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 chapter 21 of title 41 to persons
      described in section 2102(a)(3) 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 - 
          (A) safeguards which restrict the use or disclosure of
        information concerning applicants and recipients to purposes
        directly connected with - 
            (i) the administration of the plan; and
            (ii) the exchange of information necessary to certify or
          verify the certification of eligibility of children for free
          or reduced price breakfasts under the Child Nutrition Act of
          1966 [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; and

          (B) that, notwithstanding the Express Lane option under
        subsection (e)(13), the State may enter into an agreement with
        the State agency administering the school lunch program
        established under the Richard B. Russell National School Lunch
        Act under which the State shall establish procedures to ensure
        that - 
            (i) a child receiving medical assistance under the State
          plan under this subchapter whose family income does not
          exceed 133 percent of the poverty line (as defined in section
          9902(2) of this title, including any revision required by
          such section), as determined without regard to any expense,
          block, or other income disregard, applicable to a family of
          the size involved, may be certified as eligible for free
          lunches under the Richard B. Russell National School Lunch
          Act and free breakfasts under the Child Nutrition Act of 1966
          without further application; and
            (ii) the State agencies responsible for administering the
          State plan under this subchapter, and for carrying out the
          school lunch program established under the Richard B. Russell
          National School Lunch Act (42 U.S.C. 1751 et seq.) or the
          school breakfast program established by section 4 of the
          Child Nutrition Act of 1966 (42 U.S.C. 1773), cooperate in
          carrying out paragraphs (3)(F) and (15) of section 9(b) of
          that Act [42 U.S.C. 1758(b)];

        (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,
          (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, and
          (D) that the State maintain a consumer-oriented website
        providing useful information to consumers regarding all skilled
        nursing facilities and all nursing facilities in the State,
        including for each facility, Form 2567 State inspection reports
        (or a successor form), complaint investigation reports, the
        facility's plan of correction, and such other information that
        the State or the Secretary considers useful in assisting the
        public to assess the quality of long term care options and the
        quality of care provided by individual facilities;

        (10) provide - 
          (A) for making medical assistance available, including at
        least the care and services listed in paragraphs (1) through
        (5), (17), (21), and (28) 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)(aa) 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), (bb) who are qualified severely impaired
            individuals (as defined in section 1396d(q) of this title),
            or (cc) who are under 21 years of age and with respect to
            whom supplemental security income benefits would be paid
            under subchapter XVI if subparagraphs (A) and (B) of
            section 1382(c)(7) of this title were applied without
            regard to the phrase "the first day of the month
            following",
              (III) who are qualified pregnant women or children as
            defined in section 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,
              (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; (!2) or
              (VIII) beginning January 1, 2014, who are under 65 years
            of age, not pregnant, not entitled to, or enrolled for,
            benefits under part A of subchapter XVIII, or enrolled for
            benefits under part B of subchapter XVIII, and are not
            described in a previous subclause of this clause, and whose
            income (as determined under subsection (e)(14)) does not
            exceed 133 percent of the poverty line (as defined in
            section 1397jj(c)(5) of this title) applicable to a family
            of the size involved, subject to subsection (k); (!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; (!2)
              (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; (!2)

              (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); (!2)
              (X) who are described in subsection (m)(1) of this
            section; (!2)
              (XI) who receive only an optional State supplementary
            payment based on need and paid on a regular basis, equal to
            the difference between the individual's countable income
            and the income standard used to determine eligibility for
            such supplementary payment (with countable income being the
            income remaining after deductions as established by the
            State pursuant to standards that may be more restrictive
            than the standards for supplementary security income
            benefits under subchapter XVI 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; (!2)
              (XII) who are described in subsection (z)(1) of this
            section (relating to certain TB-infected individuals); (!2)
              (XIII) who are in families whose income is less than 250
            percent of the income official poverty line (as defined by
            the Office of Management and Budget, and revised annually
            in accordance with 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); (!2)
              (XIV) who are optional targeted low-income children
            described in section 1396d(u)(2)(B) of this title; (!2)
              (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; (!2)
              (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); (!2)
              (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; (!2)
              (XVIII) who are described in subsection (aa) of this
            section (relating to certain breast or cervical cancer
            patients); (!2)
              (XIX) who are disabled children described in subsection
            (cc)(1); (!2)
              (XX) beginning January 1, 2014, who are under 65 years of
            age and are not described in or enrolled under a previous
            subclause of this clause, and whose income (as determined
            under subsection (e)(14)) exceeds 133 percent of the
            poverty line (as defined in section 1397jj(c)(5) of this
            title) applicable to a family of the size involved but does
            not exceed the highest income eligibility level established
            under the State plan or under a waiver of the plan, subject
            to subsection (hh); (!2)
              (XXI) who are described in subsection (ii) (relating to
            individuals who meet certain income standards); (!2) or
              (XXII) who are eligible for home and community-based
            services under needs-based criteria established under
            paragraph (1)(A) of section 1396n(i) of this title, or who
            are eligible for home and community-based services under
            paragraph (6) of such section, and who will receive home
            and community-based services pursuant to a State plan
            amendment under such subsection;

          (B) that the medical assistance made available to any
        individual described in subparagraph (A) - 
            (i) shall not be less in amount, duration, or scope than
          the medical assistance made available to any other such
          individual, and
            (ii) shall not be less in amount, duration, or scope than
          the medical assistance made available to individuals not
          described in subparagraph (A);

          (C) that if medical assistance is included for any group of
        individuals described in section 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 February 2012) 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), (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 (!5) (XV) the
      medical assistance made available to an individual described in
      subparagraph (A)(i)(VIII) shall be limited to medical assistance
      described in subsection (k)(1), (XVI) the medical assistance made
      available to an individual described in subsection (ii) shall be
      limited to family planning services and supplies described in
      section 1396d(a)(4)(C) of this title including medical diagnosis
      and treatment services that are provided pursuant to a family
      planning service in a family planning setting (!5) and (XVII) if
      an individual is described in subclause (IX) of subparagraph
      (A)(i) and is also described in subclause (VIII) of that
      subparagraph, the medical assistance shall be made available to
      the individual through subclause (IX) instead of through
      subclause (VIII);

        (11)(A) provide for entering into cooperative arrangements with
      the State agencies responsible for administering or supervising
      the administration of health services and vocational
      rehabilitation services in the State looking toward maximum
      utilization of such services in the provision of medical
      assistance under the plan, (B) provide, to the extent prescribed
      by the Secretary, for entering into agreements, with any agency,
      institution, or organization receiving payments under (or through
      an allotment under) 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 (!5) (ii) making such provision as
      may be appropriate for reimbursing such agency, institution, or
      organization for the cost of any such care and services furnished
      any individual for which payment would otherwise be made to the
      State with respect to the individual under 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;

          (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; and
          (C) payment for primary care services (as defined in
        subsection (jj)) furnished in 2013 and 2014 by a physician with
        a primary specialty designation of family medicine, general
        internal medicine, or pediatric medicine at a rate not less
        than 100 percent of the payment rate that applies to such
        services and physician under part B of subchapter XVIII (or, if
        greater, the payment rate that would be applicable under such
        part if the conversion factor under section 1395w-4(d) of this
        title for the year involved were the conversion factor under
        such section for 2009);

        (14) provide that enrollment fees, premiums, or similar
      charges, and deductions, cost sharing, or similar charges, may be
      imposed only as provided in section 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 (e)(14), (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,,(!6) 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) (!1) or section
        1383(a)(4)(A)(i) and (ii) (!1) of this title which are
        appropriate for such recipients and for such patients; and for
        methods of administration necessary to assure that the
        responsibilities of the State agency under the State plan with
        respect to such recipients and such patients will be
        effectively carried out;

        (21) if the State plan includes medical assistance in behalf of
      individuals 65 years of age or older who are patients in public
      institutions for mental diseases, show that the State is making
      satisfactory progress toward developing and implementing a
      comprehensive mental health program, including provision for
      utilization of community mental health centers, nursing
      facilities, and other alternatives to care in public institutions
      for mental diseases;
        (22) include descriptions of (A) the kinds and numbers of
      professional medical personnel and supporting staff that will be
      used in the administration of the plan and of the
      responsibilities they will have, (B) the standards, for private
      or public institutions in which recipients of medical assistance
      under the plan may receive care or services, that will be
      utilized by the State authority or authorities responsible for
      establishing and maintaining such standards, (C) the cooperative
      arrangements with State health agencies and State vocational
      rehabilitation agencies entered into with a view to maximum
      utilization of and coordination of the provision of medical
      assistance with the services administered or supervised by such
      agencies, and (D) other standards and methods that the State will
      use to assure that medical or remedial care and services provided
      to recipients of medical assistance are of high quality;
        (23) provide that (A) any individual eligible for medical
      assistance (including drugs) may obtain such assistance from any
      institution, agency, community pharmacy, or person, qualified to
      perform the service or services required (including an
      organization which provides such services, or arranges for their
      availability, on a prepayment basis), who undertakes to provide
      him such services, and (B) an enrollment of an individual
      eligible for medical assistance in a primary care case-management
      system (described in 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 or
      by a provider or supplier to which a moratorium under subsection
      (kk)(4) is applied during the period of such moratorium;
        (24) effective July 1, 1969, provide for consultative services
      by health agencies and other appropriate agencies of the State to
      hospitals, nursing facilities, home health agencies, clinics,
      laboratories, and such other institutions as the Secretary may
      specify in order to assist them (A) to qualify for payments under
      this chapter, (B) to establish and maintain such fiscal records
      as may be necessary for the proper and efficient administration
      of this chapter, and (C) to provide information needed to
      determine payments due under this chapter on account of care and
      services furnished to individuals;
        (25) provide - 
          (A) that the State or local agency administering such plan
        will take all reasonable measures to ascertain the legal
        liability of third parties (including health insurers, self-
        insured plans, group health plans (as defined in section
        607(1) of the Employee Retirement Income Security Act of 1974
        [29 U.S.C. 1167(1)]), service benefit plans, managed care
        organizations, pharmacy benefit managers, or other parties that
        are, by statute, contract, or agreement, legally responsible
        for payment of a claim for a health care item or service) to
        pay for care and services available under the plan, including -
        
            (i) the collection of sufficient information (as specified
          by the Secretary in regulations) to enable the State to
          pursue claims against such third parties, with such
          information being collected at the time of any determination
          or redetermination of eligibility for medical assistance, and
            (ii) the submission to the Secretary of a plan (subject to
          approval by the Secretary) for pursuing claims against such
          third parties, which plan shall be integrated with, and be
          monitored as a part of the Secretary's review of, the State's
          mechanized claims processing and information retrieval
          systems required under section 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
        self-insured plan, a service benefit plan, a managed care
        organization, a pharmacy benefit manager, or other party that
        is, by statute, contract, or agreement, legally responsible for
        payment of a claim for a health care item or service), in
        enrolling an individual or in making any payments for benefits
        to the individual or on the individual's behalf, from taking
        into account that the individual is eligible for or is provided
        medical assistance under a plan under this subchapter for such
        State, or any other State;
          (H) that to the extent that payment has been made under the
        State plan for medical assistance in any case where a third
        party has a legal liability to make payment for such
        assistance, the State has in effect laws under which, to the
        extent that payment has been made under the State plan for
        medical assistance for health care items or services furnished
        to an individual, the State is considered to have acquired the
        rights of such individual to payment by any other party for
        such health care items or services; and
          (I) that the State shall provide assurances satisfactory to
        the Secretary that the State has in effect laws requiring
        health insurers, including self-insured plans, group health
        plans (as defined in section 607(1) of the Employee Retirement
        Income Security Act of 1974 [29 U.S.C. 1167(1)]), service
        benefit plans, managed care organizations, pharmacy benefit
        managers, or other parties that are, by statute, contract, or
        agreement, legally responsible for payment of a claim for a
        health care item or service, as a condition of doing business
        in the State, to - 
            (i) provide, with respect to individuals who are eligible
          (and, at State option, individuals who apply or whose
          eligibility for medical assistance is being evaluated in
          accordance with section 1396a(e)(13)(D) of this title) for,
          or are provided, medical assistance under the State plan
          under this subchapter (and, at State option, child health
          assistance under subchapter XXI), upon the request of the
          State, information to determine during what period the
          individual or their spouses or their dependents may be (or
          may have been) covered by a health insurer and the nature of
          the coverage that is or was provided by the health insurer
          (including the name, address, and identifying number of the
          plan) in a manner prescribed by the Secretary;
            (ii) accept the State's right of recovery and the
          assignment to the State of any right of an individual or
          other entity to payment from the party for an item or service
          for which payment has been made under the State plan;
            (iii) respond to any inquiry by the State regarding a claim
          for payment for any health care item or service that is
          submitted not later than 3 years after the date of the
          provision of such health care item or service; and
            (iv) agree not to deny a claim submitted by the State
          solely on the basis of the date of submission of the claim,
          the type or format of the claim form, or a failure to present
          proper documentation at the point-of-sale that is the basis
          of the claim, if - 
              (I) the claim is submitted by the State within the 3-year
            period beginning on the date on which the item or service
            was furnished; and
              (II) any action by the State to enforce its rights with
            respect to such claim is commenced within 6 years of the
            State's submission of such claim;

        (26) if the State plan includes medical assistance for
      inpatient mental hospital services, provide, with respect to each
      patient receiving such services, for a regular program of medical
      review (including medical evaluation) of his need for such
      services, and for a written plan of care;
        (27) provide for agreements with every person or institution
      providing services under the State plan under which such person
      or institution agrees (A) to keep such records as are necessary
      fully to disclose the extent of the services provided to
      individuals receiving assistance under the State plan, and (B) to
      furnish the State agency or the Secretary with such information,
      regarding any payments claimed by such person or institution for
      providing services under the State plan, as the State agency or
      the Secretary may from time to time request;
        (28) provide - 
          (A) that any nursing facility receiving payments under such
        plan must satisfy all the requirements of subsections (b)
        through (d) of section 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, terminate the
      participation of any individual or entity in such program if
      (subject to such exceptions as are permitted with respect to
      exclusion under sections 1320a-7(c)(3)(B) and 1320a-7(d)(3)(B) of
      this title) participation of such individual or entity is
      terminated under subchapter XVIII or any other State plan under
      this subchapter, 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 - 
          (A) the records of any entity participating in the plan and
        providing services reimbursable on a cost-related basis will be
        audited as the Secretary determines to be necessary to insure
        that proper payments are made under the plan; and
          (B) not later than December 31, 2010, the State shall - 
            (i) establish a program under which the State contracts
          (consistent with State law and in the same manner as the
          Secretary enters into contracts with recovery audit
          contractors under section 1395ddd(h) of this title, subject
          to such exceptions or requirements as the Secretary may
          require for purposes of this subchapter or a particular
          State) with 1 or more recovery audit contractors for the
          purpose of identifying underpayments and overpayments and
          recouping overpayments under the State plan and under any
          waiver of the State plan with respect to all services for
          which payment is made to any entity under such plan or
          waiver; and
            (ii) provide assurances satisfactory to the Secretary that -
           
              (I) under such contracts, payment shall be made to such a
            contractor only from amounts recovered;
              (II) from such amounts recovered, payment - 
                (aa) shall be made on a contingent basis for collecting
              overpayments; and
                (bb) may be made in such amounts as the State may
              specify for identifying underpayments;

              (III) the State has an adequate process for entities to
            appeal any adverse determination made by such contractors;
            and
              (IV) such program is carried out in accordance with such
            requirements as the Secretary shall specify, including - 
                (aa) for purposes of section 1396b(a)(7) of this title,
              that amounts expended by the State to carry out the
              program shall be considered amounts expended as necessary
              for the proper and efficient administration of the State
              plan or a waiver of the plan;
                (bb) that section 1396b(d) of this title shall apply to
              amounts recovered under the program; and
                (cc) that the State and any such contractors under
              contract with the State shall coordinate such recovery
              audit efforts with other contractors or entities
              performing audits of entities receiving payments under
              the State plan or waiver in the State, including efforts
              with Federal and State law enforcement with respect to
              the Department of Justice, including the Federal Bureau
              of Investigations,(!7) the Inspector General of the
              Department of Health and Human Services, and the State
              medicaid fraud control unit; and

        (43) provide for - 
          (A) informing all persons in the State who are under the age
        of 21 and who have been determined to be eligible for medical
        assistance including services described in 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
          other information relating to the provision of dental
          services to such children described in section 1397hh(e) (!8)
          of this title and

            (iv) the State's results in attaining the participation
          goals set for the State under 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)(A) provide that information is requested and exchanged for
      purposes of income and eligibility verification in accordance
      with a State system which meets the requirements of section 1320b-
      7 of this title; and
        (B) provide, with respect to an individual declaring to be a
      citizen or national of the United States for purposes of
      establishing eligibility under this subchapter, that the State
      shall satisfy the requirements of - 
          (i) section 1396b(x) of this title; or
          (ii) subsection (ee);

        (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;
        (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);
        (68) provide that any entity that receives or makes annual
      payments under the State plan of at least $5,000,000, as a
      condition of receiving such payments, shall - 
          (A) establish written policies for all employees of the
        entity (including management), and of any contractor or agent
        of the entity, that provide detailed information about the
        False Claims Act established under sections 3729 through 3733
        of title 31, administrative remedies for false claims and
        statements established under chapter 38 of title 31, any State
        laws pertaining to civil or criminal penalties for false claims
        and statements, and whistleblower protections under such laws,
        with respect to the role of such laws in preventing and
        detecting fraud, waste, and abuse in Federal health care
        programs (as defined in section 1320a-7b(f) of this title);
          (B) include as part of such written policies, detailed
        provisions regarding the entity's policies and procedures for
        detecting and preventing fraud, waste, and abuse; and
          (C) include in any employee handbook for the entity, a
        specific discussion of the laws described in subparagraph (A),
        the rights of employees to be protected as whistleblowers, and
        the entity's policies and procedures for detecting and
        preventing fraud, waste, and abuse;

        (69) provide that the State must comply with any requirements
      determined by the Secretary to be necessary for carrying out the
      Medicaid Integrity Program established under section 1396u-6 of
      this title;
        (70) at the option of the State and notwithstanding paragraphs
      (1), (10)(B), and (23), provide for the establishment of a non-
      emergency medical transportation brokerage program in order to
      more cost-effectively provide transportation for individuals
      eligible for medical assistance under the State plan who need
      access to medical care or services and have no other means of
      transportation which - 
          (A) may include a wheelchair van, taxi, stretcher car, bus
        passes and tickets, secured transportation, and such other
        transportation as the Secretary determines appropriate; and
          (B) may be conducted under contract with a broker who - 
            (i) is selected through a competitive bidding process based
          on the State's evaluation of the broker's experience,
          performance, references, resources, qualifications, and
          costs;
            (ii) has oversight procedures to monitor beneficiary access
          and complaints and ensure that transport personnel are
          licensed, qualified, competent, and courteous;
            (iii) is subject to regular auditing and oversight by the
          State in order to ensure the quality of the transportation
          services provided and the adequacy of beneficiary access to
          medical care and services; and
            (iv) complies with such requirements related to
          prohibitions on referrals and conflict of interest as the
          Secretary shall establish (based on the prohibitions on
          physician referrals under section 1395nn of this title and
          such other prohibitions and requirements as the Secretary
          determines to be appropriate);

        (71) provide that the State will implement an asset
      verification program as required under section 1396w of this
      title;
        (72) provide that the State will not prevent a Federally-
      qualified health center from entering into contractual
      relationships with private practice dental providers in the
      provision of Federally-qualified health center services;
        (73) in the case of any State in which 1 or more Indian Health
      Programs or Urban Indian Organizations furnishes health care
      services, provide for a process under which the State seeks
      advice on a regular, ongoing basis from designees of such Indian
      Health Programs and Urban Indian Organizations on matters
      relating to the application of this subchapter that are likely to
      have a direct effect on such Indian Health Programs and Urban
      Indian Organizations and that - 
          (A) shall include solicitation of advice prior to submission
        of any plan amendments, waiver requests, and proposals for
        demonstration projects likely to have a direct effect on
        Indians, Indian Health Programs, or Urban Indian Organizations;
        and
          (B) may include appointment of an advisory committee and of a
        designee of such Indian Health Programs and Urban Indian
        Organizations to the medical care advisory committee advising
        the State on its State plan under this subchapter;

        (74) provide for maintenance of effort under the State plan or
      under any waiver of the plan in accordance with subsection (gg);
        (75) provide that, beginning January 2015, and annually
      thereafter, the State shall submit a report to the Secretary that
      contains - 
          (A) the total number of enrolled and newly enrolled
        individuals in the State plan or under a waiver of the plan for
        the fiscal year ending on September 30 of the preceding
        calendar year, disaggregated by population, including children,
        parents, nonpregnant childless adults, disabled individuals,
        elderly individuals, and such other categories or sub-
        categories of individuals eligible for medical assistance
        under the State plan or under a waiver of the plan as the
        Secretary may require;
          (B) a description, which may be specified by population, of
        the outreach and enrollment processes used by the State during
        such fiscal year; and
          (C) any other data reporting determined necessary by the
        Secretary to monitor enrollment and retention of individuals
        eligible for medical assistance under the State plan or under a
        waiver of the plan;

        (76) provide that any data collected under the State plan meets
      the requirements of section 3101 of the Public Health Service Act
      [42 U.S.C. 300kk];
        (77) provide that the State shall comply with provider and
      supplier screening, oversight, and reporting requirements in
      accordance with subsection (kk);
        (79) )10(! provide that any agent, clearinghouse, or other
      alternate payee (as defined by the Secretary) that submits claims
      on behalf of a health care provider must register with the State
      and the Secretary in a form and manner specified by the
      Secretary;

        (80) provide that the State shall not provide any payments for
      items or services provided under the State plan or under a waiver
      to any financial institution or entity located outside of the
      United States;
        (81) provide that the State will comply with such regulations
      regarding the application of primary and secondary payor rules
      with respect to individuals who are eligible for medical
      assistance under this subchapter and are eligible beneficiaries
      under the CLASS program established under title XXXII of the
      Public Health Service Act [42 U.S.C. 300ll et seq.] as the
      Secretary shall establish;
        (82) provide that, not later than 2 years after March 23, 2010,
      each State shall - 
          (A) assess the extent to which entities such as providers of
        home care, home health services, home and community service
        providers, public authorities created to provide personal care
        services to individuals eligible for medical assistance under
        the State plan, and nonprofit organizations, are serving or
        have the capacity to serve as fiscal agents for, employers of,
        and providers of employment-related benefits for, personal care
        attendant workers who provide personal care services to
        individuals receiving benefits under the CLASS program
        established under title XXXII of the Public Health Service Act
        [42 U.S.C. 300ll et seq.], including in rural and underserved
        areas;
          (B) designate or create such entities to serve as fiscal
        agents for, employers of, and providers of employment-related
        benefits for, such workers to ensure an adequate supply of the
        workers for individuals receiving benefits under the CLASS
        program, including in rural and underserved areas; and
          (C) ensure that the designation or creation of such entities
        will not negatively alter or impede existing programs, models,
        methods, or administration of service delivery that provide for
        consumer controlled or self-directed home and community
        services and further ensure that such entities will not impede
        the ability of individuals to direct and control their home and
        community services, including the ability to select, manage,
        dismiss, co-employ, or employ such workers or inhibit such
        individuals from relying on family members for the provision of
        personal care services; and

        (83) provide for implementation of the payment models specified
      by the Secretary under section 1315a(c) of this title for
      implementation on a nationwide basis unless the State
      demonstrates to the satisfaction of the Secretary that
      implementation would not be administratively feasible or
      appropriate to the health care delivery system of the State.

    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 )11(!
    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 February 29, 2012. 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. During the period in which a child is deemed
    under the preceding sentence to be eligible for medical assistance,
    the medical assistance eligibility identification number of the
    mother shall also serve as the identification number of the child,
    and all claims shall be submitted and paid under such number
    (unless the State issues a separate identification number for the
    child before such period expires). Notwithstanding the preceding
    sentence, in the case of a child who is born in the United States
    to an alien mother for whom medical assistance for the delivery of
    the child is made available pursuant to section 1396b(v) of this
    title, the State immediately shall issue a separate identification
    number for the child upon notification by the facility at which
    such delivery occurred of the child's birth.
      (5) A woman who, while pregnant, is eligible for, has applied
    for, and has received medical assistance under the State plan,
    shall continue to be eligible under the plan, as though she were
    pregnant, for all pregnancy-related and postpartum medical
    assistance under the plan, through the end of the month in which
    the 60-day period (beginning on the last day of her pregnancy)
    ends.
      (6) In the case of a pregnant woman described in subsection
    (a)(10) 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) (!1) of this title shall not be
    construed as denying (or permitting a State to deny) medical
    assistance under this subchapter to such individual, child, or
    woman who is eligible for assistance under this subchapter on a
    basis other than the receipt of aid under such part.
      (B) If an individual, child, or pregnant woman is receiving aid
    under part A of subchapter IV of this chapter and such aid is
    terminated pursuant to section 602(a)(43) (!1) of this title, the
    State may not discontinue medical assistance under this subchapter
    for the individual, child, or woman until the State has determined
    that the individual, child, or woman is not eligible for assistance
    under this subchapter on a basis other than the receipt of aid
    under such part.
      (11)(A) In the case of an individual who is enrolled with a group
    health plan under 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.

      (13) Express Lane Option. - 
        (A) In general. - 
          (i) Option to use a finding from an express lane agency. - At
        the option of the State, the State plan may provide that in
        determining eligibility under this subchapter for a child (as
        defined in subparagraph (G)), the State may rely on a finding
        made within a reasonable period (as determined by the State)
        from an Express Lane agency (as defined in subparagraph (F))
        when it determines whether a child satisfies one or more
        components of eligibility for medical assistance under this
        subchapter. The State may rely on a finding from an Express
        Lane agency notwithstanding sections 1396a(a)(46)(B) and 1320b-
        7(d) of this title or any differences in budget unit,
        disregard, deeming or other methodology, if the following
        requirements are met:
            (I) Prohibition on determining children ineligible for
          coverage. - If a finding from an Express Lane agency would
          result in a determination that a child does not satisfy an
          eligibility requirement for medical assistance under this
          subchapter and for child health assistance under subchapter
          XXI, the State shall determine eligibility for assistance
          using its regular procedures.
            (II) Notice requirement. - For any child who is found
          eligible for medical assistance under the State plan under
          this subchapter or child health assistance under subchapter
          XXI and who is subject to premiums based on an Express Lane
          agency's finding of such child's income level, the State
          shall provide notice that the child may qualify for lower
          premium payments if evaluated by the State using its regular
          policies and of the procedures for requesting such an
          evaluation.
            (III) Compliance with screen and enroll requirement. - The
          State shall satisfy the requirements under subparagraphs (A)
          and (B) of section 1397bb(b)(3) of this title (relating to
          screen and enroll) before enrolling a child in child health
          assistance under subchapter XXI. At its option, the State may
          fulfill such requirements in accordance with either option
          provided under subparagraph (C) of this paragraph.
            (IV) Verification of citizenship or nationality status. -
          The State shall satisfy the requirements of section
          1396a(a)(46)(B) or 1397ee(c)(9) of this title, as applicable
          for verifications of citizenship or nationality status.
            (V) Coding. - The State meets the requirements of
          subparagraph (E).

          (ii) Option to apply to renewals and redeterminations. - The
        State may apply the provisions of this paragraph when
        conducting initial determinations of eligibility,
        redeterminations of eligibility, or both, as described in the
        State plan.

        (B) Rules of construction. - Nothing in this paragraph shall be
      construed - 
          (i) to limit or prohibit a State from taking any actions
        otherwise permitted under this subchapter or subchapter XXI in
        determining eligibility for or enrolling children into medical
        assistance under this subchapter or child health assistance
        under subchapter XXI; or
          (ii) to modify the limitations in section 1396a(a)(5) of this
        title concerning the agencies that may make a determination of
        eligibility for medical assistance under this subchapter.

        (C) Options for satisfying the screen and enroll requirement. -
      
          (i) In general. - With respect to a child whose eligibility
        for medical assistance under this subchapter or for child
        health assistance under subchapter XXI has been evaluated by a
        State agency using an income finding from an Express Lane
        agency, a State may carry out its duties under subparagraphs
        (A) and (B) of section 1397bb(b)(3) of this title (relating to
        screen and enroll) in accordance with either clause (ii) or
        clause (iii).
          (ii) Establishing a screening threshold. - 
            (I) In general. - Under this clause, the State establishes
          a screening threshold set as a percentage of the Federal
          poverty level that exceeds the highest income threshold
          applicable under this subchapter to the child by a minimum of
          30 percentage points or, at State option, a higher number of
          percentage points that reflects the value (as determined by
          the State and described in the State plan) of any differences
          between income methodologies used by the program administered
          by the Express Lane agency and the methodologies used by the
          State in determining eligibility for medical assistance under
          this subchapter.
            (II) Children with income not above threshold. - If the
          income of a child does not exceed the screening threshold,
          the child is deemed to satisfy the income eligibility
          criteria for medical assistance under this subchapter
          regardless of whether such child would otherwise satisfy such
          criteria.
            (III) Children with income above threshold. - If the income
          of a child exceeds the screening threshold, the child shall
          be considered to have an income above the Medicaid applicable
          income level described in section 1397jj(b)(4) of this title
          and to satisfy the requirement under section 1397jj(b)(1)(C)
          of this title (relating to the requirement that CHIP matching
          funds be used only for children not eligible for Medicaid).
          If such a child is enrolled in child health assistance under
          subchapter XXI, the State shall provide the parent, guardian,
          or custodial relative with the following:
              (aa) Notice that the child may be eligible to receive
            medical assistance under the State plan under this
            subchapter if evaluated for such assistance under the
            State's regular procedures and notice of the process
            through which a parent, guardian, or custodial relative can
            request that the State evaluate the child's eligibility for
            medical assistance under this subchapter using such regular
            procedures.
              (bb) A description of differences between the medical
            assistance provided under this subchapter and child health
            assistance under subchapter XXI, including differences in
            cost-sharing requirements and covered benefits.

          (iii) Temporary enrollment in chip pending screen and enroll.
        - 
            (I) In general. - Under this clause, a State enrolls a
          child in child health assistance under subchapter XXI for a
          temporary period if the child appears eligible for such
          assistance based on an income finding by an Express Lane
          agency.
            (II) Determination of eligibility. - During such temporary
          enrollment period, the State shall determine the child's
          eligibility for child health assistance under subchapter XXI
          or for medical assistance under this subchapter in accordance
          with this clause.
            (III) Prompt follow up. - In making such a determination,
          the State shall take prompt action to determine whether the
          child should be enrolled in medical assistance under this
          subchapter or child health assistance under subchapter XXI
          pursuant to subparagraphs (A) and (B) of section 1397bb(b)(3)
          of this title (relating to screen and enroll).
            (IV) Requirement for simplified determination. - In making
          such a determination, the State shall use procedures that, to
          the maximum feasible extent, reduce the burden imposed on the
          individual of such determination. Such procedures may not
          require the child's parent, guardian, or custodial relative
          to provide or verify information that already has been
          provided to the State agency by an Express Lane agency or
          another source of information unless the State agency has
          reason to believe the information is erroneous.
            (V) Availability of chip matching funds during temporary
          enrollment period. - Medical assistance for items and
          services that are provided to a child enrolled in subchapter
          XXI during a temporary enrollment period under this clause
          shall be treated as child health assistance under such
          subchapter.

        (D) Option for automatic enrollment. - 
          (i) In general. - The State may initiate and determine
        eligibility for medical assistance under the State Medicaid
        plan or for child health assistance under the State CHIP plan
        without a program application from, or on behalf of, the child
        based on data obtained from sources other than the child (or
        the child's family), but a child can only be automatically
        enrolled in the State Medicaid plan or the State CHIP plan if
        the child or the family affirmatively consents to being
        enrolled through affirmation in writing, by telephone, orally,
        through electronic signature, or through any other means
        specified by the Secretary or by signature on an Express Lane
        agency application, if the requirement of clause (ii) is met.
          (ii) Information requirement. - The requirement of this
        clause is that the State informs the parent, guardian, or
        custodial relative of the child of the services that will be
        covered, appropriate methods for using such services, premium
        or other cost sharing charges (if any) that apply, medical
        support obligations (under section 1396k(a) of this title)
        created by enrollment (if applicable), and the actions the
        parent, guardian, or relative must take to maintain enrollment
        and renew coverage.

        (E) Coding; application to enrollment error rates. - 
          (i) In general. - For purposes of subparagraph (A)(iv),)12(!
        the requirement of this subparagraph for a State is that the
        State agrees to - 

            (I) assign such codes as the Secretary shall require to the
          children who are enrolled in the State Medicaid plan or the
          State CHIP plan through reliance on a finding made by an
          Express Lane agency for the duration of the State's election
          under this paragraph;
            (II) annually provide the Secretary with a statistically
          valid sample (that is approved by Secretary) of the children
          enrolled in such plans through reliance on such a finding by
          conducting a full Medicaid eligibility review of the children
          identified for such sample for purposes of determining an
          eligibility error rate (as described in clause (iv)) with
          respect to the enrollment of such children (and shall not
          include such children in any data or samples used for
          purposes of complying with a Medicaid Eligibility Quality
          Control (MEQC) review or a payment error rate measurement
          (PERM) requirement);
            (III) submit the error rate determined under subclause (II)
          to the Secretary;
            (IV) if such error rate exceeds 3 percent for either of the
          first 2 fiscal years in which the State elects to apply this
          paragraph, demonstrate to the satisfaction of the Secretary
          the specific corrective actions implemented by the State to
          improve upon such error rate; and
            (V) if such error rate exceeds 3 percent for any fiscal
          year in which the State elects to apply this paragraph, a
          reduction in the amount otherwise payable to the State under
          section 1396b(a) of this title for quarters for that fiscal
          year, equal to the total amount of erroneous excess payments
          determined for the fiscal year only with respect to the
          children included in the sample for the fiscal year that are
          in excess of a 3 percent error rate with respect to such
          children.

          (ii) No punitive action based on error rate. - The Secretary
        shall not apply the error rate derived from the sample under
        clause (i) to the entire population of children enrolled in the
        State Medicaid plan or the State CHIP plan through reliance on
        a finding made by an Express Lane agency, or to the population
        of children enrolled in such plans on the basis of the State's
        regular procedures for determining eligibility, or penalize the
        State on the basis of such error rate in any manner other than
        the reduction of payments provided for under clause (i)(V).
          (iii) Rule of construction. - Nothing in this paragraph shall
        be construed as relieving a State that elects to apply this
        paragraph from being subject to a penalty under section
        1396b(u) of this title, for payments made under the State
        Medicaid plan with respect to ineligible individuals and
        families that are determined to exceed the error rate permitted
        under that section (as determined without regard to the error
        rate determined under clause (i)(II)).
          (iv) Error rate defined. - In this subparagraph, the term
        "error rate" means the rate of erroneous excess payments for
        medical assistance (as defined in section 1396b(u)(1)(D) of
        this title) for the period involved, except that such payments
        shall be limited to individuals for which eligibility
        determinations are made under this paragraph and except that in
        applying this paragraph under subchapter XXI, there shall be
        substituted for references to provisions of this subchapter
        corresponding provisions within subchapter XXI.

        (F) Express lane agency. - 
          (i) In general. - In this paragraph, the term "Express Lane
        agency" means a public agency that - 
            (I) is determined by the State Medicaid agency or the State
          CHIP agency (as applicable) to be capable of making the
          determinations of one or more eligibility requirements
          described in subparagraph (A)(i);
            (II) is identified in the State Medicaid plan or the State
          CHIP plan; and
            (III) notifies the child's family - 
              (aa) of the information which shall be disclosed in
            accordance with this paragraph;
              (bb) that the information disclosed will be used solely
            for purposes of determining eligibility for medical
            assistance under the State Medicaid plan or for child
            health assistance under the State CHIP plan; and
              (cc) that the family may elect to not have the
            information disclosed for such purposes; and

            (IV) enters into, or is subject to, an interagency
          agreement to limit the disclosure and use of the information
          disclosed.

          (ii) Inclusion of specific public agencies and Indian tribes
        and tribal organizations. - Such term includes the following:
            (I) A public agency that determines eligibility for
          assistance under any of the following:
              (aa) The temporary assistance for needy families program
            funded under part A of subchapter IV.
              (bb) A State program funded under part D of subchapter
            IV.
              (cc) The State Medicaid plan.
              (dd) The State CHIP plan.
              (ee) The Food and Nutrition Act of 2008 (7 U.S.C. 2011 et
            seq.).
              (ff) The Head Start Act [42 U.S.C. 9831 et seq.].
              (gg) The Richard B. Russell National School Lunch Act (42
            U.S.C. 1751 et seq.).
              (hh) The Child Nutrition Act of 1966 (42 U.S.C. 1771 et
            seq.).
              (ii) The Child Care and Development Block Grant Act of
            1990 (42 U.S.C. 9858 et seq.).
              (jj) The Stewart B. McKinney Homeless Assistance Act (!1)
            (42 U.S.C. 11301 et seq.).
              (kk) The United States Housing Act of 1937 (42 U.S.C.
            1437 et seq.).
              (ll) The Native American Housing Assistance and Self-
            Determination Act of 1996 (25 U.S.C. 4101 et seq.).

            (II) A State-specified governmental agency that has fiscal
          liability or legal responsibility for the accuracy of the
          eligibility determination findings relied on by the State.
            (III) A public agency that is subject to an interagency
          agreement limiting the disclosure and use of the information
          disclosed for purposes of determining eligibility under the
          State Medicaid plan or the State CHIP plan.
            (IV) The Indian Health Service, an Indian Tribe, Tribal
          Organization, or Urban Indian Organization (as defined in
          section 1320b-9(c) of this title).

          (iii) Exclusions. - Such term does not include an agency that
        determines eligibility for a program established under the
        Social Services Block Grant established under subchapter XX or
        a private, for-profit organization.
          (iv) Rules of construction. - Nothing in this paragraph shall
        be construed as - 
            (I) exempting a State Medicaid agency from complying with
          the requirements of section 1396a(a)(4) of this title
          relating to merit-based personnel standards for employees of
          the State Medicaid agency and safeguards against conflicts of
          interest); )13(! or

            (II) authorizing a State Medicaid agency that elects to use
          Express Lane agencies under this subparagraph to use the
          Express Lane option to avoid complying with such requirements
          for purposes of making eligibility determinations under the
          State Medicaid plan.

          (v) Additional definitions. - In this paragraph:
            (I) State. - The term "State" means 1 of the 50 States or
          the District of Columbia.
            (II) State chip agency. - The term "State CHIP agency"
          means the State agency responsible for administering the
          State CHIP plan.
            (III) State chip plan. - The term "State CHIP plan" means
          the State child health plan established under subchapter XXI
          and includes any waiver of such plan.
            (IV) State medicaid agency. - The term "State Medicaid
          agency" means the State agency responsible for administering
          the State Medicaid plan.
            (V) State medicaid plan. - The term "State Medicaid plan"
          means the State plan established under subchapter XIX and
          includes any waiver of such plan.

        (G) Child defined. - For purposes of this paragraph, the term
      "child" means an individual under 19 years of age, or, at the
      option of a State, such higher age, not to exceed 21 years of
      age, as the State may elect.
        (H) State option to rely on state income tax data or return. -
      At the option of the State, a finding from an Express Lane agency
      may include gross income or adjusted gross income shown by State
      income tax records or returns.
        (I) Application. - This paragraph shall not apply with respect
      to eligibility determinations made after September 30, 2013.

      (14) Exclusion of compensation for participation in a clinical
    trial for testing of treatments for a rare disease or condition. -
    The first $2,000 received by an individual (who has attained 19
    years of age) as compensation for participation in a clinical trial
    meeting the requirements of section 1382a(b)(26) of this title
    shall be disregarded for purposes of determining the income
    eligibility of such individual for medical assistance under the
    State plan or any waiver of such plan.
    (f) 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 )14(! 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) Minimum coverage for individuals with income at or below 133
      percent of the poverty line
      (1) The medical assistance provided to an individual described in
    subclause (VIII) of subsection (a)(10)(A)(i) shall consist of
    benchmark coverage described in section 1396u-7(b)(1) of this title
    or benchmark equivalent coverage described in section 1396u-7(b)(2)
    of this title. Such medical assistance shall be provided subject to
    the requirements of section 1396u-7 of this title, without regard
    to whether a State otherwise has elected the option to provide
    medical assistance through coverage under that section, unless an
    individual described in subclause (VIII) of subsection
    (a)(10)(A)(i) is also an individual for whom, under subparagraph
    (B) of section 1396u-7(a)(2) of this title, the State may not
    require enrollment in benchmark coverage described in subsection
    (b)(1) of section 1396u-7 of this title or benchmark equivalent
    coverage described in subsection (b)(2) of that section.
      (2) Beginning with the first day of any fiscal year quarter that
    begins on or after April 1, 2010, and before January 1, 2014, a
    State may elect through a State plan amendment to provide medical
    assistance to individuals who would be described in subclause
    (VIII) of subsection (a)(10)(A)(i) if that subclause were effective
    before January 1, 2014. A State may elect to phase-in the extension
    of eligibility for medical assistance to such individuals based on
    income, so long as the State does not extend such eligibility to
    individuals described in such subclause with higher income before
    making individuals described in such subclause with lower income
    eligible for medical assistance.
      (3) If an individual described in subclause (VIII) of subsection
    (a)(10)(A)(i) is the parent of a child who is under 19 years of age
    (or such higher age as the State may have elected) who is eligible
    for medical assistance under the State plan or under a waiver of
    such plan (under that subclause or under a State plan amendment
    under paragraph (2),)15(! the individual may not be enrolled under
    the State plan unless the individual's child is enrolled under the
    State plan or under a waiver of the plan or is enrolled in other
    health insurance coverage. For purposes of the preceding sentence,
    the term "parent" includes an individual treated as a caretaker
    relative for purposes of carrying out section 1396u-1 of this
    title.

    (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 (or,
    beginning January 1, 2014, 133 percent) of the income official
    poverty line described in subparagraph (A) applicable to a family
    of the size involved.
      (3) Notwithstanding subsection (a)(17) 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 )16(! 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) )17(! 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 (!1) 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) (!1) 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.
    (cc) Disabled children eligible to receive medical assistance at
      option of State
      (1) Individuals described in this paragraph are individuals - 
        (A) who are children who have not attained 19 years of age and
      are born - 
          (i) on or after January 1, 2001 (or, at the option of a
        State, on or after an earlier date), in the case of the second,
        third, and fourth quarters of fiscal year 2007;
          (ii) on or after October 1, 1995 (or, at the option of a
        State, on or after an earlier date), in the case of each
        quarter of fiscal year 2008; and
          (iii) after October 1, 1989, in the case of each quarter of
        fiscal year 2009 and each quarter of any fiscal year
        thereafter;

        (B) who would be considered disabled under section
      1382c(a)(3)(C) of this title (as determined under subchapter XVI
      for children but without regard to any income or asset
      eligibility requirements that apply under such subchapter with
      respect to children); and
        (C) whose family income does not exceed such income level as
      the State establishes and does not exceed - 
          (i) 300 percent of the poverty line (as defined in section
        1397jj(c)(5) of this title) applicable to a family of the size
        involved; or
          (ii) such higher percent of such poverty line as a State may
        establish, except that - 
            (I) any medical assistance provided to an individual whose
          family income exceeds 300 percent of such poverty line may
          only be provided with State funds; and
            (II) no Federal financial participation shall be provided
          under section 1396b(a) of this title for any medical
          assistance provided to such an individual.

      (2)(A) If an employer of a parent of an individual described in
    paragraph (1) offers family coverage under a group health plan (as
    defined in section 2791(a) of the Public Health Service Act [42
    U.S.C. 300gg-91(a)]), the State shall - 
        (i) notwithstanding section 1396e of this title, require such
      parent to apply for, enroll in, and pay premiums for such
      coverage as a condition of such parent's child being or remaining
      eligible for medical assistance under subsection
      (a)(10)(A)(ii)(XIX) if the parent is determined eligible for such
      coverage and the employer contributes at least 50 percent of the
      total cost of annual premiums for such coverage; and
        (ii) if such coverage is obtained - 
          (I) subject to paragraph (2) of section 1396o(h) )18(! of
        this title, reduce the premium imposed by the State under that
        section in an amount that reasonably reflects the premium
        contribution made by the parent for private coverage on behalf
        of a child with a disability; and

          (II) treat such coverage as a third party liability under
        subsection (a)(25).

      (B) In the case of a parent to which subparagraph (A) applies, a
    State, notwithstanding section 1396e of this title but subject to
    paragraph (1)(C)(ii), may provide for payment of any portion of the
    annual premium for such family coverage that the parent is required
    to pay. Any payments made by the State under this subparagraph
    shall be considered, for purposes of section 1396b(a) of this
    title, to be payments for medical assistance.
    (dd) Electronic transmission of information
      If the State agency determining eligibility for medical
    assistance under this subchapter or child health assistance under
    subchapter XXI verifies an element of eligibility based on
    information from an Express Lane Agency )19(! (as defined in
    subsection (e)(13)(F)), or from another public agency, then the
    applicant's signature under penalty of perjury shall not be
    required as to such element. Any signature requirement for an
    application for medical assistance may be satisfied through an
    electronic signature, as defined in section 1710(1) of the
    Government Paperwork Elimination Act (44 U.S.C. 3504 note). The
    requirements of subparagraphs (A) and (B) of section 1320b-7(d)(2)
    of this title may be met through evidence in digital or electronic
    form.

    (ee) Alternate State process for verification of citizenship or
      nationality declaration
      (1) For purposes of subsection (a)(46)(B)(ii), the requirements
    of this subsection with respect to an individual declaring to be a
    citizen or national of the United States for purposes of
    establishing eligibility under this subchapter, are, in lieu of
    requiring the individual to present satisfactory documentary
    evidence of citizenship or nationality under section 1396b(x) of
    this title (if the individual is not described in paragraph (2) of
    that section), as follows:
        (A) The State submits the name and social security number of
      the individual to the Commissioner of Social Security as part of
      the program established under paragraph (2).
        (B) If the State receives notice from the Commissioner of
      Social Security that the name or social security number, or the
      declaration of citizenship or nationality, of the individual is
      inconsistent with information in the records maintained by the
      Commissioner - 
          (i) the State makes a reasonable effort to identify and
        address the causes of such inconsistency, including through
        typographical or other clerical errors, by contacting the
        individual to confirm the accuracy of the name or social
        security number submitted or declaration of citizenship or
        nationality and by taking such additional actions as the
        Secretary, through regulation or other guidance, or the State
        may identify, and continues to provide the individual with
        medical assistance while making such effort; and
          (ii) in the case such inconsistency is not resolved under
        clause (i), the State - 
            (I) notifies the individual of such fact;
            (II) provides the individual with a period of 90 days from
          the date on which the notice required under subclause (I) is
          received by the individual to either present satisfactory
          documentary evidence of citizenship or nationality (as
          defined in section 1396b(x)(3) of this title) or resolve the
          inconsistency with the Commissioner of Social Security (and
          continues to provide the individual with medical assistance
          during such 90-day period); and
            (III) disenrolls the individual from the State plan under
          this subchapter within 30 days after the end of such 90-day
          period if no such documentary evidence is presented or if
          such inconsistency is not resolved.

      (2)(A) Each State electing to satisfy the requirements of this
    subsection for purposes of section 1396a(a)(46)(B) of this title
    shall establish a program under which the State submits at least
    monthly to the Commissioner of Social Security for comparison of
    the name and social security number, of each individual newly
    enrolled in the State plan under this subchapter that month who is
    not described in section 1396b(x)(2) of this title and who declares
    to be a United States citizen or national, with information in
    records maintained by the Commissioner.
      (B) In establishing the State program under this paragraph, the
    State may enter into an agreement with the Commissioner of Social
    Security - 
        (i) to provide, through an on-line system or otherwise, for the
      electronic submission of, and response to, the information
      submitted under subparagraph (A) for an individual enrolled in
      the State plan under this subchapter who declares to be )20(!
      citizen or national on at least a monthly basis; or

        (ii) to provide for a determination of the consistency of the
      information submitted with the information maintained in the
      records of the Commissioner through such other method as agreed
      to by the State and the Commissioner and approved by the
      Secretary, provided that such method is no more burdensome for
      individuals to comply with than any burdens that may apply under
      a method described in clause (i).

      (C) The program established under this paragraph shall provide
    that, in the case of any individual who is required to submit a
    social security number to the State under subparagraph (A) and who
    is unable to provide the State with such number, shall be provided
    with at least the reasonable opportunity to present satisfactory
    documentary evidence of citizenship or nationality (as defined in
    section 1396b(x)(3) of this title) as is provided under clauses (i)
    and (ii) of section 1320b-7(d)(4)(A) of this title to an individual
    for the submittal to the State of evidence indicating a
    satisfactory immigration status.
      (3)(A) The State agency implementing the plan approved under this
    subchapter shall, at such times and in such form as the Secretary
    may specify, provide information on the percentage each month that
    the inconsistent submissions bears to the total submissions made
    for comparison for such month. For purposes of this subparagraph, a
    name, social security number, or declaration of citizenship or
    nationality of an individual shall be treated as inconsistent and
    included in the determination of such percentage only if - 
        (i) the information submitted by the individual is not
      consistent with information in records maintained by the
      Commissioner of Social Security;
        (ii) the inconsistency is not resolved by the State;
        (iii) the individual was provided with a reasonable period of
      time to resolve the inconsistency with the Commissioner of Social
      Security or provide satisfactory documentation of citizenship
      status and did not successfully resolve such inconsistency; and
        (iv) payment has been made for an item or service furnished to
      the individual under this subchapter.

      (B) If, for any fiscal year, the average monthly percentage
    determined under subparagraph (A) is greater than 3 percent - 
        (i) the State shall develop and adopt a corrective plan to
      review its procedures for verifying the identities of individuals
      seeking to enroll in the State plan under this subchapter and to
      identify and implement changes in such procedures to improve
      their accuracy; and
        (ii) pay to the Secretary an amount equal to the amount which
      bears the same ratio to the total payments under the State plan
      for the fiscal year for providing medical assistance to
      individuals who provided inconsistent information as the number
      of individuals with inconsistent information in excess of 3
      percent of such total submitted bears to the total number of
      individuals with inconsistent information.

      (C) The Secretary may waive, in certain limited cases, all or
    part of the payment under subparagraph (B)(ii) if the State is
    unable to reach the allowable error rate despite a good faith
    effort by such State.
      (D) Subparagraphs (A) and (B) shall not apply to a State for a
    fiscal year if there is an agreement described in paragraph (2)(B)
    in effect as of the close of the fiscal year that provides for the
    submission on a real-time basis of the information described in
    such paragraph.
      (4) Nothing in this subsection shall affect the rights of any
    individual under this subchapter to appeal any disenrollment from a
    State plan.
    (ff) Disregard of certain property in determination of eligibility
      of Indians
      Notwithstanding any other requirement of this subchapter or any
    other provision of Federal or State law, a State shall disregard
    the following property from resources for purposes of determining
    the eligibility of an individual who is an Indian for medical
    assistance under this subchapter:
        (1) Property, including real property and improvements, that is
      held in trust, subject to Federal restrictions, or otherwise
      under the supervision of the Secretary of the Interior, located
      on a reservation, including any federally recognized Indian
      Tribe's reservation, pueblo, or colony, including former
      reservations in Oklahoma, Alaska Native regions established by
      the Alaska Native Claims Settlement Act [43 U.S.C. 1601 et seq.],
      and Indian allotments on or near a reservation as designated and
      approved by the Bureau of Indian Affairs of the Department of the
      Interior.
        (2) For any federally recognized Tribe not described in
      paragraph (1), property located within the most recent boundaries
      of a prior Federal reservation.
        (3) Ownership interests in rents, leases, royalties, or usage
      rights related to natural resources (including extraction of
      natural resources or harvesting of timber, other plants and plant
      products, animals, fish, and shellfish) resulting from the
      exercise of federally protected rights.
        (4) Ownership interests in or usage rights to items not covered
      by paragraphs (1) through (3) that have unique religious,
      spiritual, traditional, or cultural significance or rights that
      support subsistence or a traditional lifestyle according to
      applicable tribal law or custom.
    (gg) Maintenance of effort
      (1) General requirement to maintain eligibility standards until
        State exchange is fully operational
        Subject to the succeeding paragraphs of this subsection, during
      the period that begins on March 23, 2010, and ends on the date on
      which the Secretary determines that an Exchange established by
      the State under section 18031 of this title is fully operational,
      as a condition for receiving any Federal payments under section
      1396b(a) of this title for calendar quarters occurring during
      such period, a State shall not have in effect eligibility
      standards, methodologies, or procedures under the State plan
      under this subchapter or under any waiver of such plan that is in
      effect during that period, that are more restrictive than the
      eligibility standards, methodologies, or procedures,
      respectively, under the plan or waiver that are in effect on
      March 23, 2010.
      (2) Continuation of eligibility standards for children until
        October 1, 2019
        The requirement under paragraph (1) shall continue to apply to
      a State through September 30, 2019, with respect to the
      eligibility standards, methodologies, and procedures under the
      State plan under this subchapter or under any waiver of such plan
      that are applicable to determining the eligibility for medical
      assistance of any child who is under 19 years of age (or such
      higher age as the State may have elected).
      (3) Nonapplication
        During the period that begins on January 1, 2011, and ends on
      December 31, 2013, the requirement under paragraph (1) shall not
      apply to a State with respect to nonpregnant, nondisabled adults
      who are eligible for medical assistance under the State plan or
      under a waiver of the plan at the option of the State and whose
      income exceeds 133 percent of the poverty line (as defined in
      section 1397jj(c)(5) of this title) applicable to a family of the
      size involved if, on or after December 31, 2010, the State
      certifies to the Secretary that, with respect to the State fiscal
      year during which the certification is made, the State has a
      budget deficit, or with respect to the succeeding State fiscal
      year, the State is projected to have a budget deficit. Upon
      submission of such a certification to the Secretary, the
      requirement under paragraph (1) shall not apply to the State with
      respect to any remaining portion of the period described in the
      preceding sentence.
      (4) Determination of compliance
        (A) States shall apply modified adjusted gross income
          A State's determination of income in accordance with
        subsection (e)(14) shall not be considered to be eligibility
        standards, methodologies, or procedures that are more
        restrictive than the standards, methodologies, or procedures in
        effect under the State plan or under a waiver of the plan on
        March 23, 2010, for purposes of determining compliance with the
        requirements of paragraph (1), (2), or (3).
        (B) States may expand eligibility or move waivered populations
          into coverage under the State plan
          With respect to any period applicable under paragraph (1),
        (2), or (3), a State that applies eligibility standards,
        methodologies, or procedures under the State plan under this
        subchapter or under any waiver of the plan that are less
        restrictive than the eligibility standards, methodologies, or
        procedures, applied under the State plan or under a waiver of
        the plan on March 23, 2010, or that makes individuals who, on
        March 23, 2010, are eligible for medical assistance under a
        waiver of the State plan, after March 23, 2010, eligible for
        medical assistance through a State plan amendment with an
        income eligibility level that is not less than the income
        eligibility level that applied under the waiver, or as a result
        of the application of subclause (VIII) of subsection
        (a)(10)(A)(i), shall not be considered to have in effect
        eligibility standards, methodologies, or procedures that are
        more restrictive than the standards, methodologies, or
        procedures in effect under the State plan or under a waiver of
        the plan on March 23, 2010, for purposes of determining
        compliance with the requirements of paragraph (1), (2), or (3).
    (hh) State option for coverage for individuals with income that
      exceeds 133 percent of the poverty line
      (1) A State may elect to phase-in the extension of eligibility
    for medical assistance to individuals described in subclause (XX)
    of subsection (a)(10)(A)(ii) based on the categorical group
    (including nonpregnant childless adults) or income, so long as the
    State does not extend such eligibility to individuals described in
    such subclause with higher income before making individuals
    described in such subclause with lower income eligible for medical
    assistance.
      (2) If an individual described in subclause (XX) of subsection
    (a)(10)(A)(ii) is the parent of a child who is under 19 years of
    age (or such higher age as the State may have elected) who is
    eligible for medical assistance under the State plan or under a
    waiver of such plan, the individual may not be enrolled under the
    State plan unless the individual's child is enrolled under the
    State plan or under a waiver of the plan or is enrolled in other
    health insurance coverage. For purposes of the preceding sentence,
    the term "parent" includes an individual treated as a caretaker
    relative for purposes of carrying out section 1396u-1 of this
    title.
    (ii) State eligibility option for family planning services
      (1) Individuals described in this subsection are individuals - 
        (A) whose income does not exceed an income eligibility level
      established by the State that does not exceed the highest income
      eligibility level established under the State plan under this
      subchapter (or under its State child health plan under subchapter
      XXI) for pregnant women; and
        (B) who are not pregnant.

      (2) At the option of a State, individuals described in this
    subsection may include individuals who, had individuals applied on
    or before January 1, 2007, would have been made eligible pursuant
    to the standards and processes imposed by that State for benefits
    described in clause (XVI) of the matter following subparagraph (G)
    of section )21(! subsection (a)(10) pursuant to a waiver granted
    under section 1315 of this title.

      (3) At the option of a State, for purposes of subsection
    (a)(17)(B), in determining eligibility for services under this
    subsection, the State may consider only the income of the applicant
    or recipient.
    (jj) Primary care services defined
      For purposes of subsection (a)(13)(C), the term "primary care
    services" means - 
        (1) evaluation and management services that are procedure codes
      (for services covered under subchapter XVIII) for services in the
      category designated Evaluation and Management in the Healthcare
      Common Procedure Coding System (established by the Secretary
      under section 1395w-4(c)(5) of this title as of December 31,
      2009, and as subsequently modified); and
        (2) services related to immunization administration for
      vaccines and toxoids for which CPT codes 90465, 90466, 90467,
      90468, 90471, 90472, 90473, or 90474 (as subsequently modified)
      apply under such System.
    (kk) Provider and supplier screening, oversight, and reporting
      requirements
      For purposes of subsection (a)(77), the requirements of this
    subsection are the following:
      (1) Screening
        The State complies with the process for screening providers and
      suppliers under this subchapter, as established by the Secretary
      under section 1395cc(j)(2) (!1) of this title.
      (2) Provisional period of enhanced oversight for new providers
        and suppliers
        The State complies with procedures to provide for a provisional
      period of enhanced oversight for new providers and suppliers
      under this subchapter, as established by the Secretary under
      section 1395cc(j)(3) (!1) of this title.
      (3) Disclosure requirements
        The State requires providers and suppliers under the State plan
      or under a waiver of the plan to comply with the disclosure
      requirements established by the Secretary under section
      1395cc(j)(4) (!1) of this title.
      (4) Temporary moratorium on enrollment of new providers or
        suppliers
        (A) Temporary moratorium imposed by the Secretary
          (i) In general
            Subject to clause (ii), the State complies with any
          temporary moratorium on the enrollment of new providers or
          suppliers imposed by the Secretary under section 1395cc(j)(6)
          (!1) of this title.
          (ii) Exception
            A State shall not be required to comply with a temporary
          moratorium described in clause (i) if the State determines
          that the imposition of such temporary moratorium would
          adversely impact beneficiaries' access to medical assistance.
        (B) Moratorium on enrollment of providers and suppliers
          At the option of the State, the State imposes, for purposes
        of entering into participation agreements with providers or
        suppliers under the State plan or under a waiver of the plan,
        periods of enrollment moratoria, or numerical caps or other
        limits, for providers or suppliers identified by the Secretary
        as being at high-risk for fraud, waste, or abuse as necessary
        to combat fraud, waste, or abuse, but only if the State
        determines that the imposition of any such period, cap, or
        other limits would not adversely impact beneficiaries' access
        to medical assistance.
      (5) Compliance programs
        The State requires providers and suppliers under the State plan
      or under a waiver of the plan to establish, in accordance with
      the requirements of section 1395cc(j)(7) (!1) of this title, a
      compliance program that contains the core elements established
      under subparagraph (B) of that section 1395cc(j)(7) (!1) of this
      title for providers or suppliers within a particular industry or
      category.
      (6) Reporting of adverse provider actions
        The State complies with the national system for reporting
      criminal and civil convictions, sanctions, negative licensure
      actions, and other adverse provider actions to the Secretary,
      through the Administrator of the Centers for Medicare & Medicaid
      Services, in accordance with regulations of the Secretary.
      (7) Enrollment and NPI of ordering or referring providers
        The State requires - 
          (A) all ordering or referring physicians or other
        professionals to be enrolled under the State plan or under a
        waiver of the plan as a participating provider; and
          (B) the national provider identifier of any ordering or
        referring physician or other professional to be specified on
        any claim for payment that is based on an order or referral of
        the physician or other professional.
      (8) Other State oversight
        Nothing in this subsection shall be interpreted to preclude or
      limit the ability of a State to engage in provider and supplier
      screening or enhanced provider and supplier oversight activities
      beyond those required by the Secretary.