursing facilities or of the skill of the
personnel involved in such programs, an amount equal to
50 percent (or, for calendar quarters beginning on or
after July 1, 1988, and before October 1, 1990, the
lesser of 90 percent or the Federal medical assistance
percentage plus 25 percentage points) of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to such programs; plus
(C) an amount equal to 75 percent of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to preadmission screening and resident review
activities conducted by the State under section
1919(e)(7); plus
(D) for each calendar quarter during--
(i) fiscal year 1991, an amount equal to 90
percent,
(ii) fiscal year 1992, an amount equal to 85
percent,
(iii) fiscal year 1993, an amount equal to 80
percent, and
(iv) fiscal year 1994 and thereafter, an
amount equal to 75 percent,
of so much of the sums expended during such quarter (as
found necessary by the Secretary for the proper and
efficient administration of the State plan) as are
attributable to State activities under section 1919(g);
plus
(E) an amount equal to 75 percent of so much of the
sums expended during such quarter (as found necessary
by the Secretary for the proper and efficient
administration of the State plan) as are attributable
to translation or interpretation services in connection
with the enrollment of, retention of, and use of
services under this title by, children of families for
whom English is not the primary language; plus
(3) an amount equal to--
(A)(i) 90 per centum of so much of the sums
expended during such quarter as are
attributable to the design, development, or
installation of such mechanized claims
processing and information retrieval systems as
the Secretary determines are likely to provide
more efficient, economical, and effective
administration of the plan and to be compatible
with the claims processing and information
retrieval systems utilized in the
administration of title XVIII, including the
State's share of the cost of installing such a
system to be used jointly in the administration
of such State's plan and the plan of any other
State approved under this title,
(ii) 90 per centum of so much of the sums
expended during any such quarter in the fiscal
year ending June 30, 1972, or the fiscal year
ending June 30, 1973, as are attributable to
the design, development, or installation of
cost determination systems for State-owned
general hospitals (except that the total amount
paid to all States under this clause for either
such fiscal year shall not exceed $150,000),
and
(iii) an amount equal to the Federal medical
assistance percentage (as defined in section
1905(b)) of so much of the sums expended during
such quarter (as found necessary by the
Secretary for the proper and efficient
administration of the State plan) as are
attributable to such developments or
modifications of systems of the type described
in clause (i) as are necessary for the
efficient collection and reporting on child
health measures; and
(B) 75 per centum of so much of the sums
expended during such quarter as are
attributable to the operation of systems
(whether such systems are operated directly by
the State or by another person under a contract
with the State) of the type described in
subparagraph (A)(i) (whether or not designed,
developed, or installed with assistance under
such subparagraph) which are approved by the
Secretary and which include provision for
prompt written notice to each individual who is
furnished services covered by the plan, or to
each individual in a sample group of
individuals who are furnished such services, of
the specific services (other than confidential
services) so covered, the name of the person or
persons furnishing the services, the date or
dates on which the services were furnished, and
the amount of the payment or payments made
under the plan on account of the services; and
(C)(i) 75 per centum of the sums expended
with respect to costs incurred during such
quarter (as found necessary by the Secretary
for the proper and efficient administration of
the State plan) as are attributable to the
performance of medical and utilization review
by a utilization and quality control peer
review organization or by an entity which meets
the requirements of section 1152, as determined
by the Secretary, under a contract entered into
under section 1902(d); and
(ii) 75 percent of the sums expended with
respect to costs incurred during such quarter
(as found necessary by the Secretary for the
proper and efficient administration of the
State plan) as are attributable to the
performance of independent external reviews
conducted under section 1932(c)(2); and
(D) 75 percent of so much of the sums
expended by the State plan during a quarter in
1991, 1992, or 1993, as the Secretary
determines is attributable to the statewide
adoption of a drug use review program which
conforms to the requirements of section
1927(g);
(E) 50 percent of the sums expended with
respect to costs incurred during such quarter
as are attributable to providing--
(i) services to identify and educate
individuals who are likely to be
eligible for medical assistance under
this title and who have Sickle Cell
Disease or who are carriers of the
sickle cell gene, including education
regarding how to identify such
individuals; or
(ii) education regarding the risks of
stroke and other complications, as well
as the prevention of stroke and other
complications, in individuals who are
likely to be eligible for medical
assistance under this title and who
have Sickle Cell Disease; and
(F)(i) 100 percent of so much of the sums
expended during such quarter as are
attributable to payments to Medicaid providers
described in subsection (t)(1) to encourage the
adoption and use of certified EHR technology;
and
(ii) 90 percent of so much of the sums
expended during such quarter as are
attributable to payments for reasonable
administrative expenses related to the
administration of payments described in clause
(i) if the State meets the condition described
in subsection (t)(9); plus
(H)(i) 90 percent of the sums expended during
the quarter as are attributable to the design,
development, or installation of such mechanized
verification and information retrieval systems
as the Secretary determines are necessary to
implement section 1902(ee) (including a system
described in paragraph (2)(B) thereof), and
(ii) 75 percent of the sums expended during
the quarter as are attributable to the
operation of systems to which clause (i)
applies, plus
(4) an amount equal to 100 percent of the sums
expended during the quarter which are attributable to
the costs of the implementation and operation of the
immigration status verification system described in
section 1137(d); plus
(5) an amount equal to 90 per centum of the sums
expended during such quarter which are attributable to
the offering, arranging, and furnishing (directly or on
a contract basis) of family planning services and
supplies;
(6) subject to subsection (b)(3), an amount equal
to--
(A) 90 per centum of the sums expended during
such a quarter within the twelve-quarter period
beginning with the first quarter in which a
payment is made to the State pursuant to this
paragraph, and
(B) 75 per centum of the sums expended during
each succeeding calendar quarter,
with respect to costs incurred during such quarter (as
found necessary by the Secretary for the elimination of
fraud in the provision and administration of medical
assistance provided under the State plan) which are
attributable to the establishment and operation of
(including the training of personnel employed by) a
State medicaid fraud control unit (described in
subsection (q)); plus
(7) subject to section 1919(g)(3)(B), an amount equal
to 50 per centum of the remainder of the amounts
expended during such quarter as found necessary by the
Secretary for the proper and efficient administration
of the State plan.
(b)(1) Notwithstanding the preceding provisions of this
section, the amount determined under subsection (a)(1) for any
State for any quarter beginning after December 31, 1969, shall
not take into account any amounts expended as medical
assistance with respect to individuals aged 65 or over and
disabled individuals entitled to hospital insurance benefits
under title XVIII which would not have been so expended if the
individuals involved had been enrolled in the insurance program
established by part B of title XVIII, other than amounts
expended under provisions of the plan of such State required by
section 1902(a)(34).
(2) For limitation on Federal participation for capital
expenditures which are out of conformity with a comprehensive
plan of a State or areawide planning agency, see section 1122.
(3) The amount of funds which the Secretary is otherwise
obligated to pay a State during a quarter under subsection
(a)(6) may not exceed the higher of--
(A) $125,000, or
(B) one-quarter of 1 per centum of the sums expended
by the Federal, State, and local governments during the
previous quarter in carrying out the State's plan under
this title.
(4) Amounts expended by a State for the use of an enrollment
broker in marketing medicaid managed care organizations and
other managed care entities to eligible individuals under this
title shall be considered, for purposes of subsection (a)(7),
to be necessary for the proper and efficient administration of
the State plan but only if the following conditions are met
with respect to the broker:
(A) The broker is independent of any such entity and
of any health care providers (whether or not any such
provider participates in the State plan under this
title) that provide coverage of services in the same
State in which the broker is conducting enrollment
activities.
(B) No person who is an owner, employee, consultant,
or has a contract with the broker either has any direct
or indirect financial interest with such an entity or
health care provider or has been excluded from
participation in the program under this title or title
XVIII or debarred by any Federal agency, or subject to
a civil money penalty under this Act.
(5) Notwithstanding the preceding provisions of this section,
the amount determined under subsection (a)(1) for any State
shall be decreased in a quarter by the amount of any health
care related taxes (described in section 1902(w)(3)(A)) that
are imposed on a hospital described in subsection (w)(3)(F) in
that quarter.
(c) Nothing in this title shall be construed as prohibiting
or restricting, or authorizing the Secretary to prohibit or
restrict, payment under subsection (a) for medical assistance
for covered services furnished to a child with a disability
because such services are included in the child's
individualized education program established pursuant to part B
of the Individuals with Disabilities Education Act or furnished
to an infant or toddler with a disability because such services
are included in the child's individualized family service plan
adopted pursuant to part C of such Act.
(d)(1) Prior to the beginning of each quarter, the Secretary
shall estimate the amount to which a State will be entitled
under subsections (a) and (b) for such quarter, such estimates
to be based on (A) a report filed by the State containing its
estimate of the total sum to be expended in such quarter in
accordance with the provisions of such subsections, and stating
the amount appropriated or made available by the State and its
political subdivisions for such expenditures in such quarter,
and if such amount is less than the State's proportionate share
of the total sum of such estimated expenditures, the source or
sources from which the difference is expected to be derived,
and (B) such other investigation as the Secretary may find
necessary.
(2)(A) The Secretary shall then pay to the State, in such
installments as he may determine, the amount so estimated,
reduced or increased to the extent of any overpayment or
underpayment which the Secretary determines was made under this
section to such State for any prior quarter and with respect to
which adjustment has not already been made under this
subsection.
(B) Expenditures for which payments were made to the State
under subsection (a) shall be treated as an overpayment to the
extent that the State or local agency administering such plan
has been reimbursed for such expenditures by a third party
pursuant to the provisions of its plan in compliance with
section 1902(a)(25).
(C) For purposes of this subsection, when an overpayment is
discovered, which was made by a State to a person or other
entity, the State shall have a period of 1 year in which to
recover or attempt to recover such overpayment before
adjustment is made in the Federal payment to such State on
account of such overpayment. Except as otherwise provided in
subparagraph (D), the adjustment in the Federal payment shall
be made at the end of the 1-year period, whether or not
recovery was made.
(D)(i) In any case where the State is unable to recover a
debt which represents an overpayment (or any portion thereof)
made to a person or other entity on account of such debt having
been discharged in bankruptcy or otherwise being uncollectable,
no adjustment shall be made in the Federal payment to such
State on account of such overpayment (or portion thereof).
(ii) In any case where the State is unable to recover a debt
which represents an overpayment (or any portion thereof) made
to a person or other entity due to fraud within 1 year of
discovery because there is not a final determination of the
amount of the overpayment under an administrative or judicial
process (as applicable), including as a result of a judgment
being under appeal, no adjustment shall be made in the Federal
payment to such State on account of such overpayment (or
portion thereof) before the date that is 30 days after the date
on which a final judgment (including, if applicable, a final
determination on an appeal) is made.
(3)(A) The pro rata share to which the United States is
equitably entitled, as determined by the Secretary, of the net
amount recovered during any quarter by the State or any
political subdivision thereof with respect to medical
assistance furnished under the State plan shall be considered
an overpayment to be adjusted under this subsection.
(B)(i) Subparagraph (A) and paragraph (2)(B) shall not apply
to any amount recovered or paid to a State as part of the
comprehensive settlement of November 1998 between manufacturers
of tobacco products, as defined in section 5702(d) of the
Internal Revenue Code of 1986, and State Attorneys General, or
as part of any individual State settlement or judgment reached
in litigation initiated or pursued by a State against one or
more such manufacturers.
(ii) Except as provided in subsection (i)(19), a State may
use amounts recovered or paid to the State as part of a
comprehensive or individual settlement, or a judgment,
described in clause (i) for any expenditures determined
appropriate by the State.
(4) Upon the making of any estimate by the Secretary under
this subsection, any appropriations available for payments
under this section shall be deemed obligated.
(5) In any case in which the Secretary estimates that there
has been an overpayment under this section to a State on the
basis of a claim by such State that has been disallowed by the
Secretary under section 1116(d), and such State disputes such
disallowance, the amount of the Federal payment in controversy
shall, at the option of the State, be retained by such State or
recovered by the Secretary pending a final determination with
respect to such payment amount. If such final determination is
to the effect that any amount was properly disallowed, and the
State chose to retain payment of the amount in controversy, the
Secretary shall offset, from any subsequent payments made to
such State under this title, an amount equal to the proper
amount of the disallowance plus interest on such amount
disallowed for the period beginning on the date such amount was
disallowed and ending on the date of such final determination
at a rate (determined by the Secretary) based on the average of
the bond equivalent of the weekly 90-day treasury bill auction
rates during such period.
(6)(A) Each State (as defined in subsection (w)(7)(D)) shall
include, in the first report submitted under paragraph (1)
after the end of each fiscal year, information related to--
(i) provider-related donations made to the State or
units of local government during such fiscal year, and
(ii) health care related taxes collected by the State
or such units during such fiscal year.
(B) Each State shall include, in the first report submitted
under paragraph (1) after the end of each fiscal year,
information related to the total amount of payment adjustments
made, and the amount of payment adjustments made to individual
providers (by provider), under section 1923(c) during such
fiscal year.
(e) A State plan approved under this title may include, as a
cost with respect to hospital services under the plan under
this title, periodic expenditures made to reflect transitional
allowances established with respect to a hospital closure or
conversion under section 1884.
(f)(1)(A) Except as provided in paragraph (4), payment under
the preceding provisions of this section shall not be made with
respect to any amount expended as medical assistance in a
calendar quarter, in any State, for any member of a family the
annual income of which exceeds the applicable income limitation
determined under this paragraph.
(B)(i) Except as provided in clause (ii) of this
subparagraph, the applicable income limitation with respect to
any family is the amount determined, in accordance with
standards prescribed by the Secretary, to be equivalent to
133\1/3\ percent of the highest amount which would ordinarily
be paid to a family of the same size without any income or
resources, in the form of money payments, under the plan of the
State approved under part A of title IV of this Act.
(ii) If the Secretary finds that the operation of a uniform
maximum limits payments to families of more than one size, he
may adjust the amount otherwise determined under clause (i) to
take account of families of different sizes.
(C) The total amount of any applicable income limitation
determined under subparagraph (B) shall, if it is not a
multiple of $100 or such other amount as the Secretary may
prescribe, be rounded to the next higher multiple of $100 or
such other amount, as the case may be.
(2)(A) In computing a family's income for purposes of
paragraph (1), there shall be excluded any costs (whether in
the form of insurance premiums or otherwise and regardless of
whether such costs are reimbursed under another public program
of the State or political subdivision thereof) incurred by such
family for medical care or for any other type of remedial care
recognized under State law or, (B) notwithstanding section 1916
at State option, an amount paid by such family, at the family's
option, to the State, provided that the amount, when combined
with costs incurred in prior months, is sufficient when
excluded from the family's income to reduce such family's
income below the applicable income limitation described in
paragraph (1). The amount of State expenditures for which
medical assistance is available under subsection (a)(1) will be
reduced by amounts paid to the State pursuant to this
subparagraph.
(3) For purposes of paragraph (1)(B), in the case of a family
consisting of only one individual, the ``highest amount which
would ordinarily be paid'' to such family under the State's
plan approved under part A of title IV of this Act shall be the
amount determined by the State agency (on the basis of
reasonable relationship to the amounts payable under such plan
to families consisting of two or more persons) to be the amount
of the aid which would ordinarily be payable under such plan to
a family (without any income or resources) consisting of one
person if such plan provided for aid to such a family.
(4) The limitations on payment imposed by the preceding
provisions of this subsection shall not apply with respect to
any amount expended by a State as medical assistance for any
individual described in section 1902(a)(10)(A)(i)(III),
1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(V),
1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII),
1902(a)(10)(A)(i)(VIII),1902(a)(10)(A)(i)(IX),
1902(a)(10)(A)(ii)(IX), 1902(a)(10)(A)(ii)(X),
1902(a)(10)(A)(ii)(XIII), 1902(a)(10)(A)(ii)(XIV), or
1902(a)(10)(A)(ii)(XV), 1902(a)(10)(A)(ii)(XVI),
1902(a)(10)(A)(ii)(XVII), 1902(a)(10)(A)(ii)(XVIII),
1902(a)(10)(A)(ii)(XIX), 1902(a)(10)(A)(ii)(XX),
1902(a)(10)(A)(ii)(XXI), 1902(a)(10)(A)(ii)(XXII), 1905(p)(1)
or for any individual--
(A) who is 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) who is not receiving such aid or assistance, and
with respect to whom such benefits are not being paid,
but (i) is eligible to receive such aid or assistance,
or to have such benefits paid with respect to him, or
(ii) would be eligible to receive such aid or
assistance, or to have such benefits paid with respect
to him if he were not in a medical institution, or
(C) with respect to whom there is being paid, or who
is eligible, or would be eligible if he were not in a
medical institution, to have paid with respect to him,
a State supplementary payment and is eligible for
medical assistance equal in amount, duration, and scope
to the medical assistance made available to individuals
described in section 1902(a)(10)(A), or who is a PACE
program eligible individual enrolled in a PACE program
under section 1934, but only if the income of such
individual (as determined under section 1612, but
without regard to subsection (b) thereof) does not
exceed 300 percent of the supplemental security income
benefit rate established by section 1611(b)(1),
at the time of the provision of the medical assistance giving
rise to such expenditure.
(g)(1) Subject to paragraph (3), with respect to amounts paid
for the following services furnished under the State plan after
June 30, 1973 (other than services furnished pursuant to a
contract with a health maintenance organization as defined in
section 1876 or which is a qualified health maintenance
organization (as defined in section 1310(d) of the Public
Health Service Act)), the Federal medical assistance percentage
shall be decreased as follows: After an individual has received
inpatient hospital services or services in an intermediate care
facility for the mentally retarded for 60 days or inpatient
mental hospital services for 90 days (whether or not such days
are consecutive), during any fiscal year, the Federal medical
assistance percentage with respect to amounts paid for any such
care furnished thereafter to such individual shall be decreased
by a per centum thereof (determined under paragraph (5)) unless
the State agency responsible for the administration of the plan
makes a showing satisfactory to the Secretary that, with
respect to each calendar quarter for which the State submits a
request for payment at the full Federal medical assistance
percentage for amounts paid for inpatient hospital services or
services in an intermediate care facility for the mentally
retarded furnished beyond 60 days (or inpatient mental hospital
services furnished beyond 90 days), such State has an effective
program of medical review of the care of patients in mental
hospitals and intermediate care facilities for the mentally
retarded pursuant to paragraphs (26) and (31) of section
1902(a) whereby the professional management of each case is
reviewed and evaluated at least annually by independent
professional review teams. In determining the number of days on
which an individual has received services described in this
subsection, there shall not be counted any days with respect to
which such individual is entitled to have payments made (in
whole or in part) on his behalf under section 1812.
(2) The Secretary shall, as part of his validation procedures
under this subsection, conduct timely sample onsite surveys of
private and public institutions in which recipients of medical
assistance may receive care and services under a State plan
approved under this title, and his findings with respect to
such surveys (as well as the showings of the State agency
required under this subsection) shall be made available for
public inspection.
(3)(A) No reduction in the Federal medical assistance
percentage of a State otherwise required to be imposed under
this subsection shall take effect--
(i) if such reduction is due to the State's
unsatisfactory or invalid showing made with respect to
a calendar quarter beginning before January 1, 1977;
(ii) before January 1, 1978;
(iii) unless a notice of such reduction has been
provided to the State at least 30 days before the date
such reduction takes effect; or
(iv) due to the State's unsatisfactory or invalid
showing made with respect to a calendar quarter
beginning after September 30, 1977, unless notice of
such reduction has been provided to the State no later
than the first day of the fourth calendar quarter
following the calendar quarter with respect to which
such showing was made.
(B) The Secretary shall waive application of any reduction in
the Federal medical assistance percentage of a State otherwise
required to be imposed under paragraph (1) because a showing by
the State, made under such paragraph with respect to a calendar
quarter ending after January 1, 1977, and before January 1,
1978, is determined to be either unsatisfactory under such
paragraph or invalid under paragraph (2), if the Secretary
determines that the State's showing made under paragraph (1)
with respect to any calendar quarter ending on or before
December 31, 1978, is satisfactory under such paragraph and is
valid under paragraph (2).
(4)(A) The Secretary may not find the showing of a State,
with respect to a calendar quarter under paragraph (1), to be
satisfactory if the showing is submitted to the Secretary later
than the 30th day after the last day of the calendar quarter,
unless the State demonstrates to the satisfaction of the
Secretary good cause for not meeting such deadline.
(B) The Secretary shall find a showing of a State, with
respect to a calendar quarter under paragraph (1), to be
satisfactory under such paragraph with respect to the
requirement that the State conduct annual onsite inspections in
mental hospitals and intermediate care facilities for the
mentally retarded under paragraphs (26) and (31) of section
1902(a), if the showing demonstrates that the State has
conducted such an onsite inspection during the 12-month period
ending on the last date of the calendar quarter--
(i) in each of not less than 98 per centum of the
number of such hospitals and facilities requiring such
inspection, and
(ii) in every such hospital or facility which has 200
or more beds,
and that, with respect to such hospitals and facilities not
inspected within such period, the State has exercised good
faith and due diligence in attempting to conduct such
inspection, or if the State demonstrates to the satisfaction of
the Secretary that it would have made such a showing but for
failings of a technical nature only.
(5) In the case of a State's unsatisfactory or invalid
showing made with respect to a type of facility or
institutional services in a calendar quarter, the per centum
amount of the reduction of the State's Federal medical
assistance percentage for that type of services under paragraph
(1) is equal to 33\1/3\ per centum multiplied by a fraction,
the denominator of which is equal to the total number of
patients receiving that type of services in that quarter under
the State plan in facilities or institutions for which a
showing was required to be made under this subsection, and the
numerator of which is equal to the number of such patients
receiving such type of services in that quarter in those
facilities or institutions for which a satisfactory and valid
showing was not made for that calendar quarter.
(6)(A) Recertifications required under section 1902(a)(44)
shall be conducted at least every 60 days in the case of
inpatient hospital services.
(B) Such recertifications in the case of services in an
intermediate care facility for the mentally retarded shall be
conducted at least--
(i) 60 days after the date of the initial
certification,
(ii) 180 days after the date of the initial
certification,
(iii) 12 months after the date of the initial
certification,
(iv) 18 months after the date of the initial
certification,
(v) 24 months after the date of the initial
certification, and
(vi) every 12 months thereafter.
(C) For purposes of determining compliance with the schedule
established by this paragraph, a recertification shall be
considered to have been done on a timely basis if it was
performed not later than 10 days after the date the
recertification was otherwise required and the State
establishes good cause why the physician or other person making
such recertification did not meet such schedule.
(i) Payment under the preceding provisions of this section
shall not be made--
(1) for organ transplant procedures unless the State
plan provides for written standards respecting the
coverage of such procedures and unless such standards
provide that--
(A) similarly situated individuals are
treated alike; and
(B) any restriction, on the facilities or
practitioners which may provide such
procedures, is consistent with the
accessibility of high quality care to
individuals eligible for the procedures under
the State plan; or
(2) with respect to any amount expended for an item
or service (other than an emergency item or service,
not including items or services furnished in an
emergency room of a hospital) furnished--
(A) under the plan by any individual or
entity during any period when the individual or
entity is excluded from participation under
title V, XVIII, or XX or under this title
pursuant to section 1128, 1128A, 1156, or
1842(j)(2);
(B) at the medical direction or on the
prescription of a physician, during the period
when such physician is excluded from
participation under title V, XVIII, or XX or
under this title pursuant to section 1128,
1128A, 1156, or 1842(j)(2) 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);
(C) by any individual or entity to whom the
State has failed to suspend payments under the
plan during any period when there is pending an
investigation of a credible allegation of fraud
against the individual or entity, as determined
by the State in accordance with regulations
promulgated by the Secretary for purposes of
section 1862(o) and this subparagraph, unless
the State determines in accordance with such
regulations there is good cause not to suspend
such payments;
(D) beginning on July 1, 2018, under the plan
by any provider of services or person whose
participation in the State plan is terminated
(as described in section 1902(kk)(8)) after the
date that is 60 days after the date on which
such termination is included in the database or
other system under section 1902(ll); or
(E) with respect to any amount expended for
such an item or service furnished during
calendar quarters beginning on or after October
1, 2017, subject to section
1902(kk)(4)(A)(ii)(II), within a geographic
area that is subject to a moratorium imposed
under section 1866(j)(7) by a provider or
supplier that meets the requirements specified
in subparagraph (C)(iii) of such section,
during the period of such moratorium; or
(3) with respect to any amount expended for inpatient
hospital services furnished under the plan (other than
amounts attributable to the special situation of a
hospital which serves a disproportionate number of low
income patients with special needs) to the extent that
such amount exceeds the hospital's customary charges
with respect to such services or (if such services are
furnished under the plan by a public institution free
of charge or at nominal charges to the public) exceeds
an amount determined on the basis of those items
(specified in regulations prescribed by the Secretary)
included in the determination of such payment which the
Secretary finds will provide fair compensation to such
institution for such services; or
(4) with respect to any amount expended for care or
services furnished under the plan by a hospital unless
such hospital has in effect a utilization review plan
which meets the requirements imposed by section 1861(k)
for purposes of title XVIII; and if such hospital has
in effect such a utilization review plan for purposes
of title XVIII, such plan shall serve as the plan
required by this subsection (with the same standards
and procedures and the same review committee or group)
as a condition of payment under this title; the
Secretary is authorized to waive the requirements of
this paragraph if the State agency demonstrates to his
satisfaction that it has in operation utilization
review procedures which are superior in their
effectiveness to the procedures required under section
1861(k); or
(5) with respect to any amount expended for any drug
product for which payment may not be made under part B
of title XVIII because of section 1862(c); or
(6) with respect to any amount expended for inpatient
hospital tests (other than in emergency situations) not
specifically ordered by the attending physician or
other responsible practitioner; or
(7) with respect to any amount expended for clinical
diagnostic laboratory tests performed by a physician,
independent laboratory, or hospital, to the extent such
amount exceeds the amount that would be recognized
under section 1833(h) for such tests performed for an
individual enrolled under part B of title XVIII; or
(8) with respect to any amount expended for medical
assistance (A) for nursing facility services to
reimburse (or otherwise compensate) a nursing facility
for payment of a civil money penalty imposed under
section 1919(h) or (B) for home and community care to
reimburse (or otherwise compensate) a provider of such
care for payment of a civil money penalty imposed under
this title or title XI or for legal expenses in defense
of an exclusion or civil money penalty under this title
or title XI if there is no reasonable legal ground for
the provider's case; or
(10)(A) with respect to covered outpatient drugs
unless there is a rebate agreement in effect under
section 1927 with respect to such drugs or unless
section 1927(a)(3) applies,
(B) with respect to any amount expended for an
innovator multiple source drug (as defined in section
1927(k)) dispensed on or after July 1, 1991, if, under
applicable State law, a less expensive multiple source
drug could have been dispensed, but only to the extent
that such amount exceeds the upper payment limit for
such multiple source drug;
(C) with respect to covered outpatient drugs
described in section 1927(a)(7), unless information
respecting utilization data and coding on such drugs
that is required to be submitted under such section is
submitted in accordance with such section;
(D) with respect to any amount expended for
reimbursement to a pharmacy under this title for the
ingredient cost of a covered outpatient drug for which
the pharmacy has already received payment under this
title (other than with respect to a reasonable
restocking fee for such drug); and
(E) with respect to any amount expended for a covered
outpatient drug for which a suspension under section
1927(c)(4)(B)(ii)(II) is in effect; or
(11) with respect to any amount expended for
physicians' services furnished on or after the first
day of the first quarter beginning more than 60 days
after the date of establishment of the physician
identifier system under section 1902(x), unless the
claim for the services includes the unique physician
identifier provided under such system; or
(12) with respect to any amounts expended for--
(A) a vacuum erection system that is not
medically necessary; or
(B) the insertion, repair, or removal and
replacement of a penile prosthetic implant
(unless such insertion, repair, or removal and
replacement is medically necessary); or
(13) with respect to any amount expended to reimburse
(or otherwise compensate) a nursing facility for
payment of legal expenses associated with any action
initiated by the facility that is dismissed on the
basis that no reasonable legal ground existed for the
institution of such action; or
(14) with respect to any amount expended on
administrative costs to carry out the program under
section 1928; or
(15) with respect to any amount expended for a
single-antigen vaccine and its administration in any
case in which the administration of a combined-antigen
vaccine was medically appropriate (as determined by the
Secretary); or
(16) with respect to any amount expended for which
funds may not be used under the Assisted Suicide
Funding Restriction Act of 1997; or
(17) with respect to any amount expended for roads,
bridges, stadiums, or any other item or service not
covered under a State plan under this title; or
(18) with respect to any amount expended for home
health care services provided by an agency or
organization unless the agency or organization provides
the State agency on a continuing basis a surety bond in
a form specified by the Secretary under paragraph (7)
of section 1861(o) and in an amount that is not less
than $50,000 or such comparable surety bond as the
Secretary may permit under the last sentence of such
section; or
(19) with respect to any amount expended on
administrative costs to initiate or pursue litigation
described in subsection (d)(3)(B);
(20) with respect to amounts expended for medical
assistance provided to an individual described in
subclause (XV) or (XVI) of section 1902(a)(10)(A)(ii)
for a fiscal year unless the State demonstrates to the
satisfaction of the Secretary that the level of State
funds expended for such fiscal year for programs to
enable working individuals with disabilities to work
(other than for such medical assistance) is not less
than the level expended for such programs during the
most recent State fiscal year ending before the date of
the enactment of this paragraph;
(21) with respect to amounts expended for covered
outpatient drugs described in section 1927(d)(2)(C)
(relating to drugs when used for cosmetic purposes or
hair growth), except where medically necessary, and
section 1927(d)(2)(K) (relating to drugs when used for
treatment of sexual or erectile dysfunction);
(22) with respect to amounts expended for medical
assistance for an individual who declares under section
1137(d)(1)(A) to be a citizen or national of the United
States for purposes of establishing eligibility for
benefits under this title, unless the requirement of
section 1902(a)(46)(B) is met;
(23) with respect to amounts expended for medical
assistance for covered outpatient drugs (as defined in
section 1927(k)(2)) for which the prescription was
executed in written (and non-electronic) form unless
the prescription was executed on a tamper-resistant
pad;
(24) if a State is required to implement an asset
verification program under section 1940 and fails to
implement such program in accordance with such section,
with respect to amounts expended by such State for
medical assistance for individuals subject to asset
verification under such section, unless--
(A) the State demonstrates to the Secretary's
satisfaction that the State made a good faith
effort to comply;
(B) not later than 60 days after the date of
a finding that the State is in noncompliance,
the State submits to the Secretary (and the
Secretary approves) a corrective action plan to
remedy such noncompliance; and
(C) not later than 12 months after the date
of such submission (and approval), the State
fulfills the terms of such corrective action
plan;
(25) with respect to any amounts expended for medical
assistance for individuals for whom the State does not
report enrollee encounter data (as defined by the
Secretary) to the Medicaid Statistical Information
System (MSIS) in a timely manner (as determined by the
Secretary);
(26) with respect to any amounts expended for medical
assistance for individuals described in subclause
(VIII) of subsection (a)(10)(A)(i) other than medical
assistance provided through benchmark coverage
described in section 1937(b)(1) or benchmark equivalent
coverage described in section 1937(b)(2); or
(27) with respect to any amounts expended by the
State on the basis of a fee schedule for items
described in section 1861(n) and furnished on or after
January 1, 2018, as determined in the aggregate with
respect to each class of such items as defined by the
Secretary, in excess of the aggregate amount, if any,
that would be paid for such items within such class on
a fee-for-service basis under the program under part B
of title XVIII, including, as applicable, under a
competitive acquisition program under section 1847 in
an area of the State.
Nothing in paragraph (1) shall be construed as permitting a
State to provide services under its plan under this title that
are not reasonable in amount, duration, and scope to achieve
their purpose. Paragraphs (1), (2), (16), (17), and (18) shall
apply with respect to items or services furnished and amounts
expended by or through a managed care entity (as defined in
section 1932(a)(1)(B)) in the same manner as such paragraphs
apply to items or services furnished and amounts expended
directly by the State.
(j) Notwithstanding the preceding provisions of this section,
the amount determined under subsection (a)(1) for any State for
any quarter shall be adjusted in accordance with section 1914.
(k) The Secretary is authorized to provide at the request of
any State (and without cost to such State) such technical and
actuarial assistance as may be necessary to assist such State
to contract with any medicaid managed care organization which
meets the requirements of subsection (m) of this section for
the purpose of providing medical care and services to
individuals who are entitled to medical assistance under this
title.
(l)(1) Subject to paragraphs (3) and (4), with respect to any
amount expended for personal care services or home health care
services requiring an in-home visit by a provider that are
provided under a State plan under this title (or under a waiver
of the plan) and furnished in a calendar quarter beginning on
or after January 1, 2020 (or, in the case of home health care
services, on or after January 1, 2023), unless a State requires
the use of an electronic visit verification system for such
services furnished in such quarter under the plan or such
waiver, the Federal medical assistance percentage shall be
reduced--
(A) in the case of personal care services--
(i) for calendar quarters in 2020, by .25
percentage points;
(ii) for calendar quarters in 2021, by .5
percentage points;
(iii) for calendar quarters in 2022, by .75
percentage points; and
(iv) for calendar quarters in 2023 and each
year thereafter, by 1 percentage point; and
(B) in the case of home health care services--
(i) for calendar quarters in 2023 and 2024,
by .25 percentage points;
(ii) for calendar quarters in 2025, by .5
percentage points;
(iii) for calendar quarters in 2026, by .75
percentage points; and
(iv) for calendar quarters in 2027 and each
year thereafter, by 1 percentage point.
(2) Subject to paragraphs (3) and (4), in implementing the
requirement for the use of an electronic visit verification
system under paragraph (1), a State shall--
(A) consult with agencies and entities that provide
personal care services, home health care services, or
both under the State plan (or under a waiver of the
plan) to ensure that such system--
(i) is minimally burdensome;
(ii) takes into account existing best
practices and electronic visit verification
systems in use in the State; and
(iii) is conducted in accordance with the
requirements of HIPAA privacy and security law
(as defined in section 3009 of the Public
Health Service Act);
(B) take into account a stakeholder process that
includes input from beneficiaries, family caregivers,
individuals who furnish personal care services or home
health care services, and other stakeholders, as
determined by the State in accordance with guidance
from the Secretary; and
(C) ensure that individuals who furnish personal care
services, home health care services, or both under the
State plan (or under a waiver of the plan) are provided
the opportunity for training on the use of such system.
(3) Paragraphs (1) and (2) shall not apply in the case of a
State that, as of the date of the enactment of this subsection,
requires the use of any system for the electronic verification
of visits conducted as part of both personal care services and
home health care services, so long as the State continues to
require the use of such system with respect to the electronic
verification of such visits.
(4)(A) In the case of a State described in subparagraph (B),
the reduction under paragraph (1) shall not apply--
(i) in the case of personal care services, for
calendar quarters in 2020; and
(ii) in the case of home health care services, for
calendar quarters in 2023.
(B) For purposes of subparagraph (A), a State described in
this subparagraph is a State that demonstrates to the Secretary
that the State--
(i) has made a good faith effort to comply with the
requirements of paragraphs (1) and (2) (including by
taking steps to adopt the technology used for an
electronic visit verification system); and
(ii) in implementing such a system, has encountered
unavoidable system delays.
(5) In this subsection:
(A) The term ``electronic visit verification system''
means, with respect to personal care services or home
health care services, a system under which visits
conducted as part of such services are electronically
verified with respect to--
(i) the type of service performed;
(ii) the individual receiving the service;
(iii) the date of the service;
(iv) the location of service delivery;
(v) the individual providing the service; and
(vi) the time the service begins and ends.
(B) The term ``home health care services'' means
services described in section 1905(a)(7) provided under
a State plan under this title (or under a waiver of the
plan).
(C) The term ``personal care services'' means
personal care services provided under a State plan
under this title (or under a waiver of the plan),
including services provided under section 1905(a)(24),
1915(c), 1915(i), 1915(j), or 1915(k) or under a wavier
under section 1115.
(6)(A) In the case in which a State requires personal care
service and home health care service providers to utilize an
electronic visit verification system operated by the State or a
contractor on behalf of the State, the Secretary shall pay to
the State, for each quarter, an amount equal to 90 per centum
of so much of the sums expended during such quarter as are
attributable to the design, development, or installation of
such system, and 75 per centum of so much of the sums for the
operation and maintenance of such system.
(B) Subparagraph (A) shall not apply in the case in which a
State requires personal care service and home health care
service providers to utilize an electronic visit verification
system that is not operated by the State or a contractor on
behalf of the State.
(m)(1)(A) The term ``medicaid managed care organization''
means a health maintenance organization, an eligible
organization with a contract under section 1876 or a
Medicare+Choice organization with a contract under part C of
title XVIII, a provider sponsored organization, or any other
public or private organization, which meets the requirement of
section 1902(w) and--
(i) makes services it provides to individuals
eligible for benefits under this title accessible to
such individuals, within the area served by the
organization, to the same extent as such services are
made accessible to individuals (eligible for medical
assistance under the State plan) not enrolled with the
organization, and
(ii) has made adequate provision against the risk of
insolvency, which provision is satisfactory to the
State, meets the requirements of subparagraph (C)(i)
(if applicable), and which assures that individuals
eligible for benefits under this title are in no case
held liable for debts of the organization in case of
the organization's insolvency.
An organization that is a qualified health maintenance
organization (as defined in section 1310(d) of the Public
Health Service Act) is deemed to meet the requirements of
clauses (i) and (ii).
(B) The duties and functions of the Secretary, insofar as
they involve making determinations as to whether an
organization is a medicaid managed care organization within the
meaning of subparagraph (A), shall be integrated with the
administration of section 1312 (a) and (b) of the Public Health
Service Act.
(C)(i) Subject to clause (ii), a provision meets the
requirements of this subparagraph for an organization if the
organization meets solvency standards established by the State
for private health maintenance organizations or is licensed or
certified by the State as a risk-bearing entity.
(ii) Clause (i) shall not apply to an organization if--
(I) the organization is not responsible for the
provision (directly or through arrangements with
providers of services) of inpatient hospital services
and physicians' services;
(II) the organization is a public entity;
(III) the solvency of the organization is guaranteed
by the State; or
(IV) the organization is (or is controlled by) one or
more Federally-qualified health centers and meets
solvency standards established by the State for such an
organization.
For purposes of subclause (IV), the term ``control'' means the
possession, whether direct or indirect, of the power to direct
or cause the direction of the management and policies of the
organization through membership, board representation, or an
ownership interest equal to or greater than 50.1 percent.
(2)(A) Except as provided in subparagraphs (B), (C), and (G),
no payment shall be made under this title to a State with
respect to expenditures incurred by it for payment (determined
under a prepaid capitation basis or under any other risk basis)
for services provided by any entity (including a health
insuring organization) which is responsible for the provision
(directly or through arrangements with providers of services)
of inpatient hospital services and any other service described
in paragraph (2), (3), (4), (5), or (7) of section 1905(a) or
for the provision of any three or more of the services
described in such paragraphs unless--
(i) the Secretary has determined that the entity is a
medicaid managed care organization organization as
defined in paragraph (1);
(iii) such services are provided for the benefit of
individuals eligible for benefits under this title in
accordance with a contract between the State and the
entity under which prepaid payments to the entity are
made on an actuarially sound basis and under which the
Secretary must provide prior approval for contracts
providing for expenditures in excess of $1,000,000 for
1998 and, for a subsequent year, the amount established
under this clause for the previous year increased by
the percentage increase in the consumer price index for
all urban consumers over the previous year;
(iv) such contract provides that the Secretary and
the State (or any person or organization designated by
either) shall have the right to audit and inspect any
books and records of the entity (and of any
subcontractor) that pertain (I) to the ability of the
entity to bear the risk of potential financial losses,
or (II) to services performed or determinations of
amounts payable under the contract;
(v) such contract provides that in the entity's
enrollment, reenrollment, or disenrollment of
individuals who are eligible for benefits under this
title and eligible to enroll, reenroll, or disenroll
with the entity pursuant to the contract, the entity
will not discriminate among such individuals on the
basis of their health status or requirements for health
care services;
(vi) such contract (I) permits individuals who have
elected under the plan to enroll with the entity for
provision of such benefits to terminate such enrollment
in accordance with section 1932(a)(4), and (II)
provides for notification in accordance with such
section of each such individual, at the time of the
individual's enrollment, of such right to terminate
such enrollment;
(vii) such contract provides that, in the case of
medically necessary services which were provided (I) to
an individual enrolled with the entity under the
contract and entitled to benefits with respect to such
services under the State's plan and (II) other than
through the organization because the services were
immediately required due to an unforeseen illness,
injury, or condition, either the entity or the State
provides for reimbursement with respect to those
services,
(viii) such contract provides for disclosure of
information in accordance with section 1124 and
paragraph (4) of this subsection;
(ix) such contract provides, in the case of an entity
that has entered into a contract for the provision of
services with a Federally-qualified health center or a
rural health clinic, that the entity shall provide
payment that is not less than the level and amount of
payment which the entity would make for the services if
the services were furnished by a provider which is not
a Federally-qualified health center or a rural health
clinic;
(x) any physician incentive plan that it operates
meets the requirements described in section 1876(i)(8);
(xi) such contract provides for maintenance of
sufficient patient encounter data to identify the
physician who delivers services to patients and for the
provision of such data to the State at a frequency and
level of detail to be specified by the Secretary;
(xii) such contract, and the entity complies with the
applicable requirements of section 1932; and
(xiii) such contract provides that (I)
covered outpatient drugs dispensed to
individuals eligible for medical assistance who
are enrolled with the entity shall be subject
to the same rebate required by the agreement
entered into under section 1927 as the State is
subject to and that the State shall collect
such rebates from manufacturers, (II)
capitation rates paid to the entity shall be
based on actual cost experience related to
rebates and subject to the Federal regulations
requiring actuarially sound rates, and (III)
the entity shall report to the State, on such
timely and periodic basis as specified by the
Secretary in order to include in the
information submitted by the State to a
manufacturer and the Secretary under section
1927(b)(2)(A), information on the total number
of units of each dosage form and strength and
package size by National Drug Code of each
covered outpatient drug dispensed to
individuals eligible for medical assistance who
are enrolled with the entity and for which the
entity is responsible for coverage of such drug
under this subsection (other than covered
outpatient drugs that under subsection (j)(1)
of section 1927 are not subject to the
requirements of that section) and such other
data as the Secretary determines necessary to
carry out this subsection.
(B) Subparagraph (A) except with respect to clause (ix) of
subparagraph (A), does not apply with respect to payments under
this title to a State with respect to expenditures incurred by
it for payment for services provided by an entity which--
(i)(I) received a grant of at least $100,000 in the
fiscal year ending June 30, 1976, under section
329(d)(1)(A) or 330(d)(1) of the Public Health Service
Act, and for the period beginning July 1, 1976, and
ending on the expiration of the period for which
payments are to be made under this title has been the
recipient of a grant under either such section; and
(II) provides to its enrollees, on a prepaid
capitation risk basis or on any other risk basis, all
of the services and benefits described in paragraphs
(1), (2), (3), (4)(C), and (5) of section 1905(a) and,
to the extent required by section 1902(a)(10)(D) to be
provided under a State plan for medical assistance, the
services and benefits described in paragraph (7) of
section 1905(a); or
(ii) is a nonprofit primary health care entity
located in a rural area (as defined by the Appalachian
Regional Commission)--
(I) which received in the fiscal year ending
June 30, 1976, at least $100,000 (by grant,
subgrant, or subcontract) under the Appalachian
Regional Development Act of 1965, and
(II) for the period beginning July 1, 1976,
and ending on the expiration of the period for
which payments are to be made under this title
either has been the recipient of a grant,
subgrant, or subcontract under such Act or has
provided services under a contract (initially
entered into during a year in which the entity
was the recipient of such a grant, subgrant, or
subcontract) with a State agency under this
title on a prepaid capitation risk basis or on
any other risk basis; or
(iii) which has contracted with the single State
agency for the provision of services (but not including
inpatient hospital services) to persons eligible under
this title on a prepaid risk basis prior to 1970.
(G) In the case of an entity which is receiving (and has
received during the previous two years) a grant of at least
$100,000 under section 329(d)(1)(A) or 330(d)(1) of the Public
Health Service Act or is receiving (and has received during the
previous two years) at least $100,000 (by grant, subgrant, or
subcontract) under the Appalachian Regional Development Act of
1965, clause (i) of subparagraph (A) shall not apply.
(H) In the case of an individual who--
(i) in a month is eligible for benefits under this
title and enrolled with a medicaid managed care
organization with a contract under this paragraph or
with a primary care case manager with a contract
described in section 1905(t)(3),
(ii) in the next month (or in the next 2 months) is
not eligible for such benefits, but
(iii) in the succeeding month is again eligible for
such benefits,
the State plan, subject to subparagraph (A)(vi), may enroll the
individual for that succeeding month with the organization
described in clause (i) if the organization continues to have a
contract under this paragraph with the State or with the
manager described in such clause if the manager continues to
have a contract described in section 1905(t)(3) with the State.
(3) No payment shall be made under this title to a State with
respect to expenditures incurred by the State for payment for
services provided by a managed care entity (as defined under
section 1932(a)(1)) under the State plan under this title (or
under a waiver of the plan) unless the State--
(A) beginning on July 1, 2018, has a contract with
such entity that complies with the requirement
specified in section 1932(d)(5); and
(B) beginning on January 1, 2018, complies with the
requirement specified in section 1932(d)(6)(A).
(4)(A) Each medicaid managed care organization which is not a
qualified health maintenance organization (as defined in
section 1310(d) of the Public Health Service Act) must report
to the State and, upon request, to the Secretary, the Inspector
General of the Department of Health and Human Services, and the
Comptroller General a description of transactions between the
organization and a party in interest (as defined in section
1318(b) of such Act), including the following transactions:
(i) Any sale or exchange, or leasing of any property
between the organization and such a party.
(ii) Any furnishing for consideration of goods,
services (including management services), or facilities
between the organization and such a party, but not
including salaries paid to employees for services
provided in the normal course of their employment.
(iii) Any lending of money or other extension of
credit between the organization and such a party.
The State or Secretary may require that information reported
respecting an organization which controls, or is controlled by,
or is under common control with, another entity be in the form
of a consolidated financial statement for the organization and
such entity.
(B) Each organization shall make the information reported
pursuant to subparagraph (A) available to its enrollees upon
reasonable request.
(5)(A) If the Secretary determines that an entity with a
contract under this subsection--
(i) fails substantially to provide medically
necessary items and services that are required (under
law or under the contract) to be provided to an
individual covered under the contract, if the failure
has adversely affected (or has substantial likelihood
of adversely affecting) the individual;
(ii) imposes premiums on individuals enrolled under
this subsection in excess of the premiums permitted
under this title;
(iii) acts to discriminate among individuals in
violation of the provision of paragraph (2)(A)(v),
including expulsion or refusal to re-enroll an
individual or engaging in any practice that would
reasonably be expected to have the effect of denying or
discouraging enrollment (except as permitted by this
subsection) by eligible individuals with the
organization whose medical condition or history
indicates a need for substantial future medical
services;
(iv) misrepresents or falsifies information that is
furnished--
(I) to the Secretary or the State under this
subsection, or
(II) to an individual or to any other entity
under this subsection, or
(v) fails to comply with the requirements of section
1876(i)(8),
the Secretary may provide, in addition to any other remedies
available under law, for any of the remedies described in
subparagraph (B).
(B) The remedies described in this subparagraph are--
(i) civil money penalties of not more than $25,000
for each determination under subparagraph (A), or, with
respect to a determination under clause (iii) or
(iv)(I) of such subparagraph, of not more than $100,000
for each such determination, plus, with respect to a
determination under subparagraph (A)(ii), double the
excess amount charged in violation of such subparagraph
(and the excess amount charged shall be deducted from
the penalty and returned to the individual concerned),
and plus, with respect to a determination under
subparagraph (A)(iii), $15,000 for each individual not
enrolled as a result of a practice described in such
subparagraph, or
(ii) denial of payment to the State for medical
assistance furnished under the contract under this
subsection for individuals enrolled after the date the
Secretary notifies the organization of a determination
under subparagraph (A) and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur.
The provisions of section 1128A (other than subsections (a) and
(b)) shall apply to a civil money penalty under clause (i) in
the same manner as such provisions apply to a penalty or
proceeding under section 1128A(a).
(6)(A) For purposes of this subsection and section
1902(e)(2)(A), in the case of the State of New Jersey, the term
``contract'' shall be deemed to include an undertaking by the
State agency, in the State plan under this title, to operate a
program meeting all requirements of this subsection.
(B) The undertaking described in subparagraph (A) must
provide--
(i) for the establishment of a separate entity
responsible for the operation of a program meeting the
requirements of this subsection, which entity may be a
subdivision of the State agency administering the State
plan under this title;
(ii) for separate accounting for the funds used to
operate such program; and
(iii) for setting the capitation rates and any other
payment rates for services provided in accordance with
this subsection using a methodology satisfactory to the
Secretary designed to ensure that total Federal
matching payments under this title for such services
will be lower than the matching payments that would be
made for the same services, if provided under the State
plan on a fee for service basis to an actuarially
equivalent population.
(C) The undertaking described in subparagraph (A) shall be
subject to approval (and annual re-approval) by the Secretary
in the same manner as a contract under this subsection.
(D) The undertaking described in subparagraph (A) shall not
be eligible for a waiver under section 1915(b).
(7) Payment shall be made under this title to a State for
expenditures for capitation payments described in section
438.6(e) of title 42, Code of Federal Regulations (or any
successor regulation).
(8)(A) The State agency administering the State plan under
this title may have reasonable access, as determined by the
State, to 1 or more prescription drug monitoring program
databases administered or accessed by the State to the extent
the State agency is permitted to access such databases under
State law.
(B) Such State agency may facilitate reasonable access, as
determined by the State, to 1 or more prescription drug
monitoring program databases administered or accessed by the
State, to same extent that the State agency is permitted under
State law to access such databases, for--
(i) any provider enrolled under the State plan to
provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
section 1932(a)(1)(B)) that has a contract with the
State under this subsection or under section
1905(t)(3).
(C) Such State agency may share information in such
databases, to the same extent that the State agency is
permitted under State law to share information in such
databases, with--
(i) any provider enrolled under the State plan to
provide services to Medicaid beneficiaries; and
(ii) any managed care entity (as defined under
section 1932(a)(1)(B)) that has a contract with the
State under this subsection or under section
1905(t)(3).
(9)(A) With respect to expenditures described in subparagraph
(B) that are incurred by a State for any fiscal year after
fiscal year 2020 (and before fiscal year 2024), in determining
the pro rata share to which the United States is equitably
entitled under subsection (d)(3), the Secretary shall
substitute the Federal medical assistance percentage that
applies for such fiscal year to the State under section 1905(b)
(without regard to any adjustments to such percentage
applicable under such section or any other provision of law)
for the percentage that applies to such expenditures under
section 1905(y).
(B) Expenditures described in this subparagraph, with respect
to a fiscal year to which subparagraph (A) applies, are
expenditures incurred by a State for payment for medical
assistance provided to individuals described in subclause
(VIII) of section 1902(a)(10)(A)(i) by a managed care entity,
or other specified entity (as defined in subparagraph
(D)(iii)), that are treated as remittances because the State--
(i) has satisfied the requirement of section 438.8 of
title 42, Code of Federal Regulations (or any successor
regulation), by electing--
(I) in the case of a State described in
subparagraph (C), to apply a minimum medical
loss ratio (as defined in subparagraph (D)(ii))
that is at least 85 percent but not greater
than the minimum medical loss ratio (as so
defined) that such State applied as of May 31,
2018; or
(II) in the case of a State not described in
subparagraph (C), to apply a minimum medical
loss ratio that is equal to 85 percent; and
(ii) recovered all or a portion of the expenditures
as a result of the entity's failure to meet such ratio.
(C) For purposes of subparagraph (B), a State described in
this subparagraph is a State that as of May 31, 2018, applied a
minimum medical loss ratio (as calculated under subsection (d)
of section 438.8 of title 42, Code of Federal Regulations (as
in effect on June 1, 2018)) for payment for services provided
by entities described in such subparagraph under the State plan
under this title (or a waiver of the plan) that is equal to or
greater than 85 percent.
(D) For purposes of this paragraph:
(i) The term ``managed care entity'' means a medicaid
managed care organization described in section
1932(a)(1)(B)(i).
(ii) The term ``minimum medical loss ratio'' means,
with respect to a State, a minimum medical loss ratio
(as calculated under subsection (d) of section 438.8 of
title 42, Code of Federal Regulations (as in effect on
June 1, 2018)) for payment for services provided by
entities described in subparagraph (B) under the State
plan under this title (or a waiver of the plan).
(iii) The term ``other specified entity'' means--
(I) a prepaid inpatient health plan, as
defined in section 438.2 of title 42, Code of
Federal Regulations (or any successor
regulation); and
(II) a prepaid ambulatory health plan, as
defined in such section (or any successor
regulation).
(o) Notwithstanding the preceding provisions of this section,
no payment shall be made to a State under the preceding
provisions of this section for expenditures for medical
assistance provided for an individual under its State plan
approved under this title to the extent that a private insurer
(as defined by the Secretary by regulation and including a
group health plan (as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974), a service benefit
plan, and a health maintenance organization) would have been
obligated to provide such assistance but for a provision of its
insurance contract which has the effect of limiting or
excluding such obligation because the individual is eligible
for or is provided medical assistance under the plan.
(p)(1) When a political subdivision of a State makes, for the
State of which it is a political subdivision, or one State
makes, for another State, the enforcement and collection of
rights of support or payment assigned under section 1912,
pursuant to a cooperative arrangement under such section
(either within or outside of such State), there shall be paid
to such political subdivision or such other State from amounts
which would otherwise represent the Federal share of payments
for medical assistance provided to the eligible individuals on
whose behalf such enforcement and collection was made, an
amount equal to 15 percent of any amount collected which is
attributable to such rights of support or payment.
(2) Where more than one jurisdiction is involved in such
enforcement or collection, the amount of the incentive payment
determined under paragraph (1) shall be allocated among the
jurisdictions in a manner to be prescribed by the Secretary.
(q) For the purposes of this section, the term ``State
medicaid fraud control unit'' means a single identifiable
entity of the State government which the Secretary certifies
(and annually recertifies) as meeting the following
requirements:
(1) The entity (A) is a unit of the office of the
State Attorney General or of another department of
State government which possesses statewide authority to
prosecute individuals for criminal violations, (B) is
in a State the constitution of which does not provide
for the criminal prosecution of individuals by a
statewide authority and has formal procedures, approved
by the Secretary, that (i) assure its referral of
suspected criminal violations relating to the program
under this title to the appropriate authority or
authorities in the State for prosecution and (ii)
assure its assistance of, and coordination with, such
authority or authorities in such prosecutions, or (C)
has a formal working relationship with the office of
the State Attorney General and has formal procedures
(including procedures for its referral of suspected
criminal violations to such office) which are approved
by the Secretary and which provide effective
coordination of activities between the entity and such
office with respect to the detection, investigation,
and prosecution of suspected criminal violations
relating to the program under this title.
(2) The entity is separate and distinct from the
single State agency that administers or supervises the
administration of the State plan under this title.
(3) The entity's function is conducting a statewide
program for the investigation and prosecution of
violations of all applicable State laws regarding any
and all aspects of fraud in connection with (A) any
aspect of the provision of medical assistance and the
activities of providers of such assistance under the
State plan under this title; and (B) upon the approval
of the Inspector General of the relevant Federal
agency, any aspect of the provision of health care
services and activities of providers of such services
under any Federal health care program (as defined in
section 1128B(f)(1)), if the suspected fraud or
violation of law in such case or investigation is
primarily related to the State plan under this title.
(4)(A) The entity has--
(i) procedures for reviewing complaints of
abuse or neglect of patients in health care
facilities which receive payments under the
State plan under this title;
(ii) at the option of the entity, procedures
for reviewing complaints of abuse or neglect of
patients residing in board and care facilities;
and
(iii) procedures for acting upon such
complaints under the criminal laws of the State
or for referring such complaints to other State
agencies for action.
(B) For purposes of this paragraph, the term ``board
and care facility'' means a residential setting which
receives payment (regardless of whether such payment is
made under the State plan under this title) from or on
behalf of two or more unrelated adults who reside in
such facility, and for whom one or both of the
following is provided:
(i) Nursing care services provided by, or
under the supervision of, a registered nurse,
licensed practical nurse, or licensed nursing
assistant.
(ii) A substantial amount of personal care
services that assist residents with the
activities of daily living, including personal
hygiene, dressing, bathing, eating, toileting,
ambulation, transfer, positioning, self-
medication, body care, travel to medical
services, essential shopping, meal preparation,
laundry, and housework.
(5) The entity provides for the collection, or
referral for collection to a single State agency, of
overpayments that are made under the State plan or
under any Federal health care program (as so defined)
to health care facilities and that are discovered by
the entity in carrying out its activities. All funds
collected in accordance with this paragraph shall be
credited exclusively to, and available for expenditure
under, the Federal health care program (including the
State plan under this title) that was subject to the
activity that was the basis for the collection.
(6) The entity employs such auditors, attorneys,
investigators, and other necessary personnel and is
organized in such a manner as is necessary to promote
the effective and efficient conduct of the entity's
activities.
(7) The entity submits to the Secretary an
application and annual reports containing such
information as the Secretary determines, by regulation,
to be necessary to determine whether the entity meets
the other requirements of this subsection.
(r)(1) In order to receive payments under subsection (a) for
use of automated data systems in administration of the State
plan under this title, a State must, in addition to meeting the
requirements of paragraph (3), have in operation mechanized
claims processing and information retrieval systems that meet
the requirements of this subsection and that the Secretary has
found--
(A) are adequate to provide efficient, economical,
and effective administration of such State plan;
(B) are compatible with the claims processing and
information retrieval systems used in the
administration of title XVIII, and for this purpose--
(i) have a uniform identification coding
system for providers, other payees, and
beneficiaries under this title or title XVIII;
(ii) provide liaison between States and
carriers and intermediaries with agreements
under title XVIII to facilitate timely exchange
of appropriate data;
(iii) provide for exchange of data between
the States and the Secretary with respect to
persons sanctioned under this title or title
XVIII; and
(iv) effective for claims filed on or after
October 1, 2010, incorporate compatible
methodologies of the National Correct Coding
Initiative administered by the Secretary (or
any successor initiative to promote correct
coding and to control improper coding leading
to inappropriate payment) and such other
methodologies of that Initiative (or such other
national correct coding methodologies) as the
Secretary identifies in accordance with
paragraph (4);
(C) are capable of providing accurate and timely
data;
(D) are complying with the applicable provisions of
part C of title XI;
(E) are designed to receive provider claims in
standard formats to the extent specified by the
Secretary; and
(F) effective for claims filed on or after January 1,
1999, provide for electronic transmission of claims
data in the format specified by the Secretary and
consistent with the Medicaid Statistical Information
System (MSIS) (including detailed individual enrollee
encounter data and other information that the Secretary
may find necessary and including, for data submitted to
the Secretary on or after January 1, 2010, data
elements from the automated data system that the
Secretary determines to be necessary for program
integrity, program oversight, and administration, at
such frequency as the Secretary shall determine).
(2) In order to meet the requirements of this paragraph,
mechanized claims processing and information retrieval systems
must meet the following requirements:
(A) The systems must be capable of developing
provider, physician, and patient profiles which are
sufficient to provide specific information as to the
use of covered types of services and items, including
prescribed drugs.
(B) The State must provide that information on
probable fraud or abuse which is obtained from, or
developed by, the systems, is made available to the
State's medicaid fraud control unit (if any) certified
under subsection (q) of this section.
(C) The systems must meet all performance standards
and other requirements for initial approval developed
by the Secretary.
(3) In order to meet the requirements of this paragraph, a
State must have in operation an eligibility determination
system which provides for data matching through the Public
Assistance Reporting Information System (PARIS) facilitated by
the Secretary (or any successor system), including matching
with medical assistance programs operated by other States.
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall
do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the
National Correct Coding Initiative administered
by the Secretary (or any successor initiative
to promote correct coding and to control
improper coding leading to inappropriate
payment) which are compatible to claims filed
under this title.
(ii) Identify those methodologies of such
Initiative (or such other national correct
coding methodologies) that should be
incorporated into claims filed under this title
with respect to items or services for which
States provide medical assistance under this
title and no national correct coding
methodologies have been established under such
Initiative with respect to title XVIII.
(iii) Notify States of--
(I) the methodologies identified
under subparagraphs (A) and (B) (and of
any other national correct coding
methodologies identified under
subparagraph (B)); and
(II) how States are to incorporate
such methodologies into claims filed
under this title.
(B) Not later than March 1, 2011, submit a report to
Congress that includes the notice to States under
clause (iii) of subparagraph (A) and an analysis
supporting the identification of the methodologies made
under clauses (i) and (ii) of subparagraph (A).
(s) Notwithstanding the preceding provisions of this section,
no payment shall be made to a State under this section for
expenditures for medical assistance under the State plan
consisting of a designated health service (as defined in
subsection (h)(6) of section 1877) furnished to an individual
on the basis of a referral that would result in the denial of
payment for the service under title XVIII if such title
provided for coverage of such service to the same extent and
under the same terms and conditions as under the State plan,
and subsections (f) and (g)(5) of such section shall apply to a
provider of such a designated health service for which payment
may be made under this title in the same manner as such
subsections apply to a provider of such a service for which
payment may be made under such title.
(t)(1) For purposes of subsection (a)(3)(F), the payments
described in this paragraph to encourage the adoption and use
of certified EHR technology are payments made by the State in
accordance with this subsection --
(A) to Medicaid providers described in paragraph
(2)(A) not in excess of 85 percent of net average
allowable costs (as defined in paragraph (3)(E)) for
certified EHR technology (and support services
including maintenance and training that is for, or is
necessary for the adoption and operation of, such
technology) with respect to such providers; and
(B) to Medicaid providers described in paragraph
(2)(B) not in excess of the maximum amount permitted
under paragraph (5) for the provider involved.
(2) In this subsection and subsection (a)(3)(F), the term
``Medicaid provider'' means--
(A) an eligible professional (as defined in paragraph
(3)(B))--
(i) who is not hospital-based and has at
least 30 percent of the professional's patient
volume (as estimated in accordance with a
methodology established by the Secretary)
attributable to individuals who are receiving
medical assistance under this title;
(ii) who is not described in clause (i), who
is a pediatrician, who is not hospital-based,
and who has at least 20 percent of the
professional's patient volume (as estimated in
accordance with a methodology established by
the Secretary) attributable to individuals who
are receiving medical assistance under this
title; and
(iii) who practices predominantly in a
Federally qualified health center or rural
health clinic and has at least 30 percent of
the professional's patient volume (as estimated
in accordance with a methodology established by
the Secretary) attributable to needy
individuals (as defined in paragraph (3)(F));
and
(B)(i) a children's hospital, or
(ii) an acute-care hospital that is not described in
clause (i) and that has at least 10 percent of the
hospital's patient volume (as estimated in accordance
with a methodology established by the Secretary)
attributable to individuals who are receiving medical
assistance under this title.
An eligible professional shall not qualify as a Medicaid
provider under this subsection unless any right to payment
under sections 1848(o) and 1853(l) with respect to the eligible
professional has been waived in a manner specified by the
Secretary. For purposes of calculating patient volume under
subparagraph (A)(iii), insofar as it is related to
uncompensated care, the Secretary may require the adjustment of
such uncompensated care data so that it would be an appropriate
proxy for charity care, including a downward adjustment to
eliminate bad debt data from uncompensated care. In applying
subparagraphs (A) and (B)(ii), the methodology established by
the Secretary for patient volume shall include individuals
enrolled in a Medicaid managed care plan (under section 1903(m)
or section 1932).
(3) In this subsection and subsection (a)(3)(F):
(A) The term ``certified EHR technology'' means a
qualified electronic health record (as defined in
3000(13) of the Public Health Service Act) that is
certified pursuant to section 3001(c)(5) of such Act as
meeting standards adopted under section 3004 of such
Act that are applicable to the type of record involved
(as determined by the Secretary, such as an ambulatory
electronic health record for office-based physicians or
an inpatient hospital electronic health record for
hospitals).
(B) The term ``eligible professional'' means a--
(i) physician;
(ii) dentist;
(iii) certified nurse mid-wife;
(iv) nurse practitioner; and
(v) physician assistant insofar as the
assistant is practicing in a rural health
clinic that is led by a physician assistant or
is practicing in a Federally qualified health
center that is so led.
(C) The term ``average allowable costs'' means, with
respect to certified EHR technology of Medicaid
providers described in paragraph (2)(A) for--
(i) the first year of payment with respect to
such a provider, the average costs for the
purchase and initial implementation or upgrade
of such technology (and support services
including training that is for, or is necessary
for the adoption and initial operation of, such
technology) for such providers, as determined
by the Secretary based upon studies conducted
under paragraph (4)(C); and
(ii) a subsequent year of payment with
respect to such a provider, the average costs
not described in clause (i) relating to the
operation, maintenance, and use of such
technology for such providers, as determined by
the Secretary based upon studies conducted
under paragraph (4)(C).
(D) The term ``hospital-based'' means, with respect
to an eligible professional, a professional (such as a
pathologist, anesthesiologist, or emergency physician)
who furnishes substantially all of the individual's
professional services in a hospital inpatient or
emergency room setting and through the use of the
facilities and equipment, including qualified
electronic health records, of the hospital. The
determination of whether an eligible professional is a
hospital-based eligible professional shall be made on
the basis of the site of service (as defined by the
Secretary) and without regard to any employment or
billing arrangement between the eligible professional
and any other provider.
(E) The term ``net average allowable costs'' means,
with respect to a Medicaid provider described in
paragraph (2)(A), average allowable costs reduced by
the average payment the Secretary estimates will be
made to such Medicaid providers (determined on a
percentage or other basis for such classes or types of
providers as the Secretary may specify) from other
sources (other than under this subsection, or by the
Federal government or a State or local government) that
is directly attributable to payment for certified EHR
technology or support services described in
subparagraph (C).
(F) The term ``needy individual'' means, with respect
to a Medicaid provider, an individual--
(i) who is receiving assistance under this
title;
(ii) who is receiving assistance under title
XXI;
(iii) who is furnished uncompensated care by
the provider; or
(iv) for whom charges are reduced by the
provider on a sliding scale basis based on an
individual's ability to pay.
(4)(A) With respect to a Medicaid provider described in
paragraph (2)(A), subject to subparagraph (B), in no case
shall--
(i) the net average allowable costs under
this subsection for the first year of payment
(which may not be later than 2016), which is
intended to cover the costs described in
paragraph (3)(C)(i), exceed $25,000 (or such
lesser amount as the Secretary determines based
on studies conducted under subparagraph (C));
(ii) the net average allowable costs under
this subsection for a subsequent year of
payment, which is intended to cover costs
described in paragraph (3)(C)(ii), exceed
$10,000; and
(iii) payments be made for costs described in
clause (ii) after 2021 or over a period of
longer than 5 years.
(B) In the case of Medicaid provider described in paragraph
(2)(A)(ii), the dollar amounts specified in subparagraph (A)
shall be \2/3\ of the dollar amounts otherwise specified.
(C) For the purposes of determining average allowable costs
under this subsection, the Secretary shall study the average
costs to Medicaid providers described in paragraph (2)(A) of
purchase and initial implementation and upgrade of certified
EHR technology described in paragraph (3)(C)(i) and the average
costs to such providers of operations, maintenance, and use of
such technology described in paragraph (3)(C)(ii). In
determining such costs for such providers, the Secretary may
utilize studies of such amounts submitted by States.
(5)(A) In no case shall the payments described in paragraph
(1)(B) with respect to a Medicaid provider described in
paragraph (2)(B) exceed--
(i) in the aggregate the product of--
(I) the overall hospital EHR amount
for the provider computed under
subparagraph (B); and
(II) the Medicaid share for such
provider computed under subparagraph
(C);
(ii) in any year 50 percent of the product described
in clause (i); and
(iii) in any 2-year period 90 percent of such
product.
(B) For purposes of this paragraph, the overall hospital EHR
amount, with respect to a Medicaid provider, is the sum of the
applicable amounts specified in section 1886(n)(2)(A) for such
provider for the first 4 payment years (as estimated by the
Secretary) determined as if the Medicare share specified in
clause (ii) of such section were 1. The Secretary shall
establish, in consultation with the State, the overall hospital
EHR amount for each such Medicaid provider eligible for
payments under paragraph (1)(B). For purposes of this
subparagraph in computing the amounts under section
1886(n)(2)(C) for payment years after the first payment year,
the Secretary shall assume that in subsequent payment years
discharges increase at the average annual rate of growth of the
most recent 3 years for which discharge data are available per
year.
(C) The Medicaid share computed under this subparagraph, for
a Medicaid provider for a period specified by the Secretary,
shall be calculated in the same manner as the Medicare share
under section 1886(n)(2)(D) for such a hospital and period,
except that there shall be substituted for the numerator under
clause (i) of such section the amount that is equal to the
number of inpatient-bed-days (as established by the Secretary)
which are attributable to individuals who are receiving medical
assistance under this title and who are not described in
section 1886(n)(2)(D)(i). In computing inpatient-bed-days under
the previous sentence, the Secretary shall take into account
inpatient-bed-days attributable to inpatient-bed-days that are
paid for individuals enrolled in a Medicaid managed care plan
(under section 1903(m) or section 1932).
(D) In no case may the payments described in paragraph (1)(B)
with respect to a Medicaid provider described in paragraph
(2)(B) be paid--
(i) for any year beginning after 2016 unless the
provider has been provided payment under paragraph
(1)(B) for the previous year; and
(ii) over a period of more than 6 years of payment.
(6) Payments described in paragraph (1) are not in accordance
with this subsection unless the following requirements are met:
(A)(i) The State provides assurances satisfactory to
the Secretary that amounts received under subsection
(a)(3)(F) with respect to payments to a Medicaid
provider are paid, subject to clause (ii), directly to
such provider (or to an employer or facility to which
such provider has assigned payments) without any
deduction or rebate.
(ii) Amounts described in clause (i) may also be paid
to an entity promoting the adoption of certified EHR
technology, as designated by the State, if
participation in such a payment arrangement is
voluntary for the eligible professional involved and if
such entity does not retain more than 5 percent of such
payments for costs not related to certified EHR
technology (and support services including maintenance
and training) that is for, or is necessary for the
operation of, such technology.
(B) A Medicaid provider described in paragraph (2)(A)
is responsible for payment of the remaining 15 percent
of the net average allowable cost and shall be
determined to have met such responsibility to the
extent that the payment to the Medicaid provider is not
in excess of 85 percent of the net average allowable
cost.
(C)(i) Subject to clause (ii), with respect to
payments to a Medicaid provider--
(I) for the first year of payment to the
Medicaid provider under this subsection, the
Medicaid provider demonstrates that it is
engaged in efforts to adopt, implement, or
upgrade certified EHR technology; and
(II) for a year of payment, other than the
first year of payment to the Medicaid provider
under this subsection, the Medicaid provider
demonstrates meaningful use of certified EHR
technology through a means that is approved by
the State and acceptable to the Secretary, and
that may be based upon the methodologies
applied under section 1848(o) or 1886(n).
(ii) In the case of a Medicaid provider who has
completed adopting, implementing, or upgrading such
technology prior to the first year of payment to the
Medicaid provider under this subsection, clause (i)(I)
shall not apply and clause (i)(II) shall apply to each
year of payment to the Medicaid provider under this
subsection, including the first year of payment.
(D) To the extent specified by the Secretary, the
certified EHR technology is compatible with State or
Federal administrative management systems.
For purposes of subparagraph (B), a Medicaid provider described
in paragraph (2)(A) may accept payments for the costs described
in such subparagraph from a State or local government. For
purposes of subparagraph (C), in establishing the means
described in such subparagraph, which may include clinical
quality reporting to the State, the State shall ensure that
populations with unique needs, such as children, are
appropriately addressed.
(7) With respect to Medicaid providers described in paragraph
(2)(A), the Secretary shall ensure coordination of payment with
respect to such providers under sections 1848(o) and 1853(l)
and under this subsection to assure no duplication of funding.
Such coordination shall include, to the extent practicable, a
data matching process between State Medicaid agencies and the
Centers for Medicare & Medicaid Services using national
provider identifiers. For such purposes, the Secretary may
require the submission of such data relating to payments to
such Medicaid providers as the Secretary may specify.
(8) In carrying out paragraph (6)(C), the State and Secretary
shall seek, to the maximum extent practicable, to avoid
duplicative requirements from Federal and State governments to
demonstrate meaningful use of certified EHR technology under
this title and title XVIII. In doing so, the Secretary may deem
satisfaction of requirements for such meaningful use for a
payment year under title XVIII to be sufficient to qualify as
meaningful use under this subsection. The Secretary may also
specify the reporting periods under this subsection in order to
carry out this paragraph.
(9) In order to be provided Federal financial participation
under subsection (a)(3)(F)(ii), a State must demonstrate to the
satisfaction of the Secretary, that the State--
(A) is using the funds provided for the purposes of
administering payments under this subsection, including
tracking of meaningful use by Medicaid providers;
(B) is conducting adequate oversight of the program
under this subsection, including routine tracking of
meaningful use attestations and reporting mechanisms;
and
(C) is pursuing initiatives to encourage the adoption
of certified EHR technology to promote health care
quality and the exchange of health care information
under this title, subject to applicable laws and
regulations governing such exchange.
(10) The Secretary shall periodically submit reports to the
Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the Senate on
status, progress, and oversight of payments described in
paragraph (1), including steps taken to carry out paragraph
(7). Such reports shall also describe the extent of adoption of
certified EHR technology among Medicaid providers resulting
from the provisions of this subsection and any improvements in
health outcomes, clinical quality, or efficiency resulting from
such adoption.
(u)(1)(A) Notwithstanding subsection (a)(1), if the ratio of
a State's erroneous excess payments for medical assistance (as
defined in subparagraph (D)) to its total expenditures for
medical assistance under the State plan approved under this
title exceeds 0.03, for the period consisting of the third and
fourth quarters of fiscal year 1983, or for any full fiscal
year thereafter, then the Secretary shall make no payment for
such period or fiscal year with respect to so much of such
erroneous excess payments as exceeds such allowable error rate
of 0.03.
(B) The Secretary may waive, in certain limited cases, all or
part of the reduction required under subparagraph (A) with
respect to any State if such State is unable to reach the
allowable error rate for a period or fiscal year despite a good
faith effort by such State.
(C) In estimating the amount to be paid to a State under
subsection (d), the Secretary shall take into consideration the
limitation on Federal financial participation imposed by
subparagraph (A) and shall reduce the estimate he makes under
subsection (d)(1), for purposes of payment to the State under
subsection (d)(3), in light of any expected erroneous excess
payments for medical assistance (estimated in accordance with
such criteria, including sampling procedures, as he may
prescribe and subject to subsequent adjustment, if necessary,
under subsection (d)(2)).
(D)(i) For purposes of this subsection, the term ``erroneous
excess payments for medical assistance'' means the total of--
(I) payments under the State plan with respect to
ineligible individuals and families, and
(II) overpayments on behalf of eligible individuals
and families by reason of error in determining the
amount of expenditures for medical care required of an
individual or family as a condition of eligibility.
(ii) In determining the amount of erroneous excess payments
for medical assistance to an ineligible individual or family
under clause (i)(I), if such ineligibility is the result of an
error in determining the amount of the resources of such
individual or family, the amount of the erroneous excess
payment shall be the smaller of (I) the amount of the payment
with respect to such individual or family, or (II) the
difference between the actual amount of such resources and the
allowable resource level established under the State plan.
(iii) In determining the amount of erroneous excess payments
for medical assistance to an individual or family under clause
(i)(II), the amount of the erroneous excess payment shall be
the smaller of (I) the amount of the payment on behalf of the
individual or family, or (II) the difference between the actual
amount incurred for medical care by the individual or family
and the amount which should have been incurred in order to
establish eligibility for medical assistance.
(iv) In determining the amount of erroneous excess payments,
there shall not be included any error resulting from a failure
of an individual to cooperate or give correct information with
respect to third-party liability as required under section
1912(a)(1)(C) or 402(a)(26)(C) or with respect to payments made
in violation of section 1906.
(v) In determining the amount of erroneous excess payments,
there shall not be included any erroneous payments made for
ambulatory prenatal care provided during a presumptive
eligibility period (as defined in section 1920(b)(1)), for
items and services described in subsection (a) of section 1920A
provided to a child during a presumptive eligibility period
under such section, for medical assistance provided to an
individual described in subsection (a) of section 1920B during
a presumptive eligibility period under such section, or for
medical assistance provided to an individual during a
presumptive eligibility period resulting from a determination
of presumptive eligibility made by a hospital that elects under
section 1902(a)(47)(B) to be a qualified entity for such
purpose.
(E) For purposes of subparagraph (D), there shall be
excluded, in determining both erroneous excess payments for
medical assistance and total expenditures for medical
assistance--
(i) payments with respect to any individual whose
eligibility therefor was determined exclusively by the
Secretary under an agreement pursuant to section 1634
and such other classes of individuals as the Secretary
may by regulation prescribe whose eligibility was
determined in part under such an agreement; and
(ii) payments made as the result of a technical
error.
(2) The State agency administering the plan approved under
this title shall, at such times and in such form as the
Secretary may specify, provide information on the rates of
erroneous excess payments made (or expected, with respect to
future periods specified by the Secretary) in connection with
its administration of such plan, together with any other data
he requests that are reasonably necessary for him to carry out
the provisions of this subsection.
(3)(A) If a State fails to cooperate with the Secretary in
providing information necessary to carry out this subsection,
the Secretary, directly or through contractual or such other
arrangements as he may find appropriate, shall establish the
error rates for that State on the basis of the best data
reasonably available to him and in accordance with such
techniques for sampling and estimating as he finds appropriate.
(B) In any case in which it is necessary for the Secretary to
exercise his authority under subparagraph (A) to determine a
State's error rates for a fiscal year, the amount that would
otherwise be payable to such State under this title for
quarters in such year shall be reduced by the costs incurred by
the Secretary in making (directly or otherwise) such
determination.
(4) This subsection shall not apply with respect to Puerto
Rico, Guam, the Virgin Islands, the Northern Mariana Islands,
or American Samoa.
(v)(1) Notwithstanding the preceding provisions of this
section, except as provided in paragraphs (2) and (4), no
payment may be made to a State under this section for medical
assistance furnished to an alien who is not lawfully admitted
for permanent residence or otherwise permanently residing in
the United States under color of law.
(2) Payment shall be made under this section for care and
services that are furnished to an alien described in paragraph
(1) only if--
(A) such care and services are necessary for the
treatment of an emergency medical condition of the
alien,
(B) such alien otherwise meets the eligibility
requirements for medical assistance under the State
plan approved under this title (other than the
requirement of the receipt of aid or assistance under
title IV, supplemental security income benefits under
title XVI, or a State supplementary payment), and
(C) such care and services are not related to an
organ transplant procedure.
(3) For purposes of this subsection, the term ``emergency
medical condition'' means a medical condition (including
emergency labor and delivery) manifesting itself by acute
symptoms of sufficient severity (including severe pain) such
that the absence of immediate medical attention could
reasonably be expected to result in--
(A) placing the patient's health in serious jeopardy,
(B) serious impairment to bodily functions, or
(C) serious dysfunction of any bodily organ or part.
(4)(A) A State may elect (in a plan amendment under this
title) to provide medical assistance under this title,
notwithstanding sections 401(a), 402(b), 403, and 421 of the
Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, to children and pregnant women who are lawfully
residing in the United States (including battered individuals
described in section 431(c) of such Act) and who are otherwise
eligible for such assistance, within either or both of the
following eligibility categories:
(i) Pregnant women.--Women during pregnancy (and
during the 60-day period, or, at the option of the
State, 1-year period, beginning on the last day of the
pregnancy).
(ii) Children.--Individuals under 21 years of age,
including optional targeted low-income children
described in section 1905(u)(2)(B).
(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subparagraph
(A), no debt shall accrue under an affidavit of support against
any sponsor of such an alien on the basis of provision of
assistance to such category and the cost of such assistance
shall not be considered as an unreimbursed cost.
(C) As part of the State's ongoing eligibility
redetermination requirements and procedures for an individual
provided medical assistance as a result of an election by the
State under subparagraph (A), a State shall verify that the
individual continues to lawfully reside in the United States
using the documentation presented to the State by the
individual on initial enrollment. If the State cannot
successfully verify that the individual is lawfully residing in
the United States in this manner, it shall require that the
individual provide the State with further documentation or
other evidence to verify that the individual is lawfully
residing in the United States.
(w)(1)(A) Notwithstanding the previous provisions of this
section, for purposes of determining the amount to be paid to a
State (as defined in paragraph (7)(D)) under subsection (a)(1)
for quarters in any fiscal year, the total amount expended
during such fiscal year as medical assistance under the State
plan (as determined without regard to this subsection) shall be
reduced by the sum of any revenues received by the State (or by
a unit of local government in the State) during the fiscal
year--
(i) from provider-related donations (as defined in
paragraph (2)(A)), other than--
(I) bona fide provider-related donations (as
defined in paragraph (2)(B)), and
(II) donations described in paragraph (2)(C);
(ii) from health care related taxes (as defined in
paragraph (3)(A)), other than broad-based health care
related taxes (as defined in paragraph (3)(B));
(iii) from a broad-based health care related tax, if
there is in effect a hold harmless provision (described
in paragraph (4)) with respect to the tax; or
(iv) only with respect to State fiscal years (or
portions thereof) occurring on or after January 1,
1992, and before October 1, 1995, from broad-based
health care related taxes to the extent the amount of
such taxes collected exceeds the limit established
under paragraph (5).
(B) Notwithstanding the previous provisions of this section,
for purposes of determining the amount to be paid to a State
under subsection (a)(7) for all quarters in a Federal fiscal
year (beginning with fiscal year 1993), the total amount
expended during the fiscal year for administrative expenditures
under the State plan (as determined without regard to this
subsection) shall be reduced by the sum of any revenues
received by the State (or by a unit of local government in the
State) during such quarters from donations described in
paragraph (2)(C), to the extent the amount of such donations
exceeds 10 percent of the amounts expended under the State plan
under this title during the fiscal year for purposes described
in paragraphs (2), (3), (4), (6), and (7) of subsection (a).
(C)(i) Except as otherwise provided in clause (ii),
subparagraph (A)(i) shall apply to donations received on or
after January 1, 1992.
(ii) Subject to the limits described in clause (iii) and
subparagraph (E), subparagraph (A)(i) shall not apply to
donations received before the effective date specified in
subparagraph (F) if such donations are received under programs
in effect or as described in State plan amendments or related
documents submitted to the Secretary by September 30, 1991, and
applicable to State fiscal year 1992, as demonstrated by State
plan amendments, written agreements, State budget
documentation, or other documentary evidence in existence on
that date.
(iii) In applying clause (ii) in the case of donations
received in State fiscal year 1993, the maximum amount of such
donations to which such clause may be applied may not exceed
the total amount of such donations received in the
corresponding period in State fiscal year 1992 (or not later
than 5 days after the last day of the corresponding period).
(D)(i) Except as otherwise provided in clause (ii),
subparagraphs (A)(ii) and (A)(iii) shall apply to taxes
received on or after January 1, 1992.
(ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to
impermissible taxes (as defined in clause (iii)) received
before the effective date specified in subparagraph (F) to the
extent the taxes (including the tax rate or base) were in
effect, or the legislation or regulations imposing such taxes
were enacted or adopted, as of November 22, 1991.
(iii) In this subparagraph and subparagraph (E), the term
``impermissible tax'' means a health care related tax for which
a reduction may be made under clause (ii) or (iii) of
subparagraph (A).
(E)(i) In no case may the total amount of donations and taxes
permitted under the exception provided in subparagraphs (C)(ii)
and (D)(ii) for the portion of State fiscal year 1992 occurring
during calendar year 1992 exceed the limit under paragraph (5)
minus the total amount of broad-based health care related taxes
received in the portion of that fiscal year.
(ii) In no case may the total amount of donations and taxes
permitted under the exception provided in subparagraphs (C)(ii)
and (D)(ii) for State fiscal year 1993 exceed the limit under
paragraph (5) minus the total amount of broad-based health care
related taxes received in that fiscal year.
(F) In this paragraph in the case of a State--
(i) except as provided in clause (iii), with a State
fiscal year beginning on or before July 1, the
effective date is October 1, 1992,
(ii) except as provided in clause (iii), with a State
fiscal year that begins after July 1, the effective
date is January 1, 1993, or
(iii) with a State legislature which is not scheduled
to have a regular legislative session in 1992, with a
State legislature which is not scheduled to have a
regular legislative session in 1993, or with a
provider-specific tax enacted on November 4, 1991, the
effective date is July 1, 1993.
(2)(A) In this subsection (except as provided in paragraph
(6)), the term ``provider-related donation'' means any donation
or other voluntary payment (whether in cash or in kind) made
(directly or indirectly) to a State or unit of local government
by--
(i) a health care provider (as defined in paragraph
(7)(B)),
(ii) an entity related to a health care provider (as
defined in paragraph (7)(C)), or
(iii) an entity providing goods or services under the
State plan for which payment is made to the State under
paragraph (2), (3), (4), (6), or (7) of subsection (a).
(B) For purposes of paragraph (1)(A)(i)(I), the term ``bona
fide provider-related donation'' means a provider-related
donation that has no direct or indirect relationship (as
determined by the Secretary) to payments made under this title
to that provider, to providers furnishing the same class of
items and services as that provider, or to any related entity,
as established by the State to the satisfaction of the
Secretary. The Secretary may by regulation specify types of
provider-related donations described in the previous sentence
that will be considered to be bona fide provider-related
donations.
(C) For purposes of paragraph (1)(A)(i)(II), donations
described in this subparagraph are funds expended by a
hospital, clinic, or similar entity for the direct cost
(including costs of training and of preparing and distributing
outreach materials) of State or local agency personnel who are
stationed at the hospital, clinic, or entity to determine the
eligibility of individuals for medical assistance under this
title and to provide outreach services to eligible or
potentially eligible individuals.
(3)(A) In this subsection (except as provided in paragraph
(6)), the term ``health care related tax'' means a tax (as
defined in paragraph (7)(F)) that--
(i) is related to health care items or services, or
to the provision of, the authority to provide, or
payment for, such items or services, or
(ii) is not limited to such items or services but
provides for treatment of individuals or entities that
are providing or paying for such items or services that
is different from the treatment provided to other
individuals or entities.
In applying clause (i), a tax is considered to relate to health
care items or services if at least 85 percent of the burden of
such tax falls on health care providers.
(B) In this subsection, the term ``broad-based health care
related tax'' means a health care related tax which is imposed
with respect to a class of health care items or services (as
described in paragraph (7)(A)) or with respect to providers of
such items or services and which, except as provided in
subparagraphs (D), (E), and (F)--
(i) is imposed at least with respect to all items or
services in the class furnished by all non-Federal,
nonpublic providers in the State (or, in the case of a
tax imposed by a unit of local government, the area
over which the unit has jurisdiction) or is imposed
with respect to all non-Federal, nonpublic providers in
the class; and
(ii) is imposed uniformly (in accordance with
subparagraph (C)).
(C)(i) Subject to clause (ii), for purposes of subparagraph
(B)(ii), a tax is considered to be imposed uniformly if--
(I) in the case of a tax consisting of a licensing
fee or similar tax on a class of health care items or
services (or providers of such items or services), the
amount of the tax imposed is the same for every
provider providing items or services within the class;
(II) in the case of a tax consisting of a licensing
fee or similar tax imposed on a class of health care
items or services (or providers of such services) on
the basis of the number of beds (licensed or otherwise)
of the provider, the amount of the tax is the same for
each bed of each provider of such items or services in
the class;
(III) in the case of a tax based on revenues or
receipts with respect to a class of items or services
(or providers of items or services) the tax is imposed
at a uniform rate for all items and services (or
providers of such items of services) in the class on
all the gross revenues or receipts, or net operating
revenues, relating to the provision of all such items
or services (or all such providers) in the State (or,
in the case of a tax imposed by a unit of local
government within the State, in the area over which the
unit has jurisdiction); or
(IV) in the case of any other tax, the State
establishes to the satisfaction of the Secretary that
the tax is imposed uniformly.
(ii) Subject to subparagraphs (D) and (E), a tax imposed with
respect to a class of health care items and services is not
considered to be imposed uniformly if the tax provides for any
credits, exclusions, or deductions which have as their purpose
or effect the return to providers of all or a portion of the
tax paid in a manner that is inconsistent with subclauses (I)
and (II) of subparagraph (E)(ii) or provides for a hold
harmless provision described in paragraph (4).
(D) A tax imposed with respect to a class of health care
items and services is considered to be imposed uniformly--
(i) notwithstanding that the tax is not imposed with
respect to items or services (or the providers thereof)
for which payment is made under a State plan under this
title or title XVIII, or
(ii) in the case of a tax described in subparagraph
(C)(i)(III), notwithstanding that the tax provides for
exclusion (in whole or in part) of revenues or receipts
from a State plan under this title or title XVIII.
(E)(i) A State may submit an application to the Secretary
requesting that the Secretary treat a tax as a broad-based
health care related tax, notwithstanding that the tax does not
apply to all health care items or services in class (or all
providers of such items and services), provides for a credit,
deduction, or exclusion, is not applied uniformly, or otherwise
does not meet the requirements of subparagraph (B) or (C).
Permissible waivers may include exemptions for rural or sole-
community providers.
(ii) The Secretary shall approve such an application if the
State establishes to the satisfaction of the Secretary that--
(I) the net impact of the tax and associated
expenditures under this title as proposed by the State
is generally redistributive in nature, and
(II) the amount of the tax is not directly correlated
to payments under this title for items or services with
respect to which the tax is imposed.
The Secretary shall by regulation specify types of credits,
exclusions, and deductions that will be considered to meet the
requirements of this subparagraph.
(F) In no case shall a tax not qualify as a broad-based
health care related tax under this paragraph because it does
not apply to a hospital that is described in section 501(c)(3)
of the Internal Revenue Code of 1986 and exempt from taxation
under section 501(a) of such Code and that does not accept
payment under the State plan under this title or under title
XVIII.
(4) For purposes of paragraph (1)(A)(iii), there is in effect
a hold harmless provision with respect to a broad-based health
care related tax imposed with respect to a class of items or
services if the Secretary determines that any of the following
applies:
(A) The State or other unit of government imposing
the tax provides (directly or indirectly) for a payment
(other than under this title) to taxpayers and the
amount of such payment is positively correlated either
to the amount of such tax or to the difference between
the amount of the tax and the amount of payment under
the State plan.
(B) All or any portion of the payment made under this
title to the taxpayer varies based only upon the amount
of the total tax paid.
(C)(i) The State or other unit of government imposing
the tax provides (directly or indirectly) for any
payment, offset, or waiver that guarantees to hold
taxpayers harmless for any portion of the costs of the
tax.
(ii) For purposes of clause (i), a determination of
the existence of an indirect guarantee shall be made
under paragraph (3)(i) of section 433.68(f) of title
42, Code of Federal Regulations, as in effect on
November 1, 2006, except that for portions of fiscal
years beginning on or after January 1, 2008, and before
October 1, 2011, ``5.5 percent'' shall be substituted
for ``6 percent'' each place it appears.
The provisions of this paragraph shall not prevent use of the
tax to reimburse health care providers in a class for
expenditures under this title nor preclude States from relying
on such reimbursement to justify or explain the tax in the
legislative process.
(5)(A) For purposes of this subsection, the limit under this
subparagraph with respect to a State is an amount equal to 25
percent (or, if greater, the State base percentage, as defined
in subparagraph (B)) of the non-Federal share of the total
amount expended under the State plan during a State fiscal year
(or portion thereof), as it would be determined pursuant to
paragraph (1)(A) without regard to paragraph (1)(A)(iv).
(B)(i) In subparagraph (A), the term ``State base
percentage'' means, with respect to a State, an amount
(expressed as a percentage) equal to--
(I) the total of the amount of health care related
taxes (whether or not broad-based) and the amount of
provider-related donations (whether or not bona fide)
projected to be collected (in accordance with clause
(ii)) during State fiscal year 1992, divided by
(II) the non-Federal share of the total amount
estimated to be expended under the State plan during
such State fiscal year.
(ii) For purposes of clause (i)(I), in the case of a tax that
is not in effect throughout State fiscal year 1992 or the rate
(or base) of which is increased during such fiscal year, the
Secretary shall project the amount to be collected during such
fiscal year as if the tax (or increase) were in effect during
the entire State fiscal year.
(C)(i) The total amount of health care related taxes under
subparagraph (B)(i)(I) shall be determined by the Secretary
based on only those taxes (including the tax rate or base)
which were in effect, or for which legislation or regulations
imposing such taxes were enacted or adopted, as of November 22,
1991.
(ii) The amount of provider-related donations under
subparagraph (B)(i)(I) shall be determined by the Secretary
based on programs in effect on September 30, 1991, and
applicable to State fiscal year 1992, as demonstrated by State
plan amendments, written agreements, State budget
documentation, or other documentary evidence in existence on
that date.
(iii) The amount of expenditures described in subparagraph
(B)(i)(II) shall be determined by the Secretary based on the
best data available as of the date of the enactment of this
subsection.
(6)(A) Notwithstanding the provisions of this subsection, the
Secretary may not restrict States' use of funds where such
funds are derived from State or local taxes (or funds
appropriated to State university teaching hospitals)
transferred from or certified by units of government within a
State as the non-Federal share of expenditures under this
title, regardless of whether the unit of government is also a
health care provider, except as provided in section 1902(a)(2),
unless the transferred funds are derived by the unit of
government from donations or taxes that would not otherwise be
recognized as the non-Federal share under this section.
(B) For purposes of this subsection, funds the use of which
the Secretary may not restrict under subparagraph (A) shall not
be considered to be a provider-related donation or a health
care related tax.
(7) For purposes of this subsection:
(A) Each of the following shall be considered a
separate class of health care items and services:
(i) Inpatient hospital services.
(ii) Outpatient hospital services.
(iii) Nursing facility services (other than
services of intermediate care facilities for
the mentally retarded).
(iv) Services of intermediate care facilities
for the mentally retarded.
(v) Physicians' services.
(vi) Home health care services.
(vii) Outpatient prescription drugs.
(viii) Services of managed care organizations
(including health maintenance organizations,
preferred provider organizations, and such
other similar organizations as the Secretary
may specify by regulation).
(ix) Such other classification of health care
items and services consistent with this
subparagraph as the Secretary may establish by
regulation.
(B) The term ``health care provider'' means an
individual or person that receives payments for the
provision of health care items or services.
(C) An entity is considered to be ``related'' to a
health care provider if the entity--
(i) is an organization, association,
corporation or partnership formed by or on
behalf of health care providers;
(ii) is a person with an ownership or control
interest (as defined in section 1124(a)(3)) in
the provider;
(iii) is the employee, spouse, parent, child,
or sibling of the provider (or of a person
described in clause (ii)); or
(iv) has a similar, close relationship (as
defined in regulations) to the provider.
(D) The term ``State'' means only the 50 States and
the District of Columbia but does not include any State
whose entire program under this title is operated under
a waiver granted under section 1115.
(E) The ``State fiscal year'' means, with respect to
a specified year, a State fiscal year ending in that
specified year.
(F) The term ``tax'' includes any licensing fee,
assessment, or other mandatory payment, but does not
include payment of a criminal or civil fine or penalty
(other than a fine or penalty imposed in lieu of or
instead of a fee, assessment, or other mandatory
payment).
(G) The term ``unit of local government'' means, with
respect to a State, a city, county, special purpose
district, or other governmental unit in the State.
(x)(1) For purposes of section 1902(a)(46)(B)(i), the
requirement of this subsection is, with respect to an
individual declaring to be a citizen or national of the United
States, that, subject to paragraph (2), there is presented
satisfactory documentary evidence of citizenship or nationality
(as defined in paragraph (3)) of the individual.
(2) The requirement of paragraph (1) shall not apply to an
individual declaring to be a citizen or national of the United
States who is eligible for medical assistance under this
title--
(A) and is entitled to or enrolled for benefits under
any part of title XVIII;
(B) and is receiving--
(i) disability insurance benefits under
section 223 or monthly insurance benefits under
section 202 based on such individual's
disability (as defined in section 223(d)); or
(ii) supplemental security income benefits
under title XVI;
(C) and with respect to whom--
(i) child welfare services are made available
under part B of title IV on the basis of being
a child in foster care; or
(ii) adoption or foster care assistance is
made available under part E of title IV;
(D) pursuant to the application of section 1902(e)(4)
(and, in the case of an individual who is eligible for
medical assistance on such basis, the individual shall
be deemed to have provided satisfactory documentary
evidence of citizenship or nationality and shall not be
required to provide further documentary evidence on any
date that occurs during or after the period in which
the individual is eligible for medical assistance on
such basis); or
(E) on such basis as the Secretary may specify under
which satisfactory documentary evidence of citizenship
or nationality has been previously presented.
(3)(A) For purposes of this subsection, the term
``satisfactory documentary evidence of citizenship or
nationality'' means--
(i) any document described in subparagraph (B); or
(ii) a document described in subparagraph (C) and a
document described in subparagraph (D).
(B) The following are documents described in this
subparagraph:
(i) A United States passport.
(ii) Form N-550 or N-570 (Certificate of
Naturalization).
(iii) Form N-560 or N-561 (Certificate of United
States Citizenship).
(iv) A valid State-issued driver's license or other
identity document described in section 274A(b)(1)(D) of
the Immigration and Nationality Act, but only if the
State issuing the license or such document requires
proof of United States citizenship before issuance of
such license or document or obtains a social security
number from the applicant and verifies before
certification that such number is valid and assigned to
the applicant who is a citizen.
(v)(I) Except as provided in subclause (II), a
document issued by a federally recognized Indian tribe
evidencing membership or enrollment in, or affiliation
with, such tribe (such as a tribal enrollment card or
certificate of degree of Indian blood).
(II) With respect to those federally recognized
Indian tribes located within States having an
international border whose membership includes
individuals who are not citizens of the United States,
the Secretary shall, after consulting with such tribes,
issue regulations authorizing the presentation of such
other forms of documentation (including tribal
documentation, if appropriate) that the Secretary
determines to be satisfactory documentary evidence of
citizenship or nationality for purposes of satisfying
the requirement of this subsection.
(vi) Such other document as the Secretary may
specify, by regulation, that provides proof of United
States citizenship or nationality and that provides a
reliable means of documentation of personal identity.
(C) The following are documents described in this
subparagraph:
(i) A certificate of birth in the United States.
(ii) Form FS-545 or Form DS-1350 (Certification of
Birth Abroad).
(iii) Form I-197 (United States Citizen
Identification Card).
(iv) Form FS-240 (Report of Birth Abroad of a Citizen
of the United States).
(v) Such other document (not described in
subparagraph (B)(iv)) as the Secretary may specify that
provides proof of United States citizenship or
nationality.
(D) The following are documents described in this
subparagraph:
(i) Any identity document described in section
274A(b)(1)(D) of the Immigration and Nationality Act.
(ii) Any other documentation of personal identity of
such other type as the Secretary finds, by regulation,
provides a reliable means of identification.
(E) A reference in this paragraph to a form includes a
reference to any successor form.
(4) In the case of an individual declaring to be a citizen or
national of the United States with respect to whom a State
requires the presentation of satisfactory documentary evidence
of citizenship or nationality under section 1902(a)(46)(B)(i),
the individual shall be provided at least the reasonable
opportunity to present satisfactory documentary evidence of
citizenship or nationality under this subsection 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.
(5) Nothing in subparagraph (A) or (B) of section
1902(a)(46), the preceding paragraphs of this subsection, or
the Deficit Reduction Act of 2005, including section 6036 of
such Act, shall be construed as changing the requirement of
section 1902(e)(4) that a child born in the United States to an
alien mother for whom medical assistance for the delivery of
such child is available as treatment of an emergency medical
condition pursuant to subsection (v) shall be deemed eligible
for medical assistance during the first year of such child's
life.
(y) Payments for Establishment of Alternate Non-Emergency
Services Providers.--
(1) Payments.--In addition to the payments otherwise
provided under subsection (a), subject to paragraph
(2), the Secretary shall provide for payments to States
under such subsection for the establishment of
alternate non-emergency service providers (as defined
in section 1916A(e)(5)(B)), or networks of such
providers.
(2) Limitation.--The total amount of payments under
this subsection shall not exceed $50,000,000 during the
4-year period beginning with 2006. This subsection
constitutes budget authority in advance of
appropriations Acts and represents the obligation of
the Secretary to provide for the payment of amounts
provided under this subsection.
(3) Preference.--In providing for payments to States
under this subsection, the Secretary shall provide
preference to States that establish, or provide for,
alternate non-emergency services providers or networks
of such providers that--
(A) serve rural or underserved areas where
beneficiaries under this title may not have
regular access to providers of primary care
services; or
(B) are in partnership with local community
hospitals.
(4) Form and manner of payment.--Payment to a State
under this subsection shall be made only upon the
filing of such application in such form and in such
manner as the Secretary shall specify. Payment to a
State under this subsection shall be made in the same
manner as other payments under section 1903(a).
(z) Medicaid Transformation Payments.--
(1) In general.--In addition to the payments provided
under subsection (a), subject to paragraph (4), the
Secretary shall provide for payments to States for the
adoption of innovative methods to improve the
effectiveness and efficiency in providing medical
assistance under this title.
(2) Permissible uses of funds.--The following are
examples of innovative methods for which funds provided
under this subsection may be used:
(A) Methods for reducing patient error rates
through the implementation and use of
electronic health records, electronic clinical
decision support tools, or e-prescribing
programs.
(B) Methods for improving rates of collection
from estates of amounts owed under this title.
(C) Methods for reducing waste, fraud, and
abuse under the program under this title, such
as reducing improper payment rates as measured
by annual payment error rate measurement (PERM)
project rates.
(D) Implementation of a medication risk
management program as part of a drug use review
program under section 1927(g).
(E) Methods in reducing, in clinically
appropriate ways, expenditures under this title
for covered outpatient drugs, particularly in
the categories of greatest drug utilization, by
increasing the utilization of generic drugs
through the use of education programs and other
incentives to promote greater use of generic
drugs.
(F) Methods for improving access to primary
and specialty physician care for the uninsured
using integrated university-based hospital and
clinic systems.
(3) Application; terms and conditions.--
(A) In general.--No payments shall be made to
a State under this subsection unless the State
applies to the Secretary for such payments in a
form, manner, and time specified by the
Secretary.
(B) Terms and conditions.--Such payments are
made under such terms and conditions consistent
with this subsection as the Secretary
prescribes.
(C) Annual report.--Payment to a State under
this subsection is conditioned on the State
submitting to the Secretary an annual report on
the programs supported by such payment. Such
report shall include information on--
(i) the specific uses of such
payment;
(ii) an assessment of quality
improvements and clinical outcomes
under such programs; and
(iii) estimates of cost savings
resulting from such programs.
(4) Funding.--
(A) Limitation on funds.--The total amount of
payments under this subsection shall be equal
to, and shall not exceed--
(i) $75,000,000 for fiscal year 2007;
and
(ii) $75,000,000 for fiscal year
2008.
This subsection constitutes budget authority in
advance of appropriations Acts and represents
the obligation of the Secretary to provide for
the payment of amounts provided under this
subsection.
(B) Allocation of funds.--The Secretary shall
specify a method for allocating the funds made
available under this subsection among States.
Such method shall provide preference for States
that design programs that target health
providers that treat significant numbers of
Medicaid beneficiaries. Such method shall
provide that not less than 25 percent of such
funds shall be allocated among States the
population of which (as determined according to
data collected by the United States Census
Bureau) as of July 1, 2004, was more than 105
percent of the population of the respective
State (as so determined) as of April 1, 2000.
(C) Form and manner of payment.--Payment to a
State under this subsection shall be made in
the same manner as other payments under section
1903(a). There is no requirement for State
matching funds to receive payments under this
subsection.
(5) Medication risk management program.--
(A) In general.--For purposes of this
subsection, the term ``medication risk
management program'' means a program for
targeted beneficiaries that ensures that
covered outpatient drugs are appropriately used
to optimize therapeutic outcomes through
improved medication use and to reduce the risk
of adverse events.
(B) Elements.--Such program may include the
following elements:
(i) The use of established principles
and standards for drug utilization
review and best practices to analyze
prescription drug claims of targeted
beneficiaries and identify outlier
physicians.
(ii) On an ongoing basis provide
outlier physicians--
(I) a comprehensive pharmacy
claims history for each
targeted beneficiary under
their care;
(II) information regarding
the frequency and cost of
relapses and hospitalizations
of targeted beneficiaries under
the physician's care; and
(III) applicable best
practice guidelines and
empirical references.
(iii) Monitor outlier physician's
prescribing, such as failure to refill,
dosage strengths, and provide
incentives and information to encourage
the adoption of best clinical
practices.
(C) Targeted beneficiaries.--For purposes of
this paragraph, the term ``targeted
beneficiaries'' means Medicaid eligible
beneficiaries who are identified as having high
prescription drug costs and medical costs, such
as individuals with behavioral disorders or
multiple chronic diseases who are taking
multiple medications.
(aa) Demonstration Project To Increase Substance Use Provider
Capacity.--
(1) In general.--Not later than the date that is 180
days after the date of the enactment of this
subsection, the Secretary shall, in consultation, as
appropriate, with the Director of the Agency for
Healthcare Research and Quality and the Assistant
Secretary for Mental Health and Substance Use, conduct
a 54-month demonstration project for the purpose
described in paragraph (2) under which the Secretary
shall--
(A) for the first 18-month period of such
project, award planning grants described in
paragraph (3); and
(B) for the remaining 36-month period of such
project, provide to each State selected under
paragraph (4) payments in accordance with
paragraph (5).
(2) Purpose.--The purpose described in this paragraph
is for each State selected under paragraph (4) to
increase the treatment capacity of providers
participating under the State plan (or a waiver of such
plan) to provide substance use disorder treatment or
recovery services under such plan (or waiver) through
the following activities:
(A) For the purpose described in paragraph
(3)(C)(i), activities that support an ongoing
assessment of the behavioral health treatment
needs of the State, taking into account the
matters described in subclauses (I) through
(IV) of such paragraph.
(B) Activities that, taking into account the
results of the assessment described in
subparagraph (A), support the recruitment,
training, and provision of technical assistance
for providers participating under the State
plan (or a waiver of such plan) that offer
substance use disorder treatment or recovery
services.
(C) Improved reimbursement for and expansion
of, through the provision of education,
training, and technical assistance, the number
or treatment capacity of providers
participating under the State plan (or waiver)
that--
(i) are authorized to dispense drugs
approved by the Food and Drug
Administration for individuals with a
substance use disorder who need
withdrawal management or maintenance
treatment for such disorder;
(ii) have in effect a registration or
waiver under section 303(g) of the
Controlled Substances Act for purposes
of dispensing narcotic drugs to
individuals for maintenance treatment
or detoxification treatment and are in
compliance with any regulation
promulgated by the Assistant Secretary
for Mental Health and Substance Use for
purposes of carrying out the
requirements of such section 303(g);
and
(iii) are qualified under applicable
State law to provide substance use
disorder treatment or recovery
services.
(D) Improved reimbursement for and expansion
of, through the provision of education,
training, and technical assistance, the number
or treatment capacity of providers
participating under the State plan (or waiver)
that have the qualifications to address the
treatment or recovery needs of--
(i) individuals enrolled under the
State plan (or a waiver of such plan)
who have neonatal abstinence syndrome,
in accordance with guidelines issued by
the American Academy of Pediatrics and
American College of Obstetricians and
Gynecologists relating to maternal care
and infant care with respect to
neonatal abstinence syndrome;
(ii) pregnant women, postpartum
women, and infants, particularly the
concurrent treatment, as appropriate,
and comprehensive case management of
pregnant women, post-partum women and
infants, enrolled under the State plan
(or a waiver of such plan);
(iii) adolescents and young adults
between the ages of 12 and 21 enrolled
under the State plan (or a waiver of
such plan); or
(iv) American Indian and Alaska
Native individuals enrolled under the
State plan (or a waiver of such plan).
(3) Planning grants.--
(A) In general.--The Secretary shall, with
respect to the first 18-month period of the
demonstration project conducted under paragraph
(1), award planning grants to at least 10
States selected in accordance with subparagraph
(B) for purposes of preparing an application
described in paragraph (4)(C) and carrying out
the activities described in subparagraph (C).
(B) Selection.--In selecting States for
purposes of this paragraph, the Secretary
shall--
(i) select States that have a State
plan (or waiver of the State plan)
approved under this title;
(ii) select States in a manner that
ensures geographic diversity; and
(iii) give preference to States with
a prevalence of substance use disorders
(in particular opioid use disorders)
that is comparable to or higher than
the national average prevalence, as
measured by aggregate per capita drug
overdoses, or any other measure that
the Secretary deems appropriate.
(C) Activities described.--Activities
described in this subparagraph are, with
respect to a State, each of the following:
(i) Activities that support the
development of an initial assessment of
the behavioral health treatment needs
of the State to determine the extent to
which providers are needed (including
the types of such providers and
geographic area of need) to improve the
network of providers that treat
substance use disorders under the State
plan (or waiver), including the
following:
(I) An estimate of the number
of individuals enrolled under
the State plan (or a waiver of
such plan) who have a substance
use disorder.
(II) Information on the
capacity of providers to
provide substance use disorder
treatment or recovery services
to individuals enrolled under
the State plan (or waiver),
including information on
providers who provide such
services and their
participation under the State
plan (or waiver).
(III) Information on the gap
in substance use disorder
treatment or recovery services
under the State plan (or
waiver) based on the
information described in
subclauses (I) and (II).
(IV) Projections regarding
the extent to which the State
participating under the
demonstration project would
increase the number of
providers offering substance
use disorder treatment or
recovery services under the
State plan (or waiver) during
the period of the demonstration
project.
(ii) Activities that, taking into
account the results of the assessment
described in clause (i), support the
development of State infrastructure to,
with respect to the provision of
substance use disorder treatment or
recovery services under the State plan
(or a waiver of such plan), recruit
prospective providers and provide
training and technical assistance to
such providers.
(D) Funding.--For purposes of subparagraph
(A), there is appropriated, out of any funds in
the Treasury not otherwise appropriated,
$50,000,000, to remain available until
expended.
(4) Post-planning states.--
(A) In general.--The Secretary shall, with
respect to the remaining 36-month period of the
demonstration project conducted under paragraph
(1), select not more than 5 States in
accordance with subparagraph (B) for purposes
of carrying out the activities described in
paragraph (2) and receiving payments in
accordance with paragraph (5).
(B) Selection.--In selecting States for
purposes of this paragraph, the Secretary
shall--
(i) select States that received a
planning grant under paragraph (3);
(ii) select States that submit to the
Secretary an application in accordance
with the requirements in subparagraph
(C), taking into consideration the
quality of each such application;
(iii) select States in a manner that
ensures geographic diversity; and
(iv) give preference to States with a
prevalence of substance use disorders
(in particular opioid use disorders)
that is comparable to or higher than
the national average prevalence, as
measured by aggregate per capita drug
overdoses, or any other measure that
the Secretary deems appropriate.
(C) Applications.--
(i) In general.--A State seeking to
be selected for purposes of this
paragraph shall submit to the
Secretary, at such time and in such
form and manner as the Secretary
requires, an application that includes
such information, provisions, and
assurances, as the Secretary may
require, in addition to the following:
(I) A proposed process for
carrying out the ongoing
assessment described in
paragraph (2)(A), taking into
account the results of the
initial assessment described in
paragraph (3)(C)(i).
(II) A review of
reimbursement methodologies and
other policies related to
substance use disorder
treatment or recovery services
under the State plan (or
waiver) that may create
barriers to increasing the
number of providers delivering
such services.
(III) The development of a
plan, taking into account
activities carried out under
paragraph (3)(C)(ii), that will
result in long-term and
sustainable provider networks
under the State plan (or
waiver) that will offer a
continuum of care for substance
use disorders. Such plan shall
include the following:
(aa) Specific
activities to increase
the number of providers
(including providers
that specialize in
providing substance use
disorder treatment or
recovery services,
hospitals, health care
systems, Federally
qualified health
centers, and, as
applicable, certified
community behavioral
health clinics) that
offer substance use
disorder treatment,
recovery, or support
services, including
short-term
detoxification
services, outpatient
substance use disorder
services, and evidence-
based peer recovery
services.
(bb) Strategies that
will incentivize
providers described in
subparagraphs (C) and
(D) of paragraph (2) to
obtain the necessary
training, education,
and support to deliver
substance use disorder
treatment or recovery
services in the State.
(cc) Milestones and
timeliness for
implementing activities
set forth in the plan.
(dd) Specific
measurable targets for
increasing the
substance use disorder
treatment and recovery
provider network under
the State plan (or a
waiver of such plan).
(IV) A proposed process for
reporting the information
required under paragraph
(6)(A), including information
to assess the effectiveness of
the efforts of the State to
expand the capacity of
providers to deliver substance
use disorder treatment or
recovery services during the
period of the demonstration
project under this subsection.
(V) The expected financial
impact of the demonstration
project under this subsection
on the State.
(VI) A description of all
funding sources available to
the State to provide substance
use disorder treatment or
recovery services in the State.
(VII) A preliminary plan for
how the State will sustain any
increase in the capacity of
providers to deliver substance
use disorder treatment or
recovery services resulting
from the demonstration project
under this subsection after the
termination of such
demonstration project.
(VIII) A description of how
the State will coordinate the
goals of the demonstration
project with any waiver granted
(or submitted by the State and
pending) pursuant to section
1115 for the delivery of
substance use services under
the State plan, as applicable.
(ii) Consultation.--In completing an
application under clause (i), a State
shall consult with relevant
stakeholders, including Medicaid
managed care plans, health care
providers, and Medicaid beneficiary
advocates, and include in such
application a description of such
consultation.
(5) Payment.--
(A) In general.--For each quarter occurring
during the period for which the demonstration
project is conducted (after the first 18 months
of such period), the Secretary shall pay under
this subsection, subject to subparagraph (C),
to each State selected under paragraph (4) an
amount equal to 80 percent of so much of the
qualified sums expended during such quarter.
(B) Qualified sums defined.--For purposes of
subparagraph (A), the term ``qualified sums''
means, with respect to a State and a quarter,
the amount equal to the amount (if any) by
which the sums expended by the State during
such quarter attributable to substance use
disorder treatment or recovery services
furnished by providers participating under the
State plan (or a waiver of such plan) exceeds
1/4 of such sums expended by the State during
fiscal year 2018 attributable to substance use
disorder treatment or recovery services.
(C) Non-duplication of payment.--In the case
that payment is made under subparagraph (A)
with respect to expenditures for substance use
disorder treatment or recovery services
furnished by providers participating under the
State plan (or a waiver of such plan), payment
may not also be made under subsection (a) with
respect to expenditures for the same services
so furnished.
(6) Reports.--
(A) State reports.--A State receiving
payments under paragraph (5) shall, for the
period of the demonstration project under this
subsection, submit to the Secretary a quarterly
report, with respect to expenditures for
substance use disorder treatment or recovery
services for which payment is made to the State
under this subsection, on the following:
(i) The specific activities with
respect to which payment under this
subsection was provided.
(ii) The number of providers that
delivered substance use disorder
treatment or recovery services in the
State under the demonstration project
compared to the estimated number of
providers that would have otherwise
delivered such services in the absence
of such demonstration project.
(iii) The number of individuals
enrolled under the State plan (or a
waiver of such plan) who received
substance use disorder treatment or
recovery services under the
demonstration project compared to the
estimated number of such individuals
who would have otherwise received such
services in the absence of such
demonstration project.
(iv) Other matters as determined by
the Secretary.
(B) CMS reports.--
(i) Initial report.--Not later than
October 1, 2020, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress
an initial report on--
(I) the States awarded
planning grants under paragraph
(3);
(II) the criteria used in
such selection; and
(III) the activities carried
out by such States under such
planning grants.
(ii) Interim report.--Not later than
October 1, 2022, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress
an interim report--
(I) on activities carried out
under the demonstration project
under this subsection;
(II) on the extent to which
States selected under paragraph
(4) have achieved the stated
goals submitted in their
applications under subparagraph
(C) of such paragraph;
(III) with a description of
the strengths and limitations
of such demonstration project;
and
(IV) with a plan for the
sustainability of such project.
(iii) Final report.--Not later than
October 1, 2024, the Administrator of
the Centers for Medicare & Medicaid
Services shall, in consultation with
the Director of the Agency for
Healthcare Research and Quality and the
Assistant Secretary for Mental Health
and Substance Use, submit to Congress a
final report--
(I) providing updates on the
matters reported in the interim
report under clause (ii);
(II) including a description
of any changes made with
respect to the demonstration
project under this subsection
after the submission of such
interim report; and
(III) evaluating such
demonstration project.
(C) AHRQ report.--Not later than 3 years
after the date of the enactment of this
subsection, the Director of the Agency for
Healthcare Research and Quality, in
consultation with the Administrator of the
Centers for Medicare & Medicaid Services, shall
submit to Congress a summary on the experiences
of States awarded planning grants under
paragraph (3) and States selected under
paragraph (4).
(7) Data sharing and best practices.--During the
period of the demonstration project under this
subsection, the Secretary shall, in collaboration with
States selected under paragraph (4), facilitate data
sharing and the development of best practices between
such States and States that were not so selected.
(8) CMS funding.--There is appropriated, out of any
funds in the Treasury not otherwise appropriated,
$5,000,000 to the Centers for Medicare & Medicaid
Services for purposes of implementing this subsection.
Such amount shall remain available until expended.
* * * * * * *
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 (except in the case of servicesprovided
under a State plan amendment described in
section1915(l)).
For purposes of clause (vi) of the preceding sentence, a person
shall be considered essential to another individual if such
person is the spouse of and is living with such individual, the
needs of such 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, or, at
the option of the State, 1-year 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)] (ff),
and (gg) 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).
(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.
(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.
(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.
(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
(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 December 20, 2019.
(gg) Specified Coverage Extension States.--
(1) In general.--Notwithstanding subsection (b),
beginning January 1, 2020, in the case of a specified
coverage extension State, for the initial extension
calendar quarters with respect to such State, the
Federal medical assistance percentage that would
otherwise apply to the State without application of
this subsection, shall be increased by 5 percentage
points.
(2) Specified coverage extension state.--For purposes
of this subsection, the term ``specified coverage
extension State'' means a State, the State plan of
which has in effect the application of the 1-year
period of continuous medical assistance pursuant to
each of paragraphs (5) and (6) of section 1902(e).
(3) Initial extension calendar quarter.--For purposes
of this subsection, the term ``initial extension
calendar quarter'' means, with respect to a State, each
calendar quarter occurring in the first fiscal year
that the State is a specified coverage extension State.
* * * * * * *
TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
* * * * * * *
SEC. 2112. OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN
THROUGH A STATE PLAN AMENDMENT.
(a) In General.--Subject to the succeeding provisions of this
section, a State may elect through an amendment to its State
child health plan under section 2102 to provide pregnancy-
related assistance under such plan for targeted low-income
pregnant women.
(b) Conditions.--A State may only elect the option under
subsection (a) if the following conditions are satisfied:
(1) Minimum income eligibility levels for pregnant
women and children.--The State has established an
income eligibility level--
(A) for pregnant women under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or
(l)(1)(A) of section 1902 that is at least 185
percent (or such higher percent as the State
has in effect with regard to pregnant women
under this title) of the poverty line
applicable to a family of the size involved,
but in no case lower than the percent in effect
under any such subsection as of July 1, 2008;
and
(B) for children under 19 years of age under
this title (or title XIX) that is at least 200
percent of the poverty line applicable to a
family of the size involved.
(2) No chip income eligibility level for pregnant
women lower than the state's medicaid level.--The State
does not apply an effective income level for pregnant
women under the State plan amendment that is lower than
the effective income level (expressed as a percent of
the poverty line and considering applicable income
disregards) specified under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of
section 1902, on the date of enactment of this
paragraph to be eligible for medical assistance as a
pregnant woman.
(3) No coverage for higher income pregnant women
without covering lower income pregnant women.--The
State does not provide coverage for pregnant women with
higher family income without covering pregnant women
with a lower family income.
(4) Application of requirements for coverage of
targeted low-income children.--The State provides
pregnancy-related assistance for targeted low-income
pregnant women in the same manner, and subject to the
same requirements, as the State provides child health
assistance for targeted low-income children under the
State child health plan, and in addition to providing
child health assistance for such women.
(5) No preexisting condition exclusion or waiting
period.--The State does not apply any exclusion of
benefits for pregnancy-related assistance based on any
preexisting condition or any waiting period (including
any waiting period imposed to carry out section
2102(b)(3)(C)) for receipt of such assistance.
(6) Application of cost-sharing protection.--The
State provides pregnancy-related assistance to a
targeted low-income woman consistent with the cost-
sharing protections under section 2103(e) and applies
the limitation on total annual aggregate cost sharing
imposed under paragraph (3)(B) of such section to the
family of such a woman.
(7) No waiting list for children.--The State does not
impose, with respect to the enrollment under the State
child health plan of targeted low-income children
during the quarter, any enrollment cap or other
numerical limitation on enrollment, any waiting list,
any procedures designed to delay the consideration of
applications for enrollment, or similar limitation with
respect to enrollment.
(c) Option To Provide Presumptive Eligibility.--A State that
elects the option under subsection (a) and satisfies the
conditions described in subsection (b) may elect to apply
section 1920 (relating to presumptive eligibility for pregnant
women) to the State child health plan in the same manner as
such section applies to the State plan under title XIX.
(d) Definitions.--For purposes of this section:
(1) Pregnancy-related assistance.--The term
``pregnancy-related assistance'' has the meaning given
the term ``child health assistance'' in section 2110(a)
with respect to an individual during the period
described in paragraph (2)(A).
(2) Targeted low-income pregnant woman.--The term
``targeted low-income pregnant woman'' means an
individual--
(A) during pregnancy and through the end of
the month in which the 60-day period, or, at
the option of the State, 1-year period
(beginning on the last day of her pregnancy)
ends;
(B) whose family income exceeds 185 percent
(or, if higher, the percent applied under
subsection (b)(1)(A)) of the poverty line
applicable to a family of the size involved,
but does not exceed the income eligibility
level established under the State child health
plan under this title for a targeted low-income
child; and
(C) who satisfies the requirements of
paragraphs (1)(A), (1)(C), (2), and (3) of
section 2110(b) in the same manner as a child
applying for child health assistance would have
to satisfy such requirements.
(e) Automatic Enrollment for Children Born to Women Receiving
Pregnancy-Related Assistance.--If a child is born to a targeted
low-income pregnant woman who was receiving pregnancy-related
assistance under this section on the date of the child's birth,
the child shall be deemed to have applied for child health
assistance under the State child health plan and to have been
found eligible for such assistance under such plan or to have
applied for medical assistance under title XIX and to have been
found eligible for such assistance under such title, as
appropriate, on the date of such birth and to remain eligible
for such assistance until the child attains 1 year of age.
During the period in which a child is deemed under the
preceding sentence to be eligible for child health or medical
assistance, the child health or 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).
(f) States Providing Assistance Through Other Options.--
(1) Continuation of other options for providing
assistance.--The option to provide assistance in
accordance with the preceding subsections of this
section shall not limit any other option for a State to
provide--
(A) child health assistance through the
application of sections 457.10, 457.350(b)(2),
457.622(c)(5), and 457.626(a)(3) of title 42,
Code of Federal Regulations (as in effect after
the final rule adopted by the Secretary and set
forth at 67 Fed. Reg. 61956-61974 (October 2,
2002)), or
(B) pregnancy-related services through the
application of any waiver authority (as in
effect on June 1, 2008).
(2) Clarification of authority to provide postpartum
services.--Any State that provides child health
assistance under any authority described in paragraph
(1) may continue to provide such assistance, as well as
postpartum services, through the end of the month in
which the 60-day period, or, at the option of the
State, 1-year period (beginning on the last day of the
pregnancy) ends, in the same manner as such assistance
and postpartum services would be provided if provided
under the State plan under title XIX, but only if the
mother would otherwise satisfy the eligibility
requirements that apply under the State child health
plan (other than with respect to age) during such
period.
(3) No inference.--Nothing in this subsection shall
be construed--
(A) to infer congressional intent regarding
the legality or illegality of the content of
the sections specified in paragraph (1)(A); or
(B) to modify the authority to provide
pregnancy-related services under a waiver
specified in paragraph (1)(B).
* * * * * * *