SEC. 1902.
[42 U.S.C. 1396a] (a)
A State plan for medical assistance must—
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(1) provide that it shall be in effect in all political subdivisions
of the State, and, if administered by them, be mandatory upon them;
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(2) provide for financial participation by the State equal to
not less than 40 per centum of the non-Federal share of the expenditures
under the plan with respect to which payments under section 1903
are authorized by this title; and, effective July 1, 1969, provide
for financial participation by the State equal to all of such non-Federal
share or provide for distribution of funds from Federal or State
sources, for carrying out the State plan, on an equalization or
other basis which will assure that the lack of adequate funds from
local sources will not result in lowering the amount, duration,
scope, or quality of care and services available under the plan;
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(3) provide for granting an opportunity for a fair hearing before
the State agency to any individual whose claim for medical assistance
under the plan is denied or is not acted upon with reasonable promptness;
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(4) provide (A) such methods of administration (including methods relating
to the establishment and maintenance of personnel standards on a merit
basis, except that the Secretary shall exercise no authority with respect
to the selection, tenure of office, and compensation of any individual
employed in accordance with such methods, and including provision
for utilization of professional medical personnel in the administration
and, where administered locally, supervision of administration of
the plan) as are found by the Secretary to be necessary for the
proper and efficient operation of the plan,[4] (B) for the training
and effective use of paid subprofessional staff, with particular
emphasis on the full-time or part-time employment of recipients
and other persons of low income, as community service aides, in the
administration of the plan and for the use of nonpaid or partially
paid volunteers in a social service volunteer program in providing
services to applicants and recipients and in assisting any advisory
committees established by the State agency, (C) that each State
or local officer, employee, or independent contractor who is responsible
for the expenditure of substantial amounts of funds under the State
plan, each individual who formerly was such an officer, employee,
or contractor and each partner of such an officer or employee shall
be prohibited from committing any act, in relation to any activity
under the plan, the commission of which, in connection with any activity
concerning the United States Government, by an officer or employee
of the United States Government, an individual who was such an officer,
employee, or contractor or a partner of such an officer or employee is
prohibited by section 207 or 208 of title 18, United States Code[5],
and (D) that each State or local officer, employee, or independent
contractor who is responsible for selecting, awarding, or otherwise
obtaining items and services under the State plan shall be subject
to safeguards against conflicts of interest that are at least as
stringent as the safeguards that apply under section 27 of the Office
of Federal Procurement Policy Act (41 U.S.C. 423) to persons described
in subsection (a)(2) of such section of that Act;
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(5) either provide for the establishment or designation of a
single State agency to administer or to supervise the administration
of the plan; or provide for the establishment or designation of
a single State agency to administer or to supervise the administration
of the plan, except that the determination of eligibility for medical
assistance under the plan shall be made by the State or local agency
administering the State plan approved under title I or XVI (insofar
as it relates to the aged) if the State is eligible to participate
in the State plan program established under title XVI, or by the
agency or agencies administering the supplemental security income program
established under title XVI or the State plan approved under part A
of title IV if the State is not eligible to participate in the State
plan program established under title XVI;
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(6) provide that the State agency will make such reports, in
such form and containing such information, as the Secretary may
from time to time require, and comply with such provisions as the
Secretary may from time to time find necessary to assure the correctness
and verification of such reports;
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(7) provide safeguards which restrict the use or disclosure
of information concerning applicants and recipients to purposes
directly connected with the administration of the plan;
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(8) provide that all individuals wishing to make application
for medical assistance under the plan shall have opportunity to
do so, and that such assistance shall be furnished with reasonable
promptness to all eligible individuals;
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(9) provide—
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(A) that the State health agency, or other appropriate State
medical agency (whichever is utilized by the Secretary for the purpose
specified in the first sentence of section 1864(a)), shall be responsible
for establishing and maintaining health standards for private or
public institutions in which recipients of medical assistance under
the plan may receive care or services,
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(B) for the establishment or designation of a State authority
or authorities which shall be responsible for establishing and maintaining standards,
other than those relating to health, for such institutions, and
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(C) that any laboratory services paid for under such plan must
be provided by a laboratory which meets the applicable requirements
of section 1861(e)(9) or paragraphs (16) and (17) of section 1861(s),
or, in the case of a laboratory which is in a rural health clinic,
of section 1861(aa)(2)(G);
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(10) provide—
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(A) for making medical assistance available, including at least
the care and services listed in paragraphs (1) through (5), (17)
and (21) of section 1905(a), to—
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(i) all individuals—
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(I) who are receiving aid or assistance under any plan of the State
approved under title I, X, XIV, or XVI, or part A or part E of title
IV (including individuals eligible under this title by reason of
section 402(a)(37), 406(h), or 473(b), or considered by the State
to be receiving such aid as authorized under section 482(e)(6)),
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(II) with respect to whom supplemental security income benefits
are being paid under title XVI (or were being paid as of the date
of the enactment of section 211(a) of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193))
and would continue to be paid but for the enactment of that section
or who are qualified severely impaired individuals (as defined in
section 1905(q)),
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(III) who are qualified pregnant women or children as defined
in section 1905(n),
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(IV) who are described in subparagraph (A) or (B) of subsection
(l)(1) and whose family income does not exceed the minimum income
level the State is required to establish under subsection (l)(2)(A)
for such a family;
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(V) who are qualified family members as defined in section 1905(m)(1),
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(VI) who are described in subparagraph (C) of subsection (l)(1)
and whose family income does not exceed the income level the State
is required to establish under subsection (l)(2)(B) for such a family,
or
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(VII) who are described in subparagraph (D) of subsection (l)(1)
and whose family income does not exceed the income level the State
is required to establish under subsection (l)(2)(C) for such a family;
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(ii) at the option of the State, to any group or groups of individuals
described in section 1905(a) (or, in the case of individuals described
in section 1905(a)(i), to any reasonable categories of such individuals)
who are not individuals described in clause (i) of this subparagraph
but—
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(I) who meet the income and resources requirements of the appropriate
State plan described in clause (i) or the supplemental security
income program (as the case may be),
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(II) who would meet the income and resources requirements of
the appropriate State plan described in clause (i) if their work-related
child care costs were paid from their earnings rather than by a
State agency as a service expenditure,
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(III) who would be eligible to receive aid under the appropriate
State plan described in clause (i) if coverage under such plan was
as broad as allowed under Federal law,
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(IV) with respect to whom there is being paid, or who are eligible,
or would be eligible if they were not in a medical institution,
to have paid with respect to them, aid or assistance under the appropriate
State plan described in clause (i), supplemental security income
benefits under title XVI, or a State supplementary payment;
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(V) who are in a medical institution for a period of not less than
30 consecutive days (with eligibility by reason of this subclause
beginning on the first day of such period), who meet the resource
requirements of the appropriate State plan described in clause (i)
or the supplemental security income program, and whose income does
not exceed a separate income standard established by the State which
is consistent with the limit established under section 1903(f)(4)(C),
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(VI) who would be eligible under the State plan under this title
if they were in a medical institution, with respect to whom there
has been a determination that but for the provision of home or community-based
services described in subsection (c), (d), or (e) of section 1915
they would require the level of care provided in a hospital, nursing
facility or intermediate care facility for the mentally retarded
the cost of which could be reimbursed under the State plan, and
who will receive home or community-based services pursuant to a
waiver granted by the Secretary under subsection (c), (d), or (e)
of section 1915,
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(VII) who would be eligible under the State plan under this title
if they were in a medical institution, who are terminally ill, and
who will receive hospice care pursuant to a voluntary election described
in section 1905(o);
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(VIII) who is a child described in section 1905(a)(i)—
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(aa) for whom there is in effect an adoption assistance agreement
(other than an agreement under part E of title IV) between the State
and an adoptive parent or parents,
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(bb) who the State agency responsible for adoption assistance
has determined cannot be placed with adoptive parents without medical
assistance because such child has special needs for medical or rehabilitative
care, and
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(cc) who was eligible for medical assistance under the State
plan prior to the adoption assistance agreement being entered into,
or who would have been eligible for medical assistance at such time
if the eligibility standards and methodologies of the State's foster
care program under part E of title IV were applied rather than the
eligibility standards and methodologies of the State's aid to families
with dependent children program under part A of title IV;[6]
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(IX) who are described in subsection (l)(1) and are not described
in clause (i)(IV), clause (i)(VI), or clause (i)(VII);
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(X) who are described in subsection (m)(1);
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(XI) who receive only an optional State supplementary payment
based on need and paid on a regular basis, equal to the difference
between the individual's countable income and the income standard
used to determine eligibility for such supplementary payment (with
countable income being the income remaining after deductions as
established by the State pursuant to standards that may be more
restrictive than the standards for supplementary security income
benefits under title XVI), which are available to all individuals
in the State (but which may be based on different income standards
by political subdivision according to cost of living differences),
and which are paid by a State that does not have an agreement with
the Commissioner of Social Security under section 1616 or 1634;
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(XII) who are described in subsection (z)(1) (relating to certain
TB-infected individuals);
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(XIII) who are in families whose income is less than 250 percent
of the income official poverty line (as defined by the Office of
Management and Budget, and revised annually in accordance with section
673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable
to a family of the size involved, and who but for earnings in excess
of the limit established under section 1905(q)(2)(B), would be considered
to be receiving supplemental security income (subject, notwithstanding
section 1916, to payment of premiums or other cost-sharing
charges (set on a sliding scale based on income) that the State
may determine);
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(XIV) who are optional targeted low-income children described
in section 1905(u)(2)(B);
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(XV) who, but for earnings in excess of the limit established under
section 1905(q)(2)(B), would be considered to be receiving supplemental
security income, who is at least 16, but less than 65, years of
age, and whose assets, resources, and earned or unearned income
(or both) do not exceed such limitations (if any) as the State may
establish;
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(XVI) who are employed individuals with a medically improved
disability described in section 1905(v)(1) and whose assets, resources,
and earned or unearned income (or both) do not exceed such limitations
(if any) as the State may establish, but only if the State provides
medical assistance to individuals described in subclause (XV);
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(XVII) who are independent foster care adolescents (as defined
in section 1905(w)(1)), or who are within any reasonable categories
of such adolescents specified by the State; or
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(XVIII) who are described in subsection (aa) (relating to certain
breast or cervical cancer patients);
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(B) that the medical assistance made available to any individual described
in subparagraph (A)—
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(i) shall not be less in amount, duration, or scope than the medical
assistance made available to any other such individual, and
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(ii) shall not be less in amount, duration, or scope than the medical
assistance made available to individuals not described in subparagraph
(A);
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(C) that if medical assistance is included for any group of
individuals described in section 1905(a) who are not described in
subparagraph (A) or (E), then—
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(i) the plan must include a description of (I) the criteria
for determining eligibility of individuals in the group for such
medical assistance, (II) the amount, duration, and scope of medical
assistance made available to individuals in the group, and (III)
the single standard to be employed in determining income and resource
eligibility for all such groups, and the methodology to be employed
in determining such eligibility, which shall be no more restrictive
than the methodology which would be employed under the supplemental
security income program in the case of groups consisting of aged,
blind, or disabled individuals in a State in which such program
is in effect, and which shall be no more restrictive than the methodology
which would be employed under the appropriate State plan (described
in subparagraph (A)(i)) to which such group is most closely categorically
related in the case of other groups;
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(ii) the plan must make available medical assistance—
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(I) to individuals under the age of 18 who (but for income and
resources) would be eligible for medical assistance as an individual
described in subparagraph (A)(i), and
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(II) to pregnant women, during the course of their pregnancy,
who (but for income and resources) would be eligible for medical
assistance as an individual described in subparagraph (A);
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(iii) such medical assistance must include (I) with respect
to children under 18 and individuals entitled to institutional services, ambulatory
services, and (II) with respect to pregnant women, prenatal care
and delivery services; and
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(iv) if such medical assistance includes services in institutions for
mental diseases or in an intermediate care facility for the mentally
retarded (or both) for any such group, it also must include for all
groups covered at least the care and services listed in paragraphs (1)
through (5) and (17) of section 1905(a) or the care and services listed
in any 7 of the paragraphs numbered (1) through (24) of such section;
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(D) for the inclusion of home health services for any individual
who, under the State plan, is entitled to nursing facility services;
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(E)(i) for making medical assistance available for medicare
cost-sharing (as defined in section 1905(p)(3)) for qualified medicare
beneficiaries described in section 1905(p)(1);
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(ii) for making medical assistance available for payment of
medicare cost-sharing described in section 1905(p)(3)(A)(i) for
qualified disabled and working individuals described in section 1905(s);
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(iii) for making medical assistance available for medicare cost sharing
described in section 1905(p)(3)(A)(ii) subject to section 1905(p)(4),
for individuals who would be qualified medicare beneficiaries described
in section 1905(p)(1) but for the fact that their income exceeds
the income level established by the State under section 1905(p)(2)
but is less than 110 percent in 1993 and 1994, and 120 percent in
1995 and years thereafter of the official poverty line (referred to
in such section) for a family of the size involved;
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(iv) subject to sections 1933 and 1905(p)(4), for making medical assistance
available (but only for premiums payable with respect to months
during the period beginning with January 1998, and ending with September
2004[7]) for medicare cost-sharing described[8] in section 1905(p)(3)(A)(ii) for individuals who would be qualified medicare
beneficiaries described in section 1905(p)(1) but for the fact that their
income exceeds the income level established by the State under section 1905(p)(2) and is at least 120 percent, but less than 135 percent, of
the official poverty line (referred to in such section) for a family
of the size involved and who are not otherwise eligible for medical
assistance under the State plan;[9]
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(F) at the option of a State, for making medical assistance
available for COBRA premiums (as defined in subsection (u)(2)) for
qualified COBRA continuation beneficiaries described in section 1902(u)(1) and
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(G) that, in applying eligibility criteria of the supplemental
security income program under title XVI for purposes of determining
eligibility for medical assistance under the State plan of an individual
who is not receiving supplemental security income, the State will
disregard the provisions of subsections (c) and (e) of section 1613;
except that (I) the making available of the services described
in paragraph (4), (14), or (16) of section 1905(a) to individuals
meeting the age requirements prescribed therein shall not, by reason
of this paragraph (10), require the making available of any such
services, or the making available of such services of the same amount,
duration, and scope, to individuals of any other ages, (II) the making
available of supplementary medical insurance benefits under part
B of title XVIII to individuals eligible therefor (either pursuant
to an agreement entered into under section 1843 or by reason of
the payment of premiums under such title by the State agency on
behalf of such individuals), or provision for meeting part or all
of the cost of deductibles, cost sharing, or similar charges under
part B of title XVIII for individuals eligible for benefits under
such part, shall not, by reason of this paragraph (10), require
the making available of any such benefits, or the making available
of services of the same amount, duration, and scope, to any other
individuals, (III) the making available of medical assistance equal
in amount, duration, and scope to the medical assistance made available
to individuals described in clause (A) to any classification of
individuals approved by the Secretary with respect to whom there
is being paid, or who are eligible, or would be eligible if they
were not in a medical institution, to have paid with respect to
them, a State supplementary payment shall not, by reason of this
paragraph (10), require the making available of any such assistance,
or the making available of such assistance of the same amount, duration, and
scope, to any other individuals not described in clause (A), (IV)
the imposition of a deductible, cost sharing, or similar charge
for any item or service furnished to an individual not eligible
for the exemption under section 1916(a)(2) or (b)(2) shall not require
the imposition of a deductible, cost sharing, or similar charge
for the same item or service furnished to an individual who is eligible
for such exemption, (V) the making available to pregnant women covered
under the plan of services relating to pregnancy (including prenatal,
delivery, and postpartum services) or to any other condition which
may complicate pregnancy shall not, by reason of this paragraph
(10), require the making available of such services, or the making
available of such services of the same amount, duration, and scope,
to any other individuals, provided such services are made available
(in the same amount, duration, and scope) to all pregnant women covered
under the State plan, (VI) with respect to the making available
of medical assistance for hospice care to terminally ill individuals
who have made a voluntary election described in section 1905(o)
to receive hospice care instead of medical assistance for certain
other services, such assistance may not be made available in an
amount, duration, or scope less than that provided under title XVIII,
and the making available of such assistance shall not, by reason
of this paragraph (10), require the making available of medical
assistance for hospice care to other individuals or the making available
of medical assistance for services waived by such terminally ill
individuals, (VII) the medical assistance made available to an individual
described in subsection (l)(1)(A) who is eligible for medical assistance
only because of subparagraph (A)(i)(IV) or (A)(ii)(IX) shall be
limited to medical assistance for services related to pregnancy
(including prenatal, delivery, postpartum, and family planning services) and
to other conditions which may complicate pregnancy, (VIII) the medical assistance
made available to a qualified medicare beneficiary described in section 1905(p)(1) who is only entitled to medical assistance because the
individual is such a beneficiary shall be limited to medical assistance
for medicare cost-sharing (described in section 1905(p)(3)), subject
to the provisions of subsection (n) and section 1916(b), (IX) the
making available of respiratory care services in accordance with
subsection (e)(9) shall not, by reason of this paragraph (10), require
the making available of such services, or the making available of
such services of the same amount, duration, and scope, to any individuals
not included under subsection (e)(9)(A), provided such services
are made available (in the same amount, duration, and scope) to
all individuals described in such subsection, (X) if the plan provides
for any fixed durational limit on medical assistance for inpatient
hospital services (whether or not such a limit varies by medical
condition or diagnosis), the plan must establish exceptions to such
a limit for medically necessary inpatient hospital services furnished
with respect to individuals under one year of age in a hospital
defined under the State plan, pursuant to section 1923(a)(1)(A),
as a disproportionate share hospital and subparagraph (B) (relating
to comparability) shall not be construed as requiring such an exception
for other individuals, services, or hospitals, (XI) the making available
of medical assistance to cover the costs of premiums, deductibles,
coinsurance, and other cost-sharing obligations for certain individuals
for private health coverage as described in section 1906 shall not, by
reason of paragraph (10), require the making available of any such
benefits or the making available of services of the same amount,
duration, and scope of such private coverage to any other individuals,
(XII) the medical assistance made available to an individual described
in subsection (u)(1) who is eligible for medical assistance only
because of subparagraph (F) shall be limited to medical assistance
for COBRA continuation premiums (as defined in subsection (u)(2)),
(XIII) the medical assistance made available to an individual described
in subsection (z)(1) who is eligible for medical assistance only because
of subparagraph (A)(ii)(XII) shall be limited to medical assistance
for TB-related services (described in subsection (z)(2)),
and (XIV) the medical assistance made available to an individual
described in subsection (aa) who is eligible for medical assistance
only because of subparagraph (A)(10)(ii)(XVIII) shall be limited
to medical assistance provided during the period in which such an
individual requires treatment for breast or cervical cancer;
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(11)(A) provide for entering into cooperative arrangements with
the State agencies responsible for administering or supervising
the administration of health services and vocational rehabilitation
services in the State looking toward maximum utilization of such
services in the provision of medical assistance under the plan,
(B) provide, to the extent prescribed by the Secretary, for entering
into agreements, with any agency, institution, or organization receiving
payments under (or through an allotment under) title V, (i) providing
for utilizing such agency, institution, or organization in furnishing
care and services which are available under such title or allotment and
which are included in the State plan approved under this section
(ii) making such provision as may be appropriate for reimbursing
such agency, institution, or organization for the cost of any such
care and services furnished any individual for which payment would
otherwise be made to the State with respect to the individual under
section 1903, and (iii) providing for coordination of information
and education on pediatric vaccinations and delivery of immunization
services provide for coordination of the operations under this title,
including the provision of information and education on pediatric
vaccinations and the delivery of immunization services, with the
State's operations under the special supplemental nutrition program
for women, infants, and children under section 17 of the Child Nutrition
Act of 1966[10];
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(12) provide that, in determining whether an individual is blind,
there shall be an examination by a physician skilled in the diseases
of the eye or by an optometrist, whichever the individual may select;
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(13) provide—
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(A) for a public process for determination of rates of payment
under the plan for hospital services, nursing facility services,
and services of intermediate care facilities for the mentally retarded
under which—
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(i) proposed rates, the methodologies underlying the establishment
of such rates, and justifications for the proposed rates are published,
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(ii) providers, beneficiaries and their representatives, and
other concerned State residents are given a reasonable opportunity
for review and comment on the proposed rates, methodologies, and justifications,
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(iii) final rates, the methodologies underlying the establishment of
such rates, and justifications for such final rates are published, and
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(iv) in the case of hospitals, such rates take into account
(in a manner consistent with section 1923) the situation of hospitals which
serve a disproportionate number of low-income patients with
special needs; and[11]
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(B) for payment for hospice care in amounts no lower than the amounts,
using the same methodology, used under part A of title XVIII and
for payment of amounts under section 1905(o)(3); except that in
the case of hospice care which is furnished to an individual who
is a resident of a nursing facility or intermediate care facility
for the mentally retarded, and who would be eligible under the plan
for nursing facility services or services in an intermediate care
facility for the mentally retarded if he had not elected to receive
hospice care, there shall be paid an additional amount, to take
into account the room and board furnished by the facility, equal
to at least 95 percent of the rate that would have been paid by
the State under the plan for facility services in that facility
for that individual;
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(14) provide that enrollment fees, premiums, or similar charges,
and deductions, cost sharing, or similar charges, may be imposed
only as provided in section 1916;
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(15) provide for payment for services described in clause (B)
or (C) of section 1905(a)(2) under the plan in accordance with subsection
(bb)[12];
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(16) provide for inclusion, to the extent required by regulations
prescribed by the Secretary, of provisions (conforming to such regulations) with
respect to the furnishing of medical assistance under the plan to
individuals who are residents of the State but are absent therefrom;
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(17) except as provided in subsections (l)(3), (m)(3), and (m)(4),
include reasonable standards (which shall be comparable for all
groups and may, in accordance with standards prescribed by the Secretary,
differ with respect to income levels, but only in the case of applicants
or recipients of assistance under the plan who are not receiving
aid or assistance under any plan of the State approved under title
I, X, XIV, or XVI, or part A of title IV, and with respect to whom
supplemental security income benefits are not being paid under title
XVI, based on the variations between shelter costs in urban areas
and in rural areas) for determining eligibility for and the extent
of medical assistance under the plan which (A) are consistent with
the objectives of this title, (B) provide for taking into account
only such income and resources as are, as determined in accordance
with standards prescribed by the Secretary, available to the applicant
or recipient and (in the case of any applicant or recipient who
would, except for income and resources, be eligible for aid or assistance
in the form of money payments under any plan of the State approved
under title I, X, XIV, or XVI, or part A of title IV, or to have
paid with respect to him supplemental security income benefits under title
XVI) as would not be disregarded (or set aside for future needs)
in determining his eligibility for such aid, assistance, or benefits,
(C) provide for reasonable evaluation of any such income or resources,
and (D) do not take into account the financial responsibility of
any individual for any applicant or recipient of assistance under
the plan unless such applicant or recipient is such individual's
spouse or such individual's child who is under age 21 or (with respect
to States eligible to participate in the State program established
under title XVI), is blind or permanently and totally disabled,
or is blind or disabled as defined in section 1614 (with respect
to States which are not eligible to participate in such program);
and provide for flexibility in the application of such standards
with respect to income by taking into account, except to the extent
prescribed by the Secretary, the costs (whether in the form of insurance
premiums, payments made to the State under section 1903(f)(2)(B),
or otherwise and regardless of whether such costs are reimbursed
under another public program of the State or political subdivision
thereof) incurred for medical care or for any other type of remedial care
recognized under State law;[13]
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(18) comply with the provisions of section 1917 with respect
to liens, adjustments and recoveries of medical assistance correctly
paid, transfers of assets, and treatment of certain trusts;
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(19) provide such safeguards as may be necessary to assure that
eligibility for care and services under the plan will be determined,
and such care and services will be provided, in a manner consistent
with simplicity of administration and the best interests of the
recipients;
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(20) if the State plan includes medical assistance in behalf
of individuals 65 years of age or older who are patients in institutions
for mental diseases—
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(A) provide for having in effect such agreements or other arrangements
with State authorities concerned with mental diseases, and, where
appropriate, with such institutions, as may be necessary for carrying
out the State plan, including arrangements for joint planning and for
development of alternate methods of care, arrangements providing assurance
of immediate readmittance to institutions where needed for individuals
under alternate plans of care, and arrangements providing for access
to patients and facilities, for furnishing information, and for making
reports;
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(B) provide for an individual plan for each such patient to
assure that the institutional care provided to him is in his best
interests, including, to that end, assurances that there will be
initial and periodic review of his medical and other needs, that
he will be given appropriate medical treatment within the institution,
and that there will be a periodic determination of his need for
continued treatment in the institution; and
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(C) provide for the development of alternate plans of care,
making maximum utilization of available resources, for recipients
65 years of age or older who would otherwise need care in such institutions,
including appropriate medical treatment and other aid or assistance;
for services referred to in section 3(a)(4)(A)(i) and (ii)[14] or
section 1603(a)(4)(A)(i) and (ii)[15] which are appropriate for
such recipients and for such patients; and for methods of administration
necessary to assure that the responsibilities of the State agency
under the State plan with respect to such recipients and such patients
will be effectively carried out;
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(21) if the State plan includes medical assistance in behalf
of individuals 65 years of age or older who are patients in public
institutions for mental diseases, show that the State is making
satisfactory progress toward developing and implementing a comprehensive
mental health program, including provision for utilization of community
mental health centers, nursing facilities, and other alternatives
to care in public institutions for mental diseases;
-
(22) include descriptions of (A) the kinds and numbers of professional medical
personnel and supporting staff that will be used in the administration
of the plan and of the responsibilities they will have, (B) the
standards, for private or public institutions in which recipients
of medical assistance under the plan may receive care or services,
that will be utilized by the State authority or authorities responsible
for establishing and maintaining such standards, (C) the cooperative
arrangements with State health agencies and State vocational rehabilitation
agencies entered into with a view to maximum utilization of and
coordination of the provision of medical assistance with the services
administered or supervised by such agencies, and (D) other standards
and methods that the State will use to assure that medical or remedial
care and services provided to recipients of medical assistance are
of high quality;
-
(23) provide that (A) any individual eligible for medical assistance (including
drugs) may obtain such assistance from any institution, agency, community
pharmacy, or person, qualified to perform the service or services
required (including an organization which provides such services,
or arranges for their availability, on a prepayment basis), who
undertakes to provide him such services, and (B) an enrollment of
an individual eligible for medical assistance in a primary care
case-management system (described in section 1915(b)(1)), a medicaid
managed care organization, or a similar entity shall not restrict
the choice of the qualified person from whom the individual may
receive services under section 1905(a)(4)(C), except as provided
in subsection (g), in section 1915, and in section 1932(a), except
that this paragraph shall not apply in the case of Puerto Rico,
the Virgin Islands, and Guam, and except that nothing in this paragraph
shall be construed as requiring a State to provide medical assistance for
such services furnished by a person or entity convicted of a felony
under Federal or State law for an offense which the State agency
determines is inconsistent with the best interests of beneficiaries
under the State plan;
-
(24) effective July 1, 1969, provide for consultative services
by health agencies and other appropriate agencies of the State to
hospitals, nursing facilities, home health agencies, clinics, laboratories,
and such other institutions as the Secretary may specify in order
to assist them (A) to qualify for payments under this Act, (B) to
establish and maintain such fiscal records as may be necessary for
the proper and efficient administration of this Act to provide information
needed to determine payments due under this Act on account of care
and services furnished to individuals;
-
(25) provide—
-
(A) that the State or local agency administering such plan will
take all reasonable measures to ascertain the legal liability of
third parties (including health insurers, group health plans (as
defined in section 607(1) of the Employee Retirement Income Security
Act of 1974), service benefit plans, and health maintenance organizations)
to pay for care and services available under the plan, including—
-
(i) the collection of sufficient information as specified by
the Secretary in regulations) to enable the State to pursue claims against
such third parties, with such information being collected at the
time of any determination or redetermination of eligibility for medical
assistance, and
-
(ii) the submission to the Secretary of a plan (subject to approval by
the Secretary) for pursuing claims against such third parties, which
plan shall be integrated with, and be monitored as a part of the
Secretary's review of, the State's mechanized claims processing and
information retrieval systems required under section 1903(r);
-
(B) that in any case where such a legal liability is found to
exist after medical assistance has been made available on behalf
of the individual and where the amount of reimbursement the State
can reasonably expect to recover exceeds the costs of such recovery,
the State or local agency will seek reimbursement for such assistance
to the extent of such legal liability;
-
(C) that in the case of an individual who is entitled to medical
assistance under the State plan with respect to a service for which
a third party is liable for payment, the person furnishing the service
may not seek to collect from the individual (or any financially
responsible relative or representative of that individual) payment
of an amount for that service (i) if the total of the amount of
the liabilities of third parties for that service is at least equal
to the amount payable for that service under the plan (disregarding
section 1916), or (ii) in an amount which exceeds the lesser of
(I) the amount which may be collected under section 1916, or (II)
the amount by which the amount payable for that service under the
plan (disregarding section 1916) exceeds the total of the amount
of the liabilities of third parties for that service;
-
(D) that a person who furnishes services and is participating
under the plan may not refuse to furnish services to an individual
(who is entitled to have payment made under the plan for the services
the person furnishes) because of a third party's potential liability
for payment for the service;
-
(E) that in the case of prenatal or preventive pediatric care
(including early and periodic screening and diagnosis services under
section 1905(a)(4)(B)) covered under the State plan, the State shall—
-
(i) make payment for such service in accordance with the usual payment
schedule under such plan for such services without regard to the
liability of a third party for payment for such services; and
-
(ii) seek reimbursement from such third party in accordance
with subparagraph (B);
-
(F) that in the case of any services covered under such plan
which are provided to an individual on whose behalf child support
enforcement is being carried out by the State agency under part
D of title IV of this Act, the State shall—
-
(i) make payment for such service in accordance with the usual payment
schedule under such plan for such services without regard to any
third-party liability for payment for such services, if such third-party
liability is derived (through insurance or otherwise) from the parent
whose obligation to pay support is being enforced by such agency,
if payment has not been made by such third party within 30 days
after such services are furnished;
-
(ii) seek reimbursement from such third party in accordance
with subparagraph (B);
-
(G) that the State prohibits any health insurer (including a
group health plan, as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974, a service benefit plan,
and a health maintenance organization), in enrolling an individual
or in making any payments for benefits to the individual or on the
individual's behalf, from taking into account that the individual
is eligible for or is provided medical assistance under a plan under
this title for such State, or any other State; and
-
(H) that to the extent that payment has been made under the
State plan for medical assistance in any case where a third party
has a legal liability to make payment for such assistance, the State
has in effect laws under which, to the extent that payment has been
made under the State plan for medical assistance for health care
items or services furnished to an individual, the State is considered
to have acquired the rights of such individual to payment by any
other party for such health care items or services;
-
(26) if the State plan includes medical assistance for inpatient
mental hospital services, provide, with respect to each patient
receiving such services, for a regular program of medical review
(including medical evaluation) of his need for such services, and
for a written plan of care;
-
(27) provide for agreements with every person or institution
providing services under the State plan under which such person
or institution agrees (A) to keep such records as are necessary
fully to disclose the extent of the services provided to individuals
receiving assistance under the State plan, and (B) to furnish the
State agency or the Secretary with such information, regarding any
payments claimed by such person or institution for providing services
under the State plan, as the State agency or the Secretary may from time
to time request;
-
(28) provide—
-
(A) that any nursing facility receiving payments under such
plan must satisfy all the requirements of subsections (b) through
(d) of section 1919 as they apply to such facilities;
-
(B) for including in “nursing facility services” at
least the items and services specified (or deemed to be specified)
by the Secretary under section 1919(f)(7) and making available upon
request a description of the items and services so included;
-
(C) for procedures to make available to the public the data
and methodology used in establishing payment rates for nursing facilities
under this title; and
-
(D) for compliance (by the date specified in the respective
sections) with the requirements of—
-
(i) section 1919(e);
-
(ii) section 1919(g) (relating to responsibility for survey
and certification of nursing facilities); and
-
(iii) sections 1919(h)(2)(B) and 1919(h)(2)(D) (relating to
establishment and application of remedies);
-
(29) include a State program which meets the requirements set
forth in section 1908, for the licensing of administrators of nursing
homes;
-
(30)(A) provide such methods and procedures relating to the
utilization of, and the payment for, care and services available
under the plan (including but not limited to utilization review
plans as provided for in section 1903(i)(4)) as may be necessary
to safeguard against unnecessary utilization of such care and services
and to assure that payments are consistent with efficiency, economy,
and quality of care and are sufficient to enlist enough providers
so that care and services are available under the plan at least
to the extent that such care and services are available to the general population
in the geographic area; and
-
(B) provide, under the program described in subparagraph (A),
that—
-
(i) each admission to a hospital, intermediate care facility
for the mentally retarded, or hospital for mental diseases is reviewed
or screened in accordance with criteria established by medical and
other professional personnel who are not themselves directly responsible
for the care of the patient involved, and who do not have a significant financial
interest in any such institution and are not, except in the case of
a hospital, employed by the institution providing the care involved, and
-
(ii) the information developed from such review or screening,
along with the data obtained from prior reviews of the necessity
for admission and continued stay of patients by such professional
personnel, shall be used as the basis for establishing the size
and composition of the sample of admissions to be subject to review
and evaluation by such personnel, and any such sample may be of
any size up to 100 percent of all admissions and must be of sufficient
size to serve the purpose of (I) identifying the patterns of care
being provided and the changes occurring over time in such patterns
so that the need for modification may be ascertained, and (II) subjecting
admissions to early or more extensive review where information indicates
that such consideration is warranted to a hospital, intermediate
care facility for the mentally retarded, or hospital for mental
diseases;
-
(31) with respect to services in an intermediate care facility
for the mentally retarded (where the State plan includes medical
assistance for such services) provide, with respect to each patient
receiving such services, for a written plan of care, prior to admission
to or authorization of benefits in such facility, in accordance
with regulations of the Secretary, and for a regular program of
independent professional review (including medical evaluation) which
shall periodically review his need for such services;
-
(32) provide that no payment under the plan for any care or
service provided to an individual shall be made to anyone other
than such individual or the person or institution providing such
care or service, under an assignment or power of attorney or otherwise;
except that—
-
(A) in the case of any care or service provided by a physician,
dentist, or other individual practitioner, such payment may be made
(i) to the employer of such physician, dentist, or other practitioner
if such physician, dentist, or practitioner is required as a condition
of his employment to turn over his fee for such care or service
to his employer, or (ii) (where the care or service was provided
in a hospital, clinic, or other facility) to the facility in which
the care or service was provided if there is a contractual arrangement
between such physician, dentist, or practitioner and such facility
under which such facility submits the bill for such care or service;
-
(B) nothing in this paragraph shall be construed (i) to prevent
the making of such a payment in accordance with an assignment from
the person or institution providing the care or service involved
if such assignment is made to a governmental agency or entity or
is established by or pursuant to the order of a court of competent
jurisdiction, or (ii) to preclude an agent of such person or institution
from receiving any such payment if (but only if) such agent does
so pursuant to an agency agreement under which the compensation
to be paid to the agent for his services for or in connection with
the billing or collection of payments due such person or institution
under the plan is unrelated (directly or indirectly) to the amount
of such payments or the billings therefor, and is not dependent
upon the actual collection of any such payment;
-
(C) in the case of services furnished (during a period that
does not exceed 14 continuous days in the case of an informal reciprocal arrangement
or 90 continuous days (or such longer period as the Secretary may
provide) in the case of an arrangement involving per diem or other
fee-for-time compensation) by, or incident to the services of, one physician
to the patients of another physician who submits the claim for such
services, payment shall be made to the physician submitting the claim
(as if the services were furnished by, or incident to, the physician's
services), but only if the claim identifies (in a manner specified by
the Secretary) the physician who furnished the services; and
-
(D) in the case of payment for a childhood vaccine administered before
October 1, 1994, to individuals entitled to medical assistance under
the State plan, the State plan may make payment directly to the manufacturer
of the vaccine under a voluntary replacement program agreed to by
the State pursuant to which the manufacturer (i) supplies doses
of the vaccine to providers administering the vaccine, (ii) periodically
replaces the supply of the vaccine, and (iii) charges the State
the manufacturer's price to the Centers for Disease Control and
Prevention for the vaccine so administered (which price includes
a reasonable amount to cover shipping and the handling of returns);
-
(33) provide—
-
(A) that the State health agency, or other appropriate State
medical agency, shall be responsible for establishing a plan, consistent
with regulations prescribed by the Secretary, for the review by
appropriate professional health personnel of the appropriateness
and quality of care and services furnished to recipients of medical
assistance under the plan in order to provide guidance with respect
thereto in the administration of the plan to the State agency established
or designated pursuant to paragraph (5) and, where applicable, to
the State agency described in the second sentence of this subsection;
and
-
(B) that, except as provided in section 1919(g), the State or
local agency utilized by the Secretary for the purpose specified
in the first sentence of section 1864(a), or, if such agency is
not the State agency which is responsible for licensing health institutions,
the State agency responsible for such licensing, will perform for
the State agency administering or supervising the administration
of the plan approved under this title the function of determining
whether institutions and agencies meet the requirements for participation
in the program under such plan, except that, if the Secretary has
cause to question the adequacy of such determinations, the Secretary
is authorized to validate State determinations and, on that basis,
make independent and binding determinations concerning the extent
to which individual institutions and agencies meet the requirements
for participation;
-
(34) provide that in the case of any individual who has been
determined to be eligible for medical assistance under the plan,
such assistance will be made available to him for care and services
included under the plan and furnished in or after the third month
before the month in which he made application (or application was
made on his behalf in the case of a deceased individual) for such
assistance if such individual was (or upon application would have
been) eligible for such assistance at the time such care and services
were furnished;
-
(35) provide that any disclosing entity (as defined in section 1124(a)(2)) receiving payments under such plan complies with the
requirements of section 1124;
-
(36) provide that within 90 days following the completion of
each survey of any health care facility, laboratory, agency, clinic,
or organization, by the appropriate State agency described in paragraph
(9), such agency shall (in accordance with regulations of the Secretary)
make public in readily available form and place the pertinent findings
of each such survey relating to the compliance of each such health
care facility, laboratory, clinic, agency, or organization with
(A) the statutory conditions of participation imposed under this
title, and (B) the major additional conditions which the Secretary finds
necessary in the interest of health and safety of individuals who
are furnished care or services by any such facility, laboratory,
clinic, agency, or organization;
-
(37) provide for claims payment procedures which (A) ensure
that 90 per centum of claims for payment (for which no further written
information or substantiation is required in order to make payment)
made for services covered under the plan and furnished by health
care practitioners through individual or group practices or through
shared health facilities are paid within 30 days of the date of
receipt of such claims and that 99 per centum of such claims are
paid within 90 days of the date of receipt of such claims, and (B)
provide for procedures of prepayment and postpayment claims review,
including review of appropriate data with respect to the recipient and
provider of a service and the nature of the service for which payment
is claimed, to ensure the proper and efficient payment of claims
and management of the program;
-
(38) require that an entity (other than an individual practitioner
or a group of practitioners) that furnishes, or arranges for the
furnishing of, items or services under the plan, shall supply (within
such period as may be specified in regulations by the Secretary
or by the single State agency which administers or supervises the
administration of the plan) upon request specifically addressed
to such entity by the Secretary or such State agency, the information
described in section 1128(b)(9);[16]
-
(39) provide that the State agency shall exclude any specified
individual or entity from participation in the program under the
State plan for the period specified by the Secretary, when required
by him to do so pursuant to section 1128 or section 1128A, and provide
that no payment may be made under the plan with respect to any item
or service furnished by such individual or entity during such period;
-
(40) require each health services facility or organization which
receives payments under the plan and of a type for which a uniform
reporting system has been established under section 1121(a) to make
reports to the Secretary of information described in such section
in accordance with the uniform reporting system (established under
such section) for that type of facility or organization;
-
(41) provide that whenever a provider of services or any other
person is terminated, suspended, or otherwise sanctioned or prohibited
from participating under the State plan, the State agency shall
promptly notify the Secretary and, in the case of a physician and
notwithstanding paragraph (7), the State medical licensing board
of such action;
-
(42) provide that the records of any entity participating in
the plan and providing services reimbursable on a cost-related basis
will be audited as the Secretary determines to be necessary to insure
that proper payments are made under the plan;
-
(43) provide for—
-
(A) informing all persons in the State who are under the age
of 21 and who have been determined to be eligible for medical assistance including
services described in section 1905(a)(4)(B), of the availability
of early and periodic screening, diagnostic, and treatment services as
described in section 1905(r) and the need for age-appropriate immunizations
against vaccine-preventable diseases,
-
(B) providing or arranging for the provision of such screening
services in all cases where they are requested,
-
(C) arranging for (directly or through referral to appropriate
agencies, organizations, or individuals) corrective treatment the
need for which is disclosed by such child health screening services,
and
-
(D) reporting to the Secretary (in a uniform form and manner
established by the Secretary, by age group and by basis of eligibility
for medical assistance, and by not later than April 1 after the
end of each fiscal year, beginning with fiscal year 1990) the following
information relating to early and periodic screening, diagnostic,
and treatment services provided under the plan during each fiscal
year:
-
(i) the number of children provided child health screening services,
-
(ii) the number of children referred for corrective treatment
(the need for which is disclosed by such child health screening
services),
-
(iii) the number of children receiving dental services, and
-
(iv) the State's results in attaining the participation goals
set for the State under section 1905(r);
-
(44) in each case for which payment for inpatient hospital services,
services in an intermediate care facility for the mentally retarded,
or inpatient mental hospital services is made under the State plan—
-
(A) a physician (or, in the case of skilled nursing facility
services or intermediate care facility services, a physician, or
a nurse practitioner or clinical nurse specialist who is not an
employee of the facility but is working in collaboration with a
physician) certifies at the time of admission, or, if later, the
time the individual applies for medical assistance under the State
plan (and a physician, a physician assistant under the supervision
of a physician, or, in the case of skilled nursing facility services
or intermediate care facility services, a physician, or a nurse practitioner
or clinical nurse specialist who is not an employee of the facility
but is working in collaboration with a physician, recertifies, where
such services are furnished over a period of time, in such cases, at
least as often as required under section 1903(g)(6) (or, in the
case of services that are services provided in an intermediate care
facility for the mentally retarded, every year), and accompanied
by such supporting material, appropriate to the case involved, as
may be provided in regulations of the Secretary), that such services
are or were required to be given on an inpatient basis because the
individual needs or needed such services, and
-
(B) such services were furnished under a plan established and
periodically reviewed and evaluated by a physician, or, in the case
of skilled nursing facility services or intermediate care facility
services, a physician, or a nurse practitioner or clinical nurse
specialist who is not an employee of the facility but is working
in collaboration with a physician;
-
(45) provide for mandatory assignment of rights of payment for
medical support and other medical care owed to recipients, in accordance
with section 1912;
-
(46) provide that information is requested and exchanged for
purposes of income and eligibility verification in accordance with
a State system which meets the requirements of section 1137 of this
Act;
-
(47) at the option of the State, provide for making ambulatory
prenatal care available to pregnant women during a presumptive eligibility
period in accordance with section 1920 and provide for making medical
assistance for items and services described in subsection (a) of
section 1920A available to children during a presumptive eligibility
period in accordance with such section and provide for making medical
assistance available to individuals described in subsection (a)
of section 1920B during a presumptive eligible period in accordance
with such section and provide for making medical assistance available
to individuals described in subsection (a) of section 1920B during
a presumptive eligibility period in accordance with such section;
-
(48) provide a method of making cards evidencing eligibility
for medical assistance available to an eligible individual who does
not reside in a permanent dwelling or does not have a fixed home
or mailing address;
-
(49) provide that the State will provide information and access
to certain information respecting sanctions taken against health
care practitioners and providers by State licensing authorities
in accordance with section 1921;
-
(50) provide, in accordance with subsection (q), for a monthly
personal needs allowance for certain institutionalized individuals
and couples;
-
(51) meet the requirements of section 1924 (relating to protection
of community spouses);
-
(52) meet the requirements of section 1925 (relating to extension
of eligibility for medical assistance);
-
(53) provide—
-
(A) for notifying in a timely manner all individuals in the
State who are determined to be eligible for medical assistance and
who are pregnant women, breastfeeding or postpartum women (as defined
in section 17 of the Child Nutrition Act of 1966), or children below
the age of 5, of the availability of benefits furnished by the special
supplemental nutrition program under such section, and
-
(B) for referring any such individual to the State agency responsible for
administering such program;
-
(54) in the case of a State plan that provides medical assistance
for covered outpatient drugs (as defined in section 1927(k)), comply
with the applicable requirements of section 1927;
-
(55) provide for receipt and initial processing of applications
of individuals for medical assistance under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
(a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)—
-
(A) at locations which are other than those used for the receipt
and processing of applications for aid under part A of title IV
and which include facilities defined as disproportionate share hospitals
under section 1923(a)(1)(A) and Federally-qualified health centers
described in section 1905(1)(2)(B)[17], and
-
(B) using applications which are other than those used for applications
for aid under such part;
-
(56) provide, in accordance with subsection (s), for adjusted
payments for certain inpatient hospital services;
-
(57) provide that each hospital, nursing facility, provider
of home health care or personal care services, hospice program,
or medicaid managed care organization (as defined in section 1903(m)(1)(A))
receiving funds under the plan shall comply with the requirements
of subsection (w);
-
(58) provide that the State, acting through a State agency,
association, or other private nonprofit entity, develop a written
description of the law of the State (whether statutory or as recognized
by the courts of the State) concerning advance directives that would
be distributed by providers or organizations under the requirements
of subsection (w);
-
(59) maintain a list (updated not less often than monthly, and
containing each physician's unique identifier provided under the
system established under subsection (x) of all physicians who are
certified to participate under the State plan;
-
(60) provide that the State agency shall provide assurances
satisfactory to the Secretary that the State has in effect the laws
relating to medical child support required under section 1908A;
-
(61) provide that the State must demonstrate that it operates
a medicaid fraud and abuse control unit described in section 1903(q)
that effectively carries out the functions and requirements described
in such section, as determined in accordance with standards established
by the Secretary, unless the State demonstrates to the satisfaction
of the Secretary that the effective operation of such a unit in
the State would not be cost-effective because minimal fraud exists
in connection with the provision of covered services to eligible
individuals under the State plan, and that beneficiaries under the
plan will be protected from abuse and neglect in connection with the
provision of medical assistance under the plan without the existence
of such a unit;
-
(62) provide for a program for the distribution of pediatric
vaccines to program-registered providers for the immunization of
vaccine-eligible children in accordance with section 1928;
-
(63) provide for administration and determinations of eligibility
with respect to individuals who are (or seek to be) eligible for
medical assistance based on the application of section 1931;
-
(64) provide, not later than 1 year after the date of the enactment
of this paragraph, a mechanism to receive reports from beneficiaries
and others and compile data concerning alleged instances of waste,
fraud, and abuse relating to the operation of this title; [18]
-
(65) provide that the State shall issue provider numbers for
all suppliers of medical assistance consisting of durable medical
equipment, as defined in section 1861(n), and the State shall not
issue or renew such a supplier number for any such supplier unless—
-
(A)(i) full and complete information as to the identity of each
person with an ownership or control interest (as defined in section 1124(a)(3)) in the supplier or in any subcontractor (as defined
by the Secretary in regulations) in which the supplier directly
or indirectly has a 5 percent or more ownership interest; and
-
(ii) to the extent determined to be feasible under regulations
of the Secretary, the name of any disclosing entity (as defined
in section 1124(a)(2)) with respect to which a person with such
an ownership or control interest in the supplier is a person with
such an ownership or control interest in the disclosing entity;
and
-
(B) a surety bond in a form specified by the Secretary under
section 1834(a)(16)(B) and in an amount that is not less than $50,000
or such comparable surety bond as the Secretary may permit under
the second sentence of such section; [19]
-
(66)[20] provide for making eligibility determinations under
section 1935(a); and[21]
-
(67)[22] provide, with respect to services covered under the
State plan (but not under title XVIII) that are furnished to a PACE
program eligible individual enrolled with a PACE provider by a provider
participating under the State plan that does not have a contract
or other agreement with the PACE provider that establishes payment
amounts for such services, that such participating provider may
not require the PACE provider to pay the participating provider
an amount greater than the amount that would otherwise be payable
for the service to the participating provider under the State plan
for the State where the PACE provider is located (in accordance
with regulations issued by the Secretary).
Notwithstanding paragraph (5), if on January 1, 1965, and on
the date on which a State submits its plan for approval under this
title, the State agency which administered or supervised the administration
of the plan of such State approved under title X (or title XVI,
insofar as it relates to the blind) was different from the State
agency which administered or supervised the administration of the
State plan approved under title I (or title XVI, insofar as it relates
to the aged), the State agency which administered or supervised
the administration of such plan approved under title X (or title
XVI, insofar as it relates to the blind) may be designated to administer
or supervise the administration of the portion of the State plan
for medical assistance which relates to blind individuals and a different
State agency may be established or designated to administer or supervise
the administration of the rest of the State plan for medical assistance;
and in such case the part of the plan which each such agency administers,
or the administration of which each such agency supervises, shall
be regarded as a separate plan for purposes of this title (except
for purposes of paragraph (10)). The provisions of paragraphs (9)(A),
(31), and (33) and of section 1903(i)(4) shall not apply to a religious
nonmedical health care institution (as defined in section 1861(ss)(1)).
For purposes of paragraph (10) any individual who, for the month
of August 1972, was eligible for or receiving aid or assistance
under a State plan approved under title I, X, XIV, or XVI, or part
A of title IV and who for such month was entitled to monthly insurance
benefits under title II shall for purposes of this title only be
deemed to be eligible for financial aid or assistance for any month thereafter
if such individual would have been eligible for financial aid or
assistance for such month had the increase in monthly insurance
benefits under title II resulting from enactment of Public Law 92-336 [23]
not been applicable to such individual.
The requirement of clause[24] (A) of paragraph (37) with respect
to a State plan may be waived by the Secretary if he finds that
the State has exercised good faith in trying to meet such requirement.
For purposes of this title, any child who meets the requirements
of paragraph (1) or (2) of section 473(b) shall be deemed to be
a dependent child as defined in section 406 and shall be deemed to
be a recipient of aid to families with dependent children under
part A of title IV in the State where such child resides. Notwithstanding
paragraph (10)(B) or any other provision of this subsection, a State
plan shall provide medical assistance with respect to an alien who
is not lawfully admitted for permanent residence or otherwise permanently
residing in the United States under color of law only in accordance
with section 1903(v).[25]
(b)
The Secretary shall approve any plan which
fulfills the conditions specified in subsection (a) of this section,
except that he shall not approve any plan which imposes, as a condition
of eligibility for medical assistance under the plan—
-
(1) an age requirement of more than 65 years; or
-
(2) any residence requirement which excludes any individual
who resides in the State, regardless of whether or not the residence
is maintained permanently or at a fixed address; or
-
(3) any citizenship requirement which excludes any citizen of
the United States.
(c)
Notwithstanding subsection (b), the Secretary
shall not approve any State plan for medical assistance if the State
requires individuals described in subsection (l)(1) to apply for
assistance under the State program funded under part A of title
IV as a condition of applying for or receiving medical assistance under
this title.
(d)
If a State contracts with an entity which
meets the requirements of section 1152, as determined by the Secretary,
or a utilization and quality control peer review organization having
a contract with the Secretary under part B of title XI for the performance
of medical or utilization review functions required under this title
of a State plan with respect to specific services or providers (or services
or providers in a geographic area of the State), such requirements
shall be deemed to be met for those services or providers (or services
or providers in that area) by delegation to such an entity or organization
under the contract of the State's authority to conduct such review
activities if the contract provides for the performance of activities
not inconsistent with part B of title XI and provides for such assurances
of satisfactory performance by such an entity or organization as
the Secretary may prescribe.
(e)(1)(A)
Notwithstanding any other provision
of this title, effective January 1, 1974, subject to subparagraph
(B) each State plan approved under this title must provide that
each family which was receiving aid pursuant to a plan of the State
approved under part A of title IV in at least 3 of the 6 months immediately
preceding the month in which such family became ineligible for such
aid because of increased hours of, or increased income from, employment, shall,
while a member of such family is employed, remain eligible for assistance
under the plan approved under this title (as though the family was
receiving aid under the plan approved under part A of title IV)
for 4 calendar months beginning with the month in which such family
became ineligible for aid under the plan approved under part A of
title IV because of income and resources or hours of work limitations
contained in such plan.
(B) Subparagraph (A) shall not apply with respect to families
that cease to be eligible for aid under part A of title IV during
the period beginning on April 1, 1990, and ending on September 30,
2003[26]. During such period, for provisions relating to extension
of eligibility for medical assistance for certain families who have
received aid pursuant to a State plan approved under part A of title
IV and have earned income, see section 1925.
(2)(A) In the case of an individual who is enrolled with a medicaid
managed care organization (as defined in section 1903(m)(1)(A)),
with a primary care case manager (as defined in section 1905(t)),
or with an eligible organization with a contract under section 1876
and who would (but for this paragraph) lose eligibility for benefits
under this title before the end of the minimum enrollment period
(defined in subparagraph (B)), the State plan may provide, notwithstanding
any other provision of this title, that the individual shall be
deemed to continue to be eligible for such benefits until the end
of such minimum period, but, except for benefits furnished under
section 1905(a)(4)(C), only with respect to such benefits provided
to the individual as an enrollee of such organization or entity
or by or through the case manager.[27]
(B) For purposes of subparagraph (A), the term “minimum
enrollment period” means, with respect to an individual's
enrollment with an organization or entity under a State plan, a
period, established by the State, of not more than six months beginning
on the date the individual's enrollment with the organization or
entity becomes effective.
(3) At the option of the State, any individual who—
-
(A) is 18 years of age or younger and qualifies as a disabled
individual under section 1614(a);
-
(B) with respect to whom there has been a determination by the
State that—
-
(i) the individual requires a level of care provided in a hospital, nursing
facility, or intermediate care facility for the mentally retarded,
-
(ii) it is appropriate to provide such care for the individual
outside such an institution, and
-
(iii) the estimated amount which would be expended for medical assistance
for the individual for such care outside an institution is not greater
than the estimated amount which would otherwise be expended for
medical assistance for the individual within an appropriate institution;
and
-
(C) if the individual were in a medical institution, would be
eligible for medical assistance under the State plan under this
title,
shall be deemed, for purposes of this title only, to be an individual
with respect to whom a supplemental security income payment, or
State supplemental payment, respectively, is being paid under title
XVI.
(4) A child born to a woman eligible for and receiving medical
assistance under a State plan on the date of the child's birth shall
be deemed to have applied for medical assistance and to have been
found eligible for such assistance under such plan on the date of
such birth and to remain eligible for such assistance for a period
of one year so long as the child is a member of the woman's household
and the woman remains (or would remain if pregnant) eligible for
such assistance. During the period in which a child is deemed under the
preceding sentence to be eligible for medical assistance, the medical
assistance eligibility identification number of the mother shall
also serve as the identification number of the child, and all claims
shall be submitted and paid under such number (unless the State
issues a separate identification number for the child before such
period expires).
(5) A woman who, while pregnant, is eligible for, has applied
for, and has received medical assistance under the State plan, shall
continue to be eligible under the plan, as though she were pregnant,
for all pregnancy-related and postpartum medical assistance under
the plan, through the end of the month in which the 60-day period
(beginning on the last day of her pregnancy) ends.
(6) In the case of a pregnant woman described in subsection (a)(10)
who, because of a change in income of the family of which she is
a member, would not otherwise continue to be described in such subsection,
the woman shall be deemed to continue to be an individual described
in subsection (a)(10)(A)(i)(IV) and subsection (l)(1)(A) without
regard to such change of income through the end of the month in
which the 60-day period (beginning on the last day of her pregnancy)
ends. The preceding sentence shall not apply in the case of a woman
who has been provided ambulatory prenatal care pursuant to section 1920 during a presumptive eligibility period and is then, in accordance
with such section, determined to be ineligible for medical assistance under
the State plan.
(7) In the case of an infant or child described in subparagraph
(B), (C), or (D) of subsection (l)(1) or paragraph (2) of section 1905(n)—
-
(A) who is receiving inpatient services for which medical assistance
is provided on the date the infant or child attains the maximum
age with respect to which coverage is provided under the State plan
for such individuals, and
-
(B) who, but for attaining such age, would remain eligible for
medical assistance under such subsection,
the infant or child shall continue to be treated as an individual
described in such respective provision until the end of the stay
for which the inpatient services are furnished.
(8) If an individual is determined to be a qualified medicare
beneficiary (as defined in section 1905(p)(1)), such determination
shall apply to services furnished after the end of the month in
which the determination first occurs. For purposes of payment to
a State under section 1903(a), such determination shall be considered
to be valid for an individual for a period of 12 months, except
that a State may provide for such determinations more frequently,
but not more frequently than once every 6 months for an individual.
(9)(A) At the option of the State, the plan may include as medical
assistance respiratory care services for any individual who—
-
(i) is medically dependent on a ventilator for life support
at least six hours per day;
-
(ii) has been so dependent for at least 30 consecutive days
(or the maximum number of days authorized under the State plan,
whichever is less) as an inpatient;
-
(iii) but for the availability of respiratory care services,
would require respiratory care as an inpatient in a hospital, nursing
facility, or intermediate care facility for the mentally retarded
and would be eligible to have payment made for such inpatient care
under the State plan;
-
(iv) has adequate social support services to be cared for at
home; and
-
(v) wishes to be cared for at home.
(B) The requirements of subparagraph (A)(ii) may be satisfied
by a continuous stay in one or more hospitals, nursing facilities,
or intermediate care facilities for the mentally retarded.
(C) For purposes of this paragraph, respiratory care services
means services provided on a part-time basis in the home of the
individual by a respiratory therapist or other health care professional
trained in respiratory therapy (as determined by the State), payment
for which is not otherwise included within other items and services
furnished to such individual as medical assistance under the plan.
(10)(A) The fact that an individual, child, or pregnant woman
may be denied aid under part A of title IV pursuant to section 402(a)(43)
shall not be construed as denying (or permitting a State to deny)
medical assistance under this title to such individual, child, or
woman who is eligible for assistance under this title on a basis
other than the receipt of aid under such part.
(B) If an individual, child, or pregnant woman is receiving aid
under part A of title IV and such aid is terminated pursuant to
section 402(a)(43), the State may not discontinue medical assistance
under this title for the individual, child, or woman until the State
has determined that the individual, child, or woman is not eligible
for assistance under this title on a basis other than the receipt
of aid under such part.
(11)(A) In the case of an individual who is enrolled with a group
health plan under section 1906 and who would (but for this paragraph)
lose eligibility for benefits under this title before the end of
the minimum enrollment period (defined in subparagraph (B)), the
State plan may provide, notwithstanding any other provision of this
title, that the individual shall be deemed to continue to be eligible
for such benefits until the end of such minimum period, but only
with respect to such benefits provided to the individual as an enrollee
of such plan.
(B) For purposes of subparagraph (A), the term “minimum
enrollment period” means, with respect to an individual's
enrollment with a group health plan, a period established by the
State, of not more than 6 months beginning on the date the individual's
enrollment under the plan becomes effective.
(12) At the option of the State, the plan may provide that an
individual who is under an age specified by the State (not to exceed
19 years of age) and who is determined to be eligible for benefits
under a State plan approved under this title under subsection (a)(10)(A)
shall remain eligible for those benefits until the earlier of—
-
(A) the end of a period (not to exceed 12 months) following
the determination; or
-
(B) the time that the individual exceeds that age.
(f)
Notwithstanding any other provision of this
title, except as provided in subsection (e) and section 1619(b)(3)
and section 1924, except with respect to qualified disabled and
working individuals (described in section 1905(s)), and except with
respect to qualified medicare beneficiaries, qualified severely impaired
individuals, and individuals described in subsection (m)(1), no
State not eligible to participate in the State plan program established
under title XVI shall be required to provide medical assistance
to any aged, blind, or disabled individual (within the meaning of
title XVI) for any month unless such State would be (or would have
been) required to provide medical assistance to such individual
for such month had its plan for medical assistance approved under this
title and in effect on January 1, 1972, been in effect in such month,
except that for this purpose any such individual shall be deemed
eligible for medical assistance under such State plan if (in addition
to meeting such other requirements as are or may be imposed under
the State plan) the income of any such individual as determined
in accordance with section 1903(f) (after deducting any supplemental
security income payment and State supplementary payment made with
respect to such individual, and incurred expenses for medical care
as recognized under State law regardless of whether such expenses
are reimbursed under another public program of the State or political
subdivision thereof) is not in excess of the standard for medical
assistance established under the State plan as in effect on January
1, 1972. In States which provide medical assistance to individuals
pursuant to paragraph (10)(C) of subsection (a) of this section,
an individual who is eligible for medical assistance by reason of
the requirements of this section concerning the deduction of incurred
medical expenses from income shall be considered an individual eligible
for medical assistance under paragraph (10)(A) of that subsection
if that individual is, or is eligible to be (1) an individual with
respect to whom there is payable a State supplementary payment on
the basis of which similarly situated individuals are eligible to receive
medical assistance equal in amount, duration, and scope to that
provided to individuals eligible under paragraph (10)(A), or (2)
an eligible individual or eligible spouse, as defined in title XVI,
with respect to whom supplemental security income benefits are payable;
otherwise that individual shall be considered to be an individual
eligible for medical assistance under paragraph (10)(C) of that
subsection. In States which do not provide medical assistance to
individuals pursuant to paragraph (10)(C) of that subsection, an individual
who is eligible for medical assistance by reason of the requirements of
this section concerning the deduction of incurred medical expenses
from income shall be considered an individual eligible for medical
assistance under paragraph (10)(A) of that subsection.
(g)
In addition to any other sanction available
to a State, a State may provide for a reduction of any payment amount
otherwise due with respect to a person who furnishes services under
the plan in an amount equal to up to three times the amount of any
payment sought to be collected by that person in violation of subsection
(a)(25)(C).
(h)
Nothing in this title (including subsections
(a)(13) and (a)(30) of this section) shall be construed as authorizing
the Secretary to limit the amount of payment that may be made under
a plan under this title for home and community care.
(i)(1)
In addition to any other authority under
State law, where a State determines that a intermediate care facility
for the mentally retarded which is certified for participation under
its plan no longer substantially meets the requirements for such
a facility under this title and further determines that the facility's
deficiencies—
-
(A) immediately jeopardize the health and safety of its patients,
the State+ shall provide for the termination of the facility's certification
for participation under the plan and may provide, or
-
(B) do not immediately jeopardize the health and safety of its
patients, the State may, in lieu of providing for terminating the
facility's certification for participation under the plan, establish
alternative remedies if the State demonstrates to the Secretary's
satisfaction that the alternative remedies are effective in deterring
noncompliance and correcting deficiencies, and may provide
that no payment will be made under the State plan with respect
to any individual admitted to such facility after a date specified
by the State.
(2) The State shall not make such a decision with respect to
a facility until the facility has had a reasonable opportunity,
following the initial determination that it no longer substantially
meets the requirements for such a facility under this title, to
correct its deficiencies, and, following this period, has been given reasonable
notice and opportunity for a hearing.
(3) The State's decision to deny payment may be made effective
only after such notice to the public and to the facility as may
be provided for by the State, and its effectiveness shall terminate
(A) when the State finds that the facility is in substantial compliance
(or is making good faith efforts to achieve substantial compliance)
with the requirements for such a facility under this title, or (B)
in the case described in paragraph (1)(B), with the end of the eleventh
month following the month such decision is made effective, whichever
occurs first. If a facility to which clause (B) of the previous
sentence applies still fails to substantially meet the provisions
of the respective section on the date specified in such clause,
the State shall terminate such facility's certification for participation
under the plan effective with the first day of the first month following
the month specified in such clause.
(j)
Notwithstanding any other requirement of
this title, the Secretary may waive or modify any requirement of
this title with respect to the medical assistance program in American
Samoa and the Northern Mariana Islands, other than a waiver of the
Federal medical assistance percentage, the limitation in section 1108(f), or the requirement that payment may be made for medical assistance
only with respect to amounts expended by American Samoa or the Northern
Mariana Islands for care and services described in a numbered paragraph
of section 1905(a).
[(k) Stricken.[28]]
(l)(1)
Individuals described in this paragraph
are—
-
(A) women during pregnancy (and during the 60-day period beginning on
the last day of the pregnancy),
-
(B) infants under one year of age,
-
(C) children who have attained one year of age but have not
attained 6 years of age, and
-
(D) children born after September 30, 1983 (or, at the option
of a State, after any earlier date), who have attained 6 years of
age but have not attained 19 years of age,
who are not described in any of subclauses (I) through (III)
of subsection (a)(10)(A)(i) and whose family income does not exceed
the income level established by the State under paragraph (2) for
a family size equal to the size of the family, including the woman,
infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to individuals
described in subparagraph (A) or (B) of that paragraph, the State
shall establish an income level which is a percentage (not less
than the percentage provided under clause (ii) and not more than
185 percent) of the income official poverty line (as defined by
the Office of Management and Budget and Budget, and revised annually
in accordance with section 673(2) of the Omnibus Budget Reconciliation
Act of 1981[29]) applicable to a family of the size involved.
(ii) The percentage provided under this clause, with respect
to eligibility for medical assistance on or after—
-
(I) July 1, 1989, is 75 percent, or, if greater, the percentage
provided under clause (iii), and
-
(II) April 1, 1990, 133 percent, or, if greater, the percentage
provided under clause (iv).
(iii) In the case of a State which, as of the date of the enactment
of this clause[30], has elected to provide, and provides, medical
assistance to individuals described in this subsection or has enacted
legislation authorizing, or appropriating funds, to provide such
assistance to such individuals before July 1, 1989, the percentage
provided under clause (ii)(I) shall not be less than—
-
(I) the percentage specified by the State in an amendment to
its State plan (whether approved or not) as of the date of the enactment
of this clause, or
-
(II) if no such percentage is specified as of the date of the
enactment of this clause, the percentage established under the State's
authorizing legislation or provided for under the State's appropriations;
but in no case shall this clause require the percentage provided
under clause (ii)(I) to exceed 100 percent.
(iv) In the case of a State which, as of the date of the enactment
of this clause[31], has established under clause (i), or has enacted
legislation authorizing, or appropriating funds, to provide for,
a percentage (of the income official poverty line) that is greater
than 133 percent, the percentage provided under clause (ii) for
medical assistance on or after April 1, 1990, shall not be less than—
-
(I) the percentage specified by the State in an amendment to
its State plan (whether approved or not) as of the date of the enactment
of this clause, or
-
(II) if no such percentage is specified as of the date of the
enactment of this clause, the percentage established under the State's
authorizing legislation or provided for under the State's appropriations.
(B) For purposes of paragraph (1) with respect to individuals
described in subparagraph (C) of such paragraph, the State shall
establish an income level which is equal to 133 percent of the income
official poverty line described in subparagraph (A) applicable to
a family of the size involved.
(C) For purposes of paragraph (1) with respect to individuals
described in subparagraph (D) of that paragraph, the State shall
establish an income level which is equal to 100 percent of the income
official poverty line described in subparagraph (A) applicable to
a family of the size involved.
(3) Notwithstanding subsection (a)(17), for individuals who are
eligible for medical assistance because of subsection (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)—
-
(A) application of a resource standard shall be at the option
of the State;
-
(B) any resource standard or methodology that is applied with
respect to an individual described in subparagraph (A) of paragraph
(1) may not be more restrictive than the resource standard or methodology
that is applied under title XVI;
-
(C) any resource standard or methodology that is applied with
respect to an individual described in subparagraph (B), (C), or
(D) of paragraph (1) may not be more restrictive than the corresponding
methodology that is applied under the State plan under part A of
title IV;
-
(D) the income standard to be applied is the appropriate income
standard established under paragraph (2); and
-
(E) family income shall be determined in accordance with the
methodology employed under the State plan under part A or E of title
IV (except to the extent such methodology is inconsistent with clause
(D) of subsection (a)(17)), and costs incurred for medical care
or for any other type of remedial care shall not be taken into account.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require or
permit such treatment for other individuals.
(4)(A) In the case of any State which is providing medical assistance
to its residents under a waiver granted under section 1115, the
Secretary shall require the State to provide medical assistance
for pregnant women and infants under age 1 described in subsection
(a)(10)(A)(i)(IV) and for children described in subsection (a)(10)(A)(i)(VI)
or subsection (a)(10)(A)(i)(VII) in the same manner as the State
would be required to provide such assistance for such individuals
if the State had in effect a plan approved under this title.
(B) In the case of a State which is not one of the 50 States
or the District of Columbia, the State need not meet the requirement
of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), or (a)(10)(A)(i)(VII)
and, for purposes of paragraph (2)(A), the State may substitute
for the percentage provided under clause (ii) of such paragraph
any percentage.
(m)(1)
Individuals described in this paragraph
are individuals—
-
(A) who are 65 years of age or older or are disabled individuals
(as determined under section 1614(a)(3)),
-
(B) whose income (as determined under section 1612 for purposes
of the supplemental security income program, except as provided
in paragraph (2)(C)) does not exceed an income level established
by the State consistent with paragraph (2)(A), and
-
(C) whose resources (as determined under section 1613 for purposes
of the supplemental security income program) do not exceed (except
as provided in paragraph (2)(B)) the maximum amount of resources
that an individual may have and obtain benefits under that program.
(2)(A) The income level established under paragraph (1)(B) may
not exceed a percentage (not more than 100 percent) of the official
poverty line (as defined by the Office of Management and Budget,
and revised annually in accordance with section 673(2) of the Omnibus
Budget Reconciliation Act of 1981[32]) applicable to a family
of the size involved.
(B) In the case of a State that provides medical assistance to
individuals not described in subsection (a)(10)(A) and at the State's
option, the State may use under paragraph (1)(C) such resource level
(which is higher than the level described in that paragraph) as
may be applicable with respect to individuals described in paragraph
(1)(A) who are not described in subsection (a)(10)(A).
(C) The provisions of section 1905(p)(2)(D) shall apply to determinations
of income under this subsection in the same manner as they apply
to determinations of income under section 1905(p).
(3) Notwithstanding subsection (a)(17), for individuals described
in paragraph (1) who are covered under the State plan by virtue
of subsection (a)(10)(A)(ii)(X)—
-
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
-
(B) except as provided in section 1612(b)(4)(B)(ii), costs incurred
for medical care or for any other type of remedial care shall not
be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require or
permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17), for qualified medicare
beneficiaries described in section 1905(p)(1)—
-
(A) the income standard to be applied is the income standard
described in section 1905(p)(1)(B), and
-
(B) except as provided in section 1612(b)(4)(B)(ii), costs incurred
for medical care or for any other type of remedial care shall not
be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17), require or
permit such treatment for other individuals.
(n)(1)[33]
In the case of medical assistance
furnished under this title for medicare cost-sharing respecting
the furnishing of a service or item to a qualified medicare beneficiary,
the State plan may provide payment in an amount with respect to
the service or item that results in the sum of such payment amount
and any amount of payment made under title XVIII with respect to
the service or item exceeding the amount that is otherwise payable
under the State plan for the item or service for eligible individuals
who are not qualified medicare beneficiaries.
(2) In carrying out paragraph (1), a State is not required to
provide any payment for any expenses incurred relating to payment
for deductibles, coinsurance, or copayments for medicare cost-sharing
to the extent that payment under title XVIII for the service would
exceed the payment amount that otherwise would be made under the
State plan under this title for such service if provided to an eligible
recipient other than a medicare beneficiary.
(3) In the case in which a State's payment for medicare cost-sharing
for a qualified medicare beneficiary with respect to an item or
service is reduced or eliminated through the application of paragraph
(2)—
-
(A) for purposes of applying any limitation under title XVIII
on the amount that the beneficiary may be billed or charged for
the service, the amount of payment made under title XVIII plus the
amount of payment (if any) under the State plan shall be considered
to be payment in full for the service;
-
(B) the beneficiary shall not have any legal liability to make
payment to a provider or to an organization described insection 1903(m)(1)(A) for the service; and
-
(C) any lawful sanction that may be imposed upon a provider
or such an organization for excess charges under this title or title
XVIII shall apply to the imposition of any charge imposed upon the
individual in such case.
-
This paragraph shall not be construed as preventing payment
of any medicare cost-sharing by a medicare supplemental
policy or an employer retiree health plan on behalf of an individual.
(o)
Notwithstanding any provision of subsection
(a) to the contrary, a State plan under this title shall provide
that any supplemental security income benefits paid by reason of
subparagraph (E) or (G) of section 1611(e)(1) to an individual who—
-
(1) is eligible for medical assistance under the plan, and
-
(2) is in a hospital, skilled nursing facility, or intermediate
care facility at the time such benefits are paid,
will be disregarded for purposes of determining the amount of
any post-eligibility contribution by the individual to the cost
of the care and services provided by the hospital, skilled nursing
facility, or intermediate care facility.
(p)(1)
In addition to any other authority, a
State may exclude any individual or entity for purposes of participating
under the State plan under this title for any reason for which the
Secretary could exclude the individual or entity from participation
in a program under title XVIII under section 1128, 1128A, or 1866(b)(2).
(2) In order for a State to receive payments for medical assistance
under section 1903(a), with respect to payments the State makes
to a medicaid managed care organization (as defined in section 1903(m))
or to an entity furnishing services under a waiver approved under
section 1915(b)(1), the State must provide that it will exclude
from participation, as such an organization or entity, any organization
or entity that—
-
(A) could be excluded under section 1128(b)(8) (relating to
owners and managing employees who have been convicted of certain
crimes or received other sanctions),
-
(B) has, directly or indirectly, a substantial contractual relationship
(as defined by the Secretary) with an individual or entity that
is described in section 1128(b)(8)(B), or
-
(C) employs or contracts with any individual or entity that
is excluded from participation under this title under section 1128
or 1128A for the provision of health care, utilization review, medical
social work, or administrative services or employs or contracts
with any entity for the provision (directly or indirectly) through
such an excluded individual or entity of such services.
(3) As used in this subsection, the term “exclude” includes
the refusal to enter into or renew a participation agreement or
the termination of such an agreement.
(q)(1)(A)
In order to meet the requirement of
subsection (a)(50), the State plan must provide that, in the case
of an institutionalized individual or couple described in subparagraph
(B), in determining the amount of the individual's or couple's income
to be applied monthly to payment for the cost of care in an institution,
there shall be deducted from the monthly income (in addition to other
allowances otherwise provided under the State plan) a monthly personal needs
allowance—
-
(i) which is reasonable in amount for clothing and other personal
needs of the individual (or couple) while in an institution, and
-
(ii) which is not less (and may be greater) than the minimum
monthly personal needs allowance described in paragraph (2).
(B) In this subsection, the term “institutionalized
individual or couple” means an individual or married couple—
-
(i) who is an inpatient (or who are inpatients) in a medical
institution or nursing facility for which payments are made under
this title throughout a month, and
-
(ii) who is or are determined to be eligible for medical assistance
under the State plan.
(2) The minimum monthly personal needs allowance described in
this paragraph is $30 for an institutionalized individual and $60
for an institutionalized couple (if both are aged, blind, or disabled,
and their incomes are considered available to each other in determining
eligibility).
(r)(1)(A)
For purposes of sections 1902(a)(17)
and 1924(d)(1)(D) and for purposes of a waiver under section 1915,
with respect to the post-eligibility treatment of income of individuals
who are institutionalized or receiving home or community-based services
under such a waiver, the treatment described in subparagraph (B)
shall apply, there shall be disregarded reparation payments made
by the Federal Republic of Germany, and there shall be taken into
account amounts for incurred expenses for medical or remedial care
that are not subject to payment by a third party, including—
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(i) medicare and other health insurance premiums, deductibles,
or coinsurance, and
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(ii) necessary medical or remedial care recognized under State
law but not covered under the State plan under this title, subject
to reasonable limits the State may establish on the amount of these
expenses.
(B)(i) In the case of a veteran who does not have a spouse or
a child, if the veteran—
-
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(I) receives, after the veteran has been determined to be eligible
for medical assistance under the State plan under this title, a
veteran's pension in excess of $90 per month, and
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(II) resides in a State veterans home with respect to which
the Secretary of Veterans Affairs makes per diem payments for nursing
home care pursuant to section 1741(a) of title 38, United States
Code,
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any such pension payment, including any payment made due to
the need for aid and attendance, or for unreimbursed medical expenses,
that is in excess of $90 per month shall be counted as income only
for the purpose of applying such excess payment to the State veterans
home's cost of providing nursing home care to the veteran.
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(ii) The provisions of clause (i) shall apply with respect to
a surviving spouse of a veteran who does not have a child in the
same manner as they apply to a veteran described in such clause.
(2)(A) The methodology to be employed in determining income and resource
eligibility for individuals under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III),
or (f) or under section 1905(p) may be less restrictive, and shall
be no more restrictive, than the methodology—
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(i) in the case of groups consisting of aged, blind, or disabled
individuals, under the supplemental security income program under
title XVI, or
-
(ii) in the case of other groups, under the State plan most
closely categorically related.
(B) For purposes of this subsection and subsection (a)(10), methodology
is considered to be “no more restrictive” if,
using the methodology, additional individuals may be eligible for
medical assistance and no individuals who are otherwise eligible
are made ineligible for such assistance.
(s)
In order to meet the requirements of subsection
(a)(55), the State plan must provide that payments to hospitals
under the plan for inpatient hospital services furnished to infants
who have not attained the age of 1 year, and to children who have
not attained the age of 6 years and who receive such services in a
disproportionate share hospital described in section 1923(b)(1),
shall—
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(1) if made on a prospective basis (whether per diem, per case,
or otherwise) provide for an outlier adjustment in payment amounts
for medically necessary inpatient hospital services involving exceptionally
high costs or exceptionally long lengths of stay,
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(2) not be limited by the imposition of day limits with respect
to the delivery of such services to such individuals, and
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(3) not be limited by the imposition of dollar limits (other
than such limits resulting from prospective payments as adjusted
pursuant to paragraph (1)) with respect to the delivery of such
services to any such individual who has not attained their first
birthday (or in the case of such an individual who is an inpatient
on his first birthday until such individual is discharged).
(t)
Nothing in this title (including sections
1903(a) and 1905(a)) shall be construed as authorizing the Secretary
to deny or limit payments to a State for expenditures, for medical
assistance for items or services, attributable to taxes of general
applicability imposed with respect to the provision of such items
or services.
(u)(1)
Individuals described in this paragraph
are individuals—
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(A) who are entitled to elect COBRA continuation coverage (as
defined in paragraph (3)),
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(B) whose income (as determined under section 1612 for purposes
of the supplemental security income program) does not exceed 100
percent of the official poverty line (as defined by the Office of
Management and Budget, and revised annually in accordance with section
673(2) of the Omnibus Budget Reconciliation Act of 1981[34]) applicable
to a family of the size involved,
-
(C) whose resources (as determined under section 1613 for purposes
of the supplemental security income program) do not exceed twice
the maximum amount of resources that an individual may have and
obtain benefits under that program, and
-
(D) with respect to whose enrollment for COBRA continuation
coverage the State has determined that the savings in expenditures
under this title resulting from such enrollment is likely to exceed
the amount of payments for COBRA premiums made.
(2) For purposes of subsection (a)(10)(F) and this subsection,
the term “COBRA premiums” means the applicable
premium imposed with respect to COBRA continuation coverage.
(3) In this subsection, the term “COBRA continuation
coverage” means coverage under a group health plan provided
by an employer with 75 or more employees provided pursuant to title
XXII of the Public Health Service Act, section 4980B of the Internal
Revenue Code of 1986, or title VI of the Employee Retirement Income
Security Act of 1974[35].
(4) Notwithstanding subsection (a)(17), for individuals described
in paragraph (1) who are covered under the State plan by virtue
of subsection (a)(10)(A)(ii)(XI)—
-
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
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(B) except as provided in section 1612(b)(4)(B)(ii), costs incurred
for medical care or for any other type of remedial care shall not
be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(10)(B) or (a)(17),
require or permit such treatment for other individuals.
(v)
A State plan may provide for the making of
determinations of disability or blindness for the purpose of determining
eligibility for medical assistance under the State plan by the single
State agency or its designee, and make medical assistance available
to individuals whom it finds to be blind or disabled and who are
determined otherwise eligible for such assistance during the period of
time prior to which a final determination of disability or blindness
is made by the Social Security Administration with respect to such
an individual. In making such determinations, the State must apply
the definitions of disability and blindness found in section 1614(a)
of the Social Security Act.
(w)(1)
For purposes of subsection (a)(57) and
sections 1903(m)(1)(A) and 1919(c)(2)(E), the requirement of this
subsection is that a provider or organization (as the case may be)
maintain written policies and procedures with respect to all adult
individuals receiving medical care by or through the provider or
organization—
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(A) to provide written information to each such individual concerning—
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(i) an individual's rights under State law (whether statutory
or as recognized by the courts of the State) to make decisions concerning
such medical care, including the right to accept or refuse medical
or surgical treatment and the right to formulate advance directives
(as defined in paragraph (3)), and
-
(ii) the provider's or organization's written policies respecting
the implementation of such rights;
-
(B) to document in the individual's medical record whether or
not the individual has executed an advance directive;
-
(C) not to condition the provision of care or otherwise discriminate against
an individual based on whether or not the individual has executed an
advance directive;
-
(D) to ensure compliance with requirements of State law (whether
statutory or as recognized by the courts of the State) respecting
advance directives; and
-
(E) to provide (individually or with others) for education for
staff and the community on issues concerning advance directives.
Subparagraph (C) shall not be construed as requiring the provision
of care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A) shall
be provided to an adult individual—
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(A) in the case of a hospital, at the time of the individual's
admission as an inpatient,
-
(B) in the case of a nursing facility, at the time of the individual's
admission as a resident,
-
(C) in the case of a provider of home health care or personal
care services, in advance of the individual coming under the care
of the provider,
-
(D) in the case of a hospice program, at the time of initial
receipt of hospice care by the individual from the program, and
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(E) in the case of a medicaid managed care organization, at
the time of enrollment of the individual with the organization.
(3) Nothing in this section shall be construed to prohibit the
application of a State law which allows for an objection on the
basis of conscience for any health care provider or any agent of
such provider which as a matter of conscience cannot implement an
advance directive.
(4) In this subsection, the term “advance directive” means
a written instruction, such as a living will or durable power of
attorney for health care, recognized under State law (whether statutory
or as recognized by the courts of the State) and relating to the
provision of such care when the individual is incapacitated.
(5) For construction relating to this subsection, see section
7 of the Assisted Suicide Funding Restriction Act of 1997 (relating
to clarification respecting assisted suicide, euthanasia, and mercy
killing).
(x)
The Secretary shall establish a system, for
implementation by not later than July 1, 1991, which provides for
a unique identifier for each physician who furnishes services for
which payment may be made under a State plan approved under this
title.[36]
(y)(1)
In addition to any other authority under
State law, where a State determines that a psychiatric hospital
which is certified for participation under its plan no longer meets
the requirements for a psychiatric hospital (referred to in section 1905(h)) and further finds that the hospital's deficiencies—
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(A) immediately jeopardize the health and safety of its patients,
the State shall terminate the hospital's participation under the
State plan; or
-
(B) do not immediately jeopardize the health and safety of its
patients, the State may terminate the hospital's participation under
the State plan, or provide that no payment will be made under the
State plan with respect to any individual admitted to such hospital
after the effective date of the finding, or both.
(2) Except as provided in paragraph (3), if a psychiatric hospital
described in paragraph (1)(B) has not complied with the requirements
for a psychiatric hospital under this title—
-
(A) within 3 months after the date the hospital is found to
be out of compliance with such requirements, the State shall provide
that no payment will be made under the State plan with respect to
any individual admitted to such hospital after the end of such 3-month
period, or
-
(B) within 6 months after the date the hospital is found to
be out of compliance with such requirements, no Federal financial
participation shall be provided under section 1903(a) with respect
to further services provided in the hospital until the State finds
that the hospital is in compliance with the requirements of this
title.
(3) The Secretary may continue payments, over a period of not
longer than 6 months from the date the hospital is found to be out
of compliance with such requirements, if—
-
(A) the State finds that it is more appropriate to take alternative
action to assure compliance of the hospital with the requirements
than to terminate the certification of the hospital,
-
(B) the State has submitted a plan and timetable for corrective
action to the Secretary for approval and the Secretary approves
the plan of corrective action, and
-
(C) the State agrees to repay to the Federal Government payments received
under this paragraph if the corrective action is not taken in accordance
with the approved plan and timetable.
(z)(1)
Individuals described in this paragraph
are individuals not described in subsection (a)(10)(A)(i)—
-
(A) who are infected with tuberculosis;
-
(B) whose income (as determined under the State plan under this
title with respect to disabled individuals) does not exceed the
maximum amount of income a disabled individual described in subsection
(a)(10)(A)(i) may have and obtain medical assistance under the plan;
and
-
(C) whose resources (as determined under the State plan under
this title with respect to disabled individuals) do not exceed the
maximum amount of resources a disabled individual described in subsection
(a)(10)(A)(i) may have and obtain medical assistance under the plan.
(2) For purposes of subsection (a)(10), the term “TB-related
services” means each of the following services relating
to treatment of infection with tuberculosis:
-
(A) Prescribed drugs.
-
(B) Physicians' services and services described in section 1905(a)(2).
-
(C) Laboratory and X-ray services (including services to confirm
the presence of infection).
-
(D) Clinic services and Federally-qualified health center services.
-
(E) Case management services (as defined in section 1915(g)(2)).
-
(F) Services (other than room and board) designed to encourage
completion of regimens of prescribed drugs by outpatients, including
services to observe directly the intake of prescribed drugs.
(aa) INDIVIDUALS DESCRIBED IN THIS SUBSECTION
ARE INDIVIDUALS WHO—
-
(1) are not described in subsection (a)(10)(A)(i);
-
(2) have not attained age 65;
-
(3) have been screened for breast and cervical cancer under
the Centers for Disease Control and Prevention breast and cervical
cancer early detection program established under title XV of the
Public Health Service Act (42 U.S.C. 300k et seq.) in accordance
with the requirements of section 1504 of that Act (42 U.S.C. 300n)
and need treatment for breast or cervical cancer; and
-
(4) are not otherwise covered under creditable coverage, as
defined in section 2701(c) of the Public Health Service Act (42
U.S.C. 300gg(c)), but applied without regard to paragraph (1)(F)
of such section.[37]
(bb)[38] PAYMENT FOR SERVICES PROVIDED BY
FEDERALLY-QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS.—
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(1) IN GENERAL.—Beginning with fiscal
year 2001 with respect to services furnished on or after January
1, 2001, and each succeeding fiscal year, the State plan shall provide
for payment for services described in section 1905(a)(2)(C) furnished
by a Federally-qualified health center and services described in
section 1905(a)(2)(B) furnished by a rural health clinic in accordance
with the provisions of this subsection.
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(2) FISCAL YEAR 2001.—Subject to paragraph
(4), for services furnished on and after January 1, 2001, during
fiscal year 2001, the State plan shall provide for payment for such
services in an amount (calculated on a per visit basis) that is
equal to 100 percent of the average of the costs of the center or
clinic of furnishing such services during fiscal years 1999 and 2000
which are reasonable and related to the cost of furnishing such
services, or based on such other tests of reasonableness as the
Secretary prescribes in regulations under section 1833(a)(3), or,
in the case of services to which such regulations do not apply,
the same methodology used under section 1833(a)(3), adjusted to
take into account any increase or decrease in the scope of such
services furnished by the center or clinic during fiscal year 2001.
-
(3) FISCAL YEAR 2002 AND SUCCEEDING FISCAL YEARS.—Subject
to paragraph (4), for services furnished during fiscal year 2002
or a succeeding fiscal year, the State plan shall provide for payment
for such services in an amount (calculated on a per visit basis)
that is equal to the amount calculated for such services under this
subsection for the preceding fiscal year—
-
(A) increased by the percentage increase in the MEI (as defined
in section 1842(i)(3)) applicable to primary care services (as defined
in section 1842(i)(4)) for that fiscal year; and
-
(B) adjusted to take into account any increase or decrease in
the scope of such services furnished by the center or clinic during
that fiscal year.
-
(4) ESTABLISHMENT OF INITIAL YEAR PAYMENT AMOUNT
FOR NEW CENTERS OR CLINICS.—In any case in which an
entity first qualifies as a Federally-qualified health center or
rural health clinic after fiscal year 2000, the State plan shall
provide for payment for services described in section 1905(a)(2)(C)
furnished by the center or services described in section 1905(a)(2)(B)
furnished by the clinic in the first fiscal year in which the center
or clinic so qualifies in an amount (calculated on a per visit basis) that
is equal to 100 percent of the costs of furnishing such services
during such fiscal year based on the rates established under this
subsection for the fiscal year for other such centers or clinics
located in the same or adjacent area with a similar case load or,
in the absence of such a center or clinic, in accordance with the
regulations and methodology referred to in paragraph (2) or based
on such other tests of reasonableness as the Secretary may specify.
For each fiscal year following the fiscal year in which the entity first
qualifies as a Federally-qualified health center or rural health
clinic, the State plan shall provide for the payment amount to be
calculated in accordance with paragraph (3).
-
(5) ADMINISTRATION IN THE CASE OF MANAGED CARE.—
-
(A) IN GENERAL.—In the case of services
furnished by a Federally-qualified health center or rural health
clinic pursuant to a contract between the center or clinic and a
managed care entity (as defined in section 1932(a)(1)(B)), the State
plan shall provide for payment to the center or clinic by the State
of a supplemental payment equal to the amount (if any) by which
the amount determined under paragraphs (2), (3), and (4) of this
subsection exceeds the amount of the payments provided under the
contract.
-
(B) PAYMENT SCHEDULE.—The supplemental
payment required under subparagraph (A) shall be made pursuant to
a payment schedule agreed to by the State and the Federally-qualified
health center or rural health clinic, but in no case less frequently
than every 4 months.
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(6) ALTERNATIVE PAYMENT METHODOLOGIES.—Notwithstanding
any other provision of this section, the State plan may provide
for payment in any fiscal year to a Federally-qualified health center
for services described in section 1905(a)(2)(C) or to a rural health
clinic for services described in section 1905(a)(2)(B) in an amount
which is determined under an alternative payment methodology that—
-
(A) is agreed to by the State and the center or clinic; and
-
(B) results in payment to the center or clinic of an amount
which is at least equal to the amount otherwise required to be paid
to the center or clinic under this section.