US (United States) Code. Title 42. Chapter 7: Social Security

Codificación normativa de EEUU (Estados Unidos). Legislación federal estadounidense # The Public Health and Welfare

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(B) Coinsurance under subchapter XVIII of this chapter

(including coinsurance described in section 1395e of this title).

(C) Deductibles established under subchapter XVIII of this

chapter (including those described in section 1395e of this title

and section 1395l(b) of this title).

(D) The difference between the amount that is paid under

section 1395l(a) of this title and the amount that would be paid

under such section if any reference to "80 percent" therein were

deemed a reference to "100 percent".

Such term also may include, at the option of a State, premiums for

enrollment of a qualified medicare beneficiary with an eligible

organization under section 1395mm of this title.

(4) Notwithstanding any other provision of this subchapter, in

the case of a State (other than the 50 States and the District of

Columbia) -

(A) the requirement stated in section 1396a(a)(10)(E) of this

title shall be optional, and

(B) for purposes of paragraph (2), the State may substitute for

the percent provided under subparagraph (B) (!7) or (!8)

1396a(a)(10)(E)(iii) of this title of such paragraph (!7) any

percent.

In the case of any State which is providing medical assistance to

its residents under a waiver granted under section 1315 of this

title, the Secretary shall require the State to meet the

requirement of section 1396a(a)(10)(E) of this title in the same

manner as the State would be required to meet such requirement if

the State had in effect a plan approved under this subchapter.

(5)(A) The Secretary shall develop and distribute to States a

simplified application form for use by individuals (including both

qualified medicare beneficiaries and specified low-income medicare

beneficiaries) in applying for medical assistance for medicare

cost-sharing under this subchapter in the States which elect to use

such form. Such form shall be easily readable by applicants and

uniform nationally.

(B) In developing such form, the Secretary shall consult with

beneficiary groups and the States.

(6) For provisions relating to outreach efforts to increase

awareness of the availability of medicare cost-sharing, see section

1320b-14 of this title.

(q) Qualified severely impaired individual

The term "qualified severely impaired individual" means an

individual under age 65 -

(1) who for the month preceding the first month to which this

subsection applies to such individual -

(A) received (i) a payment of supplemental security income

benefits under section 1382(b) of this title on the basis of

blindness or disability, (ii) a supplementary payment under

section 1382e of this title or under section 212 of Public Law

93-66 on such basis, (iii) a payment of monthly benefits under

section 1382h(a) of this title, or (iv) a supplementary payment

under section 1382e(c)(3), and

(B) was eligible for medical assistance under the State plan

approved under this subchapter; and

(2) with respect to whom the Commissioner of Social Security

determines that -

(A) the individual continues to be blind or continues to have

the disabling physical or mental impairment on the basis of

which he was found to be under a disability and, except for his

earnings, continues to meet all non-disability-related

requirements for eligibility for benefits under subchapter XVI

of this chapter,

(B) the income of such individual would not, except for his

earnings, be equal to or in excess of the amount which would

cause him to be ineligible for payments under section 1382(b)

of this title (if he were otherwise eligible for such

payments),

(C) the lack of eligibility for benefits under this

subchapter would seriously inhibit his ability to continue or

obtain employment, and

(D) the individual's earnings are not sufficient to allow him

to provide for himself a reasonable equivalent of the benefits

under subchapter XVI of this chapter (including any federally

administered State supplementary payments), this subchapter,

and publicly funded attendant care services (including personal

care assistance) that would be available to him in the absence

of such earnings.

In the case of an individual who is eligible for medical assistance

pursuant to section 1382h(b) of this title in June, 1987, the

individual shall be a qualified severely impaired individual for so

long as such individual meets the requirements of paragraph (2).

(r) Early and periodic screening, diagnostic, and treatment

services

The term "early and periodic screening, diagnostic, and treatment

services" means the following items and services:

(1) Screening services -

(A) which are provided -

(i) at intervals which meet reasonable standards of medical

and dental practice, as determined by the State after

consultation with recognized medical and dental organizations

involved in child health care and, with respect to

immunizations under subparagraph (B)(iii), in accordance with

the schedule referred to in section 1396s(c)(2)(B)(i) of this

title for pediatric vaccines, and

(ii) at such other intervals, indicated as medically

necessary, to determine the existence of certain physical or

mental illnesses or conditions; and

(B) which shall at a minimum include -

(i) a comprehensive health and developmental history

(including assessment of both physical and mental health

development),

(ii) a comprehensive unclothed physical exam,

(iii) appropriate immunizations (according to the schedule

referred to in section 1396s(c)(2)(B)(i) of this title for

pediatric vaccines) according to age and health history,

(iv) laboratory tests (including lead blood level

assessment appropriate for age and risk factors), and

(v) health education (including anticipatory guidance).

(2) Vision services -

(A) which are provided -

(i) at intervals which meet reasonable standards of medical

practice, as determined by the State after consultation with

recognized medical organizations involved in child health

care, and

(ii) at such other intervals, indicated as medically

necessary, to determine the existence of a suspected illness

or condition; and

(B) which shall at a minimum include diagnosis and treatment

for defects in vision, including eyeglasses.

(3) Dental services -

(A) which are provided -

(i) at intervals which meet reasonable standards of dental

practice, as determined by the State after consultation with

recognized dental organizations involved in child health

care, and

(ii) at such other intervals, indicated as medically

necessary, to determine the existence of a suspected illness

or condition; and

(B) which shall at a minimum include relief of pain and

infections, restoration of teeth, and maintenance of dental

health.

(4) Hearing services -

(A) which are provided -

(i) at intervals which meet reasonable standards of medical

practice, as determined by the State after consultation with

recognized medical organizations involved in child health

care, and

(ii) at such other intervals, indicated as medically

necessary, to determine the existence of a suspected illness

or condition; and

(B) which shall at a minimum include diagnosis and treatment

for defects in hearing, including hearing aids.

(5) Such other necessary health care, diagnostic services,

treatment, and other measures described in subsection (a) of this

section to correct or ameliorate defects and physical and mental

illnesses and conditions discovered by the screening services,

whether or not such services are covered under the State plan.

Nothing in this subchapter shall be construed as limiting providers

of early and periodic screening, diagnostic, and treatment services

to providers who are qualified to provide all of the items and

services described in the previous sentence or as preventing a

provider that is qualified under the plan to furnish one or more

(but not all) of such items or services from being qualified to

provide such items and services as part of early and periodic

screening, diagnostic, and treatment services. The Secretary shall,

not later than July 1, 1990, and every 12 months thereafter,

develop and set annual participation goals for each State for

participation of individuals who are covered under the State plan

under this subchapter in early and periodic screening, diagnostic,

and treatment services.

(s) Qualified disabled and working individual

The term "qualified disabled and working individual" means an

individual -

(1) who is entitled to enroll for hospital insurance benefits

under part A of subchapter XVIII of this chapter under section

1395i-2a of this title;

(2) whose income (as determined under section 1382a of this

title for purposes of the supplemental security income program)

does not exceed 200 percent of the official poverty line (as

defined by the Office of Management and Budget and revised

annually in accordance with section 9902(2) of this title)

applicable to a family of the size involved;

(3) whose resources (as determined under section 1382b of this

title for purposes of the supplemental security income program)

do not exceed twice the maximum amount of resources that an

individual or a couple (in the case of an individual with a

spouse) may have and obtain benefits for supplemental security

income benefits under subchapter XVI of this chapter; and

(4) who is not otherwise eligible for medical assistance under

this subchapter.

(t) Primary care case management services; primary care case

manager; primary care case management contract; and primary care

(1) The term "primary care case management services" means

case-management related services (including locating, coordinating,

and monitoring of health care services) provided by a primary care

case manager under a primary care case management contract.

(2) The term "primary care case manager" means any of the

following that provides services of the type described in paragraph

(1) under a contract referred to in such paragraph:

(A) A physician, a physician group practice, or an entity

employing or having other arrangements with physicians to provide

such services.

(B) At State option -

(i) a nurse practitioner (as described in subsection (a)(21)

of this section);

(ii) a certified nurse-midwife (as defined in section

1395x(gg) of this title); or

(iii) a physician assistant (as defined in section

1395x(aa)(5) of this title).

(3) The term "primary care case management contract" means a

contract between a primary care case manager and a State under

which the manager undertakes to locate, coordinate, and monitor

covered primary care (and such other covered services as may be

specified under the contract) to all individuals enrolled with the

manager, and which -

(A) provides for reasonable and adequate hours of operation,

including 24-hour availability of information, referral, and

treatment with respect to medical emergencies;

(B) restricts enrollment to individuals residing sufficiently

near a service delivery site of the manager to be able to reach

that site within a reasonable time using available and affordable

modes of transportation;

(C) provides for arrangements with, or referrals to, sufficient

numbers of physicians and other appropriate health care

professionals to ensure that services under the contract can be

furnished to enrollees promptly and without compromise to quality

of care;

(D) prohibits discrimination on the basis of health status or

requirements for health care services in enrollment,

disenrollment, or reenrollment of individuals eligible for

medical assistance under this subchapter;

(E) provides for a right for an enrollee to terminate

enrollment in accordance with section 1396u-2(a)(4) of this

title; and

(F) complies with the other applicable provisions of section

1396u-2 of this title.

(4) For purposes of this subsection, the term "primary care"

includes all health care services customarily provided in

accordance with State licensure and certification laws and

regulations, and all laboratory services customarily provided by or

through, a general practitioner, family medicine physician,

internal medicine physician, obstetrician/gynecologist, or

pediatrician.

(u) Conditions for State plans

(1) The conditions described in this paragraph for a State plan

are as follows:

(A) The State is complying with the requirement of section

1397ee(d)(1) of this title.

(B) The plan provides for such reporting of information about

expenditures and payments attributable to the operation of this

subsection as the Secretary deems necessary in order to carry out

the fourth sentence of subsection (b) of this section.

(2)(A) For purposes of subsection (b) of this section, the

expenditures described in this subparagraph are expenditures for

medical assistance for optional targeted low-income children

described in subparagraph (B).

(B) For purposes of this paragraph, the term "optional targeted

low-income child" means a targeted low-income child as defined in

section 1397jj(b)(1) of this title (determined without regard to

that portion of subparagraph (C) of such section concerning

eligibility for medical assistance under this subchapter) who would

not qualify for medical assistance under the State plan under this

subchapter as in effect on March 31, 1997 (but taking into account

the expansion of age of eligibility effected through the operation

of section 1396a(l)(1)(D) of this title).

(3) For purposes of subsection (b) of this section, the

expenditures described in this paragraph are expenditures for

medical assistance for children who are born before October 1,

1983, and who would be described in section 1396a(l)(1)(D) of this

title if they had been born on or after such date, and who are not

eligible for such assistance under the State plan under this

subchapter based on such State plan as in effect as of March 31,

1997.

(4) The limitations on payment under subsections (f) and (g) of

section 1308 of this title shall not apply to Federal payments made

under section 1396b(a)(1) of this title based on an enhanced FMAP

described in section 1397ee(b) of this title.

(v) Employed individual with a medically improved disability

(1) The term "employed individual with a medically improved

disability" means an individual who -

(A) is at least 16, but less than 65, years of age;

(B) is employed (as defined in paragraph (2));

(C) ceases to be eligible for medical assistance under section

1396a(a)(10)(A)(ii)(XV) of this title because the individual, by

reason of medical improvement, is determined at the time of a

regularly scheduled continuing disability review to no longer be

eligible for benefits under section 423(d) or 1382c(a)(3) of this

title; and

(D) continues to have a severe medically determinable

impairment, as determined under regulations of the Secretary.

(2) For purposes of paragraph (1), an individual is considered to

be "employed" if the individual -

(A) is earning at least the applicable minimum wage requirement

under section 206 of title 29 and working at least 40 hours per

month; or

(B) is engaged in a work effort that meets substantial and

reasonable threshold criteria for hours of work, wages, or other

measures, as defined by the State and approved by the Secretary.

(w) Independent foster care adolescent

(1) For purposes of this subchapter, the term "independent foster

care adolescent" means an individual -

(A) who is under 21 years of age;

(B) who, on the individual's 18th birthday, was in foster care

under the responsibility of a State; and

(C) whose assets, resources, and income do not exceed such

levels (if any) as the State may establish consistent with

paragraph (2).

(2) The levels established by a State under paragraph (1)(C) may

not be less than the corresponding levels applied by the State

under section 1396u-1(b) of this title.

(3) A State may limit the eligibility of independent foster care

adolescents under section 1396a(a)(10)(A)(ii)(XVII) of this title

to those individuals with respect to whom foster care maintenance

payments or independent living services were furnished under a

program funded under part E of subchapter IV of this chapter before

the date the individuals attained 18 years of age.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1905, as added Pub. L.

89-97, title I, Sec. 121(a), July 30, 1965, 79 Stat. 351; amended

Pub. L. 90-248, title II, Secs. 230, 233, 241(f)(6), 248(e), title

III, Sec. 302(a), Jan. 2, 1968, 81 Stat. 905, 917, 919, 929; Pub.

L. 92-223, Sec. 4(a), Dec. 28, 1971, 85 Stat. 809; Pub. L. 92-603,

title II, Secs. 212(a), 247(b), 275(a), 278(a)(21)-(23), 280,

297(a), 299, 299B, 299E(b), 299L, Oct. 30, 1972, 86 Stat. 1384,

1425, 1452-1454, 1459-1462, 1464; Pub. L. 93-233, Secs.

13(a)(13)-(88), 18(w), (x)(7)-(10), (y)(2), Dec. 31, 1973, 87 Stat.

963, 964, 972, 973; Pub. L. 94-437, title IV, Sec. 402(e), Sept.

30, 1976, 90 Stat. 1410; Pub. L. 95-210, Sec. 2(a), (b), Dec. 13,

1977, 91 Stat. 1488; Pub. L. 95-292, Sec. 8(a), (b), June 13, 1978,

92 Stat. 316; Pub. L. 96-473, Sec. 6(k), Oct. 19, 1980, 94 Stat.

2266; Pub. L. 96-499, title IX, Sec. 965(a), Dec. 5, 1980, 94 Stat.

2651; Pub. L. 97-35, title XXI, Secs. 2162(a)(2), 2172(b), Aug. 13,

1981, 95 Stat. 806, 808; Pub. L. 97-248, title I, Secs. 136(c),

137(b)(17), (18), (f), Sept. 3, 1982, 96 Stat. 376, 379, 381; Pub.

L. 98-369, div. B, title III, Secs. 2335(f), 2340(b), 2361(b),

2371(a), 2373(b)(15)-(20), July 18, 1984, 98 Stat. 1091, 1093,

1104, 1110, 1112; Pub. L. 99-272, title IX, Secs. 9501(a), 9505(a),

9511(a), Apr. 7, 1986, 100 Stat. 201, 208, 212; Pub. L. 99-509,

title IX, Secs. 9403(b), (d), (g)(3), 9404(b), 9408(c)(1),

9435(b)(2), Oct. 21, 1986, 100 Stat. 2053, 2054, 2056, 2061, 2070;

Pub. L. 99-514, title XVIII, Sec. 1895(c)(3)(A), Oct. 22, 1986, 100

Stat. 2935; Pub. L. 100-203, title IV, Secs. 4073(d), 4101(c)(1),

4103(a), 4105(a), 4114, 4118(p)(8), 4211(e), (f), (h)(6), Dec. 22,

1987, 101 Stat. 1330-119, 1330-141, 1330-146, 1330-147, 1330-152,

1330-159, 1330-204 to 1330-206; Pub. L. 100-360, title III, Sec.

301(a)(2)-(d), (g)(2), title IV, Sec. 411(h)(4)(E), (k)(4), (8),

(14)(A), July 1, 1988, 102 Stat. 748-750, 787, 791, 794, 798; Pub.

L. 100-485, title III, Sec. 303(b)(2), title IV, Sec. 401(d)(2),

title VI, Sec. 608(d)(14)(A)-(G), (J), (f)(3), Oct. 13, 1988, 102

Stat. 2392, 2396, 2415, 2416, 2424; Pub. L. 100-647, title VIII,

Sec. 8434(a), (b)(3), (4), Nov. 10, 1988, 102 Stat. 3805; Pub. L.

101-234, title II, Sec. 201(b), Dec. 13, 1989, 103 Stat. 1981; Pub.

L. 101-239, title VI, Secs. 6402(c)(1), 6403(a), (c), (d)(2),

6404(a), (b), 6405(a), 6408(d)(2), (4)(A), (B), Dec. 19, 1989, 103

Stat. 2261-2265, 2268, 2269; Pub. L. 101-508, title IV, Secs.

4402(d)(2), 4501(a), (c), (e)(1), 4601(a)(2), 4704(c), (d), (e)(1),

4705(a), 4711(a), 4712(a), 4713(b), 4717, 4719(a), 4721(a), 4722,

4755(a)(1)(A), Nov. 5, 1990, 104 Stat. 1388-163 to 1388-166,

1388-172, 1388-174, 1388-187, 1388-191, 1388-193, 1388-194,

1388-209; Pub. L. 103-66, title XIII, Secs. 13601(a), 13603(e),

13605(a), 13606(a), 13631(f)(2), (g)(1), Aug. 10, 1993, 107 Stat.

612, 620, 621, 644, 645; Pub. L. 103-296, title I, Sec. 108(d)(2),

(3), Aug. 15, 1994, 108 Stat. 1486; Pub. L. 104-299, Sec. 4(b)(2),

Oct. 11, 1996, 110 Stat. 3645; Pub. L. 105-33, title IV, Secs.

4702(a), 4711(c)(1), 4712(d)(1), 4714(a)(2), 4725(b)(1), 4732(b),

4802(a)(1), 4911(a), Aug. 5, 1997, 111 Stat. 494, 508-510, 518,

520, 538, 570; Pub. L. 105-100, title I, Sec. 162(1), (2), Nov. 19,

1997, 111 Stat. 2188; Pub. L. 106-113, div. B, Sec. 1000(a)(6)

[title VI, Secs. 605(a), 608(l), (m), (aa)(3)], Nov. 29, 1999, 113

Stat. 1536, 1501A-396 to 1501A-398; Pub. L. 106-169, title I, Sec.

121(a)(2), (c)(5), Dec. 14, 1999, 113 Stat. 1829, 1830; Pub. L.

106-170, title II, Sec. 201(a)(2)(B), (C), Dec. 17, 1999, 113 Stat.

1892; Pub. L. 106-354, Sec. 2(a)(4), (c), Oct. 24, 2000, 114 Stat.

1382, 1384; Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 709(a),

title VIII, Sec. 802(d)(1), (2), title IX, Sec. 911(a)(2)], Dec.

21, 2000, 114 Stat. 2763, 2763A-578, 2763A-581, 2763A-584.)

-REFTEXT-

REFERENCES IN TEXT

Part A of subchapter IV of this chapter, referred to in subsecs.

(a), (m)(1), and (n), is classified to section 601 et seq. of this

title.

Parts A and B of subchapter XVIII of this chapter, referred to in

subsecs. (a), (l)(2)(B)(iv), (o)(3)(B), (p)(1)(A), and (s)(1), are

classified to sections 1395c et seq. and 1395j et seq.,

respectively, of this title.

Section 606 of this title, referred to in subsec. (a)(ii), was

repealed and a new section 606 enacted by Pub. L. 104-193, title I,

Sec. 103(a)(1), Aug. 22, 1996, 110 Stat. 2112, and, as so enacted,

no longer contains a subsec. (b)(1).

Section 211 of Pub. L. 93-66, referred to in subsec. (k), is

section 211 of Pub. L. 93-66, July 9, 1973, 87 Stat. 152, as

amended, which is set out as a note under section 1382 of this

title.

The Indian Self-Determination Act, referred to in subsec.

(l)(2)(B), is title I of Pub. L. 93-638, Jan. 4, 1975, 88 Stat.

2206, as amended, which is classified principally to part A (Sec.

450f et seq.) of subchapter II of chapter 14 of Title 25, Indians.

For complete classification of this Act to the Code, see Short

Title note set out under section 450 of Title 25 and Tables.

The Indian Health Care Improvement Act, referred to in subsec.

(l)(2)(B), is Pub. L. 94-437, Sept. 30, 1976, 90 Stat. 1400, as

amended. Title V of the Act is classified generally to subchapter

IV (Sec. 1651 et seq.) of chapter 18 of Title 25. For complete

classification of this Act to the Code, see Short Title note set

out under section 1601 of Title 25 and Tables.

Clause (ii), referred to in subsec. (l)(2)(B), was redesignated

as cl. (iii) by Pub. L. 101-508, title IV, Sec. 4704(c)(3), Nov. 5,

1990, 104 Stat. 1388-172.

Section 607 of this title, referred to in subsec. (m)(1), was

repealed and a new section 607 enacted by Pub. L. 104-193, title I,

Sec. 103(a)(1), Aug. 22, 1996, 110 Stat. 2112, and, as so enacted,

no longer contains a subsec. (b)(2)(B)(i).

Section 212 of Public Law 93-66, referred to in subsec.

(q)(1)(A), is section 212 of Pub. L. 93-66, title II, July 9, 1973,

87 Stat. 155, as amended, which is set out as a note under section

1382 of this title.

-MISC1-

AMENDMENTS

2000 - Subsec. (a)(xiii). Pub. L. 106-354, Sec. 2(a)(4), added

cl. (xiii).

Subsec. (b). Pub. L. 106-554, Sec. 1(a)(6) [title VIII, Sec.

802(d)(1)], in last sentence, substituted "the State's available

allotment under section 1397dd of this title" for "the State's

allotment under section 1397dd of this title (not taking into

account reductions under section 1397dd(d)(2) of this title) for

the fiscal year reduced by the amount of any payments made under

section 1397ee of this title to the State from such allotment for

such fiscal year".

Pub. L. 106-354, Sec. 2(c), in first sentence, struck out "and"

before "(3)" and inserted before period at end ", and (4) the

Federal medical assistance percentage shall be equal to the

enhanced FMAP described in section 1397ee(b) of this title with

respect to medical assistance provided to individuals who are

eligible for such assistance only on the basis of section

1396a(a)(10)(A)(ii)(XVIII) of this title".

Subsec. (p)(5). Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec.

709(a)], added par. (5).

Subsec. (p)(6). Pub. L. 106-554, Sec. 1(a)(6) [title IX, Sec.

911(a)(2)], added par. (6).

Subsec. (u)(1)(B). Pub. L. 106-554, Sec. 1(a)(6) [title VIII,

Sec. 802(d)(2)], struck out "and section 1397dd(d) of this title"

before period at end.

1999 - Subsec. (a)(xii). Pub. L. 106-170, Sec. 201(a)(2)(C),

added cl. (xii).

Subsec. (a)(15). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(aa)(3)], substituted "1396a(a)(31) of this title" for

"1396a(a)(31)(A) of this title".

Subsec. (b). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

605(a)], inserted "(other than expenditures under section 1396r-4

of this title)" after "with respect to expenditures" in last

sentence.

Subsec. (b)(1). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(l)], substituted "83 per centum," for "83 per centum,,".

Subsec. (l)(2)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(m)], substituted "an entity" for "a entity" in

introductory provisions.

Subsec. (v). Pub. L. 106-169, Sec. 121(c)(5)(A), redesignated

subsec. (v), related to independent foster care adolescent, as (w).

Pub. L. 106-169, Sec. 121(a)(2), added subsec. (v), related to

independent foster care adolescent.

Pub. L. 106-170, Sec. 201(a)(2)(B), added subsec. (v).

Subsec. (w). Pub. L. 106-169, Sec. 121(c)(5), redesignated

subsec. (v) as (w) and substituted "1396a(a)(10)(A)(ii)(XVII)" for

"1396a(a)(10)(A)(ii)(XV)".

1997 - Subsec. (a)(25). Pub. L. 105-33, Sec. 4702(a)(1), added

par. (25). Former par. (25) redesignated (26).

Subsec. (a)(26). Pub. L. 105-33, Sec. 4802(a)(1), added par.

(26). Former par. (26) redesignated (27).

Pub. L. 105-33, Sec. 4702(a)(1)(B), redesignated par. (25) as

(26) and substituted comma for period at end.

Subsec. (a)(27). Pub. L. 105-33, Sec. 4802(a)(1)(B), redesignated

par. (26) as (27).

Subsec. (b). Pub. L. 105-100, Sec. 162(1), inserted "for the

State for a fiscal year, and that do not exceed the amount of the

State's allotment under section 1397dd of this title (not taking

into account reductions under section 1397dd(d)(2) of this title)

for the fiscal year reduced by the amount of any payments made

under section 1397ee of this title to the State from such allotment

for such fiscal year," after "subsection (u)(3) of this section".

Pub. L. 105-33, Sec. 4911(a)(1), inserted at end "Notwithstanding

the first sentence of this subsection, in the case of a State plan

that meets the condition described in subsection (u)(1) of this

section, with respect to expenditures described in subsection

(u)(2)(A) of this section or subsection (u)(3) of this section the

Federal medical assistance percentage is equal to the enhanced FMAP

described in section 1397ee(b) of this title."

Pub. L. 105-33, Sec. 4732(b), substituted "Subject to section

1396u-3(d) of this title, the term" for "The term".

Pub. L. 105-33, Sec. 4725(b)(1), in first sentence, substituted

", (2)" for "and (2)" and inserted before period ", and (3) for

purposes of this subchapter and subchapter XXI of this chapter, the

Federal medical assistance percentage for the District of Columbia

shall be 70 percent".

Subsec. (l)(2)(B)(iii). Pub. L. 105-33, Sec. 4712(d)(1), inserted

"including requirements of the Secretary that an entity may not be

owned, controlled, or operated by another entity," after "such a

grant,".

Subsec. (o)(3). Pub. L. 105-33, Sec. 4711(c)(1), substituted

"amount determined in section 1396a(a)(13)(B) of this title" for

"amount described in section 1396a(a)(13)(D) of this title" in

concluding provisions.

Subsec. (p)(3). Pub. L. 105-33, Sec. 4714(a)(2), inserted

"(subject to section 1396a(n)(2) of this title)" after "means" in

introductory provisions.

Subsec. (t). Pub. L. 105-33, Sec. 4702(a)(2), added subsec. (t).

Subsec. (u). Pub. L. 105-33, Sec. 4911(a)(2), added subsec. (u).

Subsec. (u)(1)(B). Pub. L. 105-100, Sec. 162(2)(A), substituted

"the fourth sentence of subsection (b) of this section" for

"paragraph (2)".

Subsec. (u)(2)(A). Pub. L. 105-100, Sec. 162(2)(B), substituted

"subparagraph (B)" for "subparagraph (C), but not in excess, for a

State for a fiscal year, of the amount described in subparagraph

(B) for the State and fiscal year".

Subsec. (u)(2)(B), (C). Pub. L. 105-100, Sec. 162(2)(C), added

subpar. (B) and struck out former subpars. (B) and (C) which read

as follows:

"(B) The amount described in this subparagraph, for a State for a

fiscal year, is the amount of the State's allotment under section

1397dd of this title (not taking into account reductions under

section 1397dd(d)(2) of this title) for the fiscal year reduced by

the amount of any payments made under section 1397ee of this title

to the State from such allotment for such fiscal year.

"(C) For purposes of this paragraph, the term 'optional targeted

low-income child' means a targeted low-income child as defined in

section 1397jj(b)(1) of this title who would not qualify for

medical assistance under the State plan under this subchapter based

on such plan as in effect on April 15, 1997 (but taking into

account the expansion of age of eligibility effected through the

operation of section 1396a(l)(2)(D) of this title)."

Subsec. (u)(3). Pub. L. 105-100, Sec. 162(2)(D), substituted

"described in this paragraph" for "described in this subparagraph"

and "March 31, 1997" for "April 15, 1997".

Subsec. (u)(4). Pub. L. 105-100, Sec. 162(2)(E), added par. (4).

1996 - Subsec. (l)(2)(B)(i), (ii)(II). Pub. L. 104-299

substituted "section 254b of this title" for "section 254b, 254c,

256, or 256a of this title".

1994 - Subsecs. (j), (q)(2). Pub. L. 103-296 substituted

"Commissioner of Social Security" for "Secretary".

1993 - Subsec. (a)(xi). Pub. L. 103-66, Sec. 13603(e)(1)-(3),

added cl. (xi).

Subsec. (a)(7). Pub. L. 103-66, Sec. 13601(a)(1), struck out

"including personal care services (A) prescribed by a physician for

an individual in accordance with a plan of treatment, (B) provided

by an individual who is qualified to provide such services and who

is not a member of the individual's family, (C) supervised by a

registered nurse, and (D) furnished in a home or other location;

but not including such services furnished to an inpatient or

resident of a nursing facility" after "services".

Subsec. (a)(17). Pub. L. 103-66, Sec. 13605(a), inserted before

semicolon at end ", and without regard to whether or not the

services are performed in the area of management of the care of

mothers and babies throughout the maternity cycle".

Subsec. (a)(19). Pub. L. 103-66, Sec. 13603(e)(4), amended par.

(19) generally, inserting reference to TB-related services

described in section 1396a(z)(2)(F) of this title.

Subsec. (a)(21). Pub. L. 103-66, Sec. 13601(a)(2), struck out

"and" at end.

Subsec. (a)(22). Pub. L. 103-66, Sec. 13601(a)(4), redesignated

par. (23) as (22). Former par. (22) redesignated (25).

Subsec. (a)(23). Pub. L. 103-66, Sec. 13601(a)(4), redesignated

par. (24) as (23). Former par. (23) redesignated (22).

Subsec. (a)(24). Pub. L. 103-66, Sec. 13601(a)(5), added par.

(24). Former par. (24) redesignated (23).

Pub. L. 103-66, Sec. 13601(a)(3), which directed amendment of

par. (24) by substituting semicolon for comma at end, was executed

by substituting semicolon for period at end to reflect the probable

intent of Congress.

Subsec. (a)(25). Pub. L. 103-66, Sec. 13601(a)(4), redesignated

par. (22) as (25), transferred such par. to appear after par. (23),

and substituted period for semicolon at end.

Subsec. (l)(2)(B). Pub. L. 103-66, Sec. 13631(f)(2)(B), in

concluding provisions, inserted "or by an urban Indian organization

receiving funds under title V of the Indian Health Care Improvement

Act for the provision of primary health services" before ". In

applying clause".

Subsec. (l)(2)(B)(i). Pub. L. 103-66, Sec. 13631(f)(2)(A),

substituted "256, or 256a" for "or 256".

Pub. L. 103-66, Sec. 13606(a)(1), struck out "or" at end.

Subsec. (l)(2)(B)(ii). Pub. L. 103-66, Sec. 13631(f)(2)(A),

substituted "256, or 256a" for "or 256" in subcl. (II).

Pub. L. 103-66, Sec. 13606(a)(2), (3), realigned margin and

substituted a comma for semicolon at end.

Subsec. (l)(2)(B)(iv). Pub. L. 103-66, Sec. 13606(a)(4), (5),

added cl. (iv).

Subsec. (r)(1)(A)(i). Pub. L. 103-66, Sec. 13631(g)(1)(A),

inserted "and, with respect to immunizations under subparagraph

(B)(iii), in accordance with the schedule referred to in section

1396s(c)(2)(B)(i) of this title for pediatric vaccines" after

"child health care".

Subsec. (r)(1)(B)(iii). Pub. L. 103-66, Sec. 13631(g)(1)(B),

inserted "(according to the schedule referred to in section

1396s(c)(2)(B)(i) of this title for pediatric vaccines)" after

"appropriate immunizations".

1990 - Subsec. (a). Pub. L. 101-508, Sec. 4722, inserted at end

"No service (including counseling) shall be excluded from the

definition of 'medical assistance' solely because it is provided as

a treatment service for alcoholism or drug dependency."

Pub. L. 101-508, Sec. 4402(d)(2), inserted at end "The payment

described in the first sentence may include expenditures for

medicare cost-sharing and for premiums under part B of subchapter

XVIII of this chapter for individuals who are eligible for medical

assistance under the plan and (A) are receiving aid or assistance

under any plan of the State approved under subchapter I, X, XIV, or

XVI of this chapter, or part A of subchapter IV of this chapter, or

with respect to whom supplemental security income benefits are

being paid under subchapter XVI of this chapter, or (B) with

respect to whom there is being paid a State supplementary payment

and are eligible for medical assistance equal in amount, duration,

and scope to the medical assistance made available to individuals

described in section 1396a(a)(10)(A) of this title, and, except in

the case of individuals 65 years of age or older and disabled

individuals entitled to health insurance benefits under subchapter

XVIII of this chapter who are not enrolled under part B of

subchapter XVIII of this chapter, other insurance premiums for

medical or any other type of remedial care or the cost thereof."

Subsec. (a)(x). Pub. L. 101-508, Sec. 4713(b), added cl. (x).

Subsec. (a)(2)(C). Pub. L. 101-508, Sec. 4704(e)(1), repealed

Pub. L. 101-239, Sec. 6402(c)(1). See 1989 Amendment note below.

Subsec. (a)(7). Pub. L. 101-508, Sec. 4721(a), substituted

"services including personal care services" for "services" and

added subpars. (A) to (D).

Subsec. (a)(13). Pub. L. 101-508, Sec. 4719(a), inserted before

semicolon at end ", including any medical or remedial services

(provided in a facility, a home, or other setting) recommended by a

physician or other licensed practitioner of the healing arts within

the scope of their practice under State law, for the maximum

reduction of physical or mental disability and restoration of an

individual to the best possible functional level".

Subsec. (a)(22). Pub. L. 101-508, Sec. 4711(a)(1), which directed

amendment of par. (22) by striking "and" at end, could not be

executed because the word did not appear.

Subsec. (a)(23). Pub. L. 101-508, Sec. 4712(a)(1), inserted "and"

after semicolon at end.

Pub. L. 101-508, Sec. 4711(a)(2), (3), which directed amendment

of subsec. (a) by redesignating par. (23) as (24) and adding a new

par. (23), was executed by adding the new par. (23), there being no

former par. (23).

Subsec. (a)(24). Pub. L. 101-508, Sec. 4712(a)(2), (3), which

directed amendment of subsec. (a) by redesignating par. (24) as

(25) and adding a new par. (24), was executed by adding the new

par. (24), there being no former par. (24).

Subsec. (h)(1)(A). Pub. L. 101-508, Sec. 4755(a)(1)(A), inserted

"or in another inpatient setting that the Secretary has specified

in regulations" after "section 1395x(f) of this title".

Subsec. (l)(2)(A). Pub. L. 101-508, Sec. 4704(c)(1), substituted

"patient" for "outpatient".

Subsec. (l)(2)(B). Pub. L. 101-508, Sec. 4704(d)(2), which

directed amendment of subpar. (B) by inserting "and includes an

outpatient health program or facility operated by a tribe or tribal

organization under the Indian Self-Determination Act (Public Law

93-638)." after and below cl. (ii), was executed by inserting the

new language after cl. (iii) to reflect the probable intent of

Congress and the intervening redesignation of former cl. (ii) as

(iii) by Pub. L. 101-508, Sec. 4704(c)(3). See below.

Pub. L. 101-508, Sec. 4704(c)(2), substituted "entity" for

"facility" in introductory provisions.

Subsec. (l)(2)(B)(ii), (iii). Pub. L. 101-508, Sec. 4704(c)(3),

(d)(1), added cl. (ii), redesignated former cl. (ii) as (iii), and

substituted comma for period at end of cl. (iii).

Subsec. (n)(2). Pub. L. 101-508, Sec. 4601(a)(2), substituted

"age of 19" for "age of 7 (or any age designated by the State that

exceeds 7 but does not exceed 8)".

Subsec. (o)(1)(A). Pub. L. 101-508, Sec. 4717, inserted "and for

which payment may otherwise be made under subchapter XVIII of this

chapter" after "section 1395d(d)(2)(A) of this title".

Subsec. (o)(3). Pub. L. 101-508, Sec. 4705(a)(1), struck out "a

State which elects not to provide medical assistance for hospice

care, but provides medical assistance for skilled nursing or

intermediate care facility services with respect to" after "In the

case of" in introductory provisions.

Pub. L. 101-508, Sec. 4705(a)(3), (4), in concluding provisions,

substituted "the additional amount described in section

1396a(a)(13)(D) of this title" for "the amounts allocated under the

plan for room and board in the facility, in accordance with the

rates established under section 1396a(a)(13) of this title," and

struck out at end "For purposes of this paragraph and section

1396a(a)(13)(D) of this title, the term 'room and board' includes

performance of personal care services, including assistance in

activities of daily living, in socializing activities,

administration of medication, maintaining the cleanliness of a

resident's room, and supervising and assisting in the use of

durable medical equipment and prescribed therapies."

Subsec. (o)(3)(A), (C). Pub. L. 101-508, Sec. 4705(a)(2),

substituted "nursing facility or intermediate care facility for the

mentally retarded" for "skilled nursing or intermediate care

facility".

Subsec. (p)(1)(B). Pub. L. 101-508, Sec. 4501(e)(1)(A), which

directed amendment of subpar. (B) by inserting ", except as

provided in paragraph (2)(D)" after "supplementary social security

income program", was executed by inserting the new language after

"supplemental security income program" to reflect the probable

intent of Congress.

Subsec. (p)(2)(B). Pub. L. 101-508, Sec. 4501(a)(1), inserted

"and" at end of cl. (ii), substituted "100 percent." for "95

percent, and" in cl. (iii), and struck out cl. (iv) which read as

follows: "January 1, 1992, is 100 percent."

Subsec. (p)(2)(C). Pub. L. 101-508, Sec. 4501(a)(2), substituted

"95 percent, and" for "90 percent," in cl. (iii) and "100 percent."

for "95 percent, and" in cl. (iv) and struck out cl. (v) which read

as follows: "January 1, 1993, is 100 percent."

Subsec. (p)(2)(D). Pub. L. 101-508, Sec. 4501(e)(1)(B), added

subpar. (D).

Subsec. (p)(4). Pub. L. 101-508, Sec. 4501(c)(2), inserted at end

"In the case of any State which is providing medical assistance to

its residents under a waiver granted under section 1315 of this

title, the Secretary shall require the State to meet the

requirement of section 1396a(a)(10)(E) of this title in the same

manner as the State would be required to meet such requirement if

the State had in effect a plan approved under this subchapter."

Subsec. (p)(4)(B). Pub. L. 101-508, Sec. 4501(c)(1), inserted "or

1396a(a)(10)(E)(iii) of this title" after "subparagraph (B)".

1989 - Subsec. (a)(2)(B). Pub. L. 101-239, Sec. 6404(a)(2),

substituted "subsection (l)(1)" for "subsection (l)" in two places.

Subsec. (a)(2)(C). Pub. L. 101-239, Sec. 6404(a)(3), added cl.

(C) relating to Federally-qualified health center services.

Pub. L. 101-239, Sec. 6402(c)(1), which directed addition of cl.

(C) relating to ambulatory services, was repealed by Pub. L.

101-508, Sec. 4704(e)(1).

Subsec. (a)(4)(B). Pub. L. 101-239, Sec. 6403(d)(2), amended cl.

(B) generally. Prior to amendment, cl. (B) read as follows:

"effective July 1, 1969, such early and periodic screening and

diagnosis of individuals who are eligible under the plan and are

under the age of 21 to ascertain their physical or mental defects,

and such health care, treatment, and other measures to correct or

ameliorate defects and chronic conditions discovered thereby, as

may be provided in regulations of the Secretary; and".

Subsec. (a)(21), (22). Pub. L. 101-239, Sec. 6405(a), added par.

(21) and redesignated former par. (21) as (22).

Subsec. (l). Pub. L. 101-239, Sec. 6404(b), designated existing

provisions as par. (1), redesignated former cls. (1) and (2) as (A)

and (B), respectively, and added par. (2).

Subsec. (p)(1)(A). Pub. L. 101-239, Sec. 6408(d)(4)(B), inserted

", but not including an individual entitled to such benefits only

pursuant to an enrollment under section 1395i-2a of this title"

after "section 1395i-2 of this title".

Subsec. (p)(3)(A). Pub. L. 101-239, Sec. 6408(d)(4)(A)(i),

amended subpar. (A) generally. Prior to amendment, subpar. (A) read

as follows: "Premiums under subchapter XVIII of this chapter

(including under part B and, if applicable, under section 1395i-2

of this title)."

Subsec. (p)(3)(A)(i). Pub. L. 101-239, Sec. 6408(d)(4)(A)(ii),

substituted "section 1395i-2 or 1395i-2a" for "section 1395i-2".

Subsec. (p)(3)(C). Pub. L. 101-234, Sec. 201(b)(1), substituted

"Deductibles" for "Subject to paragraph (4), deductibles" and

"section 1395e of this title and section 1395l(b) of this title)"

for "section 1395e of this title, section 1395l(b) of this title,

and section 1395m(c)(1) of this title".

Subsec. (p)(4), (5). Pub. L. 101-234, Sec. 201(b)(2),

redesignated par. (5) as (4) and struck out former par. (4) which

read as follows: "In a State which provides medical assistance for

prescribed drugs under subsection (a)(12) of this section, instead

of providing to qualified medicare beneficiaries, under paragraph

(3)(C), medicare cost-sharing with respect to the annual deductible

for covered outpatient drugs under section 1395m(c)(1) of this

title, the State may provide to such beneficiaries, before charges

for covered outpatient drugs for a year reach such deductible

amount, benefits for prescribed drugs in the same amount, duration,

and scope as the benefits made available under the State plan for

individuals described in section 1396a(a)(10)(A)(i) of this title."

Subsec. (r). Pub. L. 101-239, Sec. 6403(c), inserted at end "The

Secretary shall, not later than July 1, 1990, and every 12 months

thereafter, develop and set annual participation goals for each

State for participation of individuals who are covered under the

State plan under this subchapter in early and periodic screening,

diagnostic, and treatment services."

Pub. L. 101-239, Sec. 6403(a), added subsec. (r).

Subsec. (s). Pub. L. 101-239, Sec. 6408(d)(2), added subsec. (s).

1988 - Subsec. (a). Pub. L. 100-647, Sec. 8434(b)(3), substituted

"in the case of medicare cost-sharing with respect to a qualified

medicare beneficiary" for "in the case of a qualified medicare

beneficiary" in introductory provisions.

Subsec. (a)(ix). Pub. L. 100-485, Sec. 303(b)(2), added cl. (ix).

Subsec. (a)(5)(B). Pub. L. 100-360, Sec. 411(k)(4), substituted

"described in clause (A) if" for "described in subparagraph (A)

if".

Subsec. (a)(17). Pub. L. 100-360, Sec. 411(h)(4)(E), amended Pub.

L. 100-203, Sec. 4073(d)(1), see 1987 Amendment note below.

Subsec. (i). Pub. L. 100-360, Sec. 411(k)(14)(A), added subsec.

(i).

Subsec. (m). Pub. L. 100-485, Sec. 401(d)(2), added subsec. (m).

Subsec. (o)(1). Pub. L. 100-360, Sec. 411(k)(8)(A), made

clarifying amendment to directory language of Pub. L. 100-203, Sec.

4114, see 1987 Amendment note below.

Subsec. (o)(1)(B). Pub. L. 100-360, Sec. 411(k)(8)(B), struck out

"only" after "For purposes of this subchapter" and substituted

"immune deficiency syndrome (AIDS)" for "immunodeficiency

syndrome".

Subsec. (o)(3). Pub. L. 100-485, Sec. 608(f)(3), realigned the

margin of par. (3).

Subsec. (p)(1). Pub. L. 100-647, Sec. 8434(a), redesignated

subpars. (C) and (D) as (B) and (C), respectively, and struck out

former subpar. (B) which read: "who, but for section

1396a(a)(10)(E) of this title, is not eligible for medical

assistance under the plan,".

Subsec. (p)(1)(B). Pub. L. 100-360, Sec. 301(a)(2), struck out

"and the election of the State" after "1396a(a)(10)(E) of this

title".

Subsec. (p)(1)(C). Pub. L. 100-360, Sec. 301(c)(1), as amended by

Pub. L. 100-485, Sec. 608(d)(14)(E)(i), substituted "paragraph (2)"

for "paragraph (2)(A)".

Subsec. (p)(1)(D). Pub. L. 100-360, Sec. 301(c)(2), as amended by

Pub. L. 100-485, Sec. 608(d)(14)(E)(ii), substituted "twice" for

"(except as provided in paragraph (2)(B))".

Subsec. (p)(2)(A). Pub. L. 100-647, Sec. 8434(b)(4), substituted

"paragraph (1)(B)" for "paragraph (1)(C)".

Pub. L. 100-360, Sec. 301(b)(1), as amended by Pub. L. 100-485,

Sec. 608(d)(14)(A), substituted "shall be at least the percent

provided under subparagraph (B) (but not more than 100 percent)"

for "may not exceed a percentage (not more than 100 percent)".

Pub. L. 100-360, Sec. 301(c)(3)(A), which directed amendment of

subpar. (A) by striking "(2)(A)" and inserting "(2)", was repealed

by Pub. L. 100-485, Sec. 608(d)(14)(E)(iii).

Pub. L. 100-360, Sec. 301(b)(2), which directed amendment of

subpar. (A) by inserting "(i)" after "(2)(A)", was repealed by Pub.

L. 100-485, Sec. 608(d)(14)(B).

Subsec. (p)(2)(B). Pub. L. 100-360, Sec. 301(b)(2), formerly Sec.

301(b)(3), as renumbered and amended by Pub. L. 100-485, Sec.

608(d)(14)(B)-(D)(ii), added subpar. (B) and struck out former

subpar. (B) which read as follows: "In the case of a State that

provides medical assistance to individuals not described in section

1396a(a)(10)(A) of this title and at the State's option, the State

may use under paragraph (1)(D) 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 section 1396a(a)(10)(A) of this title."

Pub. L. 100-360, Sec. 301(c)(3)(B), which directed amendment of

par. (2) by striking subpar. (B), was repealed by Pub. L. 100-485,

Sec. 608(d)(14)(E)(iii).

Subsec. (p)(2)(C). Pub. L. 100-360, Sec. 301(b)(2), formerly Sec.

301(b)(3), as renumbered and amended by Pub. L. 100-485, Sec.

608(d)(14)(B), (C), (D)(i), (iii), added subpar. (C).

Subsec. (p)(3). Pub. L. 100-360, Sec. 301(d)(1), as added by Pub.

L. 100-485, Sec. 608(d)(14)(G)(ii), inserted "without regard to

whether the costs incurred were for items and services for which

medical assistance is otherwise available under the plan" after

"qualified medicare beneficiary" in introductory provisions.

Subsec. (p)(3)(A). Pub. L. 100-360, Sec. 301(d)(2), formerly Sec.

301(d)(1), as renumbered by Pub. L. 100-485, Sec. 608(d)(14)(G)(i),

substituted "under subchapter XVIII of this chapter (including

under part B and, if applicable, under section 1395i-2 of this

title)" for "under part B and (if applicable) under section 1395i-2

of this title".

Subsec. (p)(3)(B). Pub. L. 100-360, Sec. 301(d)(3), formerly Sec.

301(d)(2), as renumbered by Pub. L. 100-485, Sec. 608(d)(14)(G)(i),

amended subpar. (B) generally. Prior to amendment, subpar. (B) read

as follows: "Deductibles and coinsurance described in section 1395e

of this title."

Subsec. (p)(3)(C). Pub. L. 100-360, Sec. 301(d)(3), formerly Sec.

301(d)(2), as renumbered and amended by Pub. L. 100-485, Sec.

608(d)(14)(F), (G)(i), amended subpar. (C) generally. Prior to

amendment, subpar. (C) read as follows: "The annual deductible

described in section 1395l(b) of this title."

Subsec. (p)(4). Pub. L. 100-360, Sec. 301(d)(4), formerly Sec.

301(d)(3), as renumbered by Pub. L. 100-485, Sec. 618(d)(14)(G)(i),

added par. (4).

Subsec. (p)(5). Pub. L. 100-360, Sec. 301(g)(2), as amended by

Pub. L. 100-485, Sec. 608(d)(14)(J), added par. (5).

1987 - Subsec. (a)(4)(A). Pub. L. 100-203, Sec. 4211(f), struck

out "skilled" before "nursing".

Subsec. (a)(5). Pub. L. 100-203, Sec. 4211(h)(6)(A), struck out

"skilled" before "nursing" in cl. (A).

Pub. L. 100-203, Sec. 4103(a), designated existing provisions as

cl. (A) and added cl. (B).

Subsec. (a)(9). Pub. L. 100-203, Sec. 4105(a), inserted provision

including services furnished to an eligible individual who does not

reside in a permanent dwelling or have a fixed home or mailing

address.

Subsec. (a)(14). Pub. L. 100-203, Sec. 4211(h)(6)(B), substituted

"and nursing facility services" for ", skilled nursing facility

services, and intermediate care facility services".

Subsec. (a)(15). Pub. L. 100-203, Sec. 4211(h)(6)(C), substituted

"services in an intermediate care facility for the mentally

retarded (other than" for "intermediate care facility services

(other than such services".

Subsec. (a)(17). Pub. L. 100-203, Sec. 4073(d)(1), as amended by

Pub. L. 100-360, Sec. 411(h)(4)(E), substituted "(as defined in

section 1395x(gg) of this title)" for "(as defined in subsection

(m) of this section)".

Subsec. (c). Pub. L. 100-203, Sec. 4211(e)(1), amended subsec.

(c) generally. Prior to amendment, subsec. (c) defined

"intermediate care facility".

Subsec. (d). Pub. L. 100-203, Sec. 4211(e)(2), substituted

"intermediate care facility for the mentally retarded" for

"intermediate care facility" and "means an" for "may include

services in a public", and in par. (3) inserted "in the case of a

public institution" after "(3)".

Subsec. (f). Pub. L. 100-203, Sec. 4211(e)(3), struck out

"skilled" before "nursing" in four places and before

"rehabilitation".

Subsec. (i). Pub. L. 100-203, Sec. 4211(e)(4), struck out subsec.

(i) which provided that for purposes of this subchapter "skilled

nursing facility" also includes any institution which is located in

a State on an Indian reservation and is certified by the Secretary

as being a qualified skilled nursing facility by meeting the

requirements of section 1395x(j) of this title.

Subsec. (m). Pub. L. 100-203, Sec. 4073(d)(2), struck out subsec.

(m) which defined "nurse-midwife". See section 1395x(gg) of this

title.

Subsec. (n)(2). Pub. L. 100-203, Sec. 4101(c)(1), substituted

"has not attained the age of 7 (or any age designated by the State

that exceeds 7 but does not exceed 8)" for "is under 5 years of

age".

Subsec. (o)(1). Pub. L. 100-203, Sec. 4114, as amended by Pub. L.

100-360, Sec. 411(k)(8)(A), designated existing provisions as

subpar. (A), substituted "Subject to subparagraph (B), the" for

"The", and added subpar. (B).

Subsec. (p)(2)(A). Pub. L. 100-203, Sec. 4118(p)(8), struck out

"nonfarm" before "official".

1986 - Subsec. (a). Pub. L. 99-509, Sec. 9403(g)(3), inserted

"or, in the case of a qualified medicare beneficiary described in

subsection (p)(1) of this section, if provided after the month in

which the individual becomes such a beneficiary" after "makes

application for assistance".

Subsec. (a)(18). Pub. L. 99-272, Sec. 9505(a)(1), added par.

(18). Former par. (18) redesignated (19).

Subsec. (a)(19). Pub. L. 99-514, Sec. 1895(c)(3)(A), added par.

(19). Former par. (19) redesignated (20).

Pub. L. 99-272, Sec. 9505(a)(1)(B), redesignated former par. (18)

as (19).

Subsec. (a)(20). Pub. L. 99-509, Sec. 9408(c)(1), added par.

(20). Former par. (20) redesignated (21).

Pub. L. 99-514, Sec. 1895(c)(3)(A)(ii), redesignated former par.

(19) as (20).

Subsec. (a)(21). Pub. L. 99-509, Sec. 9408(c)(1)(B), redesignated

former par. (20) as (21).

Subsec. (n)(1)(C). Pub. L. 99-272, Sec. 9501(a), added subpar.

(C).

Subsec. (n)(2). Pub. L. 99-272, Sec. 9511(a), inserted "(or such

earlier date as the State may designate)" after "September 30,

1983".

Subsec. (o). Pub. L. 99-272, Sec. 9505(a)(2), added subsec. (o).

Subsec. (o)(3). Pub. L. 99-509, Sec. 9435(b)(2), added par. (3).

Subsec. (p). Pub. L. 99-509, Sec. 9403(b), (d), added subsec.

(p).

Subsec. (q). Pub. L. 99-509, Sec. 9404(b), added subsec. (q).

1984 - Subsec. (a). Pub. L. 98-369, Sec. 2335(f), substituted

"mental diseases" for "tuberculosis or mental diseases" in subd.

(B) following par. (18).

Pub. L. 98-369, Sec. 2373(b)(17), substituted "clause (vi)" for

"clauses (vi)" and "well-being" for "well being" in last sentence.

Subsec. (a)(1). Pub. L. 98-369, Sec. 2335(f), substituted "mental

diseases" for "tuberculosis or mental diseases".

Subsec. (a)(4). Pub. L. 98-369, Sec. 2335(f), substituted "mental

diseases" for "tuberculosis or mental diseases".

Pub. L. 98-369, Sec. 2373(b)(15), inserted a semicolon before

"(B)".

Subsec. (a)(9). Pub. L. 98-369, Sec. 2371(a), amended par. (9)

generally, inserting "furnished by or under the direction of a

physician, without regard to whether the clinic itself is

administered by a physician".

Subsec. (a)(14), (15). Pub. L. 98-369, Sec. 2335(f), substituted

"mental diseases" for "tuberculosis or mental diseases".

Subsec. (a)(17). Pub. L. 98-369, Sec. 2373(b)(16), substituted

"the nurse-midwife" for "he" in two places.

Subsec. (b). Pub. L. 98-369, Sec. 2373(b)(18), substituted

"section 1301(a)(8)(B) of this title" for "subparagraph (B) of

section 1301(a)(8) of this title".

Subsec. (d)(1). Pub. L. 98-369, Sec. 2373(b)(19), substituted

"the institution meets" for "which meet".

Subsec. (h)(1)(A). Pub. L. 98-369, Sec. 2340(b), amended subpar.

(A) generally. Prior to amendment, subpar. (A) read as follows:

"inpatient services which are provided in an institution which is

accredited as a psychiatric hospital by the Joint Commission on

Accreditation of Hospitals;".

Subsec. (m). Pub. L. 98-369, Sec. 2373(b)(20), substituted "the

nurse" for "he" in two places.

Subsec. (n). Pub. L. 98-369, Sec. 2361(b), added subsec. (n).

1982 - Subsec. (a)(i). Pub. L. 97-248, Sec. 137(b)(17), struck

out "or any reasonable category of such individuals," after "as the

State may choose,".

Subsec. (a)(viii). Pub. L. 97-248, Sec. 137(b)(18), added cl.

(viii).

Subsec. (b)(2). Pub. L. 97-248, Sec. 136(c), substituted "the

Northern Mariana Islands, and American Samoa" for "and the Northern

Mariana Islands".

Subsec. (h)(1)(C). Pub. L. 97-248, Sec. 137(f), redesignated cls.

(i) and (ii) as subcls. (I) and (II), respectively, and

redesignated cls. (A) and (B) as cls. (i) and (ii), respectively.

1981 - Subsec. (a). Pub. L. 97-35, Sec. 2172(b), in cl. (i),

inserted "or, at the option of the State, under the age of 20, 19,

or 18 as the State may choose, or any reasonable category of such

individuals," and in cl. (ii), struck out reference to section

606(a)(2) of this title.

Subsec. (b). Pub. L. 97-35, Sec. 2162(a)(2), inserted reference

to Northern Mariana Islands.

1980 - Subsec. (a)(17), (18). Pub. L. 96-499, Sec. 965(a)(1)(B),

(C), added par. (17) and redesignated former par. (17) as (18).

Subsec. (c). Pub. L. 96-473 substituted "clause (1)" for "clauses

(1)".

Subsec. (m). Pub. L. 96-499, Sec. 965(a)(2), added subsec. (m).

1978 - Subsec. (c). Pub. L. 95-292 added cl. (4) to first

sentence relating to a requirement that intermediate care

facilities meet section 1395x(j)(14) of this title with respect to

protection of patients' personal funds, and inserted reference to

that cl. (4) in provisions covering intermediate care facilities on

Indian reservations.

1977 - Subsec. (a)(2). Pub. L. 95-210, Sec. 2(a), designated

existing provisions as cl. (A) and added cl. (B).

Subsec. (l). Pub. L. 95-210, Sec. 2(b), added subsec. (l).

1976 - Subsec. (b). Pub. L. 94-437 inserted provision requiring

that the Federal medical assistance percentage be 100 per centum

for services received through an Indian Health Service facility.

1973 - Subsec. (a). Pub. L. 93-233, Sec. 13(a)(13), substituted

in introductory text "individuals (other than individuals with

respect to whom there is being paid, or who are eligible or would

be eligible if they were not in a medical institution, to have paid

with respect to them a State supplementary payment and are eligible

for medical assistance equal in amount, duration, and scope to the

medical assistance made available to individuals described in

section 1396a(a)(10)(A) of this title) not receiving aid or

assistance under any plan of the State approved under subchapter I,

X, XIV, or XVI, or part A of subchapter IV of this chapter, and

with respect to whom supplemental security income benefits are not

being paid under subchapter XVI of this chapter" for "individuals

not receiving aid or assistance under the State's plan approved

under subchapter I, X, XIV, or XVI, or part A of subchapter IV of

this chapter".

Subsec. (a)(iv). Pub. L. 93-233, Sec. 13(a)(14), inserted "with

respect to States eligible to participate in the State plan program

established under subchapter XVI of this chapter," after "blind,".

Subsec. (a)(v). Pub. L. 93-233, Sec. 13(a)(15), substituted "with

respect to States eligible to participate in the State plan program

established under subchapter XVI of this chapter," for "or".

Subsec. (a)(vi). Pub. L. 93-233, Sec. 13(a)(16), inserted "or" at

end of text.

Subsec. (a)(vii). Pub. L. 93-233, Sec. 13(a)(17), added cl.

(vii).

Subsec. (a)(16). Pub. L. 93-233, Sec. 18(x)(7), substituted

"under age 21, as defined in subsection (h) of this section; and"

for "under 21, as defined in subsection (e) of this section;".

Subsec. (b). Pub. L. 93-233, Sec. 18(y)(2), struck out "; except

that the Secretary shall promulgate such percentage as soon as

possible after July 30, 1965, which promulgation shall be

conclusive for each of the six quarters in the period beginning

January 1, 1966, and ending with the close of June 30, 1966" after

"section 1301(a)(8) of this title".

Subsec. (c). Pub. L. 93-233, Sec. 18(x)(8), substituted "skilled

nursing facility" for "skilled nursing home" wherever appearing.

Subsec. (h)(1)(B). Pub. L. 93-233, Sec. 18(w), substituted "(i)

involve active treatment" for ", involves active treatment (i)";

struck out "pursuant to subchapter XVIII of this chapter" after

"may be prescribed"; and substituted "(ii)" for "(ii) which",

respectively.

Subsec. (h)(2). Pub. L. 93-233, Sec. 18(x)(10), substituted

"paragraph (1)" for "paragraph (e)(1)".

Subsec. (i). Pub. L. 93-233, Sec. 18(x)(9), redesignated subsec.

(h) as added by Pub. L. 92-603, Sec. 299L(b), as subsec. (i).

Subsecs. (j), (k). Pub. L. 93-233, Sec. 13(a)(18), added subsecs.

(j) and (k).

1972 - Subsec. (a). Pub. L. 92-603, Sec. 299B(c), in text

following redesignated subsec. (a)(17) substituted "as otherwise

provided in paragraph (16)," for "that".

Subsec. (a)(4). Pub. L. 92-603, Secs. 278(a)(21), 299E(b),

substituted "skilled nursing facility" for "skilled nursing home"

and added cl. (C).

Subsec. (a)(5). Pub. L. 92-603, Secs. 278(a)(22), 280,

substituted "skilled nursing facility" for "skilled nursing home"

and inserted "furnished by a physician (as defined in section

1395x(r)(1) of this title) after "physicians' services".

Subsec. (a)(14). Pub. L. 92-603, Secs. 278(a)(23), 297(a),

substituted "skilled nursing facility" for "skilled nursing home"

and inserted reference to intermediate care facility services.

Subsec. (a)(15) to (17). Pub. L. 92-603, Sec. 299B(a), added par.

(16) and redesignated existing pars. (15) and (16) as (17) and

(15), respectively.

Subsec. (c). Pub. L. 92-603, Sec. 299L(a), inserted provision

defining "intermediate care facility" with respect to any

institution located in a State on an Indian reservation.

Subsec. (d)(3). Pub. L. 92-603, Sec. 299, inserted provisions

relating to reduction of non-Federal expenditures in any calendar

quarter prior to January 1, 1975.

Subsec. (e). Pub. L. 92-603, Sec. 212(a), added subsec. (e).

Subsec. (f). Pub. L. 92-603, Sec. 247(b), added subsec. (f).

Subsec. (g). Pub. L. 92-603, Sec. 275(a), added subsec. (g).

Subsec. (h). Pub. L. 92-603, Sec. 299B(b), added subsec. (h).

Subsec. (i). Pub. L. 92-603, Sec. 299L(b), added subsec. (i),

1971 - Subsec. (a)(16). Pub. L. 92-223, Sec. 4(a)(1)(C), added

cl. (16).

Subsecs. (c), (d). Pub. L. 92-223, Sec. 4(a)(2), added subsecs.

(c) and (d).

1968 - Subsec. (a). Pub. L. 90-248, Sec. 230, inserted ", and

with respect to physicians' or dentists' services, at the option of

the State, to individuals not receiving aid or assistance under the

State's plan approved under subchapter I, X, XIV, XVI of this

chapter, or part A of subchapter IV of this chapter" after "for

individuals" in text preceding cl. (i).

Pub. L. 90-248, Sec. 233(b), inserted provision deeming, for

purposes of cl. (vi) of the preceding sentence, a person as

essential to another individual if such person is the spouse of and

is living with such individual, the needs of such person are taken

into account in determining the amount of aid or assistance

furnished to such individual (under a State plan approved under

subchapter I, X, XIV, or XV of this chapter, and such person is

determined, under such a State plan, to be essential to the well

being of such individual.

Subsec. (a)(ii). Pub. L. 90-248, Sec. 241(f)(6), inserted "part A

of" before "subchapter IV".

Subsec. (a)(vi). Pub. L. 90-248, Sec. 233(a), added cl. (vi).

Subsec. (a)(4). Pub. L. 90-248, Sec. 302(a), designated existing

provisions as cl. (A) and added cl. (B).

Subsec. (b). Pub. L. 90-248, Sec. 248(e), substituted in cl. (2)

of first sentence "50" for "55".

EFFECTIVE DATE OF 2000 AMENDMENTS

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 709(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-578, provided that: "The amendment made

by subsection (a) [amending this section] shall take effect 1 year

after the date of the enactment of this Act [Dec. 21, 2000],

regardless of whether regulations have been promulgated to carry

out such amendment by such date. The Secretary of Health and Human

Services shall develop the uniform application form under such

amendment by not later than 9 months after the date of the

enactment of this Act."

Pub. L. 106-554, Sec. 1(a)(6) [title VIII, Sec. 802(f)], Dec. 21,

2000, 114 Stat. 2763, 2763A-582, provided that: "The amendments

made by this section [amending this section and sections 1397dd,

1397ee, and 1397jj of this title] shall be effective as if included

in the enactment of section 4901 of the BBA [Pub. L. 105-33] (111

Stat. 552)."

Amendment by section 1(a)(6) [title IX, Sec. 911(a)(2)] of Pub.

L. 106-554 effective one year after Dec. 21, 2000, see section

1(a)(6) [title IX, Sec. 911(c)] of Pub. L. 106-554, set out as an

Effective Date note under section 1320b-14 of this title.

Amendment by Pub. L. 106-354 applicable to medical assistance for

items and services furnished on or after Oct. 1, 2000, without

regard to whether final regulations to carry out such amendments

have been promulgated by such date, see section 2(d) of Pub. L.

106-354, set out as a note under section 1396a of this title.

EFFECTIVE DATE OF 1999 AMENDMENTS

Amendment by Pub. L. 106-170 applicable to medical assistance for

items and services furnished on or after Oct. 1, 2000, see section

201(d) of Pub. L. 106-170, set out as a note under section 1396a of

this title.

Amendment by section 121(a)(2) of Pub. L. 106-169 applicable to

medical assistance for items and services furnished on or after

Oct. 1, 1999, see section 121(b) of Pub. L. 106-169, set out as a

note under section 1396a of this title.

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 605(b)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-396, provided that: "The

amendment made by subsection (a) [amending this section] takes

effect on October 1, 1999, and applies to expenditures made on or

after such date."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec.

608(aa)], Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided that

the amendment made by section 1000(a)(6) [title VI, Sec.

608(aa)(3)] is effective as if included in the enactment of BBA

[the Balanced Budget Act of 1997, Pub. L. 105-33].

Amendment by section 1000(a)(6) [title VI, Sec. 608(l), (m)] of

Pub. L. 106-113 effective Nov. 29, 1999, see section 1000(a)(6)

[title VI, Sec. 608(bb)] of Pub. L. 106-113, set out as a note

under section 1396a of this title.

EFFECTIVE DATE OF 1997 AMENDMENTS

Section 162 of Pub. L. 105-100 provided that the amendment made

by that section is effective as if included in the enactment of

subtitle J (Secs. 4901-4923) of title IV of the Balanced Budget Act

of 1997, Pub. L. 105-33.

Amendment by section 4702(a) of Pub. L. 105-33 applicable to

primary care case management services furnished on or after Oct. 1,

1997, subject to provisions relating to extension of effective date

for State law amendments, and to nonapplication to waivers, see

section 4710(b)(1) of Pub. L. 105-33, set out as a note under

section 1396b of this title.

Amendment by section 4711(c)(1) of Pub. L. 105-33 effective Aug.

5, 1997, and applicable to payment for items and services furnished

on or after Oct. 1, 1997, see section 4711(d) of Pub. L. 105-33,

set out as a note under section 1396a of this title.

Section 4712(d)(2) of Pub. L. 105-33 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to services furnished on or after the date of the enactment of this

Act [Aug. 5, 1997]."

Amendment by section 4714(a)(2) of Pub. L. 105-33 applicable to

payment for (and with respect to provider agreements with respect

to) items and services furnished on or after Aug. 5, 1997, and to

payment by a State for items and services furnished before such

date if such payment is subject of lawsuit that is based on

subsection (p) of this section and section 1396a(n) of this title

and that is pending as of, or is initiated after Aug. 5, 1997, see

section 4714(c) of Pub. L. 105-33, set out as a note under section

1396a of this title.

Section 4725(b)(2) of Pub. L. 105-33 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to -

"(A) items and services furnished on or after October 1, 1997;

"(B) payments made on a capitation or other risk-basis for

coverage occurring on or after such date; and

"(C) payments attributable to DSH allotments for such States

determined under section 1923(f) of such Act (42 U.S.C.

1396r-4(f)) for fiscal years beginning with fiscal year 1998."

Amendment by section 4911(a) of Pub. L. 105-33 applicable to

medical assistance for items and services furnished on or after

Oct. 1, 1997, see section 4911(c) of Pub. L. 105-33, set out as a

note under section 1396a of this title.

EFFECTIVE DATE OF 1996 AMENDMENT

Amendment by Pub. L. 104-299 effective Oct. 1, 1996, see section

5 of Pub. L. 104-299, as amended, set out as a note under section

233 of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1993 AMENDMENT

Amendment by section 13601(a) of Pub. L. 103-66 effective as if

included in enactment of section 4721(a) of the Omnibus Budget

Reconciliation Act of 1990, Pub. L. 101-508, see section 13601(c)

of Pub. L. 103-66, set out as a note under section 1396a of this

title.

Amendment by section 13603(e) of Pub. L. 103-66 applicable to

medical assistance furnished on or after Jan. 1, 1994, without

regard to whether or not final regulations to carry out the

amendments by section 13603 of Pub. L. 103-66 have been promulgated

by such date, see section 13603(f) of Pub. L. 103-66, set out as a

note under section 1396a of this title.

Section 13605(b) of Pub. L. 103-66 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after October 1, 1993."

Section 13606(b) of Pub. L. 103-66 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

calendar quarters beginning on or after July 1, 1993."

Amendment by section 13631(f)(2) of Pub. L. 103-66 applicable,

except as otherwise provided, to calendar quarters beginning on or

after Oct. 1, 1993, without regard to whether or not final

regulations to carry out the amendments by section 13631(f) of Pub.

L. 103-66 have been promulgated by such date, see section

13631(f)(3) of Pub. L. 103-66, set out as a note under section

1396a of this title.

Section 13631(g)(2) of Pub. L. 103-66 provided that: "The

amendments made by subparagraphs (A) and (B) of paragraph (1)

[amending this section] shall first apply 90 days after the date

the schedule referred to in subparagraphs (A)(i) and subparagraph

(B)(iii) of section 1905(r)(1) of the Social Security Act [subsec.

(r)(1)(B)(iii) of this section] (as amended by such respective

subparagraphs) is first established."

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by section 4402(d)(2) of Pub. L. 101-508 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after Jan. 1, 1991, without

regard to whether or not final regulations to carry out the

amendments by section 4402 of Pub. L. 101-508 have been promulgated

by such date, see section 4402(e) of Pub. L. 101-508, set out as a

note under section 1396a of this title.

Amendment by section 4501(a), (c), (e)(1) of Pub. L. 101-508

applicable to calendar quarters beginning on or after Jan. 1, 1991,

without regard to whether or not regulations to implement the

amendments by section 4501 of Pub. L. 101-508 are promulgated by

such date, except that amendment by section 4501(e)(1) of Pub. L.

101-508 is applicable to determinations of income for months

beginning with January 1991, see section 4501(f) of Pub. L.

101-508, set out as a note under section 1396a of this title.

Amendment by section 4601(a)(2) of Pub. L. 101-508 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after July 1, 1991, without

regard to whether or not final regulations to carry out the

amendments by section 4601 of Pub. L. 101-508 have been promulgated

by such date, see section 4601(b) of Pub. L. 101-508, set out as a

note under section 1396a of this title.

Amendment by section 4704(c), (d), (e)(1) of Pub. L. 101-508

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1989, Pub. L. 101-239, see section 4704(f) of

Pub. L. 101-508, set out as a note under section 1396a of this

title.

Section 4705(b) of Pub. L. 101-508 provided that: "The amendments

made by subsection (a) [amending this section] shall be effective

as if included in the amendments made by section 6408(c)(1) of the

Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239,

amending section 1396a of this title]."

Amendment by section 4711(a) of Pub. L. 101-508 applicable to

home and community care furnished on or after July 1, 1991, without

regard to whether or not final regulations to carry out the

amendments by section 4711 of Pub. L. 101-508 have been promulgated

by such date, see section 4711(e) of Pub. L. 101-508, set out as a

note under section 1396a of this title.

Amendment by section 4712(a) of Pub. L. 101-508 applicable to

community supported living arrangements services furnished on or

after the later of July 1, 1991, or 30 days after the publication

of regulations setting forth interim requirements under section

1396u(h) of this title without regard to whether or not final

regulations to carry out the amendments by section 4712 of Pub. L.

101-508 have been promulgated by such date, see section 4712(c) of

Pub. L. 101-508, set out as an Effective Date note under section

1396u of this title.

Amendment by section 4713(b) of Pub. L. 101-508 applicable to

medical assistance furnished on or after Jan. 1, 1991, see section

4713(c) of Pub. L. 101-508, set out as a note under section 1396a

of this title.

Section 4719(b) of Pub. L. 101-508 provided that: "The amendment

made by subsection (a) [amending this section] shall take effect on

the date of the enactment of this Act [Nov. 5, 1990]."

Section 4721(b) of Pub. L. 101-508 provided that: "The amendment

made by this section [amending this section] shall become effective

with respect to personal care services provided on or after October

1, 1994."

Section 4755(a)(1)(B) of Pub. L. 101-508 provided that: "The

amendment made by subparagraph (A) [amending this section] shall be

effective as if included in the enactment of the Deficit Reduction

Act of 1984 [Pub. L. 98-369]."

EFFECTIVE DATE OF 1989 AMENDMENTS

Amendment by section 6403(a), (c), (d)(2) of Pub. L. 101-239

effective Apr. 1, 1990, without regard to whether or not final

regulations to carry out the amendments by section 6403 of Pub. L.

101-239 have been promulgated by such date, see section 6403(e) of

Pub. L. 101-239, set out as a note under section 1396a of this

title.

Amendment by section 6404(a), (b) of Pub. L. 101-239 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after Apr. 1, 1990, without

regard to whether or not final regulations to carry out the

amendments by section 6404 of Pub. L. 101-239 have been promulgated

by such date, see section 6404(d) of Pub. L. 101-239, set out as a

note under section 1396a of this title.

Amendment by section 6405(a) of Pub. L. 101-239 effective with

respect to services furnished by a certified pediatric nurse

practitioner or certified family nurse practitioner on or after

July 1, 1990, see section 6405(c) of Pub. L. 101-239, set out as a

note under section 1396a of this title.

Amendment by section 6408(d)(2), (4)(A), (B) of Pub. L. 101-239

applicable, except as otherwise provided, to payments under this

subchapter for calendar quarters beginning on or after July 1,

1990, without regard to whether or not final regulations to carry

out the amendments by section 6408(d) of Pub. L. 101-239 have been

promulgated by such date, see section 6408(d)(5) of Pub. L.

101-239, set out as a note under section 1396a of this title.

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a

of this title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-647 effective as if included in the

enactment of section 301 of the Medicare Catastrophic Coverage Act

of 1988, Pub. L. 100-360, see section 8434(c) of Pub. L. 100-647,

set out as a note under section 1396a of this title.

Amendment by section 303(b)(2) of Pub. L. 100-485 applicable to

payments under this subchapter for calendar quarters beginning on

or after Apr. 1, 1990 (or, in the case of the Commonwealth of

Kentucky, Oct. 1, 1990) (without regard to whether regulations to

implement such amendment are promulgated by such date), with

respect to families that cease to be eligible for aid under part A

of subchapter IV of this chapter on or after that date, see section

303(f)(1) of Pub. L. 100-485, set out as a note under section 1396a

of this title.

Amendment by section 401(d)(2) of Pub. L. 100-485 effective Oct.

1, 1990, except as provided in subsec. (m)(2) of this section and

not effective for Puerto Rico, Guam, American Samoa, and the Virgin

Islands, until the date of repeal of limitations contained in

section 1308(a) of this title on payments to such jurisdictions for

purposes of making maintenance payments under this part and part E

of this subchapter, see section 401(g) of Pub. L. 100-485, as

amended, set out as a note under section 1396a of this title.

Amendment by section 608(d)(14)(A)-(G), (J) of Pub. L. 100-485

effective as if included in the enactment of the Medicare

Catastrophic Coverage Act of 1988, Pub. L. 100-360, see section

608(g)(1) of Pub. L. 100-485, set out as a note under section 704

of this title.

Amendment by section 608(f)(3) of Pub. L. 100-485 effective Oct.

13, 1988, see section 608(g)(2) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Amendment by section 301(a)(2)-(d) of Pub. L. 100-360 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after Jan. 1, 1989, without

regard to whether or not final regulations to carry out such

amendment have been promulgated by that date, with respect to

medical assistance for monthly premiums under subchapter XVIII of

this chapter for months beginning with January 1989, and items and

services furnished on and after Jan. 1, 1989, see section 301(h) of

Pub. L. 100-360, set out as a note under section 1396a of this

title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(h)(4)(E), (k)(4), (8) of Pub. L.

100-360, as it relates to a provision in the Omnibus Budget

Reconciliation Act of 1987, Pub. L. 100-203, effective as if

included in the enactment of that provision in Pub. L. 100-203, see

section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA;

Effective Date note under section 106 of Title 1, General

Provisions.

Section 411(k)(14)(B) of Pub. L. 100-360 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

take effect on the date of the enactment of this Act [July 1,

1988]."

EFFECTIVE DATE OF 1987 AMENDMENT

Amendment by section 4073(d) of Pub. L. 100-203 effective with

respect to services performed on or after July 1, 1988, see section

4073(e) of Pub. L. 100-203, set out as a note under section 1395k

of this title.

Section 4101(c)(3) of Pub. L. 100-203 provided that:

"(A) The amendments made by this subsection [amending this

section and section 1396a of this title] shall apply to medical

assistance furnished on or after October 1, 1988.

"(B) For purposes of section 1905(n)(2) of the Social Security

Act [section 1396d(n)(2) of this title] (as amended by subsection

(a) [probably means "subsection (c)"]) for medical assistance

furnished during fiscal year 1989, any reference to 'age of 7' is

deemed to be a reference to 'age of 6'."

Section 4103(b) of Pub. L. 100-203 provided that:

"(1) The amendment made by subsection (a) [amending this section]

applies (except as provided under paragraph (2)) to payments under

title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for

calendar quarters beginning on or after January 1, 1988, without

regard to whether or not final regulations to carry out such

amendment have been promulgated by such date.

"(2) In the case of a State plan for medical assistance under

title XIX of the Social Security Act which the Secretary of Health

and Human Services determines requires State legislation (other

than legislation appropriating funds) in order for the plan to meet

the additional requirement imposed by the amendment made by

subsection (a), the State plan shall not be regarded as failing to

comply with the requirements of such title solely on the basis of

its failure to meet this additional requirement before the first

day of the first calendar quarter beginning after the close of the

first regular session of the State legislature that begins after

the date of enactment of this Act [Dec. 22, 1987]."

Section 4105(b) of Pub. L. 100-203 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after January 1, 1988, without regard to

whether regulations to implement such amendment are promulgated by

such date."

Amendments by section 4211(e), (f), (h)(6) of Pub. L. 100-203

applicable to nursing facility services furnished on or after Oct.

1, 1990, without regard to whether regulations implementing such

amendments are promulgated by such date, except as otherwise

specifically provided in section 1396r of this title, with

transitional rule, see section 4214(a), (b)(2) of Pub. L. 100-203,

as amended, set out as an Effective Date note under section 1396r

of this title.

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by Pub. L. 99-514 effective, except as otherwise

provided, as if included in enactment of the Consolidated Omnibus

Budget Reconciliation Act of 1985, Pub. L. 99-272, see section

1895(e) of Pub. L. 99-514, set out as a note under section 162 of

Title 26, Internal Revenue Code.

Amendment by section 9403(b), (d), (g)(3) of Pub. L. 99-509

applicable to payments under this subchapter for calendar quarters

beginning on or after July 1, 1987, without regard to whether or

not final regulations to carry out such amendments have been

promulgated by such date, see section 9403(h) of Pub. L. 99-509,

set out as a note under section 1396a of this title.

Amendment by section 9404(b) of Pub. L. 99-509 applicable, except

as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after July 1, 1987, without

regard to whether regulations to implement such amendments are

promulgated by such date, see section 9404(c) of Pub. L. 99-509,

set out as a note under section 1396a of this title.

Amendment by section 9408(c)(1) of Pub. L. 99-509 applicable to

services furnished on or after Oct. 21, 1986, see section 9408(d)

of Pub. L. 99-509, set out as a note under section 1396a of this

title.

Section 9501(d)(1) of Pub. L. 99-272 provided that:

"(A) The amendments made by subsection (a) [amending this

section] apply (except as provided under subparagraph (B)) to

payments under title XIX of the Social Security Act [this

subchapter] for calendar quarters beginning on or after the [sic]

July 1, 1986, without regard to whether or not final regulations to

carry out the amendments have been promulgated by that date.

"(B) In the case of a State plan for medical assistance under

title XIX of the Social Security Act which the Secretary of Health

and Human Services determines requires State legislation (other

than legislation appropriating funds) in order for the plan to meet

the additional requirement imposed by the amendments made by

subsection (a), the State plan shall not be regarded as failing to

comply with the requirements of such title solely on the basis of

its failure to meet this additional requirement before the first

day of the first calendar quarter beginning after the close of the

first regular session of the State legislature that begins after

the date of the enactment of this Act [Apr. 7, 1986]."

Amendment by section 9505(a) of Pub. L. 99-272 applicable to

medical assistance provided for hospice care furnished on or after

Apr. 7, 1986, see section 9505(e) of Pub. L. 99-272, set out as a

note under section 1396a of this title.

Section 9511(b) of Pub. L. 99-272, as amended by Pub. L. 99-509,

title IX, Sec. 9435(d)(2), Oct. 21, 1986, 100 Stat. 2070, provided

that: "The amendment made by this section [amending this section]

shall apply to services furnished on or after April 1, 1986,

without regard to whether or not regulations to carry out the

amendment have been promulgated by that date."

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by section 2335(f) of Pub. L. 98-369 effective July 18,

1984, see section 2335(g) of Pub. L. 98-369, set out as a note

under section 1395f of this title.

Amendment by section 2340(b) of Pub. L. 98-369 effective July 18,

1984, see section 2340(c) of Pub. L. 98-369, set out as a note

under section 1395x of this title.

Amendment by section 2361(b) of Pub. L. 98-369 applicable to

calendar quarters beginning on or after Oct. 1, 1984, without

regard to whether or not final regulations to carry out the

amendment have been promulgated by such date, except as otherwise

provided, see section 2361(d) of Pub. L. 98-369, set out as a note

under section 1396a of this title.

Section 2371(b) of Pub. L. 98-369 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after the date of the enactment of this

Act [July 18, 1984]."

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by section 136(c) of Pub. L. 97-248 effective Oct. 1,

1982, see section 136(e) of Pub. L. 97-248, set out as a note under

section 1301 of this title.

Amendment by section 137(b)(17), (18) of Pub. L. 97-248 effective

as if originally included as part of this section as this section

was amended by the Omnibus Budget Reconciliation Act of 1981, Pub.

L. 97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a

note under section 1396a of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by section 2172(b) of Pub. L. 97-35 effective Aug. 13,

1981, see section 2172(c) of Pub. L. 97-35, set out as a note under

section 1396a of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

For effective date of amendment by Pub. L. 96-499, see section

965(c) of Pub. L. 96-499, set out as a note under section 1396a of

this title.

EFFECTIVE DATE OF 1978 AMENDMENT

Section 8(d)(1) of Pub. L. 95-292 provided that: "The amendments

made by subsections (a) and (b) [amending this section] shall

become effective on July 1, 1978."

EFFECTIVE DATE OF 1977 AMENDMENT

Amendment by Pub. L. 95-210 applicable to medical assistance

provided, under a State plan approved under subchapter XIX of this

chapter, on and after the first day of the first calendar quarter

that begins more than six months after Dec. 13, 1977, with

exception for plans requiring State legislation, see section 2(f)

of Pub. L. 95-210, set out as a note under section 1395cc of this

title.

EFFECTIVE DATE OF 1973 AMENDMENT

Amendment by section 13(a)(13)-(18) of Pub. L. 93-233 effective

with respect to payments under section 1396b of this title for

calendar quarters commencing after Dec. 31, 1973, see section 13(d)

of Pub. L. 93-233, set out as a note under section 1396a of this

title.

EFFECTIVE DATE OF 1972 AMENDMENT

Section 212(b) of Pub. L. 92-603 provided that: "The provisions

of subsection (e) of section 1905 of the Social Security Act

[subsec. (e) of this section] (as added by subsection (a) of this

section) shall be applicable in the case of services performed on

or after the date of enactment of this Act [Oct. 30, 1972]."

Amendment by section 247(b) of Pub. L. 92-603 effective with

respect to services furnished after Dec. 31, 1972, see section

247(c) of Pub. L. 92-603, set out as a note under section 1395f of

this title.

Section 275(b) of Pub. L. 92-603 provided that: "The amendment

made by this section [amending this section] shall be effective

with respect to services furnished after June 30, 1973."

Section 297(b) of Pub. L. 92-603 provided that: "The amendment

made by this section [amending this section] shall apply with

respect to services furnished after December 31, 1972."

EFFECTIVE DATE OF 1971 AMENDMENT

Amendment by Pub. L. 92-223 effective Jan. 1, 1972, see section

4(d) of Pub. L. 92-223, set out as a note under section 1396a of

this title.

EFFECTIVE DATE OF 1968 AMENDMENT

Section 248(e) of Pub. L. 90-248 provided that the amendment made

by that section is effective with respect to quarters after 1967.

CONSTRUCTION OF 1999 AMENDMENT

Amendment by Pub. L. 106-170 to be executed as if Pub. L. 106-169

had been enacted after the enactment of Pub. L. 106-170, see

section 121(c)(1) of Pub. L. 106-169, set out as a note under

section 1396a of this title.

ALASKA FMAPS

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 706], Dec. 21,

2000, 114 Stat. 2763, 2763A-577, provided that: "Notwithstanding

the first sentence of section 1905(b) of the Social Security Act

(42 U.S.C. 1396d(b)), only with respect to each of fiscal years

2001 through 2005, for purposes of titles XIX and XXI of the Social

Security Act [this subchapter and subchapter XXI of this chapter],

the State percentage used to determine the Federal medical

assistance percentage for Alaska shall be that percentage which

bears the same ratio to 45 percent as the square of the adjusted

per capita income of Alaska (determined by dividing the State's

3-year average per capita income by 1.05) bears to the square of

the per capita income of the 50 States."

Section 4725(a) of Pub. L. 105-33 provided that: "Notwithstanding

the first sentence of section 1905(b) of the Social Security Act

(42 U.S.C. 1396d(b)), the Federal medical assistance percentage

determined under such sentence for Alaska shall be 59.8 percent but

only with respect to -

"(1) items and services furnished under a State plan under

title XIX [this subchapter] or under a State child health plan

under title XXI of such Act [subchapter XXI of this chapter]

during fiscal years 1998, 1999, and 2000;

"(2) payments made on a capitation or other risk-basis under

such titles for coverage occurring during such period; and

"(3) payments under title XIX of such Act attributable to DSH

allotments for such State determined under section 1923(f) of

such Act (42 U.S.C. 1396r-4(f)) for such fiscal years."

EPSDT BENEFIT STUDY AND REPORT

Section 4744 of Pub. L. 105-33 provided that:

"(a) Study. -

"(1) In general. - The Secretary of Health and Human Services,

in consultation with Governors, directors of State medicaid

programs, the American Academy of Actuaries, and representatives

of appropriate provider and beneficiary organizations, shall

conduct a study of the provision of early and periodic screening,

diagnostic, and treatment services under the medicaid program

under title XIX of the Social Security Act [this subchapter] in

accordance with the requirements of section 1905(r) of such Act

(42 U.S.C. 1396d(r)).

"(2) Required contents. - The study conducted under paragraph

(1) shall include examination of the actuarial value of the

provision of such services under the medicaid program and an

examination of the portions of such actuarial value that are

attributable to paragraph (5) of section 1905(r) of such Act and

to the second sentence of such section.

"(b) Report. - Not later than 12 months after the date of the

enactment of this Act [Aug. 5, 1997], the Secretary of Health and

Human Services shall submit a report to Congress on the results of

the study conducted under subsection (a)."

REFERENCES TO PROVISIONS OF PART A OF SUBCHAPTER IV CONSIDERED

REFERENCES TO SUCH PROVISIONS AS IN EFFECT JULY 16, 1996

For provisions that certain references to provisions of part A

(Sec. 601 et seq.) of subchapter IV of this chapter be considered

references to such provisions of part A as in effect July 16, 1996,

see section 1396u-1(a) of this title.

LIMITATION ON DISALLOWANCES OR DEFERRAL OF FEDERAL FINANCIAL

PARTICIPATION FOR CERTAIN INPATIENT PSYCHIATRIC HOSPITAL SERVICES

FOR INDIVIDUALS UNDER AGE 21

Section 4706 of Pub. L. 101-508 provided that:

"(a) In General. - (1) If the Secretary of Health and Human

Services makes a determination that a psychiatric facility has

failed to comply with certification of need requirements for

inpatient psychiatric hospital services for individuals under age

21 pursuant to section 1905(h) of the Social Security Act [subsec.

(h) of this section], and such determination has not been subject

to a final judicial decision, any disallowance or deferral of

Federal financial participation under such Act [this chapter] based

on such determination shall only apply to the period of time

beginning with the first day of noncompliance and ending with the

date by which the psychiatric facility develops documentation

(using plan of care or utilization review procedures) of the need

for inpatient care with respect to such individuals.

"(2) Any disallowance of Federal financial participation under

title XIX of the Social Security Act [this subchapter] relating to

the failure of a psychiatric facility to comply with certification

of need requirements -

"(A) shall not exceed 25 percent of the amount of Federal

financial participation for the period described in paragraph

(1); and

"(B) shall not apply to any fiscal year before the fiscal year

that is 3 years before the fiscal year in which the determination

of noncompliance described in paragraph (1) is made.

"(b) Effective Date. - Subsection (a) shall apply to disallowance

actions and deferrals of Federal financial participation with

respect to services provided before the date of enactment of this

Act [Nov. 5, 1990]."

INTERMEDIATE CARE FACILITY; ACCESS AND VISITATION RIGHTS

Section 411(l)(3)(C)(i), formerly Sec. 411(l)(3)(C), of Pub. L.

100-360, as redesignated by Pub. L. 100-485, title VI, Sec.

608(d)(27)(E), Oct. 13, 1988, 102 Stat. 2423, provided that:

"Effective as of the date of the enactment of this Act [July 1,

1988] and until the effective date of section 1919(c) of such Act

[section 1396r(c) of this title, see Effective Date note set out

under section 1396r of this title], section 1905(c) of the Social

Security Act [subsec. (c) of this section] is deemed to include the

requirement described in section 1919(c)(3)(A) of such Act (as

inserted by section 4211(a)(3) of OBRA)."

REGULATIONS FOR INTERMEDIATE CARE FACILITIES FOR MENTALLY RETARDED

Section 9514 of Pub. L. 99-272 provided that: "The Secretary of

Health and Human Services shall promulgate proposed regulations

revising standards for intermediate care facilities for the

mentally retarded under title XIX of the Social Security Act [this

subchapter] within 60 days after the date of the enactment of this

Act [Apr. 7, 1986]."

LIFE SAFETY CODE RECOGNITION

Section 9515 of Pub. L. 99-272 provided that: "For purposes of

section 1905(c) of the Social Security Act [subsec. (c) of this

section], an intermediate care facility for the mentally retarded

(as defined in section 1905(d) of such Act) which meets the

requirements of the relevant sections of the 1985 edition of the

Life Safety Code of the National Fire Protection Association shall

be deemed to meet the fire safety requirements for intermediate

care facilities for the mentally retarded until such time as the

Secretary specifies a later edition of the Life Safety Code for

purposes of such section, or the Secretary determines that more

stringent standards are necessary to protect the safety of

residents of such facilities."

STUDY OF FEDERAL MEDICAL ASSISTANCE PERCENTAGE FORMULA AND OF

ADJUSTMENTS OF TARGET AMOUNTS FOR FEDERAL MEDICAID EXPENDITURES;

REPORT TO CONGRESS

Section 2165 of Pub. L. 97-35 directed the Comptroller General,

in consultation with the Advisory Committee for Intergovernmental

Relations, to study the Federal medical assistance percentage

formula as applicable to distribution of Federal funds to States,

with a view to revising the medicaid matching formula so as to take

into account factors which might result in a more equitable

distribution of Federal funds to States under this chapter, and to

report to Congress on such study not later than Oct. 1, 1982.

COSTS CHARGED TO PERSONAL FUNDS OF PATIENTS IN INTERMEDIATE CARE

FACILITIES; COSTS INCLUDED IN CHARGES FOR SERVICES; REGULATIONS

Section 8(c), (d)(2) of Pub. L. 95-292 required the Secretary of

Health, Education, and Welfare to issue regulations, within 90 days

after enactment of Pub. L. 95-292 but not later than July 1, 1978,

defining those costs that may be charged to the personal funds of

patients in intermediate care facilities who are individuals

receiving medical assistance under a State plan approved under

title XIX of the Social Security Act, and those costs that are to

be included in the reasonable cost or reasonable charge for

intermediate care facility services. See section 1302 of this

title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 256b, 280c-6, 290bb-1,

290jj, 300ff-52, 603, 618, 657, 674, 705, 1318, 1395i-2, 1395s,

1395v, 1395w-4, 1395w-21, 1395ss, 1396a, 1396b, 1396i, 1396n,

1396o, 1396p, 1396r, 1396r-1, 1396r-1b, 1396r-6, 1396r-8, 1396s,

1396t, 1396u-2, 1397ee, 1397jj, 11398 of this title; title 25

section 1645.

-FOOTNOTE-

(!1) See References in Text note below.

(!2) Probably means the subsec. (aa) of section 1396a relating

to certain breast or cervical cancer patients.

(!3) So in original. Probably should be "a".

(!4) So in original. Probably should be clause "(iii),". See

References in Text note below.

(!5) See References in Text note below.

(!6) So in original. The comma probably should be a period.

(!7) So in original. The words "of such paragraph" probably

should follow "subparagraph (B)".

(!8) So in original. Probably should be "or section".

-End-

-CITE-

42 USC Sec. 1396e 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396e. Enrollment of individuals under group health plans

-STATUTE-

(a) Requirements of each State plan; guidelines

Each State plan -

(1) may implement guidelines established by the Secretary,

consistent with subsection (b) of this section, to identify those

cases in which enrollment of an individual otherwise entitled to

medical assistance under this subchapter in a group health plan

(in which the individual is otherwise eligible to be enrolled) is

cost-effective (as defined in subsection (e)(2) of this section);

(2) may require, in case of an individual so identified and as

a condition of the individual being or remaining eligible for

medical assistance under this subchapter and subject to

subsection (b)(2) of this section, notwithstanding any other

provision of this subchapter, that the individual (or in the case

of a child, the child's parent) apply for enrollment in the group

health plan; and

(3) in the case of such enrollment (except as provided in

subsection (c)(1)(B) of this section), shall provide for payment

of all enrollee premiums for such enrollment and all deductibles,

coinsurance, and other cost-sharing obligations for items and

services otherwise covered under the State plan under this

subchapter (exceeding the amount otherwise permitted under

section 1396o of this title), and shall treat coverage under the

group health plan as a third party liability (under section

1396a(a)(25) of this title).

(b) Timing of enrollment; failure to enroll

(1) In establishing guidelines under subsection (a)(1) of this

section, the Secretary shall take into account that an individual

may only be eligible to enroll in group health plans at limited

times and only if other individuals (not entitled to medical

assistance under the plan) are also enrolled in the plan

simultaneously.

(2) If a parent of a child fails to enroll the child in a group

health plan in accordance with subsection (a)(2) of this section,

such failure shall not affect the child's eligibility for benefits

under this subchapter.

(c) Premiums considered payments for medical assistance;

eligibility

(1)(A) In the case of payments of premiums, deductibles,

coinsurance, and other cost-sharing obligations under this section

shall be considered, for purposes of section 1396b(a) of this

title, to be payments for medical assistance.

(B) If all members of a family are not eligible for medical

assistance under this subchapter and enrollment of the members so

eligible in a group health plan is not possible without also

enrolling members not so eligible -

(i) payment of premiums for enrollment of such other members

shall be treated as payments for medical assistance for eligible

individuals, if it would be cost-effective (taking into account

payment of all such premiums), but

(ii) payment of deductibles, coinsurance, and other

cost-sharing obligations for such other members shall not be

treated as payments for medical assistance for eligible

individuals.

(2) The fact that an individual is enrolled in a group health

plan under this section shall not change the individual's

eligibility for benefits under the State plan, except insofar as

section 1396a(a)(25) of this title provides that payment for such

benefits shall first be made by such plan.

(d) Repealed. Pub. L. 105-33, title IV, Sec. 4741(b)(2), Aug. 5,

1997, 111 Stat. 523

(e) Definitions

In this section:

(1) The term "group health plan" has the meaning given such

term in section 5000(b)(1) of the Internal Revenue Code of 1986,

and includes the provision of continuation coverage by such a

plan pursuant to title XXII of the Public Health Service Act [42

U.S.C. 300bb-1 et seq.], section 4980B of the Internal Revenue

Code of 1986, or title VI (!1) of the Employee Retirement Income

Security Act of 1974.

(2) The term "cost-effective" means, as established by the

Secretary, that the reduction in expenditures under this

subchapter with respect to an individual who is enrolled in a

group health plan is likely to be greater than the additional

expenditures for premiums and cost-sharing required under this

section with respect to such enrollment.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1906, as added Pub. L.

101-508, title IV, Sec. 4402(a)(2), Nov. 5, 1990, 104 Stat.

1388-161; amended Pub. L. 105-33, title IV, Sec. 4741(b), Aug. 5,

1997, 111 Stat. 523.)

-REFTEXT-

REFERENCES IN TEXT

The Internal Revenue Code of 1986, referred to in subsec. (e)(1),

is classified generally to Title 26, Internal Revenue Code.

The Public Health Service Act, referred to in subsec. (e)(1), is

act July 1, 1944, ch. 373, 58 Stat. 682, as amended. Title XXII of

the Act is classified generally to subchapter XX (Sec. 300bb-1 et

seq.) of chapter 6A of this title. For complete classification of

this Act to the Code, see Short Title note set out under section

201 of this title and Tables.

The Employee Retirement Income Security Act of 1974, referred to

in subsec. (e)(1), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 829,

as amended. Title VI of the Act probably means part 6 of subtitle B

of title I of the Act which is classified generally to part 6 (Sec.

1161 et seq.) of subtitle B of subchapter I of chapter 18 of Title

29, Labor, because the Act has no title VI. For complete

classification of this Act to the Code, see Short Title note set

out under section 1001 of Title 29 and Tables.

-MISC1-

PRIOR PROVISIONS

A prior section 1396e, act Aug. 14, 1935, ch. 531, title XIX,

Sec. 1906, as added Jan. 2, 1968, Pub. L. 90-248, title II, Sec.

226, 81 Stat. 903, created Advisory Council on Medical Assistance,

set forth composition of Council, term of membership of members,

and purposes of Council, and provided for compensation of members,

prior to repeal by Pub. L. 92-603, title II, Sec. 287, Oct. 30,

1972, 86 Stat. 1457, effective on the first day of the third

calendar month following Oct. 30, 1972.

AMENDMENTS

1997 - Subsec. (a). Pub. L. 105-33, Sec. 4741(b)(1), in

introductory provisions, substituted "Each" for "For purposes of

section 1396a(a)(25)(G) of this title and subject to subsection (d)

of this section, each" and, in pars. (1) and (2), substituted "may"

for "shall".

Subsec. (d). Pub. L. 105-33, Sec. 4741(b)(2), struck out subsec.

(d) which read as follows:

"(1) In the case of any State which is providing medical

assistance to its residents under a waiver granted under section

1315 of this title, the Secretary shall require the State to meet

the requirements of this section in the same manner as the State

would be required to meet such requirement if the State had in

effect a plan approved under this subchapter.

"(2) This section, and section 1396a(a)(25)(G) of this title,

shall only apply to a State that is one of the 50 States or the

District of Columbia."

EFFECTIVE DATE

Section applicable, except as otherwise provided, to payments

under this subchapter for calendar quarters beginning on or after

Jan. 1, 1991, without regard to whether or not final regulations to

carry out the amendments by section 4402 of Pub. L. 101-508 have

been promulgated by such date, see section 4402(e) of Pub. L.

101-508, set out as an Effective Date of 1990 Amendment note under

section 1396a of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1396a, 1396b of this

title.

-FOOTNOTE-

(!1) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1396f 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396f. Observance of religious beliefs

-STATUTE-

Nothing in this subchapter shall be construed to require any

State which has a plan approved under this subchapter to compel any

person to undergo any medical screening, examination, diagnosis, or

treatment or to accept any other health care or services provided

under such plan for any purpose (other than for the purpose of

discovering and preventing the spread of infection or contagious

disease or for the purpose of protecting environmental health), if

such person objects (or, in case such person is a child, his parent

or guardian objects) thereto on religious grounds.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1907, as added Pub. L.

90-248, title II, Sec. 232, Jan. 2, 1968, 81 Stat. 905.)

-End-

-CITE-

42 USC Sec. 1396g 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396g. State programs for licensing of administrators of

nursing homes

-STATUTE-

(a) Nature of State program

For purposes of section 1396a(a)(29) of this title, a "State

program for the licensing of administrators of nursing homes" is a

program which provides that no nursing home within the State may

operate except under the supervision of an administrator licensed

in the manner provided in this section.

(b) Licensing by State agency or board representative of concerned

professions and institutions

Licensing of nursing home administrators shall be carried out by

the agency of the State responsible for licensing under the healing

arts licensing act of the State, or, in the absence of such act or

such an agency, a board representative of the professions and

institutions concerned with care of chronically ill and infirm aged

patients and established to carry out the purposes of this section.

(c) Functions and duties of State agency or board

It shall be the function and duty of such agency or board to -

(1) develop, impose, and enforce standards which must be met by

individuals in order to receive a license as a nursing home

administrator, which standards shall be designed to insure that

nursing home administrators will be individuals who are of good

character and are otherwise suitable, and who, by training or

experience in the field of institutional administration, are

qualified to serve as nursing home administrators;

(2) develop and apply appropriate techniques, including

examinations and investigations, for determining whether an

individual meets such standards;

(3) issue licenses to individuals determined, after the

application of such techniques, to meet such standards, and

revoke or suspend licenses previously issued by the board in any

case where the individual holding any such license is determined

substantially to have failed to conform to the requirements of

such standards;

(4) establish and carry out procedures designed to insure that

individuals licensed as nursing home administrators will, during

any period that they serve as such, comply with the requirements

of such standards;

(5) receive, investigate, and take appropriate action with

respect to, any charge or complaint filed with the board to the

effect that any individual licensed as a nursing home

administrator has failed to comply with the requirements of such

standards; and

(6) conduct a continuing study and investigation of nursing

homes and administrators of nursing homes within the State with a

view to the improvement of the standards imposed for the

licensing of such administrators and of procedures and methods

for the enforcement of such standards with respect to

administrators of nursing homes who have been licensed as such.

(d) Waiver of standards other than good character or suitability

standards

No State shall be considered to have failed to comply with the

provisions of section 1396a(a)(29) of this title because the agency

or board of such State (established pursuant to subsection (b) of

this section) shall have granted any waiver, with respect to any

individual who, during all of the three calendar years immediately

preceding the calendar year in which the requirements prescribed in

section 1396a(a)(29) of this title are first met by the State, has

served as a nursing home administrator, of any of the standards

developed, imposed, and enforced by such agency or board pursuant

to subsection (c) of this section.

(e) "Nursing home" and "nursing home administrator" defined

As used in this section, the term -

(1) "nursing home" means any institution or facility defined as

such for licensing purposes under State law, or, if State law

does not employ the term nursing home, the equivalent term or

terms as determined by the Secretary, but does not include a

religious nonmedical health care institution (as defined in

section 1395x(ss)(1) of this title).(!1)

(2) "nursing home administrator" means any individual who is

charged with the general administration of a nursing home whether

or not such individual has an ownership interest in such home and

whether or not his functions and duties are shared with one or

more other individuals.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1908, as added Pub. L.

90-248, title II, Sec. 236(b), Jan. 2, 1968, 81 Stat. 908; amended

Pub. L. 92-603, title II, Secs. 268(b), 269, 274(b), Oct. 30, 1972,

86 Stat. 1451, 1452; Pub. L. 93-233, Sec. 18(y)(3), Dec. 31, 1973,

87 Stat. 973; Pub. L. 104-193, title IX, Sec. 913, Aug. 22, 1996,

110 Stat. 2354; Pub. L. 105-33, title IV, Sec. 4454(b)(2), Aug. 5,

1997, 111 Stat. 431.)

-STATAMEND-

REPEAL OF SECTION

Pub. L. 101-508, title IV, Sec. 4801(e)(11), Nov. 5, 1990, 104

Stat. 1388-217, provided that, effective on the date on which the

Secretary promulgates standards regarding the qualifications of

nursing facility administrators under section 1396r(f)(4) of this

title, this section is repealed.

-COD-

CODIFICATION

Another section 1908 of act Aug. 14, 1935, was renumbered section

1908A and is classified to section 1396g-1 of this title.

-MISC1-

AMENDMENTS

1997 - Subsec. (e)(1). Pub. L. 105-33 which directed substitution

of "a religious nonmedical health care institution (as defined in

section 1395x(ss)(1) of this title)." for "a Christian Science

sanatorium operated, or listed and certified, by the First Church

of Christ, Scientist, Boston, Massachusetts; and" in "Section

1908(e)(1) (42 U.S.C. 1396g-1(e)(1))" of the Social Security Act,

was executed by making the substitution in subsec. (e)(1) of this

section to reflect the probable intent of Congress, because section

1396g-1 of this title, which is also section 1908 of the Social

Security Act, does not have a subsec. (e).

1996 - Subsec. (e)(1). Pub. L. 104-193, which directed

substitution of "The Commission for Accreditation of Christian

Science Nursing Organizations/Facilities, Inc." for "The First

Church of Christ, Scientist, Boston, Massachusetts" in section

1908(e)(1) of the Social Security Act (42 U.S.C. 1396g-1(e)(1))

could not be executed to this section or section 1396g-1 of this

title, both of which are section 1908. Section 1396g-1 does not

have a subsec. (e) and subsec. (e)(1) of this section does not

contain the quoted language with the word "the" capitalized.

1973 - Subsec. (d). Pub. L. 93-233 struck out second sentence

reading substantially the same as the first sentence but containing

the following additional text reading "other than such standards as

relate to good character or suitability if -

"(1) such waiver is for a period which ends after being in

effect for two years or on June 30, 1972, whichever is earlier,

and

"(2) there is provided in the State (during all of the period

for which waiver is in effect), a program of training and

instruction designed to enable all individuals with respect to

whom any such waiver is granted, to attain the qualifications

necessary in order to meet such standards" and also "calendar

year" instead of "three calendar years" and reference to

"subsection (c)(1) of this section" instead of "subsection (c) of

this section".

Subsec. (e). Pub. L. 93-233 redesignated subsec. (g) as (e), and

repealed prior subsec. (e) relating to authorization of

appropriations for fiscal years 1968 through 1972 and to limitation

of grants.

Subsec. (f). Pub. L. 93-233 repealed subsec. (f) providing for

creation of National Advisory Council on Nursing Home

Administration and for its composition, appointment of members, the

Chairman, representation of interests, functions and duties,

compensation and travel expenses, technical assistance,

availability of assistance and data, and termination date of Dec.

31, 1971.

Subsec. (g). Pub. L. 93-233, redesignated subsec. (g) as (e).

1972 - Subsec. (d). Pub. L. 92-603, Secs. 269, 274(b), inserted

references to the grant of waivers to individuals who, during all

of the three calendar years immediately preceding the calendar year

in which the requirements prescribed in section 1396a(a)(29) of

this title are first met by the State, have served as nursing home

administrators and substituted "subsection (c)(1)" for "subsection

(b)(1)".

Subsec. (g)(1). Pub. L. 92-603, Sec. 268(b), inserted ", but does

not include a Christian Science sanatorium operated, or listed and

certified, by the First Church of Christ, Scientist, Boston,

Massachusetts" after "Secretary".

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 effective Aug. 5, 1997, and

applicable to items and services furnished on or after such date,

with provision that Secretary of Health and Human Services issue

regulations to carry out such amendment by not later than July 1,

1998, see section 4454(d) of Pub. L. 105-33, set out as an

Effective Date note under section 1395i-5 of this title.

EFFECTIVE DATE OF 1996 AMENDMENT

Section 913 of Pub. L. 104-193 provided that the amendment made

by that section is effective Jan. 1, 1997.

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by section 268(b) of Pub. L. 92-603 effective Oct. 30,

1972, see section 268(c) of Pub. L. 92-603, set out as a note under

section 1396a of this title.

EFFECTIVE DATE

Section 236(c) of Pub. L. 90-248 provided that: "Except as

otherwise specified in the text thereof, the amendments made by

this section [enacting this section and amending section 1396a of

this title] shall take effect on July 1, 1970."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1396a of this title; title

29 section 1169.

-FOOTNOTE-

(!1) So in original. The period probably should be "; and".

-End-

-CITE-

42 USC Sec. 1396g-1 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396g-1. Required laws relating to medical child support

-STATUTE-

(a) In general

The laws relating to medical child support, which a State is

required to have in effect under section 1396a(a)(60) of this

title, are as follows:

(1) A law that prohibits an insurer from denying enrollment of

a child under the health coverage of the child's parent on the

ground that -

(A) the child was born out of wedlock,

(B) the child is not claimed as a dependent on the parent's

Federal income tax return, or

(C) the child does not reside with the parent or in the

insurer's service area.

(2) In any case in which a parent is required by a court or

administrative order to provide health coverage for a child and

the parent is eligible for family health coverage through an

insurer, a law that requires such insurer -

(A) to permit such parent to enroll under such family

coverage any such child who is otherwise eligible for such

coverage (without regard to any enrollment season

restrictions);

(B) if such a parent is enrolled but fails to make

application to obtain coverage of such child, to enroll such

child under such family coverage upon application by the

child's other parent or by the State agency administering the

program under this subchapter or part D of subchapter IV of

this chapter; and

(C) not to disenroll (or eliminate coverage of) such a child

unless the insurer is provided satisfactory written evidence

that -

(i) such court or administrative order is no longer in

effect, or

(ii) the child is or will be enrolled in comparable health

coverage through another insurer which will take effect not

later than the effective date of such disenrollment.

(3) In any case in which a parent is required by a court or

administrative order to provide health coverage for a child and

the parent is eligible for family health coverage through an

employer doing business in the State, a law that requires such

employer -

(A) to permit such parent to enroll under such family

coverage any such child who is otherwise eligible for such

coverage (without regard to any enrollment season

restrictions);

(B) if such a parent is enrolled but fails to make

application to obtain coverage of such child, to enroll such

child under such family coverage upon application by the

child's other parent or by the State agency administering the

program under this subchapter or part D of subchapter IV of

this chapter; and

(C) not to disenroll (or eliminate coverage of) any such

child unless -

(i) the employer is provided satisfactory written evidence

that -

(I) such court or administrative order is no longer in

effect, or

(II) the child is or will be enrolled in comparable

health coverage which will take effect not later than the

effective date of such disenrollment, or

(ii) the employer has eliminated family health coverage for

all of its employees; and

(D) to withhold from such employee's compensation the

employee's share (if any) of premiums for health coverage

(except that the amount so withheld may not exceed the maximum

amount permitted to be withheld under section 1673(b) of title

15), and to pay such share of premiums to the insurer, except

that the Secretary may provide by regulation for appropriate

circumstances under which an employer may withhold less than

such employee's share of such premiums.

(4) A law that prohibits an insurer from imposing requirements

on a State agency, which has been assigned the rights of an

individual eligible for medical assistance under this subchapter

and covered for health benefits from the insurer, that are

different from requirements applicable to an agent or assignee of

any other individual so covered.

(5) A law that requires an insurer, in any case in which a

child has health coverage through the insurer of a noncustodial

parent -

(A) to provide such information to the custodial parent as

may be necessary for the child to obtain benefits through such

coverage;

(B) to permit the custodial parent (or provider, with the

custodial parent's approval) to submit claims for covered

services without the approval of the noncustodial parent; and

(C) to make payment on claims submitted in accordance with

subparagraph (B) directly to such custodial parent, the

provider, or the State agency.

(6) A law that permits the State agency under this subchapter

to garnish the wages, salary, or other employment income of, and

requires withholding amounts from State tax refunds to, any

person who -

(A) is required by court or administrative order to provide

coverage of the costs of health services to a child who is

eligible for medical assistance under this subchapter,

(B) has received payment from a third party for the costs of

such services to such child, but

(C) has not used such payments to reimburse, as appropriate,

either the other parent or guardian of such child or the

provider of such services,

to the extent necessary to reimburse the State agency for

expenditures for such costs under its plan under this subchapter,

but any claims for current or past-due child support shall take

priority over any such claims for the costs of such services.

(b) "Insurer" defined

For purposes of this section, the term "insurer" includes a group

health plan, as defined in section 1167(1) of title 29, a health

maintenance organization, and an entity offering a service benefit

plan.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1908A, formerly Sec. 1908,

as added Pub. L. 103-66, title XIII, Sec. 13623(b), Aug. 10, 1993,

107 Stat. 633, renumbered Sec. 1908A, Pub. L. 106-113, div. B, Sec.

1000(a)(6) [title VI, Sec. 608(y)(1)], Nov. 29, 1999, 113 Stat.

1536, 1501A-398.)

-REFTEXT-

REFERENCES IN TEXT

Part D of subchapter IV of this chapter, referred to in subsec.

(a)(2)(B), (3)(B), is classified to section 651 et seq. of this

title.

-MISC1-

EFFECTIVE DATE

Section 13623(c) of Pub. L. 103-66 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [enacting this section and amending section 1396a of

this title] apply to calendar quarters beginning on or after April

1, 1994, without regard to whether or not final regulations to

carry out such amendments have been promulgated by such date.

"(2) In the case of a State plan under title XIX of the Social

Security Act [this subchapter] which the Secretary of Health and

Human Services determines requires State legislation in order for

the plan to meet the additional requirements imposed by the

amendments made by this section, the State plan shall not be

regarded as failing to comply with the requirements of such title

solely on the basis of its failure to meet these additional

requirements before the first day of the first calendar quarter

beginning after the close of the first regular session of the State

legislature that begins after the date of enactment of this Act

[Aug. 10, 1993]. For purposes of the preceding sentence, in the

case of a State that has a 2-year legislative session, each year of

such session shall be deemed to be a separate regular session of

the State legislature."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1396a of this title.

-End-

-CITE-

42 USC Sec. 1396h 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396h. Transferred

-COD-

CODIFICATION

Section, act Aug. 14, 1935, ch. 531, title XIX, Sec. 1909, as

added and amended Oct. 30, 1972, Pub. L. 92-603, title II, Secs.

242(c), 278(b)(9), 86 Stat. 1419, 1454; Oct. 25, 1977, Pub. L.

95-142, Sec. 4(b), 91 Stat. 1181; Dec. 5, 1980, Pub. L. 96-499,

title IX, Sec. 917, 94 Stat. 2625; Aug. 18, 1987, Pub. L. 100-93,

Sec. 4(a)-(c), 101 Stat. 688, 689, which related to criminal

penalties for acts involving Medicare and State health care

programs, was renumbered section 1128B of title XI of act Aug. 14,

1935, by section 4(d) of Pub. L. 100-93 and transferred to section

1320a-7b of this title.

-End-

-CITE-

42 USC Sec. 1396i 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396i. Certification and approval of rural health clinics and

intermediate care facilities for mentally retarded

-STATUTE-

(a)(1) Whenever the Secretary certifies a facility in a State to

be qualified as a rural health clinic under subchapter XVIII of

this chapter, such facility shall be deemed to meet the standards

for certification as a rural health clinic for purposes of

providing rural health clinic services under this title.

(2) The Secretary shall notify the State agency administering the

medical assistance plan of his approval or disapproval of any

facility in that State which has applied for certification by him

as a qualified rural health clinic.

(b)(1) The Secretary may cancel approval of any intermediate care

facility for the mentally retarded at any time if he finds on the

basis of a determination made by him as provided in section

1396a(a)(33)(B) of this title that a facility fails to meet the

requirements contained in section 1396a(a)(31) of this title or

section 1396d(d) of this title, or if he finds grounds for

termination of his agreement with the facility pursuant to section

1395cc(b) of this title. In that event the Secretary shall notify

the State agency and the intermediate care facility for the

mentally retarded that approval of eligibility of the facility to

participate in the programs established by this subchapter and

subchapter XVIII of this chapter shall be terminated at a time

specified by the Secretary. The approval of eligibility of any such

facility to participate in such programs may not be reinstated

unless the Secretary finds that the reason for termination has been

removed and there is reasonable assurance that it will not recur.

(2) Any intermediate care facility for the mentally retarded

which is dissatisfied with a determination by the Secretary that it

no longer qualifies as a (!1) intermediate care facility for the

mentally retarded for purposes of this subchapter, shall be

entitled to a hearing by the Secretary to the same extent as is

provided in section 405(b) of this title and to judicial review of

the Secretary's final decision after such hearing as is provided in

section 405(g) of this title, except that, in so applying such

sections and in applying section 405(l) of this title thereto, any

reference therein to the Commissioner of Social Security or the

Social Security Administration shall be considered a reference to

the Secretary or the Department of Health and Human Services,

respectively. Any agreement between such facility and the State

agency shall remain in effect until the period for filing a request

for a hearing has expired or, if a request has been filed, until a

decision has been made by the Secretary; except that the agreement

shall not be extended if the Secretary makes a written

determination, specifying the reasons therefor, that the

continuation of provider status constitutes an immediate and

serious threat to the health and safety of patients, and the

Secretary certifies that the facility has been notified of its

deficiencies and has failed to correct them.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1910, as added and amended

Pub. L. 92-603, title II, Secs. 249A(a), 278(b)(12), Oct. 30, 1972,

86 Stat. 1426, 1454; Pub. L. 95-210, Sec. 2(d), Dec. 13, 1977, 91

Stat. 1489; Pub. L. 96-499, title IX, Sec. 916(b)(2), Dec. 5, 1980,

94 Stat. 2624; Pub. L. 100-203, title IV, Sec. 4212(e)(3), Dec. 22,

1987, 101 Stat. 1330-213; Pub. L. 100-360, title IV, Sec.

411(l)(6)(F), July 1, 1988, as added Pub. L. 100-485, title VI,

Sec. 608(d)(27)(J), Oct. 13, 1988, 102 Stat. 2423; Pub. L. 101-239,

title VI, Sec. 6901(d)(5), Dec. 19, 1989, 103 Stat. 2301; Pub. L.

103-296, title I, Sec. 108(d)(4), Aug. 15, 1994, 108 Stat. 1486;

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(n)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-397.)

-MISC1-

AMENDMENTS

1999 - Pub. L. 106-113 struck out "of" after "approval of" in

section catchline.

1994 - Subsec. (b)(2). Pub. L. 103-296 inserted before period at

end of first sentence ", except that, in so applying such sections

and in applying section 405(l) of this title thereto, any reference

therein to the Commissioner of Social Security or the Social

Security Administration shall be considered a reference to the

Secretary or the Department of Health and Human Services,

respectively".

1989 - Pub. L. 101-239, Sec. 6901(d)(5)(A), substituted "rural

health clinics and intermediate care facilities for the mentally

retarded" for "rural health clinics" in section catchline.

Subsec. (b)(1). Pub. L. 101-239, Sec. 6901(d)(5)(B)-(D),

substituted "any intermediate care facility for the mentally

retarded" for "any skilled nursing or intermediate care facility",

"section 1396a(a)(31) of this title or section 1396d(d) of this

title" for "section 1396a(a)(28) of this title or section 1396r of

this title or section 1396d(c) of this title", and "the

intermediate care facility for the mentally retarded" for "the

skilled nursing facility or intermediate care facility".

Subsec. (b)(2). Pub. L. 101-239, Sec. 6901(d)(5)(D), substituted

"intermediate care facility for the mentally retarded" for "skilled

nursing facility or intermediate care facility" in two places.

1988 - Subsec. (b)(1). Pub. L. 100-360, Sec. 411(l)(6)(F), as

added by Pub. L. 100-485, Sec. 608(d)(27)(J), inserted "or section

1396r of this title" after "1396a(a)(28) of this title".

1987 - Pub. L. 100-203 struck out "skilled nursing facilities

and" before "of rural" in section catchline, redesignated subsecs.

(b) and (c) as (a) and (b), respectively, and struck out former

subsec. (a) which related to certification and approval of skilled

nursing facilities.

1980 - Subsec. (c). Pub. L. 96-499 added subsec. (c).

1977 - Pub. L. 95-210 substituted "facilities and of rural health

clinics" for "facilities" in section catchline, redesignated

existing subsecs. (a) and (b) as (a)(1) and (2), respectively, and

added subsec. (b).

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-239 effective as if included in the

enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L.

100-203, see section 6901(d)(6) of Pub. L. 101-239, set out as a

note under section 1395i-3 of this title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if included in the

enactment of the Medicare Catastrophic Coverage Act of 1988, Pub.

L. 100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENT

Amendment by Pub. L. 100-203 applicable to nursing facility

services furnished on or after Oct. 1, 1990, without regard to

whether regulations implementing such amendment are promulgated by

such date, except as otherwise specifically provided in section

1396r of this title, with transitional rule, see section 4214(a),

(b)(2) of Pub. L. 100-203, as amended, set out as an Effective Date

note under section 1396r of this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Amendment by Pub. L. 95-210 applicable to medical assistance

provided, under a State plan approved under subchapter XIX of this

chapter, on and after first day of first calendar quarter that

begins more than six months after Dec. 13, 1977, with exception for

plans requiring State legislation, see section 2(f) of Pub. L.

95-210, set out as a note under section 1395cc of this title.

EFFECTIVE DATE

Section effective with respect to agreements filed with Secretary

under section 1395cc of this title by skilled nursing facilities

before, on, or after Oct. 30, 1972, but accepted by him on or after

such date, see section 249A(e) of Pub. L. 92-603, set out as an

Effective Date of 1972 Amendment note under section 1395cc of this

title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1396r-3 of this title.

-FOOTNOTE-

(!1) So in original. Probably should be "an".

-End-

-CITE-

42 USC Sec. 1396j 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396j. Indian health service facilities

-STATUTE-

(a) Eligibility for reimbursement for medical assistance

A facility of the Indian Health Service (including a hospital,

nursing facility, or any other type of facility which provides

services of a type otherwise covered under the State plan), whether

operated by such Service or by an Indian tribe or tribal

organization (as those terms are defined in section 1603 of title

25), shall be eligible for reimbursement for medical assistance

provided under a State plan if and for so long as it meets all of

the conditions and requirements which are applicable generally to

such facilities under this subchapter.

(b) Facilities deemed to meet requirements upon submission of

acceptable plan for achieving compliance

Notwithstanding subsection (a) of this section, a facility of the

Indian Health Service (including a hospital, nursing facility, or

any other type of facility which provides services of a type

otherwise covered under the State plan) which does not meet all of

the conditions and requirements of this title which are applicable

generally to such facility, but which submits to the Secretary

within six months after September 30, 1976, an acceptable plan for

achieving compliance with such conditions and requirements, shall

be deemed to meet such conditions and requirements (and to be

eligible for reimbursement under this subchapter), without regard

to the extent of its actual compliance with such conditions and

requirements, during the first twelve months after the month in

which such plan is submitted.

(c) Agreement to reimburse State agency for providing care and

services

The Secretary is authorized to enter into agreements with the

State agency for the purpose of reimbursing such agency for health

care and services provided in Indian Health Service facilities to

Indians who are eligible for medical assistance under the State

plan.

(d) Cross reference

For provisions relating to the authority of certain Indian

tribes, tribal organizations, and Alaska Native health

organizations to elect to directly bill for, and receive payment

for, health care services provided by a hospital or clinic of such

tribes or organizations and for which payment may be made under

this subchapter, see section 1645 of title 25.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1911, as added Pub. L.

94-437, title IV, Sec. 402(a), Sept. 30, 1976, 90 Stat. 1409;

amended Pub. L. 100-203, title IV, Secs. 4118(f)(1), 4211(h)(8),

Dec. 22, 1987, 101 Stat. 1330-155, 1330-206; Pub. L. 100-360, title

IV, Sec. 411(k)(10)(E), July 1, 1988, 102 Stat. 796; Pub. L.

106-417, Sec. 3(b)(2), Nov. 1, 2000, 114 Stat. 1815.)

-MISC1-

AMENDMENTS

2000 - Subsec. (d). Pub. L. 106-417 added subsec. (d).

1988 - Subsecs. (a), (b). Pub. L. 100-360, Sec. 411(k)(10)(E),

made technical correction to directory language of Pub. L. 100-203,

Sec. 4118(f)(1)(A), see 1987 Amendment note below.

1987 - Subsecs. (a), (b). Pub. L. 100-203, Sec. 4118(f)(1)(A), as

amended by Pub. L. 100-360, Sec. 411(k)(10)(E), substituted ",

nursing facility, or any other type of facility which provides

services of a type otherwise covered under the State plan" for "or

nursing facility".

Pub. L. 100-203, Sec. 4211(h)(8), substituted "or nursing

facility" for ", intermediate care facility, or skilled nursing

facility" wherever appearing.

Subsec. (c). Pub. L. 100-203, Sec. 4118(f)(1)(B), added subsec.

(c).

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-417 effective Oct. 1, 2000, see section

3(c) of Pub. L. 106-417, set out as a note under section 1645 of

Title 25, Indians.

EFFECTIVE DATE OF 1988 AMENDMENT

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENT

Section 4118(f)(2) of Pub. L. 100-203 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to health care services performed on or after the date of the

enactment of this Act [Dec. 22, 1987]."

Amendment by section 4211(h)(8) of Pub. L. 100-203 applicable to

nursing facility services furnished on or after Oct. 1, 1990,

without regard to whether regulations implementing such amendment

are promulgated by such date, except as otherwise specifically

provided in section 1396r of this title, with transitional rule,

see section 4214(a), (b)(2) of Pub. L. 100-203, as amended, set out

as an Effective Date note under section 1396r of this title.

AGREEMENTS TO REIMBURSE STATE AGENCY FOR HEALTH CARE AND SERVICES

PROVIDED BY AGENCY TO INDIANS

Pub. L. 94-437, title IV, Sec. 402(b), Sept. 30, 1976, 90 Stat.

1409, which authorized Secretary to enter into agreements to

reimburse State agencies for health care and services provided in

Service facilities to Indians eligible for medical assistance under

this subchapter, was repealed by Pub. L. 100-713, title IV, Sec.

401(b), Nov. 23, 1988, 102 Stat. 4818, applicable to services

performed on or after the Nov. 23, 1988.

PAYMENTS INTO SPECIAL FUND TO IMPROVE INDIAN HEALTH SERVICE

FACILITIES TO ACHIEVE COMPLIANCE WITH CONDITIONS AND REQUIREMENTS;

CERTIFICATION OF COMPLIANCE BY SECRETARY

Section 402(c) of Pub. L. 94-437, as amended by Pub. L. 100-713,

title IV, Sec. 401(a), Nov. 23, 1988, 102 Stat. 4818, provided that

payments to which any Indian Health Service facility was entitled

by reason of this section were to be placed in a special fund of

the Secretary for improvements of facilities of the Service to

comply with requirements of this subchapter, required minimum

funding for each service unit making collections for such

facilities, and provided for section 402(c) of Pub. L. 94-437 to

cease to apply when Secretary determined that substantially all

such facilities complied with requirements of this subchapter,

prior to the general amendment of section 402 of Pub. L. 94-437 by

Pub. L. 102-573, title IV, Sec. 401(b)(1), Oct. 29, 1992, 106 Stat.

4565. Similar provisions are contained in section 402(a) of Pub. L.

94-437 which is classified to section 1642(a) of Title 25, Indians.

MEDICAID PAYMENTS NOT CONSIDERED IN DETERMINING APPROPRIATIONS FOR

INDIAN HEALTH CARE

Section 402(d) of Pub. L. 94-437 provided that any payments

received for services provided recipients under this section were

not to be considered in determining appropriations for the

provision of health care and services to Indians, prior to the

general amendment of section 402 of Pub. L. 94-437 by Pub. L.

102-573, title IV, Sec. 401(b)(1), Oct. 29, 1992, 106 Stat. 4565.

Similar provisions are contained in section 402(b) of Pub. L.

94-437 which is classified to section 1642(b) of Title 25, Indians.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 290ff of this title; title

25 sections 1642, 1645.

-End-

-CITE-

42 USC Sec. 1396k 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396k. Assignment, enforcement, and collection of rights of

payments for medical care; establishment of procedures pursuant

to State plan; amounts retained by State

-STATUTE-

(a) For the purpose of assisting in the collection of medical

support payments and other payments for medical care owed to

recipients of medical assistance under the State plan approved

under this subchapter, a State plan for medical assistance shall -

(1) provide that, as a condition of eligibility for medical

assistance under the State plan to an individual who has the

legal capacity to execute an assignment for himself, the

individual is required -

(A) to assign the State any rights, of the individual or of

any other person who is eligible for medical assistance under

this subchapter and on whose behalf the individual has the

legal authority to execute an assignment of such rights, to

support (specified as support for the purpose of medical care

by a court or administrative order) and to payment for medical

care from any third party;

(B) to cooperate with the State (i) in establishing the

paternity of such person (referred to in subparagraph (A)) if

the person is a child born out of wedlock, and (ii) in

obtaining support and payments (described in subparagraph (A))

for himself and for such person, unless (in either case) the

individual is described in section 1396a(l)(1)(A) of this title

or the individual is found to have good cause for refusing to

cooperate as determined by the State agency in accordance with

standards prescribed by the Secretary, which standards shall

take into consideration the best interests of the individuals

involved; and

(C) to cooperate with the State in identifying, and providing

information to assist the State in pursuing, any third party

who may be liable to pay for care and services available under

the plan, unless such individual has good cause for refusing to

cooperate as determined by the State agency in accordance with

standards prescribed by the Secretary, which standards shall

take into consideration the best interests of the individuals

involved; and

(2) provide for entering into cooperative arrangements

(including financial arrangements), with any appropriate agency

of any State (including, with respect to the enforcement and

collection of rights of payment for medical care by or through a

parent, with a State's agency established or designated under

section 654(3) of this title) and with appropriate courts and law

enforcement officials, to assist the agency or agencies

administering the State plan with respect to (A) the enforcement

and collection of rights to support or payment assigned under

this section and (B) any other matters of common concern.

(b) Such part of any amount collected by the State under an

assignment made under the provisions of this section shall be

retained by the State as is necessary to reimburse it for medical

assistance payments made on behalf of an individual with respect to

whom such assignment was executed (with appropriate reimbursement

of the Federal Government to the extent of its participation in the

financing of such medical assistance), and the remainder of such

amount collected shall be paid to such individual.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1912, as added Pub. L.

95-142, Sec. 11(b), Oct. 25, 1977, 91 Stat. 1196; amended Pub. L.

98-369, div. B, title III, Sec. 2367(b), July 18, 1984, 98 Stat.

1109; Pub. L. 99-272, title IX, Sec. 9503(e), Apr. 7, 1986, 100

Stat. 207; Pub. L. 101-508, title IV, Sec. 4606(a), Nov. 5, 1990,

104 Stat. 1388-170.)

-MISC1-

AMENDMENTS

1990 - Subsec. (a)(1)(B). Pub. L. 101-508 inserted "the

individual is described in section 1396a(l)(1)(A) of this title or"

after "unless (in either case)".

1986 - Subsec. (a)(1)(C). Pub. L. 99-272 added subpar. (C).

1984 - Subsec. (a). Pub. L. 98-369 substituted "State plan for

medical assistance shall" for "State plan for medical assistance

may".

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4606(b) of Pub. L. 101-508 provided that: "The amendment

made by subsection (a) [amending this section] shall take effect on

the date of the enactment of this Act [Nov. 5, 1990]."

EFFECTIVE DATE OF 1986 AMENDMENT

Amendment by Pub. L. 99-272 applicable to calendar quarters

beginning on or after Apr. 7, 1986, except as otherwise provided,

see section 9503(g)(1), (2) of Pub. L. 99-272, set out as a note

under section 1396a of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by Pub. L. 98-369 effective Oct. 1, 1984, except as

otherwise provided, see section 2367(c) of Pub. L. 98-369, set out

as a note under section 1396a of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 652, 654, 666, 1396a,

1396b of this title; title 29 section 1169.

-End-

-CITE-

42 USC Sec. 1396l 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396l. Hospital providers of nursing facility services

-STATUTE-

(a) Notwithstanding any other provision of this subchapter,

payment may be made, in accordance with this section, under a State

plan approved under this subchapter for nursing facility services

furnished by a hospital which has in effect an agreement under

section 1395tt of this title and which, with respect to the

provision of such services, meets the requirements of subsections

(b) through (d) of section 1396r of this title.

(b)(1) Except as provided in paragraph (3), payment to any such

hospital, for any nursing facility services furnished pursuant to

subsection (a) of this section, shall be at a rate equal to the

average rate per patient-day paid for routine services during the

previous calendar year under the State plan to nursing facilities,

respectively,(!1) located in the State in which the hospital is

located. The reasonable cost of ancillary services shall be

determined in the same manner as the reasonable cost of ancillary

services provided for inpatient hospital services.

(2) With respect to any period for which a hospital has an

agreement under section 1395tt of this title, in order to allocate

routine costs between hospital and long-term care services, the

total reimbursement for routine services due from all classes of

long-term care patients (including subchapter XVIII of this

chapter, this subchapter, and private pay patients) shall be

subtracted from the hospital total routine costs before

calculations are made to determine reimbursement for routine

hospital services under the State plan.

(3) Payment to all such hospitals, for any nursing facility

services furnished pursuant to subsection (a) of this section, may

be made at a payment rate established by the State in accordance

with the requirements of section 1396a(a)(13)(A) of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1913, as added Pub. L.

96-499, title IX, Sec. 904(b), Dec. 5, 1980, 94 Stat. 2617; amended

Pub. L. 98-369, div. B, title III, Sec. 2369(a), July 18, 1984, 98

Stat. 1110; Pub. L. 100-203, title IV, Sec. 4211(h)(9), Dec. 22,

1987, 101 Stat. 1330-206.)

-MISC1-

AMENDMENTS

1987 - Pub. L. 100-203, Sec. 4211(h)(9)(A), substituted "nursing

facility services" for "skilled nursing and intermediate care

services" in section catchline.

Subsec. (a). Pub. L. 100-203, Sec. 4211(h)(9)(B), substituted

"nursing facility services" for "skilled nursing facility services

and intermediate care facility services" and inserted "and which,

with respect to the provision of such services, meets the

requirements of subsections (b) through (d) of section 1396r of

this title" before period at end.

Subsec. (b)(1). Pub. L. 100-203, Sec. 4211(h)(9)(C), substituted

"nursing facility services" for "skilled nursing or intermediate

care facility services" and "nursing facilities" for "skilled

nursing and intermediate care facilities".

Subsec. (b)(3). Pub. L. 100-203, Sec. 4211(h)(9)(D), substituted

"nursing facility services" for "skilled nursing or intermediate

care facility services".

1984 - Subsec. (b)(1). Pub. L. 98-369, Sec. 2369(a)(1),

substituted "Except as provided in paragraph (3), payment" for

"Payment".

Subsec. (b)(3). Pub. L. 98-369, Sec. 2369(a)(2), added par. (3).

EFFECTIVE DATE OF 1987 AMENDMENT

Amendment by Pub. L. 100-203 applicable to nursing facility

services furnished on or after Oct. 1, 1990, without regard to

whether regulations implementing such amendment are promulgated by

such date, except as otherwise specifically provided in section

1396r of this title, with transitional rule, see section 4214(a),

(b)(2) of Pub. L. 100-203, as amended, set out as an Effective Date

note under section 1396r of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Section 2369(b) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section] shall apply to

payments for services furnished after the date of the enactment of

this Act [July 18, 1984]."

EFFECTIVE DATE

Section effective on date on which final regulations to implement

the section are first issued, see section 904(d) of Pub. L. 96-499,

set out as an Effective Date note under section 1395tt of this

title.

-FOOTNOTE-

(!1) So in original, ", respectively," probably should not appear.

-End-

-CITE-

42 USC Sec. 1396m 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396m. Withholding of Federal share of payments for certain

medicare providers

-STATUTE-

(a) Adjustment of Federal matching payments

The Secretary may adjust, in accordance with this section, the

Federal matching payment to a State with respect to expenditures

for medical assistance for care or services furnished in any

quarter by -

(1) an institution (A) which has or previously had in effect an

agreement with the Secretary under section 1395cc of this title;

and (B)(i) from which the Secretary has been unable to recover

overpayments made under subchapter XVIII of this chapter, or (ii)

from which the Secretary has been unable to collect the

information necessary to enable him to determine the amount (if

any) of the overpayments made to such institution under

subchapter XVIII of this chapter; and

(2) any person (A) who (i) has previously accepted payment on

the basis of an assignment under section 1395u(b)(3)(B)(ii) of

this title, and (ii) during the annual period immediately

preceding such quarter submitted no claims for payment under

subchapter XVIII of this chapter, or submitted claims for payment

under subchapter XVIII of this chapter which aggregated less than

the amount of overpayments made to him, and (B)(i) from whom the

Secretary has been unable to recover overpayments received in

violation of the terms of such assignment, or (ii) from whom the

Secretary has been unable to collect the information necessary to

enable him to determine the amount (if any) of the overpayments

made to such person under subchapter XVIII of this chapter.

(b) Reductions in payments to and by States

The Secretary may (subject to the remaining provisions of this

section) reduce payment to a State under this subchapter for any

quarter by an amount equal to the lesser of the Federal matching

share of payments to any institution or person specified in

subsection (a) of this section, or the total overpayments to such

institution or person under subchapter XVIII of this chapter, and

may require the State to reduce its payment to such institution or

person by such amount.

(c) Notice

The Secretary shall not make any adjustment in the payment to a

State, nor require any adjustment in the payment to an institution

or person, pursuant to subsection (b) of this section until after

he has provided adequate notice (which shall be not less than 60

days) to the State agency and the institution or person.

(d) Regulations

The Secretary shall by regulation provide procedures for

implementation of this section, which procedures shall (1)

determine the amount of the Federal payment to which the

institution or person would otherwise be entitled under this

section which shall be treated as a setoff against overpayments

under subchapter XVIII of this chapter, and (2) assure the

restoration to the institution or person of amounts withheld under

this section which are ultimately determined to be in excess of

overpayments under subchapter XVIII of this chapter and to which

the institution or person would otherwise be entitled under this

subchapter.

(e) Restoration to trust funds of recovered amounts

The Secretary shall restore to the trust funds established under

sections 1395i and 1395t of this title, as appropriate, amounts

recovered under this section as setoffs against overpayments under

subchapter XVIII of this chapter.

(f) Liability of States for withheld payments

Notwithstanding any other provision of this subchapter, an

institution or person shall not be entitled to recover from any

State any amount in payment for medical care and services under

this subchapter which is withheld by the State agency pursuant to

an order by the Secretary under subsection (b) of this section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1914, as added Pub. L.

96-499, title IX, Sec. 905(d), Dec. 5, 1980, 94 Stat. 2618.)

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1396b of this title.

-End-

-CITE-

42 USC Sec. 1396n 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396n. Compliance with State plan and payment provisions

-STATUTE-

(a) Activities deemed as compliance

A State shall not be deemed to be out of compliance with the

requirements of paragraphs (1), (10), or (23) of section 1396a(a)

of this title solely by reason of the fact that the State (or any

political subdivision thereof) -

(1) has entered into -

(A) a contract with an organization which has agreed to

provide care and services in addition to those offered under

the State plan to individuals eligible for medical assistance

who reside in the geographic area served by such organization

and who elect to obtain such care and services from such

organization, or by reason of the fact that the plan provides

for payment for rural health clinic services only if those

services are provided by a rural health clinic; or

(B) arrangements through a competitive bidding process or

otherwise for the purchase of laboratory services referred to

in section 1396d(a)(3) of this title or medical devices if the

Secretary has found that -

(i) adequate services or devices will be available under

such arrangements, and

(ii) any such laboratory services will be provided only

through laboratories -

(I) which meet the applicable requirements of section

1395x(e)(9) of this title or paragraphs (16) and (17) of

section 1395x(s) of this title, and such additional

requirements as the Secretary may require, and

(II) no more than 75 percent of whose charges for such

services are for services provided to individuals who are

entitled to benefits under this subchapter or under part A

or part B of subchapter XVIII of this chapter; or

(2) restricts for a reasonable period of time the provider or

providers from which an individual (eligible for medical

assistance for items or services under the State plan) can

receive such items or services, if -

(A) the State has found, after notice and opportunity for a

hearing (in accordance with procedures established by the

State), that the individual has utilized such items or services

at a frequency or amount not medically necessary (as determined

in accordance with utilization guidelines established by the

State), and

(B) under such restriction, individuals eligible for medical

assistance for such services have reasonable access (taking

into account geographic location and reasonable travel time) to

such services of adequate quality.

(b) Waivers to promote cost-effectiveness and efficiency

The Secretary, to the extent he finds it to be cost-effective and

efficient and not inconsistent with the purposes of this

subchapter, may waive such requirements of section 1396a of this

title (other than subsection (s)) (other than sections

1396a(a)(15), 1396a(bb), and 1396a(a)(10)(A) of this title insofar

as it requires provision of the care and services described in

section 1396d(a)(2)(C) of this title) as may be necessary for a

State -

(1) to implement a primary care case-management system or a

specialty physician services arrangement which restricts the

provider from (or through) whom an individual (eligible for

medical assistance under this subchapter) can obtain medical care

services (other than in emergency circumstances), if such

restriction does not substantially impair access to such services

of adequate quality where medically necessary,

(2) to allow a locality to act as a central broker in assisting

individuals (eligible for medical assistance under this

subchapter) in selecting among competing health care plans, if

such restriction does not substantially impair access to services

of adequate quality where medically necessary,

(3) to share (through provision of additional services) with

recipients of medical assistance under the State plan cost

savings resulting from use by the recipient of more

cost-effective medical care, and

(4) to restrict the provider from (or through) whom an

individual (eligible for medical assistance under this

subchapter) can obtain services (other than in emergency

circumstances) to providers or practitioners who undertake to

provide such services and who meet, accept, and comply with the

reimbursement, quality, and utilization standards under the State

plan, which standards shall be consistent with the requirements

of section 1396r-4 of this title and are consistent with access,

quality, and efficient and economic provision of covered care and

services, if such restriction does not discriminate among classes

of providers on grounds unrelated to their demonstrated

effectiveness and efficiency in providing those services and if

providers under such restriction are paid on a timely basis in

the same manner as health care practitioners must be paid under

section 1396a(a)(37)(A) of this title.

No waiver under this subsection may restrict the choice of the

individual in receiving services under section 1396d(a)(4)(C) of

this title.

(c) Waiver respecting medical assistance requirement in State plan;

scope, etc.; "habilitation services" defined; imposition of

certain regulatory limits prohibited; computation of expenditures

for certain disabled patients; coordinated services; substitution

of participants

(1) The Secretary may by waiver provide that a State plan

approved under this subchapter may include as "medical assistance"

under such plan payment for part or all of the cost of home or

community-based services (other than room and board) approved by

the Secretary which are provided pursuant to a written plan of care

to individuals with respect to whom there has been a determination

that but for the provision of such services the individuals would

require the level of care provided in a hospital or a nursing

facility or intermediate care facility for the mentally retarded

the cost of which could be reimbursed under the State plan. For

purposes of this subsection, the term "room and board" shall not

include an amount established under a method determined by the

State to reflect the portion of costs of rent and food attributable

to an unrelated personal caregiver who is residing in the same

household with an individual who, but for the assistance of such

caregiver, would require admission to a hospital, nursing facility,

or intermediate care facility for the mentally retarded.

(2) A waiver shall not be granted under this subsection unless

the State provides assurances satisfactory to the Secretary that -

(A) necessary safeguards (including adequate standards for

provider participation) have been taken to protect the health and

welfare of individuals provided services under the waiver and to

assure financial accountability for funds expended with respect

to such services;

(B) the State will provide, with respect to individuals who -

(i) are entitled to medical assistance for inpatient hospital

services, nursing facility services, or services in an

intermediate care facility for the mentally retarded under the

State plan,

(ii) may require such services, and

(iii) may be eligible for such home or community-based care

under such waiver,

for an evaluation of the need for inpatient hospital services,

nursing facility services, or services in an intermediate care

facility for the mentally retarded;

(C) such individuals who are determined to be likely to require

the level of care provided in a hospital, nursing facility, or

intermediate care facility for the mentally retarded are informed

of the feasible alternatives, if available under the waiver, at

the choice of such individuals, to the provision of inpatient

hospital services, nursing facility services, or services in an

intermediate care facility for the mentally retarded;

(D) under such waiver the average per capita expenditure

estimated by the State in any fiscal year for medical assistance

provided with respect to such individuals does not exceed 100

percent of the average per capita expenditure that the State

reasonably estimates would have been made in that fiscal year for

expenditures under the State plan for such individuals if the

waiver had not been granted; and

(E) the State will provide to the Secretary annually,

consistent with a data collection plan designed by the Secretary,

information on the impact of the waiver granted under this

subsection on the type and amount of medical assistance provided

under the State plan and on the health and welfare of recipients.

(3) A waiver granted under this subsection may include a waiver

of the requirements of section 1396a(a)(1) of this title (relating

to statewideness), section 1396a(a)(10)(B) of this title (relating

to comparability), and section 1396a(a)(10)(C)(i)(III) of this

title (relating to income and resource rules applicable in the

community). A waiver under this subsection shall be for an initial

term of three years and, upon the request of a State, shall be

extended for additional five-year periods unless the Secretary

determines that for the previous waiver period the assurances

provided under paragraph (2) have not been met. A waiver may

provide, with respect to post-eligibility treatment of income of

all individuals receiving services under that waiver, that the

maximum amount of the individual's income which may be disregarded

for any month for the maintenance needs of the individual may be an

amount greater than the maximum allowed for that purpose under

regulations in effect on July 1, 1985.

(4) A waiver granted under this subsection may, consistent with

paragraph (2) -

(A) limit the individuals provided benefits under such waiver

to individuals with respect to whom the State has determined that

there is a reasonable expectation that the amount of medical

assistance provided with respect to the individual under such

waiver will not exceed the amount of such medical assistance

provided for such individual if the waiver did not apply, and

(B) provide medical assistance to individuals (to the extent

consistent with written plans of care, which are subject to the

approval of the State) for case management services,

homemaker/home health aide services and personal care services,

adult day health services, habilitation services, respite care,

and such other services requested by the State as the Secretary

may approve and for day treatment or other partial

hospitalization services, psychosocial rehabilitation services,

and clinic services (whether or not furnished in a facility) for

individuals with chronic mental illness.

Except as provided under paragraph (2)(D), the Secretary may not

restrict the number of hours or days of respite care in any period

which a State may provide under a waiver under this subsection.

(5) For purposes of paragraph (4)(B), the term "habilitation

services" -

(A) means services designed to assist individuals in acquiring,

retaining, and improving the self-help, socialization, and

adaptive skills necessary to reside successfully in home and

community based settings; and

(B) includes (except as provided in subparagraph (C))

prevocational, educational, and supported employment services;

but

(C) does not include -

(i) special education and related services (as defined in

paragraphs (16) and (17) of section 1401(a) (!1) of title 20)

which otherwise are available to the individual through a local

educational agency; and

(ii) vocational rehabilitation services which otherwise are

available to the individual through a program funded under

section 730 of title 29.

(6) The Secretary may not require, as a condition of approval of

a waiver under this section under paragraph (2)(D), that the actual

total expenditures for home and community-based services under the

waiver (and a claim for Federal financial participation in

expenditures for the services) cannot exceed the approved estimates

for these services. The Secretary may not deny Federal financial

payment with respect to services under such a waiver on the ground

that, in order to comply with paragraph (2)(D), a State has failed

to comply with such a requirement.

(7)(A) In making estimates under paragraph (2)(D) in the case of

a waiver that applies only to individuals with a particular illness

or condition who are inpatients in, or who would require the level

of care provided in, hospitals, nursing facilities, or intermediate

care facilities for the mentally retarded, the State may determine

the average per capita expenditure that would have been made in a

fiscal year for those individuals under the State plan separately

from the expenditures for other individuals who are inpatients in,

or who would require the level of care provided in, those

respective facilities.

(B) In making estimates under paragraph (2)(D) in the case of a

waiver that applies only to individuals with developmental

disabilities who are inpatients in a nursing facility and whom the

State has determined, on the basis of an evaluation under paragraph

(2)(B), to need the level of services provided by an intermediate

care facility for the mentally retarded, the State may determine

the average per capita expenditures that would have been made in a

fiscal year for those individuals under the State plan on the basis

of the average per capita expenditures under the State plan for

services to individuals who are inpatients in an intermediate care

facility for the mentally retarded, without regard to the

availability of beds for such inpatients.

(C) In making estimates under paragraph (2)(D) in the case of a

waiver to the extent that it applies to individuals with mental

retardation or a related condition who are resident in an

intermediate care facility for the mentally retarded the

participation of which under the State plan is terminated, the

State may determine the average per capita expenditures that would

have been made in a fiscal year for those individuals without

regard to any such termination.

(8) The State agency administering the plan under this subchapter

may, whenever appropriate, enter into cooperative arrangements with

the State agency responsible for administering the program for

children with special health care needs under subchapter V of this

chapter in order to assure improved access to coordinated services

to meet the needs of such children.

(9) In the case of any waiver under this subsection which

contains a limit on the number of individuals who shall receive

home or community-based services, the State may substitute

additional individuals to receive such services to replace any

individuals who die or become ineligible for services under the

State plan.

(10) The Secretary shall not limit to fewer than 200 the number

of individuals in the State who may receive home and

community-based services under a waiver under this subsection.

(d) Home and community-based services for elderly

(1) Subject to paragraph (2), the Secretary shall grant a waiver

to provide that a State plan approved under this subchapter shall

include as "medical assistance" under such plan payment for part or

all of the cost of home or community-based services (other than

room and board) which are provided pursuant to a written plan of

care to individuals 65 years of age or older with respect to whom

there has been a determination that but for the provision of such

services the individuals would be likely to require the level of

care provided in a skilled nursing facility or intermediate care

facility the cost of which could be reimbursed under the State

plan. For purposes of this subsection, the term "room and board"

shall not include an amount established under a method determined

by the State to reflect the portion of costs of rent and food

attributable to an unrelated personal caregiver who is residing in

the same household with an individual who, but for the assistance

of such caregiver, would require admission to a hospital, nursing

facility, or intermediate care facility for the mentally retarded.

(2) A waiver shall not be granted under this subsection unless

the State provides assurances satisfactory to the Secretary that -

(A) necessary safeguards (including adequate standards for

provider participation) have been taken to protect the health and

welfare of individuals provided services under the waiver and to

assure financial accountability for funds expended with respect

to such services;

(B) with respect to individuals 65 years of age or older who -

(i) are entitled to medical assistance for skilled nursing or

intermediate care facility services under the State plan,

(ii) may require such services, and

(iii) may be eligible for such home or community-based

services under such waiver,

the State will provide for an evaluation of the need for such

skilled nursing facility or intermediate care facility services;

and

(C) such individuals who are determined to be likely to require

the level of care provided in a skilled nursing facility or

intermediate care facility are informed of the feasible

alternatives to the provision of skilled nursing facility or

intermediate care facility services, which such individuals may

choose if available under the waiver.

Each State with a waiver under this subsection shall provide to the

Secretary annually, consistent with a reasonable data collection

plan designed by the Secretary, information on the impact of the

waiver granted under this subsection on the type and amount of

medical assistance provided under the State plan and on the health

and welfare of recipients.

(3) A waiver granted under this subsection may include a waiver

of the requirements of section 1396a(a)(1) of this title (relating

to statewideness), section 1396a(a)(10)(B) of this title (relating

to comparability), and section 1396a(a)(10)(C)(i)(III) of this

title (relating to income and resource rules applicable in the

community). Subject to a termination by the State (with notice to

the Secretary) at any time, a waiver under this subsection shall be

for an initial term of 3 years and, upon the request of a State,

shall be extended for additional 5-year periods unless the

Secretary determines that for the previous waiver period the

assurances provided under paragraph (2) have not been met. A waiver

may provide, with respect to post-eligibility treatment of income

of all individuals receiving services under the waiver, that the

maximum amount of the individual's income which may be disregarded

for any month is equal to the amount that may be allowed for that

purpose under a waiver under subsection (c) of this section.

(4) A waiver under this subsection may, consistent with paragraph

(2), provide medical assistance to individuals for case management

services, homemaker/home health aide services and personal care

services, adult day health services, respite care, and other

medical and social services that can contribute to the health and

well-being of individuals and their ability to reside in a

community-based care setting.

(5)(A) In the case of a State having a waiver approved under this

subsection, notwithstanding any other provision of section 1396b of

this title to the contrary, the total amount expended by the State

for medical assistance with respect to skilled nursing facility

services, intermediate care facility services, and home and

community-based services under the State plan for individuals 65

years of age or older during a waiver year under this subsection

may not exceed the projected amount determined under subparagraph

(B).

(B) For purposes of subparagraph (A), the projected amount under

this subparagraph is the sum of the following:

(i) The aggregate amount of the State's medical assistance

under this subchapter for skilled nursing facility services and

intermediate care facility services furnished to individuals who

have attained the age of 65 for the base year increased by a

percentage which is equal to the lesser of 7 percent times the

number of years (rounded to the nearest quarter of a year)

beginning after the base year and ending at the end of the waiver

year involved or the sum of -

(I) the percentage increase (based on an appropriate

market-basket index representing the costs of elements of such

services) between the beginning of the base year and the

beginning of the waiver year involved, plus

(II) the percentage increase between the beginning of the

base year and the beginning of the waiver year involved in the

number of residents in the State who have attained the age of

65, plus

(III) 2 percent for each year (rounded to the nearest quarter

of a year) beginning after the base year and ending at the end

of the waiver year.

(ii) The aggregate amount of the State's medical assistance

under this subchapter for home and community-based services for

individuals who have attained the age of 65 for the base year

increased by a percentage which is equal to the lesser of 7

percent times the number of years (rounded to the nearest quarter

of a year) beginning after the base year and ending at the end of

the waiver year involved or the sum of -

(I) the percentage increase (based on an appropriate

market-basket index representing the costs of elements of such

services) between the beginning of the base year and the

beginning of the waiver year involved, plus

(II) the percentage increase between the beginning of the

base year and the beginning of the waiver year involved in the

number of residents in the State who have attained the age of

65, plus

(III) 2 percent for each year (rounded to the nearest quarter

of a year) beginning after the base year and ending at the end

of the waiver year.

(iii) The Secretary shall develop and promulgate by regulation

(by not later than October 1, 1989) -

(I) a method, based on an index of appropriately weighted

indicators of changes in the wages and prices of the mix of

goods and services which comprise both skilled nursing facility

services and intermediate care facility services (regardless of

the source of payment for such services), for projecting the

percentage increase for purposes of clause (i)(I);

(II) a method, based on an index of appropriately weighted

indicators of changes in the wages and prices of the mix of

goods and services which comprise home and community-based

services (regardless of the source of payment for such

services), for projecting the percentage increase for purposes

of clause (ii)(I); and

(III) a method for projecting, on a State specific basis, the

percentage increase in the number of residents in each State

who are over 65 years of age for any period.

The Secretary shall develop (by not later than October 1, 1989) a

method for projecting, on a State-specific basis, the percentage

increase in the number of residents in each State who are over 65

years of age for any period. Effective on and after the date the

Secretary promulgates the regulation under clause (iii), any

reference in this subparagraph to the "lesser of 7 percent" shall

be deemed to be a reference to the "greater of 7 percent".

(iv) If there is enacted after December 22, 1987, an Act which

amends this subchapter whose provisions become effective on or

after such date and which results in an increase in the aggregate

amount of medical assistance under this subchapter for nursing

facility services and home and community-based services for

individuals who have attained the age of 65 years, the Secretary,

at the request of a State with a waiver under this subsection for

a waiver year or years and in close consultation with the State,

shall adjust the projected amount computed under this

subparagraph for the waiver year or years to take into account

such increase.

(C) In this paragraph:

(i) The term "home and community-based services" includes

services described in sections 1396d(a)(7) and 1396d(a)(8) of

this title, services described in subsection (c)(4)(B) of this

section, services described in paragraph (4), and personal care

services.

(ii)(I) Subject to subclause (II), the term "base year" means

the most recent year (ending before December 22, 1987) for which

actual final expenditures under this subchapter have been

reported to, and accepted by, the Secretary.

(II) For purposes of subparagraph (C), in the case of a State

that does not report expenditures on the basis of the age

categories described in such subparagraph for a year ending

before December 22, 1987, the term "base year" means fiscal year

1989.

(iii) The term "intermediate care facility services" does not

include services furnished in an institution certified in

accordance with section 1396d(d) of this title.

(6)(A) A determination by the Secretary to deny a request for a

waiver (or extension of waiver) under this subsection shall be

subject to review to the extent provided under section 1316(b) of

this title.

(B) Notwithstanding any other provision of this chapter, if the

Secretary denies a request of the State for an extension of a

waiver under this subsection, any waiver under this subsection in

effect on the date such request is made shall remain in effect for

a period of not less than 90 days after the date on which the

Secretary denies such request (or, if the State seeks review of

such determination in accordance with subparagraph (A), the date on

which a final determination is made with respect to such review).

(e) Waiver for children infected with AIDS or drug dependent at

birth

(1)(A) Subject to paragraph (2), the Secretary shall grant a

waiver to provide that a State plan approved under this subchapter

shall include as "medical assistance" under such plan payment for

part or all of the cost of nursing care, respite care, physicians'

services, prescribed drugs, medical devices and supplies,

transportation services, and such other services requested by the

State as the Secretary may approve which are provided pursuant to a

written plan of care to a child described in subparagraph (B) with

respect to whom there has been a determination that but for the

provision of such services the infants would be likely to require

the level of care provided in a hospital or nursing facility the

cost of which could be reimbursed under the State plan.

(B) Children described in this subparagraph are individuals under

5 years of age who -

(i) at the time of birth were infected with (or tested

positively for) the etiologic agent for acquired immune

deficiency syndrome (AIDS),

(ii) have such syndrome, or

(iii) at the time of birth were dependent on heroin, cocaine,

or phencyclidine,

and with respect to whom adoption or foster care assistance is (or

will be) made available under part E of subchapter IV of this

chapter.

(2) A waiver shall not be granted under this subsection unless

the State provides assurances satisfactory to the Secretary that -

(A) necessary safeguards (including adequate standards for

provider participation) have been taken to protect the health and

welfare of individuals provided services under the waiver and to

assure financial accountability for funds expended with respect

to such services;

(B) under such waiver the average per capita expenditure

estimated by the State in any fiscal year for medical assistance

provided with respect to such individuals does not exceed 100

percent of the average per capita expenditure that the State

reasonably estimates would have been made in that fiscal year for

expenditures under the State plan for such individuals if the

waiver had not been granted; and

(C) the State will provide to the Secretary annually,

consistent with a data collection plan designed by the Secretary,

information on the impact of the waiver granted under this

subsection on the type and amount of medical assistance provided

under the State plan and on the health and welfare of recipients.

(3) A waiver granted under this subsection may include a waiver

of the requirements of section 1396a(a)(1) of this title (relating

to statewideness) and section 1396a(a)(10)(B) of this title

(relating to comparability). A waiver under this subsection shall

be for an initial term of 3 years and, upon the request of a State,

shall be extended for additional five-year periods unless the

Secretary determines that for the previous waiver period the

assurances provided under paragraph (2) have not been met.

(4) The provisions of paragraph (6) of subsection (d) of this

section shall apply to this subsection in the same manner as it

applies to subsection (d) of this section.

(f) Monitor of implementation of waivers; termination of waiver for

noncompliance; time limitation for action on requests for plan

approval, amendments, or waivers

(1) The Secretary shall monitor the implementation of waivers

granted under this section to assure that the requirements for such

waiver are being met and shall, after notice and opportunity for a

hearing, terminate any such waiver where he finds noncompliance has

occurred.

(2) A request to the Secretary from a State for approval of a

proposed State plan or plan amendment or a waiver of a requirement

of this subchapter submitted by the State pursuant to a provision

of this subchapter shall be deemed granted unless the Secretary,

within 90 days after the date of its submission to the Secretary,

either denies such request in writing or informs the State agency

in writing with respect to any additional information which is

needed in order to make a final determination with respect to the

request. After the date the Secretary receives such additional

information, the request shall be deemed granted unless the

Secretary, within 90 days of such date, denies such request.

(g) Optional targeted case management services

(1) A State may provide, as medical assistance, case management

services under the plan without regard to the requirements of

section 1396a(a)(1) of this title and section 1396a(a)(10)(B) of

this title. The provision of case management services under this

subsection shall not restrict the choice of the individual to

receive medical assistance in violation of section 1396a(a)(23) of

this title. A State may limit the provision of case management

services under this subsection to individuals with acquired immune

deficiency syndrome (AIDS), or with AIDS-related conditions, or

with either, or to individuals described in section 1396a(z)(1)(A)

of this title and a State may limit the provision of case

management services under this subsection to individuals with

chronic mental illness. The State may limit the case managers

available with respect to case management services for eligible

individuals with developmental disabilities or with chronic mental

illness in order to ensure that the case managers for such

individuals are capable of ensuring that such individuals receive

needed services.

(2) For purposes of this subsection, the term "case management

services" means services which will assist individuals eligible

under the plan in gaining access to needed medical, social,

educational, and other services.

(h) Period of waivers; continuations

No waiver under this section (other than a waiver under

subsection (c), (d), or (e) of this section) may extend over a

period of longer than two years unless the State requests

continuation of such waiver, and such request shall be deemed

granted unless the Secretary, within 90 days after the date of its

submission to the Secretary, either denies such request in writing

or informs the State agency in writing with respect to any

additional information which is needed in order to make a final

determination with respect to the request. After the date the

Secretary receives such additional information, the request shall

be deemed granted unless the Secretary, within 90 days of such

date, denies such request.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1915, as added Pub. L.

97-35, title XXI, Sec. 2175(b), Aug. 13, 1981, 95 Stat. 809;

amended Pub. L. 97-35, title XXI, Secs. 2176, 2177(a), Aug. 13,

1981, 95 Stat. 812, 813; Pub. L. 97-248, title I, Sec.

137(b)(19)(A), (20)-(25), Sept. 3, 1982, 96 Stat. 380; Pub. L.

97-448, title III, Sec. 309(b)(17), Jan. 12, 1983, 96 Stat. 2409;

Pub. L. 98-369, div. B, title III, Sec. 2373(b)(21), July 18, 1984,

98 Stat. 1112; Pub. L. 99-272, title IX, Secs. 9502(a)-(e),

(g)-(i), 9508(a), Apr. 7, 1986, 100 Stat. 202-204, 210; Pub. L.

99-509, title IX, Secs. 9320(h)(3), 9411(a)-(d), Oct. 21, 1986, 100

Stat. 2016, 2061, 2062; Pub. L. 100-93, Sec. 8(h)(2), Aug. 18,

1987, 101 Stat. 694; Pub. L. 100-203, title IV, Secs. 4072(d),

4102(a)(1), (b)(2), 4118(a)(1), (b), (i)(1), (k), (l)(1), (p)(10),

4211(h)(10), Dec. 22, 1987, 101 Stat. 1330-117, 1330-143, 1330-146,

1330-154 to 1330-157, 1330-160, 1330-206; Pub. L. 100-360, title

II, Sec. 204(d)(3), title IV, Sec. 411(k)(3), (10)(A), (H), (I),

(17)(A), (l)(3)(G), July 1, 1988, 102 Stat. 729, 791, 794, 796,

799, 803; Pub. L. 100-485, title VI, Sec. 608(d)(26)(M), (f)(2),

Oct. 13, 1988, 102 Stat. 2422, 2424; Pub. L. 100-647, title VIII,

Secs. 8432(a), (b), 8437(a), Nov. 10, 1988, 102 Stat. 3804, 3806;

Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat.

1981; Pub. L. 101-239, title VI, Secs. 6115(c), 6411(c)(2), Dec.

19, 1989, 103 Stat. 2219, 2270; Pub. L. 101-508, title IV, Secs.

4604(c), 4704(b)(3), 4741, 4742(a), (c)(1), (d)(1), Nov. 5, 1990,

104 Stat. 1388-169, 1388-172, 1388-197, 1388-198; Pub. L. 102-119,

Sec. 26(i)(2), Oct. 7, 1991, 105 Stat. 607; Pub. L. 103-66, title

XIII, Sec. 13603(d), Aug. 10, 1993, 107 Stat. 620; Pub. L. 105-33,

title IV, Secs. 4106(c), 4743(a), Aug. 5, 1997, 111 Stat. 368, 524;

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(o),

(z)], Nov. 29, 1999, 113 Stat. 1536, 1501A-397, 1501A-398; Pub. L.

106-554, Sec. 1(a)(6) [title VII, Sec. 702(c)(2)], Dec. 21, 2000,

114 Stat. 2763, 2763A-574; Pub. L. 107-121, Sec. 2(b)(3), Jan. 15,

2002, 115 Stat. 2384.)

-STATAMEND-

AMENDMENT OF SUBSECTION (B)

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(z)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided that, effective

Oct. 1, 2004, subsection (b) of this section is amended, in the

matter preceding paragraph (1), by striking "sections

1396a(a)(13)(C) and" and inserting "section".

-REFTEXT-

REFERENCES IN TEXT

Parts A and B of subchapter XVIII of this chapter, referred to in

subsec. (a)(1)(B)(ii)(II), are classified to sections 1395c et seq.

and 1395j et seq., respectively, of this title.

Section 1401 of title 20, referred to in subsec. (c)(5)(C)(i),

was in the original a reference to section 602 of the Individuals

with Disabilities Education Act, Pub. L. 91-230, title VI. Section

602 of Pub. L. 91-230 was omitted in the general amendment of

subchapter I of chapter 33 of Title 20, Education, by Pub. L.

105-17, title I, Sec. 101, June 4, 1997, 111 Stat. 37. Pub. L.

105-17 enacted a new section 602 of Pub. L. 91-230, which is

classified to section 1401 of Title 20, and which contains

provisions defining "special education" and "related services".

Part E of subchapter IV of this chapter, referred to in subsec.

(e)(1)(B), is classified to section 670 et seq. of this title.

-MISC1-

AMENDMENTS

2002 - Subsec. (b). Pub. L. 107-121 substituted "1396a(bb)" for

"1396a(aa)".

2000 - Subsec. (b). Pub. L. 106-554 substituted "1396a(a)(15),

1396a(aa)," for "1396a(a)(13)(C)" in introductory provisions.

1999 - Subsec. (b). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(o)(1)], substituted "1396a(a)(13)(C)" for

"1396a(a)(13)(E)" in introductory provisions.

Subsec. (d)(5)(B)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 608(o)(2)], which directed substitution of "65" for "75"

in last sentence of cl. (iii), was executed by making the

substitution in the penultimate sentence to reflect the probable

intent of Congress.

Subsec. (h). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(o)(3)], substituted "90 days of such date" for "90 day of such

date".

1997 - Subsec. (a)(1)(B)(ii)(I). Pub. L. 105-33, Sec. 4106(c),

substituted "paragraphs (16) and (17)" for "paragraphs (15) and

(16)".

Subsec. (c)(5). Pub. L. 105-33, Sec. 4743(a), in introductory

provisions, struck out ", with respect to individuals who receive

such services after discharge from a nursing facility or

intermediate care facility for the mentally retarded" after "

'habilitation services' ".

1993 - Subsec. (g)(1). Pub. L. 103-66 inserted "or to individuals

described in section 1396a(z)(1)(A) of this title" after "or with

either,".

1991 - Subsec. (c)(5)(C)(i). Pub. L. 102-119 substituted "(as

defined in paragraphs (16) and (17) of section 1401(a) of title

20)" for "(as defined in section 1401(16) and (17) of title 20)".

The reference to section 1401 of title 20 includes the substitution

of "Individuals with Disabilities Education Act" for "Education of

the Handicapped Act" in the original.

1990 - Subsec. (b). Pub. L. 101-508, Sec. 4704(b)(3), inserted

"(other than sections 1396a(a)(13)(E) and 1396a(a)(10)(A) of this

title insofar as it requires provision of the care and services

described in section 1396d(a)(2)(C) of this title)" after "section

1396a of this title" in introductory provisions.

Pub. L. 101-508, Sec. 4604(c), which directed amendment of

subsec. (b) by inserting "(other than subsection (s))" after

"Section 1396a of this title", was executed by inserting the new

language after "section 1396a of this title" to reflect the

probable intent of Congress.

Subsec. (b)(4). Pub. L. 101-508, Sec. 4742(a), inserted before

period at end "and if providers under such restriction are paid on

a timely basis in the same manner as health care practitioners must

be paid under section 1396a(a)(37)(A) of this title".

Subsec. (c)(1). Pub. L. 101-508, Sec. 4741(a), inserted at end

"For purposes of this subsection, the term 'room and board' shall

not include an amount established under a method determined by the

State to reflect the portion of costs of rent and food attributable

to an unrelated personal caregiver who is residing in the same

household with an individual who, but for the assistance of such

caregiver, would require admission to a hospital, nursing facility,

or intermediate care facility for the mentally retarded."

Subsec. (c)(4). Pub. L. 101-508, Sec. 4742(d)(1), inserted at end

"Except as provided under paragraph (2)(D), the Secretary may not

restrict the number of hours or days of respite care in any period

which a State may provide under a waiver under this subsection."

Subsec. (c)(7)(C). Pub. L. 101-508, Sec. 4742(c)(1), added

subpar. (C).

Subsec. (d)(1). Pub. L. 101-508, Sec. 4741(a), inserted at end

"For purposes of this subsection, the term 'room and board' shall

not include an amount established under a method determined by the

State to reflect the portion of costs of rent and food attributable

to an unrelated personal caregiver who is residing in the same

household with an individual who, but for the assistance of such

caregiver, would require admission to a hospital, nursing facility,

or intermediate care facility for the mentally retarded."

Subsec. (d)(5)(B)(iv). Pub. L. 101-508, Sec. 4741(b), substituted

"this subchapter whose provisions become effective on or after such

date" for first reference to "this subchapter".

1989 - Subsec. (a)(1)(B)(ii)(I). Pub. L. 101-239, Sec. 6115(c),

substituted "paragraphs (15) and (16)" for "paragraphs (14) and

(15)".

Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 204(d)(3), and

provided that the provisions of law amended or repealed by such

section are restored or revived as if such section had not been

enacted, see 1988 Amendment note below.

Subsec. (b)(4). Pub. L. 101-239, Sec. 6411(c)(2), inserted "shall

be consistent with the requirements of section 1396r-4 of this

title and" after "which standards".

1988 - Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-360, Sec. 204(d)(3),

substituted "paragraphs (14) and (15)" for "paragraphs (13) and

(14)".

Subsec. (a)(2). Pub. L. 100-485, Sec. 608(f)(2), substituted

"restricts" for "Restricts" in introductory provisions.

Subsec. (c)(7). Pub. L. 100-360, Sec. 411(l)(3)(G), amended Pub.

L. 100-203, Sec. 4211(h)(10)(G), see 1987 Amendment note below.

Subsec. (c)(7)(A). Pub. L. 100-647, Sec. 8437(a), substituted

"who are inpatients in, or who would require the level of care

provided in, hospitals," for "who are inpatients in hospitals," and

"who are inpatients in, or who would require the level of care

provided in, those respective facilities" for "who are inpatients

of those respective facilities".

Subsec. (c)(7)(B). Pub. L. 100-360, Sec. 411(k)(10)(H), inserted

", without regard to the availability of beds for such inpatients"

before period at end.

Subsec. (c)(10). Pub. L. 100-360, Sec. 411(k)(10)(A), substituted

"The Secretary shall not limit to fewer than 200" for "No waiver

under this subsection shall limit by an amount less than 200" and

"under a waiver under this subsection" for "under such waiver".

Subsec. (d)(5)(B)(i), (ii). Pub. L. 100-647, Sec. 8432(b), in

introductory provisions, substituted "the number of years (rounded

to the nearest quarter of a year) beginning after the base year and

ending at the end of the waiver year" for "the number of years

beginning after the base year and ending before the waiver year",

in subcls. (I) and (II), substituted "between the beginning of the

base year and the beginning of the waiver year" for "between the

base year and the waiver year", and in subcl. (III), inserted

"(rounded to the nearest quarter of a year)" after "for each year"

and substituted "at the end of the waiver year" for "before the

waiver year".

Subsec. (d)(5)(B)(iii). Pub. L. 100-360, Sec. 411(k)(3)(A)(ii),

inserted before last sentence "The Secretary shall develop (by not

later than October 1, 1989) a method for projecting, on a

State-specific basis, the percentage increase in the number of

residents in each State who are over 75 years of age for any

period."

Subsec. (d)(5)(B)(iii)(III). Pub. L. 100-360, Sec.

411(k)(3)(A)(i), substituted "65" for "75".

Subsec. (d)(5)(B)(iv). Pub. L. 100-647, Sec. 8432(a), added cl.

(iv).

Subsec. (d)(5)(C)(i). Pub. L. 100-360, Sec. 411(k)(3)(B),

substituted "paragraph (4), and personal care services" for

"paragraph (4)(B), personal care services, and services furnished

pursuant to a waiver under subsection (c) of this section".

Subsec. (e). Pub. L. 100-360, Sec. 411(k)(17)(A)(ii), (iii),

added subsec. (e), redesignated former subsec. (e)(1) as (f)(1),

and struck out former subsec. (e)(2) which read as follows: "The

Secretary shall report, not later than September 30, 1984, to

Congress on waivers granted under this section."

Subsec. (f)(1). Pub. L. 100-360, Sec. 411(k)(17)(A)(ii),

redesignated former subsec. (e)(1) as (f)(1).

Subsec. (f)(2). Pub. L. 100-360, Sec. 411(k)(17)(A)(i),

redesignated former subsec. (f) as subsec. (f)(2).

Subsec. (h). Pub. L. 100-360, Sec. 411(k)(10)(I), made technical

amendment to directory language of Pub. L. 100-203, Sec.

4118(l)(1), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(k)(17)(A)(iv), as amended by Pub. L.

100-485, Sec. 608(d)(26)(M), substituted ", (d), or (e)" for "or

(d)".

1987 - Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-203, Sec. 4072(d),

substituted "paragraphs (13) and (14)" for "paragraphs (12) and

(13)".

Subsec. (a)(2). Pub. L. 100-93 amended par. (2) generally. Prior

to amendment, par. (2) read as follows: "restricts -

"(A) for a reasonable period of time the provider or providers

from which an individual (eligible for medical assistance for

items or services under the State plan) can receive such items or

services, if the State has found, after notice and opportunity

for a hearing (in accordance with procedures established by the

State), that the individual has utilized such items or services

at a frequency or amount not medically necessary (as determined

in accordance with utilization guidelines established by the

State), or

"(B) (through suspension or otherwise) for a reasonable period

of time the participation of a provider of items or services

under the State plan, if the State has found, after notice and

opportunity for a hearing (in accordance with procedures

established by the State), that the provider has (in a

significant number or proportion of cases) provided such items or

services either (i) at a frequency or amount not medically

necessary (as determined in accordance with utilization

guidelines established by the State), or (ii) of a quality which

does not meet professionally recognized standards of health care,

if, under such restriction, individuals eligible for medical

assistance for such services have reasonable access (taking into

account geographic location and reasonable travel time) to such

services of adequate quality."

Subsec. (c)(1). Pub. L. 100-203, Sec. 4211(h)(10)(A), substituted

"nursing facility or intermediate care facility for the mentally

retarded" for "skilled nursing facility or intermediate care

facility".

Subsec. (c)(2)(B). Pub. L. 100-203, Sec. 4211(h)(10)(C), in

closing provisions, substituted "need for inpatient hospital

services, nursing facility services, or services in an intermediate

care facility for the mentally retarded" for "need for such

inpatient hospital, skilled nursing facility or intermediate care

facility services".

Pub. L. 100-203, Sec. 4118(p)(10), in closing provisions inserted

"such" after "need for".

Subsec. (c)(2)(B)(i). Pub. L. 100-203, Sec. 4211(h)(10)(B),

substituted "services, nursing facility services, or services in an

intermediate care facility for the mentally retarded" for ",

skilled nursing facility, or intermediate care facility services".

Subsec. (c)(2)(C). Pub. L. 100-203, Sec. 4211(h)(10)(D), (E),

substituted ", nursing facility, or intermediate care facility for

the mentally retarded" for "or skilled nursing facility or

intermediate care facility" and ", nursing facility services, or

services in an intermediate care facility for the mentally

retarded" for "or skilled nursing facility or intermediate care

facility services".

Subsec. (c)(3). Pub. L. 100-203, Sec. 4118(a)(1), substituted ",

section 1396a(a)(10)(B) of this title (relating to comparability),

and section 1396a(a)(10)(C)(i)(III) of this title (relating to

income and resource rules applicable in the community)" for "and

section 1396a(a)(10)(B) of this title (relating to comparability)".

Subsec. (c)(5). Pub. L. 100-203, Sec. 4211(h)(10)(F), substituted

"nursing facility or intermediate care facility for the mentally

retarded" for "skilled nursing facility or intermediate care

facility".

Subsec. (c)(7). Pub. L. 100-203, Sec. 4211(h)(10)(G), as amended

by Pub. L. 100-360, Sec. 411(l)(3)(G), substituted ", nursing

facilities, or intermediate care facilities for the mentally

retarded" for "or in skilled nursing or intermediate care

facilities" in subpar. (A) and "nursing facility" for "skilled

nursing facility or intermediate care facility" in subpar. (B).

Pub. L. 100-203, Sec. 4118(k), designated existing provisions as

subpar. (A) and added subpar. (B).

Subsec. (c)(10). Pub. L. 100-203, Sec. 4118(b), added par. (10).

Subsec. (d). Pub. L. 100-203, Sec. 4102(a)(1), added subsec. (d).

Former subsec. (d) redesignated (h).

Subsec. (g)(1). Pub. L. 100-203, Sec. 4118(i)(1), inserted at end

"The State may limit the case managers available with respect to

case management services for eligible individuals with

developmental disabilities or with chronic mental illness in order

to ensure that the case managers for such individuals are capable

of ensuring that such individuals receive needed services."

Subsec. (h). Pub. L. 100-203, Sec. 4118(l)(1), as amended by Pub.

L. 100-360, Sec. 411(k)(10)(I), substituted ", within 90 days after

the date of its submission to the Secretary, either denies such

request in writing or informs the State agency in writing with

respect to any additional information which is needed in order to

make a final determination with respect to the request. After the

date the Secretary receives such additional information, the

request shall be deemed granted unless the Secretary, within 90 day

of such date, denies such request." for "denies such request in

writing within 90 days after the date of its submission to the

Secretary."

Pub. L. 100-203, Sec. 4102(b)(2), substituted "subsection (c) or

(d) of this section" for "subsection (c) of this section".

Pub. L. 100-203, Sec. 4102(a)(1)(A), redesignated former subsec.

(d) as (h).

1986 - Subsec. (a)(1)(B)(ii)(I). Pub. L. 99-509, Sec. 9320(h)(3),

substituted "paragraphs (12) and (13)" for "paragraphs (11) and

(12)".

Subsec. (b). Pub. L. 99-272, Sec. 9508(a)(2), inserted provision,

following par. (4), that no waiver under this subsection may

restrict the choice of the individual in receiving services under

section 1396d(a)(4)(C) of this title.

Subsec. (c)(1). Pub. L. 99-509, Sec. 9411(a)(1), inserted "a

hospital or" after "level of care provided in", and struck out

provision added by Pub. L. 99-272, Sec. 9502(b)(1).

Pub. L. 99-272, Sec. 9502(b)(1), inserted provision relating to

individuals with respect to whom there has been a determination

that but for the provision of such services the individuals would

continue to receive inpatient hospital services, skilled nursing

facility services, or intermediate care facility services because

they are dependent on ventilator support the cost of which is

reimbursed under the State plan.

Subsec. (c)(2)(B). Pub. L. 99-509, Sec. 9411(a)(2), substituted

"inpatient hospital, skilled nursing facility, or" for "skilled

nursing facility or" in cl. (i) and inserted "inpatient hospital,"

after "need for" in concluding provision following cl. (iii).

Subsec. (c)(2)(C). Pub. L. 99-272, Sec. 9502(b)(2), inserted

"hospital or" after "provided in a", and "inpatient hospital

services or" after "the provision of".

Subsec. (c)(2)(D). Pub. L. 99-272, Sec. 9502(c)(1), inserted "100

percent of" after "does not exceed".

Subsec. (c)(3). Pub. L. 99-509, Sec. 9411(c), substituted "and

section 1396a(a)(10)(B) of this title (relating to comparability)"

for "and section 1396a(a)(10) of this title".

Pub. L. 99-272, Sec. 9502(g), substituted "additional five-year

periods" for "additional three-year periods", and "previous waiver

period" for "previous three-year period".

Pub. L. 99-272, Sec. 9502(e), inserted at end "A waiver may

provide, with respect to post-eligibility treatment of income of

all individuals receiving services under that waiver, that the

maximum amount of the individual's income which may be disregarded

for any month for the maintenance needs of the individual may be an

amount greater than the maximum allowed for that purpose under

regulations in effect on July 1, 1985."

Subsec. (c)(4)(B). Pub. L. 99-509, Sec. 9411(d), inserted before

the period "and for day treatment or other partial hospitalization

services, psychosocial rehabilitation services, and clinic services

(whether or not furnished in a facility) for individuals with

chronic mental illness".

Subsec. (c)(5). Pub. L. 99-272, Sec. 9502(a), added par. (5).

Subsec. (c)(6). Pub. L. 99-272, Sec. 9502(c)(2), added par. (6).

Subsec. (c)(7). Pub. L. 99-509, Sec. 9411(a)(3), amended par. (7)

generally. Prior to amendment, par. (7) read as follows: "In making

estimates under paragraph (2)(D) in the case of a waiver which

applies only to physically disabled individuals who are inpatients

in skilled nursing or intermediate care facilities, the State may

determine the average per capita expenditure which would have been

made in a fiscal year for those individuals under the State plan

separately from the expenditure for other individuals who are

inpatients of those facilities."

Pub. L. 99-272, Sec. 9502(d), added par. (7).

Subsec. (c)(8). Pub. L. 99-272, Sec. 9502(h), added par. (8).

Subsec. (c)(9). Pub. L. 99-272, Sec. 9502(i), added par. (9).

Subsec. (g). Pub. L. 99-272, Sec. 9508(a)(1), added subsec. (g).

Subsec. (g)(1). Pub. L. 99-509, Sec. 9411(b), inserted provision

at end allowing a State to limit case management services to AIDS

victims or to individuals with chronic mental illness.

1984 - Subsec. (c)(1). Pub. L. 98-369 substituted "under this

subchapter" for "under this part".

1983 - Subsec. (c)(2)(B). Pub. L. 97-448 substituted "need for

such skilled nursing facility or intermediate care facility

services" for "need for such services" in provisions following cl.

(iii).

1982 - Subsec. (b). Pub. L. 97-248, Sec. 137(b)(19)(A), struck

out "and section 1396b(m) of this title" after "section 1396a of

this title".

Subsec. (b)(1). Pub. L. 97-248, Sec. 137(b)(20), inserted

"primary care" before "case-management system", and substituted

"medical care services" for "primary care services".

Subsec. (c)(1). Pub. L. 97-248, Sec. 137(b)(21), inserted

"payment for part or all of the cost of" after "may include as

'medical assistance' under such plan".

Subsec. (c)(2)(B). Pub. L. 97-248, Sec. 137(b)(22), redesignated

existing provisions as cls. (i) and (ii) and added cl. (iii).

Subsec. (c)(3). Pub. L. 97-248, Sec. 137(b)(23), substituted

"section 1396a(a)(1) of this title" for "subsection (a)(1) of this

section" and "section 1396a(a)(10) of this title" for "subsection

(a)(10) of section 1396a of this title".

Subsec. (c)(4). Pub. L. 97-248, Sec. 137(b)(24), substituted

"this subsection" for "this section".

Subsec. (f). Pub. L. 97-248, Sec. 137(b)(25), inserted "approval

of" before "a proposed State plan".

1981 - Subsecs. (c) to (e). Pub. L. 97-35, Sec. 2176, added

subsec. (c), redesignated former subsec. (c) as (d) and inserted

"(other than a waiver under subsection (c) of this section)", and

redesignated former subsec. (d) as (e).

Subsec. (f). Pub. L. 97-35, Sec. 2177(a), added subsec. (f).

EFFECTIVE DATE OF 2002 AMENDMENT

Amendment by Pub. L. 107-121 effective as if included in the

enactment of section 702 of the Medicare, Medicaid, and SCHIP

Benefits Improvement and Protection Act of 2000 as enacted into law

by section 1(a)(6) of Pub. L. 106-554, see section 2(c)(2) of Pub.

L. 107-121, set out as a note under section 1396a of this title.

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 effective Jan. 1, 2001, and

applicable to services furnished on or after such date, see section

1(a)(6) [title VII, Sec. 702(e)] of Pub. L. 106-554, set out as a

note under section 1396a of this title.

EFFECTIVE DATE OF 1999 AMENDMENT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(z)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided that the

amendment made by section 1000(a)(6) [title VI, Sec. 608(z)] is

effective Oct. 1, 2004.

Amendment by section 1000(a)(6) [title VI, Sec. 608o] of Pub. L.

106-113 effective Nov. 29, 1999, see section 1000(a)(6) [title VI,

Sec. 608(bb)] of Pub. L. 106-113, set out as a note under section

1396a of this title.

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by section 4106(c) of Pub. L. 105-33 applicable to bone

mass measurements performed on or after July 1, 1998, see section

4106(d) of Pub. L. 105-33, set out as a note under section 1395x of

this title.

Section 4743(b) of Pub. L. 105-33 provided that: "The amendment

made by subsection (a) [amending this section] apply to services

furnished on or after October 1, 1997."

EFFECTIVE DATE OF 1993 AMENDMENT

Amendment by Pub. L. 103-66 applicable to medical assistance

furnished on or after Jan. 1, 1994, without regard to whether or

not final regulations to carry out the amendments by section 13603

of Pub. L. 103-66 have been promulgated by such date, see section

13603(f) of Pub. L. 103-66, set out as a note under section 1396a

of this title.

EFFECTIVE DATE OF 1990 AMENDMENTS

Amendment by section 4604(c) of Pub. L. 101-508 effective with

respect to payments under this subchapter for calendar quarters

beginning on or after July 1, 1991, without regard to whether or

not final regulations to carry out the amendments by section 4604

of Pub. L. 101-508 have been promulgated by such date, see section

4604(d) of Pub. L. 101-508, set out as a note under section 1396a

of this title.

Amendment by section 4704(b)(3) of Pub. L. 101-508 effective as

if included in the enactment of the Omnibus Budget Reconciliation

Act of 1989, Pub. L. 101-239, see section 4704(f) of Pub. L.

101-508, set out as a note under section 1396a of this title.

Section 4742(b) of Pub. L. 101-508 provided that: "The amendment

made by subsection (a) [amending this section] shall take effect as

of the first calendar quarter beginning more than 30 days after the

date of the enactment of this Act [Nov. 5, 1990]."

Section 4742(c)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1981 [Pub. L. 97-35], but shall only apply to

facilities the participation of which under a State plan under

title XIX of the Social Security Act [this subchapter] is

terminated on or after the date of the enactment of this Act [Nov.

5, 1990]."

Section 4742(d)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1981 [Pub. L. 97-35]."

EFFECTIVE DATE OF 1989 AMENDMENTS

Amendment by section 6115(c) of Pub. L. 101-239 applicable to

screening pap smears performed on or after July 1, 1990, see

section 6115(d) of Pub. L. 101-239, set out as a note under section

1395x of this title.

Section 6411(c)(4) of Pub. L. 101-239 provided that: "The

amendment made by paragraph (2) [amending this section] shall be

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203]."

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a

of this title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Section 8432(c) of Pub. L. 100-647 provided that: "The amendments

made by this section [amending this section] shall apply to waiver

years beginning during or after fiscal year 1989."

Section 8437(b) of Pub. L. 100-647 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to waiver applications submitted before, on, or after the

date of the enactment of this Act [Nov. 10, 1988]."

Amendment by section 608(d)(26)(M) of Pub. L. 100-485 effective

as if included in the enactment of the Medicare Catastrophic

Coverage Act of 1988, Pub. L. 100-360, see section 608(g)(1) of

Pub. L. 100-485, set out as a note under section 704 of this title.

Amendment by section 608(f)(2) of Pub. L. 100-485 effective Oct.

13, 1988, see section 608(g)(2) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Amendment by section 204(d)(3) of Pub. L. 100-360 applicable to

screening mammography performed on or after Jan. 1, 1990, see

section 204(e) of Pub. L. 100-360, set out as a note under section

1395m of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(k)(3), (10)(A), (H), (I),

(17)(A), (l)(3)(G) of Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENTS

For effective date of amendment by section 4072(d) of Pub. L.

100-203, see section 4072(e) of Pub. L. 100-203, set out as a note

under section 1395x of this title.

Section 4102(a)(2) of Pub. L. 100-203 provided that: "The

amendments made by paragraph (1) [amending this section] shall

become effective on January 1, 1988."

Section 4118(a)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall be

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1986 [Pub. L. 99-509]."

Section 4118(i)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall take

effect as though it were included in the enactment of the

Consolidated Omnibus Budget Reconciliation Act of 1985 [Pub. L.

99-272]."

Section 4118(l)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to requests for continuation of waivers received after the date of

the enactment of this Act [Dec. 22, 1987]."

Section 4118(p)(10) of Pub. L. 100-203 provided that the

amendment made by that section is effective as if included in the

enactment of Pub. L. 99-509.

Amendment by section 4211(h)(10) of Pub. L. 100-203 applicable to

nursing facility services furnished on or after Oct. 1, 1990,

without regard to whether regulations implementing such amendment

are promulgated by such date, except as otherwise specifically

provided in section 1396r of this title, with transitional rule,

see section 4214(a), (b)(2) of Pub. L. 100-203, as amended, set out

as an Effective Date note under section 1396r of this title.

Amendment by Pub. L. 100-93 effective at end of fourteen-day

period beginning Aug. 18, 1987, and inapplicable to administrative

proceedings commenced before end of such period, see section 15(a)

of Pub. L. 100-93, set out as a note under section 1320a-7 of this

title.

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by section 9320(h)(3) of Pub. L. 99-509 applicable to

services furnished on or after Jan. 1, 1989, with exceptions for

hospitals located in rural areas which meet certain requirements

related to certified registered nurse anesthetists, see section

9320(i), (k) of Pub. L. 99-509, as amended, set out as notes under

section 1395k of this title.

Section 9411(e) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section] shall apply to

applications for waivers (or renewals thereof) approved on or after

the date of the enactment of this Act [Oct. 21, 1986]."

Section 9502(j) of Pub. L. 99-272, as amended by Pub. L. 99-509,

title IX, Sec. 9435(a), Oct. 21, 1986, 100 Stat. 2069; Pub. L.

100-203, title IV, Sec. 4118(j), Dec. 22, 1987, 101 Stat. 1330-156,

provided that:

"(1) Habilitation services. - The amendment made by subsection

(a) [amending this section] shall be effective for services

furnished on or after the date of the enactment of this Act [Apr.

7, 1986] to individuals eligible for services under a waiver

granted under section 1915(c) of the Social Security Act [subsec.

(c) of this section], without regard to whether such individuals

were receiving institutional services before their participation in

the waiver.

"(2) Hospitalized patients. - The amendments made by subsection

(b) [amending this section] shall be effective for services

furnished on or after October 1, 1985.

"(3) Prohibition of regulatory limits and treatment of certain

physically disabled individuals. - The amendments made by

subsections (c) and (d) [amending this section] shall apply to

applications for waivers (or renewals thereof) filed before, on, or

after, the date of the enactment of this Act [Apr. 7, 1986] and for

services furnished on or after August 13, 1981.

"(4) Income standards. - The amendment made by subsection (e)

[amending this section] shall apply to waivers (or renewals

thereof) approved before, on, or after the date of the enactment of

this Act [Apr. 7, 1986].

"(5) Waiver extensions. - Subsection (f) [enacting provisions set

out below] shall apply to waivers expiring on or after September

30, 1985, and before September 30, 1986.

"(6) Waiver renewals. - The amendments made by subsection (g)

[amending this section] shall become effective on September 30,

1986.

"(7) Coordinated services and substitution of participants. - The

amendments made by subsections (h) and (i) [amending this section]

shall become effective on the date of the enactment of this Act

[Apr. 7, 1986]."

Section 9508(b) of Pub. L. 99-272, as amended by Pub. L. 99-509,

title IX, Sec. 9435(d)(1), Oct. 21, 1986, 100 Stat. 2070, provided

that: "The amendments made by this section [amending this section]

shall apply to services furnished on or after the date of the

enactment of this Act [Apr. 7, 1986], without regard to whether or

not regulations to carry out the amendments have been promulgated

by that date."

[Section 4118(j) of Pub. L. 100-203 provided that the amendment

made by that section to section 9502(j)(1) of Pub. L. 99-272, set

out above, is effective as if included in the enactment of section

9502 of Pub. L. 99-272.]

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was amended by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Section 137(b)(19)(B) of Pub. L. 97-248 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

not apply with respect to any waiver if such waiver was granted,

and the arrangement covered by the waiver was in place, prior to

August 10, 1982."

Amendment by section 137(b)(20)-(25) of Pub. L. 97-248 effective

as if originally included as part of this section as this section

was amended by the Omnibus Budget Reconciliation Act of 1981, Pub.

L. 97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a

note under section 1396a of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Section 2177(b) of Pub. L. 97-35 provided that: "The amendment

made by this section [amending this section] shall become effective

90 days after the date of the enactment of this Act [Aug. 13,

1981]".

PERMITTING ADJUSTMENT IN ESTIMATES TO TAKE INTO ACCOUNT

PREADMISSION SCREENING REQUIREMENT

Section 4742(e) of Pub. L. 101-508 provided that: "In the case of

a waiver under section 1915(c) of the Social Security Act [subsec.

(c) of this section] for individuals with mental retardation or a

related condition in a State, the Secretary of Health and Human

Services shall permit the State to adjust the estimate of average

per capita expenditures submitted under paragraph (2)(D) of such

section, with respect to such expenditures made on or after January

1, 1989, to take into account increases in expenditures for, or

utilization of, intermediate care facilities for the mentally

retarded resulting from implementation of section 1919(e)(7)(A) of

such Act [section 1396r(e)(7)(A) of this title]."

EXTENSIONS OF WAIVERS UNDER SUBSECTION (C)

Section 4102(c) of Pub. L. 100-203 provided that: "In the case of

a State which, as of December 1, 1987, has a waiver approved with

respect to elderly individuals under section 1915(c) of the Social

Security Act [subsec. (c) of this section], which waiver is

scheduled to expire before July 1, 1988, if the State notifies the

Secretary of Health and Human Services of the State's intention to

file an application for a waiver under section 1915(d) of such Act

(as amended by subsection (a) of this section), the Secretary shall

extend approval of the State's waiver, under section 1915(c) of

such Act, on the same terms and conditions through September 30,

1988."

Section 9502(f) of Pub. L. 99-272 provided that: "The Secretary

of Health and Human Services shall extend, upon request of the

State, any waiver under section 1915(c) of the Social Security Act

[subsec. (c) of this section] which expires on or after September

30, 1985, and before September 30, 1986. Such extension shall be

for a period of not less than one year nor more than five years,

subject to section 1915(e)(1) of such Act."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1320a-7, 1382c, 1396a,

1396b, 1396d, 1396p, 1396r-4, 1396s, 1396t, 1396u-2, 1396u-4, 1786,

15024, 15025, 15043 of this title.

-FOOTNOTE-

(!1) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1396o 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396o. Use of enrollment fees, premiums, deductions, cost

sharing, and similar charges

-STATUTE-

(a) Imposition of certain charges under plan in case of individuals

described in section 1396a(a)(10)(A) or (E)

Subject to subsection (g) of this section, the State plan shall

provide that in the case of individuals described in subparagraph

(A) or (E)(i) of section 1396a(a)(10) of this title who are

eligible under the plan -

(1) no enrollment fee, premium, or similar charge will be

imposed under the plan (except for a premium imposed under

subsection (c) of this section);

(2) no deduction, cost sharing or similar charge will be

imposed under the plan with respect to -

(A) services furnished to individuals under 18 years of age

(and, at the option of the State, individuals under 21, 20, or

19 years of age, or any reasonable category of individuals 18

years of age or over),

(B) services furnished to pregnant women, if such services

relate to the pregnancy or to any other medical condition which

may complicate the pregnancy (or, at the option of the State,

any services furnished to pregnant women),

(C) services furnished to any individual who is an inpatient

in a hospital, nursing facility, intermediate care facility for

the mentally retarded, or other medical institution, if such

individual is required, as a condition of receiving services in

such institution under the State plan, to spend for costs of

medical care all but a minimal amount of his income required

for personal needs,

(D) emergency services (as defined by the Secretary), family

planning services and supplies described in section

1396d(a)(4)(C) of this title, or

(E) services furnished to an individual who is receiving

hospice care (as defined in section 1396d(o) of this title);

and

(3) any deduction, cost sharing, or similar charge imposed

under the plan with respect to other such individuals or other

care and services will be nominal in amount (as determined by the

Secretary in regulations which shall, if the definition of

"nominal" under the regulations in effect on July 1, 1982 is

changed, take into account the level of cash assistance provided

in such State and such other criteria as the Secretary determines

to be appropriate); except that a deduction, cost-sharing, or

similar charge of up to twice the nominal amount established for

outpatient services may be imposed by a State under a waiver

granted by the Secretary for services received at a hospital

emergency room if the services are not emergency services

(referred to in paragraph (2)(D)) and the State has established

to the satisfaction of the Secretary that individuals eligible

for services under the plan have actually available and

accessible to them alternative sources of nonemergency,

outpatient services.

(b) Imposition of certain charges under plan in case of individuals

other than those described in section 1396a(a)(10)(A) or (E)

The State plan shall provide that in the case of individuals

other than those described in subparagraph (A) or (E) of section

1396a(a)(10) of this title who are eligible under the plan -

(1) there may be imposed an enrollment fee, premium, or similar

charge, which (as determined in accordance with standards

prescribed by the Secretary) is related to the individual's

income,

(2) no deduction, cost sharing, or similar charge will be

imposed under the plan with respect to -

(A) services furnished to individuals under 18 years of age

(and, at the option of the State, individuals under 21, 20, or

19 years of age, or any reasonable category of individuals 18

years of age or over),

(B) services furnished to pregnant women, if such services

relate to the pregnancy or to any other medical condition which

may complicate the pregnancy (or, at the option of the State,

any services furnished to pregnant women),

(C) services furnished to any individual who is an inpatient

in a hospital, nursing facility, intermediate care facility for

the mentally retarded, or other medical institution, if such

individual is required, as a condition of receiving services in

such institution under the State plan, to spend for costs of

medical care all but a minimal amount of his income required

for personal needs,

(D) emergency services (as defined by the Secretary), family

planning services and supplies described in section

1396d(a)(4)(C) of this title, or

(E) services furnished to an individual who is receiving

hospice care (as defined in section 1396d(o) of this title);

and

(3) any deduction, cost sharing, or similar charge imposed

under the plan with respect to other such individuals or other

care and services will be nominal in amount (as determined by the

Secretary in regulations which shall, if the definition of

"nominal" under the regulations in effect on July 1, 1982 is

changed, take into account the level of cash assistance provided

in such State and such other criteria as the Secretary determines

to be appropriate); except that a deduction, cost-sharing, or

similar charge of up to twice the nominal amount established for

outpatient services may be imposed by a State under a waiver

granted by the Secretary for services received at a hospital

emergency room if the services are not emergency services

(referred to in paragraph (2)(D)) and the State has established

to the satisfaction of the Secretary that individuals eligible

for services under the plan have actually available and

accessible to them alternative sources of nonemergency,

outpatient services.

(c) Imposition of monthly premium; persons affected; amount;

prepayment; failure to pay; use of funds from other programs

(1) The State plan of a State may at the option of the State

provide for imposing a monthly premium (in an amount that does not

exceed the limit established under paragraph (2)) with respect to

an individual described in subparagraph (A) or (B) of section

1396a(l)(1) of this title who is receiving medical assistance on

the basis of section 1396a(a)(10)(A)(ii)(IX) of this title and

whose family income (as determined in accordance with the

methodology specified in section 1396a(l)(3) of this title) equals

or exceeds 150 percent of the income official poverty line (as

defined by the Office of Management and Budget, and revised

annually in accordance with section 9902(2) of this title)

applicable to a family of the size involved.

(2) In no case may the amount of any premium imposed under

paragraph (1) exceed 10 percent of the amount by which the family

income (less expenses for the care of a dependent child) of an

individual exceeds 150 percent of the line described in paragraph

(1).

(3) A State shall not require prepayment of a premium imposed

pursuant to paragraph (1) and shall not terminate eligibility of an

individual for medical assistance under this subchapter on the

basis of failure to pay any such premium until such failure

continues for a period of not less than 60 days. The State may

waive payment of any such premium in any case where the State

determines that requiring such payment would create an undue

hardship.

(4) A State may permit State or local funds available under other

programs to be used for payment of a premium imposed under

paragraph (1). Payment of a premium with such funds shall not be

counted as income to the individual with respect to whom such

payment is made.

(d) Premiums for qualified disabled and working individuals

described in section 1396d(s)

With respect to a qualified disabled and working individual

described in section 1396d(s) of this title whose income (as

determined under paragraph (3) of that section) exceeds 150 percent

of the official poverty line referred to in that paragraph, the

State plan of a State may provide for the charging of a premium

(expressed as a percentage of the medicare cost-sharing described

in section 1396d(p)(3)(A)(i) of this title provided with respect to

the individual) according to a sliding scale under which such

percentage increases from 0 percent to 100 percent, in reasonable

increments (as determined by the Secretary), as the individual's

income increases from 150 percent of such poverty line to 200

percent of such poverty line.

(e) Prohibition of denial of services on basis of individual's

inability to pay certain charges

The State plan shall require that no provider participating under

the State plan may deny care or services to an individual eligible

for such care or services under the plan on account of such

individual's inability to pay a deduction, cost sharing, or similar

charge. The requirements of this subsection shall not extinguish

the liability of the individual to whom the care or services were

furnished for payment of the deduction, cost sharing, or similar

charge.

(f) Charges imposed under waiver authority of Secretary

No deduction, cost sharing, or similar charge may be imposed

under any waiver authority of the Secretary, except as provided in

subsections (a)(3) and (b)(3) of this section, unless such waiver

is for a demonstration project which the Secretary finds after

public notice and opportunity for comment -

(1) will test a unique and previously untested use of

copayments,

(2) is limited to a period of not more than two years,

(3) will provide benefits to recipients of medical assistance

which can reasonably be expected to be equivalent to the risks to

the recipients,

(4) is based on a reasonable hypothesis which the demonstration

is designed to test in a methodologically sound manner, including

the use of control groups of similar recipients of medical

assistance in the area, and

(5) is voluntary, or makes provision for assumption of

liability for preventable damage to the health of recipients of

medical assistance resulting from involuntary participation.

(g) Individuals provided medical assistance under section

1396a(a)(10)(A)(ii)(XV) or (XVI)

With respect to individuals provided medical assistance only

under subclause (XV) or (XVI) of section 1396a(a)(10)(A)(ii) of

this title -

(1) a State may (in a uniform manner for individuals described

in either such subclause) -

(A) require such individuals to pay premiums or other

cost-sharing charges set on a sliding scale based on income

that the State may determine; and

(B) require payment of 100 percent of such premiums for such

year in the case of such an individual who has income for a

year that exceeds 250 percent of the income official poverty

line (referred to in subsection (c)(1) of this section)

applicable to a family of the size involved, except that in the

case of such an individual who has income for a year that does

not exceed 450 percent of such poverty line, such requirement

may only apply to the extent such premiums do not exceed 7.5

percent of such income; and

(2) such State shall require payment of 100 percent of such

premiums for a year by such an individual whose adjusted gross

income (as defined in section 62 of the Internal Revenue Code of

1986) for such year exceeds $75,000, except that a State may

choose to subsidize such premiums by using State funds which may

not be federally matched under this subchapter.

In the case of any calendar year beginning after 2000, the dollar

amount specified in paragraph (2) shall be increased in accordance

with the provisions of section 415(i)(2)(A)(ii) of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1916, as added Pub. L.

97-248, title I, Sec. 131(b), Sept. 3, 1982, 96 Stat. 367; amended

Pub. L. 97-448, title III, Sec. 309(b)(18)-(20), Jan. 12, 1983, 96

Stat. 2409, 2410; Pub. L. 99-272, title IX, Sec. 9505(c)(2), Apr.

7, 1986, 100 Stat. 209; Pub. L. 99-509, title IX, Sec.

9403(g)(4)(B), Oct. 21, 1986, 100 Stat. 2056; Pub. L. 100-203,

title IV, Secs. 4101(d)(1), 4211(h)(11), Dec. 22, 1987, 101 Stat.

1330-142, 1330-207; Pub. L. 100-360, title IV, Sec. 411(k)(2), July

1, 1988, 102 Stat. 791; Pub. L. 101-239, title VI, Sec. 6408(d)(3),

Dec. 19, 1989, 103 Stat. 2269; Pub. L. 105-33, title IV, Sec.

4708(b), Aug. 5, 1997, 111 Stat. 506; Pub. L. 106-170, title II,

Sec. 201(a)(3), Dec. 17, 1999, 113 Stat. 1893.)

-REFTEXT-

REFERENCES IN TEXT

The Internal Revenue Code of 1986, referred to in subsec. (g)(2),

is classified generally to Title 26, Internal Revenue Code.

-MISC1-

AMENDMENTS

1999 - Subsec. (a). Pub. L. 106-170, Sec. 201(a)(3)(A),

substituted "Subject to subsection (g) of this section, the State

plan" for "The State plan" in introductory provisions.

Subsec. (g). Pub. L. 106-170, Sec. 201(a)(3)(B), added subsec.

(g).

1997 - Subsec. (a)(2)(D). Pub. L. 105-33, Sec. 4708(b)(1), struck

out "or services furnished to such an individual by a health

maintenance organization (as defined in section 1396b(m) of this

title) in which he is enrolled," after "section 1396d(a)(4)(C) of

this title,".

Subsec. (b)(2)(D). Pub. L. 105-33, Sec. 4708(b)(2), struck out

"or (at the option of the State) services furnished to such an

individual by a health maintenance organization (as defined in

section 1396b(m) of this title) in which he is enrolled," after

"section 1396d(a)(4)(C) of this title,".

1989 - Subsec. (a). Pub. L. 101-239, Sec. 6408(d)(3)(A),

substituted "subparagraph (A) or (E)(i)" for "subparagraph (A) or

(E)" in introductory provisions.

Subsecs. (d) to (f). Pub. L. 101-239, Sec. 6408(d)(3)(B), (C),

added subsec. (d) and redesignated former subsecs. (d) and (e) as

(e) and (f), respectively.

1988 - Subsec. (c)(1). Pub. L. 100-360 struck out "nonfarm" after

"150 percent of the".

1987 - Subsec. (a)(1). Pub. L. 100-203, Sec. 4101(d)(1)(A),

inserted "(except for a premium imposed under subsection (c) of

this section)" after "plan".

Subsecs. (a)(2)(C), (b)(2)(C). Pub. L. 100-203, Sec. 4211(h)(11),

substituted "nursing facility, intermediate care facility for the

mentally retarded" for "skilled nursing facility, intermediate care

facility".

Subsecs. (c) to (e). Pub. L. 100-203, Sec. 4101(d)(1)(B), (C),

added subsec. (c) and redesignated former subsecs. (c) and (d) as

(d) and (e), respectively.

1986 - Subsec. (a). Pub. L. 99-509 substituted "subparagraph (A)

or (E) of section 1396a(a)(10) of this title" for "section

1396a(a)(10)(A) of this title".

Subsec. (a)(2)(E). Pub. L. 99-272 added subpar. (E).

Subsec. (b). Pub. L. 99-509 substituted "subparagraph (A) or (E)

of section 1396a(a)(10) of this title" for "section 1396a(a)(10)(A)

of this title".

Subsec. (b)(2)(E). Pub. L. 99-272 added subpar. (E).

1983 - Subsec. (c). Pub. L. 97-448, Sec. 309(b)(18), substituted

"subsection" for "subparagraph".

Subsec. (d). Pub. L. 97-448, Sec. 309(b)(19), (20), substituted

in introductory text ", except as provided in subsections (a)(3)

and (b)(3) of this section" for "unless authorized under this

section", and in cl. (5) substituted "is voluntary, or makes

provision" for "in which participation is voluntary, or in which

provision is made".

EFFECTIVE DATE OF 1999 AMENDMENT

Amendment by Pub. L. 106-170 applicable to medical assistance for

items and services furnished on or after Oct. 1, 2000, see section

201(d) of Pub. L. 106-170, set out as a note under section 1396a of

this title.

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 effective Aug. 5, 1997, and

applicable to contracts entered into or renewed on or after Oct. 1,

1997, see section 4710 of Pub. L. 105-33, set out as a note under

section 1396b of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-239 applicable, except as otherwise

provided, to payments under this subchapter for calendar quarters

beginning on or after July 1, 1990, without regard to whether or

not final regulations have been promulgated by such date, see

section 6408(d)(5) of Pub. L. 101-239, set out as a note under

section 1396a of this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENT

Section 4101(d)(2) of Pub. L. 100-203 provided that: "The

amendments made by paragraph (1) [amending this section] shall

become effective on July 1, 1988."

Amendment by section 4211(h)(11) of Pub. L. 100-203 applicable to

nursing facility services furnished on or after Oct. 1, 1990,

without regard to whether regulations implementing such amendment

are promulgated by such date, except as otherwise specifically

provided in section 1396r of this title, with transitional rule,

see section 4214(a), (b)(2) of Pub. L. 100-203, as amended, set out

as an Effective Date note under section 1396r of this title.

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by Pub. L. 99-509 applicable to payments under this

subchapter for calendar quarters beginning on or after July 1,

1987, without regard to whether or not final regulations to carry

out such amendments have been promulgated by such date, see section

9403(h) of Pub. L. 99-509, set out as a note under section 1396a of

this title.

Amendment by Pub. L. 99-272 applicable to medical assistance

provided for hospice care furnished on or after Apr. 7, 1986, see

section 9505(e) of Pub. L. 99-272, set out as a note under section

1396a of this title.

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was added by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE

Section 131(d), formerly Sec. 131(c), of Pub. L. 97-248,

redesignated by section 309(a)(8) of Pub. L. 97-448, provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [enacting this section and amending section 1396a of

this title] shall become effective on October 1, 1982.

"(2) In the case of a State plan for medical assistance under

title XIX of the Social Security Act [this subchapter] which the

Secretary of Health and Human Services determines requires State

legislation in order for the plan to meet the additional

requirements imposed by the amendments made by this section, the

State plan shall not be regarded as failing to comply with the

requirements of such title solely on the basis of its failure to

meet these additional requirements before the first day of the

first calendar quarter beginning after the close of the first

regular session of the State legislature that begins after the date

of the enactment of this Act [Sept. 3, 1982]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1396a, 1396b, 1396e,

1396r, 1396r-6, 1397cc of this title; title 8 section 1255a.

-End-

-CITE-

42 USC Sec. 1396p 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396p. Liens, adjustments and recoveries, and transfers of

assets

-STATUTE-

(a) Imposition of lien against property of an individual on account

of medical assistance rendered to him under a State plan

(1) No lien may be imposed against the property of any individual

prior to his death on account of medical assistance paid or to be

paid on his behalf under the State plan, except -

(A) pursuant to the judgment of a court on account of benefits

incorrectly paid on behalf of such individual, or

(B) in the case of the real property of an individual -

(i) who is an inpatient in a nursing facility, intermediate

care facility for the mentally retarded, or other medical

institution, if such individual is required, as a condition of

receiving services in such institution under the State plan, to

spend for costs of medical care all but a minimal amount of his

income required for personal needs, and

(ii) with respect to whom the State determines, after notice

and opportunity for a hearing (in accordance with procedures

established by the State), that he cannot reasonably be

expected to be discharged from the medical institution and to

return home,

except as provided in paragraph (2).

(2) No lien may be imposed under paragraph (1)(B) on such

individual's home if -

(A) the spouse of such individual,

(B) such individual's child who is under age 21, or (with

respect to States eligible to participate in the State program

established under subchapter XVI of this chapter) is blind or

permanently and totally disabled, or (with respect to States

which are not eligible to participate in such program) is blind

or disabled as defined in section 1382c of this title, or

(C) a sibling of such individual (who has an equity interest in

such home and who was residing in such individual's home for a

period of at least one year immediately before the date of the

individual's admission to the medical institution),

is lawfully residing in such home.

(3) Any lien imposed with respect to an individual pursuant to

paragraph (1)(B) shall dissolve upon that individual's discharge

from the medical institution and return home.

(b) Adjustment or recovery of medical assistance correctly paid

under a State plan

(1) No adjustment or recovery of any medical assistance correctly

paid on behalf of an individual under the State plan may be made,

except that the State shall seek adjustment or recovery of any

medical assistance correctly paid on behalf of an individual under

the State plan in the case of the following individuals:

(A) In the case of an individual described in subsection

(a)(1)(B) of this section, the State shall seek adjustment or

recovery from the individual's estate or upon sale of the

property subject to a lien imposed on account of medical

assistance paid on behalf of the individual.

(B) In the case of an individual who was 55 years of age or

older when the individual received such medical assistance, the

State shall seek adjustment or recovery from the individual's

estate, but only for medical assistance consisting of -

(i) nursing facility services, home and community-based

services, and related hospital and prescription drug services,

or

(ii) at the option of the State, any items or services under

the State plan.

(C)(i) In the case of an individual who has received (or is

entitled to receive) benefits under a long-term care insurance

policy in connection with which assets or resources are

disregarded in the manner described in clause (ii), except as

provided in such clause, the State shall seek adjustment or

recovery from the individual's estate on account of medical

assistance paid on behalf of the individual for nursing facility

and other long-term care services.

(ii) Clause (i) shall not apply in the case of an individual

who received medical assistance under a State plan of a State

which had a State plan amendment approved as of May 14, 1993,

which provided for the disregard of any assets or resources -

(I) to the extent that payments are made under a long-term

care insurance policy; or

(II) because an individual has received (or is entitled to

receive) benefits under a long-term care insurance policy.

(2) Any adjustment or recovery under paragraph (1) may be made

only after the death of the individual's surviving spouse, if any,

and only at a time -

(A) when he has no surviving child who is under age 21, or

(with respect to States eligible to participate in the State

program established under subchapter XVI of this chapter) is

blind or permanently and totally disabled, or (with respect to

States which are not eligible to participate in such program) is

blind or disabled as defined in section 1382c of this title; and

(B) in the case of a lien on an individual's home under

subsection (a)(1)(B) of this section, when -

(i) no sibling of the individual (who was residing in the

individual's home for a period of at least one year immediately

before the date of the individual's admission to the medical

institution), and

(ii) no son or daughter of the individual (who was residing

in the individual's home for a period of at least two years

immediately before the date of the individual's admission to

the medical institution, and who establishes to the

satisfaction of the State that he or she provided care to such

individual which permitted such individual to reside at home

rather than in an institution),

is lawfully residing in such home who has lawfully resided in

such home on a continuous basis since the date of the

individual's admission to the medical institution.

(3) The State agency shall establish procedures (in accordance

with standards specified by the Secretary) under which the agency

shall waive the application of this subsection (other than

paragraph (1)(C)) if such application would work an undue hardship

as determined on the basis of criteria established by the

Secretary.

(4) For purposes of this subsection, the term "estate", with

respect to a deceased individual -

(A) shall include all real and personal property and other

assets included within the individual's estate, as defined for

purposes of State probate law; and

(B) may include, at the option of the State (and shall include,

in the case of an individual to whom paragraph (1)(C)(i)

applies), any other real and personal property and other assets

in which the individual had any legal title or interest at the

time of death (to the extent of such interest), including such

assets conveyed to a survivor, heir, or assign of the deceased

individual through joint tenancy, tenancy in common,

survivorship, life estate, living trust, or other arrangement.

(c) Taking into account certain transfers of assets

(1)(A) In order to meet the requirements of this subsection for

purposes of section 1396a(a)(18) of this title, the State plan must

provide that if an institutionalized individual or the spouse of

such an individual (or, at the option of a State, a

noninstitutionalized individual or the spouse of such an

individual) disposes of assets for less than fair market value on

or after the look-back date specified in subparagraph (B)(i), the

individual is ineligible for medical assistance for services

described in subparagraph (C)(i) (or, in the case of a

noninstitutionalized individual, for the services described in

subparagraph (C)(ii)) during the period beginning on the date

specified in subparagraph (D) and equal to the number of months

specified in subparagraph (E).

(B)(i) The look-back date specified in this subparagraph is a

date that is 36 months (or, in the case of payments from a trust or

portions of a trust that are treated as assets disposed of by the

individual pursuant to paragraph (3)(A)(iii) or (3)(B)(ii) of

subsection (d) of this section, 60 months) before the date

specified in clause (ii).

(ii) The date specified in this clause, with respect to -

(I) an institutionalized individual is the first date as of

which the individual both is an institutionalized individual and

has applied for medical assistance under the State plan, or

(II) a noninstitutionalized individual is the date on which the

individual applies for medical assistance under the State plan

or, if later, the date on which the individual disposes of assets

for less than fair market value.

(C)(i) The services described in this subparagraph with respect

to an institutionalized individual are the following:

(I) Nursing facility services.

(II) A level of care in any institution equivalent to that of

nursing facility services.

(III) Home or community-based services furnished under a waiver

granted under subsection (c) or (d) of section 1396n of this

title.

(ii) The services described in this subparagraph with respect to

a noninstitutionalized individual are services (not including any

services described in clause (i)) that are described in paragraph

(7), (22), or (24) of section 1396d(a) of this title, and, at the

option of a State, other long-term care services for which medical

assistance is otherwise available under the State plan to

individuals requiring long-term care.

(D) The date specified in this subparagraph is the first day of

the first month during or after which assets have been transferred

for less than fair market value and which does not occur in any

other periods of ineligibility under this subsection.

(E)(i) With respect to an institutionalized individual, the

number of months of ineligibility under this subparagraph for an

individual shall be equal to -

(I) the total, cumulative uncompensated value of all assets

transferred by the individual (or individual's spouse) on or

after the look-back date specified in subparagraph (B)(i),

divided by

(II) the average monthly cost to a private patient of nursing

facility services in the State (or, at the option of the State,

in the community in which the individual is institutionalized) at

the time of application.

(ii) With respect to a noninstitutionalized individual, the

number of months of ineligibility under this subparagraph for an

individual shall not be greater than a number equal to -

(I) the total, cumulative uncompensated value of all assets

transferred by the individual (or individual's spouse) on or

after the look-back date specified in subparagraph (B)(i),

divided by

(II) the average monthly cost to a private patient of nursing

facility services in the State (or, at the option of the State,

in the community in which the individual is institutionalized) at

the time of application.

(iii) The number of months of ineligibility otherwise determined

under clause (i) or (ii) with respect to the disposal of an asset

shall be reduced -

(I) in the case of periods of ineligibility determined under

clause (i), by the number of months of ineligibility applicable

to the individual under clause (ii) as a result of such disposal,

and

(II) in the case of periods of ineligibility determined under

clause (ii), by the number of months of ineligibility applicable

to the individual under clause (i) as a result of such disposal.

(2) An individual shall not be ineligible for medical assistance

by reason of paragraph (1) to the extent that -

(A) the assets transferred were a home and title to the home

was transferred to -

(i) the spouse of such individual;

(ii) a child of such individual who (I) is under age 21, or

(II) (with respect to States eligible to participate in the

State program established under subchapter XVI of this chapter)

is blind or permanently and totally disabled, or (with respect

to States which are not eligible to participate in such

program) is blind or disabled as defined in section 1382c of

this title;

(iii) a sibling of such individual who has an equity interest

in such home and who was residing in such individual's home for

a period of at least one year immediately before the date the

individual becomes an institutionalized individual; or

(iv) a son or daughter of such individual (other than a child

described in clause (ii)) who was residing in such individual's

home for a period of at least two years immediately before the

date the individual becomes an institutionalized individual,

and who (as determined by the State) provided care to such

individual which permitted such individual to reside at home

rather than in such an institution or facility;

(B) the assets -

(i) were transferred to the individual's spouse or to another

for the sole benefit of the individual's spouse,

(ii) were transferred from the individual's spouse to another

for the sole benefit of the individual's spouse,

(iii) were transferred to, or to a trust (including a trust

described in subsection (d)(4) of this section) established

solely for the benefit of, the individual's child described in

subparagraph (A)(ii)(II), or

(iv) were transferred to a trust (including a trust described

in subsection (d)(4) of this section) established solely for

the benefit of an individual under 65 years of age who is

disabled (as defined in section 1382c(a)(3) of this title);

(C) a satisfactory showing is made to the State (in accordance

with regulations promulgated by the Secretary) that (i) the

individual intended to dispose of the assets either at fair

market value, or for other valuable consideration, (ii) the

assets were transferred exclusively for a purpose other than to

qualify for medical assistance, or (iii) all assets transferred

for less than fair market value have been returned to the

individual; or

(D) the State determines, under procedures established by the

State (in accordance with standards specified by the Secretary),

that the denial of eligibility would work an undue hardship as

determined on the basis of criteria established by the Secretary;

(!1)

(3) For purposes of this subsection, in the case of an asset held

by an individual in common with another person or persons in a

joint tenancy, tenancy in common, or similar arrangement, the asset

(or the affected portion of such asset) shall be considered to be

transferred by such individual when any action is taken, either by

such individual or by any other person, that reduces or eliminates

such individual's ownership or control of such asset.

(4) A State (including a State which has elected treatment under

section 1396a(f) of this title) may not provide for any period of

ineligibility for an individual due to transfer of resources for

less than fair market value except in accordance with this

subsection. In the case of a transfer by the spouse of an

individual which results in a period of ineligibility for medical

assistance under a State plan for such individual, a State shall,

using a reasonable methodology (as specified by the Secretary),

apportion such period of ineligibility (or any portion of such

period) among the individual and the individual's spouse if the

spouse otherwise becomes eligible for medical assistance under the

State plan.

(5) In this subsection, the term "resources" has the meaning

given such term in section 1382b of this title, without regard to

the exclusion described in subsection (a)(1) thereof.

(d) Treatment of trust amounts

(1) For purposes of determining an individual's eligibility for,

or amount of, benefits under a State plan under this subchapter,

subject to paragraph (4), the rules specified in paragraph (3)

shall apply to a trust established by such individual.

(2)(A) For purposes of this subsection, an individual shall be

considered to have established a trust if assets of the individual

were used to form all or part of the corpus of the trust and if any

of the following individuals established such trust other than by

will:

(i) The individual.

(ii) The individual's spouse.

(iii) A person, including a court or administrative body, with

legal authority to act in place of or on behalf of the individual

or the individual's spouse.

(iv) A person, including any court or administrative body,

acting at the direction or upon the request of the individual or

the individual's spouse.

(B) In the case of a trust the corpus of which includes assets of

an individual (as determined under subparagraph (A)) and assets of

any other person or persons, the provisions of this subsection

shall apply to the portion of the trust attributable to the assets

of the individual.

(C) Subject to paragraph (4), this subsection shall apply without

regard to -

(i) the purposes for which a trust is established,

(ii) whether the trustees have or exercise any discretion under

the trust,

(iii) any restrictions on when or whether distributions may be

made from the trust, or

(iv) any restrictions on the use of distributions from the

trust.

(3)(A) In the case of a revocable trust -

(i) the corpus of the trust shall be considered resources

available to the individual,

(ii) payments from the trust to or for the benefit of the

individual shall be considered income of the individual, and

(iii) any other payments from the trust shall be considered

assets disposed of by the individual for purposes of subsection

(c) of this section.

(B) In the case of an irrevocable trust -

(i) if there are any circumstances under which payment from the

trust could be made to or for the benefit of the individual, the

portion of the corpus from which, or the income on the corpus

from which, payment to the individual could be made shall be

considered resources available to the individual, and payments

from that portion of the corpus or income -

(I) to or for the benefit of the individual, shall be

considered income of the individual, and

(II) for any other purpose, shall be considered a transfer of

assets by the individual subject to subsection (c) of this

section; and

(ii) any portion of the trust from which, or any income on the

corpus from which, no payment could under any circumstances be

made to the individual shall be considered, as of the date of

establishment of the trust (or, if later, the date on which

payment to the individual was foreclosed) to be assets disposed

by the individual for purposes of subsection (c) of this section,

and the value of the trust shall be determined for purposes of

such subsection by including the amount of any payments made from

such portion of the trust after such date.

(4) This subsection shall not apply to any of the following

trusts:

(A) A trust containing the assets of an individual under age 65

who is disabled (as defined in section 1382c(a)(3) of this title)

and which is established for the benefit of such individual by a

parent, grandparent, legal guardian of the individual, or a court

if the State will receive all amounts remaining in the trust upon

the death of such individual up to an amount equal to the total

medical assistance paid on behalf of the individual under a State

plan under this subchapter.

(B) A trust established in a State for the benefit of an

individual if -

(i) the trust is composed only of pension, Social Security,

and other income to the individual (and accumulated income in

the trust),

(ii) the State will receive all amounts remaining in the

trust upon the death of such individual up to an amount equal

to the total medical assistance paid on behalf of the

individual under a State plan under this subchapter; and

(iii) the State makes medical assistance available to

individuals described in section 1396a(a)(10)(A)(ii)(V) of this

title, but does not make such assistance available to

individuals for nursing facility services under section

1396a(a)(10)(C) of this title.

(C) A trust containing the assets of an individual who is

disabled (as defined in section 1382c(a)(3) of this title) that

meets the following conditions:

(i) The trust is established and managed by a non-profit

association.

(ii) A separate account is maintained for each beneficiary of

the trust, but, for purposes of investment and management of

funds, the trust pools these accounts.

(iii) Accounts in the trust are established solely for the

benefit of individuals who are disabled (as defined in section

1382c(a)(3) of this title) by the parent, grandparent, or legal

guardian of such individuals, by such individuals, or by a

court.

(iv) To the extent that amounts remaining in the

beneficiary's account upon the death of the beneficiary are not

retained by the trust, the trust pays to the State from such

remaining amounts in the account an amount equal to the total

amount of medical assistance paid on behalf of the beneficiary

under the State plan under this subchapter.

(5) The State agency shall establish procedures (in accordance

with standards specified by the Secretary) under which the agency

waives the application of this subsection with respect to an

individual if the individual establishes that such application

would work an undue hardship on the individual as determined on the

basis of criteria established by the Secretary.

(6) The term "trust" includes any legal instrument or device that

is similar to a trust but includes an annuity only to such extent

and in such manner as the Secretary specifies.

(e) Definitions

In this section, the following definitions shall apply:

(1) The term "assets", with respect to an individual, includes

all income and resources of the individual and of the

individual's spouse, including any income or resources which the

individual or such individual's spouse is entitled to but does

not receive because of action -

(A) by the individual or such individual's spouse,

(B) by a person, including a court or administrative body,

with legal authority to act in place of or on behalf of the

individual or such individual's spouse, or

(C) by any person, including any court or administrative

body, acting at the direction or upon the request of the

individual or such individual's spouse.

(2) The term "income" has the meaning given such term in

section 1382a of this title.

(3) The term "institutionalized individual" means an individual

who is an inpatient in a nursing facility, who is an inpatient in

a medical institution and with respect to whom payment is made

based on a level of care provided in a nursing facility, or who

is described in section 1396a(a)(10)(A)(ii)(VI) of this title.

(4) The term "noninstitutionalized individual" means an

individual receiving any of the services specified in subsection

(c)(1)(C)(ii) of this section.

(5) The term "resources" has the meaning given such term in

section 1382b of this title, without regard (in the case of an

institutionalized individual) to the exclusion described in

subsection (a)(1) of such section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1917, as added Pub. L.

97-248, title I, Sec. 132(b), Sept. 3, 1982, 96 Stat. 370; amended

Pub. L. 97-448, title III, Sec. 309(b)(21), (22), Jan. 12, 1983, 96

Stat. 2410; Pub. L. 100-203, title IV, Sec. 4211(h)(12), Dec. 22,

1987, 101 Stat. 1330-207; Pub. L. 100-360, title III, Sec. 303(b),

title IV, Sec. 411(l)(3)(I), July 1, 1988, 102 Stat. 760, 803; Pub.

L. 100-485, title VI, Sec. 608(d)(16)(B), Oct. 13, 1988, 102 Stat.

2417; Pub. L. 101-239, title VI, Sec. 6411(e)(1), Dec. 19, 1989,

103 Stat. 2271; Pub. L. 103-66, title XIII, Secs. 13611(a)-(c),

13612(a)-(c), Aug. 10, 1993, 107 Stat. 622-628.)

-MISC1-

AMENDMENTS

1993 - Subsec. (b)(1). Pub. L. 103-66, Sec. 13612(a), substituted

"except that the State shall seek adjustment or recovery of any

medical assistance correctly paid on behalf of an individual under

the State plan in the case of the following individuals:" and

subpars. (A) to (C) for "except - " and former subpars. (A) and (B)

which read as follows:

"(A) in the case of an individual described in subsection

(a)(1)(B) of this section, from his estate or upon sale of the

property subject to a lien imposed on account of medical assistance

paid on behalf of such individual, and

"(B) in the case of any other individual who was 65 years of age

or older when he received such assistance, from his estate."

Subsec. (b)(3). Pub. L. 103-66, Sec. 13612(b), added par. (3).

Subsec. (b)(4). Pub. L. 103-66, Sec. 13612(c), added par. (4).

Subsec. (c)(1). Pub. L. 103-66, Sec. 13611(a)(1), amended par.

(1) generally. Prior to amendment, par. (1) read as follows: "In

order to meet the requirements of this subsection (for purposes of

section 1396a(a)(51)(B) of this title), the State plan must provide

for a period of ineligibility for nursing facility services and for

a level of care in a medical institution equivalent to that of

nursing facility services and for services under section 1396n(c)

of this title in the case of an institutionalized individual (as

defined in paragraph (3)) who, or whose spouse, at any time during

or after the 30-month period immediately before the date the

individual becomes an institutionalized individual (if the

individual is entitled to medical assistance under the State plan

on such date) or, if the individual is not so entitled, the date

the individual applies for such assistance while an

institutionalized individual, disposed of resources for less than

fair market value. The period of ineligibility shall begin with the

month in which such resources were transferred and the number of

months in such period shall be equal to the lesser of -

"(A) 30 months, or

"(B)(i) the total uncompensated value of the resources so

transferred, divided by (ii) the average cost, to a private

patient at the time of the application, of nursing facility

services in the State or, at State option, in the community in

which the individual is institutionalized."

Subsec. (c)(2)(A). Pub. L. 103-66, Sec. 13611(a)(2)(A),

substituted "assets" for "resources" in introductory provisions.

Subsec. (c)(2)(B). Pub. L. 103-66, Sec. 13611(a)(2)(B), amended

subpar. (B) generally. Prior to amendment, subpar. (B) read as

follows: "the resources were transferred (i) to or from (or to

another for the sole benefit of) the individual's spouse, or (ii)

to the individual's child described in subparagraph (A)(ii)(II);".

Subsec. (c)(2)(C). Pub. L. 103-66, Sec. 13611(a)(2)(C), in

introductory provisions, substituted "with regulations" for "with

any regulations", in cl. (i), substituted "assets" for "resources"

and struck out "or" at end, in cl. (ii), substituted "assets" for

"resources" and ", or" for "; or", and added cl. (iii).

Subsec. (c)(2)(D). Pub. L. 103-66, Sec. 13611(a)(2)(D), amended

subpar. (D) generally. Prior to amendment, subpar. (D) read as

follows: "the State determines that denial of eligibility would

work an undue hardship."

Subsec. (c)(3). Pub. L. 103-66, Sec. 13611(a)(2)(E), added par.

(3) and struck out former par. (3) which read as follows: "In this

subsection, the term 'institutionalized individual' means an

individual who is an inpatient in a nursing facility, who is an

inpatient in a medical institution and with respect to whom payment

is made based on a level of care provided in a nursing facility, or

who is described in section 1396a(a)(10)(A)(ii)(VI) of this title."

Subsec. (c)(4). Pub. L. 103-66, Sec. 13611(a)(2)(F), inserted at

end "In the case of a transfer by the spouse of an individual which

results in a period of ineligibility for medical assistance under a

State plan for such individual, a State shall, using a reasonable

methodology (as specified by the Secretary), apportion such period

of ineligibility (or any portion of such period) among the

individual and the individual's spouse if the spouse otherwise

becomes eligible for medical assistance under the State plan."

Subsec. (d). Pub. L. 103-66, Sec. 13611(b), added subsec. (d).

Subsec. (e). Pub. L. 103-66, Sec. 13611(c), added subsec. (e).

1989 - Subsec. (c)(1). Pub. L. 101-239, Sec. 6411(e)(1)(A),

inserted "or whose spouse," after "an institutionalized individual

(as defined in paragraph (3)) who,".

Subsec. (c)(2)(B)(i). Pub. L. 101-239, Sec. 6411(e)(1)(B)(i),

amended cl. (i) generally. Prior to amendment, cl. (i) read as

follows: "to (or to another for the sole benefit of) the community

spouse, as defined in section 1396r-5(h)(2) of this title,,".

Subsec. (c)(2)(B)(ii), (iii). Pub. L. 101-239, Sec.

6411(e)(1)(B)(ii), struck out ", or" after "subparagraph

(A)(ii)(II)" in cl. (ii) and struck out cl. (iii) which read as

follows: "to (or to another for the sole benefit of) the

individual's spouse if such spouse does not transfer such resources

to another person other than the spouse for less than fair market

value".

1988 - Subsec. (c). Pub. L. 100-360, Sec. 303(b), amended subsec.

(c) generally, substituting pars. (1) to (4) relating to taking

into account certain transfers of assets, for former pars. (1) to

(3) relating to denial of medical assistance, period of

eligibility, and exceptions.

Subsec. (c)(1). Pub. L. 100-485, Sec. 608(d)(16)(B)(i),

substituted "period of ineligibility for nursing facility services

and for a level of care in a medical institution equivalent to that

of nursing facility services and for services under section

1396n(c) of this title in the case of an institutionalized

individual (as defined in paragraph (3)) who, at any time during or

after the 30-month period immediately before the date the

individual becomes an institutionalized individual (if the

individual is entitled to medical assistance under the State plan

on such date) or, if the individual is not so entitled, the date

the individual applies for such assistance while an

institutionalized individual" for "period of ineligibility in the

case of an institutionalized individual (as defined in paragraph

(3)) who, at any time during the 30-month period immediately before

the individual's application for medical assistance under the State

plan".

Subsec. (c)(2)(A)(ii). Pub. L. 100-485, Sec. 608(d)(16)(B)(ii),

inserted subcl. (I) and (II) designations.

Subsec. (c)(2)(A)(iii). Pub. L. 100-485, Sec. 608(d)(16)(B)(iii),

substituted "the individual becomes an institutionalized

individual" for "of the individual's admission to the medical

institution or nursing facility".

Subsec. (c)(2)(A)(iv). Pub. L. 100-485, Sec. 608(d)(16)(B)(iv),

substituted "the individual becomes an institutionalized

individual" for "of such individual's admission to the medical

institution or nursing facility".

Subsec. (c)(2)(B). Pub. L. 100-485, Sec. 608(d)(16)(B)(v),

inserted cl. (i) designation, substituted "section 1396r-5(h)(2) of

this title,," for "section 1396r-5(h)(2) of this title, or the

individual's child who is blind or permanently and totally

disabled", and added cl. (ii).

Subsec. (c)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(3)(I),

amended Pub. L. 100-203, Sec. 4211(h)(12)(B), see 1987 Amendment

note below.

Subsec. (c)(3). Pub. L. 100-485, Sec. 608(d)(16)(B)(vi),

substituted "in a nursing facility, who is an inpatient in a

medical institution and with respect to whom payment is made based

on a level of care provided in a nursing facility, or who is

described in section 1396a(a)(10)(A)(ii)(VI) of this title" for "in

a medical institution or nursing facility".

Subsec. (c)(5). Pub. L. 100-485, Sec. 608(d)(16)(B)(vii), added

par. (5).

1987 - Subsecs. (a)(1)(B)(i), (c)(2)(B)(i). Pub. L. 100-203, Sec.

4211(h)(12)(A), substituted "nursing facility, intermediate care

facility for the mentally retarded" for "skilled nursing facility,

intermediate care facility".

Subsec. (c)(2)(B)(ii). Pub. L. 100-203, Sec. 4211(h)(12)(B), as

amended by Pub. L. 100-360, Sec. 411(l)(3)(I), substituted "a

nursing facility" for "a skilled nursing facility" in two places

each in subcls. (I) and (II).

1983 - Subsec. (b)(2)(B). Pub. L. 97-448, Sec. 309(b)(21),

substituted "who" for "and" before "has lawfully resided".

Subsec. (c)(2)(B)(iii). Pub. L. 97-448, Sec. 309(b)(22),

substituted in subcl. (I) "can" for "cannot" and struck out from

subcl. (IV) the introductory word "if".

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13611(e) of Pub. L. 103-66 provided that:

"(1) The amendments made by this section [amending this section

and sections 1396a and 1396r-5 of this title] shall apply, except

as provided in this subsection, to payments under title XIX of the

Social Security Act [this subchapter] for calendar quarters

beginning on or after October 1, 1993, without regard to whether or

not final regulations to carry out such amendments have been

promulgated by such date.

"(2) The amendments made by this section shall not apply -

"(A) to medical assistance provided for services furnished

before October 1, 1993,

"(B) with respect to assets disposed of on or before the date

of the enactment of this Act [Aug. 10, 1993], or

"(C) with respect to trusts established on or before the date

of the enactment of this Act.

"(3) In the case of a State plan for medical assistance under

title XIX of the Social Security Act [this subchapter] which the

Secretary of Health and Human Services determines requires State

legislation (other than legislation appropriating funds) in order

for the plan to meet the additional requirements imposed by the

amendment made by subsection (b) [amending this section], the State

plan shall not be regarded as failing to comply with the

requirements imposed by such amendment solely on the basis of its

failure to meet these additional requirements before the first day

of the first calendar quarter beginning after the close of the

first regular session of the State legislature that begins after

the date of the enactment of this Act [Aug. 10, 1993]. For purposes

of the preceding sentence, in the case of a State that has a 2-year

legislative session, each year of such session shall be deemed to

be a separate regular session of the State legislature."

Section 13612(d) of Pub. L. 103-66 provided that:

"(1)(A) Except as provided in subparagraph (B), the amendments

made by this section [amending this section] shall apply to

payments under title XIX of the Social Security Act [this

subchapter] for calendar quarters beginning on or after October 1,

1993, without regard to whether or not final regulations to carry

out such amendments have been promulgated by such date.

"(B) In the case of a State plan for medical assistance under

title XIX of the Social Security Act which the Secretary of Health

and Human Services determines requires State legislation (other

than legislation appropriating funds) in order for the plan to meet

the additional requirements imposed by the amendments made by this

section, the State plan shall not be regarded as failing to comply

with the requirements imposed by such amendments solely on the

basis of its failure to meet these additional requirements before

the first day of the first calendar quarter beginning after the

close of the first regular session of the State legislature that

begins after the date of the enactment of this Act [Aug. 10, 1993].

For purposes of the preceding sentence, in the case of a State that

has a 2-year legislative session, each year of such session shall

be deemed to be a separate regular session of the State

legislature.

"(2) The amendments made by this section shall not apply to

individuals who died before October 1, 1993."

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-239 applicable to transfers occurring

after Dec. 19, 1989, see section 6411(e)(4) of Pub. L. 101-239, set

out as a note under section 1396a of this title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if included in the

enactment of the Medicare Catastrophic Coverage Act of 1988, Pub.

L. 100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Amendment by section 303(b) of Pub. L. 100-360 applicable to

payments under this subchapter for calendar quarters beginning on

or after July 1, 1988 (except in certain situations requiring State

legislative action), without regard to whether or not final

regulations to carry out such amendment have been promulgated by

such date, and subsection (c) of this section, as amended by

section 303(b) of Pub. L. 100-360, applicable to resources disposed

of on or after July 1, 1988, but not applicable with respect to

inter-spousal transfers occurring before Oct. 1, 1989, see section

303(g)(2), (5) of Pub. L. 100-360, set out as an Effective Date

note under section 1396r-5 of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(l)(3)(I) of Pub. L. 100-360, as

it relates to a provision in the Omnibus Budget Reconciliation Act

of 1987, Pub. L. 100-203, effective as if included in the enactment

of that provision in Pub. L. 100-203, see section 411(a) of Pub. L.

100-360, set out as a Reference to OBRA; Effective Date note under

section 106 of Title 1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENT

Amendment by Pub. L. 100-203 applicable to nursing facility

services furnished on or after Oct. 1, 1990, without regard to

whether regulations implementing such amendment are promulgated by

such date, except as otherwise specifically provided in section

1396r of this title, with transitional rule, see section 4214(a),

(b)(2) of Pub. L. 100-203, as amended, set out as an Effective Date

note under section 1396r of this title.

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was added by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE

Section 132(d) of Pub. L. 97-248 provided that: "The amendments

made by this section [enacting this section and amending section

1396a of this title] shall become effective on the date of the

enactment of this Act [Sept. 3, 1982], but the provisions of

section 1917(c)(2)(B) of the Social Security Act [subsec. (c)(2)(B)

of this section] shall not apply with respect to a transfer of

assets which took place prior to such date of enactment."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1320a-7b, 1382, 1382b,

1396a, 1396r-5 of this title; title 26 section 642.

-FOOTNOTE-

(!1) So in original. The semicolon probably should be a period.

-End-

-CITE-

42 USC Sec. 1396q 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396q. Application of provisions of subchapter II relating to

subpoenas

-STATUTE-

The provisions of subsections (d) and (e) of section 405 of this

title shall apply with respect to this subchapter to the same

extent as they are applicable with respect to subchapter II of this

chapter, except that, in so applying such subsections, and in

applying section 405(l) of this title thereto, with respect to this

subchapter, any reference therein to the Commissioner of Social

Security or the Social Security Administration shall be considered

a reference to the Secretary or the Department of Health and Human

Services, respectively.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1918, as added Pub. L.

98-369, div. B, title III, Sec. 2370(a), July 18, 1984, 98 Stat.

1110; amended Pub. L. 103-296, title I, Sec. 108(d)(5), Aug. 15,

1994, 108 Stat. 1486.)

-MISC1-

AMENDMENTS

1994 - Pub. L. 103-296 inserted before period at end ", except

that, in so applying such subsections, and in applying section

405(l) of this title thereto, with respect to this subchapter, any

reference therein to the Commissioner of Social Security or the

Social Security Administration shall be considered a reference to

the Secretary or the Department of Health and Human Services,

respectively".

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE

Section 2370(b) of Pub. L. 98-369 provided that: "The amendment

made by this section [enacting this section] shall become effective

on the date of the enactment of this Act [July 18, 1984]."

-End-

-CITE-

42 USC Sec. 1396r 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r. Requirements for nursing facilities

-STATUTE-

(a) "Nursing facility" defined

In this subchapter, the term "nursing facility" means an

institution (or a distinct part of an institution) which -

(1) is primarily engaged in providing to residents -

(A) skilled nursing care and related services for residents

who require medical or nursing care,

(B) rehabilitation services for the rehabilitation of

injured, disabled, or sick persons, or

(C) on a regular basis, health-related care and services to

individuals who because of their mental or physical condition

require care and services (above the level of room and board)

which can be made available to them only through institutional

facilities,

and is not primarily for the care and treatment of mental

diseases;

(2) has in effect a transfer agreement (meeting the

requirements of section 1395x(l) of this title) with one or more

hospitals having agreements in effect under section 1395cc of

this title; and

(3) meets the requirements for a nursing facility described in

subsections (b), (c), and (d) of this section.

Such term also includes any facility which is located in a State on

an Indian reservation and is certified by the Secretary as meeting

the requirements of paragraph (1) and subsections (b), (c), and (d)

of this section.

(b) Requirements relating to provision of services

(1) Quality of life

(A) In general

A nursing facility must care for its residents in such a

manner and in such an environment as will promote maintenance

or enhancement of the quality of life of each resident.

(B) Quality assessment and assurance

A nursing facility must maintain a quality assessment and

assurance committee, consisting of the director of nursing

services, a physician designated by the facility, and at least

3 other members of the facility's staff, which (i) meets at

least quarterly to identify issues with respect to which

quality assessment and assurance activities are necessary and

(ii) develops and implements appropriate plans of action to

correct identified quality deficiencies. A State or the

Secretary may not require disclosure of the records of such

committee except insofar as such disclosure is related to the

compliance of such committee with the requirements of this

subparagraph.

(2) Scope of services and activities under plan of care

A nursing facility must provide services and activities to

attain or maintain the highest practicable physical, mental, and

psychosocial well-being of each resident in accordance with a

written plan of care which -

(A) describes the medical, nursing, and psychosocial needs of

the resident and how such needs will be met;

(B) is initially prepared, with the participation to the

extent practicable of the resident or the resident's family or

legal representative, by a team which includes the resident's

attending physician and a registered professional nurse with

responsibility for the resident; and

(C) is periodically reviewed and revised by such team after

each assessment under paragraph (3).

(3) Residents' assessment

(A) Requirement

A nursing facility must conduct a comprehensive, accurate,

standardized, reproducible assessment of each resident's

functional capacity, which assessment -

(i) describes the resident's capability to perform daily

life functions and significant impairments in functional

capacity;

(ii) is based on a uniform minimum data set specified by

the Secretary under subsection (f)(6)(A) of this section;

(iii) uses an instrument which is specified by the State

under subsection (e)(5) of this section; and

(iv) includes the identification of medical problems.

(B) Certification

(i) In general

Each such assessment must be conducted or coordinated (with

the appropriate participation of health professionals) by a

registered professional nurse who signs and certifies the

completion of the assessment. Each individual who completes a

portion of such an assessment shall sign and certify as to

the accuracy of that portion of the assessment.

(ii) Penalty for falsification

(I) An individual who willfully and knowingly certifies

under clause (i) a material and false statement in a resident

assessment is subject to a civil money penalty of not more

than $1,000 with respect to each assessment.

(II) An individual who willfully and knowingly causes

another individual to certify under clause (i) a material and

false statement in a resident assessment is subject to a

civil money penalty of not more than $5,000 with respect to

each assessment.

(III) The provisions of section 1320a-7a of this title

(other than subsections (a) and (b)) shall apply to a civil

money penalty under this clause in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title.

(iii) Use of independent assessors

If a State determines, under a survey under subsection (g)

of this section or otherwise, that there has been a knowing

and willful certification of false assessments under this

paragraph, the State may require (for a period specified by

the State) that resident assessments under this paragraph be

conducted and certified by individuals who are independent of

the facility and who are approved by the State.

(C) Frequency

(i) In general

Such an assessment must be conducted -

(I) promptly upon (but no later than 14 days after the

date of) admission for each individual admitted on or after

October 1, 1990, and by not later than October 1, 1991, for

each resident of the facility on that date;

(II) promptly after a significant change in the

resident's physical or mental condition; and

(III) in no case less often than once every 12 months.

(ii) Resident review

The nursing facility must examine each resident no less

frequently than once every 3 months and, as appropriate,

revise the resident's assessment to assure the continuing

accuracy of the assessment.

(D) Use

The results of such an assessment shall be used in

developing, reviewing, and revising the resident's plan of care

under paragraph (2).

(E) Coordination

Such assessments shall be coordinated with any State-required

preadmission screening program to the maximum extent

practicable in order to avoid duplicative testing and effort.

In addition, a nursing facility shall notify the State mental

health authority or State mental retardation or developmental

disability authority, as applicable, promptly after a

significant change in the physical or mental condition of a

resident who is mentally ill or mentally retarded.

(F) Requirements relating to preadmission screening for

mentally ill and mentally retarded individuals

Except as provided in clauses (ii) and (iii) of subsection

(e)(7)(A) of this section, a nursing facility must not admit,

on or after January 1, 1989, any new resident who -

(i) is mentally ill (as defined in subsection (e)(7)(G)(i)

of this section) unless the State mental health authority has

determined (based on an independent physical and mental

evaluation performed by a person or entity other than the

State mental health authority) prior to admission that,

because of the physical and mental condition of the

individual, the individual requires the level of services

provided by a nursing facility, and, if the individual

requires such level of services, whether the individual

requires specialized services for mental illness, or

(ii) is mentally retarded (as defined in subsection

(e)(7)(G)(ii) of this section) unless the State mental

retardation or developmental disability authority has

determined prior to admission that, because of the physical

and mental condition of the individual, the individual

requires the level of services provided by a nursing

facility, and, if the individual requires such level of

services, whether the individual requires specialized

services for mental retardation.

A State mental health authority and a State mental retardation

or developmental disability authority may not delegate (by

subcontract or otherwise) their responsibilities under this

subparagraph to a nursing facility (or to an entity that has a

direct or indirect affiliation or relationship with such a

facility).

(4) Provision of services and activities

(A) In general

To the extent needed to fulfill all plans of care described

in paragraph (2), a nursing facility must provide (or arrange

for the provision of) -

(i) nursing and related services and specialized

rehabilitative services to attain or maintain the highest

practicable physical, mental, and psychosocial well-being of

each resident;

(ii) medically-related social services to attain or

maintain the highest practicable physical, mental, and

psychosocial well-being of each resident;

(iii) pharmaceutical services (including procedures that

assure the accurate acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to meet the needs

of each resident;

(iv) dietary services that assure that the meals meet the

daily nutritional and special dietary needs of each resident;

(v) an on-going program, directed by a qualified

professional, of activities designed to meet the interests

and the physical, mental, and psychosocial well-being of each

resident;

(vi) routine dental services (to the extent covered under

the State plan) and emergency dental services to meet the

needs of each resident; and

(vii) treatment and services required by mentally ill and

mentally retarded residents not otherwise provided or

arranged for (or required to be provided or arranged for) by

the State.

The services provided or arranged by the facility must meet

professional standards of quality.

(B) Qualified persons providing services

Services described in clauses (i), (ii), (iii), (iv), and

(vi) of subparagraph (A) must be provided by qualified persons

in accordance with each resident's written plan of care.

(C) Required nursing care; facility waivers

(i) General requirements

With respect to nursing facility services provided on or

after October 1, 1990, a nursing facility -

(I) except as provided in clause (ii), must provide

24-hour licensed nursing services which are sufficient to

meet the nursing needs of its residents, and

(II) except as provided in clause (ii), must use the

services of a registered professional nurse for at least 8

consecutive hours a day, 7 days a week.

(ii) Waiver by State

To the extent that a facility is unable to meet the

requirements of clause (i), a State may waive such

requirements with respect to the facility if -

(I) the facility demonstrates to the satisfaction of the

State that the facility has been unable, despite diligent

efforts (including offering wages at the community

prevailing rate for nursing facilities), to recruit

appropriate personnel,

(II) the State determines that a waiver of the

requirement will not endanger the health or safety of

individuals staying in the facility,

(III) the State finds that, for any such periods in which

licensed nursing services are not available, a registered

professional nurse or a physician is obligated to respond

immediately to telephone calls from the facility,

(IV) the State agency granting a waiver of such

requirements provides notice of the waiver to the State

long-term care ombudsman (established under section

307(a)(12) (!1) of the Older Americans Act of 1965) and the

protection and advocacy system in the State for the

mentally ill and the mentally retarded, and

(V) the nursing facility that is granted such a waiver by

a State notifies residents of the facility (or, where

appropriate, the guardians or legal representatives of such

residents) and members of their immediate families of the

waiver.

A waiver under this clause shall be subject to annual review

and to the review of the Secretary and subject to clause

(iii) shall be accepted by the Secretary for purposes of this

subchapter to the same extent as is the State's certification

of the facility. In granting or renewing a waiver, a State

may require the facility to use other qualified, licensed

personnel.

(iii) Assumption of waiver authority by Secretary

If the Secretary determines that a State has shown a clear

pattern and practice of allowing waivers in the absence of

diligent efforts by facilities to meet the staffing

requirements, the Secretary shall assume and exercise the

authority of the State to grant waivers.

(5) Required training of nurse aides

(A) In general

(i) Except as provided in clause (ii), a nursing facility

must not use on a full-time basis any individual as a nurse

aide in the facility on or after October 1, 1990, for more than

4 months unless the individual -

(I) has completed a training and competency evaluation

program, or a competency evaluation program, approved by the

State under subsection (e)(1)(A) of this section, and

(II) is competent to provide nursing or nursing-related

services.

(ii) A nursing facility must not use on a temporary, per

diem, leased, or on any other basis other than as a permanent

employee any individual as a nurse aide in the facility on or

after January 1, 1991, unless the individual meets the

requirements described in clause (i).

(B) Offering competency evaluation programs for current

employees

A nursing facility must provide, for individuals used as a

nurse aide by the facility as of January 1, 1990, for a

competency evaluation program approved by the State under

subsection (e)(1) of this section and such preparation as may

be necessary for the individual to complete such a program by

October 1, 1990.

(C) Competency

The nursing facility must not permit an individual, other

than in a training and competency evaluation program approved

by the State, to serve as a nurse aide or provide services of a

type for which the individual has not demonstrated competency

and must not use such an individual as a nurse aide unless the

facility has inquired of any State registry established under

subsection (e)(2)(A) of this section that the facility believes

will include information concerning the individual.

(D) Re-training required

For purposes of subparagraph (A), if, since an individual's

most recent completion of a training and competency evaluation

program, there has been a continuous period of 24 consecutive

months during none of which the individual performed nursing or

nursing-related services for monetary compensation, such

individual shall complete a new training and competency

evaluation program, or a new competency evaluation program.

(E) Regular in-service education

The nursing facility must provide such regular performance

review and regular in-service education as assures that

individuals used as nurse aides are competent to perform

services as nurse aides, including training for individuals

providing nursing and nursing-related services to residents

with cognitive impairments.

(F) "Nurse aide" defined

In this paragraph, the term "nurse aide" means any individual

providing nursing or nursing-related services to residents in a

nursing facility, but does not include an individual -

(i) who is a licensed health professional (as defined in

subparagraph (G)) or a registered dietician, or

(ii) who volunteers to provide such services without

monetary compensation.

(G) Licensed health professional defined

In this paragraph, the term "licensed health professional"

means a physician, physician assistant, nurse practitioner,

physical, speech, or occupational therapist, physical or

occupational therapy assistant, registered professional nurse,

licensed practical nurse, or licensed or certified social

worker.

(6) Physician supervision and clinical records

A nursing facility must -

(A) require that the health care of every resident be

provided under the supervision of a physician (or, at the

option of a State, under the supervision of a nurse

practitioner, clinical nurse specialist, or physician assistant

who is not an employee of the facility but who is working in

collaboration with a physician);

(B) provide for having a physician available to furnish

necessary medical care in case of emergency; and

(C) maintain clinical records on all residents, which records

include the plans of care (described in paragraph (2)) and the

residents' assessments (described in paragraph (3)), as well as

the results of any pre-admission screening conducted under

subsection (e)(7) of this section.

(7) Required social services

In the case of a nursing facility with more than 120 beds, the

facility must have at least one social worker (with at least a

bachelor's degree in social work or similar professional

qualifications) employed full-time to provide or assure the

provision of social services.

(8) Information on nurse staffing

(A) In general

A nursing facility shall post daily for each shift the

current number of licensed and unlicensed nursing staff

directly responsible for resident care in the facility. The

information shall be displayed in a uniform manner (as

specified by the Secretary) and in a clearly visible place.

(B) Publication of data

A nursing facility shall, upon request, make available to the

public the nursing staff data described in subparagraph (A).

(c) Requirements relating to residents' rights

(1) General rights

(A) Specified rights

A nursing facility must protect and promote the rights of

each resident, including each of the following rights:

(i) Free choice

The right to choose a personal attending physician, to be

fully informed in advance about care and treatment, to be

fully informed in advance of any changes in care or treatment

that may affect the resident's well-being, and (except with

respect to a resident adjudged incompetent) to participate in

planning care and treatment or changes in care and treatment.

(ii) Free from restraints

The right to be free from physical or mental abuse,

corporal punishment, involuntary seclusion, and any physical

or chemical restraints imposed for purposes of discipline or

convenience and not required to treat the resident's medical

symptoms. Restraints may only be imposed -

(I) to ensure the physical safety of the resident or

other residents, and

(II) only upon the written order of a physician that

specifies the duration and circumstances under which the

restraints are to be used (except in emergency

circumstances specified by the Secretary until such an

order could reasonably be obtained).

(iii) Privacy

The right to privacy with regard to accommodations, medical

treatment, written and telephonic communications, visits, and

meetings of family and of resident groups.

(iv) Confidentiality

The right to confidentiality of personal and clinical

records and to access to current clinical records of the

resident upon request by the resident or the resident's legal

representative, within 24 hours (excluding hours occurring

during a weekend or holiday) after making such a request.

(v) Accommodation of needs

The right -

(I) to reside and receive services with reasonable

accommodation of individual needs and preferences, except

where the health or safety of the individual or other

residents would be endangered, and

(II) to receive notice before the room or roommate of the

resident in the facility is changed.

(vi) Grievances

The right to voice grievances with respect to treatment or

care that is (or fails to be) furnished, without

discrimination or reprisal for voicing the grievances and the

right to prompt efforts by the facility to resolve grievances

the resident may have, including those with respect to the

behavior of other residents.

(vii) Participation in resident and family groups

The right of the resident to organize and participate in

resident groups in the facility and the right of the

resident's family to meet in the facility with the families

of other residents in the facility.

(viii) Participation in other activities

The right of the resident to participate in social,

religious, and community activities that do not interfere

with the rights of other residents in the facility.

(ix) Examination of survey results

The right to examine, upon reasonable request, the results

of the most recent survey of the facility conducted by the

Secretary or a State with respect to the facility and any

plan of correction in effect with respect to the facility.

(x) Refusal of certain transfers

The right to refuse a transfer to another room within the

facility, if a purpose of the transfer is to relocate the

resident from a portion of the facility that is not a skilled

nursing facility (for purposes of subchapter XVIII of this

chapter) to a portion of the facility that is such a skilled

nursing facility.

(xi) Other rights

Any other right established by the Secretary.

Clause (iii) shall not be construed as requiring the provision

of a private room. A resident's exercise of a right to refuse

transfer under clause (x) shall not affect the resident's

eligibility or entitlement to medical assistance under this

subchapter or a State's entitlement to Federal medical

assistance under this subchapter with respect to services

furnished to such a resident.

(B) Notice of rights

A nursing facility must -

(i) inform each resident, orally and in writing at the time

of admission to the facility, of the resident's legal rights

during the stay at the facility and of the requirements and

procedures for establishing eligibility for medical

assistance under this subchapter, including the right to

request an assessment under section 1396r-5(c)(1)(B) of this

title;

(ii) make available to each resident, upon reasonable

request, a written statement of such rights (which statement

is updated upon changes in such rights) including the notice

(if any) of the State developed under subsection (e)(6) of

this section;

(iii) inform each resident who is entitled to medical

assistance under this subchapter -

(I) at the time of admission to the facility or, if

later, at the time the resident becomes eligible for such

assistance, of the items and services (including those

specified under section 1396a(a)(28)(B) of this title) that

are included in nursing facility services under the State

plan and for which the resident may not be charged (except

as permitted in section 1396o of this title), and of those

other items and services that the facility offers and for

which the resident may be charged and the amount of the

charges for such items and services, and

(II) of changes in the items and services described in

subclause (I) and of changes in the charges imposed for

items and services described in that subclause; and

(iv) inform each other resident, in writing before or at

the time of admission and periodically during the resident's

stay, of services available in the facility and of related

charges for such services, including any charges for services

not covered under subchapter XVIII of this chapter or by the

facility's basic per diem charge.

The written description of legal rights under this subparagraph

shall include a description of the protection of personal funds

under paragraph (6) and a statement that a resident may file a

complaint with a State survey and certification agency

respecting resident abuse and neglect and misappropriation of

resident property in the facility.

(C) Rights of incompetent residents

In the case of a resident adjudged incompetent under the laws

of a State, the rights of the resident under this subchapter

shall devolve upon, and, to the extent judged necessary by a

court of competent jurisdiction, be exercised by, the person

appointed under State law to act on the resident's behalf.

(D) Use of psychopharmacologic drugs

Psychopharmacologic drugs may be administered only on the

orders of a physician and only as part of a plan (included in

the written plan of care described in paragraph (2)) designed

to eliminate or modify the symptoms for which the drugs are

prescribed and only if, at least annually an independent,

external consultant reviews the appropriateness of the drug

plan of each resident receiving such drugs.

(2) Transfer and discharge rights

(A) In general

A nursing facility must permit each resident to remain in the

facility and must not transfer or discharge the resident from

the facility unless -

(i) the transfer or discharge is necessary to meet the

resident's welfare and the resident's welfare cannot be met

in the facility;

(ii) the transfer or discharge is appropriate because the

resident's health has improved sufficiently so the resident

no longer needs the services provided by the facility;

(iii) the safety of individuals in the facility is

endangered;

(iv) the health of individuals in the facility would

otherwise be endangered;

(v) the resident has failed, after reasonable and

appropriate notice, to pay (or to have paid under this

subchapter or subchapter XVIII of this chapter on the

resident's behalf) for a stay at the facility; or

(vi) the facility ceases to operate.

In each of the cases described in clauses (i) through (iv), the

basis for the transfer or discharge must be documented in the

resident's clinical record. In the cases described in clauses

(i) and (ii), the documentation must be made by the resident's

physician, and in the case described in clause (iv) the

documentation must be made by a physician. For purposes of

clause (v), in the case of a resident who becomes eligible for

assistance under this subchapter after admission to the

facility, only charges which may be imposed under this

subchapter shall be considered to be allowable.

(B) Pre-transfer and pre-discharge notice

(i) In general

Before effecting a transfer or discharge of a resident, a

nursing facility must -

(I) notify the resident (and, if known, an immediate

family member of the resident or legal representative) of

the transfer or discharge and the reasons therefor,

(II) record the reasons in the resident's clinical record

(including any documentation required under subparagraph

(A)), and

(III) include in the notice the items described in clause

(iii).

(ii) Timing of notice

The notice under clause (i)(I) must be made at least 30

days in advance of the resident's transfer or discharge

except -

(I) in a case described in clause (iii) or (iv) of

subparagraph (A);

(II) in a case described in clause (ii) of subparagraph

(A), where the resident's health improves sufficiently to

allow a more immediate transfer or discharge;

(III) in a case described in clause (i) of subparagraph

(A), where a more immediate transfer or discharge is

necessitated by the resident's urgent medical needs; or

(IV) in a case where a resident has not resided in the

facility for 30 days.

In the case of such exceptions, notice must be given as many

days before the date of the transfer or discharge as is

practicable.

(iii) Items included in notice

Each notice under clause (i) must include -

(I) for transfers or discharges effected on or after

October 1, 1989, notice of the resident's right to appeal

the transfer or discharge under the State process

established under subsection (e)(3) of this section;

(II) the name, mailing address, and telephone number of

the State long-term care ombudsman (established under title

III or VII of the Older Americans Act of 1965 [42 U.S.C.

3021 et seq., 3058 et seq.] in accordance with section 712

of the Act [42 U.S.C. 3058g]);

(III) in the case of residents with developmental

disabilities, the mailing address and telephone number of

the agency responsible for the protection and advocacy

system for developmentally disabled individuals established

under subtitle C of the Developmental Disabilities

Assistance and Bill of Rights Act of 2000 [42 U.S.C. 15041

et seq.]; and

(IV) in the case of mentally ill residents (as defined in

subsection (e)(7)(G)(i) of this section), the mailing

address and telephone number of the agency responsible for

the protection and advocacy system for mentally ill

individuals established under the Protection and Advocacy

for Mentally Ill Individuals Act (!2) [42 U.S.C. 10801 et

seq.].

(C) Orientation

A nursing facility must provide sufficient preparation and

orientation to residents to ensure safe and orderly transfer or

discharge from the facility.

(D) Notice on bed-hold policy and readmission

(i) Notice before transfer

Before a resident of a nursing facility is transferred for

hospitalization or therapeutic leave, a nursing facility must

provide written information to the resident and an immediate

family member or legal representative concerning -

(I) the provisions of the State plan under this

subchapter regarding the period (if any) during which the

resident will be permitted under the State plan to return

and resume residence in the facility, and

(II) the policies of the facility regarding such a

period, which policies must be consistent with clause

(iii).

(ii) Notice upon transfer

At the time of transfer of a resident to a hospital or for

therapeutic leave, a nursing facility must provide written

notice to the resident and an immediate family member or

legal representative of the duration of any period described

in clause (i).

(iii) Permitting resident to return

A nursing facility must establish and follow a written

policy under which a resident -

(I) who is eligible for medical assistance for nursing

facility services under a State plan,

(II) who is transferred from the facility for

hospitalization or therapeutic leave, and

(III) whose hospitalization or therapeutic leave exceeds

a period paid for under the State plan for the holding of a

bed in the facility for the resident,

will be permitted to be readmitted to the facility

immediately upon the first availability of a bed in a

semiprivate room in the facility if, at the time of

readmission, the resident requires the services provided by

the facility.

(E) Information respecting advance directives

A nursing facility must comply with the requirement of

section 1396a(w) of this title (relating to maintaining written

policies and procedures respecting advance directives).

(F) Continuing rights in case of voluntary withdrawal from

participation

(i) In general

In the case of a nursing facility that voluntarily

withdraws from participation in a State plan under this

subchapter but continues to provide services of the type

provided by nursing facilities -

(I) the facility's voluntary withdrawal from

participation is not an acceptable basis for the transfer

or discharge of residents of the facility who were residing

in the facility on the day before the effective date of the

withdrawal (including those residents who were not entitled

to medical assistance as of such day);

(II) the provisions of this section continue to apply to

such residents until the date of their discharge from the

facility; and

(III) in the case of each individual who begins residence

in the facility after the effective date of such

withdrawal, the facility shall provide notice orally and in

a prominent manner in writing on a separate page at the

time the individual begins residence of the information

described in clause (ii) and shall obtain from each such

individual at such time an acknowledgment of receipt of

such information that is in writing, signed by the

individual, and separate from other documents signed by

such individual.

Nothing in this subparagraph shall be construed as affecting

any requirement of a participation agreement that a nursing

facility provide advance notice to the State or the

Secretary, or both, of its intention to terminate the

agreement.

(ii) Information for new residents

The information described in this clause for a resident is

the following:

(I) The facility is not participating in the program

under this subchapter with respect to that resident.

(II) The facility may transfer or discharge the resident

from the facility at such time as the resident is unable to

pay the charges of the facility, even though the resident

may have become eligible for medical assistance for nursing

facility services under this subchapter.

(iii) Continuation of payments and oversight authority

Notwithstanding any other provision of this subchapter,

with respect to the residents described in clause (i)(I), a

participation agreement of a facility described in clause (i)

is deemed to continue in effect under such plan after the

effective date of the facility's voluntary withdrawal from

participation under the State plan for purposes of -

(I) receiving payments under the State plan for nursing

facility services provided to such residents;

(II) maintaining compliance with all applicable

requirements of this subchapter; and

(III) continuing to apply the survey, certification, and

enforcement authority provided under subsections (g) and

(h) of this section (including involuntary termination of a

participation agreement deemed continued under this

clause).

(iv) No application to new residents

This paragraph (other than subclause (III) of clause (i))

shall not apply to an individual who begins residence in a

facility on or after the effective date of the withdrawal

from participation under this subparagraph.

(3) Access and visitation rights

A nursing facility must -

(A) permit immediate access to any resident by any

representative of the Secretary, by any representative of the

State, by an ombudsman or agency described in subclause (II),

(III), or (IV) of paragraph (2)(B)(iii), or by the resident's

individual physician;

(B) permit immediate access to a resident, subject to the

resident's right to deny or withdraw consent at any time, by

immediate family or other relatives of the resident;

(C) permit immediate access to a resident, subject to

reasonable restrictions and the resident's right to deny or

withdraw consent at any time, by others who are visiting with

the consent of the resident;

(D) permit reasonable access to a resident by any entity or

individual that provides health, social, legal, or other

services to the resident, subject to the resident's right to

deny or withdraw consent at any time; and

(E) permit representatives of the State ombudsman (described

in paragraph (2)(B)(iii)(II)), with the permission of the

resident (or the resident's legal representative) and

consistent with State law, to examine a resident's clinical

records.

(4) Equal access to quality care

(A) In general

A nursing facility must establish and maintain identical

policies and practices regarding transfer, discharge, and the

provision of services required under the State plan for all

individuals regardless of source of payment.

(B) Construction

(i) Nothing prohibiting any charges for non-medicaid patients

Subparagraph (A) shall not be construed as prohibiting a

nursing facility from charging any amount for services

furnished, consistent with the notice in paragraph (1)(B)

describing such charges.

(ii) No additional services required

Subparagraph (A) shall not be construed as requiring a

State to offer additional services on behalf of a resident

than are otherwise provided under the State plan.

(5) Admissions policy

(A) Admissions

With respect to admissions practices, a nursing facility must

-

(i)(I) not require individuals applying to reside or

residing in the facility to waive their rights to benefits

under this subchapter or subchapter XVIII of this chapter,

(II) not require oral or written assurance that such

individuals are not eligible for, or will not apply for,

benefits under this subchapter or subchapter XVIII of this

chapter, and (III) prominently display in the facility

written information, and provide to such individuals oral and

written information, about how to apply for and use such

benefits and how to receive refunds for previous payments

covered by such benefits;

(ii) not require a third party guarantee of payment to the

facility as a condition of admission (or expedited admission)

to, or continued stay in, the facility; and

(iii) in the case of an individual who is entitled to

medical assistance for nursing facility services, not charge,

solicit, accept, or receive, in addition to any amount

otherwise required to be paid under the State plan under this

subchapter, any gift, money, donation, or other consideration

as a precondition of admitting (or expediting the admission

of) the individual to the facility or as a requirement for

the individual's continued stay in the facility.

(B) Construction

(i) No preemption of stricter standards

Subparagraph (A) shall not be construed as preventing

States or political subdivisions therein from prohibiting,

under State or local law, the discrimination against

individuals who are entitled to medical assistance under the

State plan with respect to admissions practices of nursing

facilities.

(ii) Contracts with legal representatives

Subparagraph (A)(ii) shall not be construed as preventing a

facility from requiring an individual, who has legal access

to a resident's income or resources available to pay for care

in the facility, to sign a contract (without incurring

personal financial liability) to provide payment from the

resident's income or resources for such care.

(iii) Charges for additional services requested

Subparagraph (A)(iii) shall not be construed as preventing

a facility from charging a resident, eligible for medical

assistance under the State plan, for items or services the

resident has requested and received and that are not

specified in the State plan as included in the term "nursing

facility services".

(iv) Bona fide contributions

Subparagraph (A)(iii) shall not be construed as prohibiting

a nursing facility from soliciting, accepting, or receiving a

charitable, religious, or philanthropic contribution from an

organization or from a person unrelated to the resident (or

potential resident), but only to the extent that such

contribution is not a condition of admission, expediting

admission, or continued stay in the facility.

(6) Protection of resident funds

(A) In general

The nursing facility -

(i) may not require residents to deposit their personal

funds with the facility, and

(ii) upon the written authorization of the resident, must

hold, safeguard, and account for such personal funds under a

system established and maintained by the facility in

accordance with this paragraph.

(B) Management of personal funds

Upon written authorization of a resident under subparagraph

(A)(ii), the facility must manage and account for the personal

funds of the resident deposited with the facility as follows:

(i) Deposit

The facility must deposit any amount of personal funds in

excess of $50 with respect to a resident in an interest

bearing account (or accounts) that is separate from any of

the facility's operating accounts and credits all interest

earned on such separate account to such account. With respect

to any other personal funds, the facility must maintain such

funds in a non-interest bearing account or petty cash fund.

(ii) Accounting and records

The facility must assure a full and complete separate

accounting of each such resident's personal funds, maintain a

written record of all financial transactions involving the

personal funds of a resident deposited with the facility, and

afford the resident (or a legal representative of the

resident) reasonable access to such record.

(iii) Notice of certain balances

The facility must notify each resident receiving medical

assistance under the State plan under this subchapter when

the amount in the resident's account reaches $200 less than

the dollar amount determined under section 1382(a)(3)(B) of

this title and the fact that if the amount in the account (in

addition to the value of the resident's other nonexempt

resources) reaches the amount determined under such section

the resident may lose eligibility for such medical assistance

or for benefits under subchapter XVI of this chapter.

(iv) Conveyance upon death

Upon the death of a resident with such an account, the

facility must convey promptly the resident's personal funds

(and a final accounting of such funds) to the individual

administering the resident's estate.

(C) Assurance of financial security

The facility must purchase a surety bond, or otherwise

provide assurance satisfactory to the Secretary, to assure the

security of all personal funds of residents deposited with the

facility.

(D) Limitation on charges to personal funds

The facility may not impose a charge against the personal

funds of a resident for any item or service for which payment

is made under this subchapter or subchapter XVIII of this

chapter.

(7) Limitation on charges in case of medicaid-eligible

individuals

(A) In general

A nursing facility may not impose charges, for certain

medicaid-eligible individuals for nursing facility services

covered by the State under its plan under this subchapter, that

exceed the payment amounts established by the State for such

services under this subchapter.

(B) "Certain medicaid-eligible individual" defined

In subparagraph (A), the term "certain medicaid-eligible

individual" means an individual who is entitled to medical

assistance for nursing facility services in the facility under

this subchapter but with respect to whom such benefits are not

being paid because, in determining the amount of the

individual's income to be applied monthly to payment for the

costs of such services, the amount of such income exceeds the

payment amounts established by the State for such services

under this subchapter.

(8) Posting of survey results

A nursing facility must post in a place readily accessible to

residents, and family members and legal representatives of

residents, the results of the most recent survey of the facility

conducted under subsection (g) of this section.

(d) Requirements relating to administration and other matters

(1) Administration

(A) In general

A nursing facility must be administered in a manner that

enables it to use its resources effectively and efficiently to

attain or maintain the highest practicable physical, mental,

and psychosocial well-being of each resident (consistent with

requirements established under subsection (f)(5) of this

section).

(B) Required notices

If a change occurs in -

(i) the persons with an ownership or control interest (as

defined in section 1320a-3(a)(3) of this title) in the

facility,

(ii) the persons who are officers, directors, agents, or

managing employees (as defined in section 1320a-5(b) of this

title) of the facility,

(iii) the corporation, association, or other company

responsible for the management of the facility, or

(iv) the individual who is the administrator or director of

nursing of the facility,

the nursing facility must provide notice to the State agency

responsible for the licensing of the facility, at the time of

the change, of the change and of the identity of each new

person, company, or individual described in the respective

clause.

(C) Nursing facility administrator

The administrator of a nursing facility must meet standards

established by the Secretary under subsection (f)(4) of this

section.

(2) Licensing and Life Safety Code

(A) Licensing

A nursing facility must be licensed under applicable State

and local law.

(B) Life Safety Code

A nursing facility must meet such provisions of such edition

(as specified by the Secretary in regulation) of the Life

Safety Code of the National Fire Protection Association as are

applicable to nursing homes; except that -

(i) the Secretary may waive, for such periods as he deems

appropriate, specific provisions of such Code which if

rigidly applied would result in unreasonable hardship upon a

facility, but only if such waiver would not adversely affect

the health and safety of residents or personnel, and

(ii) the provisions of such Code shall not apply in any

State if the Secretary finds that in such State there is in

effect a fire and safety code, imposed by State law, which

adequately protects residents of and personnel in nursing

facilities.

(3) Sanitary and infection control and physical environment

A nursing facility must -

(A) establish and maintain an infection control program

designed to provide a safe, sanitary, and comfortable

environment in which residents reside and to help prevent the

development and transmission of disease and infection, and

(B) be designed, constructed, equipped, and maintained in a

manner to protect the health and safety of residents,

personnel, and the general public.

(4) Miscellaneous

(A) Compliance with Federal, State, and local laws and

professional standards

A nursing facility must operate and provide services in

compliance with all applicable Federal, State, and local laws

and regulations (including the requirements of section 1320a-3

of this title) and with accepted professional standards and

principles which apply to professionals providing services in

such a facility.

(B) Other

A nursing facility must meet such other requirements relating

to the health and safety of residents or relating to the

physical facilities thereof as the Secretary may find

necessary.

(e) State requirements relating to nursing facility requirements

As a condition of approval of its plan under this subchapter, a

State must provide for the following:

(1) Specification and review of nurse aide training and

competency evaluation programs and of nurse aide competency

evaluation programs

The State must -

(A) by not later than January 1, 1989, specify those training

and competency evaluation programs, and those competency

evaluation programs, that the State approves for purposes of

subsection (b)(5) of this section and that meet the

requirements established under subsection (f)(2) of this

section, and

(B) by not later than January 1, 1990, provide for the review

and reapproval of such programs, at a frequency and using a

methodology consistent with the requirements established under

subsection (f)(2)(A)(iii) of this section.

The failure of the Secretary to establish requirements under

subsection (f)(2) of this section shall not relieve any State of

its responsibility under this paragraph.

(2) Nurse aide registry

(A) In general

By not later than January 1, 1989, the State shall establish

and maintain a registry of all individuals who have

satisfactorily completed a nurse aide training and competency

evaluation program, or a nurse aide competency evaluation

program, approved under paragraph (1) in the State, or any

individual described in subsection (f)(2)(B)(ii) of this

section or in subparagraph (B), (C), or (D) of section

6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.

(B) Information in registry

The registry under subparagraph (A) shall provide (in

accordance with regulations of the Secretary) for the inclusion

of specific documented findings by a State under subsection

(g)(1)(C) of this section of resident neglect or abuse or

misappropriation of resident property involving an individual

listed in the registry, as well as any brief statement of the

individual disputing the findings. The State shall make

available to the public information in the registry. In the

case of inquiries to the registry concerning an individual

listed in the registry, any information disclosed concerning

such a finding shall also include disclosure of any such

statement in the registry relating to the finding or a clear

and accurate summary of such a statement.

(C) Prohibition against charges

A State may not impose any charges on a nurse aide relating

to the registry established and maintained under subparagraph

(A).

(3) State appeals process for transfers and discharges

The State, for transfers and discharges from nursing facilities

effected on or after October 1, 1989, must provide for a fair

mechanism, meeting the guidelines established under subsection

(f)(3) of this section, for hearing appeals on transfers and

discharges of residents of such facilities; but the failure of

the Secretary to establish such guidelines under such subsection

shall not relieve any State of its responsibility under this

paragraph.

(4) Nursing facility administrator standards

By not later than July 1, 1989, the State must have implemented

and enforced the nursing facility administrator standards

developed under subsection (f)(4) of this section respecting the

qualification of administrators of nursing facilities.

(5) Specification of resident assessment instrument

Effective July 1, 1990, the State shall specify the instrument

to be used by nursing facilities in the State in complying with

the requirement of subsection (b)(3)(A)(iii) of this section.

Such instrument shall be -

(A) one of the instruments designated under subsection

(f)(6)(B) of this section, or

(B) an instrument which the Secretary has approved as being

consistent with the minimum data set of core elements, common

definitions, and utilization guidelines specified by the

Secretary under subsection (f)(6)(A) of this section.

(6) Notice of medicaid rights

Each State, as a condition of approval of its plan under this

subchapter, effective April 1, 1988, must develop (and

periodically update) a written notice of the rights and

obligations of residents of nursing facilities (and spouses of

such residents) under this subchapter.

(7) State requirements for preadmission screening and resident

review

(A) Preadmission screening

(i) In general

Effective January 1, 1989, the State must have in effect a

preadmission screening program, for making determinations

(using any criteria developed under subsection (f)(8) of this

section) described in subsection (b)(3)(F) of this section

for mentally ill and mentally retarded individuals (as

defined in subparagraph (G)) who are admitted to nursing

facilities on or after January 1, 1989. The failure of the

Secretary to develop minimum criteria under subsection (f)(8)

of this section shall not relieve any State of its

responsibility to have a preadmission screening program under

this subparagraph or to perform resident reviews under

subparagraph (B).

(ii) Clarification with respect to certain readmissions

The preadmission screening program under clause (i) need

not provide for determinations in the case of the readmission

to a nursing facility of an individual who, after being

admitted to the nursing facility, was transferred for care in

a hospital.

(iii) Exception for certain hospital discharges

The preadmission screening program under clause (i) shall

not apply to the admission to a nursing facility of an

individual -

(I) who is admitted to the facility directly from a

hospital after receiving acute inpatient care at the

hospital,

(II) who requires nursing facility services for the

condition for which the individual received care in the

hospital, and

(III) whose attending physician has certified, before

admission to the facility, that the individual is likely to

require less than 30 days of nursing facility services.

(B) State requirement for resident review

(i) For mentally ill residents

As of April 1, 1990, in the case of each resident of a

nursing facility who is mentally ill, the State mental health

authority must review and determine (using any criteria

developed under subsection (f)(8) of this section and based

on an independent physical and mental evaluation performed by

a person or entity other than the State mental health

authority) -

(I) whether or not the resident, because of the

resident's physical and mental condition, requires the

level of services provided by a nursing facility or

requires the level of services of an inpatient psychiatric

hospital for individuals under age 21 (as described in

section 1396d(h) of this title) or of an institution for

mental diseases providing medical assistance to individuals

65 years of age or older; and

(II) whether or not the resident requires specialized

services for mental illness.

(ii) For mentally retarded residents

As of April 1, 1990, in the case of each resident of a

nursing facility who is mentally retarded, the State mental

retardation or developmental disability authority must review

and determine (using any criteria developed under subsection

(f)(8) of this section) -

(I) whether or not the resident, because of the

resident's physical and mental condition, requires the

level of services provided by a nursing facility or

requires the level of services of an intermediate care

facility described under section 1396d(d) of this title;

and

(II) whether or not the resident requires specialized

services for mental retardation.

(iii) Review required upon change in resident's condition

A review and determination under clause (i) or (ii) must be

conducted promptly after a nursing facility has notified the

State mental health authority or State mental retardation or

developmental disability authority, as applicable, under

subsection (b)(3)(E) of this section with respect to a

mentally ill or mentally retarded resident, that there has

been a significant change in the resident's physical or

mental condition.

(iv) Prohibition of delegation

A State mental health authority, a State mental retardation

or developmental disability authority, and a State may not

delegate (by subcontract or otherwise) their responsibilities

under this subparagraph to a nursing facility (or to an

entity that has a direct or indirect affiliation or

relationship with such a facility).

(C) Response to preadmission screening and resident review

As of April 1, 1990, the State must meet the following

requirements:

(i) Long-term residents not requiring nursing facility

services, but requiring specialized services

In the case of a resident who is determined, under

subparagraph (B), not to require the level of services

provided by a nursing facility, but to require specialized

services for mental illness or mental retardation, and who

has continuously resided in a nursing facility for at least

30 months before the date of the determination, the State

must, in consultation with the resident's family or legal

representative and care-givers -

(I) inform the resident of the institutional and

noninstitutional alternatives covered under the State plan

for the resident,

(II) offer the resident the choice of remaining in the

facility or of receiving covered services in an alternative

appropriate institutional or noninstitutional setting,

(III) clarify the effect on eligibility for services

under the State plan if the resident chooses to leave the

facility (including its effect on readmission to the

facility), and

(IV) regardless of the resident's choice, provide for (or

arrange for the provision of) such specialized services for

the mental illness or mental retardation.

A State shall not be denied payment under this subchapter for

nursing facility services for a resident described in this

clause because the resident does not require the level of

services provided by such a facility, if the resident chooses

to remain in such a facility.

(ii) Other residents not requiring nursing facility services,

but requiring specialized services

In the case of a resident who is determined, under

subparagraph (B), not to require the level of services

provided by a nursing facility, but to require specialized

services for mental illness or mental retardation, and who

has not continuously resided in a nursing facility for at

least 30 months before the date of the determination, the

State must, in consultation with the resident's family or

legal representative and care-givers -

(I) arrange for the safe and orderly discharge of the

resident from the facility, consistent with the

requirements of subsection (c)(2) of this section,

(II) prepare and orient the resident for such discharge,

and

(III) provide for (or arrange for the provision of) such

specialized services for the mental illness or mental

retardation.

(iii) Residents not requiring nursing facility services and

not requiring specialized services

In the case of a resident who is determined, under

subparagraph (B), not to require the level of services

provided by a nursing facility and not to require specialized

services for mental illness or mental retardation, the State

must -

(I) arrange for the safe and orderly discharge of the

resident from the facility, consistent with the

requirements of subsection (c)(2) of this section, and

(II) prepare and orient the resident for such discharge.

(iv) Annual report

Each State shall report to the Secretary annually

concerning the number and disposition of residents described

in each of clauses (ii) and (iii).

(D) Denial of payment

(i) For failure to conduct preadmission screening or review

No payment may be made under section 1396b(a) of this title

with respect to nursing facility services furnished to an

individual for whom a determination is required under

subsection (b)(3)(F) of this section or subparagraph (B) but

for whom the determination is not made.

(ii) For certain residents not requiring nursing facility

level of services

No payment may be made under section 1396b(a) of this title

with respect to nursing facility services furnished to an

individual (other than an individual described in

subparagraph (C)(i)) who does not require the level of

services provided by a nursing facility.

(E) Permitting alternative disposition plans

With respect to residents of a nursing facility who are

mentally retarded or mentally ill and who are determined under

subparagraph (B) not to require the level of services of such a

facility, but who require specialized services for mental

illness or mental retardation, a State and the nursing facility

shall be considered to be in compliance with the requirements

of subparagraphs (A) through (C) of this paragraph if, before

April 1, 1989, the State and the Secretary have entered into an

agreement relating to the disposition of such residents of the

facility and the State is in compliance with such agreement.

Such an agreement may provide for the disposition of the

residents after the date specified in subparagraph (C). The

State may revise such an agreement, subject to the approval of

the Secretary, before October 1, 1991, but only if, under the

revised agreement, all residents subject to the agreement who

do not require the level of services of such a facility are

discharged from the facility by not later than April 1, 1994.

(F) Appeals procedures

Each State, as a condition of approval of its plan under this

subchapter, effective January 1, 1989, must have in effect an

appeals process for individuals adversely affected by

determinations under subparagraph (A) or (B).

(G) Definitions

In this paragraph and in subsection (b)(3)(F) of this

section:

(i) An individual is considered to be "mentally ill" if the

individual has a serious mental illness (as defined by the

Secretary in consultation with the National Institute of

Mental Health) and does not have a primary diagnosis of

dementia (including Alzheimer's disease or a related

disorder) or a diagnosis (other than a primary diagnosis) of

dementia and a primary diagnosis that is not a serious mental

illness.

(ii) An individual is considered to be "mentally retarded"

if the individual is mentally retarded or a person with a

related condition (as described in section 1396d(d) of this

title).

(iii) The term "specialized services" has the meaning given

such term by the Secretary in regulations, but does not

include, in the case of a resident of a nursing facility,

services within the scope of services which the facility must

provide or arrange for its residents under subsection (b)(4)

of this section.

(f) Responsibilities of Secretary relating to nursing facility

requirements

(1) General responsibility

It is the duty and responsibility of the Secretary to assure

that requirements which govern the provision of care in nursing

facilities under State plans approved under this subchapter, and

the enforcement of such requirements, are adequate to protect the

health, safety, welfare, and rights of residents and to promote

the effective and efficient use of public moneys.

(2) Requirements for nurse aide training and competency

evaluation programs and for nurse aide competency evaluation

programs

(A) In general

For purposes of subsections (b)(5) and (e)(1)(A) of this

section, the Secretary shall establish, by not later than

September 1, 1988 -

(i) requirements for the approval of nurse aide training

and competency evaluation programs, including requirements

relating to (I) the areas to be covered in such a program

(including at least basic nursing skills, personal care

skills, recognition of mental health and social service

needs, care of cognitively impaired residents, basic

restorative services, and residents' rights) and content of

the curriculum, (II) minimum hours of initial and ongoing

training and retraining (including not less than 75 hours in

the case of initial training), (III) qualifications of

instructors, and (IV) procedures for determination of

competency;

(ii) requirements for the approval of nurse aide competency

evaluation programs, including requirement relating to the

areas to be covered in such a program, including at least

basic nursing skills, personal care skills, recognition of

mental health and social service needs, care of cognitively

impaired residents, basic restorative services, and

residents' rights, and procedures for determination of

competency;

(iii) requirements respecting the minimum frequency and

methodology to be used by a State in reviewing such programs'

compliance with the requirements for such programs; and

(iv) requirements, under both such programs, that -

(I) provide procedures for determining competency that

permit a nurse aide, at the nurse aide's option, to

establish competency through procedures or methods other

than the passing of a written examination and to have the

competency evaluation conducted at the nursing facility at

which the aide is (or will be) employed (unless the

facility is described in subparagraph (B)(iii)(I)),

(II) prohibit the imposition on a nurse aide who is

employed by (or who has received an offer of employment

from) a facility on the date on which the aide begins

either such program of any charges (including any charges

for textbooks and other required course materials and any

charges for the competency evaluation) for either such

program, and

(III) in the case of a nurse aide not described in

subclause (II) who is employed by (or who has received an

offer of employment from) a facility not later than 12

months after completing either such program, the State

shall provide for the reimbursement of costs incurred in

completing such program on a prorata basis during the

period in which the nurse aide is so employed.

(B) Approval of certain programs

Such requirements -

(i) may permit approval of programs offered by or in

facilities, as well as outside facilities (including employee

organizations), and of programs in effect on December 22,

1987;

(ii) shall permit a State to find that an individual who

has completed (before July 1, 1989) a nurse aide training and

competency evaluation program shall be deemed to have

completed such a program approved under subsection (b)(5) of

this section if the State determines that, at the time the

program was offered, the program met the requirements for

approval under such paragraph; and

(iii) subject to subparagraph (C), shall prohibit approval

of such a program -

(I) offered by or in a nursing facility which, within the

previous 2 years -

(a) has operated under a waiver under subsection

(b)(4)(C)(ii) of this section that was granted on the

basis of a demonstration that the facility is unable to

provide the nursing care required under subsection

(b)(4)(C)(i) of this section for a period in excess of 48

hours during a week;

(b) has been subject to an extended (or partial

extended) survey under section 1395i-3(g)(2)(B)(i) of

this title or subsection (g)(2)(B)(i) of this section; or

(c) has been assessed a civil money penalty described

in section 1395i-3(h)(2)(B)(ii) of this title or

subsection (h)(2)(A)(ii) of this section of not less than

$5,000, or has been subject to a remedy described in

subsection (h)(1)(B)(i) of this section, clauses (!3)

(i), (iii), or (iv) of subsection (h)(2)(A) of this

section, clauses (!3) (i) or (iii) of section

1395i-3(h)(2)(B) of this title, or section 1395i-3(h)(4)

of this title, or

(II) offered by or in a nursing facility unless the State

makes the determination, upon an individual's completion of

the program, that the individual is competent to provide

nursing and nursing-related services in nursing facilities.

A State may not delegate (through subcontract or otherwise)

its responsibility under clause (iii)(II) to the nursing

facility.

(C) Waiver authorized

Clause (iii)(I) of subparagraph (B) shall not apply to a

program offered in (but not by) a nursing facility (or skilled

nursing facility for purposes of subchapter XVIII of this

chapter) in a State if the State -

(i) determines that there is no other such program offered

within a reasonable distance of the facility,

(ii) assures, through an oversight effort, that an adequate

environment exists for operating the program in the facility,

and

(iii) provides notice of such determination and assurances

to the State long-term care ombudsman.

(3) Federal guidelines for State appeals process for transfers

and discharges

For purposes of subsections (c)(2)(B)(iii) and (e)(3) of this

section, by not later than October 1, 1988, the Secretary shall

establish guidelines for minimum standards which State appeals

processes under subsection (e)(3) of this section must meet to

provide a fair mechanism for hearing appeals on transfers and

discharges of residents from nursing facilities.

(4) Secretarial standards qualification of administrators

For purposes of subsections (d)(1)(C) and (e)(4) of this

section, the Secretary shall develop, by not later than March 1,

1988, standards to be applied in assuring the qualifications of

administrators of nursing facilities.

(5) Criteria for administration

The Secretary shall establish criteria for assessing a nursing

facility's compliance with the requirement of subsection (d)(1)

of this section with respect to -

(A) its governing body and management,

(B) agreements with hospitals regarding transfers of

residents to and from the hospitals and to and from other

nursing facilities,

(C) disaster preparedness,

(D) direction of medical care by a physician,

(E) laboratory and radiological services,

(F) clinical records, and

(G) resident and advocate participation.

(6) Specification of resident assessment data set and instruments

The Secretary shall -

(A) not later than January 1, 1989, specify a minimum data

set of core elements and common definitions for use by nursing

facilities in conducting the assessments required under

subsection (b)(3) of this section, and establish guidelines for

utilization of the data set; and

(B) by not later than April 1, 1990, designate one or more

instruments which are consistent with the specification made

under subparagraph (A) and which a State may specify under

subsection (e)(5)(A) of this section for use by nursing

facilities in complying with the requirements of subsection

(b)(3)(A)(iii) of this section.

(7) List of items and services furnished in nursing facilities

not chargeable to the personal funds of a resident

(A) Regulations required

Pursuant to the requirement of section 21(b) of the

Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the

Secretary shall issue regulations, on or before the first day

of the seventh month to begin after December 22, 1987, that

define those costs which may be charged to the personal funds

of residents in nursing facilities who are individuals

receiving medical assistance with respect to nursing facility

services under this subchapter and those costs which are to be

included in the payment amount under this subchapter for

nursing facility services.

(B) Rule if failure to publish regulations

If the Secretary does not issue the regulations under

subparagraph (A) on or before the date required in that

subparagraph, in the case of a resident of a nursing facility

who is eligible to receive benefits for nursing facility

services under this subchapter, for purposes of section

1396a(a)(28)(B) of this title, the Secretary shall be deemed to

have promulgated regulations under this paragraph which provide

that the costs which may not be charged to the personal funds

of such resident (and for which payment is considered to be

made under this subchapter) include, at a minimum, the costs

for routine personal hygiene items and services furnished by

the facility.

(8) Federal minimum criteria and monitoring for preadmission

screening and resident review

(A) Minimum criteria

The Secretary shall develop, by not later than October 1,

1988, minimum criteria for States to use in making

determinations under subsections (b)(3)(F) and (e)(7)(B) of

this section and in permitting individuals adversely affected

to appeal such determinations, and shall notify the States of

such criteria.

(B) Monitoring compliance

The Secretary shall review, in a sufficient number of cases

to allow reasonable inferences, each State's compliance with

the requirements of subsection (e)(7)(C)(ii) of this section

(relating to discharge and placement for active treatment of

certain residents).

(9) Criteria for monitoring State waivers

The Secretary shall develop, by not later than October 1, 1988,

criteria and procedures for monitoring State performances in

granting waivers pursuant to subsection (b)(4)(C)(ii) of this

section.

(g) Survey and certification process

(1) State and Federal responsibility

(A) In general

Under each State plan under this subchapter, the State shall

be responsible for certifying, in accordance with surveys

conducted under paragraph (2), the compliance of nursing

facilities (other than facilities of the State) with the

requirements of subsections (b), (c), and (d) of this section.

The Secretary shall be responsible for certifying, in

accordance with surveys conducted under paragraph (2), the

compliance of State nursing facilities with the requirements of

such subsections.

(B) Educational program

Each State shall conduct periodic educational programs for

the staff and residents (and their representatives) of nursing

facilities in order to present current regulations, procedures,

and policies under this section.

(C) Investigation of allegations of resident neglect and abuse

and misappropriation of resident property

The State shall provide, through the agency responsible for

surveys and certification of nursing facilities under this

subsection, for a process for the receipt and timely review and

investigation of allegations of neglect and abuse and

misappropriation of resident property by a nurse aide of a

resident in a nursing facility or by another individual used by

the facility in providing services to such a resident. The

State shall, after notice to the individual involved and a

reasonable opportunity for a hearing for the individual to

rebut allegations, make a finding as to the accuracy of the

allegations. If the State finds that a nurse aide has neglected

or abused a resident or misappropriated resident property in a

facility, the State shall notify the nurse aide and the

registry of such finding. If the State finds that any other

individual used by the facility has neglected or abused a

resident or misappropriated resident property in a facility,

the State shall notify the appropriate licensure authority. A

State shall not make a finding that an individual has neglected

a resident if the individual demonstrates that such neglect was

caused by factors beyond the control of the individual.

(D) Removal of name from nurse aide registry

(i) In general

In the case of a finding of neglect under subparagraph (C),

the State shall establish a procedure to permit a nurse aide

to petition the State to have his or her name removed from

the registry upon a determination by the State that -

(I) the employment and personal history of the nurse aide

does not reflect a pattern of abusive behavior or neglect;

and

(II) the neglect involved in the original finding was a

singular occurrence.

(ii) Timing of determination

In no case shall a determination on a petition submitted

under clause (i) be made prior to the expiration of the

1-year period beginning on the date on which the name of the

petitioner was added to the registry under subparagraph (C).

(E) Construction

The failure of the Secretary to issue regulations to carry

out this subsection shall not relieve a State of its

responsibility under this subsection.

(2) Surveys

(A) Annual standard survey

(i) In general

Each nursing facility shall be subject to a standard

survey, to be conducted without any prior notice to the

facility. Any individual who notifies (or causes to be

notified) a nursing facility of the time or date on which

such a survey is scheduled to be conducted is subject to a

civil money penalty of not to exceed $2,000. The provisions

of section 1320a-7a of this title (other than subsections (a)

and (b)) shall apply to a civil money penalty under the

previous sentence in the same manner as such provisions apply

to a penalty or proceeding under section 1320a-7a(a) of this

title. The Secretary shall review each State's procedures for

scheduling and conduct of standard surveys to assure that the

State has taken all reasonable steps to avoid giving notice

of such a survey through the scheduling procedures and the

conduct of the surveys themselves.

(ii) Contents

Each standard survey shall include, for a case-mix

stratified sample of residents -

(I) a survey of the quality of care furnished, as

measured by indicators of medical, nursing, and

rehabilitative care, dietary and nutrition services,

activities and social participation, and sanitation,

infection control, and the physical environment,

(II) written plans of care provided under subsection

(b)(2) of this section and an audit of the residents'

assessments under subsection (b)(3) of this section to

determine the accuracy of such assessments and the adequacy

of such plans of care, and

(III) a review of compliance with residents' rights under

subsection (c) of this section.

(iii) Frequency

(I) In general

Each nursing facility shall be subject to a standard

survey not later than 15 months after the date of the

previous standard survey conducted under this subparagraph.

The statewide average interval between standard surveys of

a nursing facility shall not exceed 12 months.

(II) Special surveys

If not otherwise conducted under subclause (I), a

standard survey (or an abbreviated standard survey) may be

conducted within 2 months of any change of ownership,

administration, management of a nursing facility, or

director of nursing in order to determine whether the

change has resulted in any decline in the quality of care

furnished in the facility.

(B) Extended surveys

(i) In general

Each nursing facility which is found, under a standard

survey, to have provided substandard quality of care shall be

subject to an extended survey. Any other facility may, at the

Secretary's or State's discretion, be subject to such an

extended survey (or a partial extended survey).

(ii) Timing

The extended survey shall be conducted immediately after

the standard survey (or, if not practicable, not later than 2

weeks after the date of completion of the standard survey).

(iii) Contents

In such an extended survey, the survey team shall review

and identify the policies and procedures which produced such

substandard quality of care and shall determine whether the

facility has complied with all the requirements described in

subsections (b), (c), and (d) of this section. Such review

shall include an expansion of the size of the sample of

residents' assessments reviewed and a review of the staffing,

of in-service training, and, if appropriate, of contracts

with consultants.

(iv) Construction

Nothing in this paragraph shall be construed as requiring

an extended or partial extended survey as a prerequisite to

imposing a sanction against a facility under subsection (h)

of this section on the basis of findings in a standard

survey.

(C) Survey protocol

Standard and extended surveys shall be conducted -

(i) based upon a protocol which the Secretary has

developed, tested, and validated by not later than January 1,

1990, and

(ii) by individuals, of a survey team, who meet such

minimum qualifications as the Secretary establishes by not

later than such date.

The failure of the Secretary to develop, test, or validate such

protocols or to establish such minimum qualifications shall not

relieve any State of its responsibility (or the Secretary of

the Secretary's responsibility) to conduct surveys under this

subsection.

(D) Consistency of surveys

Each State shall implement programs to measure and reduce

inconsistency in the application of survey results among

surveyors.

(E) Survey teams

(i) In general

Surveys under this subsection shall be conducted by a

multidisciplinary team of professionals (including a

registered professional nurse).

(ii) Prohibition of conflicts of interest

A State may not use as a member of a survey team under this

subsection an individual who is serving (or has served within

the previous 2 years) as a member of the staff of, or as a

consultant to, the facility surveyed respecting compliance

with the requirements of subsections (b), (c), and (d) of

this section, or who has a personal or familial financial

interest in the facility being surveyed.

(iii) Training

The Secretary shall provide for the comprehensive training

of State and Federal surveyors in the conduct of standard and

extended surveys under this subsection, including the

auditing of resident assessments and plans of care. No

individual shall serve as a member of a survey team unless

the individual has successfully completed a training and

testing program in survey and certification techniques that

has been approved by the Secretary.

(3) Validation surveys

(A) In general

The Secretary shall conduct onsite surveys of a

representative sample of nursing facilities in each State,

within 2 months of the date of surveys conducted under

paragraph (2) by the State, in a sufficient number to allow

inferences about the adequacies of each State's surveys

conducted under paragraph (2). In conducting such surveys, the

Secretary shall use the same survey protocols as the State is

required to use under paragraph (2). If the State has

determined that an individual nursing facility meets the

requirements of subsections (b), (c), and (d) of this section,

but the Secretary determines that the facility does not meet

such requirements, the Secretary's determination as to the

facility's noncompliance with such requirements is binding and

supersedes that of the State survey.

(B) Scope

With respect to each State, the Secretary shall conduct

surveys under subparagraph (A) each year with respect to at

least 5 percent of the number of nursing facilities surveyed by

the State in the year, but in no case less than 5 nursing

facilities in the State.

(C) Reduction in administrative costs for substandard

performance

If the Secretary finds, on the basis of such surveys, that a

State has failed to perform surveys as required under paragraph

(2) or that a State's survey and certification performance

otherwise is not adequate, the Secretary may provide for the

training of survey teams in the State and shall provide for a

reduction of the payment otherwise made to the State under

section 1396b(a)(2)(D) of this title with respect to a quarter

equal to 33 percent multiplied by a fraction, the denominator

of which is equal to the total number of residents in nursing

facilities surveyed by the Secretary that quarter and the

numerator of which is equal to the total number of residents in

nursing facilities which were found pursuant to such surveys to

be not in compliance with any of the requirements of

subsections (b), (c), and (d) of this section. A State that is

dissatisfied with the Secretary's findings under this

subparagraph may obtain reconsideration and review of the

findings under section 1316 of this title in the same manner as

a State may seek reconsideration and review under that section

of the Secretary's determination under section 1316(a)(1) of

this title.

(D) Special surveys of compliance

Where the Secretary has reason to question the compliance of

a nursing facility with any of the requirements of subsections

(b), (c), and (d) of this section, the Secretary may conduct a

survey of the facility and, on the basis of that survey, make

independent and binding determinations concerning the extent to

which the nursing facility meets such requirements.

(4) Investigation of complaints and monitoring nursing facility

compliance

Each State shall maintain procedures and adequate staff to -

(A) investigate complaints of violations of requirements by

nursing facilities, and

(B) monitor, on-site, on a regular, as needed basis, a

nursing facility's compliance with the requirements of

subsections (b), (c), and (d) of this section, if -

(i) the facility has been found not to be in compliance

with such requirements and is in the process of correcting

deficiencies to achieve such compliance;

(ii) the facility was previously found not to be in

compliance with such requirements, has corrected deficiencies

to achieve such compliance, and verification of continued

compliance is indicated; or

(iii) the State has reason to question the compliance of

the facility with such requirements.

A State may maintain and utilize a specialized team (including an

attorney, an auditor, and appropriate health care professionals)

for the purpose of identifying, surveying, gathering and

preserving evidence, and carrying out appropriate enforcement

actions against substandard nursing facilities.

(5) Disclosure of results of inspections and activities

(A) Public information

Each State, and the Secretary, shall make available to the

public -

(i) information respecting all surveys and certifications

made respecting nursing facilities, including statements of

deficiencies, within 14 calendar days after such information

is made available to those facilities, and approved plans of

correction,

(ii) copies of cost reports of such facilities filed under

this subchapter or under subchapter XVIII of this chapter,

(iii) copies of statements of ownership under section

1320a-3 of this title, and

(iv) information disclosed under section 1320a-5 of this

title.

(B) Notice to ombudsman

Each State shall notify the State long-term care ombudsman

(established under title III or VII of the Older Americans Act

of 1965 [42 U.S.C. 3021 et seq., 3058 et seq.] in accordance

with section 712 of the Act [42 U.S.C. 3058g]) of the State's

findings of noncompliance with any of the requirements of

subsections (b), (c), and (d) of this section, or of any

adverse action taken against a nursing facility under

paragraphs (!4) (1), (2), or (3) of subsection (h) of this

section, with respect to a nursing facility in the State.

(C) Notice to physicians and nursing facility administrator

licensing board

If a State finds that a nursing facility has provided

substandard quality of care, the State shall notify -

(i) the attending physician of each resident with respect

to which such finding is made, and

(ii) any State board responsible for the licensing of the

nursing facility administrator of the facility.

(D) Access to fraud control units

Each State shall provide its State medicaid fraud and abuse

control unit (established under section 1396b(q) of this title)

with access to all information of the State agency responsible

for surveys and certifications under this subsection.

(h) Enforcement process

(1) In general

If a State finds, on the basis of a standard, extended, or

partial extended survey under subsection (g)(2) of this section

or otherwise, that a nursing facility no longer meets a

requirement of subsection (b), (c), or (d) of this section, and

further finds that the facility's deficiencies -

(A) immediately jeopardize the health or safety of its

residents, the State shall take immediate action to remove the

jeopardy and correct the deficiencies through the remedy

specified in paragraph (2)(A)(iii), or terminate the facility's

participation under the State plan and may provide, in

addition, for one or more of the other remedies described in

paragraph (2); or

(B) do not immediately jeopardize the health or safety of its

residents, the State may -

(i) terminate the facility's participation under the State

plan,

(ii) provide for one or more of the remedies described in

paragraph (2), or

(iii) do both.

Nothing in this paragraph shall be construed as restricting the

remedies available to a State to remedy a nursing facility's

deficiencies. If a State finds that a nursing facility meets the

requirements of subsections (b), (c), and (d) of this section,

but, as of a previous period, did not meet such requirements, the

State may provide for a civil money penalty under paragraph

(2)(A)(ii) for the days in which it finds that the facility was

not in compliance with such requirements.

(2) Specified remedies

(A) Listing

Except as provided in subparagraph (B)(ii), each State shall

establish by law (whether statute or regulation) at least the

following remedies:

(i) Denial of payment under the State plan with respect to

any individual admitted to the nursing facility involved

after such notice to the public and to the facility as may be

provided for by the State.

(ii) A civil money penalty assessed and collected, with

interest, for each day in which the facility is or was out of

compliance with a requirement of subsection (b), (c), or (d)

of this section. Funds collected by a State as a result of

imposition of such a penalty (or as a result of the

imposition by the State of a civil money penalty for

activities described in subsections (b)(3)(B)(ii)(I),

(b)(3)(B)(ii)(II), or (g)(2)(A)(i) of this section) shall be

applied to the protection of the health or property of

residents of nursing facilities that the State or the

Secretary finds deficient, including payment for the costs of

relocation of residents to other facilities, maintenance of

operation of a facility pending correction of deficiencies or

closure, and reimbursement of residents for personal funds

lost.

(iii) The appointment of temporary management to oversee

the operation of the facility and to assure the health and

safety of the facility's residents, where there is a need for

temporary management while -

(I) there is an orderly closure of the facility, or

(II) improvements are made in order to bring the facility

into compliance with all the requirements of subsections

(b), (c), and (d) of this section.

The temporary management under this clause shall not be

terminated under subclause (II) until the State has

determined that the facility has the management capability to

ensure continued compliance with all the requirements of

subsections (b), (c), and (d) of this section.

(iv) The authority, in the case of an emergency, to close

the facility, to transfer residents in that facility to other

facilities, or both.

The State also shall specify criteria, as to when and how each

of such remedies is to be applied, the amounts of any fines,

and the severity of each of these remedies, to be used in the

imposition of such remedies. Such criteria shall be designed so

as to minimize the time between the identification of

violations and final imposition of the remedies and shall

provide for the imposition of incrementally more severe fines

for repeated or uncorrected deficiencies. In addition, the

State may provide for other specified remedies, such as

directed plans of correction.

(B) Deadline and guidance

(i) Except as provided in clause (ii), as a condition for

approval of a State plan for calendar quarters beginning on or

after October 1, 1989, each State shall establish the remedies

described in clauses (i) through (iv) of subparagraph (A) by

not later than October 1, 1989. The Secretary shall provide,

through regulations by not later than October 1, 1988, guidance

to States in establishing such remedies; but the failure of the

Secretary to provide such guidance shall not relieve a State of

the responsibility for establishing such remedies.

(ii) A State may establish alternative remedies (other than

termination of participation) other than those described in

clauses (i) through (iv) of subparagraph (A), if the State

demonstrates to the Secretary's satisfaction that the

alternative remedies are as effective in deterring

noncompliance and correcting deficiencies as those described in

subparagraph (A).

(C) Assuring prompt compliance

If a nursing facility has not complied with any of the

requirements of subsections (b), (c), and (d) of this section,

within 3 months after the date the facility is found to be out

of compliance with such requirements, the State shall impose

the remedy described in subparagraph (A)(i) for all individuals

who are admitted to the facility after such date.

(D) Repeated noncompliance

In the case of a nursing facility which, on 3 consecutive

standard surveys conducted under subsection (g)(2) of this

section, has been found to have provided substandard quality of

care, the State shall (regardless of what other remedies are

provided) -

(i) impose the remedy described in subparagraph (A)(i), and

(ii) monitor the facility under subsection (g)(4)(B) of

this section,

until the facility has demonstrated, to the satisfaction of the

State, that it is in compliance with the requirements of

subsections (b), (c), and (d) of this section, and that it will

remain in compliance with such requirements.

(E) Funding

The reasonable expenditures of a State to provide for

temporary management and other expenses associated with

implementing the remedies described in clauses (iii) and (iv)

of subparagraph (A) shall be considered, for purposes of

section 1396b(a)(7) of this title, to be necessary for the

proper and efficient administration of the State plan.

(F) Incentives for high quality care

In addition to the remedies specified in this paragraph, a

State may establish a program to reward, through public

recognition, incentive payments, or both, nursing facilities

that provide the highest quality care to residents who are

entitled to medical assistance under this subchapter. For

purposes of section 1396b(a)(7) of this title, proper expenses

incurred by a State in carrying out such a program shall be

considered to be expenses necessary for the proper and

efficient administration of the State plan under this

subchapter.

(3) Secretarial authority

(A) For State nursing facilities

With respect to a State nursing facility, the Secretary shall

have the authority and duties of a State under this subsection,

including the authority to impose remedies described in clauses

(i), (ii), and (iii) of paragraph (2)(A).

(B) Other nursing facilities

With respect to any other nursing facility in a State, if the

Secretary finds that a nursing facility no longer meets a

requirement of subsection (b), (c), (d), or (e) of this

section, and further finds that the facility's deficiencies -

(i) immediately jeopardize the health or safety of its

residents, the Secretary shall take immediate action to

remove the jeopardy and correct the deficiencies through the

remedy specified in subparagraph (C)(iii), or terminate the

facility's participation under the State plan and may

provide, in addition, for one or more of the other remedies

described in subparagraph (C); or

(ii) do not immediately jeopardize the health or safety of

its residents, the Secretary may impose any of the remedies

described in subparagraph (C).

Nothing in this subparagraph shall be construed as restricting

the remedies available to the Secretary to remedy a nursing

facility's deficiencies. If the Secretary finds that a nursing

facility meets such requirements but, as of a previous period,

did not meet such requirements, the Secretary may provide for a

civil money penalty under subparagraph (C)(ii) for the days on

which he finds that the facility was not in compliance with

such requirements.

(C) Specified remedies

The Secretary may take the following actions with respect to

a finding that a facility has not met an applicable

requirement:

(i) Denial of payment

The Secretary may deny any further payments to the State

for medical assistance furnished by the facility to all

individuals in the facility or to individuals admitted to the

facility after the effective date of the finding.

(ii) Authority with respect to civil money penalties

The Secretary may impose a civil money penalty in an amount

not to exceed $10,000 for each day of noncompliance. The

provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to a civil money penalty

under the previous sentence in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title.

(iii) Appointment of temporary management

In consultation with the State, the Secretary may appoint

temporary management to oversee the operation of the facility

and to assure the health and safety of the facility's

residents, where there is a need for temporary management

while -

(I) there is an orderly closure of the facility, or

(II) improvements are made in order to bring the facility

into compliance with all the requirements of subsections

(b), (c), and (d) of this section.

The temporary management under this clause shall not be

terminated under subclause (II) until the Secretary has

determined that the facility has the management capability to

ensure continued compliance with all the requirements of

subsections (b), (c), and (d) of this section.

The Secretary shall specify criteria, as to when and how each

of such remedies is to be applied, the amounts of any fines,

and the severity of each of these remedies, to be used in the

imposition of such remedies. Such criteria shall be designed so

as to minimize the time between the identification of

violations and final imposition of the remedies and shall

provide for the imposition of incrementally more severe fines

for repeated or uncorrected deficiencies. In addition, the

Secretary may provide for other specified remedies, such as

directed plans of correction.

(D) Continuation of payments pending remediation

The Secretary may continue payments, over a period of not

longer than 6 months after the effective date of the findings,

under this subchapter with respect to a nursing facility not in

compliance with a requirement of subsection (b), (c), or (d) of

this section, if -

(i) the State survey agency finds that it is more

appropriate to take alternative action to assure compliance

of the facility with the requirements than to terminate the

certification of the facility, and

(ii) 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.

The Secretary shall establish guidelines for approval of

corrective actions requested by States under this subparagraph.

(4) Effective period of denial of payment

A finding to deny payment under this subsection shall terminate

when the State or Secretary (or both, as the case may be) finds

that the facility is in substantial compliance with all the

requirements of subsections (b), (c), and (d) of this section.

(5) Immediate termination of participation for facility where

State or Secretary finds noncompliance and immediate jeopardy

If either the State or the Secretary finds that a nursing

facility has not met a requirement of subsection (b), (c), or (d)

of this section, and finds that the failure immediately

jeopardizes the health or safety of its residents, the State or

the Secretary, respectively (!5) shall notify the other of such

finding, and the State or the Secretary, respectively, shall take

immediate action to remove the jeopardy and correct the

deficiencies through the remedy specified in paragraph

(2)(A)(iii) or (3)(C)(iii), or terminate the facility's

participation under the State plan. If the facility's

participation in the State plan is terminated by either the State

or the Secretary, the State shall provide for the safe and

orderly transfer of the residents eligible under the State plan

consistent with the requirements of subsection (c)(2) of this

section.

(6) Special rules where State and Secretary do not agree on

finding of noncompliance

(A) State finding of noncompliance and no Secretarial finding

of noncompliance

If the Secretary finds that a nursing facility has met all

the requirements of subsections (b), (c), and (d) of this

section, but a State finds that the facility has not met such

requirements and the failure does not immediately jeopardize

the health or safety of its residents, the State's findings

shall control and the remedies imposed by the State shall be

applied.

(B) Secretarial finding of noncompliance and no State finding

of noncompliance

If the Secretary finds that a nursing facility has not met

all the requirements of subsections (b), (c), and (d) of this

section, and that the failure does not immediately jeopardize

the health or safety of its residents, but the State has not

made such a finding, the Secretary -

(i) may impose any remedies specified in paragraph (3)(C)

with respect to the facility, and

(ii) shall (pending any termination by the Secretary)

permit continuation of payments in accordance with paragraph

(3)(D).

(7) Special rules for timing of termination of participation

where remedies overlap

If both the Secretary and the State find that a nursing

facility has not met all the requirements of subsections (b),

(c), and (d) of this section, and neither finds that the failure

immediately jeopardizes the health or safety of its residents -

(A)(i) if both find that the facility's participation under

the State plan should be terminated, the State's timing of any

termination shall control so long as the termination date does

not occur later than 6 months after the date of the finding to

terminate;

(ii) if the Secretary, but not the State, finds that the

facility's participation under the State plan should be

terminated, the Secretary shall (pending any termination by the

Secretary) permit continuation of payments in accordance with

paragraph (3)(D); or

(iii) if the State, but not the Secretary, finds that the

facility's participation under the State plan should be

terminated, the State's decision to terminate, and timing of

such termination, shall control; and

(B)(i) if the Secretary or the State, but not both,

establishes one or more remedies which are additional or

alternative to the remedy of terminating the facility's

participation under the State plan, such additional or

alternative remedies shall also be applied, or

(ii) if both the Secretary and the State establish one or

more remedies which are additional or alternative to the remedy

of terminating the facility's participation under the State

plan, only the additional or alternative remedies of the

Secretary shall apply.

(8) Construction

The remedies provided under this subsection are in addition to

those otherwise available under State or Federal law and shall

not be construed as limiting such other remedies, including any

remedy available to an individual at common law. The remedies

described in clauses (i), (iii), and (iv) of paragraph (2)(A) may

be imposed during the pendency of any hearing. The provisions of

this subsection shall apply to a nursing facility (or portion

thereof) notwithstanding that the facility (or portion thereof)

also is a skilled nursing facility for purposes of subchapter

XVIII of this chapter.

(9) Sharing of information

Notwithstanding any other provision of law, all information

concerning nursing facilities required by this section to be

filed with the Secretary or a State agency shall be made

available by such facilities to Federal or State employees for

purposes consistent with the effective administration of programs

established under this subchapter and subchapter XVIII of this

chapter, including investigations by State medicaid fraud control

units.

(i) Construction

Where requirements or obligations under this section are

identical to those provided under section 1395i-3 of this title,

the fulfillment of those requirements or obligations under section

1395i-3 of this title shall be considered to be the fulfillment of

the corresponding requirements or obligations under this section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1919, as added and amended

Pub. L. 100-203, title IV, Secs. 4211(a)(3), (c), 4212(a), (b),

4213(a), 4216, Dec. 22, 1987, 101 Stat. 1330-182, 1330-196,

1330-207, 1330-213, 1330-220, as amended Pub. L. 100-360, title IV,

Sec. 411(l)(3)(C)(ii), (6)(B), (8)(A), July 1, 1988, 102 Stat.

803-805; Pub. L. 100-360, title III, Sec. 303(a)(2), title IV, Sec.

411(l)(2)(A)-(D), (F)-(K), (L)(ii), (3)(A), (B), (C)(iii), (D),

(5), (6)(A), (7), (8)(B), July 1, 1988, 102 Stat. 760, 801-805, as

amended Pub. L. 100-485, title VI, Sec. 608(d)(27)(C)-(E), (I),

Oct. 13, 1988, 102 Stat. 2423; Pub. L. 101-239, title VI, Sec.

6901(b)(1), (3), (4)(A), (d)(1), (4), Dec. 19, 1989, 103 Stat.

2298-2301; Pub. L. 101-508, title IV, Secs. 4751(b)(2),

4801(a)(2)-(6)(A), (7), (b)(2)-(5)(A), (6)-(8), (d)(1),

(e)(2)-(7)(A), (8)-(10), (12)-(15), (18), Nov. 5, 1990, 104 Stat.

1388-205, 1388-211 to 1388-219; Pub. L. 102-375, title VII, Sec.

708(a)(1)(B), Sept. 30, 1992, 106 Stat. 1292; Pub. L. 104-315,

Secs. 1(a), 2(a), (b), Oct. 19, 1996, 110 Stat. 3824; Pub. L.

105-15, Sec. 1, May 15, 1997, 111 Stat. 34; Pub. L. 105-33, title

IV, Secs. 4754(a), 4755(b), Aug. 5, 1997, 111 Stat. 526; Pub. L.

106-4, Sec. 2(a), Mar. 25, 1999, 113 Stat. 7; Pub. L. 106-113, div.

B, Sec. 1000(a)(6) [title VI, Sec. 608(p)], Nov. 29, 1999, 113

Stat. 1536, 1501A-397; Pub. L. 106-402, title IV, Sec.

401(b)(6)(A), Oct. 30, 2000, 114 Stat. 1738; Pub. L. 106-554, Sec.

1(a)(6) [title IX, Sec. 941(b)], Dec. 21, 2000, 114 Stat. 2763,

2763A-586.)

-REFTEXT-

REFERENCES IN TEXT

The Older Americans Act of 1965, referred to in subsecs.

(b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is Pub. L.

89-73, July 14, 1965, 79 Stat. 218, as amended. Section 307(a)(12)

of the Act was repealed by Pub. L. 106-501, title III, Sec. 306(5),

Nov. 13, 2000, 114 Stat. 2244, and provisions formerly appearing in

section 307(a)(12) of the Act are now contained in section

307(a)(9) of the Act, which is classified to section 3027(a)(9) of

this title. Titles III and VII of the Act are classified generally

to subchapters III (Sec. 3021 et seq.) and XI (Sec. 3058 et seq.),

respectively, of chapter 35 of this title. For complete

classification of this Act to the Code, see Short Title note set

out under section 3001 of this title and Tables.

The Developmental Disabilities Assistance and Bill of Rights Act

of 2000, referred to in subsec. (c)(2)(B)(iii)(III), is Pub. L.

106-402, Oct. 30, 2000, 114 Stat. 1677. Subtitle C of the Act

probably means subtitle C of title I of the Act, which is

classified generally to part C (Sec. 15041 et seq.) of subchapter I

of chapter 144 of this title. For complete classification of this

Act to the Code, see Short Title note set out under section 15001

of this title and Tables.

The Protection and Advocacy for Mentally Ill Individuals Act [of

1986], referred to in subsec. (c)(2)(B)(iii)(IV), was Pub. L.

99-319, May 23, 1986, 100 Stat. 478, as amended. Pub. L. 99-319 was

renamed the Protection and Advocacy for Individuals with Mental

Illness Act by Pub. L. 106-310, div. B, title XXXII, Sec. 3206(a),

Oct. 17, 2000, 114 Stat. 1193, and is classified generally to

chapter 114 (Sec. 10801 et seq.) of this title. For complete

classification of this Act to the Code, see Short Title note set

out under section 10801 of this title and Tables.

Section 6901(b)(4)(B)-(D) of the Omnibus Budget Reconciliation

Act of 1989, referred to in subsec. (e)(2)(A), is section

6901(b)(4)(B)-(D) of Pub. L. 101-239, which is set out as a note

under section 1395i-3 of this title.

Section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse

Amendments of 1977, referred to in subsec. (f)(7)(A), probably

means section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse

Amendments, Pub. L. 95-142, which is set out as a note under

section 1395x of this title.

-MISC1-

PRIOR PROVISIONS

A prior section 1919 of act Aug. 14, 1935, was renumbered section

1922 and is classified to section 1396r-3 of this title.

AMENDMENTS

2000 - Subsec. (b)(8). Pub. L. 106-554 added par. (8).

Subsec. (c)(2)(B)(iii)(III). Pub. L. 106-402 substituted

"subtitle C of the Developmental Disabilities Assistance and Bill

of Rights Act of 2000" for "part C of the Developmental

Disabilities Assistance and Bill of Rights Act".

1999 - Subsec. (b)(3)(C)(i)(I). Pub. L. 106-113, Sec. 1000(a)(6)

[title VI, Sec. 608(p)(1)], struck out "not later than" before "14

days".

Subsec. (c)(2)(F). Pub. L. 106-4 added subpar. (F).

Subsec. (d)(4)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(p)(2)], inserted closing parenthesis after "section

1320a-3 of this title".

1997 - Subsec. (f)(2)(B)(iii). Pub. L. 105-15, Sec. 1(1),

inserted "subject to subparagraph (C)," after "(iii)".

Subsec. (f)(2)(C). Pub. L. 105-15, Sec. 1(2), added subpar. (C).

Subsec. (g)(1)(D), (E). Pub. L. 105-33, Sec. 4755(b), added

subpar. (D) and redesignated former subpar. (D) as (E).

Subsec. (h)(3)(D). Pub. L. 105-33, Sec. 4754(a), inserted "and"

at end of cl. (i), substituted a period for ", and" at end of cl.

(ii), and struck out cl. (iii) which read as follows: "the State

agrees to repay to the Federal Government payments received under

this subparagraph if the corrective action is not taken in

accordance with the approved plan and timetable."

1996 - Subsec. (b)(3)(E). Pub. L. 104-315, Sec. 2(a), inserted at

end "In addition, a nursing facility shall notify the State mental

health authority or State mental retardation or developmental

disability authority, as applicable, promptly after a significant

change in the physical or mental condition of a resident who is

mentally ill or mentally retarded."

Subsec. (e)(7)(B). Pub. L. 104-315, Sec. 1(a)(1)(A), struck out

"annual" before "resident review" in heading.

Subsec. (e)(7)(B)(iii). Pub. L. 104-315, Sec. 2(b), added cl.

(iii).

Pub. L. 104-315, Sec. 1(a)(1)(B), struck out cl. (iii) which

related to frequency of reviews as annual, preadmission, and

initial.

Subsec. (e)(7)(D)(i). Pub. L. 104-315, Sec. 1(a)(2), struck out

"annual" before "review" in heading.

1992 - Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Pub. L. 102-375

substituted "title III or VII of the Older Americans Act of 1965 in

accordance with section 712 of the Act" for "section 307(a)(12) of

the Older Americans Act of 1965".

1990 - Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4801(e)(2),

inserted at end "A State or the Secretary may not require

disclosure of the records of such committee except insofar as such

disclosure is related to the compliance of such committee with the

requirements of this subparagraph."

Subsec. (b)(3)(C)(i)(I). Pub. L. 101-508, Sec. 4801(e)(3),

substituted "not later than 14 days" for "4 days".

Subsec. (b)(3)(F). Pub. L. 101-508, Sec. 4801(b)(8), substituted

"specialized services" for "active treatment" in cls. (i) and (ii).

Pub. L. 101-508, Sec. 4801(b)(4)(A), inserted at end "A State

mental health authority and a State mental retardation or

developmental disability authority may not delegate (by subcontract

or otherwise) their responsibilities under this subparagraph to a

nursing facility (or to an entity that has a direct or indirect

affiliation or relationship with such a facility)."

Pub. L. 101-508, Sec. 4801(b)(2)(A), substituted "Except as

provided in clauses (ii) and (iii) of subsection (e)(7)(A) of this

section, a nursing facility" for "A nursing facility" in

introductory provisions.

Subsec. (b)(4)(A)(vii). Pub. L. 101-508, Sec. 4801(e)(4), added

cl. (vii).

Subsec. (b)(4)(C)(ii). Pub. L. 101-508, Sec. 4801(e)(5)(A),

substituted "To the extent that a facility is unable to meet the

requirements of clause (i), a State may waive such requirements

with respect to the facility if" for "A State may waive the

requirement of subclause (I) or (II) of clause (i) with respect to

a facility if" in introductory provisions.

Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101-508, Sec.

4801(e)(5)(B)-(D), which directed amendment of cl. (ii) by adding

subcls. (IV) and (V) at the end, was executed by adding subcls.

(IV) and (V) after subcl. (III) and before concluding provisions to

reflect the probable intent of Congress.

Subsec. (b)(5)(A). Pub. L. 101-508, Sec. 4801(a)(2), designated

existing provision as cl. (i), substituted "Except as provided in

clause (ii), a nursing facility" for "A nursing facility" and "on a

full-time basis" for "(on a full-time, temporary, per diem, or

other basis)", redesignated former cls. (i) and (ii) as subcls. (I)

and (II), respectively, and added cl. (ii).

Subsec. (b)(5)(C). Pub. L. 101-508, Sec. 4801(a)(3), substituted

"any State registry established under subsection (e)(2)(A) of this

section that the facility believes will include information" for

"the State registry established under subsection (e)(2)(A) of this

section as to information in the registry".

Subsec. (b)(5)(D). Pub. L. 101-508, Sec. 4801(a)(4), inserted

before period at end ", or a new competency evaluation program".

Subsec. (b)(5)(F)(i). Pub. L. 101-508, Sec. 4801(e)(6),

substituted "(G)) or a registered dietician" for "(G))".

Subsec. (b)(6)(A). Pub. L. 101-508, Sec. 4801(d)(1), inserted

before semicolon at end "(or, at the option of a State, under the

supervision of a nurse practitioner, clinical nurse specialist, or

physician assistant who is not an employee of the facility but who

is working in collaboration with a physician)".

Subsec. (c)(1)(A). Pub. L. 101-508, Sec. 4801(e)(8)(B), inserted

at end "A resident's exercise of a right to refuse transfer under

clause (x) shall not affect the resident's eligibility or

entitlement to medical assistance under this subchapter or a

State's entitlement to Federal medical assistance under this

subchapter with respect to services furnished to such a resident."

Subsec. (c)(1)(A)(iv). Pub. L. 101-508, Sec. 4801(e)(9), inserted

before period at end "and to access to current clinical records of

the resident upon request by the resident or the resident's legal

representative, within 24 hours (excluding hours occurring during a

weekend or holiday) after making such a request".

Subsec. (c)(1)(A)(x), (xi). Pub. L. 101-508, Sec. 4801(e)(8)(A),

added cl. (x) and redesignated former cl. (x) as (xi).

Subsec. (c)(1)(B)(ii). Pub. L. 101-508, Sec. 4801(e)(10),

inserted "including the notice (if any) of the State developed

under subsection (e)(6) of this section" after "in such rights)".

Subsec. (c)(2)(E). Pub. L. 101-508, Sec. 4751(b)(2), added

subpar. (E).

Subsec. (c)(7), (8). Pub. L. 101-508, Sec. 4801(e)(7)(A), added

par. (7) and redesignated former par. (7) as (8).

Subsec. (e)(1)(A). Pub. L. 101-508, Sec. 4801(e)(18), substituted

"under subsection (f)(2) of this section" for "under clause (i) or

(ii) of subsection (f)(2)(A) of this section".

Subsec. (e)(2)(A). Pub. L. 101-508, Sec. 4801(e)(12)(A), inserted

", or any individual described in subsection (f)(2)(B)(ii) of this

section or in subparagraph (B), (C), or (D) of section 6901(b)(4)

of the Omnibus Budget Reconciliation Act of 1989" after "in the

State".

Subsec. (e)(2)(C). Pub. L. 101-508, Sec. 4801(e)(12)(B), added

subpar. (C).

Subsec. (e)(7)(A). Pub. L. 101-508, Sec. 4801(b)(2)(B),

designated existing provision as cl. (i), inserted cl. (i) heading,

and added cls. (ii) and (iii).

Subsec. (e)(7)(B)(i)(II), (ii)(II). Pub. L. 101-508, Sec.

4801(b)(8), substituted "specialized services" for "active

treatment".

Subsec. (e)(7)(B)(iv). Pub. L. 101-508, Sec. 4801(b)(4)(B), added

cl. (iv).

Subsec. (e)(7)(C)(i) to (iii). Pub. L. 101-508, Sec. 4801(b)(8),

substituted "specialized services" for "active treatment" wherever

appearing.

Subsec. (e)(7)(C)(iv). Pub. L. 101-508, Sec. 4801(b)(5)(A), added

cl. (iv).

Subsec. (e)(7)(D). Pub. L. 101-508, Sec. 4801(b)(3)(A), struck

out "where failure to conduct preadmission screening" after "Denial

of payment" in heading, designated existing provisions as cl. (i),

inserted cl. (i) heading, and added cl. (ii).

Subsec. (e)(7)(E). Pub. L. 101-508, Sec. 4801(b)(8), substituted

"specialized services" for "active treatment".

Pub. L. 101-508, Sec. 4801(b)(6), inserted at end "The State may

revise such an agreement, subject to the approval of the Secretary,

before October 1, 1991, but only if, under the revised agreement,

all residents subject to the agreement who do not require the level

of services of such a facility are discharged from the facility by

not later than April 1, 1994."

Pub. L. 101-508, Sec. 4801(b)(3)(B), substituted "the

requirements of subparagraphs (A) through (C) of this paragraph"

for "the requirement of this paragraph".

Subsec. (e)(7)(G)(i). Pub. L. 101-508, Sec. 4801(b)(7),

substituted "serious mental illness (as defined by the Secretary in

consultation with the National Institute of Mental Health)" for

"primary or secondary diagnosis of mental disorder (as defined in

the Diagnostic and Statistical Manual of Mental Disorders, 3rd

edition)" and inserted before period at end "or a diagnosis (other

than a primary diagnosis) of dementia and a primary diagnosis that

is not a serious mental illness".

Subsec. (e)(7)(G)(iii). Pub. L. 101-508, Sec. 4801(b)(8),

substituted "specialized services" for "active treatment".

Subsec. (f)(2)(A)(iv)(II). Pub. L. 101-508, Sec. 4801(a)(5)(B),

inserted "who is employed by (or who has received an offer of

employment from) a facility on the date on which the aide begins

either such program" after "nurse aide".

Subsec. (f)(2)(A)(iv)(III). Pub. L. 101-508, Sec. 4801(a)(5)(A),

(C), (D), added subcl. (III).

Subsec. (f)(2)(B). Pub. L. 101-508, Sec. 4801(a)(7), inserted

"(through subcontract or otherwise)" after "may not delegate" in

last sentence.

Subsec. (f)(2)(B)(iii)(I). Pub. L. 101-508, Sec. 4801(a)(6)(A),

amended subcl. (I) generally. Prior to amendment, subcl. (I) read

as follows: "offered by or in a nursing facility which has been

determined to be out of compliance with the requirements of

subsection (b), (c), or (d) of this section, within the previous 2

years, or".

Subsec. (g)(1)(C). Pub. L. 101-508, Sec. 4801(e)(13), inserted at

end "A State shall not make a finding that an individual has

neglected a resident if the individual demonstrates that such

neglect was caused by factors beyond the control of the

individual."

Subsec. (g)(5)(A)(i). Pub. L. 101-508, Sec. 4801(e)(14),

substituted "deficiencies, within 14 calendar days after such

information is made available to those facilities, and approved

plans" for "deficiencies and plans".

Subsec. (g)(5)(B). Pub. L. 101-508, Sec. 4801(e)(15), substituted

"or of any adverse action taken against a nursing facility under

paragraphs (1), (2), or (3) of subsection (h) of this section, with

respect" for "with respect".

1989 - Subsec. (b)(5)(A). Pub. L. 101-239, Sec. 6901(b)(1)(A),

substituted "October 1, 1990" for "January 1, 1990" in introductory

provisions.

Subsec. (b)(5)(B). Pub. L. 101-239, Sec. 6901(b)(1)(B),

substituted "January 1, 1990" and "October 1, 1990" for "July 1,

1989" and "January 1, 1990", respectively.

Subsec. (c)(1)(A)(ii)(II). Pub. L. 101-239, Sec. 6901(d)(4)(A),

substituted "Secretary until such an order could reasonably be

obtained)" for "Secretary) until such an order could reasonably be

obtained".

Subsec. (c)(1)(A)(v)(I). Pub. L. 101-239, Sec. 6901(d)(4)(B),

substituted "accommodation" for "accommodations".

Subsec. (f)(2)(A)(i)(I). Pub. L. 101-239, Sec. 6901(d)(4)(C),

substituted "and content of the curriculum" for ", content of the

curriculum".

Pub. L. 101-239, Sec. 6901(b)(3)(A), inserted "care of

cognitively impaired residents," after "social service needs,".

Subsec. (f)(2)(A)(ii). Pub. L. 101-239, Sec. 6901(b)(3)(B),

substituted "recognition of mental health and social service needs,

care of cognitively impaired residents" for "cognitive, behavioral

and social care".

Subsec. (f)(2)(A)(iv). Pub. L. 101-239, Sec. 6901(b)(3)(C), (D),

added cl. (iv).

Subsec. (f)(2)(B)(ii). Pub. L. 101-239, Sec. 6901(b)(4)(A),

substituted "July 1, 1989" for "January 1, 1989".

Subsec. (h)(3)(D). Pub. L. 101-239, Sec. 6901(d)(4)(D),

substituted "not longer than 6 months after the effective date of

the findings" for "not longer than 6 months".

Subsec. (h)(8). Pub. L. 101-239, Sec. 6901(d)(1), inserted at end

"The provisions of this subsection shall apply to a nursing

facility (or portion thereof) notwithstanding that the facility (or

portion thereof) also is a skilled nursing facility for purposes of

subchapter XVIII of this chapter."

1988 - Subsec. (b)(3)(A)(iii). Pub. L. 100-360, Sec.

411(l)(2)(B), struck out "in the case of a resident eligible for

benefits under this subchapter," before "uses an instrument".

Subsec. (b)(3)(A)(iv). Pub. L. 100-360, Sec. 411(l)(2)(A), as

amended by Pub. L. 100-485, Sec. 608(d)(27)(C), struck out "in the

case of a resident eligible for benefits under part A of subchapter

XVIII of this chapter," before "includes the identification of

medical problems".

Subsec. (b)(3)(B)(ii)(III). Pub. L. 100-360, Sec. 411(l)(2)(C),

amended subcl. (III) generally. Prior to amendment, subcl. (III)

read as follows: "The Secretary shall provide for imposition of

civil money penalties under this clause in a manner similar to that

for the imposition of civil money penalties under section 1320a-7a

of this title."

Subsec. (b)(4)(C)(i)(II). Pub. L. 100-360, Sec. 411(l)(3)(A)(i),

inserted "professional" after "registered".

Subsec. (b)(4)(C)(ii). Pub. L. 100-360, Sec.

411(l)(3)(A)(i)-(iv), in heading, substituted "(ii) Waiver" for

"(ii) Facility waivers. - (i) Waiver", in subcl. (III), inserted

"professional" after "registered", and in concluding provisions,

substituted "clause (iii)" for "clause (ii)" and "use" for

"employ".

Subsec. (b)(4)(C)(iii). Pub. L. 100-360, Sec. 411(l)(3)(A)(v),

(vi), substituted "(iii) Assumption" for "(ii) Assumption" in

heading and "exercise" for "excercise" in text.

Subsec. (b)(5)(A). Pub. L. 100-360, Sec. 411(l)(3)(B), which

directed amendment of subpar. (A) by striking "subparagraph (E)"

and inserting "subparagraph (F)", could not be executed because of

prior amendment by Pub. L. 100-360, Sec. 411(l)(2)(D)(i), see

Amendment note below.

Pub. L. 100-360, Sec. 411(l)(2)(D)(i), as amended by Pub. L.

100-485, Sec. 608(d)(27)(D), struck out ", who is not a licensed

health professional (as defined in subparagraph (E))," after "any

individual" in introductory provisions.

Subsec. (b)(5)(A)(ii). Pub. L. 100-360, Sec. 411(l)(2)(D)(ii),

substituted "nursing or nursing-related services" for "such

services".

Subsec. (b)(5)(G). Pub. L. 100-360, Sec. 411(l)(2)(D)(iii),

inserted "physical or occupational therapy assistant," after

"occupational therapist,".

Subsec. (c)(1)(B)(i). Pub. L. 100-360, Sec. 303(a)(2), inserted

before semicolon at end "and of the requirements and procedures for

establishing eligibility for medical assistance under this

subchapter, including the right to request an assessment under

section 1396r-5(c)(1)(B) of this title".

Subsec. (c)(2)(A)(v). Pub. L. 100-360, Sec. 411(l)(2)(F),

substituted "for a stay at the facility" for "an allowable charge

imposed by the facility for an item or service requested by the

resident and for which a charge may be imposed consistent with this

subchapter and subchapter XVIII of this chapter".

Subsec. (c)(2)(B)(iii)(III). Pub. L. 100-360, Sec.

411(l)(3)(C)(iii), as added by Pub. L. 100-485, Sec. 608(d)(27)(E),

substituted "responsible" for "responsibile".

Subsec. (c)(6). Pub. L. 100-360, Sec. 411(l)(2)(G), substituted

"upon the written" for "once the facility accepts the written" in

subpar. (A)(ii) and "Upon written" for "Upon a facility's

acceptance of written" in subpar. (B).

Subsec. (c)(7). Pub. L. 100-360, Sec. 411(l)(6)(B), amended Pub.

L. 100-203, Sec. 4212(b), see 1987 Amendment note below.

Subsec. (e). Pub. L. 100-360, Sec. 411(l)(3)(C)(ii), as added by

Pub. L. 100-485, Sec. 608(d)(27)(E), amended Pub. L. 100-203, Sec.

4211, see 1987 Amendment note below.

Subsec. (e)(1). Pub. L. 100-360, Sec. 411(l)(3)(D)(i), (ii),

substituted "January 1, 1989" for "September 1, 1988" in subpar.

(A) and "January" for "September" in subpar. (B).

Subsec. (e)(2)(B). Pub. L. 100-360, Sec. 411(l)(2)(H), inserted

after first sentence "The State shall make available to the public

information in the registry."

Subsec. (e)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and

discharges" after "transfers" in heading and two places in text.

Subsec. (e)(7)(E). Pub. L. 100-360, Sec. 411(l)(3)(D)(iii),

substituted "April 1, 1989" for "October 1, 1988".

Subsec. (f). Pub. L. 100-360, Sec. 411(l)(3)(C)(ii), as added by

Pub. L. 100-485, Sec. 608(d)(27)(E), amended Pub. L. 100-203, Sec.

4211, see 1987 Amendment note below.

Subsec. (f)(2)(A). Pub. L. 100-360, Sec. 411(l)(3)(D)(iv),

substituted "September" for "July" in introductory provisions.

Subsec. (f)(2)(A)(i)(I). Pub. L. 100-360, Sec. 411(l)(2)(J),

substituted "recognition of mental health and social service needs"

for "cognitive, behavioral and social care".

Subsec. (f)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and

discharges" after "transfers" in heading and in text.

Subsec. (f)(7)(A). Pub. L. 100-360, Sec. 411(l)(2)(K),

substituted "residents" for "patients".

Subsec. (f)(7)(B). Pub. L. 100-360, Sec. 411(l)(2)(L)(ii),

substituted "include" for "do not include".

Subsec. (g)(1)(C). Pub. L. 100-360, Sec. 411(l)(5)(A)-(C),

substituted "and timely review" for ", review,", inserted "or by

another individual used by the facility in providing services to

such a resident" after "a nursing facility", and substituted "The

State shall, after notice to the individual involved and a

reasonable opportunity for a hearing for the individual to rebut

allegations, make a finding as to the accuracy of the allegations.

If the State finds that a nurse aide has neglected or abused a

resident or misappropriated resident property in a facility, the

State shall notify the nurse aide and the registry of such finding.

If the State finds that any other individual used by the facility

has neglected or abused a resident or misappropriated resident

property in a facility, the State shall notify the appropriate

licensure authority" for "If the State finds, after notice to the

nurse aide involved and a reasonable opportunity for a hearing for

the nurse aide to rebut allegations, that a nurse aide whose name

is contained in a nurse aide registry has neglected or abused a

resident or misappropriated resident property in a facility, the

State shall notify the nurse aide and the registry of such

finding".

Subsec. (g)(1)(D). Pub. L. 100-360, Sec. 411(l)(5)(D),

substituted "to issue regulations to carry out this subsection" for

"to establish standards under subsection (f) of this section".

Subsec. (g)(2)(A)(i). Pub. L. 100-360, Sec. 411(l)(5)(E), amended

third sentence generally. Prior to amendment, third sentence read

as follows: "The Secretary shall provide for imposition of civil

money penalties under this clause in a manner similar to that for

the imposition of civil money penalties under section 1320a-7a of

this title."

Subsec. (g)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(5)(F), as

added by Pub. L. 100-485, Sec. 608(d)(27)(I), substituted

"practicable" for "practical".

Subsec. (g)(3)(C). Pub. L. 100-360, Sec. 411(l)(6)(A),

redesignated subpar. (C), relating to special surveys of

compliance, as (D).

Subsec. (g)(3)(D). Pub. L. 100-360, Sec. 411(l)(5)(G), formerly

Sec. 411(l)(5)(F), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(I), substituted "on the basis of that survey" for "on

that basis".

Subsec. (g)(4). Pub. L. 100-360, Sec. 411(l)(5)(H), formerly Sec.

411(l)(5)(G), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(I), struck out "chronically" after "enforcement actions

against" in last sentence.

Subsec. (h). Pub. L. 100-360, Sec. 411(l)(8)(A), made technical

correction to directory language of Pub. L. 100-203, Sec. 4213(a),

see 1987 Amendment note below.

Subsec. (h)(1). Pub. L. 100-360, Sec. 411(l)(8)(B)(i),

substituted "paragraph (2)(A)(ii)"for "paragraph (2)(A)(i)" in last

sentence.

Subsec. (h)(2)(B)(i). Pub. L. 100-360, Sec. 411(l)(8)(B)(ii),

struck out "or otherwise" after "regulations".

Subsec. (h)(3)(C)(ii). Pub. L. 100-360, Sec. 411(l)(7)(A),

substituted ". The provisions of section 1320a-7a of this title

(other than subsections (a) and (b)) shall apply to a civil money

penalty under the previous sentence in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title" for "and the Secretary shall impose and

collect such a penalty in the same manner as civil money penalties

are imposed and collected under section 1320a-7a of this title".

Subsec. (h)(5). Pub. L. 100-360, Sec. 411(l)(8)(B)(iii),

substituted "State or the Secretary, respectively" for "State and

the Secretary".

Subsec. (h)(9). Pub. L. 100-360, Sec. 411(l)(7)(B), inserted "by

such facilities" after "be made available".

1987 - Subsec. (c)(7). Pub. L. 100-203, Sec. 4212(b), as amended

by Pub. L. 100-360, Sec. 411(l)(6)(B), added par. (7).

Subsecs. (e), (f). Pub. L. 100-203, Sec. 4211, which contained

two subsecs. (c), the first of which amended this section and the

second of which enacted provisions set out as a note below, was

amended by Pub. L. 100-360, Sec. 411(l)(3)(C)(ii), to delete the

designation, heading, and directory language of the first subsec.

(c), resulting in subsecs. (e) and (f) being added by section

4211(a)(3) of Pub. L. 100-203, which enacted subsecs. (a) to (d) of

this section.

Subsec. (g). Pub. L. 100-203, Sec. 4212(a), added subsec. (g).

Subsec. (h). Pub. L. 100-203, Sec. 4213(a), as amended by Pub. L.

100-360, Sec. 411(l)(8)(A), added subsec. (h).

Subsec. (i). Pub. L. 100-203, Sec. 4216, added subsec. (i).

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 effective Jan. 1, 2003, see section

1(a)(6) [title IX, Sec. 941(c)] of Pub. L. 106-554, set out as a

note under section 1395i-3 of this title.

EFFECTIVE DATE OF 1999 AMENDMENT

Pub. L. 106-4, Sec. 2(b), Mar. 25, 1999, 113 Stat. 8, provided

that: "The amendment made by subsection (a) [amending this section]

applies to voluntary withdrawals from participation occurring on or

after the date of the enactment of this Act [Mar. 25, 1999]."

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4754(b) of Pub. L. 105-33 provided that: "The amendments

made by subsection (a) [amending this section] take effect on the

date of the enactment of this Act [Aug. 5, 1997]."

EFFECTIVE DATE OF 1996 AMENDMENT

Section 1(b) of Pub. L. 104-315 provided that: "The amendments

made by subsection (a) [amending this section] shall take effect on

the date of the enactment of this Act [Oct. 19, 1996]."

Section 2(c) of Pub. L. 104-315 provided that: "The amendments

made by this section [amending this section] shall apply to changes

in physical or mental condition occurring on or after the date of

the enactment of this Act [Oct. 19, 1996]."

EFFECTIVE DATE OF 1992 AMENDMENT

Amendment by Pub. L. 102-375 inapplicable with respect to fiscal

year 1993, see section 4(b) of Pub. L. 103-171, set out as a note

under section 3001 of this title.

Amendment by Pub. L. 102-375 inapplicable with respect to fiscal

year 1992, see section 905(b)(6) of Pub. L. 102-375, set out as a

note under section 3001 of this title.

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by section 4751(b)(2) of Pub. L. 101-508 applicable

with respect to services furnished on or after the first day of the

first month beginning more than 1 year after Nov. 5, 1990, see

section 4751(c) of Pub. L. 101-508, set out as a note under section

1396a of this title.

Section 4801(a)(6)(B) of Pub. L. 101-508 provided that: "The

amendments made by subparagraph (A) [amending this section] shall

take effect as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203], except that a State

may not approve a training and competency evaluation program or a

competency evaluation program offered by or in a nursing facility

which, pursuant to any Federal or State law within the 2-year

period beginning on October 1, 1988 -

"(i) had its participation terminated under title XVIII of the

Social Security Act [subchapter XVIII of this chapter] or under

the State plan under title XIX of such Act [this subchapter];

"(ii) was subject to a denial of payment under either such

title;

"(iii) was assessed a civil money penalty not less than $5,000

for deficiencies in nursing facility standards;

"(iv) operated under a temporary management appointed to

oversee the operation of the facility and to ensure the health

and safety of the facility's residents; or

"(v) pursuant to State action, was closed or had its residents

transferred."

Amendment by section 4801(a)(2)-(5), (7) of Pub. L. 101-508

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987, Pub. L. 100-203, see section 4801(a)(9)

of Pub. L. 101-508, set out as a note under section 1396b of this

title.

Section 4801(b)(9) of Pub. L. 101-508 provided that:

"(A) In general. - Except as provided in subparagraph (B), the

amendments made by this subsection [amending this section] shall

take effect as if they were included in the enactment of the

Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100-203].

"(B) Exception. - The amendments made by paragraphs (4), (6), and

(8) [amending this section] shall take effect on the date of the

enactment of this Act [Nov. 5, 1990], without regard to whether or

not regulations to implement such amendments have been

promulgated."

Section 4801(d)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1) [amending this section] applies

with respect to nursing facility services furnished on or after

October 1, 1990, without regard to whether or not final regulations

to carry out such amendment have been promulgated by such date."

Section 4801(e)(7)(B) of Pub. L. 101-508 provided that: "The

amendments made by subparagraph (A) [amending this section] shall

take effect on the date of the enactment of this Act [Nov. 5,

1990], without regard to whether or not regulations to implement

such amendments have been promulgated."

Amendment by section 4801(e)(2)-(6), (8)-(10), (12)-(15), and

(18) of Pub. L. 101-508 effective as if included in the enactment

of the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

see section 4801(e)(19) of Pub. L. 101-508, set out as a note under

section 1396a of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by section 6901(b)(1), (4)(A) of Pub. L. 101-239

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987, Pub. L. 100-203, and amendment by

section 6901(b)(3) of Pub. L. 101-239 applicable to nurse aide

training and competency evaluation programs, and nurse aide

competency evaluation programs, offered on or after end of 90-day

period beginning on Dec. 19, 1989, but not to affect competency

evaluations conducted under programs offered before end of that

period, see section 6901(b)(6) of Pub. L. 101-239, set out as a

note under section 1395i-3 of this title.

Amendment by section 6901(d)(1) of Pub. L. 101-239 effective Dec.

19, 1989, and amendment by section 6901(d)(4) of Pub. L. 101-239

effective as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987, Pub. L. 100-203, see section 6901(d)(6)

of Pub. L. 101-239, set out as a note under section 1395i-3 of this

title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if included in the

enactment of the Medicare Catastrophic Coverage Act of 1988, Pub.

L. 100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Amendment by section 303(a)(2) of Pub. L. 100-360 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after Sept. 30, 1989, without

regard to whether or not final regulations to carry out such

amendment has been promulgated by such date, see section

303(g)(1)(A), (5) of Pub. L. 100-360, set out as an Effective Date

note under section 1396r-5 of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(l)(2)(A)-(D), (F)-(K), (L)(ii),

(3)(A), (B), (C)(ii), (iii), (D), (5), (6)(A), (B), (7), and

(8)(A), (B) of Pub. L. 100-360, as it relates to a provision in the

Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE

Section 4214 of title IV of Pub. L. 100-203, as amended by Pub.

L. 100-360, title IV, Sec. 411(l)(10), July 1, 1988, 102 Stat. 806,

provided that:

"(a) New Requirements and Survey and Certification Process. -

Except as otherwise specifically provided in section 1919 of the

Social Security Act [this section], the amendments made by sections

4211 [enacting this section, amending sections 1320a-7b, 1396a,

1396b, 1396d, 1396j, 1396l, 1396n, 1396o, 1396p, 1396r, and 1396s

of this title, redesignating section 1396r of this title as section

1396r-3 of this title, and amending provisions set out as a note

under section 1396r-3 of this title] and 4212 [amending sections

1395cc, 1396a, 1396b, 1396i, and 1396r of this title] (relating to

nursing facility requirements and survey and certification

requirements) shall apply to nursing facility services furnished on

or after October 1, 1990, without regard to whether regulations to

implement such amendments are promulgated by such date; except that

section 1902(a)(28)(B) of the Social Security Act [section

1396a(a)(28)(B) of this title] (as amended by section 4211(b) of

this Act), relating to requiring State medical assistance plans to

specify the services included in nursing facility services, shall

apply to calendar quarters beginning more than 6 months after the

date of the enactment of this Act [Dec. 22, 1987], without regard

to whether regulations to implement such section are promulgated by

such date.

"(b) Enforcement. - (1) Except as otherwise specifically provided

in section 1919 of the Social Security Act [this section], the

amendments made by section 4213 of this Act [amending this section

and sections 1396a and 1396b of this title] apply to payments under

title XIX of the Social Security Act [this subchapter] for calendar

quarters beginning on or after the date of the enactment of this

Act [Dec. 22, 1987], without regard to whether regulations to

implement such amendments are promulgated by such date.

"(2) In applying the amendments made by this part [part 2 of

subtitle C (Secs. 4211-4218) of title IV of Pub. L. 100-203, see

Tables for classification] for services furnished before October 1,

1990 -

"(A) any reference to a nursing facility is deemed a reference

to a skilled nursing facility or intermediate care facility

(other than an intermediate care facility for the mentally

retarded), and

"(B) with respect to such a skilled nursing facility or

intermediate care facility, any reference to a requirement of

subsection (b), (c), or (d) of section 1919 of the Social

Security Act [subsec. (b), (c), or (d) of this section], is

deemed a reference to the provisions of section 1861(j) or

section 1905(c), respectively, of the Social Security Act

[section 1395x(j) or 1396d(c) of this title].

"(c) Waiver of Paperwork Reduction. - Chapter 35 of title 44,

United States Code, shall not apply to information required for

purposes of carrying out this part and implementing the amendments

made by this part."

RETROACTIVE REVIEW

For requirement that procedures developed by a State permit

individual to petition for review of any finding made by a State

under subsec. (g)(1)(C) of this section or section 1395i-3(g)(1)(C)

of this title after Jan. 1, 1995, see section 4755(c) of Pub. L.

105-33, set out as a note under section 1395i-3 of this title.

NURSE AIDE TRAINING AND COMPETENCY EVALUATION; COMPLIANCE ACTIONS

Section 4801(a)(1) of Pub. L. 101-508 provided that: "The

Secretary of Health and Human Services shall not take (and shall

not continue) any action against a State under section 1904 of the

Social Security Act [section 1396c of this title] on the basis of

the State's failure to meet the requirement of section

1919(e)(1)(A) of such Act [subsec. (e)(1)(A) of this section]

before the effective date of guidelines, issued by the Secretary,

establishing requirements under section 1919(f)(2)(A) of such Act,

if the State demonstrates to the satisfaction of the Secretary that

it has made a good faith effort to meet such requirement before

such effective date."

PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW; COMPLIANCE

ACTIONS

Section 4801(b)(1) of Pub. L. 101-508 provided that: "The

Secretary of Health and Human Services shall not take (and shall

not continue) any action against a State under section 1904 or

section 1919(e)(7)(D) of the Social Security Act [section 1396c of

this title and subsec. (e)(7)(D) of this section] on the basis of

the State's failure to meet the requirement of section

1919(e)(7)(A) of such Act before the effective date of guidelines,

issued by the Secretary, establishing minimum criteria under

section 1919(f)(8)(A) of such Act, if the State demonstrates to the

satisfaction of the Secretary that it has made a good faith effort

to meet such requirement before such effective date."

RESTRICTION ON ENFORCEMENT PROCESS

Section 4801(c) of Pub. L. 101-508 provided that: "The Secretary

of Health and Human Services shall not take (and shall not

continue) any action against a State under section 1904 of the

Social Security Act [section 1396c of this title] on the basis of

the State's failure to meet the requirements of section 1919(h)(2)

of such Act [subsec. (h)(2) of this section] before the effective

date of guidelines, issued by the Secretary, regarding the

establishment of remedies by the State under such section, if the

State demonstrates to the satisfaction of the Secretary that it has

made a good faith effort to meet such requirements before such

effective date."

STAFFING REQUIREMENTS

Pub. L. 101-508, title IV, Sec. 4801(e)(17), Nov. 5, 1990, 104

Stat. 1388-218, as amended by Pub. L. 105-362, title VI, Sec.

602(b)(1), Nov. 10, 1998, 112 Stat. 3286, provided that:

"(A) Maintaining regulatory standards for certain services. - Any

regulations promulgated and applied by the Secretary of Health and

Human Services after the date of the enactment of the Omnibus

Budget Reconciliation Act of 1987 [Dec. 22, 1987] with respect to

services described in clauses (ii), (iv), and (v) of section

1919(b)(4)(A) of the Social Security Act [subsec. (b)(4)(A)(ii),

(iv), (v) of this section] shall include requirements for providers

of such services that are at least as strict as the requirements

applicable to providers of such services prior to the enactment of

the Omnibus Budget Reconciliation Act of 1987.

"(B) Study on staffing requirements in nursing facilities. - The

Secretary shall conduct a study and report to Congress no later

than January 1, 1999, on the appropriateness of establishing

minimum caregiver to resident ratios and minimum supervisor to

caregiver ratios for skilled nursing facilities serving as

providers of services under title XVIII of the Social Security Act

[subchapter XVIII of this chapter] and nursing facilities receiving

payments under a State plan under title XIX of the Social Security

Act [this subchapter], and shall include in such study

recommendations regarding appropriate minimum ratios."

NURSE AIDE TRAINING AND COMPETENCY EVALUATION; SATISFACTION OF

REQUIREMENTS; WAIVER

For satisfaction of training and competency evaluation

requirements of subsec. (b)(5)(A) of this section and section

1395i-3(b)(5)(A) of this title and authorization for a State to

waive such competency evaluation requirements, see section

6901(b)(4)(B)-(D) of Pub. L. 101-239, set out as a note under

section 1395i-3 of this title.

PUBLICATION OF PROPOSED REGULATIONS RESPECTING PREADMISSION

SCREENING AND ANNUAL RESIDENT REVIEW

Section 6901(c) of Pub. L. 101-239 provided that: "The Secretary

of Health and Human Services shall issue proposed regulations to

establish the criteria described in section 1919(f)(8)(A) of the

Social Security Act [subsec. (f)(8)(A) of this section] by not

later than 90 days after the date of the enactment of this Act

[Dec. 19, 1989]."

EVALUATION AND REPORT ON IMPLEMENTATION OF RESIDENT ASSESSMENT

PROCESS

Section 4211(c) of Pub. L. 100-203 directed Secretary of Health

and Human Services to evaluate and report to Congress by not later

than Jan. 1, 1993, on implementation of resident assessment process

for residents of nursing facilities under amendments made by

section 4211(c).

REPORT ON STAFFING REQUIREMENTS

Section 4211(k) of Pub. L. 100-203 directed Secretary of Health

and Human Services to report to Congress, by not later than Jan. 1,

1993, on progress made in implementing the nursing facility

staffing requirements of 42 U.S.C. 1396r(b)(4)(C), including the

number and types of waivers approved under subparagraph (C)(ii) of

such section and the number of facilities which received waivers.

ANNUAL REPORT ON STATUTORY COMPLIANCE AND ENFORCEMENT ACTIONS

Section 4215 of Pub. L. 100-203, as amended by Pub. L. 101-508,

title IV, Sec. 4801(b)(5)(B), Nov. 5, 1990, 104 Stat. 1388-214,

provided that: "The Secretary of Health and Human Services shall

report to the Congress annually on the extent to which nursing

facilities are complying with the requirements of subsections (b),

(c), and (d) of section 1919 of the Social Security Act [subsecs.

(b), (c), and (d) of this section] (as added by the amendments made

by this part) and the number and type of enforcement actions taken

by States and the Secretary under section 1919(h) of such Act (as

added by section 4213 of this Act). Each such report shall also

include a summary of the information reported by States under

section 1919(e)(7)(C)(iv) of such Act."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395i-3, 1395l, 1395x,

1396a, 1396b, 1396d, 1396l, 1396n, 1396r-8, 1396t, 3002 of this

title; title 25 section 1680l; title 38 sections 3675, 5503.

-FOOTNOTE-

(!1) See References in Text note below.

(!2) See References in Text note below.

(!3) So in original. Probably should be "clause".

(!4) So in original. Probably should be "paragraph".

(!5) So in original. Probably should be followed by a comma.

-End-

-CITE-

42 USC Sec. 1396r-1 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-1. Presumptive eligibility for pregnant women

-STATUTE-

(a) Ambulatory prenatal care

A State plan approved under section 1396a of this title may

provide for making ambulatory prenatal care available to a pregnant

woman during a presumptive eligibility period.

(b) Definitions

For purposes of this section -

(1) the term "presumptive eligibility period" means, with

respect to a pregnant woman, the period that -

(A) begins with the date on which a qualified provider

determines, on the basis of preliminary information, that the

family income of the woman does not exceed the applicable

income level of eligibility under the State plan, and

(B) ends with (and includes) the earlier of -

(i) the day on which a determination is made with respect

to the eligibility of the woman for medical assistance under

the State plan, or

(ii) in the case of a woman who does not file an

application by the last day of the month following the month

during which the provider makes the determination referred to

in subparagraph (A), such last day; and

(2) the term "qualified provider" means any provider that -

(A) is eligible for payments under a State plan approved

under this subchapter,

(B) provides services of the type described in subparagraph

(A) or (B) of section 1396d(a)(2) of this title or in section

1396d(a)(9) of this title,

(C) is determined by the State agency to be capable of making

determinations of the type described in paragraph (1)(A), and

(D)(i) receives funds under -

(I) section 254b or 254c of this title,

(II) subchapter V of this chapter, or

(III) title V of the Indian Health Care Improvement Act [25

U.S.C. 1651 et seq.];

(ii) participates in a program established under -

(I) section 1786 of this title, or

(II) section 4(a) of the Agriculture and Consumer

Protection Act of 1973;

(iii) participates in a State perinatal program; or

(iv) is the Indian Health Service or is a health program or

facility operated by a tribe or tribal organization under the

Indian Self-Determination Act (Public Law 93-638) [25 U.S.C.

450f et seq.].

(c) Duties of State agency, qualified providers, and presumptively

eligible pregnant women

(1) The State agency shall provide qualified providers with -

(A) such forms as are necessary for a pregnant woman to make

application for medical assistance under the State plan, and

(B) information on how to assist such women in completing and

filing such forms.

(2) A qualified provider that determines under subsection

(b)(1)(A) of this section that a pregnant woman is presumptively

eligible for medical assistance under a State plan shall -

(A) notify the State agency of the determination within 5

working days after the date on which determination is made, and

(B) inform the woman at the time the determination is made that

she is required to make application for medical assistance under

the State plan by not later than the last day of the month

following the month during which the determination is made.

(3) A pregnant woman who is determined by a qualified provider to

be presumptively eligible for medical assistance under a State plan

shall make application for medical assistance under such plan by

not later than the last day of the month following the month during

which the determination is made, which application may be the

application used for the receipt of medical assistance by

individuals described in section 1396a(l)(1)(A) of this title.

(d) Ambulatory prenatal care as medical assistance

Notwithstanding any other provision of this subchapter,

ambulatory prenatal care that -

(1) is furnished to a pregnant woman -

(A) during a presumptive eligibility period,

(B) by a provider that is eligible for payments under the

State plan; and

(2) is included in the care and services covered by a State

plan;

shall be treated as medical assistance provided by such plan for

purposes of section 1396b of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1920, as added Pub. L.

99-509, title IX, Sec. 9407(b), Oct. 21, 1986, 100 Stat. 2058;

amended Pub. L. 100-360, title IV, Sec. 411(k)(16)(A), (B), July 1,

1988, 102 Stat. 799; Pub. L. 100-485, title VI, Sec. 608(d)(26)(L),

Oct. 13, 1988, 102 Stat. 2422; Pub. L. 101-508, title IV, Sec.

4605(a), (b), Nov. 5, 1990, 104 Stat. 1388-169; Pub. L. 106-113,

div. B, Sec. 1000(a)(6) [title VI, Sec. 608(q)], Nov. 29, 1999, 113

Stat. 1536, 1501A-397.)

-REFTEXT-

REFERENCES IN TEXT

The Indian Health Care Improvement Act, referred to in subsec.

(b)(2)(D)(i)(III), is Pub. L. 94-437, Sept. 30, 1976, 90 Stat.

1400, as amended. Title V of the Indian Health Care Improvement Act

is classified generally to subchapter IV (Sec. 1651 et seq.) of

chapter 18 of Title 25, Indians. For complete classification of

this Act to the Code, see Short Title note set out under section

1601 of Title 25 and Tables.

Section 4(a) of the Agriculture and Consumer Protection Act of

1973, referred to in subsec. (b)(2)(D)(ii)(II), is section 4(a) of

Pub. L. 93-86, Aug. 10, 1973, 87 Stat. 249, as amended, which is

set out as a note under section 612c of Title 7, Agriculture.

The Indian Self-Determination Act (Public Law 93-638), referred

to in subsec. (b)(2)(D)(iv), is title I of Pub. L. 93-638, Jan. 4,

1975, 88 Stat. 2206, as amended, which is classified principally to

part A (Sec. 450f et seq.) of subchapter II of chapter 14 of Title

25, Indians. For complete classification of this Act to the Code,

see Short Title note set out under section 450 of Title 25 and

Tables.

-MISC1-

PRIOR PROVISIONS

A prior section 1920 of act Aug. 14, 1935, was renumbered section

1928 and is classified to section 1396s of this title.

AMENDMENTS

1999 - Subsec. (b)(2)(D)(i)(I). Pub. L. 106-113 substituted

"section 254b or 254c of this title," for "section 254b, 254c, or

256 of this title,".

1990 - Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4605(a)(1),

inserted "or" at end of cl. (i), redesignated cl. (iii) as (ii) and

amended it generally, and struck out former cl. (ii). Prior to

amendment, cls. (ii) and (iii) read as follows:

"(ii) the day that is 45 days after the date on which the

provider makes the determination referred to in subparagraph (A),

or

"(iii) in the case of a woman who does not file an application

for medical assistance within 14 calendar days after the date on

which the provider makes the determination referred to in

subparagraph (A), the fourteenth calendar day after such

determination is made; and".

Subsec. (c)(2)(B). Pub. L. 101-508, Sec. 4605(a)(2), substituted

"by not later than the last day of the month following the month

during which" for "within 14 calendar days after the date on

which".

Subsec. (c)(3). Pub. L. 101-508, Sec. 4605(b), inserted before

period at end ", which application may be the application used for

the receipt of medical assistance by individuals described in

section 1396a(l)(1)(A) of this title".

Pub. L. 101-508, Sec. 4605(a)(2), substituted "by not later than

the last day of the month following the month during which" for

"within 14 calendar days after the date on which".

1988 - Subsec. (b)(2)(D)(i). Pub. L. 100-360, Sec.

411(k)(16)(B)(i), substituted "section 254b, 254c, or 256 of this

title," for "section 254b of this title or section 254c of this

title, or" in subcl. (I), substituted "chapter, or" for "chapter;"

in subcl. (II), and added subcl. (III).

Subsec. (b)(2)(D)(ii)(II). Pub. L. 100-360, Sec.

411(k)(16)(B)(ii), as amended by Pub. L. 100-485, Sec.

608(d)(26)(L)(i), struck out "or" after "1973;".

Subsec. (b)(2)(D)(iii). Pub. L. 100-360, Sec. 411(k)(16)(B)(iii),

as added by Pub. L. 100-485, Sec. 608(d)(26)(L)(iii), substituted

"program; or" for "program."

Subsec. (b)(2)(D)(iv). Pub. L. 100-360, Sec. 411(k)(16)(B)(iv),

formerly Sec. 411(k)(16)(B)(iii), as redesignated by Pub. L.

100-485, Sec. 608(d)(26)(L)(ii), added cl. (iv).

Subsec. (d)(1)(B). Pub. L. 100-360, Sec. 411(k)(16)(A),

substituted "by a provider that is eligible for payments under the

State plan" for "by a qualified provider".

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4605(c) of Pub. L. 101-508 provided that:

"(1) The amendments made by subsection (a) [amending this

section] apply to payments under title XIX of the Social Security

Act [this subchapter] for calendar quarters beginning on or after

July 1, 1991, without regard to whether or not final regulations to

carry out such amendments have been promulgated by such date.

"(2) The amendment made by subsection (b) [amending this section]

shall be effective as if included in the enactment of section

9407(b) of the Omnibus Budget Reconciliation Act of 1986 [Pub. L.

99-509, enacting this section]."

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if included in the

enactment of the Medicare Catastrophic Coverage Act of 1988, Pub.

L. 100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Section 411(k)(16)(C) of Pub. L. 100-360 provided that: "The

amendments made by this paragraph [amending this section] shall be

effective as if they were included in section 9407(b) of the

Omnibus Budget Reconciliation Act of 1986 [Pub. L. 99-509]."

EFFECTIVE DATE

Section applicable to ambulatory prenatal care furnished in

calendar quarters beginning on or after Apr. 1, 1987, without

regard to whether or not final regulations to carry out such

section have been promulgated, see section 9407(d) of Pub. L.

99-509, set out as an Effective Date of 1986 Amendment note under

section 1396a of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1396a, 1396b of this

title.

-End-

-CITE-

42 USC Sec. 1396r-1a 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-1a. Presumptive eligibility for children

-STATUTE-

(a) In general

A State plan approved under section 1396a of this title may

provide for making medical assistance with respect to health care

items and services covered under the State plan available to a

child during a presumptive eligibility period.

(b) Definitions; regulations

For purposes of this section:

(1) The term "child" means an individual under 19 years of age.

(2) The term "presumptive eligibility period" means, with

respect to a child, the period that -

(A) begins with the date on which a qualified entity

determines, on the basis of preliminary information, that the

family income of the child does not exceed the applicable

income level of eligibility under the State plan, and

(B) ends with (and includes) the earlier of -

(i) the day on which a determination is made with respect

to the eligibility of the child for medical assistance under

the State plan, or

(ii) in the case of a child on whose behalf an application

is not filed by the last day of the month following the month

during which the entity makes the determination referred to

in subparagraph (A), such last day.

(3)(A) Subject to subparagraph (B), the term "qualified entity"

means any entity that -

(i)(I) is eligible for payments under a State plan approved

under this subchapter and provides items and services described

in subsection (a) of this section, (II) is authorized to

determine eligibility of a child to participate in a Head Start

program under the Head Start Act (42 U.S.C. 9831 et seq.),

eligibility of a child to receive child care services for which

financial assistance is provided under the Child Care and

Development Block Grant Act of 1990 (42 U.S.C. 9858 et seq.),

eligibility of an infant or child to receive assistance under

the special supplemental nutrition program for women, infants,

and children (WIC) under section 1786 of this title (!1)

eligibility of a child for medical assistance under the State

plan under this subchapter, or eligibility of a child for child

health assistance under the program funded under subchapter XXI

of this chapter, (III) is an elementary school or secondary

school, as such terms are defined in section 8801 of title

20,(!2) an elementary or secondary school operated or supported

by the Bureau of Indian Affairs, a State or tribal child

support enforcement agency, an organization that is providing

emergency food and shelter under a grant under the Stewart B.

McKinney Homeless Assistance Act (!2) [42 U.S.C. 11301 et

seq.], or a State or tribal office or entity involved in

enrollment in the program under this subchapter, under part A

of subchapter IV of this chapter, under subchapter XXI of this

chapter, or that determines eligibility for any assistance or

benefits provided under any program of public or assisted

housing that receives Federal funds, including the program

under section 8 [42 U.S.C. 1437f] or any other section of the

United States Housing Act of 1937 (42 U.S.C. 1437 et seq.) or

under the Native American Housing Assistance and

Self-Determination Act of 1996 (25 U.S.C. 4101 et seq.), or

(IV) any other entity the State so deems, as approved by the

Secretary; and

(ii) is determined by the State agency to be capable of

making determinations of the type described in paragraph (2).

(B) The Secretary may issue regulations further limiting those

entities that may become qualified entities in order to prevent

fraud and abuse and for other reasons.

(C) Nothing in this section shall be construed as preventing a

State from limiting the classes of entities that may become

qualified entities, consistent with any limitations imposed under

subparagraph (B).

(c) Application for medical assistance; procedure upon

determination of presumptive eligibility

(1) The State agency shall provide qualified entities with -

(A) such forms as are necessary for an application to be made

on behalf of a child for medical assistance under the State plan,

and

(B) information on how to assist parents, guardians, and other

persons in completing and filing such forms.

(2) A qualified entity that determines under subsection (b)(2) of

this section that a child is presumptively eligible for medical

assistance under a State plan shall -

(A) notify the State agency of the determination within 5

working days after the date on which determination is made, and

(B) inform the parent or custodian of the child at the time the

determination is made that an application for medical assistance

under the State plan is required to be made by not later than the

last day of the month following the month during which the

determination is made.

(3) In the case of a child who is determined by a qualified

entity to be presumptively eligible for medical assistance under a

State plan, the parent, guardian, or other person shall make

application on behalf of the child for medical assistance under

such plan by not later than the last day of the month following the

month during which the determination is made, which application may

be the application used for the receipt of medical assistance by

individuals described in section 1396a(l)(1) of this title.

(d) Treatment of medical assistance

Notwithstanding any other provision of this subchapter, medical

assistance for items and services described in subsection (a) of

this section that -

(1) are furnished to a child -

(A) during a presumptive eligibility period,

(B) by an entity that is eligible for payments under the

State plan; and

(2) are included in the care and services covered by a State

plan;

shall be treated as medical assistance provided by such plan for

purposes of section 1396b of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1920A, as added Pub. L.

105-33, title IV, Sec. 4912(a), Aug. 5, 1997, 111 Stat. 571;

amended Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec.

608(r)], Nov. 29, 1999, 113 Stat. 1536, 1501A-397; Pub. L. 106-554,

Sec. 1(a)(6) [title VII, Sec. 708], Dec. 21, 2000, 114 Stat. 2763,

2763A-577.)

-REFTEXT-

REFERENCES IN TEXT

Section 8801 of title 20, referred to in subsec. (b)(3)(A)(i)(I),

was repealed by Pub. L. 107-110, title X, Sec. 1011(5)(C), Jan. 8,

2002, 115 Stat. 1986. See section 7801 of Title 20, Education.

The Head Start Act, referred to in subsec. (b)(3)(A)(i)(II), is

subchapter B (Secs. 635-657) of chapter 8 of subtitle A of title VI

of Pub. L. 97-35, Aug. 13, 1981, 95 Stat. 499, as amended, which is

classified generally to subchapter II (Sec. 9831 et seq.) of

chapter 105 of this title. For complete classification of this Act

to the Code, see Short Title note set out under section 9801 of

this title and Tables.

The Child Care and Development Block Grant Act of 1990, referred

to in subsec. (b)(3)(A)(i)(II), is subchapter C (Secs. 658A-658R)

of chapter 8 of subtitle A of title VI of Pub. L. 97-35, as added

by Pub. L. 101-508, title V, Sec. 5082(2), Nov. 5, 1990, 104 Stat.

1388-236, as amended, which is classified generally to subchapter

II-B (Sec. 9858 et seq.) of chapter 105 of this title. For complete

classification of this Act to the Code, see Short Title note set

out under section 9801 of this title and Tables.

The Stewart B. McKinney Homeless Assistance Act, referred to in

subsec. (b)(3)(A)(i)(III), was Pub. L. 100-77, July 22, 1987, 101

Stat. 482, as amended. Pub. L. 100-77 was renamed the

McKinney-Vento Homeless Assistance Act by Pub. L. 106-400, Sec. 1,

Oct. 30, 2000, 114 Stat. 1675, and is classified principally to

chapter 119 (Sec. 11301 et seq.) of this title. For complete

classification of this Act to the Code, see Short Title note set

out under section 11301 of this title and Tables.

Part A of subchapter IV of this chapter, referred to in subsec.

(b)(3)(A)(i)(III), is classified to section 601 et seq. of this

title.

The United States Housing Act of 1937, referred to in subsec.

(b)(3)(A)(i)(III), is act Sept. 1, 1937, ch. 896, as revised

generally by Pub. L. 93-383, title II, Sec. 201(a), Aug. 22, 1974,

88 Stat. 653, and amended, which is classified generally to chapter

8 (Sec. 1437 et seq.) of this title. For complete classification of

this Act to the Code, see Short Title note set out under section

1437 of this title and Tables.

The Native American Housing Assistance and Self-Determination Act

of 1996, referred to in subsec. (b)(3)(A)(i)(III), is Pub. L.

104-330, Oct. 26, 1996, 110 Stat. 4016, as amended, which is

classified principally to chapter 43 (Sec. 4101 et seq.) of Title

25, Indians. For complete classification of this Act to the Code,

see Short Title note set out under section 4101 of Title 25 and

Tables.

-MISC1-

AMENDMENTS

2000 - Subsec. (b)(3)(A)(i). Pub. L. 106-554, Sec. 1(a)(6) [title

VII, Sec. 708(b)(1)], substituted "42 U.S.C. 9831" for "42 U.S.C.

9821".

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 708(a)(2)],

inserted before semicolon "eligibility of a child for medical

assistance under the State plan under this subchapter, or

eligibility of a child for child health assistance under the

program funded under subchapter XXI of this chapter, (III) is an

elementary school or secondary school, as such terms are defined in

section 8801 of title 20, an elementary or secondary school

operated or supported by the Bureau of Indian Affairs, a State or

tribal child support enforcement agency, an organization that is

providing emergency food and shelter under a grant under the

Stewart B. McKinney Homeless Assistance Act, or a State or tribal

office or entity involved in enrollment in the program under this

subchapter, under part A of subchapter IV of this chapter, under

subchapter XXI of this chapter, or that determines eligibility for

any assistance or benefits provided under any program of public or

assisted housing that receives Federal funds, including the program

under section 8 or any other section of the United States Housing

Act of 1937 (42 U.S.C. 1437 et seq.) or under the Native American

Housing Assistance and Self-Determination Act of 1996 (25 U.S.C.

4101 et seq.), or (IV) any other entity the State so deems, as

approved by the Secretary".

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 708(a)(1)],

substituted ", (II)" for "or (II)".

Subsec. (b)(3)(A)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 708(b)(2)], substituted "paragraph (2)" for "paragraph

(1)(A)".

Subsec. (c)(2). Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec.

708(b)(3)], substituted "subsection (b)(2)" for "subsection

(b)(1)(A)" in introductory provisions.

1999 - Subsec. (d)(1)(B). Pub. L. 106-113 substituted "an entity"

for "a entity".

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1396a, 1396b, 1397ee,

1397gg of this title.

-FOOTNOTE-

(!1) So in original. A comma probably should appear after "title".

(!2) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1396r-1b 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-1b. Presumptive eligibility for certain breast or

cervical cancer patients

-STATUTE-

(a) State option

A State plan approved under section 1396a of this title may

provide for making medical assistance available to an individual

described in section 1396a(aa) of this title (relating to certain

breast or cervical cancer patients) during a presumptive

eligibility period.

(b) Definitions

For purposes of this section:

(1) Presumptive eligibility period

The term "presumptive eligibility period" means, with respect

to an individual described in subsection (a) of this section, the

period that -

(A) begins with the date on which a qualified entity

determines, on the basis of preliminary information, that the

individual is described in section 1396a(aa) of this title; and

(B) ends with (and includes) the earlier of -

(i) the day on which a determination is made with respect

to the eligibility of such individual for services under the

State plan; or

(ii) in the case of such an individual who does not file an

application by the last day of the month following the month

during which the entity makes the determination referred to

in subparagraph (A), such last day.

(2) Qualified entity

(A) In general

Subject to subparagraph (B), the term "qualified entity"

means any entity that -

(i) is eligible for payments under a State plan approved

under this subchapter; and

(ii) is determined by the State agency to be capable of

making determinations of the type described in paragraph

(1)(A).

(B) Regulations

The Secretary may issue regulations further limiting those

entities that may become qualified entities in order to prevent

fraud and abuse and for other reasons.

(C) Rule of construction

Nothing in this paragraph shall be construed as preventing a

State from limiting the classes of entities that may become

qualified entities, consistent with any limitations imposed

under subparagraph (B).

(c) Administration

(1) In general

The State agency shall provide qualified entities with -

(A) such forms as are necessary for an application to be made

by an individual described in subsection (a) of this section

for medical assistance under the State plan; and

(B) information on how to assist such individuals in

completing and filing such forms.

(2) Notification requirements

A qualified entity that determines under subsection (b)(1)(A)

of this section that an individual described in subsection (a) of

this section is presumptively eligible for medical assistance

under a State plan shall -

(A) notify the State agency of the determination within 5

working days after the date on which determination is made; and

(B) inform such individual at the time the determination is

made that an application for medical assistance under the State

plan is required to be made by not later than the last day of

the month following the month during which the determination is

made.

(3) Application for medical assistance

In the case of an individual described in subsection (a) of

this section who is determined by a qualified entity to be

presumptively eligible for medical assistance under a State plan,

the individual shall apply for medical assistance under such plan

by not later than the last day of the month following the month

during which the determination is made.

(d) Payment

Notwithstanding any other provision of this subchapter, medical

assistance that -

(1) is furnished to an individual described in subsection (a)

of this section -

(A) during a presumptive eligibility period;

(B) by a (!1) entity that is eligible for payments under the

State plan; and

(2) is included in the care and services covered by the State

plan,

shall be treated as medical assistance provided by such plan for

purposes of clause (4) of the first sentence of section 1396d(b) of

this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1920B, as added Pub. L.

106-354, Sec. 2(b)(1), Oct. 24, 2000, 114 Stat. 1382.)

-MISC1-

EFFECTIVE DATE

Section applicable to medical assistance for items and services

furnished on or after Oct. 1, 2000, without regard to whether final

regulations to carry out such amendments have been promulgated by

such date, see section 2(d) of Pub. L. 106-354, set out as an

Effective Date of 2000 Amendment note under section 1396a of this

title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1396a, 1396b of this

title.

-FOOTNOTE-

(!1) So in original. Probably should be "an".

-End-

-CITE-

42 USC Sec. 1396r-2 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-2. Information concerning sanctions taken by State

licensing authorities against health care practitioners and

providers

-STATUTE-

(a) Information reporting requirement

The requirement referred to in section 1396a(a)(49) of this title

is that the State must provide for the following:

(1) Information reporting system

The State must have in effect a system of reporting the

following information with respect to formal proceedings (as

defined by the Secretary in regulations) concluded against a

health care practitioner or entity by any authority of the State

(or of a political subdivision thereof) responsible for the

licensing of health care practitioners (or any peer review

organization or private accreditation entity reviewing the

services provided by health care practitioners) or entities:

(A) Any adverse action taken by such licensing authority as a

result of the proceeding, including any revocation or

suspension of a license (and the length of any such

suspension), reprimand, censure, or probation.

(B) Any dismissal or closure of the proceedings by reason of

the practitioner or entity surrendering the license or leaving

the State or jurisdiction.

(C) Any other loss of the license of the practitioner or

entity, whether by operation of law, voluntary surrender, or

otherwise.

(D) Any negative action or finding by such authority,

organization, or entity regarding the practitioner or entity.

(2) Access to documents

The State must provide the Secretary (or an entity designated

by the Secretary) with access to such documents of the authority

described in paragraph (1) as may be necessary for the Secretary

to determine the facts and circumstances concerning the actions

and determinations described in such paragraph for the purpose of

carrying out this chapter.

(b) Form of information

The information described in subsection (a)(1) of this section

shall be provided to the Secretary (or to an appropriate private or

public agency, under suitable arrangements made by the Secretary

with respect to receipt, storage, protection of confidentiality,

and dissemination of information) in such a form and manner as the

Secretary determines to be appropriate in order to provide for

activities of the Secretary under this chapter and in order to

provide, directly or through suitable arrangements made by the

Secretary, information -

(1) to agencies administering Federal health care programs,

including private entities administering such programs under

contract,

(2) to licensing authorities described in subsection (a)(1) of

this section,

(3) to State agencies administering or supervising the

administration of State health care programs (as defined in

section 1320a-7(h) of this title),

(4) to utilization and quality control peer review

organizations described in part B of subchapter XI of this

chapter and to appropriate entities with contracts under section

1320c-3(a)(4)(C) of this title with respect to eligible

organizations reviewed under the contracts,

(5) to State medicaid fraud control units (as defined in

section 1396b(q) of this title),

(6) to hospitals and other health care entities (as defined in

section 431 of the Health Care Quality Improvement Act of 1986

[42 U.S.C. 11151]), with respect to physicians or other licensed

health care practitioners that have entered (or may be entering)

into an employment or affiliation relationship with, or have

applied for clinical privileges or appointments to the medical

staff of, such hospitals or other health care entities (and such

information shall be deemed to be disclosed pursuant to section

427 [42 U.S.C. 11137] of, and be subject to the provisions of,

that Act [42 U.S.C. 11101 et seq.]),

(7) to the Attorney General and such other law enforcement

officials as the Secretary deems appropriate, and

(8) upon request, to the Comptroller General,

in order for such authorities to determine the fitness of

individuals to provide health care services, to protect the health

and safety of individuals receiving health care through such

programs, and to protect the fiscal integrity of such programs.

(c) Confidentiality of information provided

The Secretary shall provide for suitable safeguards for the

confidentiality of the information furnished under subsection (a)

of this section. Nothing in this subsection shall prevent the

disclosure of such information by a party which is otherwise

authorized, under applicable State law, to make such disclosure.

(d) Appropriate coordination

The Secretary shall provide for the maximum appropriate

coordination in the implementation of subsection (a) of this

section and section 422 of the Health Care Quality Improvement Act

of 1986 [42 U.S.C. 11132].

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1921, as added Pub. L.

100-93, Sec. 5(b), Aug. 18, 1987, 101 Stat. 690; amended Pub. L.

101-508, title IV, Sec. 4752(f)(1), Nov. 5, 1990, 104 Stat.

1388-208.)

-REFTEXT-

REFERENCES IN TEXT

Part B of subchapter XI of this chapter, referred to in subsec.

(b)(4), is classified to section 1320c et seq. of this title.

That Act, referred to in subsec. (b)(6), is title IV of Pub. L.

99-660, Nov. 14, 1986, 100 Stat. 3784, as amended, known as the

Health Care Quality Improvement Act of 1986, which is classified

generally to chapter 117 (Sec. 11101 et seq.) of this title. For

complete classification of this Act to the Code, see Short Title

note set out under section 11101 of this title and Tables.

-MISC1-

PRIOR PROVISIONS

A prior section 1921 of act Aug. 14, 1935, was renumbered section

1928 and is classified to section 1396s of this title.

AMENDMENTS

1990 - Subsec. (a)(1). Pub. L. 101-508, Sec. 4752(f)(1)(A),

inserted "(or any peer review organization or private accreditation

entity reviewing the services provided by health care

practitioners)" after "health care practitioners" in introductory

provisions.

Subsec. (a)(1)(D). Pub. L. 101-508, Sec. 4752(f)(1)(B), added

subpar. (D).

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4752(f)(2) of Pub. L. 101-508 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to State information reporting systems as of January 1, 1992,

without regard to whether or not the Secretary of Health and Human

Services has promulgated any regulations to carry out such

amendments by such date."

EFFECTIVE DATE

Section applicable, with certain exceptions, to payments under

subchapter XIX of this chapter for calendar quarters beginning more

than thirty days after Aug. 18, 1987, without regard to whether or

not final regulations to carry out this section have been published

by that date, see section 15(c)(1), (2) of Pub. L. 100-93 set out

as an Effective Date of 1987 Amendment note under section 1320a-7

of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1396a of this title.

-End-

-CITE-

42 USC Sec. 1396r-3 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-3. Correction and reduction plans for intermediate care

facilities for mentally retarded

-STATUTE-

(a) Written plans to remedy substantial deficiencies; time for

submission

If the Secretary finds that an intermediate care facility for the

mentally retarded has substantial deficiencies which do not pose an

immediate threat to the health and safety of residents (including

failure to provide active treatment), the State may elect, subject

to the limitations in this section, to -

(1) submit, within the number of days specified by the

Secretary in regulations which apply to submission of compliance

plans with respect to deficiencies of such type, a written plan

of correction which details the extent of the facility's current

compliance with the standards promulgated by the Secretary,

including all deficiencies identified during a validation survey,

and which provides for a timetable for completion of necessary

steps to correct all staffing deficiencies within 6 months, and a

timetable for rectifying all physical plant deficiencies within 6

months; or

(2) submit, within a time period consisting of the number of

days specified for submissions under paragraph (1) plus 35 days,

a written plan for permanently reducing the number of certified

beds, within a maximum of 36 months, in order to permit any

noncomplying buildings (or distinct parts thereof) to be vacated

and any staffing deficiencies to be corrected (hereinafter in

this section referred to as a "reduction plan").

(b) Conditions for approval of reduction plans

As conditions of approval of any reduction plan submitted

pursuant to subsection (a)(2) of this section, the State must -

(1) provide for a hearing to be held at the affected facility

at least 35 days prior to submission of the reduction plan, with

reasonable notice thereof to the staff and residents of the

facility, responsible members of the residents' families, and the

general public;

(2) demonstrate that the State has successfully provided home

and community services similar to the services proposed to be

provided under the reduction plan for similar individuals

eligible for medical assistance; and

(3) provide assurances that the requirements of subsection (c)

of this section shall be met with respect to the reduction plan.

(c) Contents of reduction plan

The reduction plan must -

(1) identify the number and service needs of existing facility

residents to be provided home or community services and the

timetable for providing such services, in 6 month intervals,

within the 36-month period;

(2) describe the methods to be used to select such residents

for home and community services and to develop the alternative

home and community services to meet their needs effectively;

(3) describe the necessary safeguards that will be applied to

protect the health and welfare of the former residents of the

facility who are to receive home or community services, including

adequate standards for consumer and provider participation and

assurances that applicable State licensure and applicable State

and Federal certification requirements will be met in providing

such home or community services;

(4) provide that residents of the affected facility who are

eligible for medical assistance while in the facility shall, at

their option, be placed in another setting (or another part of

the affected facility) so as to retain their eligibility for

medical assistance;

(5) specify the actions which will be taken to protect the

health and safety of, and to provide active treatment for, the

residents who remain in the affected facility while the reduction

plan is in effect;

(6) provide that the ratio of qualified staff to residents at

the affected facility (or the part thereof) which is subject to

the reduction plan will be the higher of -

(A) the ratio which the Secretary determines is necessary in

order to assure the health and safety of the residents of such

facility (or part thereof); or

(B) the ratio which was in effect at the time that the

finding of substantial deficiencies (referred to in subsection

(a) of this section) was made; and

(7) provide for the protection of the interests of employees

affected by actions under the reduction plan, including -

(A) arrangements to preserve employee rights and benefits;

(B) training and retraining of such employees where

necessary;

(C) redeployment of such employees to community settings

under the reduction plan; and

(D) making maximum efforts to guarantee the employment of

such employees (but this requirement shall not be construed to

guarantee the employment of any employee).

(d) Notice and comment; approval of more than 15 reduction plans in

any fiscal year; corrections costing $2,000,000 or more

(1) The Secretary must provide for a period of not less than 30

days after the submission of a reduction plan by a State, during

which comments on such reduction plan may be submitted to the

Secretary, before the Secretary approves or disapproves such

reduction plan.

(2) If the Secretary approves more than 15 reduction plans under

this section in any fiscal year, any reduction plans approved in

addition to the first 15 such plans approved, must be for a

facility (or part thereof) for which the costs of correcting the

substantial deficiencies (referred to in subsection (a) of this

section) are $2,000,000 or greater (as demonstrated by the State to

the satisfaction of the Secretary).

(e) Termination of provider agreements; disallowance of percentage

amounts for purposes of Federal financial participation

(1) If the Secretary, at the conclusion of the 6-month plan of

correction described in subsection (a)(1) of this section,

determines that the State has substantially failed to correct the

deficiencies described in subsection (a) of this section, the

Secretary may terminate the facility's provider agreement in

accordance with the provisions of section 1396i(b) of this title.

(2) In the case of a reduction plan described in subsection

(a)(2) of this section, if the Secretary determines, at the

conclusion of the initial 6-month period or any 6-month interval

thereafter, that the State has substantially failed to meet the

requirements of subsection (c) of this section, the Secretary shall

-

(A) terminate the facility's provider agreement in accordance

with the provisions of section 1396i(b) of this title; or

(B) if the State has failed to meet such requirements despite

good faith efforts, disallow, for purposes of Federal financial

participation, an amount equal to 5 percent of the cost of care

for all eligible individuals in the facility for each month for

which the State fails to meet such requirements.

(f) Applicability of section limited to plans approved by January

1, 1990

The provisions of this section shall apply only to plans of

correction and reduction plans approved by the Secretary by January

1, 1990.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1922, formerly Sec. 1919,

as added Pub. L. 99-272, title IX, Sec. 9516(a), Apr. 7, 1986, 100

Stat. 213; renumbered Sec. 1922 and amended Pub. L. 100-203, title

IV, Secs. 4211(a)(2), 4212(e)(5), Dec. 22, 1987, 101 Stat.

1330-182; amended Pub. L. 100-360, title IV, Sec. 411(l)(6)(E),

July 1, 1988, 102 Stat. 804; Pub. L. 100-647, title VIII, Sec.

8433(a), Nov. 10, 1988, 102 Stat. 3804.)

-MISC1-

PRIOR PROVISIONS

A prior section 1922 of act Aug. 14, 1935, was renumbered section

1928 and is classified to section 1396s of this title.

AMENDMENTS

1988 - Subsec. (a). Pub. L. 100-647, Sec. 8433(a)(1), inserted

"(including failure to provide active treatment)" after "residents"

in introductory provisions.

Subsec. (c)(5). Pub. L. 100-647, Sec. 8433(a)(2), inserted ", and

to provide active treatment for," after "safety of".

Subsec. (e)(1), (2)(A). Pub. L. 100-360, Sec. 411(l)(6)(E),

substituted "1396i(b)" for "1396i(c)".

Subsec. (f). Pub. L. 100-647, Sec. 8433(a)(3), substituted "by

January 1, 1990" for "within 3 years after the effective date of

final regulations implementing this section".

EFFECTIVE DATE OF 1988 AMENDMENTS

Section 8433(b) of Pub. L. 100-647 provided that: "The amendments

made by subsection (a) [amending this section] shall become

effective on the date of the enactment of this Act [Nov. 10, 1988],

and shall apply to any proceeding where there has not yet been a

final determination by the Secretary (as defined for purposes of

judicial review) as of the date of the enactment of this Act."

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE

Section 9516(b) of Pub. L. 99-272 provided that:

"(1) The amendment made by this section [enacting this section]

shall become effective on the date of the enactment of this Act

[Apr. 7, 1986].

"(2) The Secretary of Health and Human Services shall issue a

notice of proposed rulemaking with respect to section 1919 of the

Social Security Act [this section] within 60 days after the date of

the enactment of this Act, and shall allow a period of 30 days for

comment thereon prior to promulgating final regulations

implementing such section."

REGULATIONS

Section 4217 of Pub. L. 100-203 provided that:

"(a) In General. - Not later than 30 days after the date of

enactment of this Act [Dec. 22, 1987], the Secretary of Health and

Human Services shall promulgate final regulations to implement the

amendments made by section 9516 of the Consolidated Omnibus Budget

Reconciliation Act of 1985 [enacting this section].

"(b) The regulations promulgated under paragraph (1) shall be

effective as if promulgated on the date of enactment of the

Consolidated Omnibus Budget Reconciliation Act of 1985 [Apr. 7,

1986]."

REPORT TO CONGRESS ON IMPLEMENTATION AND RESULTS OF THIS SECTION

Section 9516(c) of Pub. L. 99-272, as amended by Pub. L. 100-203,

title IV, Sec. 4211(l), Dec. 22, 1987, 101 Stat. 1330-207, directed

Secretary of Health and Human Services to submit a report to

Congress on implementation and results of this section, such report

to be submitted not later than 30 months after the effective date

of final regulations promulgated to implement this section.

-End-

-CITE-

42 USC Sec. 1396r-4 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-HEAD-

Sec. 1396r-4. Adjustment in payment for inpatient hospital services

furnished by disproportionate share hospitals

-STATUTE-

(a) Implementation of requirement

(1) A State plan under this subchapter shall not be considered to

meet the requirement of section 1396a(a)(13)(A)(iv) of this title

(insofar as it requires payments to hospitals to take into account

the situation of hospitals which serve a disproportionate number of

low income patients with special needs), as of July 1, 1988, unless

the State has submitted to the Secretary, by not later than such

date, an amendment to such plan that -

(A) specifically defines the hospitals so described (and

includes in such definition any disproportionate share hospital

described in subsection (b)(1) of this section which meets the

requirements of subsection (d) of this section), and

(B) provides, effective for inpatient hospital services

provided not later than July 1, 1988, for an appropriate increase

in the rate or amount of payment for such services provided by

such hospitals, consistent with subsection (c) of this section.

(2)(A) In order to be considered to have met such requirement of

section 1396a(a)(13)(A) of this title as of July 1, 1989, the State

must submit to the Secretary by not later than April 1, 1989, the

State plan amendment described in paragraph (1), consistent with

subsection (c) of this section, effective for inpatient hospital

services provided on or after July 1, 1989.

(B) In order to be considered to have met such requirement of

section 1396a(a)(13)(A) of this title as of July 1, 1990, the State

must submit to the Secretary by not later than April 1, 1990, the

State plan amendment described in paragraph (1), consistent with

subsections (c) and (f) of this section, effective for inpatient

hospital services provided on or after July 1, 1990.

(C) If a State plan under this subchapter provides for payments

for inpatient hospital services on a prospective basis (whether per

diem, per case, or otherwise), in order for the plan to be

considered to have met such requirement of section 1396a(a)(13)(A)

of this title as of July 1, 1989, the State must submit to the

Secretary by not later than April 1, 1989, a State plan amendment

that provides, in the case of hospitals defined by the State as

disproportionate share hospitals under paragraph (1)(A), for an

outlier adjustment in payment amounts for medically necessary

inpatient hospital services provided on or after July 1, 1989,

involving exceptionally high costs or exceptionally long lengths of

stay for individuals under one year of age.

(D) A State plan under this subchapter shall not be considered to

meet the requirements of section 1396a(a)(13)(A)(iv) of this title

(insofar as it requires payments to hospitals to take into account

the situation of hospitals that serve a disproportionate number of

low-income patients with special needs), as of October 1, 1998,

unless the State has submitted to the Secretary by such date a

description of the methodology used by the State to identify and to

make payments to disproportionate share hospitals, including

children's hospitals, on the basis of the proportion of low-income

and medicaid patients (including such patients who receive benefits

through a managed care entity) served by such hospitals. The State

shall provide an annual report to the Secretary describing the

disproportionate share payments to each such disproportionate share

hospital.

(3) The Secretary shall, not later than 90 days after the date a

State submits an amendment under this subsection, review each such

amendment for compliance with such requirement and by such date

shall approve or disapprove each such amendment. If the Secretary

disapproves such an amendment, the State shall immediately submit a

revised amendment which meets such requirement.

(4) The requirement of this subsection may not be waived under

section 1396n(b)(4) of this title.

(b) Hospitals deemed disproportionate share

(1) For purposes of subsection (a)(1) of this section, a hospital

which meets the requirements of subsection (d) of this section is

deemed to be a disproportionate share hospital if -

(A) the hospital's medicaid inpatient utilization rate (as

defined in paragraph (2)) is at least one standard deviation

above the mean medicaid inpatient utilization rate for hospitals

receiving medicaid payments in the State; or

(B) the hospital's low-income utilization rate (as defined in

paragraph (3)) exceeds 25 percent.

(2) For purposes of paragraph (1)(A), the term "medicaid

inpatient utilization rate" means, for a hospital, a fraction

(expressed as a percentage), the numerator of which is the

hospital's number of inpatient days attributable to patients who

(for such days) were eligible for medical assistance under a State

plan approved under this subchapter in a period (regardless of

whether such patients receive medical assistance on a

fee-for-service basis or through a managed care entity), and the

denominator of which is the total number of the hospital's

inpatient days in that period. In this paragraph, the term

"inpatient day" includes each day in which an individual (including

a newborn) is an inpatient in the hospital, whether or not the

individual is in a specialized ward and whether or not the

individual remains in the hospital for lack of suitable placement

elsewhere.

(3) For purposes of paragraph (1)(B), the term "low-income

utilization rate" means, for a hospital, the sum of -

(A) the fraction (expressed as a percentage) -

(i) the numerator of which is the sum (for a period) of (I)

the total revenues paid the hospital for patient services under

a State plan under this subchapter (regardless of whether the

services were furnished on a fee-for-service basis or through a

managed care entity) and (II) the amount of the cash subsidies

for patient services received directly from State and local

governments, and

(ii) the denominator of which is the total amount of revenues

of the hospital for patient services (including the amount of

such cash subsidies) in the period; and

(B) a fraction (expressed as a percentage) -

(i) the numerator of which is the total amount of the

hospital's charges for inpatient hospital services which are

attributable to charity care in a period, less the portion of

any cash subsidies described in clause (i)(II) of subparagraph

(A) in the period reasonably attributable to inpatient hospital

services, and

(ii) the denominator of which is the total amount of the

hospital's charges for inpatient hospital services in the

hospital in the period.

The numerator under subparagraph (B)(i) shall not include

contractual allowances and discounts (other than for indigent

patients not eligible for medical assistance under a State plan

approved under this subchapter).

(4) The Secretary may not restrict a State's authority to

designate hospitals as disproportionate share hospitals under this

section. The previous sentence shall not be construed to affect the

authority of the Secretary to reduce payments pursuant to section

1396b(w)(1)(A)(iii) of this title if the Secretary determines that,

as a result of such designations, there is in effect a hold

harmless provision described in section 1396b(w)(4) of this title.

(c) Payment adjustment

Subject to subsections (f) and (g) of this section, in order to

be consistent with this subsection, a payment adjustment for a

disproportionate share hospital must either -

(1) be in an amount equal to at least the product of (A) the

amount paid under the State plan to the hospital for operating

costs for inpatient hospital services (of the kind described in

section 1395ww(a)(4) of this title), and (B) the hospital's

disproportionate share adjustment percentage (established under

section 1395ww(d)(5)(F)(iv) of this title);

(2) provide for a minimum specified additional payment amount

(or increased percentage payment) and (without regard to whether

the hospital is described in subparagraph (A) or (B) of

subsection (b)(1) of this section) for an increase in such a

payment amount (or percentage payment) in proportion to the

percentage by which the hospital's medicaid utilization rate (as

defined in subsection (b)(2) of this section) exceeds one

standard deviation above the mean medicaid inpatient utilization

rate for hospitals receiving medicaid payments in the State or

the hospital's low-income utilization rate (as defined in

paragraph (!1) (b)(3) of this section); or

(3) provide for a minimum specified additional payment amount

(or increased percentage payment) that varies according to type

of hospital under a methodology that -

(A) applies equally to all hospitals of each type; and

(B) results in an adjustment for each type of hospital that

is reasonably related to the costs, volume, or proportion of

services provided to patients eligible for medical assistance

under a State plan approved under this subchapter or to

low-income patients,

except that, for purposes of paragraphs (1)(B) and (2)(A) of

subsection (a) of this section, the payment adjustment for a

disproportionate share hospital is consistent with this subsection

if the appropriate increase in the rate or amount of payment is

equal to at least one-third of the increase otherwise applicable

under this subsection (in the case of such paragraph (1)(B)) and at

least two-thirds of such increase (in the case of paragraph

(2)(A)). In the case of a hospital described in subsection

(d)(2)(A)(i) of this section (relating to children's hospitals), in

computing the hospital's disproportionate share adjustment

percentage for purposes of paragraph (1)(B) of this subsection, the

disproportionate patient percentage (defined in section

1395ww(d)(5)(F)(vi) of this title) shall be computed by

substituting for the fraction described in subclause (I) of such

section the fraction described in subclause (II) of that section.

If a State elects in a State plan amendment under subsection (a) of

this section to provide the payment adjustment described in

paragraph (2), the State must include in the amendment a detailed

description of the specific methodology to be used in determining

the specified additional payment amount (or increased percentage

payment) to be made to each hospital qualifying for such a payment

adjustment and must publish at least annually the name of each

hospital qualifying for such a payment adjustment and the amount of

such payment adjustment made for each such hospital.

(d) Requirements to qualify as disproportionate share hospital

(1) Except as provided in paragraph (2), no hospital may be

defined or deemed as a disproportionate share hospital under a

State plan under this subchapter or under subsection (b) of this

section unless the hospital has at least 2 obstetricians who have

staff privileges at the hospital and who have agreed to provide

obstetric services to individuals who are entitled to medical

assistance for such services under such State plan.

(2)(A) Paragraph (1) shall not apply to a hospital -

(i) the inpatients of which are predominantly individuals under

18 years of age; or

(ii) which does not offer nonemergency obstetric services to

the general population as of December 22, 1987.

(B) In the case of a hospital located in a rural area (as defined

for purposes of section 1395ww of this title), in paragraph (1) the

term "obstetrician" includes any physician with staff privileges at

the hospital to perform nonemergency obstetric procedures.

(3) No hospital may be defined or deemed as a disproportionate

share hospital under a State plan under this subchapter or under

subsection (b) or (e) of this section unless the hospital has a

medicaid inpatient utilization rate (as defined in subsection

(b)(2) of this section) of not less than 1 percent.

(e) Special rule

(1) A State plan shall be considered to meet the requirement of

section 1396a(a)(13)(A)(iv) of this title (insofar as it requires

payments to hospitals to take into account the situation of

hospitals which serve a disproportionate number of low income

patients with special needs) without regard to the requirement of

subsection (a) of this section if (A)(i) the plan provided for

payment adjustments based on a pooling arrangement involving a

majority of the hospitals participating under the plan for

disproportionate share hospitals as of January 1, 1984, or (ii) the

plan as of January 1, 1987, provided for payment adjustments based

on a statewide pooling arrangement involving all acute care

hospitals and the arrangement provides for reimbursement of the

total amount of uncompensated care provided by each participating

hospital, (B) the aggregate amount of the payment adjustments under

the plan for such hospitals is not less than the aggregate amount

of such adjustments otherwise required to be made under such

subsection, and (C) the plan meets the requirement of subsection

(d)(3) of this section and such payment adjustments are made

consistent with the last sentence of subsection (c) of this

section.

(2) In the case of a State that used a health insuring

organization before January 1, 1986, to administer a portion of its

plan on a statewide basis, beginning on July 1, 1988 -

(A) the requirements of subsections (b) and (c) of this section

(other than the last sentence of subsection (c) of this section)

shall not apply if the aggregate amount of the payment

adjustments under the plan for disproportionate share hospitals

(as defined under the State plan) is not less than the aggregate

amount of payment adjustments otherwise required to be made if

such subsections applied,

(B) subsection (d)(2)(B) of this section shall apply to

hospitals located in urban areas, as well as in rural areas,

(C) subsection (d)(3) of this section shall apply, and

(D) subsection (g) of this section shall apply.

(f) Limitation on Federal financial participation

(1) In general

Payment under section 1396b(a) of this title shall not be made

to a State with respect to any payment adjustment made under this

section for hospitals in a State for quarters in a fiscal year in

excess of the disproportionate share hospital (in this subsection

referred to as "DSH") allotment for the State for the fiscal

year, as specified in paragraphs (2) and (3).

(2) State DSH allotments for fiscal years 1998 through 2002

Subject to paragraph (4), the DSH allotment for a State for

each fiscal year during the period beginning with fiscal year

1998 and ending with fiscal year 2002 is determined in accordance

with the following table:

State or District DSH Allotment (in millions of dollars)

FY 98 FY 99 FY 00 FY 01 FY 02

--------------------------------------------------------------------

Alabama 293 269 248 246 246

Alaska 10 10 10 9 9

Arizona 81 81 81 81 81

Arkansas 2 2 2 2 2

California 1,085 1,068 986 931 877

Colorado 93 85 79 74 74

Connecticut 200 194 164 160 160

Delaware 4 4 4 4 4

District of Columbia 23 23 32 32 32

Florida 207 203 197 188 160

Georgia 253 248 241 228 215

Hawaii 0 0 0 0 0

Idaho 1 1 1 1 1

Illinois 203 199 193 182 172

Indiana 201 197 191 181 171

Iowa 8 8 8 8 8

Kansas 51 49 42 36 33

Kentucky 137 134 130 123 116

Louisiana 880 795 713 658 631

Maine 103 99 84 84 84

Maryland 72 70 68 64 61

Massachusetts 288 282 273 259 244

Michigan 249 244 237 224 212

Minnesota 16 16 33 33 33

Mississippi 143 141 136 129 122

Missouri 436 423 379 379 379

Montana 0.2 0.2 0.2 0.2 0.2

Nebraska 5 5 5 5 5

Nevada 37 37 37 37 37

New Hampshire 140 136 130 130 130

New Jersey 600 582 515 515 515

New Mexico 5 5 9 9 9

New York 1,512 1,482 1,436 1,361 1,285

North Carolina 278 272 264 250 236

North Dakota 1 1 1 1 1

Ohio 382 374 363 344 325

Oklahoma 16 16 16 16 16

Oregon 20 20 20 20 20

Pennsylvania 529 518 502 476 449

Rhode Island 62 60 58 55 52

South Carolina 313 303 262 262 262

South Dakota 1 1 1 1 1

Tennessee 0 0 0 0 0

Texas 979 950 806 765 765

Utah 3 3 3 3 3

Vermont 18 18 18 18 18

Virginia 70 68 66 63 59

Washington 174 171 166 157 148

West Virginia 64 63 61 58 54

Wisconsin 7 7 7 7 7

Wyoming 0 0 0.1 0.1 0.1.

--------------------------------------------------------------------

(3) State DSH allotments for fiscal year 2003 and thereafter

(A) In general

The DSH allotment for any State for fiscal year 2003 and each

succeeding fiscal year is equal to the DSH allotment for the

State for the preceding fiscal year under paragraph (2) or this

paragraph, increased, subject to subparagraph (B) and paragraph

(5) by the percentage change in the consumer price index for

all urban consumers (all items; U.S. city average), for the

previous fiscal year.

(B) Limitation

The DSH allotment for a State shall not be increased under

subparagraph (A) for a fiscal year to the extent that such an

increase would result in the DSH allotment for the year

exceeding the greater of -

(i) the DSH allotment for the previous year, or

(ii) 12 percent of the total amount of expenditures under

the State plan for medical assistance during the fiscal year.

(4) Special rule for fiscal years 2001 and 2002

(A) In general

Notwithstanding paragraph (2), the DSH allotment for any

State for -

(i) fiscal year 2001, shall be the DSH allotment determined

under paragraph (2) for fiscal year 2000 increased, subject

to subparagraph (B) and paragraph (5), by the percentage

change in the consumer price index for all urban consumers

(all items; U.S. city average) for fiscal year 2000; and

(ii) fiscal year 2002, shall be the DSH allotment

determined under clause (i) increased, subject to

subparagraph (B) and paragraph (5), by the percentage change

in the consumer price index for all urban consumers (all

items; U.S. city average) for fiscal year 2001.

(B) Limitation

Subparagraph (B) of paragraph (3) shall apply to subparagraph

(A) of this paragraph in the same manner as that subparagraph

(B) applies to paragraph (3)(A).

(C) No application to allotments after fiscal year 2002

The DSH allotment for any State for fiscal year 2003 or any

succeeding fiscal year shall be determined under paragraph (3)

without regard to the DSH allotments determined under

subparagraph (A) of this paragraph.

(5) Special rule for extremely low DSH States

In the case of a State in which the total expenditures under

the State plan (including Federal and State shares) for

disproportionate share hospital adjustments under this section

for fiscal year 1999, as reported to the Administrator of the

Health Care Financing Administration as of August 31, 2000, is

greater than 0 but less than 1 percent of the State's total

amount of expenditures under the State plan for medical

assistance during the fiscal year, the DSH allotment for fiscal

year 2001 shall be increased to 1 percent of the State's total

amount of expenditures under such plan for such assistance during

such fiscal year. In subsequent fiscal years, such increased

allotment is subject to an increase for inflation as provided in

paragraph (3)(A).

(6) "State" defined

In this subsection, the term "State" means the 50 States and

the District of Columbia.

(g) Limit on amount of payment to hospital

(1) Amount of adjustment subject to uncompensated costs

(A) In general

A payment adjustment during a fiscal year shall not be

considered to be consistent with subsection (c) of this section

with respect to a hospital if the payment adjustment exceeds

the costs incurred during the year of furnishing hospital

services (as determined by the Secretary and net of payments

under this subchapter, other than under this section, and by

uninsured patients) by the hospital to individuals who either

are eligible for medical assistance under the State plan or

have no health insurance (or other source of third party

coverage) for services provided during the year. For purposes

of the preceding sentence, payments made to a hospital for

services provided to indigent patients made by a State or a

unit of local government within a State shall not be considered

to be a source of third party payment.

(B) Limit to public hospitals during transition period

With respect to payment adjustments during a State fiscal

year that begins before January 1, 1995, subparagraph (A) shall

apply only to hospitals owned or operated by a State (or by an

instrumentality or a unit of government within a State).

(C) Modifications for private hospitals

With respect to hospitals that are not owned or operated by a

State (or by an instrumentality or a unit of government within

a State), the Secretary may make such modifications to the

manner in which the limitation on payment adjustments is

applied to such hospitals as the Secretary considers

appropriate.

(2) Additional amount during transition period for certain

hospitals with high disproportionate share

(A) In general

In the case of a hospital with high disproportionate share

(as defined in subparagraph (B)), a payment adjustment during a

State fiscal year that begins before January 1, 1995, shall be

considered consistent with subsection (c) of this section if

the payment adjustment does not exceed 200 percent of the costs

of furnishing hospital services described in paragraph (1)(A)

during the year, but only if the Governor of the State

certifies to the satisfaction of the Secretary that the

hospital's applicable minimum amount is used for health

services during the year. In determining the amount that is

used for such services during a year, there shall be excluded

any amounts received under the Public Health Service Act [42

U.S.C. 201 et seq.], subchapter V of this chapter, subchapter

XVIII of this chapter, or from third party payors (not

including the State plan under this subchapter) that are used

for providing such services during the year.

(B) "Hospital with high disproportionate share" defined

In subparagraph (A), a hospital is a "hospital with high

disproportionate share" if -

(i) the hospital is owned or operated by a State (or by an

instrumentality or a unit of government within a State); and

(ii) the hospital -

(I) meets the requirement described in subsection

(b)(1)(A) of this section, or

(II) has the largest number of inpatient days

attributable to individuals entitled to benefits under the

State plan of any hospital in such State for the previous

State fiscal year.

(C) "Applicable minimum amount" defined

In subparagraph (A), the "applicable minimum amount" for a

hospital for a fiscal year is equal to the difference between

the amount of the hospital's payment adjustment for the fiscal

year and the costs to the hospital of furnishing hospital

services described in paragraph (1)(A) during the fiscal year.

(h) Limitation on certain State DSH expenditures

(1) In general

Payment under section 1396b(a) of this title shall not be made

to a State with respect to any payment adjustments made under

this section for quarters in a fiscal year (beginning with fiscal

year 1998) to institutions for mental diseases or other mental

health facilities, to the extent the aggregate of such

adjustments in the fiscal year exceeds the lesser of the

following:

(A) 1995 IMD DSH payment adjustments

The total State DSH expenditures that are attributable to

fiscal year 1995 for payments to institutions for mental

diseases and other mental health facilities (based on reporting

data specified by the State on HCFA Form 64 as mental health

DSH, and as approved by the Secretary).

(B) Applicable percentage of 1995 total DSH payment allotment

The amount of such payment adjustments which are equal to the

applicable percentage of the Federal share of payment

adjustments made to hospitals in the State under subsection (c)

of this section that are attributable to the 1995 DSH allotment

for the State for payments to institutions for mental diseases

and other mental health facilities (based on reporting data

specified by the State on HCFA Form 64 as mental health DSH,

and as approved by the Secretary).

(2) Applicable percentage

(A) In general

For purposes of paragraph (1), the applicable percentage with

respect to -

(i) each of fiscal years 1998, 1999, and 2000, is the

percentage determined under subparagraph (B); or

(ii) a succeeding fiscal year is the lesser of the

percentage determined under subparagraph (B) or the following

percentage:

(I) For fiscal year 2001, 50 percent.

(II) For fiscal year 2002, 40 percent.

(III) For each succeeding fiscal year, 33 percent.

(B) 1995 percentage

The percentage determined under this subparagraph is the

ratio (determined as a percentage) of -

(i) the Federal share of payment adjustments made to

hospitals in the State under subsection (c) of this section

that are attributable to the 1995 DSH allotment for the State

(as reported by the State not later than January 1, 1997, on

HCFA Form 64, and as approved by the Secretary) for payments

to institutions for mental diseases and other mental health

facilities, to

(ii) the State 1995 DSH spending amount.

(C) State 1995 DSH spending amount

For purposes of subparagraph (B)(ii), the "State 1995 DSH

spending amount", with respect to a State, is the Federal

medical assistance percentage (for fiscal year 1995) of the

payment adjustments made under subsection (c) of this section

under the State plan that are attributable to the fiscal year

1995 DSH allotment for the State (as reported by the State not

later than January 1, 1997, on HCFA Form 64, and as approved by

the Secretary).

(i) Requirement for direct payment

(1) In general

No payment may be made under section 1396b(a)(1) of this title

with respect to a payment adjustment made under this section, for

services furnished by a hospital on or after October 1, 1997,

with respect to individuals eligible for medical assistance under

the State plan who are enrolled with a managed care entity (as

defined in section 1396u-2(a)(1)(B) of this title) or under any

other managed care arrangement unless a payment, equal to the

amount of the payment adjustment -

(A) is made directly to the hospital by the State; and

(B) is not used to determine the amount of a prepaid

capitation payment under the State plan to the entity or

arrangement with respect to such individuals.

(2) Exception for current arrangements

Paragraph (1) shall not apply to a payment adjustment provided

pursuant to a payment arrangement in effect on July 1, 1997.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1923, formerly Pub. L.

100-203, title IV, Sec. 4112, Dec. 22, 1987, 101 Stat. 1330-148;

renumbered Sec. 1923 of act Aug. 14, 1935, and amended Pub. L.

100-360, title III, Sec. 302(b)(2), title IV, Sec.

411(k)(6)(A)-(B)(ix), July 1, 1988, 102 Stat. 752, 792-794; Pub. L.

100-485, title VI, Sec. 608(d)(15)(C), (26)(A)-(F), Oct. 13, 1988,

102 Stat. 2417, 2421, 2422; Pub. L. 101-239, title VI, Sec.

6411(c)(1), Dec. 19, 1989, 103 Stat. 2270; Pub. L. 101-508, title

IV, Secs. 4702(a), 4703(a)-(c), Nov. 5, 1990, 104 Stat. 1388-171;

Pub. L. 102-234, Secs. 3(b)(1), (2)(A), (c), Dec. 12, 1991, 105

Stat. 1799, 1802, 1803; Pub. L. 103-66, title XIII, Sec.

13621(a)(1), (b)(1), (2), Aug. 10, 1993, 107 Stat. 629-631; Pub. L.

105-33, title IV, Secs. 4711(c)(2), 4721(a)(1), (b)-(d), Aug. 5,

1997, 111 Stat. 508, 511, 513, 514; Pub. L. 106-113, div. B, Sec.

1000(a)(6) [title VI, Secs. 601(a), 608(s)], Nov. 29, 1999, 113

Stat. 1536, 1501A-394, 1501A-397; Pub. L. 106-554, Sec. 1(a)(6)

[title VII, Sec. 701(a)(1), (2), (b)(2)], Dec. 21, 2000, 114 Stat.

2763, 2763A-569, 2763A-570.)