42 U.S.C. § 1396d : US Code - Section 1396D: Definitions

Search 42 U.S.C. § 1396d : US Code - Section 1396D: Definitions

For purposes of this subchapter -
(a) Medical assistance
The term "medical assistance" means payment of part or all of the
cost of the following care and services (if provided in or after
the third month before the month in which the recipient makes
application for assistance or, in the case of medicare cost-sharing
with respect to a qualified medicare beneficiary described in
subsection (p)(1) of this section, if provided after the month in
which the individual becomes such a beneficiary) for individuals,
and, with respect to physicians' or dentists' services, at the
option of the State, to individuals (other than individuals with
respect to whom there is being paid, or who are eligible, or would
be eligible if they were not in a medical institution, to have paid
with respect to them a State supplementary payment and are eligible
for medical assistance equal in amount, duration, and scope to the
medical assistance made available to individuals described in
section 1396a(a)(10)(A) of this title) not receiving aid or
assistance under any plan of the State approved under subchapter I,
X, XIV, or XVI of this chapter, 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,
who are -
(i) under the age of 21, or, at the option of the State, under
the age of 20, 19, or 18 as the State may choose,
(ii) relatives specified in section 606(b)(1) (!1) of this
title with whom a child is living if such child is (or would, if
needy, be) a dependent child under part A of subchapter IV of
this chapter,
(iii) 65 years of age or older,
(iv) blind, with respect to States eligible to participate in
the State plan program established under subchapter XVI of this
chapter,
(v) 18 years of age or older and permanently and totally
disabled, with respect to States eligible to participate in the
State plan program established under subchapter XVI of this
chapter,
(vi) persons essential (as described in the second sentence of
this subsection) to individuals receiving aid or assistance under
State plans approved under subchapter I, X, XIV, or XVI of this
chapter,
(vii) blind or disabled as defined in section 1382c of this
title, with respect to States not eligible to participate in the
State plan program established under subchapter XVI of this
chapter,
(viii) pregnant women,
(ix) individuals provided extended benefits under section 1396r-
6 of this title,
(x) individuals described in section 1396a(u)(1) of this title,
(xi) individuals described in section 1396a(z)(1) of this
title,
(xii) employed individuals with a medically improved disability
(as defined in subsection (v) of this section), or
(xiii) individuals described in section 1396a(aa) (!2) of this
title,
but whose income and resources are insufficient to meet all of such
cost -
(1) inpatient hospital services (other than services in an
institution for mental diseases);
(2)(A) outpatient hospital services, (B) consistent with State
law permitting such services, rural health clinic services (as
defined in subsection (l)(1) of this section) and any other
ambulatory services which are offered by a rural health clinic
(as defined in subsection (l)(1) of this section) and which are
otherwise included in the plan, and (C) Federally-qualified
health center services (as defined in subsection (l)(2) of this
section) and any other ambulatory services offered by a Federally-
qualified health center and which are otherwise included in the
plan;
(3) other laboratory and X-ray services;
(4)(A) nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age
or older; (B) early and periodic screening, diagnostic, and
treatment services (as defined in subsection (r) of this section)
for individuals who are eligible under the plan and are under the
age of 21; and (C) family planning services and supplies
furnished (directly or under arrangements with others) to
individuals of child-bearing age (including minors who can be
considered to be sexually active) who are eligible under the
State plan and who desire such services and supplies;
(5)(A) physicians' services furnished by a physician (as
defined in section 1395x(r)(1) of this title), whether furnished
in the office, the patient's home, a hospital, or a nursing
facility, or elsewhere, and (B) medical and surgical services
furnished by a dentist (described in section 1395x(r)(2) of this
title) to the extent such services may be performed under State
law either by a doctor of medicine or by a doctor of dental
surgery or dental medicine and would be described in clause (A)
if furnished by a physician (as defined in section 1395x(r)(1) of
this title);
(6) medical care, or any other type of remedial care recognized
under State law, furnished by licensed practitioners within the
scope of their practice as defined by State law;
(7) home health care services;
(8) private duty nursing services;
(9) clinic services furnished by or under the direction of a
physician, without regard to whether the clinic itself is
administered by a physician, including such services furnished
outside the clinic by clinic personnel to an eligible individual
who does not reside in a permanent dwelling or does not have a
fixed home or mailing address;
(10) dental services;
(11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in diseases of the
eye or by an optometrist, whichever the individual may select;
(13) other diagnostic, screening, preventive, and
rehabilitative services, including any medical or remedial
services (provided in a facility, a home, or other setting)
recommended by a physician or other licensed practitioner of the
healing arts within the scope of their practice under State law,
for the maximum reduction of physical or mental disability and
restoration of an individual to the best possible functional
level;
(14) inpatient hospital services and nursing facility services
for individuals 65 years of age or over in an institution for
mental diseases;
(15) services in an intermediate care facility for the mentally
retarded (other than in an institution for mental diseases) for
individuals who are determined, in accordance with section
1396a(a)(31) of this title, to be in need of such care;
(16) effective January 1, 1973, inpatient psychiatric hospital
services for individuals under age 21, as defined in subsection
(h) of this section;
(17) services furnished by a nurse-midwife (as defined in
section 1395x(gg) of this title) which the nurse-midwife is
legally authorized to perform under State law (or the State
regulatory mechanism provided by State law), whether or not the
nurse-midwife is under the supervision of, or associated with, a
physician or other health care provider, and without regard to
whether or not the services are performed in the area of
management of the care of mothers and babies throughout the
maternity cycle;
(18) hospice care (as defined in subsection (o) of this
section);
(19) case management services (as defined in section
1396n(g)(2) of this title) and TB-related services described in
section 1396a(z)(2)(F) of this title;
(20) respiratory care services (as defined in section
1396a(e)(9)(C) of this title);
(21) services furnished by a certified pediatric nurse
practitioner or certified family nurse practitioner (as defined
by the Secretary) which the certified pediatric nurse
practitioner or certified family nurse practitioner is legally
authorized to perform under State law (or the State regulatory
mechanism provided by State law), whether or not the certified
pediatric nurse practitioner or certified family nurse
practitioner is under the supervision of, or associated with, a
physician or other health care provider;
(22) home and community care (to the extent allowed and as
defined in section 1396t of this title) for functionally disabled
elderly individuals;
(23) community supported living arrangements services (to the
extent allowed and as defined in section 1396u of this title);
(24) personal care services furnished to an individual who is
not an inpatient or resident of a hospital, nursing facility,
intermediate care facility for the mentally retarded, or
institution for mental disease that are (A) authorized for the
individual by a physician in accordance with a plan of treatment
or (at the option of the State) otherwise authorized for the
individual in accordance with a service plan approved by the
State, (B) provided by an individual who is qualified to provide
such services and who is not a member of the individual's family,
and (C) furnished in a home or other location;
(25) primary care case management services (as defined in
subsection (t) of this section);
(26) services furnished under a PACE program under section
1396u-4 of this title to PACE program eligible individuals
enrolled under the program under such section;
(27) subject to subsection (x) of this section, primary and
secondary medical strategies and treatment and services for
individuals who have Sickle Cell Disease; and
(28) any other medical care, and any other type of remedial
care recognized under State law, specified by the Secretary,
except as otherwise provided in paragraph (16), such term does not
include -
(A) any such payments with respect to care or services for any
individual who is an inmate of a public institution (except as a
patient in a medical institution); or
(B) any such payments with respect to care or services for any
individual who has not attained 65 years of age and who is a
patient in an institution for mental diseases.
For purposes of clause (vi) of the preceding sentence, a person
shall be considered essential to another individual if such person
is the spouse of and is living with such individual, the needs of
such person are taken into account in determining the amount of aid
or assistance furnished to such individual (under a State plan
approved under subchapter I, X, XIV, or XVI of this chapter), and
such person is determined, under such a State plan, to be essential
to the well-being of such individual. The payment described in the
first sentence may include expenditures for medicare cost-sharing
and for premiums under part B of subchapter XVIII of this chapter
for individuals who are eligible for medical assistance under the
plan and (A) are receiving aid or assistance under any plan of the
State approved under subchapter I, X, XIV, or XVI of this chapter,
or part A of subchapter IV of this chapter, or with respect to whom
supplemental security income benefits are being paid under
subchapter XVI of this chapter, or (B) with respect to whom there
is being paid a State supplementary payment and are eligible for
medical assistance equal in amount, duration, and scope to the
medical assistance made available to individuals described in
section 1396a(a)(10)(A) of this title, and, except in the case of
individuals 65 years of age or older and disabled individuals
entitled to health insurance benefits under subchapter XVIII of
this chapter who are not enrolled under part B of subchapter XVIII
of this chapter, other insurance premiums for medical or any other
type of remedial care or the cost thereof. No service (including
counseling) shall be excluded from the definition of "medical
assistance" solely because it is provided as a treatment service
for alcoholism or drug dependency.
(b) Federal medical assistance percentage; State percentage; Indian
health care percentage
Subject to section 1396u-3(d) of this title, the term "Federal
medical assistance percentage" for any State shall be 100 per
centum less the State percentage; and the State percentage shall be
that percentage which bears the same ratio to 45 per centum as the
square of the per capita income of such State bears to the square
of the per capita income of the continental United States
(including Alaska) and Hawaii; except that (1) the Federal medical
assistance percentage shall in no case be less than 50 per centum
or more than 83 per centum, (2) the Federal medical assistance
percentage for Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa shall be 50 per centum, (3) for
purposes of this subchapter and subchapter XXI of this chapter, the
Federal medical assistance percentage for the District of Columbia
shall be 70 percent, and (4) the Federal medical assistance
percentage shall be equal to the enhanced FMAP described in section
1397ee(b) of this title with respect to medical assistance provided
to individuals who are eligible for such assistance only on the
basis of section 1396a(a)(10)(A)(ii)(XVIII) of this title. The
Federal medical assistance percentage for any State shall be
determined and promulgated in accordance with the provisions of
section 1301(a)(8)(B) of this title. Notwithstanding the first
sentence of this section, the Federal medical assistance percentage
shall be 100 per centum with respect to amounts expended as medical
assistance for services which are received through an Indian Health
Service facility whether operated by the Indian Health Service or
by an Indian tribe or tribal organization (as defined in section
1603 of title 25). Notwithstanding the first sentence of this
subsection, in the case of a State plan that meets the condition
described in subsection (u)(1) of this section, with respect to
expenditures (other than expenditures under section 1396r-4 of this
title) described in subsection (u)(2)(A) of this section or
subsection (u)(3) of this section for the State for a fiscal year,
and that do not exceed the amount of the State's available
allotment under section 1397dd of this title, the Federal medical
assistance percentage is equal to the enhanced FMAP described in
section 1397ee(b) of this title.
(c) Nursing facility
For definition of the term "nursing facility", see section
1396r(a) of this title.
(d) Intermediate care facility for mentally retarded
The term "intermediate care facility for the mentally retarded"
means an institution (or distinct part thereof) for the mentally
retarded or persons with related conditions if -
(1) the primary purpose of such institution (or distinct part
thereof) is to provide health or rehabilitative services for
mentally retarded individuals and the institution meets such
standards as may be prescribed by the Secretary;
(2) the mentally retarded individual with respect to whom a
request for payment is made under a plan approved under this
subchapter is receiving active treatment under such a program;
and
(3) in the case of a public institution, the State or political
subdivision responsible for the operation of such institution has
agreed that the non-Federal expenditures in any calendar quarter
prior to January 1, 1975, with respect to services furnished to
patients in such institution (or distinct part thereof) in the
State will not, because of payments made under this subchapter,
be reduced below the average amount expended for such services in
such institution in the four quarters immediately preceding the
quarter in which the State in which such institution is located
elected to make such services available under its plan approved
under this subchapter.
(e) Physicians' services
In the case of any State the State plan of which (as approved
under this subchapter) -
(1) does not provide for the payment of services (other than
services covered under section 1396a(a)(12) of this title)
provided by an optometrist; but
(2) at a prior period did provide for the payment of services
referred to in paragraph (1);
the term "physicians' services" (as used in subsection (a)(5) of
this section) shall include services of the type which an
optometrist is legally authorized to perform where the State plan
specifically provides that the term "physicians' services", as
employed in such plan, includes services of the type which an
optometrist is legally authorized to perform, and shall be
reimbursed whether furnished by a physician or an optometrist.
(f) Nursing facility services
For purposes of this subchapter, the term "nursing facility
services" means services which are or were required to be given an
individual who needs or needed on a daily basis nursing care
(provided directly by or requiring the supervision of nursing
personnel) or other rehabilitation services which as a practical
matter can only be provided in a nursing facility on an inpatient
basis.
(g) Chiropractors' services
If the State plan includes provision of chiropractors' services,
such services include only -
(1) services provided by a chiropractor (A) who is licensed as
such by the State and (B) who meets uniform minimum standards
promulgated by the Secretary under section 1395x(r)(5) of this
title; and
(2) services which consist of treatment by means of manual
manipulation of the spine which the chiropractor is legally
authorized to perform by the State.
(h) Inpatient psychiatric hospital services for individuals under
age 21
(1) For purposes of paragraph (16) of subsection (a) of this
section, the term "inpatient psychiatric hospital services for
individuals under age 21" includes only -
(A) inpatient services which are provided in an institution (or
distinct part thereof) which is a psychiatric hospital as defined
in section 1395x(f) of this title or in another inpatient setting
that the Secretary has specified in regulations;
(B) inpatient services which, in the case of any individual (i)
involve active treatment which meets such standards as may be
prescribed in regulations by the Secretary, and (ii) a team,
consisting of physicians and other personnel qualified to make
determinations with respect to mental health conditions and the
treatment thereof, has determined are necessary on an inpatient
basis and can reasonably be expected to improve the condition, by
reason of which such services are necessary, to the extent that
eventually such services will no longer be necessary; and
(C) inpatient services which, in the case of any individual,
are provided prior to (i) the date such individual attains age
21, or (ii) in the case of an individual who was receiving such
services in the period immediately preceding the date on which he
attained age 21, (I) the date such individual no longer requires
such services, or (II) if earlier, the date such individual
attains age 22;
(2) Such term does not include services provided during any
calendar quarter under the State plan of any State if the total
amount of the funds expended, during such quarter, by the State
(and the political subdivisions thereof) from non-Federal funds for
inpatient services included under paragraph (1), and for active
psychiatric care and treatment provided on an outpatient basis for
eligible mentally ill children, is less than the average quarterly
amount of the funds expended, during the 4-quarter period ending
December 31, 1971, by the State (and the political subdivisions
thereof) from non-Federal funds for such services.
(i) Institution for mental diseases
The term "institution for mental diseases" means a hospital,
nursing facility, or other institution of more than 16 beds, that
is primarily engaged in providing diagnosis, treatment, or care of
persons with mental diseases, including medical attention, nursing
care, and related services.
(j) State supplementary payment
The term "State supplementary payment" means any cash payment
made by a State on a regular basis to an individual who is
receiving supplemental security income benefits under subchapter
XVI of this chapter or who would but for his income be eligible to
receive such benefits, as assistance based on need in
supplementation of such benefits (as determined by the Commissioner
of Social Security), but only to the extent that such payments are
made with respect to an individual with respect to whom
supplemental security income benefits are payable under subchapter
XVI of this chapter, or would but for his income be payable under
that subchapter.
(k) Supplemental security income benefits
Increased supplemental security income benefits payable pursuant
to section 211 of Public Law 93-66 shall not be considered
supplemental security income benefits payable under subchapter XVI
of this chapter.
(l) Rural health clinics
(1) The terms "rural health clinic services" and "rural health
clinic" have the meanings given such terms in section 1395x(aa) of
this title, except that (A) clause (ii) of section 1395x(aa)(2) of
this title shall not apply to such terms, and (B) the physician
arrangement required under section 1395x(aa)(2)(B) of this title
shall only apply with respect to rural health clinic services and,
with respect to other ambulatory care services, the physician
arrangement required shall be only such as may be required under
the State plan for those services.
(2)(A) The term "Federally-qualified health center services"
means services of the type described in subparagraphs (A) through
(C) of section 1395x(aa)(1) of this title when furnished to an
individual as an (!3) patient of a Federally-qualified health
center and, for this purpose, any reference to a rural health
clinic or a physician described in section 1395x(aa)(2)(B) of this
title is deemed a reference to a Federally-qualified health center
or a physician at the center, respectively.
(B) The term "Federally-qualified health center" means an entity
which -
(i) is receiving a grant under section 254b of this title,
(ii)(I) is receiving funding from such a grant under a contract
with the recipient of such a grant, and
(II) meets the requirements to receive a grant under section
254b of this title,
(iii) based on the recommendation of the Health Resources and
Services Administration within the Public Health Service, is
determined by the Secretary to meet the requirements for
receiving such a grant, including requirements of the Secretary
that an entity may not be owned, controlled, or operated by
another entity, or
(iv) was treated by the Secretary, for purposes of part B of
subchapter XVIII of this chapter, as a comprehensive Federally
funded health center as of January 1, 1990;
and includes an outpatient health program or facility operated by a
tribe or tribal organization under the Indian Self-Determination
Act (Public Law 93-638) [25 U.S.C. 450f et seq.] or by an urban
Indian organization receiving funds under title V of the Indian
Health Care Improvement Act [25 U.S.C. 1651 et seq.] for the
provision of primary health services. In applying clause (ii),(!4)
the Secretary may waive any requirement referred to in such clause
for up to 2 years for good cause shown.
(m) Qualified family member
(1) Subject to paragraph (2), the term "qualified family member"
means an individual (other than a qualified pregnant woman or
child, as defined in subsection (n) of this section) who is a
member of a family that would be receiving aid under the State plan
under part A of subchapter IV of this chapter pursuant to section
607 (!5) of this title if the State had not exercised the option
under section 607(b)(2)(B)(i) (!5) of this title.
(2) No individual shall be a qualified family member for any
period after September 30, 1998.
(n) "Qualified pregnant woman or child" defined
The term "qualified pregnant woman or child" means -
(1) a pregnant woman who -
(A) would be eligible for aid to families with dependent
children under part A of subchapter IV of this chapter (or
would be eligible for such aid if coverage under the State plan
under part A of subchapter IV of this chapter included aid to
families with dependent children of unemployed parents pursuant
to section 607 of this title) if her child had been born and
was living with her in the month such aid would be paid, and
such pregnancy has been medically verified;
(B) is a member of a family which would be eligible for aid
under the State plan under part A of subchapter IV of this
chapter pursuant to section 607 of this title if the plan
required the payment of aid pursuant to such section; or
(C) otherwise meets the income and resources requirements of
a State plan under part A of subchapter IV of this chapter; and
(2) a child who has not attained the age of 19, who was born
after September 30, 1983 (or such earlier date as the State may
designate), and who meets the income and resources requirements
of the State plan under part A of subchapter IV of this chapter.
(o) Optional hospice benefits
(1)(A) Subject to subparagraph (B), the term "hospice care" means
the care described in section 1395x(dd)(1) of this title furnished
by a hospice program (as defined in section 1395x(dd)(2) of this
title) to a terminally ill individual who has voluntarily elected
(in accordance with paragraph (2)) to have payment made for hospice
care instead of having payment made for certain benefits described
in section 1395d(d)(2)(A) of this title and for which payment may
otherwise be made under subchapter XVIII of this chapter and
intermediate care facility services under the plan. For purposes of
such election, hospice care may be provided to an individual while
such individual is a resident of a skilled nursing facility or
intermediate care facility, but the only payment made under the
State plan shall be for the hospice care.
(B) For purposes of this subchapter, with respect to the
definition of hospice program under section 1395x(dd)(2) of this
title, the Secretary may allow an agency or organization to make
the assurance under subparagraph (A)(iii) of such section without
taking into account any individual who is afflicted with acquired
immune deficiency syndrome (AIDS).
(2) An individual's voluntary election under this subsection -
(A) shall be made in accordance with procedures that are
established by the State and that are consistent with the
procedures established under section 1395d(d)(2) of this title;
(B) shall be for such a period or periods (which need not be
the same periods described in section 1395d(d)(1) of this title)
as the State may establish; and
(C) may be revoked at any time without a showing of cause and
may be modified so as to change the hospice program with respect
to which a previous election was made.
(3) In the case of an individual -
(A) who is residing in a nursing facility or intermediate care
facility for the mentally retarded and is receiving medical
assistance for services in such facility under the plan,
(B) who is entitled to benefits under part A of subchapter
XVIII of this chapter and has elected, under section 1395d(d) of
this title, to receive hospice care under such part, and
(C) with respect to whom the hospice program under such
subchapter and the nursing facility or intermediate care facility
for the mentally retarded have entered into a written agreement
under which the program takes full responsibility for the
professional management of the individual's hospice care and the
facility agrees to provide room and board to the individual,
instead of any payment otherwise made under the plan with respect
to the facility's services, the State shall provide for payment to
the hospice program of an amount equal to the additional amount
determined in section 1396a(a)(13)(B) of this title and, if the
individual is an individual described in section 1396a(a)(10)(A) of
this title, shall provide for payment of any coinsurance amounts
imposed under section 1395e(a)(4) of this title.
(p) Qualified medicare beneficiary; medicare cost-sharing
(1) The term "qualified medicare beneficiary" means an individual
-
(A) who is entitled to hospital insurance benefits under part A
of subchapter XVIII of this chapter (including an individual
entitled to such benefits pursuant to an enrollment under section
1395i-2 of this title, but not including an individual entitled
to such benefits only pursuant to an enrollment under section
1395i-2a 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)(D)) does not exceed an income
level established by the State consistent with paragraph (2), and
(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.
(2)(A) The income level established under paragraph (1)(B) shall
be at least the percent provided under subparagraph (B) (but not
more than 100 percent) of the official poverty line (as defined by
the Office of Management and Budget, and revised annually in
accordance with section 9902(2) of this title) applicable to a
family of the size involved.
(B) Except as provided in subparagraph (C), the percent provided
under this clause, with respect to eligibility for medical
assistance on or after -
(i) January 1, 1989, is 85 percent,
(ii) January 1, 1990, is 90 percent, and
(iii) January 1, 1991, is 100 percent.
(C) In the case of a State which has elected treatment under
section 1396a(f) of this title and which, as of January 1, 1987,
used an income standard for individuals age 65 or older which was
more restrictive than the income standard established under the
supplemental security income program under subchapter XVI of this
chapter, the percent provided under subparagraph (B), with respect
to eligibility for medical assistance on or after -
(i) January 1, 1989, is 80 percent,
(ii) January 1, 1990, is 85 percent,
(iii) January 1, 1991, is 95 percent, and
(iv) January 1, 1992, is 100 percent.
(D)(i) In determining under this subsection the income of an
individual who is entitled to monthly insurance benefits under
subchapter II of this chapter for a transition month (as defined in
clause (ii)) in a year, such income shall not include any amounts
attributable to an increase in the level of monthly insurance
benefits payable under such subchapter which have occurred pursuant
to section 415(i) of this title for benefits payable for months
beginning with December of the previous year.
(ii) For purposes of clause (i), the term "transition month"
means each month in a year through the month following the month in
which the annual revision of the official poverty line, referred to
in subparagraph (A), is published.
(3) The term "medicare cost-sharing" means (subject to section
1396a(n)(2) of this title) the following costs incurred with
respect to a qualified medicare beneficiary, without regard to
whether the costs incurred were for items and services for which
medical assistance is otherwise available under the plan:
(A)(i) premiums under section 1395i-2 or 1395i-2a of this
title, and
(ii) premiums under section 1395r of this title,(!6)
(B) Coinsurance under subchapter XVIII of this chapter
(including coinsurance described in section 1395e of this title).
(C) Deductibles established under subchapter XVIII of this
chapter (including those described in section 1395e of this title
and section 1395l(b) of this title).
(D) The difference between the amount that is paid under
section 1395l(a) of this title and the amount that would be paid
under such section if any reference to "80 percent" therein were
deemed a reference to "100 percent".
Such term also may include, at the option of a State, premiums for
enrollment of a qualified medicare beneficiary with an eligible
organization under section 1395mm of this title.
(4) Notwithstanding any other provision of this subchapter, in
the case of a State (other than the 50 States and the District of
Columbia) -
(A) the requirement stated in section 1396a(a)(10)(E) of this
title shall be optional, and
(B) for purposes of paragraph (2), the State may substitute for
the percent provided under subparagraph (B) (!7) or (!8)
1396a(a)(10)(E)(iii) of this title of such paragraph (!7) any
percent.
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 meet the
requirement of section 1396a(a)(10)(E) of this title in the same
manner as the State would be required to meet such requirement if
the State had in effect a plan approved under this subchapter.
(5)(A) The Secretary shall develop and distribute to States a
simplified application form for use by individuals (including both
qualified medicare beneficiaries and specified low-income medicare
beneficiaries) in applying for medical assistance for medicare cost-
sharing under this subchapter in the States which elect to use
such form. Such form shall be easily readable by applicants and
uniform nationally.
(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
(6) For provisions relating to outreach efforts to increase
awareness of the availability of medicare cost-sharing, see section
1320b-14 of this title.
(q) Qualified severely impaired individual
The term "qualified severely impaired individual" means an
individual under age 65 -
(1) who for the month preceding the first month to which this
subsection applies to such individual -
(A) received (i) a payment of supplemental security income
benefits under section 1382(b) of this title on the basis of
blindness or disability, (ii) a supplementary payment under
section 1382e of this title or under section 212 of Public Law
93-66 on such basis, (iii) a payment of monthly benefits under
section 1382h(a) of this title, or (iv) a supplementary payment
under section 1382e(c)(3), and
(B) was eligible for medical assistance under the State plan
approved under this subchapter; and
(2) with respect to whom the Commissioner of Social Security
determines that -
(A) the individual continues to be blind or continues to have
the disabling physical or mental impairment on the basis of
which he was found to be under a disability and, except for his
earnings, continues to meet all non-disability-related
requirements for eligibility for benefits under subchapter XVI
of this chapter,
(B) the income of such individual would not, except for his
earnings, be equal to or in excess of the amount which would
cause him to be ineligible for payments under section 1382(b)
of this title (if he were otherwise eligible for such
payments),
(C) the lack of eligibility for benefits under this
subchapter would seriously inhibit his ability to continue or
obtain employment, and
(D) the individual's earnings are not sufficient to allow him
to provide for himself a reasonable equivalent of the benefits
under subchapter XVI of this chapter (including any federally
administered State supplementary payments), this subchapter,
and publicly funded attendant care services (including personal
care assistance) that would be available to him in the absence
of such earnings.
In the case of an individual who is eligible for medical assistance
pursuant to section 1382h(b) of this title in June, 1987, the
individual shall be a qualified severely impaired individual for so
long as such individual meets the requirements of paragraph (2).
(r) Early and periodic screening, diagnostic, and treatment
services
The term "early and periodic screening, diagnostic, and treatment
services" means the following items and services:
(1) Screening services -
(A) which are provided -
(i) at intervals which meet reasonable standards of medical
and dental practice, as determined by the State after
consultation with recognized medical and dental organizations
involved in child health care and, with respect to
immunizations under subparagraph (B)(iii), in accordance with
the schedule referred to in section 1396s(c)(2)(B)(i) of this
title for pediatric vaccines, and
(ii) at such other intervals, indicated as medically
necessary, to determine the existence of certain physical or
mental illnesses or conditions; and
(B) which shall at a minimum include -
(i) a comprehensive health and developmental history
(including assessment of both physical and mental health
development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations (according to the schedule
referred to in section 1396s(c)(2)(B)(i) of this title for
pediatric vaccines) according to age and health history,
(iv) laboratory tests (including lead blood level
assessment appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).
(2) Vision services -
(A) which are provided -
(i) at intervals which meet reasonable standards of medical
practice, as determined by the State after consultation with
recognized medical organizations involved in child health
care, and
(ii) at such other intervals, indicated as medically
necessary, to determine the existence of a suspected illness
or condition; and
(B) which shall at a minimum include diagnosis and treatment
for defects in vision, including eyeglasses.
(3) Dental services -
(A) which are provided -
(i) at intervals which meet reasonable standards of dental
practice, as determined by the State after consultation with
recognized dental organizations involved in child health
care, and
(ii) at such other intervals, indicated as medically
necessary, to determine the existence of a suspected illness
or condition; and
(B) which shall at a minimum include relief of pain and
infections, restoration of teeth, and maintenance of dental
health.
(4) Hearing services -
(A) which are provided -
(i) at intervals which meet reasonable standards of medical
practice, as determined by the State after consultation with
recognized medical organizations involved in child health
care, and
(ii) at such other intervals, indicated as medically
necessary, to determine the existence of a suspected illness
or condition; and
(B) which shall at a minimum include diagnosis and treatment
for defects in hearing, including hearing aids.
(5) Such other necessary health care, diagnostic services,
treatment, and other measures described in subsection (a) of this
section to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by the screening services,
whether or not such services are covered under the State plan.
Nothing in this subchapter shall be construed as limiting providers
of early and periodic screening, diagnostic, and treatment services
to providers who are qualified to provide all of the items and
services described in the previous sentence or as preventing a
provider that is qualified under the plan to furnish one or more
(but not all) of such items or services from being qualified to
provide such items and services as part of early and periodic
screening, diagnostic, and treatment services. The Secretary shall,
not later than July 1, 1990, and every 12 months thereafter,
develop and set annual participation goals for each State for
participation of individuals who are covered under the State plan
under this subchapter in early and periodic screening, diagnostic,
and treatment services.
(s) Qualified disabled and working individual
The term "qualified disabled and working individual" means an
individual -
(1) who is entitled to enroll for hospital insurance benefits
under part A of subchapter XVIII of this chapter under section
1395i-2a of this title;
(2) whose income (as determined under section 1382a of this
title for purposes of the supplemental security income program)
does not exceed 200 percent of the official poverty line (as
defined by the Office of Management and Budget and revised
annually in accordance with section 9902(2) of this title)
applicable to a family of the size involved;
(3) 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 or a couple (in the case of an individual with a
spouse) may have and obtain benefits for supplemental security
income benefits under subchapter XVI of this chapter; and
(4) who is not otherwise eligible for medical assistance under
this subchapter.
(t) Primary care case management services; primary care case
manager; primary care case management contract; and primary care
(1) The term "primary care case management services" means case-
management related services (including locating, coordinating, and
monitoring of health care services) provided by a primary care case
manager under a primary care case management contract.
(2) The term "primary care case manager" means any of the
following that provides services of the type described in paragraph
(1) under a contract referred to in such paragraph:
(A) A physician, a physician group practice, or an entity
employing or having other arrangements with physicians to provide
such services.
(B) At State option -
(i) a nurse practitioner (as described in subsection (a)(21)
of this section);
(ii) a certified nurse-midwife (as defined in section
1395x(gg) of this title); or
(iii) a physician assistant (as defined in section
1395x(aa)(5) of this title).
(3) The term "primary care case management contract" means a
contract between a primary care case manager and a State under
which the manager undertakes to locate, coordinate, and monitor
covered primary care (and such other covered services as may be
specified under the contract) to all individuals enrolled with the
manager, and which -
(A) provides for reasonable and adequate hours of operation,
including 24-hour availability of information, referral, and
treatment with respect to medical emergencies;
(B) restricts enrollment to individuals residing sufficiently
near a service delivery site of the manager to be able to reach
that site within a reasonable time using available and affordable
modes of transportation;
(C) provides for arrangements with, or referrals to, sufficient
numbers of physicians and other appropriate health care
professionals to ensure that services under the contract can be
furnished to enrollees promptly and without compromise to quality
of care;
(D) prohibits discrimination on the basis of health status or
requirements for health care services in enrollment,
disenrollment, or reenrollment of individuals eligible for
medical assistance under this subchapter;
(E) provides for a right for an enrollee to terminate
enrollment in accordance with section 1396u-2(a)(4) of this
title; and
(F) complies with the other applicable provisions of section
1396u-2 of this title.
(4) For purposes of this subsection, the term "primary care"
includes all health care services customarily provided in
accordance with State licensure and certification laws and
regulations, and all laboratory services customarily provided by or
through, a general practitioner, family medicine physician,
internal medicine physician, obstetrician/gynecologist, or
pediatrician.
(u) Conditions for State plans
(1) The conditions described in this paragraph for a State plan
are as follows:
(A) The State is complying with the requirement of section
1397ee(d)(1) of this title.
(B) The plan provides for such reporting of information about
expenditures and payments attributable to the operation of this
subsection as the Secretary deems necessary in order to carry out
the fourth sentence of subsection (b) of this section.
(2)(A) For purposes of subsection (b) of this section, the
expenditures described in this subparagraph are expenditures for
medical assistance for optional targeted low-income children
described in subparagraph (B).
(B) For purposes of this paragraph, the term "optional targeted
low-income child" means a targeted low-income child as defined in
section 1397jj(b)(1) of this title (determined without regard to
that portion of subparagraph (C) of such section concerning
eligibility for medical assistance under this subchapter) who would
not qualify for medical assistance under the State plan under this
subchapter as in effect on March 31, 1997 (but taking into account
the expansion of age of eligibility effected through the operation
of section 1396a(l)(1)(D) of this title).
(3) For purposes of subsection (b) of this section, the
expenditures described in this paragraph are expenditures for
medical assistance for children who are born before October 1,
1983, and who would be described in section 1396a(l)(1)(D) of this
title if they had been born on or after such date, and who are not
eligible for such assistance under the State plan under this
subchapter based on such State plan as in effect as of March 31,
1997.
(4) The limitations on payment under subsections (f) and (g) of
section 1308 of this title shall not apply to Federal payments made
under section 1396b(a)(1) of this title based on an enhanced FMAP
described in section 1397ee(b) of this title.
(v) Employed individual with a medically improved disability
(1) The term "employed individual with a medically improved
disability" means an individual who -
(A) is at least 16, but less than 65, years of age;
(B) is employed (as defined in paragraph (2));
(C) ceases to be eligible for medical assistance under section
1396a(a)(10)(A)(ii)(XV) of this title because the individual, by
reason of medical improvement, is determined at the time of a
regularly scheduled continuing disability review to no longer be
eligible for benefits under section 423(d) or 1382c(a)(3) of this
title; and
(D) continues to have a severe medically determinable
impairment, as determined under regulations of the Secretary.
(2) For purposes of paragraph (1), an individual is considered to
be "employed" if the individual -
(A) is earning at least the applicable minimum wage requirement
under section 206 of title 29 and working at least 40 hours per
month; or
(B) is engaged in a work effort that meets substantial and
reasonable threshold criteria for hours of work, wages, or other
measures, as defined by the State and approved by the Secretary.
(w) Independent foster care adolescent
(1) For purposes of this subchapter, the term "independent foster
care adolescent" means an individual -
(A) who is under 21 years of age;
(B) who, on the individual's 18th birthday, was in foster care
under the responsibility of a State; and
(C) whose assets, resources, and income do not exceed such
levels (if any) as the State may establish consistent with
paragraph (2).
(2) The levels established by a State under paragraph (1)(C) may
not be less than the corresponding levels applied by the State
under section 1396u-1(b) of this title.
(3) A State may limit the eligibility of independent foster care
adolescents under section 1396a(a)(10)(A)(ii)(XVII) of this title
to those individuals with respect to whom foster care maintenance
payments or independent living services were furnished under a
program funded under part E of subchapter IV of this chapter before
the date the individuals attained 18 years of age.
(x) Strategies, treatment, and services
For purposes of subsection (a)(27) of this section, the
strategies, treatment, and services described in that subsection
include the following:
(1) Chronic blood transfusion (with deferoxamine chelation) to
prevent stroke in individuals with Sickle Cell Disease who have
been identified as being at high risk for stroke.
(2) Genetic counseling and testing for individuals with Sickle
Cell Disease or the sickle cell trait to allow health care
professionals to treat such individuals and to prevent symptoms
of Sickle Cell Disease.
(3) Other treatment and services to prevent individuals who
have Sickle Cell Disease and who have had a stroke from having
another stroke.