42 U.S.C. § 1396a : US Code - Section 1396A: State plans for medical assistance

Search 42 U.S.C. § 1396a : US Code - Section 1396A: State plans for medical assistance

(a) Contents
A State plan for medical assistance must - 
(1) provide that it shall be in effect in all political
subdivisions of the State, and, if administered by them, be
mandatory upon them;
(2) provide for financial participation by the State equal to
not less than 40 per centum of the non-Federal share of the
expenditures under the plan with respect to which payments under
section 1396b of this title are authorized by this subchapter;
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, 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 423 of title 41 to persons
described in subsection (a)(2) of section 423 of title 41;
(5) either provide for the establishment or designation of a
single State agency to administer or to supervise the
administration of the plan; or provide for the establishment or
designation of a single State agency to administer or to
supervise the administration of the plan, except that the
determination of eligibility for medical assistance under the
plan shall be made by the State or local agency administering the
State plan approved under subchapter I or XVI of this chapter
(insofar as it relates to the aged) if the State is eligible to
participate in the State plan program established under
subchapter XVI of this chapter, or by the agency or agencies
administering the supplemental security income program
established under subchapter XVI or the State plan approved under
part A of subchapter IV of this chapter if the State is not
eligible to participate in the State plan program established
under subchapter XVI of this chapter;
(6) provide that the State agency will make such reports, in
such form and containing such information, as the Secretary may
from time to time require, and comply with such provisions as the
Secretary may from time to time find necessary to assure the
correctness and verification of such reports;
(7) provide safeguards which restrict the use or disclosure of
information concerning applicants and recipients to purposes
directly connected with - 
(A) the administration of the plan; and
(B) at State option, the exchange of information necessary to
verify the certification of eligibility of children for free or
reduced price breakfasts under the Child Nutrition Act of 1966
[42 U.S.C. 1771 et seq.] and free or reduced price lunches
under the Richard B. Russell National School Lunch Act [42
U.S.C. 1751 et seq.], in accordance with section 9(b) of that
Act [42 U.S.C. 1758(b)], using data standards and formats
established by the State agency;
(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 1395aa(a) of
this title), 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, and
(C) that any laboratory services paid for under such plan
must be provided by a laboratory which meets the applicable
requirements of section 1395x(e)(9) of this title or paragraphs
(16) and (17) of section 1395x(s) of this title, or, in the
case of a laboratory which is in a rural health clinic, of
section 1395x(aa)(2)(G) of this title;
(10) provide - 
(A) for making medical assistance available, including at
least the care and services listed in paragraphs (1) through
(5), (17) and (21) of section 1396d(a) of this title, to - 
(i) all individuals - 
(I) who are receiving aid or assistance under any plan of
the State approved under subchapter I, X, XIV, or XVI of
this chapter, or part A or part E of subchapter IV of this
chapter (including individuals eligible under this
subchapter by reason of section 602(a)(37),(!1) 606(h),(!1)
or 673(b) of this title, or considered by the State to be
receiving such aid as authorized under section
682(e)(6)(!1) of this title),
(II) with respect to whom supplemental security income
benefits are being paid under subchapter XVI of this
chapter (or were being paid as of the date of the enactment
of section 211(a) of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (P.L. 104-193)) and
would continue to be paid but for the enactment of that
section or who are qualified severely impaired individuals
(as defined in section 1396d(q) of this title),
(III) who are qualified pregnant women or children as
defined in section 1396d(n) of this title,
(IV) who are described in subparagraph (A) or (B) of
subsection (l)(1) of this section and whose family income
does not exceed the minimum income level the State is
required to establish under subsection (l)(2)(A) of this
section for such a family; (!2)
(V) who are qualified family members as defined in
section 1396d(m)(1) of this title,
(VI) who are described in subparagraph (C) of subsection
(l)(1) of this section and whose family income does not
exceed the income level the State is required to establish
under subsection (l)(2)(B) of this section for such a
family, or
(VII) who are described in subparagraph (D) of subsection
(l)(1) of this section and whose family income does not
exceed the income level the State is required to establish
under subsection (l)(2)(C) of this section for such a
family; (!3)
(ii) at the option of the State, to (!4) any group or
groups of individuals described in section 1396d(a) of this
title (or, in the case of individuals described in section
1396d(a)(i) of this title, to (!4) 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
subchapter XVI of this chapter, or a State supplementary
payment; (!2)
(V) who are in a medical institution for a period of not
less than 30 consecutive days (with eligibility by reason
of this subclause beginning on the first day of such
period), who meet the resource requirements of the
appropriate State plan described in clause (i) or the
supplemental security income program, and whose income does
not exceed a separate income standard established by the
State which is consistent with the limit established under
section 1396b(f)(4)(C) of this title,
(VI) who would be eligible under the State plan under
this subchapter if they were in a medical institution, with
respect to whom there has been a determination that but for
the provision of home or community-based services described
in subsection (c), (d), or (e) of section 1396n of this
title 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
1396n of this title,
(VII) who would be eligible under the State plan under
this subchapter if they were in a medical institution, who
are terminally ill, and who will receive hospice care
pursuant to a voluntary election described in section
1396d(o) of this title; (!5)
(VIII) who is a child described in section 1396d(a)(i) of
this title - 
(aa) for whom there is in effect an adoption assistance
agreement (other than an agreement under part E of
subchapter IV of this chapter) between the State and an
adoptive parent or parents,
(bb) who the State agency responsible for adoption
assistance has determined cannot be placed with adoptive
parents without medical assistance because such child has
special needs for medical or rehabilitative care, and
(cc) who was eligible for medical assistance under the
State plan prior to the adoption assistance agreement
being entered into, or who would have been eligible for
medical assistance at such time if the eligibility
standards and methodologies of the State's foster care
program under part E of subchapter IV of this chapter
were applied rather than the eligibility standards and
methodologies of the State's aid to families with
dependent children program under part A of subchapter IV
of this chapter; (!5)
(IX) who are described in subsection (l)(1) of this
section and are not described in clause (i)(IV), clause
(i)(VI), or clause (i)(VII); (!5)
(X) who are described in subsection (m)(1) of this
section; (!5)
(XI) who receive only an optional State supplementary
payment based on need and paid on a regular basis, equal to
the difference between the individual's countable income
and the income standard used to determine eligibility for
such supplementary payment (with countable income being the
income remaining after deductions as established by the
State pursuant to standards that may be more restrictive
than the standards for supplementary security income
benefits under subchapter XVI of this chapter), which are
available to all individuals in the State (but which may be
based on different income standards by political
subdivision according to cost of living differences), and
which are paid by a State that does not have an agreement
with the Commissioner of Social Security under section
1382e or 1383c of this title; (!5)
(XII) who are described in subsection (z)(1) of this
section (relating to certain TB-infected individuals); (!5)
(XIII) who are in families whose income is less than 250
percent of the income official poverty line (as defined by
the Office of Management and Budget, and revised annually
in accordance with section 9902(2) of this title)
applicable to a family of the size involved, and who but
for earnings in excess of the limit established under
section 1396d(q)(2)(B) of this title, would be considered
to be receiving supplemental security income (subject,
notwithstanding section 1396o of this title, to payment of
premiums or other cost-sharing charges (set on a sliding
scale based on income) that the State may determine); (!5)
(XIV) who are optional targeted low-income children
described in section 1396d(u)(2)(B) of this title; (!5)
(XV) who, but for earnings in excess of the limit
established under section 1396d(q)(2)(B) of this title,
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; (!5)
(XVI) who are employed individuals with a medically
improved disability described in section 1396d(v)(1) of
this title 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); (!5)
(XVII) who are independent foster care adolescents (as
defined in section 1396d(w)(1) of this title), or who are
within any reasonable categories of such adolescents
specified by the State; or
(XVIII) who are described in subsection (aa) of this
section (relating to certain breast or cervical cancer
patients);
(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 1396d(a) of this title 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 1396d(a) of this title 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 1396d(p)(3) of this title)
for qualified medicare beneficiaries described in section
1396d(p)(1) of this title;
(ii) for making medical assistance available for payment of
medicare cost-sharing described in section 1396d(p)(3)(A)(i) of
this title for qualified disabled and working individuals
described in section 1396d(s) of this title;
(iii) for making medical assistance available for medicare
cost sharing described in section 1396d(p)(3)(A)(ii) of this
title subject to section 1396d(p)(4) of this title, for
individuals who would be qualified medicare beneficiaries
described in section 1396d(p)(1) of this title but for the fact
that their income exceeds the income level established by the
State under section 1396d(p)(2) of this title 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 1396u-3 and 1396d(p)(4) of this
title, for making medical assistance available (but only for
premiums payable with respect to months during the period
beginning with January 1998, and ending with September 2007)
for medicare cost-sharing described in section
1396d(p)(3)(A)(ii) of this title for individuals who would be
qualified medicare beneficiaries described in section
1396d(p)(1) of this title but for the fact that their income
exceeds the income level established by the State under section
1396d(p)(2) of this title 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)
of this section) for qualified COBRA continuation beneficiaries
described in subsection (u)(1) of this section; and
(G) that, in applying eligibility criteria of the
supplemental security income program under subchapter XVI of
this chapter for purposes of determining eligibility for
medical assistance under the State plan of an individual who is
not receiving supplemental security income, the State will
disregard the provisions of subsections (c) and (e) of section
1382b of this title;
except that (I) the making available of the services described in
paragraph (4), (14), or (16) of section 1396d(a) of this title 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 subchapter XVIII of
this chapter to individuals eligible therefor (either pursuant to
an agreement entered into under section 1395v of this title or by
reason of the payment of premiums under such subchapter 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 subchapter XVIII of this chapter
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
1396o(a)(2) or (b)(2) of this title 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 1396d(o) of
this title 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 subchapter XVIII of this chapter, 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) of
this section 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 1396d(p)(1) of this title 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 1396d(p)(3) of this
title), subject to the provisions of subsection (n) of this
section and section 1396o(b) of this title, (IX) the making
available of respiratory care services in accordance with
subsection (e)(9) of this section 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) of this section, 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 1396r-4(a)(1)(A) of this title, 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
1396e of this title 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) of this section 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) of this section), (XIII) the medical assistance
made available to an individual described in subsection (z)(1) of
this section 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) of this section), and (XIV) the medical assistance made
available to an individual described in subsection (aa) of this
section 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;
(11)(A) provide for entering into cooperative arrangements with
the State agencies responsible for administering or supervising
the administration of health services and vocational
rehabilitation services in the State looking toward maximum
utilization of such services in the provision of medical
assistance under the plan, (B) provide, to the extent prescribed
by the Secretary, for entering into agreements, with any agency,
institution, or organization receiving payments under (or through
an allotment under) subchapter V of this chapter, (i) providing
for utilizing such agency, institution, or organization in
furnishing care and services which are available under such
subchapter or allotment and which are included in the State plan
approved under this section (!6) (ii) making such provision as
may be appropriate for reimbursing such agency, institution, or
organization for the cost of any such care and services furnished
any individual for which payment would otherwise be made to the
State with respect to the individual under section 1396b of this
title, 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 subchapter, 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 [42
U.S.C. 1786];
(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 1396r-4 of this title)
the situation of hospitals which serve a disproportionate
number of low-income patients with special needs; and
(B) for payment for hospice care in amounts no lower than the
amounts, using the same methodology, used under part A of
subchapter XVIII of this chapter and for payment of amounts
under section 1396d(o)(3) of this title; 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;
(14) provide that enrollment fees, premiums, or similar
charges, and deductions, cost sharing, or similar charges, may be
imposed only as provided in section 1396o of this title;
(15) provide for payment for services described in clause (B)
or (C) of section 1396d(a)(2) of this title under the plan in
accordance with subsection (bb) of this section;
(16) provide for inclusion, to the extent required by
regulations prescribed by the Secretary, of provisions
(conforming to such regulations) with respect to the furnishing
of medical assistance under the plan to individuals who are
residents of the State but are absent therefrom;
(17) except as provided in subsections (l)(3), (m)(3), and
(m)(4) of this section, include reasonable standards (which shall
be comparable for all groups and may, in accordance with
standards prescribed by the Secretary, differ with respect to
income levels, but only in the case of applicants or recipients
of assistance under the plan who are not receiving aid or
assistance under any plan of the State approved under subchapter
I, X, XIV, or XVI, or part A of subchapter IV of this chapter,
and with respect to whom supplemental security income benefits
are not being paid under subchapter XVI of this chapter, based on
the variations between shelter costs in urban areas and in rural
areas) for determining eligibility for and the extent of medical
assistance under the plan which (A) are consistent with the
objectives of this subchapter, (B) provide for taking into
account only such income and resources as are, as determined in
accordance with standards prescribed by the Secretary, available
to the applicant or recipient and (in the case of any applicant
or recipient who would, except for income and resources, be
eligible for aid or assistance in the form of money payments
under any plan of the State approved under subchapter I, X, XIV,
or XVI, or part A of subchapter IV, or to have paid with respect
to him supplemental security income benefits under subchapter XVI
of this chapter) as would not be disregarded (or set aside for
future needs) in determining his eligibility for such aid,
assistance, or benefits, (C) provide for reasonable evaluation of
any such income or resources, and (D) do not take into account
the financial responsibility of any individual for any applicant
or recipient of assistance under the plan unless such applicant
or recipient is such individual's spouse or such individual's
child who is under age 21 or (with respect to States eligible to
participate in the State program established under subchapter XVI
of this chapter), is blind or permanently and totally disabled,
or is blind or disabled as defined in section 1382c of this title
(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 1396b(f)(2)(B) of this title, 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 1396p of this title
with respect to liens, adjustments and recoveries of medical
assistance correctly paid,,(!7) 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 303(a)(4)(A)(i) and (ii) (!8) or section
1383(a)(4)(A)(i) and (ii) (!8) of this title which are
appropriate for such recipients and for such patients; and for
methods of administration necessary to assure that the
responsibilities of the State agency under the State plan with
respect to such recipients and such patients will be
effectively carried out;
(21) if the State plan includes medical assistance in behalf of
individuals 65 years of age or older who are patients in public
institutions for mental diseases, show that the State is making
satisfactory progress toward developing and implementing a
comprehensive mental health program, including provision for
utilization of community mental health centers, nursing
facilities, and other alternatives to care in public institutions
for mental diseases;
(22) include descriptions of (A) the kinds and numbers of
professional medical personnel and supporting staff that will be
used in the administration of the plan and of the
responsibilities they will have, (B) the standards, for private
or public institutions in which recipients of medical assistance
under the plan may receive care or services, that will be
utilized by the State authority or authorities responsible for
establishing and maintaining such standards, (C) the cooperative
arrangements with State health agencies and State vocational
rehabilitation agencies entered into with a view to maximum
utilization of and coordination of the provision of medical
assistance with the services administered or supervised by such
agencies, and (D) other standards and methods that the State will
use to assure that medical or remedial care and services provided
to recipients of medical assistance are of high quality;
(23) provide that (A) any individual eligible for medical
assistance (including drugs) may obtain such assistance from any
institution, agency, community pharmacy, or person, qualified to
perform the service or services required (including an
organization which provides such services, or arranges for their
availability, on a prepayment basis), who undertakes to provide
him such services, and (B) an enrollment of an individual
eligible for medical assistance in a primary care case-management
system (described in section 1396n(b)(1) of this title), 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 1396d(a)(4)(C) of
this title, except as provided in subsection (g) of this section,
in section 1396n of this title, and in section 1396u-2(a) of this
title, 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;
(24) effective July 1, 1969, provide for consultative services
by health agencies and other appropriate agencies of the State to
hospitals, nursing facilities, home health agencies, clinics,
laboratories, and such other institutions as the Secretary may
specify in order to assist them (A) to qualify for payments under
this chapter, (B) to establish and maintain such fiscal records
as may be necessary for the proper and efficient administration
of this chapter, and (C) to provide information needed to
determine payments due under this chapter on account of care and
services furnished to individuals;
(25) provide - 
(A) that the State or local agency administering such plan
will take all reasonable measures to ascertain the legal
liability of third parties (including health insurers, group
health plans (as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974 [29 U.S.C. 1167(1)]),
service benefit plans, and health maintenance organizations) 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 1396b(r) of this title;
(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 1396o of this title), or (ii) in an amount which
exceeds the lesser of (I) the amount which may be collected
under section 1396o of this title, or (II) the amount by which
the amount payable for that service under the plan
(disregarding section 1396o of this title) 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 prenatal or preventive pediatric care
(including early and periodic screening and diagnosis services
under section 1396d(a)(4)(B) of this title) covered under the
State plan, the State shall - 
(i) make payment for such service in accordance with the
usual payment schedule under such plan for such services
without regard to the liability of a third party for payment
for such services; and
(ii) seek reimbursement from such third party in accordance
with subparagraph (B);
(F) that in the case of any services covered under such plan
which are provided to an individual on whose behalf child
support enforcement is being carried out by the State agency
under part D of subchapter IV of this chapter, the State shall -

(i) make payment for such service in accordance with the
usual payment schedule under such plan for such services
without regard to any third-party liability for payment for
such services, if such third-party liability is derived
(through insurance or otherwise) from the parent whose
obligation to pay support is being enforced by such agency,
if payment has not been made by such third party within 30
days after such services are furnished; and
(ii) seek reimbursement from such third party in accordance
with subparagraph (B);
(G) that the State prohibits any health insurer (including a
group health plan, as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974 [29 U.S.C. 1167(1)], a
service benefit plan, and a health maintenance organization),
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 subchapter
for such State, or any other State; and
(H) that to the extent that payment has been made under the
State plan for medical assistance in any case where a third
party has a legal liability to make payment for such
assistance, the State has in effect laws under which, to the
extent that payment has been made under the State plan for
medical assistance for health care items or services furnished
to an individual, the State is considered to have acquired the
rights of such individual to payment by any other party for
such health care items or services;
(26) if the State plan includes medical assistance for
inpatient mental hospital services, provide, with respect to each
patient receiving such services, for a regular program of medical
review (including medical evaluation) of his need for such
services, and for a written plan of care;
(27) provide for agreements with every person or institution
providing services under the State plan under which such person
or institution agrees (A) to keep such records as are necessary
fully to disclose the extent of the services provided to
individuals receiving assistance under the State plan, and (B) to
furnish the State agency or the Secretary with such information,
regarding any payments claimed by such person or institution for
providing services under the State plan, as the State agency or
the Secretary may from time to time request;
(28) provide - 
(A) that any nursing facility receiving payments under such
plan must satisfy all the requirements of subsections (b)
through (d) of section 1396r of this title 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 1396r(f)(7) of this title 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 subchapter; and
(D) for compliance (by the date specified in the respective
sections) with the requirements of - 
(i) section 1396r(e) of this title;
(ii) section 1396r(g) of this title (relating to
responsibility for survey and certification of nursing
facilities); and
(iii) sections 1396r(h)(2)(B) and 1396r(h)(2)(D) of this
title (relating to establishment and application of
remedies);
(29) include a State program which meets the requirements set
forth in section 1396g of this title, 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 1396b(i)(4) of this title) 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 1396r(g) of this
title, the State or local agency utilized by the Secretary for
the purpose specified in the first sentence of section
1395aa(a) of this title, 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 subchapter 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
1320a-3(a)(2) of this title) receiving payments under such plan
complies with the requirements of section 1320a-3 of this title;
(36) provide that within 90 days following the completion of
each survey of any health care facility, laboratory, agency,
clinic, or organization, by the appropriate State agency
described in paragraph (9), such agency shall (in accordance with
regulations of the Secretary) make public in readily available
form and place the pertinent findings of each such survey
relating to the compliance of each such health care facility,
laboratory, clinic, agency, or organization with (A) the
statutory conditions of participation imposed under this
subchapter, and (B) the major additional conditions which the
Secretary finds necessary in the interest of health and safety of
individuals who are furnished care or services by any such
facility, laboratory, clinic, agency, or organization;
(37) provide for claims payment procedures which (A) ensure
that 90 per centum of claims for payment (for which no further
written information or substantiation is required in order to
make payment) made for services covered under the plan and
furnished by health care practitioners through individual or
group practices or through shared health facilities are paid
within 30 days of the date of receipt of such claims and that 99
per centum of such claims are paid within 90 days of the date of
receipt of such claims, and (B) provide for procedures of
prepayment and postpayment claims review, including review of
appropriate data with respect to the recipient and provider of a
service and the nature of the service for which payment is
claimed, to ensure the proper and efficient payment of claims and
management of the program;
(38) require that an entity (other than an individual
practitioner or a group of practitioners) that furnishes, or
arranges for the furnishing of, items or services under the plan,
shall supply (within such period as may be specified in
regulations by the Secretary or by the single State agency which
administers or supervises the administration of the plan) upon
request specifically addressed to such entity by the Secretary or
such State agency, the information described in section 1320a-
7(b)(9) of this title;
(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 1320a-7 of this
title or section 1320a-7a of this title, 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
1320a(a) of this title 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 that whenever a provider of services or any other
person is terminated, suspended, or otherwise sanctioned or
prohibited from participating under the State plan, the State
agency shall promptly notify the Secretary and, in the case of a
physician and notwithstanding paragraph (7), the State medical
licensing board of such action;
(42) provide that the records of any entity participating in
the plan and providing services reimbursable on a cost-related
basis will be audited as the Secretary determines to be necessary
to insure that proper payments are made under the plan;
(43) provide for - 
(A) informing all persons in the State who are under the age
of 21 and who have been determined to be eligible for medical
assistance including services described in section
1396d(a)(4)(B) of this title, of the availability of early and
periodic screening, diagnostic, and treatment services as
described in section 1396d(r) of this title 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
(iv) the State's results in attaining the participation
goals set for the State under section 1396d(r) of this title;
(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 1396b(g)(6)
of this title (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 1396k of this title;
(46) provide that information is requested and exchanged for
purposes of income and eligibility verification in accordance
with a State system which meets the requirements of section 1320b-
7 of this title;
(47) at the option of the State, provide for making ambulatory
prenatal care available to pregnant women during a presumptive
eligibility period in accordance with section 1396r-1 of this
title and provide for making medical assistance for items and
services described in subsection (a) of section 1396r-1a of this
title 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 1396r-1b of this title during a
presumptive eligibility period in accordance with such section;
(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 1396r-2 of this title;
(50) provide, in accordance with subsection (q) of this
section, for a monthly personal needs allowance for certain
institutionalized individuals and couples;
(51) meet the requirements of section 1396r-5 of this title
(relating to protection of community spouses);
(52) meet the requirements of section 1396r-6 of this title
(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
[42 U.S.C. 1786]), 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
1396r-8(k) of this title), comply with the applicable
requirements of section 1396r-8 of this title;
(55) provide for receipt and initial processing of applications
of individuals for medical assistance under subsection
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or
(a)(10)(A)(ii)(IX) of this section - 
(A) at locations which are other than those used for the
receipt and processing of applications for aid under part A of
subchapter IV of this chapter and which include facilities
defined as disproportionate share hospitals under section 1396r-
4(a)(1)(A) of this title and Federally-qualified health
centers described in section 1396d(1)(2)(B) (!9) of this title,
and
(B) using applications which are other than those used for
applications for aid under such part;
(56) provide, in accordance with subsection (s) of this
section, for adjusted payments for certain inpatient hospital
services;
(57) provide that each hospital, nursing facility, provider of
home health care or personal care services, hospice program, or
medicaid managed care organization (as defined in section
1396b(m)(1)(A) of this title) receiving funds under the plan
shall comply with the requirements of subsection (w) of this
section;
(58) provide that the State, acting through a State agency,
association, or other private nonprofit entity, develop a written
description of the law of the State (whether statutory or as
recognized by the courts of the State) concerning advance
directives that would be distributed by providers or
organizations under the requirements of subsection (w) of this
section;
(59) maintain a list (updated not less often than monthly, and
containing each physician's unique identifier provided under the
system established under subsection (x) of this section) of all
physicians who are certified to participate under the State plan;
(60) provide that the State agency shall provide assurances
satisfactory to the Secretary that the State has in effect the
laws relating to medical child support required under section
1396g-1 of this title;
(61) provide that the State must demonstrate that it operates a
medicaid fraud and abuse control unit described in section
1396b(q) of this title 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 1396s of
this title;
(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 1396u-1 of this title;
(64) provide, not later than 1 year after August 5, 1997, a
mechanism to receive reports from beneficiaries and others and
compile data concerning alleged instances of waste, fraud, and
abuse relating to the operation of this subchapter;
(65) provide that the State shall issue provider numbers for
all suppliers of medical assistance consisting of durable medical
equipment, as defined in section 1395x(n) of this title, 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 1320a-3(a)(3) of this title) 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 1320a-3(a)(2) of this title) 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 1395m(a)(16)(B) of this title 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 1396u-5(a) of this title; and
(67) provide, with respect to services covered under the State
plan (but not under subchapter XVIII of this chapter) 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).
Notwithstanding paragraph (5), if on January 1, 1965, and on the
date on which a State submits its plan for approval under this
subchapter, the State agency which administered or supervised the
administration of the plan of such State approved under subchapter
X of this chapter (or subchapter XVI of this chapter, insofar as it
relates to the blind) was different from the State agency which
administered or supervised the administration of the State plan
approved under subchapter I of this chapter (or subchapter XVI of
this chapter, insofar as it relates to the aged), the State agency
which administered or supervised the administration of such plan
approved under subchapter X of this chapter (or subchapter XVI of
this chapter, insofar as it relates to the blind) may be designated
to administer or supervise the administration of the portion of the
State plan for medical assistance which relates to blind
individuals and a different State agency may be established or
designated to administer or supervise the administration of the
rest of the State plan for medical assistance; and in such case the
part of the plan which each such agency administers, or the
administration of which each such agency supervises, shall be
regarded as a separate plan for purposes of this subchapter (except
for purposes of paragraph (10)). The provisions of paragraphs
(9)(A), (31), and (33) and of section 1396b(i)(4) of this title
shall not apply to a religious nonmedical health care institution
(as defined in section 1395x(ss)(1) of this title).
For purposes of paragraph (10) any individual who, for the month
of August 1972, was eligible for or receiving aid or assistance
under a State plan approved under subchapter I, X, XIV, or XVI of
this chapter, or part A of subchapter IV of this chapter and who
for such month was entitled to monthly insurance benefits under
subchapter II of this chapter shall for purposes of this subchapter
only be deemed to be eligible for financial aid or assistance for
any month thereafter if such individual would have been eligible
for financial aid or assistance for such month had the increase in
monthly insurance benefits under subchapter II of this chapter
resulting from enactment of 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 subchapter, any child who meets the
requirements of paragraph (1) or (2) of section 673(b) of this
title shall be deemed to be a dependent child as defined in section
606 of this title and shall be deemed to be a recipient of aid to
families with dependent children under part A of subchapter IV of
this chapter 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 1396b(v) of this title.
(b) Approval by Secretary
The Secretary shall approve any plan which fulfills the
conditions specified in subsection (a) of this section, except that
he shall not approve any plan which imposes, as a condition of
eligibility for medical assistance under the plan - 
(1) an age requirement of more than 65 years; or
(2) any residence requirement which excludes any individual who
resides in the State, regardless of whether or not the residence
is maintained permanently or at a fixed address; or
(3) any citizenship requirement which excludes any citizen of
the United States.
(c) Lower payment levels or applying for benefits as condition of
applying for, or receiving, medical assistance
Notwithstanding subsection (b) of this section, the Secretary
shall not approve any State plan for medical assistance if the
State requires individuals described in subsection (l)(1) of this
section to apply for assistance under the State program funded
under part A of subchapter IV of this chapter as a condition of
applying for or receiving medical assistance under this subchapter.
(d) Performance of medical or utilization review functions
If a State contracts with an entity which meets the requirements
of section 1320c-1 of this title, as determined by the Secretary,
or a utilization and quality control peer review organization
having a contract with the Secretary under part B of subchapter XI
of this chapter for the performance of medical or utilization
review functions required under this subchapter 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
subchapter XI of this chapter and provides for such assurances of
satisfactory performance by such an entity or organization as the
Secretary may prescribe.
(e) Continued eligibility of families determined ineligible because
of income and resources or hours of work limitations of plan;
individuals enrolled with health maintenance organizations;
persons deemed recipients of supplemental security income or
State supplemental payments; entitlement for certain newborns;
postpartum eligibility for pregnant women
(1)(A) Notwithstanding any other provision of this subchapter,
effective January 1, 1974, subject to subparagraph (B) each State
plan approved under this subchapter must provide that each family
which was receiving aid pursuant to a plan of the State approved
under part A of subchapter IV of this chapter in at least 3 of the
6 months immediately preceding the month in which such family
became ineligible for such aid because of increased hours of, or
increased income from, employment, shall, while a member of such
family is employed, remain eligible for assistance under the plan
approved under this subchapter (as though the family was receiving
aid under the plan approved under part A of subchapter IV of this
chapter) for 4 calendar months beginning with the month in which
such family became ineligible for aid under the plan approved under
part A of subchapter IV of this chapter because of income and
resources or hours of work limitations contained in such plan.
(B) Subparagraph (A) shall not apply with respect to families
that cease to be eligible for aid under part A of subchapter IV of
this chapter during the period beginning on April 1, 1990, and
ending on September 30, 2003. During such period, for provisions
relating to extension of eligibility for medical assistance for
certain families who have received aid pursuant to a State plan
approved under part A of subchapter IV of this chapter and have
earned income, see section 1396r-6 of this title.
(2)(A) In the case of an individual who is enrolled with a
medicaid managed care organization (as defined in section
1396b(m)(1)(A) of this title), with a primary care case manager (as
defined in section 1396d(t) of this title), or with an eligible
organization with a contract under section 1395mm of this title and
who would (but for this paragraph) lose eligibility for benefits
under this subchapter before the end of the minimum enrollment
period (defined in subparagraph (B)), the State plan may provide,
notwithstanding any other provision of this subchapter, 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 1396d(a)(4)(C) of this title, 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 1382c(a) of this title;
(B) with respect to whom there has been a determination by the
State that - 
(i) the individual requires a level of care provided in a
hospital, nursing facility, or intermediate care facility for
the mentally retarded,
(ii) it is appropriate to provide such care for the
individual outside such an institution, and
(iii) the estimated amount which would be expended for
medical assistance for the individual for such care outside an
institution is not greater than the estimated amount which
would otherwise be expended for medical assistance for the
individual within an appropriate institution; and
(C) if the individual were in a medical institution, would be
eligible for medical assistance under the State plan under this
subchapter,
shall be deemed, for purposes of this subchapter only, to be an
individual with respect to whom a supplemental security income
payment, or State supplemental payment, respectively, is being paid
under subchapter XVI of this chapter.
(4) A child born to a woman eligible for and receiving medical
assistance under a State plan on the date of the child's birth
shall be deemed to have applied for medical assistance and to have
been found eligible for such assistance under such plan on the date
of such birth and to remain eligible for such assistance for a
period of one year so long as the child is a member of the woman's
household and the woman remains (or would remain if pregnant)
eligible for such assistance. During the period in which a child is
deemed under the preceding sentence to be eligible for medical
assistance, the medical assistance eligibility identification
number of the mother shall also serve as the identification number
of the child, and all claims shall be submitted and paid under such
number (unless the State issues a separate identification number
for the child before such period expires).
(5) A woman who, while pregnant, is eligible for, has applied
for, and has received medical assistance under the State plan,
shall continue to be eligible under the plan, as though she were
pregnant, for all pregnancy-related and postpartum medical
assistance under the plan, through the end of the month in which
the 60-day period (beginning on the last day of her pregnancy)
ends.
(6) In the case of a pregnant woman described in subsection
(a)(10) of this section who, because of a change in income of the
family of which she is a member, would not otherwise continue to be
described in such subsection, the woman shall be deemed to continue
to be an individual described in subsection (a)(10)(A)(i)(IV) of
this section and subsection (l)(1)(A) of this section without
regard to such change of income through the end of the month in
which the 60-day period (beginning on the last day of her
pregnancy) ends. The preceding sentence shall not apply in the case
of a woman who has been provided ambulatory prenatal care pursuant
to section 1396r-1 of this title during a presumptive eligibility
period and is then, in accordance with such section, determined to
be ineligible for medical assistance under the State plan.
(7) In the case of an infant or child described in subparagraph
(B), (C), or (D) of subsection (l)(1) of this section or paragraph
(2) of section 1396d(n) of this title - 
(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 1396d(p)(1) of this title), 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 1396b(a) of this title, 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 subchapter IV of this chapter
pursuant to section 602(a)(43) (!10) of this title shall not be
construed as denying (or permitting a State to deny) medical
assistance under this subchapter to such individual, child, or
woman who is eligible for assistance under this subchapter on a
basis other than the receipt of aid under such part.
(B) If an individual, child, or pregnant woman is receiving aid
under part A of subchapter IV of this chapter and such aid is
terminated pursuant to section 602(a)(43) (!10) of this title, the
State may not discontinue medical assistance under this subchapter
for the individual, child, or woman until the State has determined
that the individual, child, or woman is not eligible for assistance
under this subchapter on a basis other than the receipt of aid
under such part.
(11)(A) In the case of an individual who is enrolled with a group
health plan under section 1396e of this title and who would (but
for this paragraph) lose eligibility for benefits under this
subchapter before the end of the minimum enrollment period (defined
in subparagraph (B)), the State plan may provide, notwithstanding
any other provision of this subchapter, 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 subchapter under
subsection (a)(10)(A) of this section shall remain eligible for
those benefits until the earlier of - 
(A) the end of a period (not to exceed 12 months) following the
determination; or
(B) the time that the individual exceeds that age.
(f) Effective date of State plan as determinative of duty of State
to provide medical assistance to aged, blind, or disabled
individuals
Notwithstanding any other provision of this subchapter, except as
provided in subsection (e) of this section and section 1382h(b)(3)
of this title and section 1396r-5 of this title, except with
respect to qualified disabled and working individuals (described in
section 1396d(s) of this title), and except with respect to
qualified medicare beneficiaries, qualified severely impaired
individuals, and individuals described in subsection (m)(1) of this
subsection, no State not eligible to participate in the State plan
program established under subchapter XVI of this chapter shall be
required to provide medical assistance to any aged, blind, or
disabled individual (within the meaning of subchapter XVI of this
chapter) 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
subchapter 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 1396b(f) of this title (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 subchapter XVI of this chapter, 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) Reduction of aid or assistance to providers of services
attempting to collect from beneficiary in violation of third-
party provisions
In addition to any other sanction available to a State, a State
may provide for a reduction of any payment amount otherwise due
with respect to a person who furnishes services under the plan in
an amount equal to up to three times the amount of any payment
sought to be collected by that person in violation of subsection
(a)(25)(C) of this section.
(h) Payments for hospitals serving disproportionate number of low-
income patients and for home and community care
Nothing in this subchapter (including subsections (a)(13) and
(a)(30) of this section) shall be construed as authorizing the
Secretary to limit the amount of payment that may be made under a
plan under this subchapter for home and community care.
(i) Termination of certification for participation of and
suspension of State payments to intermediate care facilities for
the mentally retarded
(1) In addition to any other authority under State law, where a
State determines that a (!11) intermediate care facility for the
mentally retarded which is certified for participation under its
plan no longer substantially meets the requirements for such a
facility under this subchapter and further determines that the
facility's deficiencies - 
(A) immediately jeopardize the health and safety of its
patients, the State shall provide for the termination of the
facility's certification for participation under the plan and may
provide, or
(B) do not immediately jeopardize the health and safety of its
patients, the State may, in lieu of providing for terminating the
facility's certification for participation under the plan,
establish alternative remedies if the State demonstrates to the
Secretary's satisfaction that the alternative remedies are
effective in deterring noncompliance and correcting deficiencies,
and may provide
that no payment will be made under the State plan with respect to
any individual admitted to such facility after a date specified by
the State.
(2) The State shall not make such a decision with respect to a
facility until the facility has had a reasonable opportunity,
following the initial determination that it no longer substantially
meets the requirements for such a facility under this subchapter,
to correct its deficiencies, and, following this period, has been
given reasonable notice and opportunity for a hearing.
(3) The State's decision to deny payment may be made effective
only after such notice to the public and to the facility as may be
provided for by the State, and its effectiveness shall terminate
(A) when the State finds that the facility is in substantial
compliance (or is making good faith efforts to achieve substantial
compliance) with the requirements for such a facility under this
subchapter, or (B) in the case described in paragraph (1)(B), with
the end of the eleventh month following the month such decision is
made effective, whichever occurs first. If a facility to which
clause (B) of the previous sentence applies still fails to
substantially meet the provisions of the respective section on the
date specified in such clause, the State shall terminate such
facility's certification for participation under the plan effective
with the first day of the first month following the month specified
in such clause.
(j) Waiver or modification of subchapter requirements with respect
to medical assistance program in American Samoa
Notwithstanding any other requirement of this subchapter, the
Secretary may waive or modify any requirement of this subchapter
with respect to the medical assistance program in American Samoa
and the Northern Mariana Islands, other than a waiver of the
Federal medical assistance percentage, the limitation in section
1308(f) of this title, 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 1396d(a) of
this title.
(k) Repealed. Pub. L. 103-66, title XIII, Sec. 13611(d)(1)(C), Aug.
10, 1993, 107 Stat. 627
(l) Description of group
(1) Individuals described in this paragraph are - 
(A) women during pregnancy (and during the 60-day period
beginning on the last day of the pregnancy),
(B) infants under one year of age,
(C) children who have attained one year of age but have not
attained 6 years of age, and
(D) children born after September 30, 1983 (or, at the option
of a State, after any earlier date), who have attained 6 years of
age but have not attained 19 years of age,
who are not described in any of subclauses (I) through (III) of
subsection (a)(10)(A)(i) of this section and whose family income
does not exceed the income level established by the State under
paragraph (2) for a family size equal to the size of the family,
including the woman, infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to
individuals described in subparagraph (A) or (B) of that paragraph,
the State shall establish an income level which is a percentage
(not less than the percentage provided under clause (ii) and not
more than 185 percent) of the income official poverty line (as
defined by the Office of Management and Budget, and revised
annually in accordance with section 9902(2) of this title)
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 July 1, 1988, has
elected to provide, and provides, medical assistance to individuals
described in this subsection or has enacted legislation
authorizing, or appropriating funds, to provide such assistance to
such individuals before July 1, 1989, the percentage provided under
clause (ii)(I) shall not be less than - 
(I) the percentage specified by the State in an amendment to
its State plan (whether approved or not) as of July 1, 1988, or
(II) if no such percentage is specified as of July 1, 1988, the
percentage established under the State's authorizing legislation
or provided for under the State's appropriations;
but in no case shall this clause require the percentage provided
under clause (ii)(I) to exceed 100 percent.
(iv) In the case of a State which, as of December 19, 1989, has
established under clause (i), or has enacted legislation
authorizing, or appropriating funds, to provide for, a percentage
(of the income official poverty line) that is greater than 133
percent, the percentage provided under clause (ii) for medical
assistance on or after April 1, 1990, shall not be less than - 
(I) the percentage specified by the State in an amendment to
its State plan (whether approved or not) as of December 19, 1989,
or
(II) if no such percentage is specified as of December 19,
1989, the percentage established under the State's authorizing
legislation or provided for under the State's appropriations.
(B) For purposes of paragraph (1) with respect to individuals
described in subparagraph (C) of such paragraph, the State shall
establish an income level which is equal to 133 percent of the
income official poverty line described in subparagraph (A)
applicable to a family of the size involved.
(C) For purposes of paragraph (1) with respect to individuals
described in subparagraph (D) of that paragraph, the State shall
establish an income level which is equal to 100 percent of the
income official poverty line described in subparagraph (A)
applicable to a family of the size involved.
(3) Notwithstanding subsection (a)(17) of this section, for
individuals who are eligible for medical assistance because of
subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)
(A)(i)(VII), or (a)(10)(A)(ii)(IX) of this section - 
(A) application of a resource standard shall be at the option
of the State;
(B) any resource standard or methodology that is applied with
respect to an individual described in subparagraph (A) of
paragraph (1) may not be more restrictive than the resource
standard or methodology that is applied under subchapter XVI of
this chapter;
(C) any resource standard or methodology that is applied with
respect to an individual described in subparagraph (B), (C), or
(D) of paragraph (1) may not be more restrictive than the
corresponding methodology that is applied under the State plan
under part A of subchapter IV of this chapter;
(D) the income standard to be applied is the appropriate income
standard established under paragraph (2); and
(E) family income shall be determined in accordance with the
methodology employed under the State plan under part A or E of
subchapter IV of this chapter (except to the extent such
methodology is inconsistent with clause (D) of subsection (a)(17)
of this section), and costs incurred for medical care or for any
other type of remedial care shall not be taken into account.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17) of this
section, require or permit such treatment for other individuals.
(4)(A) In the case of any State which is providing medical
assistance to its residents under a waiver granted under section
1315 of this title, 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) of this section and for
children described in subsection (a)(10)(A)(i)(VI) of this section
or subsection (a)(10)(A)(i)(VII) of this section 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
subchapter.
(B) In the case of a State which is not one of the 50 States or
the District of Columbia, the State need not meet the requirement
of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), or
(a)(10)(A)(i)(VII) of this section and, for purposes of paragraph
(2)(A), the State may substitute for the percentage provided under
clause (ii) of such paragraph any percentage.
(m) Description of individuals
(1) Individuals described in this paragraph are individuals - 
(A) who are 65 years of age or older or are disabled
individuals (as determined under section 1382c(a)(3) of this
title),
(B) whose income (as determined under section 1382a of this
title 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 1382b of this
title 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 9902(2) of this
title) 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) of this section
and at the State's option, the State may use under paragraph (1)(C)
such resource level (which is higher than the level described in
that paragraph) as may be applicable with respect to individuals
described in paragraph (1)(A) who are not described in subsection
(a)(10)(A) of this section.
(C) The provisions of section 1396d(p)(2)(D) of this title shall
apply to determinations of income under this subsection in the same
manner as they apply to determinations of income under section
1396d(p) of this title.
(3) Notwithstanding subsection (a)(17) of this section, for
individuals described in paragraph (1) who are covered under the
State plan by virtue of subsection (a)(10)(A)(ii)(X) of this
section - 
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this
title, 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) of this
section, require or permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17) of this section, for
qualified medicare beneficiaries described in section 1396d(p)(1)
of this title - 
(A) the income standard to be applied is the income standard
described in section 1396d(p)(1)(B) of this title, and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this
title, 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) of this
section, require or permit such treatment for other individuals.
(n) Payment amounts
(1) In the case of medical assistance furnished under this
subchapter for medicare cost-sharing respecting the furnishing of a
service or item to a qualified medicare beneficiary, the State plan
may provide payment in an amount with respect to the service or
item that results in the sum of such payment amount and any amount
of payment made under subchapter XVIII of this chapter with respect
to the service or item exceeding the amount that is otherwise
payable under the State plan for the item or service for eligible
individuals who are not qualified medicare beneficiaries.
(2) In carrying out paragraph (1), a State is not required to
provide any payment for any expenses incurred relating to payment
for deductibles, coinsurance, or copayments for medicare cost-
sharing to the extent that payment under subchapter XVIII of this
chapter for the service would exceed the payment amount that
otherwise would be made under the State plan under this subchapter
for such service if provided to an eligible recipient other than a
medicare beneficiary.
(3) In the case in which a State's payment for medicare cost-
sharing for a qualified medicare beneficiary with respect to an
item or service is reduced or eliminated through the application of
paragraph (2) - 
(A) for purposes of applying any limitation under subchapter
XVIII of this chapter on the amount that the beneficiary may be
billed or charged for the service, the amount of payment made
under subchapter XVIII of this chapter plus the amount of payment
(if any) under the State plan shall be considered to be payment
in full for the service;
(B) the beneficiary shall not have any legal liability to make
payment to a provider or to an organization described in section
1396b(m)(1)(A) of this title for the service; and
(C) any lawful sanction that may be imposed upon a provider or
such an organization for excess charges under this subchapter or
subchapter XVIII of this chapter shall apply to the imposition of
any charge imposed upon the individual in such case.
This paragraph shall not be construed as preventing payment of any
medicare cost-sharing by a medicare supplemental policy or an
employer retiree health plan on behalf of an individual.
(o) Certain benefits disregarded for purposes of determining post-
eligibility contributions
Notwithstanding any provision of subsection (a) of this section
to the contrary, a State plan under this subchapter shall provide
that any supplemental security income benefits paid by reason of
subparagraph (E) or (G) of section 1382(e)(1) of this title 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) Exclusion power of State; exclusion as prerequisite for medical
assistance payments; "exclude" defined
(1) In addition to any other authority, a State may exclude any
individual or entity for purposes of participating under the State
plan under this subchapter for any reason for which the Secretary
could exclude the individual or entity from participation in a
program under subchapter XVIII of this chapter under section 1320a-
7, 1320a-7a, or 1395cc(b)(2) of this title.
(2) In order for a State to receive payments for medical
assistance under section 1396b(a) of this title, with respect to
payments the State makes to a medicaid managed care organization
(as defined in section 1396b(m) of this title) or to an entity
furnishing services under a waiver approved under section
1396n(b)(1) of this title, 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 1320a-7(b)(8) of this title
(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 1320a-7(b)(8)(B) of this
title, or
(C) employs or contracts with any individual or entity that is
excluded from participation under this subchapter under section
1320a-7 or 1320a-7a of this title 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) Minimum monthly personal needs allowance deduction;
"institutionalized individual or couple" defined
(1)(A) In order to meet the requirement of subsection (a)(50) of
this section, the State plan must provide that, in the case of an
institutionalized individual or couple described in subparagraph
(B), in determining the amount of the individual's or couple's
income to be applied monthly to payment for the cost of care in an
institution, there shall be deducted from the monthly income (in
addition to other allowances otherwise provided under the State
plan) a monthly personal needs allowance - 
(i) which is reasonable in amount for clothing and other
personal needs of the individual (or couple) while in an
institution, and
(ii) which is not less (and may be greater) than the minimum
monthly personal needs allowance described in paragraph (2).
(B) In this subsection, the term "institutionalized individual or
couple" means an individual or married couple - 
(i) who is an inpatient (or who are inpatients) in a medical
institution or nursing facility for which payments are made under
this subchapter throughout a month, and
(ii) who is or are determined to be eligible for medical
assistance under the State plan.
(2) The minimum monthly personal needs allowance described in
this paragraph (!12) is $30 for an institutionalized individual and
$60 for an institutionalized couple (if both are aged, blind, or
disabled, and their incomes are considered available to each other
in determining eligibility).
(r) Disregarding payments for certain medical expenses by
institutionalized individuals
(1)(A) For purposes of sections 1396a(a)(17) and 1396r-5(d)(1)(D)
of this title and for purposes of a waiver under section 1396n of
this title, 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 subchapter,
subject to reasonable limits the State may establish on the
amount of these expenses.
(B)(i) In the case of a veteran who does not have a spouse or a
child, if the veteran - 
(I) receives, after the veteran has been determined to be
eligible for medical assistance under the State plan under this
subchapter, a veteran's pension in excess of $90 per month, and
(II) resides in a State veterans home with respect to which the
Secretary of Veterans Affairs makes per diem payments for nursing
home care pursuant to section 1741(a) of title 38,
any such pension payment, including any payment made due to the
need for aid and attendance, or for unreimbursed medical expenses,
that is in excess of $90 per month shall be counted as income only
for the purpose of applying such excess payment to the State
veterans home's cost of providing nursing home care to the veteran.
(ii) The provisions of clause (i) shall apply with respect to a
surviving spouse of a veteran who does not have a child in the same
manner as they apply to a veteran described in such clause.
(2)(A) The methodology to be employed in determining income and
resource eligibility for individuals under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)
(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) of this
section or under section 1396d(p) of this title 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 subchapter XVI of this chapter, or
(ii) in the case of other groups, under the State plan most
closely categorically related.
(B) For purposes of this subsection and subsection (a)(10) of
this section, methodology is considered to be "no more restrictive"
if, using the methodology, additional individuals may be eligible
for medical assistance and no individuals who are otherwise
eligible are made ineligible for such assistance.
(s) Adjustment in payment for hospital services furnished to low-
income children under age of 6 years
In order to meet the requirements of subsection (a)(55) (!13) of
this section, the State plan must provide that payments to
hospitals under the plan for inpatient hospital services furnished
to infants who have not attained the age of 1 year, and to children
who have not attained the age of 6 years and who receive such
services in a disproportionate share hospital described in section
1396r-4(b)(1) of this title, 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) Limitation on payments to States for expenditures attributable
to taxes
Nothing in this subchapter (including sections 1396b(a) and
1396d(a) of this title) 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) Qualified COBRA continuation beneficiaries
(1) Individuals described in this paragraph are individuals - 
(A) who are entitled to elect COBRA continuation coverage (as
defined in paragraph (3)),
(B) whose income (as determined under section 1382a of this
title 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 9902(2) of this title)
applicable to a family of the size involved,
(C) whose resources (as determined under section 1382b of this
title 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 subchapter resulting from such enrollment
is likely to exceed the amount of payments for COBRA premiums
made.
(2) For purposes of subsection (a)(10)(F) of this section and
this subsection, the term "COBRA premiums" means the applicable
premium imposed with respect to COBRA continuation coverage.
(3) In this subsection, the term "COBRA continuation coverage"
means coverage under a group health plan provided by an employer
with 75 or more employees provided pursuant to title XXII of the
Public Health Service Act [42 U.S.C. 300bb-1 et seq.], section
4980B of the Internal Revenue Code of 1986, or title VI (!14) of
the Employee Retirement Income Security Act of 1974.
(4) Notwithstanding subsection (a)(17) of this section, for
individuals described in paragraph (1) who are covered under the
State plan by virtue of subsection (a)(10)(A)(ii)(XI) of this
section - 
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this
title, 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)
of this section, require or permit such treatment for other
individuals.
(v) State agency disability and blindness determinations for
medical assistance eligibility
A State plan may provide for the making of determinations of
disability or blindness for the purpose of determining eligibility
for medical assistance under the State plan by the single State
agency or its designee, and make medical assistance available to
individuals whom it finds to be blind or disabled and who are
determined otherwise eligible for such assistance during the period
of time prior to which a final determination of disability or
blindness is made by the Social Security Administration with
respect to such an individual. In making such determinations, the
State must apply the definitions of disability and blindness found
in section 1382c(a) of this title.
(w) Maintenance of written policies and procedures respecting
advance directives
(1) For purposes of subsection (a)(57) of this section and
sections 1396b(m)(1)(A) and 1396r(c)(2)(E) of this title, 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
14406 of this title (relating to clarification respecting assisted
suicide, euthanasia, and mercy killing).
(x) Physician identifier system; establishment
The Secretary shall establish a system, for implementation by not
later than July 1, 1991, which provides for a unique identifier for
each physician who furnishes services for which payment may be made
under a State plan approved under this subchapter.
(y) Intermediate sanctions for psychiatric hospitals
(1) In addition to any other authority under State law, where a
State determines that a psychiatric hospital which is certified for
participation under its plan no longer meets the requirements for a
psychiatric hospital (referred to in section 1396d(h) of this
title) 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 subchapter - 
(A) within 3 months after the date the hospital is found to be
out of compliance with such requirements, the State shall provide
that no payment will be made under the State plan with respect to
any individual admitted to such hospital after the end of such 3-
month period, or
(B) within 6 months after the date the hospital is found to be
out of compliance with such requirements, no Federal financial
participation shall be provided under section 1396b(a) of this
title with respect to further services provided in the hospital
until the State finds that the hospital is in compliance with the
requirements of this subchapter.
(3) The Secretary may continue payments, over a period of not
longer than 6 months from the date the hospital is found to be out
of compliance with such requirements, if - 
(A) the State finds that it is more appropriate to take
alternative action to assure compliance of the hospital with the
requirements than to terminate the certification of the hospital,
(B) the State has submitted a plan and timetable for corrective
action to the Secretary for approval and the Secretary approves
the plan of corrective action, and
(C) the State agrees to repay to the Federal Government
payments received under this paragraph if the corrective action
is not taken in accordance with the approved plan and timetable.
(z) Optional coverage of TB-related services
(1) Individuals described in this paragraph are individuals not
described in subsection (a)(10)(A)(i) of this section - 
(A) who are infected with tuberculosis;
(B) whose income (as determined under the State plan under this
subchapter with respect to disabled individuals) does not exceed
the maximum amount of income a disabled individual described in
subsection (a)(10)(A)(i) of this section may have and obtain
medical assistance under the plan; and
(C) whose resources (as determined under the State plan under
this subchapter with respect to disabled individuals) do not
exceed the maximum amount of resources a disabled individual
described in subsection (a)(10)(A)(i) of this section may have
and obtain medical assistance under the plan.
(2) For purposes of subsection (a)(10) of this section, the term
"TB-related services" means each of the following services relating
to treatment of infection with tuberculosis:
(A) Prescribed drugs.
(B) Physicians' services and services described in section
1396d(a)(2) of this title.
(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 1396n(g)(2)
of this title).
(F) Services (other than room and board) designed to encourage
completion of regimens of prescribed drugs by outpatients,
including services to observe directly the intake of prescribed
drugs.
(aa) Certain breast or cervical cancer patients
Individuals described in this subsection are individuals who - 
(1) are not described in subsection (a)(10)(A)(i) of this
section;
(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 1396d(a)(2)(C) of this title furnished by a
Federally-qualified health center and services described in
section 1396d(a)(2)(B) of this title 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 1395l(a)(3) of this title, or, in the
case of services to which such regulations do not apply, the same
methodology used under section 1395l(a)(3) of this title,
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 1395u(i)(3) of this title) applicable to
primary care services (as defined in section 1395u(i)(4) of
this title) 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 1396d(a)(2)(C) of this title furnished by
the center or services described in section 1396d(a)(2)(B) of
this title 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 1396u-2(a)(1)(B) of this title), 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
1396d(a)(2)(C) of this title or to a rural health clinic for
services described in section 1396d(a)(2)(B) of this title 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.