SEC. 1905.
[42 U.S.C. 1396d] For purposes of this title—
(a)
The term “medical assistance” means
payment of part or all of the cost of the following care and services
(if provided in or after the third month before the month in which
the recipient makes application for assistance or, in the case
of medicare cost-sharing with respect to a qualified medicare
beneficiary described in subsection (p)(1), if provided after the
month in which the individual becomes such a beneficiary) for individuals,
and, with respect to physicians' or dentists' services, at the
option of the State, to individuals (other than individuals with
respect to whom there is being paid, or who are eligible, or would
be eligible if they were not in a medical institution, to have
paid with respect to them a State supplementary payment and are
eligible for medical assistance equal in amount, duration, and
scope to the medical assistance made available to individuals described
in section 1902(a)(10)(A)) not receiving aid or assistance under
any plan of the State approved under title I, X, XIV, or XVI, or
part A of title IV, and with respect to whom supplemental security
income benefits are not being paid under title XVI, who are—
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(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,
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(ii) relatives specified in section 406(b)(1) with whom a child
is living if such child is (or would, if needy, be) a dependent
child under part A of title IV,
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(iii) 65 years of age or older,
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(iv) blind, with respect to States eligible to participate in
the State plan program established under title XVI,
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(v) 18 years of age or older and permanently and totally disabled,
with respect to States eligible to participate in the State plan
program established under title XVI,
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(vi) persons essential (as described in the second sentence
of this subsection) to individuals receiving aid or assistance
under State plans approved under title I, X, XIV, or XVI,
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(vii) blind or disabled as defined in section 1614, with respect
to States not eligible to participate in the State plan program
established under title XVI,
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(viii) pregnant women,
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(ix) individuals provided extended benefits under section 1925,
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(x) individuals described in section 1902(u)(1),
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(xi) individuals described in section 1902(z)(1),
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(xii) employed individuals with a medically improve disability
(as defined in subsection (v)), or
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(xiii) individuals described in section 1902(aa),
but whose income and resources are insufficient to meet all
of such cost—
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(1) inpatient hospital services (other than services in an
institution for mental diseases);
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(2)(A) outpatient hospital services, (B) consistent with State
law permitting such services, rural health clinic services (as
defined in subsection (l)(1)) and any other ambulatory services
which are offered by a rural health clinic (as defined in subsection
(l)(1)) and which are otherwise included in the plan, and (C) Federally-qualified
health center services (as defined in subsection (l)(2)) and any
other ambulatory services offered by a Federally-qualified health
center and which are otherwise included in the plan;
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(3) other laboratory and X-ray services;
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(4)(A) nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age
or older; (B) early and periodic screening, diagnostic, and treatment
services (as defined in subsection (r)) for individuals who are
eligible under the plan and are under the age of 21; 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;
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(5)(A) physicians' services furnished by a physician (as defined
in section 1861(r)(1)), whether furnished in the office, the patient's
home, a hospital, or a nursing facility, or elsewhere, and (B)
medical and surgical services furnished by a dentist (described
in section 1861(r)(2)) to the extent such services may be performed
under State law either by a doctor of medicine or by a doctor of
dental surgery or dental medicine and would be described in clause
(A) if furnished by a physician (as defined in section 1861(r)(1));
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(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;
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(7) home health care services;
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(8) private duty nursing services;
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(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;
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(10) dental services;
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(11) physical therapy and related services;
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(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;
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(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;
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(14) inpatient hospital services and nursing facility services
for individuals 65 years of age or over in an institution for
mental diseases;
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(15) services in an intermediate care facility for the mentally
retarded (other than in an institution for mental diseases) for
individuals who are determined, in accordance with section 1902(a)(31),
to be in need of such care;
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(16) effective January 1, 1973, inpatient psychiatric hospital
services for individuals under age 21, as defined in subsection
(h);
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(17) services furnished by a nurse-midwife (as defined in section 1861(gg))
which the nurse-midwife is legally authorized to perform under State
law (or the State regulatory mechanism provided by State law), whether
or not the nurse-midwife is under the supervision of, or associated with,
a physician or other health care provider, and without regard to whether
or not the services are performed in the area of management of
the care of mothers and babies throughout the maternity cycle;
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(18) hospice care (as defined in subsection (o));
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(19) case management services (as defined in section 1915(g)(2))
and TB-related services described in section 1902(z)(2)(F);
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(20) respiratory care services (as defined in section 1902(e)(9)(C));
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(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;
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(22) home and community care (to the extent allowed and as
defined in section 1929) for functionally disabled elderly individuals;
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(23) community supported living arrangements services (to the
extent allowed and as defined in section 1930);
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(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;
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(25) primary care case management services (as defined in subsection (t));
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(26) services furnished under a PACE program under section 1934
to PACE program eligible individuals enrolled under the program
under such section; and
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(27) 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—
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(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
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(B) any such payments with respect to care or services for any
individual who has not attained 65 years of age and who is a patient
in an institution for mental diseases.
For purposes of clause (vi) of the preceding sentence, a person
shall be considered essential to another individual if such person
is the spouse of and is living with such individual, the needs
of such person are taken into account in determining the amount
of aid or assistance furnished to such individual (under a State
plan approved under title I, X, XIV, or XVI), and such person is
determined, under such a State plan, to be essential to the well-being
of such individual. The payment described in the first sentence
may include expenditures for medicare cost-sharing and for premiums
under part B of title XVIII for individuals who are eligible for
medical assistance under the plan and (A) are receiving aid or
assistance under any plan of the State approved under title I, X,
XIV, or XVI, or part A of title IV, or with respect to whom supplemental security
income benefits are being paid under title XVI, or (B) with respect
to whom there is being paid a State supplementary payment and are
eligible for medical assistance equal in amount, duration, and
scope to the medical assistance made available to individuals
described in section 1902(a)(10)(A), and, except in the case of
individuals 65 years of age or older and disabled individuals
entitled to health insurance benefits under title XVIII who are
not enrolled under part B of title XVIII, other insurance premiums
for medical or any other type of remedial care or the cost thereof.
No service (including counseling) shall be excluded from the definition
of “medical assistance” solely because it is
provided as a treatment service for alcoholism or drug dependency.
(b)
Subject to section 1933(d), the term “Federal
medical assistance percentage” for any State shall be
100 per centum less the State percentage; and the State percentage
shall be that percentage which bears the same ratio to 45 per centum
as the square of the per capita income of such State bears to
the square of the per capita income of the continental United States
(including Alaska) and Hawaii; except that (1) the Federal medical
assistance percentage shall in no case be less than 50 per centum
or more than 83 per centum, (2) the Federal medical assistance
percentage for Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa shall be 50 per centum.[61] The
Federal medical assistance percentage for any State shall be determined
and promulgated in accordance with the provisions of section 1101(a)(8)(B).
Notwithstanding the first sentence of this section, the Federal medical
assistance percentage shall be 100 per centum with respect to amounts expended
as medical assistance for services which are received through an Indian
Health Service facility whether operated by the Indian Health
Service or by an Indian tribe or tribal organization (as defined
in section 4 of the Indian Health Care Improvement Act[62]).
Notwithstanding the first sentence of this subsection, in the
case of a State plan that meets the condition described in subsection
(u)(1), with respect to expenditures (other than expenditures under section 1923) described in subsection (u)(2)(A) or subsection (u)(3) for
the State for a fiscal year, and that do not exceed the amount
of the State's available allotment under section 2104, the Federal
medical assistance percentage is equal to the enhanced FMAP described
in section 2105(b), for purposes of this title and title XXI,
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 2105(b) with
respect to medical assistance provided to individuals who are eligible
for such assistance only on the basis of section 1902(a)(10)(A)(ii)(XVIII).
(c)
For definition of the term “nursing
facility”, see section 1919(a).
(d)
The term “intermediate care facility
for the mentally retarded” means an institution (or distinct
part thereof) for the mentally retarded or persons with related
conditions if—
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(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;
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(2) the mentally retarded individual with respect to whom a
request for payment is made under a plan approved under this title
is receiving active treatment under such a program; and
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(3) in the case of a public institution, the State or political
subdivision responsible for the operation of such institution
has agreed that the non-Federal expenditures in any calendar quarter
prior to January 1, 1975, with respect to services furnished to
patients in such institution (or distinct part thereof) in the
State will not, because of payments made under this title, be reduced
below the average amount expended for such services in such institution
in the four quarters immediately preceding the quarter in which the
State in which such institution is located elected to make such
services available under its plan approved under this title.
(e)
In the case of any State the State plan of
which (as approved under this title)—
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(1) does not provide for the payment of services (other than
services covered under section 1902(a)(12)) provided by an optometrist;
but
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(2) at a prior period did provide for the payment of services
referred to in paragraph (1);
the term “physicians' services” (as used in
subsection (a)(5)) shall include services of the type which an
optometrist is legally authorized to perform where the State plan
specifically provides that the term “physicians' services”,
as employed in such plan, includes services of the type which an
optometrist is legally authorized to perform, and shall be reimbursed
whether furnished by a physician or an optometrist.
(f)
For purposes of this title, the term “nursing
facility services” means services which are or were required
to be given an individual who needs or needed on a daily basis
nursing care (provided directly by or requiring the supervision
of nursing personnel) or other rehabilitation services which as
a practical matter can only be provided in a nursing facility on
an inpatient basis.
(g)
If the State plan includes provision of chiropractors'
services, such services include only—
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(1) services provided by a chiropractor (A) who is licensed
as such by the State and (B) who meets uniform minimum standards
promulgated by the Secretary under section 1861(r)(5); and
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(2) services which consist of treatment by means of manual
manipulation of the spine which the chiropractor is legally authorized
to perform by the State.
(h)(1)
For purposes of paragraph (16) of subsection
(a), the term “inpatient psychiatric hospital services
for individuals under age 21” includes only—
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(A) inpatient services which are provided in an institution
(or distinct part thereof) which is a psychiatric hospital as
defined in section 1861(f) or in another inpatient setting that
the Secretary has specified in regulations;
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(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
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(C) inpatient services which, in the case of any individual,
are provided prior to (i) the date such individual attains age
21, or (ii) in the case of an individual who was receiving such
services in the period immediately preceding the date on which
he attained age 21, (I) the date such individual no longer requires
such services, or (II) if earlier, the date such individual attains
age 22;
(2) Such term does not include services provided during any
calendar quarter under the State plan of any State if the total
amount of the funds expended, during such quarter, by the State
(and the political subdivisions thereof) from non-Federal funds
for inpatient services included under paragraph (1), and for active
psychiatric care and treatment provided on an outpatient basis
for eligible mentally ill children, is less than the average quarterly amount
of the funds expended, during the 4-quarter period ending December 31,
1971, by the State (and the political subdivisions thereof) from
non-Federal funds for such services.
(i)
The term “institution for mental
diseases” means a hospital, nursing facility, or other
institution of more than 16 beds, that is primarily engaged in providing
diagnosis, treatment, or care of persons with mental diseases,
including medical attention, nursing care, and related services.
(j)
The term “State supplementary payment” means
any cash payment made by a State on a regular basis to an individual
who is receiving supplemental security income benefits under title
XVI or who would but for his income be eligible to receive such
benefits, as assistance based on need in supplementation of such
benefits (as determined by the Commissioner of Social Security),
but only to the extent that such payments are made with respect
to an individual with respect to whom supplemental security income
benefits are payable under title XVI, or would but for his income
be payable under that title.
(k)
Increased supplemental security income benefits
payable pursuant to section 211 of Public Law 93-66[63] shall
not be considered supplemental security income benefits payable
under title XVI.
(l)(1)
The terms “rural health clinic
services” and “rural health clinic” have
the meanings given such terms in section 1861(aa), except that
(A) clause (ii) of section 1861(aa)(2) shall not apply to such
terms, and (B) the physician arrangement required under section 1861(aa)(2)(B) shall only apply with respect to rural health clinic
services and, with respect to other ambulatory care services, the
physician arrangement required shall be only such as may be required
under the State plan for those services.
(2)(A) The term “Federally-qualified health center
services” means services of the type described in subparagraphs
(A) through (C) of section 1861(aa)(1) when furnished to an individual
as an[64] patient of a Federally-qualified health center and,
for this purpose, any reference to a rural health clinic or a physician described
in section 1861(aa)(2)(B) is deemed a reference to a Federally-qualified
health center or a physician at the center, respectively.
(B) The term “Federally-qualified health center”
means a entity which—
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(i) is receiving a grant under section 330 of the Public Health
Service Act[65],
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(ii)(I) is receiving funding from such a grant under a contract
with the recipient of such a grant, and
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(II) meets the requirements to receive a grant under section
330 of such Act,
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(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
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(iv) was treated by the Secretary, for purposes of part B of
title XVIII, as a comprehensive Federally funded health center
as of January 1, 1990;
and includes an outpatient health program or facility operated
by a tribe or tribal organization under the Indian Self-Determination
Act (Public Law 93-638) or by an urban Indian organization
receiving funds under title V of the Indian Health Care Improvement
Act for the provision of primary health services. In applying clause
(ii), the Secretary may waive any requirement referred to in such
clause for up to 2 years for good cause shown.
(m)(1)
Subject to paragraph (2), the term “qualified
family member” means an individual (other than a qualified
pregnant woman or child, as defined in subsection (n)) who is a
member of a family that would be receiving aid under the State
plan under part A of title IV pursuant to section 407 if the State
had not exercised the option under section 407(b)(2)(B)(i).
(2) No individual shall be a qualified family member for any
period after September 30, 1998.
(n)
The term “qualified pregnant woman
or child” means—
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(1) a pregnant woman who—
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(A) would be eligible for aid to families with dependent children under
part A of title IV (or would be eligible for such aid if coverage under
the State plan under part A of title IV included aid to families with
dependent children of unemployed parents pursuant to section 407)
if her child had been born and was living with her in the month such
aid would be paid, and such pregnancy has been medically verified;
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(B) is a member of a family which would be eligible for aid
under the State plan under part A of title IV pursuant to section 407 if the plan required the payment of aid pursuant to such section;
or
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(C) otherwise meets the income and resources requirements of
a State plan under part A of title IV; and
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(2) a child who has not attained the age of 19, who was born
after September 30, 1983 (or such earlier date as the State may
designate), and who meets the income and resources requirements
of the State plan under part A of title IV.
(o)(1)(A)
Subject to subparagraph (B), the term “hospice
care” means the care described in section 1861(dd)(1)
furnished by a hospice program (as defined in section 1861(dd)(2))
to a terminally ill individual who has voluntarily elected (in
accordance with paragraph (2)) to have payment made for hospice
care instead of having payment made for certain benefits described
in section 1812(d)(2)(A) and for which payment may otherwise be
made under title XVIII and intermediate care facility services
under the plan. For purposes of such election, hospice care may
be provided to an individual while such individual is a resident
of a skilled nursing facility or intermediate care facility, but
the only payment made under the State plan shall be for the hospice
care.
(B) For purposes of this title, with respect to the definition
of hospice program under section 1861(dd)(2), the Secretary may
allow an agency or organization to make the assurance under subparagraph
(A)(iii) of such section without taking into account any individual
who is afflicted with acquired immune deficiency syndrome (AIDS).
(2) An individual's voluntary election under this subsection—
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(A) shall be made in accordance with procedures that are established
by the State and that are consistent with the procedures established
under section 1812(d)(2);
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(B) shall be for such a period or periods (which need not be
the same periods described in section 1812(d)(1)) as the State
may establish; and
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(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—
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(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,
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(B) who is entitled to benefits under part A of title XVIII
and has elected, under section 1812(d), to receive hospice care
under such part, and
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(C) with respect to whom the hospice program under such title
and the nursing facility or intermediate care facility for the
mentally retarded have entered into a written agreement under
which the program takes full responsibility for the professional
management of the individual's hospice care and the facility agrees
to provide room and board to the individual,
instead of any payment otherwise made under the plan with respect
to the facility's services, the State shall provide for payment
to the hospice program of an amount equal to the additional amount
determined in section 1902(a)(13)(B) and, if the individual is
an individual described in section 1902(a)(10)(A), shall provide
for payment of any coinsurance amounts imposed under section 1813(a)(4).
(p)(1)
The term “qualified medicare
beneficiary” means an individual—
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(A) who is entitled to hospital insurance benefits under part
A of title XVIII (including an individual entitled to such benefits
pursuant to an enrollment under section 1818, but not including
an individual entitled to such benefits only pursuant to an enrollment
under section 1818A),
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(B) whose income (as determined under section 1612 for purposes
of the supplemental security income program, except as provided
in paragraph (2)(D)) does not exceed an income level established
by the State consistent with paragraph (2), and
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(C) whose resources (as determined under section 1613 for purposes
of the supplemental security income program) do not exceed twice
the maximum amount of resources that an individual may have and
obtain benefits under that program.
(2)(A) The income level established under paragraph (1)(B) shall
be at least the percent provided under subparagraph (B) (but not
more than 100 percent) of the official poverty line (as defined
by the Office of Management and Budget, and revised annually in
accordance with section 673(2) of the Omnibus Budget Reconciliation
Act of 1981[66]) 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—
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(i) January 1, 1989, is 85 percent,
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(ii) January 1, 1990, is 90 percent, and
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(iii) January 1, 1991, is 100 percent.
(C) In the case of a State which has elected treatment under
section 1902(f) and which, as of January 1, 1987, used an income
standard for individuals age 65 or older which was more restrictive
than the income standard established under the supplemental security
income program under title XVI, the percent provided under subparagraph
(B), with respect to eligibility for medical assistance on or after—
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(i) January 1, 1989, is 80 percent,
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(ii) January 1, 1990, is 85 percent,
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(iii) January 1, 1991, is 95 percent, and
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(iv) January 1, 1992, is 100 percent.
(D)(i) In determining under this subsection the income of an
individual who is entitled to monthly insurance benefits under
title II for a transition month (as defined in clause (ii)) in
a year, such income shall not include any amounts attributable
to an increase in the level of monthly insurance benefits payable
under such title which have occurred pursuant to section 215(i)
for benefits payable for months beginning with December of the
previous year.
(ii) For purposes of clause (i), the term “transition
month” means each month in a year through the month following
the month in which the annual revision of the official poverty
line, referred to in subparagraph (A), is published.
(3) The term “medicare cost-sharing” means
(subject to section 1902(n)(2)) the following costs incurred with
respect to a qualified medicare beneficiary, without regard to
whether the costs incurred were for items and services for which
medical assistance is otherwise available under the plan:
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(A)(i) premiums under section 1818 or 1818A, and
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(ii) premiums under section 1839,
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(B) Coinsurance under title XVIII (including coinsurance described
in section 1813).[67]
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(C) Deductibles established under title XVIII (including those
described in section 1813 and section 1833(b)).[68]
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(D) The difference between the amount that is paid under section 1833(a) and the amount that would be paid under such section if
any reference to “80 percent” therein were deemed
a reference to “100 percent”.
Such term also may include, at the option of a State, premiums
for enrollment of a qualified medicare beneficiary with an eligible
organization under section 1876.
(4) Notwithstanding any other provision of this title, in the
case of a State (other than the 50 States and the District of
Columbia)—
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(A) the requirement stated in section 1902(a)(10)(E) shall be
optional, and
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(B) for purposes of paragraph (2), the State may substitute
for the percent provided under subparagraph (B) of such paragraph
or 1902(a)(10)(E)(iii) any percent.
In the case of any State which is providing medical assistance
to its residents under a waiver granted under section 1115, the
Secretary shall require the State to meet the requirement of section 1902(a)(10)(E) in the same manner as the State would be required
to meet such requirement if the State had in effect a plan approved
under this title.
(5)(A) The Secretary shall develop and distribute to States a
simplified application form for use by individuals (including
both qualified medicare beneficiaries and specified low-income
medicare beneficiaries) in applying for medical assistance for
medicare cost-sharing under this title in the States which
elect to use such form. Such form shall be easily readable by applicants and
uniform nationally.
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(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
(6) For provisions relating to outreach efforts to increase
awareness of the availability of medicare cost-sharing, see section 1144.
(q)
The term “qualified severely impaired
individual” means an individual under age 65—
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(1) who for the month preceding the first month to which this
subsection applies to such individual—
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(A) received (i) a payment of supplemental security income
benefits under section 1611(b) on the basis of blindness or disability,
(ii) a supplementary payment under section 1616 of this Act or
under section 212 of Public Law 93-66[69] on such basis,
(iii) a payment of monthly benefits under section 1619(a), or (iv)
a supplementary payment under section 1616(c)(3), and
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(B) was eligible for medical assistance under the State plan
approved under this title; and
-
(2) with respect to whom the Commissioner of Social Security
determines that—
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(A) the individual continues to be blind or continues to have
the disabling physical or mental impairment on the basis of which
he was found to be under a disability and, except for his earnings,
continues to meet all non-disability-related requirements for eligibility
for benefits under title XVI,
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(B) the income of such individual would not, except for his
earnings, be equal to or in excess of the amount which would cause
him to be ineligible for payments under section 1611(b) (if he
were otherwise eligible for such payments),
-
(C) the lack of eligibility for benefits under this title would
seriously inhibit his ability to continue or obtain employment,
and
-
(D) the individual's earnings are not sufficient to allow him
to provide for himself a reasonable equivalent of the benefits
under title XVI (including any federally administered State supplementary
payments), this title, and publicly funded attendant care services
(including personal care assistance) that would be available to
him in the absence of such earnings.
In the case of an individual who is eligible for medical assistance
pursuant to section 1619(b) in June, 1987, the individual shall
be a qualified severely impaired individual for so long as such
individual meets the requirements of paragraph (2).
(r)
The term “early and periodic screening,
diagnostic, and treatment services” means the following
items and services:
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(1) Screening services—
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(A) which are provided—
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(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
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1928(c)(2)(B)(i) for pediatric vaccines, and
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(ii) at such other intervals, indicated as medically necessary,
to determine the existence of certain physical or mental illnesses
or conditions; and
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(B) which shall at a minimum include—
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(i) a comprehensive health and developmental history (including
assessment of both physical and mental health development),
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(ii) a comprehensive unclothed physical exam,
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(iii) appropriate immunizations (according to the schedule referred
to in section 1928(c)(2)(B)(i) for pediatric vaccines) according
to age and health history,
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(iv) laboratory tests (including lead blood level assessment
appropriate for age and risk factors), and
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(v) health education (including anticipatory guidance).
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(2) Vision services—
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(A) which are provided—
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(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
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(ii) at such other intervals, indicated as medically necessary,
to determine the existence of a suspected illness or condition;
and
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(B) which shall at a minimum include diagnosis and treatment
for defects in vision, including eyeglasses.
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(3) Dental services—
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(A) which are provided—
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(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
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(ii) at such other intervals, indicated as medically necessary,
to determine the existence of a suspected illness or condition;
and
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(B) which shall at a minimum include relief of pain and infections, restoration
of teeth, and maintenance of dental health.
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(4) Hearing services—
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(A) which are provided—
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(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
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(ii) at such other intervals, indicated as medically necessary,
to determine the existence of a suspected illness or condition;
and
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(B) which shall at a minimum include diagnosis and treatment
for defects in hearing, including hearing aids.
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(5) Such other necessary health care, diagnostic services,
treatment, and other measures described in section 1905(a) to correct
or ameliorate defects and physical and mental illnesses and conditions
discovered by the screening services, whether or not such services
are covered under the State plan.
Nothing in this title shall be construed as limiting providers
of early and periodic screening, diagnostic, and treatment services
to providers who are qualified to provide all of the items and
services described in the previous sentence or as preventing a
provider that is qualified under the plan to furnish one or more
(but not all) of such items or services from being qualified to
provide such items and services as part of early and periodic screening,
diagnostic, and treatment services. The Secretary shall, not later
than July 1, 1990, and every 12 months thereafter, develop and
set annual participation goals for each State for participation
of individuals who are covered under the State plan under this title
in early and periodic screening, diagnostic, and treatment services.[70]
(s)
The term “qualified disabled and
working individual” means an individual—
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(1) who is entitled to enroll for hospital insurance benefits
under part A of title XVIII under section 1818A (as added by 6012
of the Omnibus Budget Reconciliation Act of 1989[71]);
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(2) whose income (as determined under section 1612 for purposes
of the supplemental security income program) does not exceed 200
percent of the official poverty line (as defined by the Office
of Management and Budget and revised annually in accordance with
section 673(2) of the Omnibus Budget Reconciliation Act of 1981 [72] )
applicable to a family of the size involved;
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(3) whose resources (as determined under section 1613 for purposes
of the supplemental security income program) do not exceed twice
the maximum amount of resources that an individual or a couple
(in the case of an individual with a spouse) may have and obtain
benefits for supplemental security income benefits under title
XVI; and
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(4) who is not otherwise eligible for medical assistance
(t)(1)
The term “primary care case management
services” means case-management related services
(including locating, coordinating, and monitoring of health care
services) provided by a primary care case manager under a primary
care case management contract.
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(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:
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(A) A physician, a physician group practice, or an entity employing or
having other arrangements with physicians to provide such services.
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(B) At State option—
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(i) a nurse practitioner (as described in section 1905(a)(21));
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(ii) a certified nurse-midwife (as defined in section 1861(gg)); or
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(iii) a physician assistant (as defined in section 1861(aa)(5)).
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(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—
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(A) provides for reasonable and adequate hours of operation,
including 24-hour availability of information, referral,
and treatment with respect to medical emergencies;
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(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;
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(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;
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(D) prohibits discrimination on the basis of health status or
requirements for health care services in enrollment, disenrollment,
or reenrollment of individuals eligible for medical assistance
under this title;
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(E) provides for a right for an enrollee to terminate enrollment
in accordance with section 1932(a)(4); and
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(F) complies with the other applicable provisions of section 1932.
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(4) For purposes of this subsection, the term “primary
care” includes all health care services customarily provided
in accordance with State licensure and certification laws and regulations,
and all laboratory services customarily provided by or through,
a general practitioner, family medicine physician, internal medicine
physician, obstetrician/gynecologist, or pediatrician.
(u)(1)
The conditions described in this paragraph
for a State plan are as follows:
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(A) The State is complying with the requirement of section 2105(d)(1).
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(B) The plan provides for such reporting of information about
expenditures and payments attributable to the operation of this
subsection as the Secretary deems necessary in order to carry
out the fourth sentence of subsection (b).
(2)(A) For purposes of subsection (b), the expenditures described
in this subparagraph are expenditures for medical assistance for
optional targeted low-income children described in subparagraph
(B).
(B) For purposes of this paragraph, the term “optional
targeted low-income child” means a targeted low-income
child as defined in section 2110(b)(1) (determined without regard
to that portion of subparagraph (C) of such section concerning
eligibility for medical assistance under this title) who would
not qualify for medical assistance under the State plan under this
title as in effect on March 31, 1997 (but taking into account the
expansion of age of eligibility effected through the operation
of section 1902(l)(1)(D)).
(3) For purposes of subsection (b), the expenditures described
in this paragraph are expenditures for medical assistance for
children who are born before October 1, 1983, and who would be
described in section 1902(l)(1)(D) if they had been born on or
after such date, and who are not eligible for such assistance under
the State plan under this title based on such State plan as in
effect as of March 31, 1997.
(4) The limitations on payment under subsections (f) and (g)
of section 1108 shall not apply to Federal payments made under
section 1903(a)(1) based on an enhanced FMAP described in section 2105(b).
(v)(1)
The term “employed individual
with a medically improved disability” means an individual
who—
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(A) is at least 16, but less than 65, years of age;
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(B) is employed (as defined in paragraph (2));
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(C) ceases to be eligible for medical assistance under section 1902(a)(10)(A)(ii)(XV) because the individual, by reason of medical improvement,
is determined at the time of a regularly scheduled continuing disability
review to no longer be eligible for benefits under section 223(d) or
1614(a)(3); and
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(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—
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(A) is earning at least the applicable minimum wage requirement
under section 6 of the Fair Labor Standards Act (29 U.S.C. 206)
and working at least 40 hours per month; or
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(B) is engaged in a work effort that meets substantial and
reasonable threshold criteria for hours of work, wages, or other
measures, as defined by the State and approved by the Secretary.
(w)(1)
For purposes of this title, the term “independent
foster care adolescent” means an individual—
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(A) who is under 21 years of age;
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(B) who, on the individual's 18th birthday, was in foster care
under the responsibility of a State; and
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(C) whose assets, resources, and income do not exceed such
levels (if any) as the State may establish consistent with paragraph
(2).
(2) The levels established by a State under paragraph (1)(C)
may not be less than the corresponding levels applied by the State
under section 1931(b).
(3) A State may limit the eligibility of independent foster care
adolescents under section 1902(a)(10)(A)(ii)(XVII) to those individuals
with respect to whom foster care maintenance payments or independent
living services were furnished under a program funded under part
E of title IV before the date the individuals attained 18 years
of age.