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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EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by section 1 [[div. A], title VII, Sec. 712(a)(2)] of

Pub. L. 106-398 effective Oct. 1, 2001, see section 1 [[div. A],

title VII, Sec. 712(a)(3)] of Pub. L. 106-398, set out as a note

under section 1086 of Title 10, Armed Forces.

Pub. L. 106-398, Sec. 1 [[div. A], title VII, Sec. 712(f)], Oct.

30, 2000, 114 Stat. 1654, 1654A-179, provided that:

"(1) Upon negotiating an agreement under the amendment made by

subsection (c)(1) [amending this section], the Secretary of Defense

and the Secretary of Health and Human Services shall jointly

transmit a notification of the proposed agreement to the Committee

on Armed Services and the Committee on Finance of the Senate and

the Committee on Armed Services and the Committee on Ways and Means

of the House of Representatives, and shall include with the

transmittal a copy of the proposed agreement and all related

agreements and supporting documents.

"(2) Such proposed agreement shall take effect, and the

amendments made by subsections (c)(2), (c)(3), (d), and (e)

[amending this section] shall take effect, on such date as is

provided for in such agreement and in an Act enacted after the date

of the enactment of this Act [Oct. 30, 2000]."

REPEAL OF SUBSECTION (K)(2)

Pub. L. 107-314, div. A, title VII, Sec. 713, Dec. 2, 2002, 116

Stat. 2589, provided that: "Notwithstanding subsection (f)(2) of

section 712 of the Floyd D. Spence National Defense Authorization

Act for Fiscal Year 2001 [set out above] (as enacted into law by

Public Law 106-398; 114 Stat. 1654A-179), the amendment made by

subsection (e) of such section [amending this section] shall not

take effect and the paragraph amended by such subsection is

repealed."

IMPLEMENTATION PLAN FOR VETERANS SUBVENTION

Section 4015(b) of Pub. L. 105-33 provided that: "Not later than

12 months after the start of the demonstration project, the

Secretary of Health and Human Services and the Secretary of

Veterans Affairs shall jointly submit to Congress a detailed

implementation plan for a subvention demonstration project (that

follows the model of the demonstration project conducted under

section 1896 of the Social Security Act [this section] (as added by

subsection (a)) to begin in 1999 for veterans (as defined in

section 101 of title 38, United States Code) that are eligible for

benefits under title XVIII of the Social Security Act [this

subchapter]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in title 10 section 1108.

-FOOTNOTE-

(!1) See References in Text note below.

-End-

-CITE-

42 USC SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL

ASSISTANCE PROGRAMS 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-

SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

-SECREF-

SUBCHAPTER REFERRED TO IN OTHER SECTIONS

This subchapter is referred to in sections 233, 247b-1, 247b-4a,

247b-5, 247b-16, 254b, 254e, 254g, 254h, 256b, 256g, 263a, 280c-6,

280g, 280g-1, 290bb-1, 290bb-25, 290bb-39, 290ff, 290ff-1, 290jj,

299a, 299b-6, 299c-2, 300b-8, 300e, 300e-6, 300l, 300l-1, 300x-3,

300x-24, 300z-5, 300aa-15, 300ff-12, 300ff-14, 300ff-21, 300ff-25,

300ff-27, 300ff-52, 300gg, 300gg-41, 602, 603, 608, 609, 611, 652,

654, 654a, 658a, 671, 672, 673, 701, 704, 705, 706, 709, 902, 904,

912, 1301, 1302, 1306, 1308, 1309, 1310, 1315, 1316, 1318, 1320a-1,

1320a-3, 1320a-5, 1320a-7, 1320a-7a, 1320a-7b, 1320a-7d, 1320a-7f,

1320a-8a, 1320b-2, 1320b-3, 1320b-4, 1320b-5, 1320b-7, 1320b-8,

1320b-20, 1320b-22, 1320c-2, 1320c-10, 1320d, 1382, 1382b, 1382g,

1382h, 1382i, 1383, 1383c, 1395b-1, 1395b-2, 1395b-4, 1395i,

1395i-2, 1395i-3, 1395i-5, 1395s, 1395u, 1395v, 1395w-4, 1395w-21,

1395w-28, 1395x, 1395z, 1395cc, 1395mm, 1395ss, 1395tt, 1395vv,

1395ww, 1395bbb, 1395eee, 1397d, 1397aa, 1397bb, 1397ee, 1397gg,

1397hh, 1397jj, 1758, 1766, 1786, 1997, 3002, 3012, 3013, 3026,

3058e, 8013, 8624, 10805, 11398, 11707, 14402, 15025 of this title;

title 7 sections 2012, 2014, 2025, 3178; title 8 sections 1182,

1255a, 1522, 1611, 1612, 1613; title 10 sections 1079, 1095; title

12 sections 1715w, 1715z-7; title 18 section 4006; title 20

sections 1412, 1413, 1440, 6082, 6537, 7182; title 21 section 862a;

title 23 section 157; title 24 section 170a; title 25 sections

1616m, 1642, 1643, 1644, 1645, 1680c; title 26 sections 35, 6103,

9801; title 29 sections 720, 1144, 1169, 1181, 2918; title 38

sections 1722, 1725, 1729, 5503, 7423, 8126.

-End-

-CITE-

42 USC Sec. 1396 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. 1396. Appropriations

-STATUTE-

For the purpose of enabling each State, as far as practicable

under the conditions in such State, to furnish (1) medical

assistance on behalf of families with dependent children and of

aged, blind, or disabled individuals, whose income and resources

are insufficient to meet the costs of necessary medical services,

and (2) rehabilitation and other services to help such families and

individuals attain or retain capability for independence or

self-care, there is hereby authorized to be appropriated for each

fiscal year a sum sufficient to carry out the purposes of this

subchapter. The sums made available under this section shall be

used for making payments to States which have submitted, and had

approved by the Secretary, State plans for medical assistance.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1901, as added Pub. L.

89-97, title I, Sec. 121(a), July 30, 1965, 79 Stat. 343; amended

Pub. L. 93-233, Sec. 13(a)(1), Dec. 31, 1973, 87 Stat. 960; Pub. L.

98-369, div. B, title VI, Sec. 2663(j)(3)(C), July 18, 1984, 98

Stat. 1171.)

-MISC1-

AMENDMENTS

1984 - Pub. L. 98-369 struck out "Health, Education, and Welfare"

after "Secretary".

1973 - Pub. L. 93-233 substituted "disabled individuals" for

"permanently and totally disabled individuals" in cl. (1).

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by Pub. L. 98-369 effective July 18, 1984, but not to

be construed as changing or affecting any right, liability, status,

or interpretation which existed (under the provisions of law

involved) before that date, see section 2664(b) of Pub. L. 98-369,

set out as a note under section 401 of this title.

EFFECTIVE DATE OF 1973 AMENDMENT

Amendment by 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.

-End-

-CITE-

42 USC Sec. 1396a 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. 1396a. State plans for medical assistance

-STATUTE-

(a) Contents

A State plan for medical assistance must -

(1) provide that it shall be in effect in all political

subdivisions of the State, and, if administered by them, be

mandatory upon them;

(2) provide for financial participation by the State equal to

not less than 40 per centum of the non-Federal share of the

expenditures under the plan with respect to which payments under

section 1396b of this title are authorized by this subchapter;

and, effective July 1, 1969, provide for financial participation

by the State equal to all of such non-Federal share or provide

for distribution of funds from Federal or State sources, for

carrying out the State plan, on an equalization or other basis

which will assure that the lack of adequate funds from local

sources will not result in lowering the amount, duration, scope,

or quality of care and services available under the plan;

(3) provide for granting an opportunity for a fair hearing

before the State agency to any individual whose claim for medical

assistance under the plan is denied or is not acted upon with

reasonable promptness;

(4) provide (A) such methods of administration (including

methods relating to the establishment and maintenance of

personnel standards on a merit basis, except that the Secretary

shall exercise no authority with respect to the selection, tenure

of office, and compensation of any individual employed in

accordance with such methods, and including provision for

utilization of professional medical personnel in the

administration and, where administered locally, supervision of

administration of the plan) as are found by the Secretary to be

necessary for the proper and efficient operation of the plan, (B)

for the training and effective use of paid subprofessional staff,

with particular emphasis on the full-time or part-time employment

of recipients and other persons of low income, as community

service aides, in the administration of the plan and for the use

of nonpaid or partially paid volunteers in a social service

volunteer program in providing services to applicants and

recipients and in assisting any advisory committees established

by the State agency, (C) that each State or local officer,

employee, or independent contractor who is responsible for the

expenditure of substantial amounts of funds under the State plan,

each individual who formerly was such an officer, employee, or

contractor, and each partner of such an officer, employee, or

contractor shall be prohibited from committing any act, in

relation to any activity under the plan, the commission of which,

in connection with any activity concerning the United States

Government, by an officer or employee of the United States

Government, an individual who was such an officer or employee, or

a partner of such an officer or employee is prohibited by section

207 or 208 of title 18, and (D) that each State or local officer,

employee, or independent contractor who is responsible for

selecting, awarding, or otherwise obtaining items and services

under the State plan shall be subject to safeguards against

conflicts of interest that are at least as stringent as the

safeguards that apply under section 423 of title 41 to persons

described in subsection (a)(2) of section 423 of title 41;

(5) either provide for the establishment or designation of a

single State agency to administer or to supervise the

administration of the plan; or provide for the establishment or

designation of a single State agency to administer or to

supervise the administration of the plan, except that the

determination of eligibility for medical assistance under the

plan shall be made by the State or local agency administering the

State plan approved under subchapter I or XVI of this chapter

(insofar as it relates to the aged) if the State is eligible to

participate in the State plan program established under

subchapter XVI of this chapter, or by the agency or agencies

administering the supplemental security income program

established under subchapter XVI or the State plan approved under

part A of subchapter IV of this chapter if the State is not

eligible to participate in the State plan program established

under subchapter XVI of this chapter;

(6) provide that the State agency will make such reports, in

such form and containing such information, as the Secretary may

from time to time require, and comply with such provisions as the

Secretary may from time to time find necessary to assure the

correctness and verification of such reports;

(7) provide safeguards which restrict the use or disclosure of

information concerning applicants and recipients to purposes

directly connected with the administration of the plan;

(8) provide that all individuals wishing to make application

for medical assistance under the plan shall have opportunity to

do so, and that such assistance shall be furnished with

reasonable promptness to all eligible individuals;

(9) provide -

(A) that the State health agency, or other appropriate State

medical agency (whichever is utilized by the Secretary for the

purpose specified in the first sentence of section 1395aa(a) of

this title), shall be responsible for establishing and

maintaining health standards for private or public institutions

in which recipients of medical assistance under the plan may

receive care or services,

(B) for the establishment or designation of a State authority

or authorities which shall be responsible for establishing and

maintaining standards, other than those relating to health, for

such institutions, and

(C) that any laboratory services paid for under such plan

must be provided by a laboratory which meets the applicable

requirements of section 1395x(e)(9) of this title or paragraphs

(16) and (17) of section 1395x(s) of this title, or, in the

case of a laboratory which is in a rural health clinic, of

section 1395x(aa)(2)(G) of this title;

(10) provide -

(A) for making medical assistance available, including at

least the care and services listed in paragraphs (1) through

(5), (17) and (21) of section 1396d(a) of this title, to -

(i) all individuals -

(I) who are receiving aid or assistance under any plan of

the State approved under subchapter I, X, XIV, or XVI of

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

chapter (including individuals eligible under this

subchapter by reason of section 602(a)(37),(!1) 606(h),(!1)

or 673(b) of this title, or considered by the State to be

receiving such aid as authorized under section

682(e)(6)(!1) of this title),

(II) with respect to whom supplemental security income

benefits are being paid under subchapter XVI of this

chapter (or were being paid as of the date of the enactment

of section 211(a) of the Personal Responsibility and Work

Opportunity Reconciliation Act of 1996 (P.L. 104-193)) and

would continue to be paid but for the enactment of that

section or who are qualified severely impaired individuals

(as defined in section 1396d(q) of this title),

(III) who are qualified pregnant women or children as

defined in section 1396d(n) of this title,

(IV) who are described in subparagraph (A) or (B) of

subsection (l)(1) of this section and whose family income

does not exceed the minimum income level the State is

required to establish under subsection (l)(2)(A) of this

section for such a family; (!2)

(V) who are qualified family members as defined in

section 1396d(m)(1) of this title,

(VI) who are described in subparagraph (C) of subsection

(l)(1) of this section and whose family income does not

exceed the income level the State is required to establish

under subsection (l)(2)(B) of this section for such a

family, or

(VII) who are described in subparagraph (D) of subsection

(l)(1) of this section and whose family income does not

exceed the income level the State is required to establish

under subsection (l)(2)(C) of this section for such a

family; (!3)

(ii) at the option of the State, to (!4) any group or

groups of individuals described in section 1396d(a) of this

title (or, in the case of individuals described in section

1396d(a)(i) of this title, to (!4) any reasonable categories

of such individuals) who are not individuals described in

clause (i) of this subparagraph but -

(I) who meet the income and resources requirements of the

appropriate State plan described in clause (i) or the

supplemental security income program (as the case may be),

(II) who would meet the income and resources requirements

of the appropriate State plan described in clause (i) if

their work-related child care costs were paid from their

earnings rather than by a State agency as a service

expenditure,

(III) who would be eligible to receive aid under the

appropriate State plan described in clause (i) if coverage

under such plan was as broad as allowed under Federal law,

(IV) with respect to whom there is being paid, or who are

eligible, or would be eligible if they were not in a

medical institution, to have paid with respect to them, aid

or assistance under the appropriate State plan described in

clause (i), supplemental security income benefits under

subchapter XVI of this chapter, or a State supplementary

payment; (!2)

(V) who are in a medical institution for a period of not

less than 30 consecutive days (with eligibility by reason

of this subclause beginning on the first day of such

period), who meet the resource requirements of the

appropriate State plan described in clause (i) or the

supplemental security income program, and whose income does

not exceed a separate income standard established by the

State which is consistent with the limit established under

section 1396b(f)(4)(C) of this title,

(VI) who would be eligible under the State plan under

this subchapter if they were in a medical institution, with

respect to whom there has been a determination that but for

the provision of home or community-based services described

in subsection (c), (d), or (e) of section 1396n of this

title they would require the level of care provided in a

hospital, nursing facility or intermediate care facility

for the mentally retarded the cost of which could be

reimbursed under the State plan, and who will receive home

or community-based services pursuant to a waiver granted by

the Secretary under subsection (c), (d), or (e) of section

1396n of this title,

(VII) who would be eligible under the State plan under

this subchapter if they were in a medical institution, who

are terminally ill, and who will receive hospice care

pursuant to a voluntary election described in section

1396d(o) of this title; (!5)

(VIII) who is a child described in section 1396d(a)(i) of

this title -

(aa) for whom there is in effect an adoption assistance

agreement (other than an agreement under part E of

subchapter IV of this chapter) between the State and an

adoptive parent or parents,

(bb) who the State agency responsible for adoption

assistance has determined cannot be placed with adoptive

parents without medical assistance because such child has

special needs for medical or rehabilitative care, and

(cc) who was eligible for medical assistance under the

State plan prior to the adoption assistance agreement

being entered into, or who would have been eligible for

medical assistance at such time if the eligibility

standards and methodologies of the State's foster care

program under part E of subchapter IV of this chapter

were applied rather than the eligibility standards and

methodologies of the State's aid to families with

dependent children program under part A of subchapter IV

of this chapter; (!5)

(IX) who are described in subsection (l)(1) of this

section and are not described in clause (i)(IV), clause

(i)(VI), or clause (i)(VII); (!5)

(X) who are described in subsection (m)(1) of this

section; (!5)

(XI) who receive only an optional State supplementary

payment based on need and paid on a regular basis, equal to

the difference between the individual's countable income

and the income standard used to determine eligibility for

such supplementary payment (with countable income being the

income remaining after deductions as established by the

State pursuant to standards that may be more restrictive

than the standards for supplementary security income

benefits under subchapter XVI of this chapter), which are

available to all individuals in the State (but which may be

based on different income standards by political

subdivision according to cost of living differences), and

which are paid by a State that does not have an agreement

with the Commissioner of Social Security under section

1382e or 1383c of this title; (!5)

(XII) who are described in subsection (z)(1) of this

section (relating to certain TB-infected individuals); (!5)

(XIII) who are in families whose income is less than 250

percent of the income official poverty line (as defined by

the Office of Management and Budget, and revised annually

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

applicable to a family of the size involved, and who but

for earnings in excess of the limit established under

section 1396d(q)(2)(B) of this title, would be considered

to be receiving supplemental security income (subject,

notwithstanding section 1396o of this title, to payment of

premiums or other cost-sharing charges (set on a sliding

scale based on income) that the State may determine); (!5)

(XIV) who are optional targeted low-income children

described in section 1396d(u)(2)(B) of this title; (!5)

(XV) who, but for earnings in excess of the limit

established under section 1396d(q)(2)(B) of this title,

would be considered to be receiving supplemental security

income, who is at least 16, but less than 65, years of age,

and whose assets, resources, and earned or unearned income

(or both) do not exceed such limitations (if any) as the

State may establish; (!5)

(XVI) who are employed individuals with a medically

improved disability described in section 1396d(v)(1) of

this title and whose assets, resources, and earned or

unearned income (or both) do not exceed such limitations

(if any) as the State may establish, but only if the State

provides medical assistance to individuals described in

subclause (XV); (!5)

(XVII) who are independent foster care adolescents (as

defined in section 1396d(w)(1) of this title), or who are

within any reasonable categories of such adolescents

specified by the State; or

(XVIII) who are described in subsection (aa) of this

section (relating to certain breast or cervical cancer

patients);

(B) that the medical assistance made available to any

individual described in subparagraph (A) -

(i) shall not be less in amount, duration, or scope than

the medical assistance made available to any other such

individual, and

(ii) shall not be less in amount, duration, or scope than

the medical assistance made available to individuals not

described in subparagraph (A);

(C) that if medical assistance is included for any group of

individuals described in section 1396d(a) of this title who are

not described in subparagraph (A) or (E), then -

(i) the plan must include a description of (I) the criteria

for determining eligibility of individuals in the group for

such medical assistance, (II) the amount, duration, and scope

of medical assistance made available to individuals in the

group, and (III) the single standard to be employed in

determining income and resource eligibility for all such

groups, and the methodology to be employed in determining

such eligibility, which shall be no more restrictive than the

methodology which would be employed under the supplemental

security income program in the case of groups consisting of

aged, blind, or disabled individuals in a State in which such

program is in effect, and which shall be no more restrictive

than the methodology which would be employed under the

appropriate State plan (described in subparagraph (A)(i)) to

which such group is most closely categorically related in the

case of other groups;

(ii) the plan must make available medical assistance -

(I) to individuals under the age of 18 who (but for

income and resources) would be eligible for medical

assistance as an individual described in subparagraph

(A)(i), and

(II) to pregnant women, during the course of their

pregnancy, who (but for income and resources) would be

eligible for medical assistance as an individual described

in subparagraph (A);

(iii) such medical assistance must include (I) with respect

to children under 18 and individuals entitled to

institutional services, ambulatory services, and (II) with

respect to pregnant women, prenatal care and delivery

services; and

(iv) if such medical assistance includes services in

institutions for mental diseases or in an intermediate care

facility for the mentally retarded (or both) for any such

group, it also must include for all groups covered at least

the care and services listed in paragraphs (1) through (5)

and (17) of section 1396d(a) of this title or the care and

services listed in any 7 of the paragraphs numbered (1)

through (24) of such section;

(D) for the inclusion of home health services for any

individual who, under the State plan, is entitled to nursing

facility services;

(E)(i) for making medical assistance available for medicare

cost-sharing (as defined in section 1396d(p)(3) of this title)

for qualified medicare beneficiaries described in section

1396d(p)(1) of this title;

(ii) for making medical assistance available for payment of

medicare cost-sharing described in section 1396d(p)(3)(A)(i) of

this title for qualified disabled and working individuals

described in section 1396d(s) of this title;

(iii) for making medical assistance available for medicare

cost sharing described in section 1396d(p)(3)(A)(ii) of this

title subject to section 1396d(p)(4) of this title, for

individuals who would be qualified medicare beneficiaries

described in section 1396d(p)(1) of this title but for the fact

that their income exceeds the income level established by the

State under section 1396d(p)(2) of this title but is less than

110 percent in 1993 and 1994, and 120 percent in 1995 and years

thereafter of the official poverty line (referred to in such

section) for a family of the size involved; and

(iv) subject to sections 1396u-3 and 1396d(p)(4) of this

title, for making medical assistance available (but only for

premiums payable with respect to months during the period

beginning with January 1998, and ending with December 2002) -

(I) for medicare cost-sharing described in section

1396d(p)(3)(A)(ii) of this title for individuals who would be

qualified medicare beneficiaries described in section

1396d(p)(1) of this title but for the fact that their income

exceeds the income level established by the State under

section 1396d(p)(2) of this title and is at least 120

percent, but less than 135 percent, of the official poverty

line (referred to in such section) for a family of the size

involved and who are not otherwise eligible for medical

assistance under the State plan, and

(II) for the portion of medicare cost-sharing described in

section 1396d(p)(3)(A)(ii) of this title that is attributable

to the operation of the amendments made by (and subsection

(e)(3) of) section 4611 of the Balanced Budget Act of 1997

for individuals who would be described in subclause (I) if

"135 percent" and "175 percent" were substituted for "120

percent" and "135 percent" respectively;

(F) at the option of a State, for making medical assistance

available for COBRA premiums (as defined in subsection (u)(2)

of this section) for qualified COBRA continuation beneficiaries

described in subsection (u)(1) of this section; and

(G) that, in applying eligibility criteria of the

supplemental security income program under subchapter XVI of

this chapter for purposes of determining eligibility for

medical assistance under the State plan of an individual who is

not receiving supplemental security income, the State will

disregard the provisions of subsections (c) and (e) of section

1382b of this title;

except that (I) the making available of the services described in

paragraph (4), (14), or (16) of section 1396d(a) of this title to

individuals meeting the age requirements prescribed therein shall

not, by reason of this paragraph (10), require the making

available of any such services, or the making available of such

services of the same amount, duration, and scope, to individuals

of any other ages, (II) the making available of supplementary

medical insurance benefits under part B of subchapter XVIII of

this chapter to individuals eligible therefor (either pursuant to

an agreement entered into under section 1395v of this title or by

reason of the payment of premiums under such subchapter by the

State agency on behalf of such individuals), or provision for

meeting part or all of the cost of deductibles, cost sharing, or

similar charges under part B of subchapter XVIII of this chapter

for individuals eligible for benefits under such part, shall not,

by reason of this paragraph (10), require the making available of

any such benefits, or the making available of services of the

same amount, duration, and scope, to any other individuals, (III)

the making available of medical assistance equal in amount,

duration, and scope to the medical assistance made available to

individuals described in clause (A) to any classification of

individuals approved by the Secretary with respect to whom there

is being paid, or who are eligible, or would be eligible if they

were not in a medical institution, to have paid with respect to

them, a State supplementary payment shall not, by reason of this

paragraph (10), require the making available of any such

assistance, or the making available of such assistance of the

same amount, duration, and scope, to any other individuals not

described in clause (A), (IV) the imposition of a deductible,

cost sharing, or similar charge for any item or service furnished

to an individual not eligible for the exemption under section

1396o(a)(2) or (b)(2) of this title shall not require the

imposition of a deductible, cost sharing, or similar charge for

the same item or service furnished to an individual who is

eligible for such exemption, (V) the making available to pregnant

women covered under the plan of services relating to pregnancy

(including prenatal, delivery, and postpartum services) or to any

other condition which may complicate pregnancy shall not , by

reason of this paragraph (10), require the making available of

such services, or the making available of such services of the

same amount, duration, and scope, to any other individuals,

provided such services are made available (in the same amount,

duration, and scope) to all pregnant women covered under the

State plan, (VI) with respect to the making available of medical

assistance for hospice care to terminally ill individuals who

have made a voluntary election described in section 1396d(o) of

this title to receive hospice care instead of medical assistance

for certain other services, such assistance may not be made

available in an amount, duration, or scope less than that

provided under subchapter XVIII of this chapter, and the making

available of such assistance shall not, by reason of this

paragraph (10), require the making available of medical

assistance for hospice care to other individuals or the making

available of medical assistance for services waived by such

terminally ill individuals, (VII) the medical assistance made

available to an individual described in subsection (l)(1)(A) of

this section who is eligible for medical assistance only because

of subparagraph (A)(i)(IV) or (A)(ii)(IX) shall be limited to

medical assistance for services related to pregnancy (including

prenatal, delivery, postpartum, and family planning services) and

to other conditions which may complicate pregnancy, (VIII) the

medical assistance made available to a qualified medicare

beneficiary described in section 1396d(p)(1) of this title who is

only entitled to medical assistance because the individual is

such a beneficiary shall be limited to medical assistance for

medicare cost-sharing (described in section 1396d(p)(3) of this

title), subject to the provisions of subsection (n) of this

section and section 1396o(b) of this title, (IX) the making

available of respiratory care services in accordance with

subsection (e)(9) of this section shall not, by reason of this

paragraph (10), require the making available of such services, or

the making available of such services of the same amount,

duration, and scope, to any individuals not included under

subsection (e)(9)(A) of this section, provided such services are

made available (in the same amount, duration, and scope) to all

individuals described in such subsection, (X) if the plan

provides for any fixed durational limit on medical assistance for

inpatient hospital services (whether or not such a limit varies

by medical condition or diagnosis), the plan must establish

exceptions to such a limit for medically necessary inpatient

hospital services furnished with respect to individuals under one

year of age in a hospital defined under the State plan, pursuant

to section 1396r-4(a)(1)(A) of this title, as a disproportionate

share hospital and subparagraph (B) (relating to comparability)

shall not be construed as requiring such an exception for other

individuals, services, or hospitals, (XI) the making available of

medical assistance to cover the costs of premiums, deductibles,

coinsurance, and other cost-sharing obligations for certain

individuals for private health coverage as described in section

1396e of this title shall not, by reason of paragraph (10),

require the making available of any such benefits or the making

available of services of the same amount, duration, and scope of

such private coverage to any other individuals, (XII) the medical

assistance made available to an individual described in

subsection (u)(1) of this section who is eligible for medical

assistance only because of subparagraph (F) shall be limited to

medical assistance for COBRA continuation premiums (as defined in

subsection (u)(2) of this section), (XIII) the medical assistance

made available to an individual described in subsection (z)(1) of

this section who is eligible for medical assistance only because

of subparagraph (A)(ii)(XII) shall be limited to medical

assistance for TB-related services (described in subsection

(z)(2) of this section), and (XIV) the medical assistance made

available to an individual described in subsection (aa) of this

section who is eligible for medical assistance only because of

subparagraph (A)(10)(ii)(XVIII) shall be limited to medical

assistance provided during the period in which such an individual

requires treatment for breast or cervical cancer;

(11)(A) provide for entering into cooperative arrangements with

the State agencies responsible for administering or supervising

the administration of health services and vocational

rehabilitation services in the State looking toward maximum

utilization of such services in the provision of medical

assistance under the plan, (B) provide, to the extent prescribed

by the Secretary, for entering into agreements, with any agency,

institution, or organization receiving payments under (or through

an allotment under) subchapter V of this chapter, (i) providing

for utilizing such agency, institution, or organization in

furnishing care and services which are available under such

subchapter or allotment and which are included in the State plan

approved under this section (!6) (ii) making such provision as

may be appropriate for reimbursing such agency, institution, or

organization for the cost of any such care and services furnished

any individual for which payment would otherwise be made to the

State with respect to the individual under section 1396b of this

title, and (iii) providing for coordination of information and

education on pediatric vaccinations and delivery of immunization

services, and (C) provide for coordination of the operations

under this subchapter, including the provision of information and

education on pediatric vaccinations and the delivery of

immunization services, with the State's operations under the

special supplemental nutrition program for women, infants, and

children under section 1786 of this title;

(12) provide that, in determining whether an individual is

blind, there shall be an examination by a physician skilled in

the diseases of the eye or by an optometrist, whichever the

individual may select;

(13) provide -

(A) for a public process for determination of rates of

payment under the plan for hospital services, nursing facility

services, and services of intermediate care facilities for the

mentally retarded under which -

(i) proposed rates, the methodologies underlying the

establishment of such rates, and justifications for the

proposed rates are published,

(ii) providers, beneficiaries and their representatives,

and other concerned State residents are given a reasonable

opportunity for review and comment on the proposed rates,

methodologies, and justifications,

(iii) final rates, the methodologies underlying the

establishment of such rates, and justifications for such

final rates are published, and

(iv) in the case of hospitals, such rates take into account

(in a manner consistent with section 1396r-4 of this title)

the situation of hospitals which serve a disproportionate

number of low-income patients with special needs; and

(B) for payment for hospice care in amounts no lower than the

amounts, using the same methodology, used under part A of

subchapter XVIII of this chapter and for payment of amounts

under section 1396d(o)(3) of this title; except that in the

case of hospice care which is furnished to an individual who is

a resident of a nursing facility or intermediate care facility

for the mentally retarded, and who would be eligible under the

plan for nursing facility services or services in an

intermediate care facility for the mentally retarded if he had

not elected to receive hospice care, there shall be paid an

additional amount, to take into account the room and board

furnished by the facility, equal to at least 95 percent of the

rate that would have been paid by the State under the plan for

facility services in that facility for that individual;

(14) provide that enrollment fees, premiums, or similar

charges, and deductions, cost sharing, or similar charges, may be

imposed only as provided in section 1396o of this title;

(15) provide for payment for services described in clause (B)

or (C) of section 1396d(a)(2) of this title under the plan in

accordance with subsection (bb) of this section;

(16) provide for inclusion, to the extent required by

regulations prescribed by the Secretary, of provisions

(conforming to such regulations) with respect to the furnishing

of medical assistance under the plan to individuals who are

residents of the State but are absent therefrom;

(17) except as provided in subsections (l)(3), (m)(3), and

(m)(4) of this section, include reasonable standards (which shall

be comparable for all groups and may, in accordance with

standards prescribed by the Secretary, differ with respect to

income levels, but only in the case of applicants or recipients

of assistance under the plan who are not receiving aid or

assistance under any plan of the State approved under subchapter

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

and with respect to whom supplemental security income benefits

are not being paid under subchapter XVI of this chapter, based on

the variations between shelter costs in urban areas and in rural

areas) for determining eligibility for and the extent of medical

assistance under the plan which (A) are consistent with the

objectives of this subchapter, (B) provide for taking into

account only such income and resources as are, as determined in

accordance with standards prescribed by the Secretary, available

to the applicant or recipient and (in the case of any applicant

or recipient who would, except for income and resources, be

eligible for aid or assistance in the form of money payments

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

or XVI, or part A of subchapter IV, or to have paid with respect

to him supplemental security income benefits under subchapter XVI

of this chapter) as would not be disregarded (or set aside for

future needs) in determining his eligibility for such aid,

assistance, or benefits, (C) provide for reasonable evaluation of

any such income or resources, and (D) do not take into account

the financial responsibility of any individual for any applicant

or recipient of assistance under the plan unless such applicant

or recipient is such individual's spouse or such individual's

child who is under age 21 or (with respect to States eligible to

participate in the State program established under subchapter XVI

of this chapter), is blind or permanently and totally disabled,

or is blind or disabled as defined in section 1382c of this title

(with respect to States which are not eligible to participate in

such program); and provide for flexibility in the application of

such standards with respect to income by taking into account,

except to the extent prescribed by the Secretary, the costs

(whether in the form of insurance premiums, payments made to the

State under section 1396b(f)(2)(B) of this title, or otherwise

and regardless of whether such costs are reimbursed under another

public program of the State or political subdivision thereof)

incurred for medical care or for any other type of remedial care

recognized under State law;

(18) comply with the provisions of section 1396p of this title

with respect to liens, adjustments and recoveries of medical

assistance correctly paid,,(!7) transfers of assets, and

treatment of certain trusts;

(19) provide such safeguards as may be necessary to assure that

eligibility for care and services under the plan will be

determined, and such care and services will be provided, in a

manner consistent with simplicity of administration and the best

interests of the recipients;

(20) if the State plan includes medical assistance in behalf of

individuals 65 years of age or older who are patients in

institutions for mental diseases -

(A) provide for having in effect such agreements or other

arrangements with State authorities concerned with mental

diseases, and, where appropriate, with such institutions, as

may be necessary for carrying out the State plan, including

arrangements for joint planning and for development of

alternate methods of care, arrangements providing assurance of

immediate readmittance to institutions where needed for

individuals under alternate plans of care, and arrangements

providing for access to patients and facilities, for furnishing

information, and for making reports;

(B) provide for an individual plan for each such patient to

assure that the institutional care provided to him is in his

best interests, including, to that end, assurances that there

will be initial and periodic review of his medical and other

needs, that he will be given appropriate medical treatment

within the institution, and that there will be a periodic

determination of his need for continued treatment in the

institution; and

(C) provide for the development of alternate plans of care,

making maximum utilization of available resources, for

recipients 65 years of age or older who would otherwise need

care in such institutions, including appropriate medical

treatment and other aid or assistance; for services referred to

in section 303(a)(4)(A)(i) and (ii) (!8) or section

1383(a)(4)(A)(i) and (ii) (!8) of this title which are

appropriate for such recipients and for such patients; and for

methods of administration necessary to assure that the

responsibilities of the State agency under the State plan with

respect to such recipients and such patients will be

effectively carried out;

(21) if the State plan includes medical assistance in behalf of

individuals 65 years of age or older who are patients in public

institutions for mental diseases, show that the State is making

satisfactory progress toward developing and implementing a

comprehensive mental health program, including provision for

utilization of community mental health centers, nursing

facilities, and other alternatives to care in public institutions

for mental diseases;

(22) include descriptions of (A) the kinds and numbers of

professional medical personnel and supporting staff that will be

used in the administration of the plan and of the

responsibilities they will have, (B) the standards, for private

or public institutions in which recipients of medical assistance

under the plan may receive care or services, that will be

utilized by the State authority or authorities responsible for

establishing and maintaining such standards, (C) the cooperative

arrangements with State health agencies and State vocational

rehabilitation agencies entered into with a view to maximum

utilization of and coordination of the provision of medical

assistance with the services administered or supervised by such

agencies, and (D) other standards and methods that the State will

use to assure that medical or remedial care and services provided

to recipients of medical assistance are of high quality;

(23) provide that (A) any individual eligible for medical

assistance (including drugs) may obtain such assistance from any

institution, agency, community pharmacy, or person, qualified to

perform the service or services required (including an

organization which provides such services, or arranges for their

availability, on a prepayment basis), who undertakes to provide

him such services, and (B) an enrollment of an individual

eligible for medical assistance in a primary care case-management

system (described in section 1396n(b)(1) of this title), a

medicaid managed care organization, or a similar entity shall not

restrict the choice of the qualified person from whom the

individual may receive services under section 1396d(a)(4)(C) of

this title, except as provided in subsection (g) of this section,

in section 1396n of this title, and in section 1396u-2(a) of this

title, except that this paragraph shall not apply in the case of

Puerto Rico, the Virgin Islands, and Guam, and except that

nothing in this paragraph shall be construed as requiring a State

to provide medical assistance for such services furnished by a

person or entity convicted of a felony under Federal or State law

for an offense which the State agency determines is inconsistent

with the best interests of beneficiaries under the State plan;

(24) effective July 1, 1969, provide for consultative services

by health agencies and other appropriate agencies of the State to

hospitals, nursing facilities, home health agencies, clinics,

laboratories, and such other institutions as the Secretary may

specify in order to assist them (A) to qualify for payments under

this chapter, (B) to establish and maintain such fiscal records

as may be necessary for the proper and efficient administration

of this chapter, and (C) to provide information needed to

determine payments due under this chapter on account of care and

services furnished to individuals;

(25) provide -

(A) that the State or local agency administering such plan

will take all reasonable measures to ascertain the legal

liability of third parties (including health insurers, group

health plans (as defined in section 607(1) of the Employee

Retirement Income Security Act of 1974 [29 U.S.C. 1167(1)]),

service benefit plans, and health maintenance organizations) to

pay for care and services available under the plan, including -

(i) the collection of sufficient information (as specified

by the Secretary in regulations) to enable the State to

pursue claims against such third parties, with such

information being collected at the time of any determination

or redetermination of eligibility for medical assistance, and

(ii) the submission to the Secretary of a plan (subject to

approval by the Secretary) for pursuing claims against such

third parties, which plan shall be integrated with, and be

monitored as a part of the Secretary's review of, the State's

mechanized claims processing and information retrieval

systems required under section 1396b(r) of this title;

(B) that in any case where such a legal liability is found to

exist after medical assistance has been made available on

behalf of the individual and where the amount of reimbursement

the State can reasonably expect to recover exceeds the costs of

such recovery, the State or local agency will seek

reimbursement for such assistance to the extent of such legal

liability;

(C) that in the case of an individual who is entitled to

medical assistance under the State plan with respect to a

service for which a third party is liable for payment, the

person furnishing the service may not seek to collect from the

individual (or any financially responsible relative or

representative of that individual) payment of an amount for

that service (i) if the total of the amount of the liabilities

of third parties for that service is at least equal to the

amount payable for that service under the plan (disregarding

section 1396o of this title), or (ii) in an amount which

exceeds the lesser of (I) the amount which may be collected

under section 1396o of this title, or (II) the amount by which

the amount payable for that service under the plan

(disregarding section 1396o of this title) exceeds the total of

the amount of the liabilities of third parties for that

service;

(D) that a person who furnishes services and is participating

under the plan may not refuse to furnish services to an

individual (who is entitled to have payment made under the plan

for the services the person furnishes) because of a third

party's potential liability for payment for the service;

(E) that in the case of prenatal or preventive pediatric care

(including early and periodic screening and diagnosis services

under section 1396d(a)(4)(B) of this title) covered under the

State plan, the State shall -

(i) make payment for such service in accordance with the

usual payment schedule under such plan for such services

without regard to the liability of a third party for payment

for such services; and

(ii) seek reimbursement from such third party in accordance

with subparagraph (B);

(F) that in the case of any services covered under such plan

which are provided to an individual on whose behalf child

support enforcement is being carried out by the State agency

under part D of subchapter IV of this chapter, the State shall

-

(i) make payment for such service in accordance with the

usual payment schedule under such plan for such services

without regard to any third-party liability for payment for

such services, if such third-party liability is derived

(through insurance or otherwise) from the parent whose

obligation to pay support is being enforced by such agency,

if payment has not been made by such third party within 30

days after such services are furnished; and

(ii) seek reimbursement from such third party in accordance

with subparagraph (B);

(G) that the State prohibits any health insurer (including a

group health plan, as defined in section 607(1) of the Employee

Retirement Income Security Act of 1974 [29 U.S.C. 1167(1)], a

service benefit plan, and a health maintenance organization),

in enrolling an individual or in making any payments for

benefits to the individual or on the individual's behalf, from

taking into account that the individual is eligible for or is

provided medical assistance under a plan under this subchapter

for such State, or any other State; and

(H) that to the extent that payment has been made under the

State plan for medical assistance in any case where a third

party has a legal liability to make payment for such

assistance, the State has in effect laws under which, to the

extent that payment has been made under the State plan for

medical assistance for health care items or services furnished

to an individual, the State is considered to have acquired the

rights of such individual to payment by any other party for

such health care items or services;

(26) if the State plan includes medical assistance for

inpatient mental hospital services, provide, with respect to each

patient receiving such services, for a regular program of medical

review (including medical evaluation) of his need for such

services, and for a written plan of care;

(27) provide for agreements with every person or institution

providing services under the State plan under which such person

or institution agrees (A) to keep such records as are necessary

fully to disclose the extent of the services provided to

individuals receiving assistance under the State plan, and (B) to

furnish the State agency or the Secretary with such information,

regarding any payments claimed by such person or institution for

providing services under the State plan, as the State agency or

the Secretary may from time to time request;

(28) provide -

(A) that any nursing facility receiving payments under such

plan must satisfy all the requirements of subsections (b)

through (d) of section 1396r of this title as they apply to

such facilities;

(B) for including in "nursing facility services" at least the

items and services specified (or deemed to be specified) by the

Secretary under section 1396r(f)(7) of this title and making

available upon request a description of the items and services

so included;

(C) for procedures to make available to the public the data

and methodology used in establishing payment rates for nursing

facilities under this subchapter; and

(D) for compliance (by the date specified in the respective

sections) with the requirements of -

(i) section 1396r(e) of this title;

(ii) section 1396r(g) of this title (relating to

responsibility for survey and certification of nursing

facilities); and

(iii) sections 1396r(h)(2)(B) and 1396r(h)(2)(D) of this

title (relating to establishment and application of

remedies);

(29) include a State program which meets the requirements set

forth in section 1396g of this title, for the licensing of

administrators of nursing homes;

(30)(A) provide such methods and procedures relating to the

utilization of, and the payment for, care and services available

under the plan (including but not limited to utilization review

plans as provided for in section 1396b(i)(4) of this title) as

may be necessary to safeguard against unnecessary utilization of

such care and services and to assure that payments are consistent

with efficiency, economy, and quality of care and are sufficient

to enlist enough providers so that care and services are

available under the plan at least to the extent that such care

and services are available to the general population in the

geographic area; and

(B) provide, under the program described in subparagraph (A),

that -

(i) each admission to a hospital, intermediate care facility

for the mentally retarded, or hospital for mental diseases is

reviewed or screened in accordance with criteria established by

medical and other professional personnel who are not themselves

directly responsible for the care of the patient involved, and

who do not have a significant financial interest in any such

institution and are not, except in the case of a hospital,

employed by the institution providing the care involved, and

(ii) the information developed from such review or screening,

along with the data obtained from prior reviews of the

necessity for admission and continued stay of patients by such

professional personnel, shall be used as the basis for

establishing the size and composition of the sample of

admissions to be subject to review and evaluation by such

personnel, and any such sample may be of any size up to 100

percent of all admissions and must be of sufficient size to

serve the purpose of (I) identifying the patterns of care being

provided and the changes occurring over time in such patterns

so that the need for modification may be ascertained, and (II)

subjecting admissions to early or more extensive review where

information indicates that such consideration is warranted to a

hospital, intermediate care facility for the mentally retarded,

or hospital for mental diseases;

(31) with respect to services in an intermediate care facility

for the mentally retarded (where the State plan includes medical

assistance for such services) provide, with respect to each

patient receiving such services, for a written plan of care,

prior to admission to or authorization of benefits in such

facility, in accordance with regulations of the Secretary, and

for a regular program of independent professional review

(including medical evaluation) which shall periodically review

his need for such services;

(32) provide that no payment under the plan for any care or

service provided to an individual shall be made to anyone other

than such individual or the person or institution providing such

care or service, under an assignment or power of attorney or

otherwise; except that -

(A) in the case of any care or service provided by a

physician, dentist, or other individual practitioner, such

payment may be made (i) to the employer of such physician,

dentist, or other practitioner if such physician, dentist, or

practitioner is required as a condition of his employment to

turn over his fee for such care or service to his employer, or

(ii) (where the care or service was provided in a hospital,

clinic, or other facility) to the facility in which the care or

service was provided if there is a contractual arrangement

between such physician, dentist, or practitioner and such

facility under which such facility submits the bill for such

care or service;

(B) nothing in this paragraph shall be construed (i) to

prevent the making of such a payment in accordance with an

assignment from the person or institution providing the care or

service involved if such assignment is made to a governmental

agency or entity or is established by or pursuant to the order

of a court of competent jurisdiction, or (ii) to preclude an

agent of such person or institution from receiving any such

payment if (but only if) such agent does so pursuant to an

agency agreement under which the compensation to be paid to the

agent for his services for or in connection with the billing or

collection of payments due such person or institution under the

plan is unrelated (directly or indirectly) to the amount of

such payments or the billings therefor, and is not dependent

upon the actual collection of any such payment;

(C) in the case of services furnished (during a period that

does not exceed 14 continuous days in the case of an informal

reciprocal arrangement or 90 continuous days (or such longer

period as the Secretary may provide) in the case of an

arrangement involving per diem or other fee-for-time

compensation) by, or incident to the services of, one physician

to the patients of another physician who submits the claim for

such services, payment shall be made to the physician

submitting the claim (as if the services were furnished by, or

incident to, the physician's services), but only if the claim

identifies (in a manner specified by the Secretary) the

physician who furnished the services; and

(D) in the case of payment for a childhood vaccine

administered before October 1, 1994, to individuals entitled to

medical assistance under the State plan, the State plan may

make payment directly to the manufacturer of the vaccine under

a voluntary replacement program agreed to by the State pursuant

to which the manufacturer (i) supplies doses of the vaccine to

providers administering the vaccine, (ii) periodically replaces

the supply of the vaccine, and (iii) charges the State the

manufacturer's price to the Centers for Disease Control and

Prevention for the vaccine so administered (which price

includes a reasonable amount to cover shipping and the handling

of returns);

(33) provide -

(A) that the State health agency, or other appropriate State

medical agency, shall be responsible for establishing a plan,

consistent with regulations prescribed by the Secretary, for

the review by appropriate professional health personnel of the

appropriateness and quality of care and services furnished to

recipients of medical assistance under the plan in order to

provide guidance with respect thereto in the administration of

the plan to the State agency established or designated pursuant

to paragraph (5) and, where applicable, to the State agency

described in the second sentence of this subsection; and

(B) that, except as provided in section 1396r(g) of this

title, the State or local agency utilized by the Secretary for

the purpose specified in the first sentence of section

1395aa(a) of this title, or, if such agency is not the State

agency which is responsible for licensing health institutions,

the State agency responsible for such licensing, will perform

for the State agency administering or supervising the

administration of the plan approved under this subchapter the

function of determining whether institutions and agencies meet

the requirements for participation in the program under such

plan, except that, if the Secretary has cause to question the

adequacy of such determinations, the Secretary is authorized to

validate State determinations and, on that basis, make

independent and binding determinations concerning the extent to

which individual institutions and agencies meet the

requirements for participation;

(34) provide that in the case of any individual who has been

determined to be eligible for medical assistance under the plan,

such assistance will be made available to him for care and

services included under the plan and furnished in or after the

third month before the month in which he made application (or

application was made on his behalf in the case of a deceased

individual) for such assistance if such individual was (or upon

application would have been) eligible for such assistance at the

time such care and services were furnished;

(35) provide that any disclosing entity (as defined in section

1320a-3(a)(2) of this title) receiving payments under such plan

complies with the requirements of section 1320a-3 of this title;

(36) provide that within 90 days following the completion of

each survey of any health care facility, laboratory, agency,

clinic, or organization, by the appropriate State agency

described in paragraph (9), such agency shall (in accordance with

regulations of the Secretary) make public in readily available

form and place the pertinent findings of each such survey

relating to the compliance of each such health care facility,

laboratory, clinic, agency, or organization with (A) the

statutory conditions of participation imposed under this

subchapter, and (B) the major additional conditions which the

Secretary finds necessary in the interest of health and safety of

individuals who are furnished care or services by any such

facility, laboratory, clinic, agency, or organization;

(37) provide for claims payment procedures which (A) ensure

that 90 per centum of claims for payment (for which no further

written information or substantiation is required in order to

make payment) made for services covered under the plan and

furnished by health care practitioners through individual or

group practices or through shared health facilities are paid

within 30 days of the date of receipt of such claims and that 99

per centum of such claims are paid within 90 days of the date of

receipt of such claims, and (B) provide for procedures of

prepayment and postpayment claims review, including review of

appropriate data with respect to the recipient and provider of a

service and the nature of the service for which payment is

claimed, to ensure the proper and efficient payment of claims and

management of the program;

(38) require that an entity (other than an individual

practitioner or a group of practitioners) that furnishes, or

arranges for the furnishing of, items or services under the plan,

shall supply (within such period as may be specified in

regulations by the Secretary or by the single State agency which

administers or supervises the administration of the plan) upon

request specifically addressed to such entity by the Secretary or

such State agency, the information described in section

1320a-7(b)(9) of this title;

(39) provide that the State agency shall exclude any specified

individual or entity from participation in the program under the

State plan for the period specified by the Secretary, when

required by him to do so pursuant to section 1320a-7 of this

title or section 1320a-7a of this title, and provide that no

payment may be made under the plan with respect to any item or

service furnished by such individual or entity during such

period;

(40) require each health services facility or organization

which receives payments under the plan and of a type for which a

uniform reporting system has been established under section

1320a(a) of this title to make reports to the Secretary of

information described in such section in accordance with the

uniform reporting system (established under such section) for

that type of facility or organization;

(41) provide that whenever a provider of services or any other

person is terminated, suspended, or otherwise sanctioned or

prohibited from participating under the State plan, the State

agency shall promptly notify the Secretary and, in the case of a

physician and notwithstanding paragraph (7), the State medical

licensing board of such action;

(42) provide that the records of any entity participating in

the plan and providing services reimbursable on a cost-related

basis will be audited as the Secretary determines to be necessary

to insure that proper payments are made under the plan;

(43) provide for -

(A) informing all persons in the State who are under the age

of 21 and who have been determined to be eligible for medical

assistance including services described in section

1396d(a)(4)(B) of this title, of the availability of early and

periodic screening, diagnostic, and treatment services as

described in section 1396d(r) of this title and the need for

age-appropriate immunizations against vaccine-preventable

diseases,

(B) providing or arranging for the provision of such

screening services in all cases where they are requested,

(C) arranging for (directly or through referral to

appropriate agencies, organizations, or individuals) corrective

treatment the need for which is disclosed by such child health

screening services, and

(D) reporting to the Secretary (in a uniform form and manner

established by the Secretary, by age group and by basis of

eligibility for medical assistance, and by not later than April

1 after the end of each fiscal year, beginning with fiscal year

1990) the following information relating to early and periodic

screening, diagnostic, and treatment services provided under

the plan during each fiscal year:

(i) the number of children provided child health screening

services,

(ii) the number of children referred for corrective

treatment (the need for which is disclosed by such child

health screening services),

(iii) the number of children receiving dental services, and

(iv) the State's results in attaining the participation

goals set for the State under section 1396d(r) of this title;

(44) in each case for which payment for inpatient hospital

services, services in an intermediate care facility for the

mentally retarded, or inpatient mental hospital services is made

under the State plan -

(A) a physician (or, in the case of skilled nursing facility

services or intermediate care facility services, a physician,

or a nurse practitioner or clinical nurse specialist who is not

an employee of the facility but is working in collaboration

with a physician) certifies at the time of admission, or, if

later, the time the individual applies for medical assistance

under the State plan (and a physician, a physician assistant

under the supervision of a physician, or, in the case of

skilled nursing facility services or intermediate care facility

services, a physician, or a nurse practitioner or clinical

nurse specialist who is not an employee of the facility but is

working in collaboration with a physician, recertifies, where

such services are furnished over a period of time, in such

cases, at least as often as required under section 1396b(g)(6)

of this title (or, in the case of services that are services

provided in an intermediate care facility for the mentally

retarded, every year), and accompanied by such supporting

material, appropriate to the case involved, as may be provided

in regulations of the Secretary), that such services are or

were required to be given on an inpatient basis because the

individual needs or needed such services, and

(B) such services were furnished under a plan established and

periodically reviewed and evaluated by a physician, or, in the

case of skilled nursing facility services or intermediate care

facility services, a physician, or a nurse practitioner or

clinical nurse specialist who is not an employee of the

facility but is working in collaboration with a physician;

(45) provide for mandatory assignment of rights of payment for

medical support and other medical care owed to recipients, in

accordance with section 1396k of this title;

(46) provide that information is requested and exchanged for

purposes of income and eligibility verification in accordance

with a State system which meets the requirements of section

1320b-7 of this title;

(47) at the option of the State, provide for making ambulatory

prenatal care available to pregnant women during a presumptive

eligibility period in accordance with section 1396r-1 of this

title and provide for making medical assistance for items and

services described in subsection (a) of section 1396r-1a of this

title available to children during a presumptive eligibility

period in accordance with such section and provide for making

medical assistance available to individuals described in

subsection (a) of section 1396r-1b of this title during a

presumptive eligibility period in accordance with such section;

(48) provide a method of making cards evidencing eligibility

for medical assistance available to an eligible individual who

does not reside in a permanent dwelling or does not have a fixed

home or mailing address;

(49) provide that the State will provide information and access

to certain information respecting sanctions taken against health

care practitioners and providers by State licensing authorities

in accordance with section 1396r-2 of this title;

(50) provide, in accordance with subsection (q) of this

section, for a monthly personal needs allowance for certain

institutionalized individuals and couples;

(51) meet the requirements of section 1396r-5 of this title

(relating to protection of community spouses);

(52) meet the requirements of section 1396r-6 of this title

(relating to extension of eligibility for medical assistance);

(53) provide -

(A) for notifying in a timely manner all individuals in the

State who are determined to be eligible for medical assistance

and who are pregnant women, breastfeeding or postpartum women

(as defined in section 1786 of this title), or children below

the age of 5, of the availability of benefits furnished by the

special supplemental nutrition program under such section, and

(B) for referring any such individual to the State agency

responsible for administering such program;

(54) in the case of a State plan that provides medical

assistance for covered outpatient drugs (as defined in section

1396r-8(k) of this title), comply with the applicable

requirements of section 1396r-8 of this title;

(55) provide for receipt and initial processing of applications

of individuals for medical assistance under subsection

(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or

(a)(10)(A)(ii)(IX) of this section -

(A) at locations which are other than those used for the

receipt and processing of applications for aid under part A of

subchapter IV of this chapter and which include facilities

defined as disproportionate share hospitals under section

1396r-4(a)(1)(A) of this title and Federally-qualified health

centers described in section 1396d(1)(2)(B) (!9) of this title,

and

(B) using applications which are other than those used for

applications for aid under such part;

(56) provide, in accordance with subsection (s) of this

section, for adjusted payments for certain inpatient hospital

services;

(57) provide that each hospital, nursing facility, provider of

home health care or personal care services, hospice program, or

medicaid managed care organization (as defined in section

1396b(m)(1)(A) of this title) receiving funds under the plan

shall comply with the requirements of subsection (w) of this

section;

(58) provide that the State, acting through a State agency,

association, or other private nonprofit entity, develop a written

description of the law of the State (whether statutory or as

recognized by the courts of the State) concerning advance

directives that would be distributed by providers or

organizations under the requirements of subsection (w) of this

section;

(59) maintain a list (updated not less often than monthly, and

containing each physician's unique identifier provided under the

system established under subsection (x) of this section) of all

physicians who are certified to participate under the State plan;

(60) provide that the State agency shall provide assurances

satisfactory to the Secretary that the State has in effect the

laws relating to medical child support required under section

1396g-1 of this title;

(61) provide that the State must demonstrate that it operates a

medicaid fraud and abuse control unit described in section

1396b(q) of this title that effectively carries out the functions

and requirements described in such section, as determined in

accordance with standards established by the Secretary, unless

the State demonstrates to the satisfaction of the Secretary that

the effective operation of such a unit in the State would not be

cost-effective because minimal fraud exists in connection with

the provision of covered services to eligible individuals under

the State plan, and that beneficiaries under the plan will be

protected from abuse and neglect in connection with the provision

of medical assistance under the plan without the existence of

such a unit;

(62) provide for a program for the distribution of pediatric

vaccines to program-registered providers for the immunization of

vaccine-eligible children in accordance with section 1396s of

this title;

(63) provide for administration and determinations of

eligibility with respect to individuals who are (or seek to be)

eligible for medical assistance based on the application of

section 1396u-1 of this title;

(64) provide, not later than 1 year after August 5, 1997, a

mechanism to receive reports from beneficiaries and others and

compile data concerning alleged instances of waste, fraud, and

abuse relating to the operation of this subchapter; and

(65) provide that the State shall issue provider numbers for

all suppliers of medical assistance consisting of durable medical

equipment, as defined in section 1395x(n) of this title, and the

State shall not issue or renew such a supplier number for any

such supplier unless -

(A)(i) full and complete information as to the identity of

each person with an ownership or control interest (as defined

in section 1320a-3(a)(3) of this title) in the supplier or in

any subcontractor (as defined by the Secretary in regulations)

in which the supplier directly or indirectly has a 5 percent or

more ownership interest; and

(ii) to the extent determined to be feasible under

regulations of the Secretary, the name of any disclosing entity

(as defined in section 1320a-3(a)(2) of this title) with

respect to which a person with such an ownership or control

interest in the supplier is a person with such an ownership or

control interest in the disclosing entity; and

(B) a surety bond in a form specified by the Secretary under

section 1395m(a)(16)(B) of this title and in an amount that is

not less than $50,000 or such comparable surety bond as the

Secretary may permit under the second sentence of such section.

Notwithstanding paragraph (5), if on January 1, 1965, and on the

date on which a State submits its plan for approval under this

subchapter, the State agency which administered or supervised the

administration of the plan of such State approved under subchapter

X of this chapter (or subchapter XVI of this chapter, insofar as it

relates to the blind) was different from the State agency which

administered or supervised the administration of the State plan

approved under subchapter I of this chapter (or subchapter XVI of

this chapter, insofar as it relates to the aged), the State agency

which administered or supervised the administration of such plan

approved under subchapter X of this chapter (or subchapter XVI of

this chapter, insofar as it relates to the blind) may be designated

to administer or supervise the administration of the portion of the

State plan for medical assistance which relates to blind

individuals and a different State agency may be established or

designated to administer or supervise the administration of the

rest of the State plan for medical assistance; and in such case the

part of the plan which each such agency administers, or the

administration of which each such agency supervises, shall be

regarded as a separate plan for purposes of this subchapter (except

for purposes of paragraph (10)). The provisions of paragraphs

(9)(A), (31), and (33) and of section 1396b(i)(4) of this title

shall not apply to a religious nonmedical health care institution

(as defined in section 1395x(ss)(1) of this title).

For purposes of paragraph (10) any individual who, for the month

of August 1972, was eligible for or receiving aid or assistance

under a State plan approved under subchapter I, X, XIV, or XVI of

this chapter, or part A of subchapter IV of this chapter and who

for such month was entitled to monthly insurance benefits under

subchapter II of this chapter shall for purposes of this subchapter

only be deemed to be eligible for financial aid or assistance for

any month thereafter if such individual would have been eligible

for financial aid or assistance for such month had the increase in

monthly insurance benefits under subchapter II of this chapter

resulting from enactment of Public Law 92-336 not been applicable

to such individual.

The requirement of clause (A) of paragraph (37) with respect to a

State plan may be waived by the Secretary if he finds that the

State has exercised good faith in trying to meet such requirement.

For purposes of this subchapter, any child who meets the

requirements of paragraph (1) or (2) of section 673(b) of this

title shall be deemed to be a dependent child as defined in section

606 of this title and shall be deemed to be a recipient of aid to

families with dependent children under part A of subchapter IV of

this chapter in the State where such child resides. Notwithstanding

paragraph (10)(B) or any other provision of this subsection, a

State plan shall provide medical assistance with respect to an

alien who is not lawfully admitted for permanent residence or

otherwise permanently residing in the United States under color of

law only in accordance with section 1396b(v) of this title.

(b) Approval by Secretary

The Secretary shall approve any plan which fulfills the

conditions specified in subsection (a) of this section, except that

he shall not approve any plan which imposes, as a condition of

eligibility for medical assistance under the plan -

(1) an age requirement of more than 65 years; or

(2) any residence requirement which excludes any individual who

resides in the State, regardless of whether or not the residence

is maintained permanently or at a fixed address; or

(3) any citizenship requirement which excludes any citizen of

the United States.

(c) Lower payment levels or applying for benefits as condition of

applying for, or receiving, medical assistance

Notwithstanding subsection (b) of this section, the Secretary

shall not approve any State plan for medical assistance if the

State requires individuals described in subsection (l)(1) of this

section to apply for assistance under the State program funded

under part A of subchapter IV of this chapter as a condition of

applying for or receiving medical assistance under this subchapter.

(d) Performance of medical or utilization review functions

If a State contracts with an entity which meets the requirements

of section 1320c-1 of this title, as determined by the Secretary,

or a utilization and quality control peer review organization

having a contract with the Secretary under part B of subchapter XI

of this chapter for the performance of medical or utilization

review functions required under this subchapter of a State plan

with respect to specific services or providers (or services or

providers in a geographic area of the State), such requirements

shall be deemed to be met for those services or providers (or

services or providers in that area) by delegation to such an entity

or organization under the contract of the State's authority to

conduct such review activities if the contract provides for the

performance of activities not inconsistent with part B of

subchapter XI of this chapter and provides for such assurances of

satisfactory performance by such an entity or organization as the

Secretary may prescribe.

(e) Continued eligibility of families determined ineligible because

of income and resources or hours of work limitations of plan;

individuals enrolled with health maintenance organizations;

persons deemed recipients of supplemental security income or

State supplemental payments; entitlement for certain newborns;

postpartum eligibility for pregnant women

(1)(A) Notwithstanding any other provision of this subchapter,

effective January 1, 1974, subject to subparagraph (B) each State

plan approved under this subchapter must provide that each family

which was receiving aid pursuant to a plan of the State approved

under part A of subchapter IV of this chapter in at least 3 of the

6 months immediately preceding the month in which such family

became ineligible for such aid because of increased hours of, or

increased income from, employment, shall, while a member of such

family is employed, remain eligible for assistance under the plan

approved under this subchapter (as though the family was receiving

aid under the plan approved under part A of subchapter IV of this

chapter) for 4 calendar months beginning with the month in which

such family became ineligible for aid under the plan approved under

part A of subchapter IV of this chapter because of income and

resources or hours of work limitations contained in such plan.

(B) Subparagraph (A) shall not apply with respect to families

that cease to be eligible for aid under part A of subchapter IV of

this chapter during the period beginning on April 1, 1990, and

ending on September 30, 2002. During such period, for provisions

relating to extension of eligibility for medical assistance for

certain families who have received aid pursuant to a State plan

approved under part A of subchapter IV of this chapter and have

earned income, see section 1396r-6 of this title.

(2)(A) In the case of an individual who is enrolled with a

medicaid managed care organization (as defined in section

1396b(m)(1)(A) of this title), with a primary care case manager (as

defined in section 1396d(t) of this title), or with an eligible

organization with a contract under section 1395mm of this title and

who would (but for this paragraph) lose eligibility for benefits

under this subchapter before the end of the minimum enrollment

period (defined in subparagraph (B)), the State plan may provide,

notwithstanding any other provision of this subchapter, that the

individual shall be deemed to continue to be eligible for such

benefits until the end of such minimum period, but, except for

benefits furnished under section 1396d(a)(4)(C) of this title, only

with respect to such benefits provided to the individual as an

enrollee of such organization or entity or by or through the case

manager.

(B) For purposes of subparagraph (A), the term "minimum

enrollment period" means, with respect to an individual's

enrollment with an organization or entity under a State plan, a

period, established by the State, of not more than six months

beginning on the date the individual's enrollment with the

organization or entity becomes effective.

(3) At the option of the State, any individual who -

(A) is 18 years of age or younger and qualifies as a disabled

individual under section 1382c(a) of this title;

(B) with respect to whom there has been a determination by the

State that -

(i) the individual requires a level of care provided in a

hospital, nursing facility, or intermediate care facility for

the mentally retarded,

(ii) it is appropriate to provide such care for the

individual outside such an institution, and

(iii) the estimated amount which would be expended for

medical assistance for the individual for such care outside an

institution is not greater than the estimated amount which

would otherwise be expended for medical assistance for the

individual within an appropriate institution; and

(C) if the individual were in a medical institution, would be

eligible for medical assistance under the State plan under this

subchapter,

shall be deemed, for purposes of this subchapter only, to be an

individual with respect to whom a supplemental security income

payment, or State supplemental payment, respectively, is being paid

under subchapter XVI of this chapter.

(4) A child born to a woman eligible for and receiving medical

assistance under a State plan on the date of the child's birth

shall be deemed to have applied for medical assistance and to have

been found eligible for such assistance under such plan on the date

of such birth and to remain eligible for such assistance for a

period of one year so long as the child is a member of the woman's

household and the woman remains (or would remain if pregnant)

eligible for such assistance. During the period in which a child is

deemed under the preceding sentence to be eligible for medical

assistance, the medical assistance eligibility identification

number of the mother shall also serve as the identification number

of the child, and all claims shall be submitted and paid under such

number (unless the State issues a separate identification number

for the child before such period expires).

(5) A woman who, while pregnant, is eligible for, has applied

for, and has received medical assistance under the State plan,

shall continue to be eligible under the plan, as though she were

pregnant, for all pregnancy-related and postpartum medical

assistance under the plan, through the end of the month in which

the 60-day period (beginning on the last day of her pregnancy)

ends.

(6) In the case of a pregnant woman described in subsection

(a)(10) of this section who, because of a change in income of the

family of which she is a member, would not otherwise continue to be

described in such subsection, the woman shall be deemed to continue

to be an individual described in subsection (a)(10)(A)(i)(IV) of

this section and subsection (l)(1)(A) of this section without

regard to such change of income through the end of the month in

which the 60-day period (beginning on the last day of her

pregnancy) ends. The preceding sentence shall not apply in the case

of a woman who has been provided ambulatory prenatal care pursuant

to section 1396r-1 of this title during a presumptive eligibility

period and is then, in accordance with such section, determined to

be ineligible for medical assistance under the State plan.

(7) In the case of an infant or child described in subparagraph

(B), (C), or (D) of subsection (l)(1) of this section or paragraph

(2) of section 1396d(n) of this title -

(A) who is receiving inpatient services for which medical

assistance is provided on the date the infant or child attains

the maximum age with respect to which coverage is provided under

the State plan for such individuals, and

(B) who, but for attaining such age, would remain eligible for

medical assistance under such subsection,

the infant or child shall continue to be treated as an individual

described in such respective provision until the end of the stay

for which the inpatient services are furnished.

(8) If an individual is determined to be a qualified medicare

beneficiary (as defined in section 1396d(p)(1) of this title), such

determination shall apply to services furnished after the end of

the month in which the determination first occurs. For purposes of

payment to a State under section 1396b(a) of this title, such

determination shall be considered to be valid for an individual for

a period of 12 months, except that a State may provide for such

determinations more frequently, but not more frequently than once

every 6 months for an individual.

(9)(A) At the option of the State, the plan may include as

medical assistance respiratory care services for any individual who

-

(i) is medically dependent on a ventilator for life support at

least six hours per day;

(ii) has been so dependent for at least 30 consecutive days (or

the maximum number of days authorized under the State plan,

whichever is less) as an inpatient;

(iii) but for the availability of respiratory care services,

would require respiratory care as an inpatient in a hospital,

nursing facility, or intermediate care facility for the mentally

retarded and would be eligible to have payment made for such

inpatient care under the State plan;

(iv) has adequate social support services to be cared for at

home; and

(v) wishes to be cared for at home.

(B) The requirements of subparagraph (A)(ii) may be satisfied by

a continuous stay in one or more hospitals, nursing facilities, or

intermediate care facilities for the mentally retarded.

(C) For purposes of this paragraph, respiratory care services

means services provided on a part-time basis in the home of the

individual by a respiratory therapist or other health care

professional trained in respiratory therapy (as determined by the

State), payment for which is not otherwise included within other

items and services furnished to such individual as medical

assistance under the plan.

(10)(A) The fact that an individual, child, or pregnant woman may

be denied aid under part A of subchapter IV of this chapter

pursuant to section 602(a)(43) (!10) of this title shall not be

construed as denying (or permitting a State to deny) medical

assistance under this subchapter to such individual, child, or

woman who is eligible for assistance under this subchapter on a

basis other than the receipt of aid under such part.

(B) If an individual, child, or pregnant woman is receiving aid

under part A of subchapter IV of this chapter and such aid is

terminated pursuant to section 602(a)(43) (!10) of this title, the

State may not discontinue medical assistance under this subchapter

for the individual, child, or woman until the State has determined

that the individual, child, or woman is not eligible for assistance

under this subchapter on a basis other than the receipt of aid

under such part.

(11)(A) In the case of an individual who is enrolled with a group

health plan under section 1396e of this title and who would (but

for this paragraph) lose eligibility for benefits under this

subchapter before the end of the minimum enrollment period (defined

in subparagraph (B)), the State plan may provide, notwithstanding

any other provision of this subchapter, that the individual shall

be deemed to continue to be eligible for such benefits until the

end of such minimum period, but only with respect to such benefits

provided to the individual as an enrollee of such plan.

(B) For purposes of subparagraph (A), the term "minimum

enrollment period" means, with respect to an individual's

enrollment with a group health plan, a period established by the

State, of not more than 6 months beginning on the date the

individual's enrollment under the plan becomes effective.

(12) At the option of the State, the plan may provide that an

individual who is under an age specified by the State (not to

exceed 19 years of age) and who is determined to be eligible for

benefits under a State plan approved under this subchapter under

subsection (a)(10)(A) of this section shall remain eligible for

those benefits until the earlier of -

(A) the end of a period (not to exceed 12 months) following the

determination; or

(B) the time that the individual exceeds that age.

(f) Effective date of State plan as determinative of duty of State

to provide medical assistance to aged, blind, or disabled

individuals

Notwithstanding any other provision of this subchapter, except as

provided in subsection (e) of this section and section 1382h(b)(3)

of this title and section 1396r-5 of this title, except with

respect to qualified disabled and working individuals (described in

section 1396d(s) of this title), and except with respect to

qualified medicare beneficiaries, qualified severely impaired

individuals, and individuals described in subsection (m)(1) of this

subsection, no State not eligible to participate in the State plan

program established under subchapter XVI of this chapter shall be

required to provide medical assistance to any aged, blind, or

disabled individual (within the meaning of subchapter XVI of this

chapter) for any month unless such State would be (or would have

been) required to provide medical assistance to such individual for

such month had its plan for medical assistance approved under this

subchapter and in effect on January 1, 1972, been in effect in such

month, except that for this purpose any such individual shall be

deemed eligible for medical assistance under such State plan if (in

addition to meeting such other requirements as are or may be

imposed under the State plan) the income of any such individual as

determined in accordance with section 1396b(f) of this title (after

deducting any supplemental security income payment and State

supplementary payment made with respect to such individual, and

incurred expenses for medical care as recognized under State law

regardless of whether such expenses are reimbursed under another

public program of the State or political subdivision thereof) is

not in excess of the standard for medical assistance established

under the State plan as in effect on January 1, 1972. In States

which provide medical assistance to individuals pursuant to

paragraph (10)(C) of subsection (a) of this section, an individual

who is eligible for medical assistance by reason of the

requirements of this section concerning the deduction of incurred

medical expenses from income shall be considered an individual

eligible for medical assistance under paragraph (10)(A) of that

subsection if that individual is, or is eligible to be (1) an

individual with respect to whom there is payable a State

supplementary payment on the basis of which similarly situated

individuals are eligible to receive medical assistance equal in

amount, duration, and scope to that provided to individuals

eligible under paragraph (10)(A), or (2) an eligible individual or

eligible spouse, as defined in subchapter XVI of this chapter, with

respect to whom supplemental security income benefits are payable;

otherwise that individual shall be considered to be an individual

eligible for medical assistance under paragraph (10)(C) of that

subsection. In States which do not provide medical assistance to

individuals pursuant to paragraph (10)(C) of that subsection, an

individual who is eligible for medical assistance by reason of the

requirements of this section concerning the deduction of incurred

medical expenses from income shall be considered an individual

eligible for medical assistance under paragraph (10)(A) of that

subsection.

(g) Reduction of aid or assistance to providers of services

attempting to collect from beneficiary in violation of

third-party provisions

In addition to any other sanction available to a State, a State

may provide for a reduction of any payment amount otherwise due

with respect to a person who furnishes services under the plan in

an amount equal to up to three times the amount of any payment

sought to be collected by that person in violation of subsection

(a)(25)(C) of this section.

(h) Payments for hospitals serving disproportionate number of

low-income patients and for home and community care

Nothing in this subchapter (including subsections (a)(13) and

(a)(30) of this section) shall be construed as authorizing the

Secretary to limit the amount of payment that may be made under a

plan under this subchapter for home and community care.

(i) Termination of certification for participation of and

suspension of State payments to intermediate care facilities for

the mentally retarded

(1) In addition to any other authority under State law, where a

State determines that a (!11) intermediate care facility for the

mentally retarded which is certified for participation under its

plan no longer substantially meets the requirements for such a

facility under this subchapter and further determines that the

facility's deficiencies -

(A) immediately jeopardize the health and safety of its

patients, the State shall provide for the termination of the

facility's certification for participation under the plan and may

provide, or

(B) do not immediately jeopardize the health and safety of its

patients, the State may, in lieu of providing for terminating the

facility's certification for participation under the plan,

establish alternative remedies if the State demonstrates to the

Secretary's satisfaction that the alternative remedies are

effective in deterring noncompliance and correcting deficiencies,

and may provide

that no payment will be made under the State plan with respect to

any individual admitted to such facility after a date specified by

the State.

(2) The State shall not make such a decision with respect to a

facility until the facility has had a reasonable opportunity,

following the initial determination that it no longer substantially

meets the requirements for such a facility under this subchapter,

to correct its deficiencies, and, following this period, has been

given reasonable notice and opportunity for a hearing.

(3) The State's decision to deny payment may be made effective

only after such notice to the public and to the facility as may be

provided for by the State, and its effectiveness shall terminate

(A) when the State finds that the facility is in substantial

compliance (or is making good faith efforts to achieve substantial

compliance) with the requirements for such a facility under this

subchapter, or (B) in the case described in paragraph (1)(B), with

the end of the eleventh month following the month such decision is

made effective, whichever occurs first. If a facility to which

clause (B) of the previous sentence applies still fails to

substantially meet the provisions of the respective section on the

date specified in such clause, the State shall terminate such

facility's certification for participation under the plan effective

with the first day of the first month following the month specified

in such clause.

(j) Waiver or modification of subchapter requirements with respect

to medical assistance program in American Samoa

Notwithstanding any other requirement of this subchapter, the

Secretary may waive or modify any requirement of this subchapter

with respect to the medical assistance program in American Samoa

and the Northern Mariana Islands, other than a waiver of the

Federal medical assistance percentage, the limitation in section

1308(f) of this title, or the requirement that payment may be made

for medical assistance only with respect to amounts expended by

American Samoa or the Northern Mariana Islands for care and

services described in a numbered paragraph of section 1396d(a) of

this title.

(k) Repealed. Pub. L. 103-66, title XIII, Sec. 13611(d)(1)(C), Aug.

10, 1993, 107 Stat. 627

(l) Description of group

(1) Individuals described in this paragraph are -

(A) women during pregnancy (and during the 60-day period

beginning on the last day of the pregnancy),

(B) infants under one year of age,

(C) children who have attained one year of age but have not

attained 6 years of age, and

(D) children born after September 30, 1983 (or, at the option

of a State, after any earlier date), who have attained 6 years of

age but have not attained 19 years of age,

who are not described in any of subclauses (I) through (III) of

subsection (a)(10)(A)(i) of this section and whose family income

does not exceed the income level established by the State under

paragraph (2) for a family size equal to the size of the family,

including the woman, infant, or child.

(2)(A)(i) For purposes of paragraph (1) with respect to

individuals described in subparagraph (A) or (B) of that paragraph,

the State shall establish an income level which is a percentage

(not less than the percentage provided under clause (ii) and not

more than 185 percent) of the income official poverty line (as

defined by the Office of Management and Budget, and revised

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

applicable to a family of the size involved.

(ii) The percentage provided under this clause, with respect to

eligibility for medical assistance on or after -

(I) July 1, 1989, is 75 percent, or, if greater, the percentage

provided under clause (iii), and

(II) April 1, 1990, 133 percent, or, if greater, the percentage

provided under clause (iv).

(iii) In the case of a State which, as of July 1, 1988, has

elected to provide, and provides, medical assistance to individuals

described in this subsection or has enacted legislation

authorizing, or appropriating funds, to provide such assistance to

such individuals before July 1, 1989, the percentage provided under

clause (ii)(I) shall not be less than -

(I) the percentage specified by the State in an amendment to

its State plan (whether approved or not) as of July 1, 1988, or

(II) if no such percentage is specified as of July 1, 1988, the

percentage established under the State's authorizing legislation

or provided for under the State's appropriations;

but in no case shall this clause require the percentage provided

under clause (ii)(I) to exceed 100 percent.

(iv) In the case of a State which, as of December 19, 1989, has

established under clause (i), or has enacted legislation

authorizing, or appropriating funds, to provide for, a percentage

(of the income official poverty line) that is greater than 133

percent, the percentage provided under clause (ii) for medical

assistance on or after April 1, 1990, shall not be less than -

(I) the percentage specified by the State in an amendment to

its State plan (whether approved or not) as of December 19, 1989,

or

(II) if no such percentage is specified as of December 19,

1989, the percentage established under the State's authorizing

legislation or provided for under the State's appropriations.

(B) For purposes of paragraph (1) with respect to individuals

described in subparagraph (C) of such paragraph, the State shall

establish an income level which is equal to 133 percent of the

income official poverty line described in subparagraph (A)

applicable to a family of the size involved.

(C) For purposes of paragraph (1) with respect to individuals

described in subparagraph (D) of that paragraph, the State shall

establish an income level which is equal to 100 percent of the

income official poverty line described in subparagraph (A)

applicable to a family of the size involved.

(3) Notwithstanding subsection (a)(17) of this section, for

individuals who are eligible for medical assistance because of

subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)

(A)(i)(VII), or (a)(10)(A)(ii)(IX) of this section -

(A) application of a resource standard shall be at the option

of the State;

(B) any resource standard or methodology that is applied with

respect to an individual described in subparagraph (A) of

paragraph (1) may not be more restrictive than the resource

standard or methodology that is applied under subchapter XVI of

this chapter;

(C) any resource standard or methodology that is applied with

respect to an individual described in subparagraph (B), (C), or

(D) of paragraph (1) may not be more restrictive than the

corresponding methodology that is applied under the State plan

under part A of subchapter IV of this chapter;

(D) the income standard to be applied is the appropriate income

standard established under paragraph (2); and

(E) family income shall be determined in accordance with the

methodology employed under the State plan under part A or E of

subchapter IV of this chapter (except to the extent such

methodology is inconsistent with clause (D) of subsection (a)(17)

of this section), and costs incurred for medical care or for any

other type of remedial care shall not be taken into account.

Any different treatment provided under this paragraph for such

individuals shall not, because of subsection (a)(17) of this

section, require or permit such treatment for other individuals.

(4)(A) In the case of any State which is providing medical

assistance to its residents under a waiver granted under section

1315 of this title, the Secretary shall require the State to

provide medical assistance for pregnant women and infants under age

1 described in subsection (a)(10)(A)(i)(IV) of this section and for

children described in subsection (a)(10)(A)(i)(VI) of this section

or subsection (a)(10)(A)(i)(VII) of this section in the same manner

as the State would be required to provide such assistance for such

individuals if the State had in effect a plan approved under this

subchapter.

(B) In the case of a State which is not one of the 50 States or

the District of Columbia, the State need not meet the requirement

of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), or

(a)(10)(A)(i)(VII) of this section and, for purposes of paragraph

(2)(A), the State may substitute for the percentage provided under

clause (ii) of such paragraph any percentage.

(m) Description of individuals

(1) Individuals described in this paragraph are individuals -

(A) who are 65 years of age or older or are disabled

individuals (as determined under section 1382c(a)(3) of this

title),

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

title for purposes of the supplemental security income program,

except as provided in paragraph (2)(C)) does not exceed an income

level established by the State consistent with paragraph (2)(A),

and

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

title for purposes of the supplemental security income program)

do not exceed (except as provided in paragraph (2)(B)) the

maximum amount of resources that an individual may have and

obtain benefits under that program.

(2)(A) The income level established under paragraph (1)(B) may

not exceed a percentage (not more than 100 percent) of the official

poverty line (as defined by the Office of Management and Budget,

and revised annually in accordance with section 9902(2) of this

title) applicable to a family of the size involved.

(B) In the case of a State that provides medical assistance to

individuals not described in subsection (a)(10)(A) of this section

and at the State's option, the State may use under paragraph (1)(C)

such resource level (which is higher than the level described in

that paragraph) as may be applicable with respect to individuals

described in paragraph (1)(A) who are not described in subsection

(a)(10)(A) of this section.

(C) The provisions of section 1396d(p)(2)(D) of this title shall

apply to determinations of income under this subsection in the same

manner as they apply to determinations of income under section

1396d(p) of this title.

(3) Notwithstanding subsection (a)(17) of this section, for

individuals described in paragraph (1) who are covered under the

State plan by virtue of subsection (a)(10)(A)(ii)(X) of this

section -

(A) the income standard to be applied is the income standard

described in paragraph (1)(B), and

(B) except as provided in section 1382a(b)(4)(B)(ii) of this

title, costs incurred for medical care or for any other type of

remedial care shall not be taken into account in determining

income.

Any different treatment provided under this paragraph for such

individuals shall not, because of subsection (a)(17) of this

section, require or permit such treatment for other individuals.

(4) Notwithstanding subsection (a)(17) of this section, for

qualified medicare beneficiaries described in section 1396d(p)(1)

of this title -

(A) the income standard to be applied is the income standard

described in section 1396d(p)(1)(B) of this title, and

(B) except as provided in section 1382a(b)(4)(B)(ii) of this

title, costs incurred for medical care or for any other type of

remedial care shall not be taken into account in determining

income.

Any different treatment provided under this paragraph for such

individuals shall not, because of subsection (a)(17) of this

section, require or permit such treatment for other individuals.

(n) Payment amounts

(1) In the case of medical assistance furnished under this

subchapter for medicare cost-sharing respecting the furnishing of a

service or item to a qualified medicare beneficiary, the State plan

may provide payment in an amount with respect to the service or

item that results in the sum of such payment amount and any amount

of payment made under subchapter XVIII of this chapter with respect

to the service or item exceeding the amount that is otherwise

payable under the State plan for the item or service for eligible

individuals who are not qualified medicare beneficiaries.

(2) In carrying out paragraph (1), a State is not required to

provide any payment for any expenses incurred relating to payment

for deductibles, coinsurance, or copayments for medicare

cost-sharing to the extent that payment under subchapter XVIII of

this chapter for the service would exceed the payment amount that

otherwise would be made under the State plan under this subchapter

for such service if provided to an eligible recipient other than a

medicare beneficiary.

(3) In the case in which a State's payment for medicare

cost-sharing for a qualified medicare beneficiary with respect to

an item or service is reduced or eliminated through the application

of paragraph (2) -

(A) for purposes of applying any limitation under subchapter

XVIII of this chapter on the amount that the beneficiary may be

billed or charged for the service, the amount of payment made

under subchapter XVIII of this chapter plus the amount of payment

(if any) under the State plan shall be considered to be payment

in full for the service;

(B) the beneficiary shall not have any legal liability to make

payment to a provider or to an organization described in section

1396b(m)(1)(A) of this title for the service; and

(C) any lawful sanction that may be imposed upon a provider or

such an organization for excess charges under this subchapter or

subchapter XVIII of this chapter shall apply to the imposition of

any charge imposed upon the individual in such case.

This paragraph shall not be construed as preventing payment of any

medicare cost-sharing by a medicare supplemental policy or an

employer retiree health plan on behalf of an individual.

(o) Certain benefits disregarded for purposes of determining

post-eligibility contributions

Notwithstanding any provision of subsection (a) of this section

to the contrary, a State plan under this subchapter shall provide

that any supplemental security income benefits paid by reason of

subparagraph (E) or (G) of section 1382(e)(1) of this title to an

individual who -

(1) is eligible for medical assistance under the plan, and

(2) is in a hospital, skilled nursing facility, or intermediate

care facility at the time such benefits are paid,

will be disregarded for purposes of determining the amount of any

post-eligibility contribution by the individual to the cost of the

care and services provided by the hospital, skilled nursing

facility, or intermediate care facility.

(p) Exclusion power of State; exclusion as prerequisite for medical

assistance payments; "exclude" defined

(1) In addition to any other authority, a State may exclude any

individual or entity for purposes of participating under the State

plan under this subchapter for any reason for which the Secretary

could exclude the individual or entity from participation in a

program under subchapter XVIII of this chapter under section

1320a-7, 1320a-7a, or 1395cc(b)(2) of this title.

(2) In order for a State to receive payments for medical

assistance under section 1396b(a) of this title, with respect to

payments the State makes to a medicaid managed care organization

(as defined in section 1396b(m) of this title) or to an entity

furnishing services under a waiver approved under section

1396n(b)(1) of this title, the State must provide that it will

exclude from participation, as such an organization or entity, any

organization or entity that -

(A) could be excluded under section 1320a-7(b)(8) of this title

(relating to owners and managing employees who have been

convicted of certain crimes or received other sanctions),

(B) has, directly or indirectly, a substantial contractual

relationship (as defined by the Secretary) with an individual or

entity that is described in section 1320a-7(b)(8)(B) of this

title, or

(C) employs or contracts with any individual or entity that is

excluded from participation under this subchapter under section

1320a-7 or 1320a-7a of this title for the provision of health

care, utilization review, medical social work, or administrative

services or employs or contracts with any entity for the

provision (directly or indirectly) through such an excluded

individual or entity of such services.

(3) As used in this subsection, the term "exclude" includes the

refusal to enter into or renew a participation agreement or the

termination of such an agreement.

(q) Minimum monthly personal needs allowance deduction;

"institutionalized individual or couple" defined

(1)(A) In order to meet the requirement of subsection (a)(50) of

this section, the State plan must provide that, in the case of an

institutionalized individual or couple described in subparagraph

(B), in determining the amount of the individual's or couple's

income to be applied monthly to payment for the cost of care in an

institution, there shall be deducted from the monthly income (in

addition to other allowances otherwise provided under the State

plan) a monthly personal needs allowance -

(i) which is reasonable in amount for clothing and other

personal needs of the individual (or couple) while in an

institution, and

(ii) which is not less (and may be greater) than the minimum

monthly personal needs allowance described in paragraph (2).

(B) In this subsection, the term "institutionalized individual or

couple" means an individual or married couple -

(i) who is an inpatient (or who are inpatients) in a medical

institution or nursing facility for which payments are made under

this subchapter throughout a month, and

(ii) who is or are determined to be eligible for medical

assistance under the State plan.

(2) The minimum monthly personal needs allowance described in

this paragraph (!12) is $30 for an institutionalized individual and

$60 for an institutionalized couple (if both are aged, blind, or

disabled, and their incomes are considered available to each other

in determining eligibility).

(r) Disregarding payments for certain medical expenses by

institutionalized individuals

(1)(A) For purposes of sections 1396a(a)(17) and 1396r-5(d)(1)(D)

of this title and for purposes of a waiver under section 1396n of

this title, with respect to the post-eligibility treatment of

income of individuals who are institutionalized or receiving home

or community-based services under such a waiver, the treatment

described in subparagraph (B) shall apply, there shall be

disregarded reparation payments made by the Federal Republic of

Germany, and there shall be taken into account amounts for incurred

expenses for medical or remedial care that are not subject to

payment by a third party, including -

(i) medicare and other health insurance premiums, deductibles,

or coinsurance, and

(ii) necessary medical or remedial care recognized under State

law but not covered under the State plan under this subchapter,

subject to reasonable limits the State may establish on the

amount of these expenses.

(B)(i) In the case of a veteran who does not have a spouse or a

child, if the veteran -

(I) receives, after the veteran has been determined to be

eligible for medical assistance under the State plan under this

subchapter, a veteran's pension in excess of $90 per month, and

(II) resides in a State veterans home with respect to which the

Secretary of Veterans Affairs makes per diem payments for nursing

home care pursuant to section 1741(a) of title 38,

any such pension payment, including any payment made due to the

need for aid and attendance, or for unreimbursed medical expenses,

that is in excess of $90 per month shall be counted as income only

for the purpose of applying such excess payment to the State

veterans home's cost of providing nursing home care to the veteran.

(ii) The provisions of clause (i) shall apply with respect to a

surviving spouse of a veteran who does not have a child in the same

manner as they apply to a veteran described in such clause.

(2)(A) The methodology to be employed in determining income and

resource eligibility for individuals under subsection

(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)

(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) of this

section or under section 1396d(p) of this title may be less

restrictive, and shall be no more restrictive, than the methodology

-

(i) in the case of groups consisting of aged, blind, or

disabled individuals, under the supplemental security income

program under subchapter XVI of this chapter, or

(ii) in the case of other groups, under the State plan most

closely categorically related.

(B) For purposes of this subsection and subsection (a)(10) of

this section, methodology is considered to be "no more restrictive"

if, using the methodology, additional individuals may be eligible

for medical assistance and no individuals who are otherwise

eligible are made ineligible for such assistance.

(s) Adjustment in payment for hospital services furnished to

low-income children under age of 6 years

In order to meet the requirements of subsection (a)(55) (!13) of

this section, the State plan must provide that payments to

hospitals under the plan for inpatient hospital services furnished

to infants who have not attained the age of 1 year, and to children

who have not attained the age of 6 years and who receive such

services in a disproportionate share hospital described in section

1396r-4(b)(1) of this title, shall -

(1) if made on a prospective basis (whether per diem, per case,

or otherwise) provide for an outlier adjustment in payment

amounts for medically necessary inpatient hospital services

involving exceptionally high costs or exceptionally long lengths

of stay,

(2) not be limited by the imposition of day limits with respect

to the delivery of such services to such individuals, and

(3) not be limited by the imposition of dollar limits (other

than such limits resulting from prospective payments as adjusted

pursuant to paragraph (1)) with respect to the delivery of such

services to any such individual who has not attained their first

birthday (or in the case of such an individual who is an

inpatient on his first birthday until such individual is

discharged).

(t) Limitation on payments to States for expenditures attributable

to taxes

Nothing in this subchapter (including sections 1396b(a) and

1396d(a) of this title) shall be construed as authorizing the

Secretary to deny or limit payments to a State for expenditures,

for medical assistance for items or services, attributable to taxes

of general applicability imposed with respect to the provision of

such items or services.

(u) Qualified COBRA continuation beneficiaries

(1) Individuals described in this paragraph are individuals -

(A) who are entitled to elect COBRA continuation coverage (as

defined in paragraph (3)),

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

title for purposes of the supplemental security income program)

does not exceed 100 percent of the official poverty line (as

defined by the Office of Management and Budget, and revised

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

applicable to a family of the size involved,

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

title for purposes of the supplemental security income program)

do not exceed twice the maximum amount of resources that an

individual may have and obtain benefits under that program, and

(D) with respect to whose enrollment for COBRA continuation

coverage the State has determined that the savings in

expenditures under this subchapter resulting from such enrollment

is likely to exceed the amount of payments for COBRA premiums

made.

(2) For purposes of subsection (a)(10)(F) of this section and

this subsection, the term "COBRA premiums" means the applicable

premium imposed with respect to COBRA continuation coverage.

(3) In this subsection, the term "COBRA continuation coverage"

means coverage under a group health plan provided by an employer

with 75 or more employees provided pursuant to title XXII of the

Public Health Service Act [42 U.S.C. 300bb-1 et seq.], section

4980B of the Internal Revenue Code of 1986, or title VI (!14) of

the Employee Retirement Income Security Act of 1974.

(4) Notwithstanding subsection (a)(17) of this section, for

individuals described in paragraph (1) who are covered under the

State plan by virtue of subsection (a)(10)(A)(ii)(XI) of this

section -

(A) the income standard to be applied is the income standard

described in paragraph (1)(B), and

(B) except as provided in section 1382a(b)(4)(B)(ii) of this

title, costs incurred for medical care or for any other type of

remedial care shall not be taken into account in determining

income.

Any different treatment provided under this paragraph for such

individuals shall not, because of subsection (a)(10)(B) or (a)(17)

of this section, require or permit such treatment for other

individuals.

(v) State agency disability and blindness determinations for

medical assistance eligibility

A State plan may provide for the making of determinations of

disability or blindness for the purpose of determining eligibility

for medical assistance under the State plan by the single State

agency or its designee, and make medical assistance available to

individuals whom it finds to be blind or disabled and who are

determined otherwise eligible for such assistance during the period

of time prior to which a final determination of disability or

blindness is made by the Social Security Administration with

respect to such an individual. In making such determinations, the

State must apply the definitions of disability and blindness found

in section 1382c(a) of this title.

(w) Maintenance of written policies and procedures respecting

advance directives

(1) For purposes of subsection (a)(57) of this section and

sections 1396b(m)(1)(A) and 1396r(c)(2)(E) of this title, the

requirement of this subsection is that a provider or organization

(as the case may be) maintain written policies and procedures with

respect to all adult individuals receiving medical care by or

through the provider or organization -

(A) to provide written information to each such individual

concerning -

(i) an individual's rights under State law (whether statutory

or as recognized by the courts of the State) to make decisions

concerning such medical care, including the right to accept or

refuse medical or surgical treatment and the right to formulate

advance directives (as defined in paragraph (3)), and

(ii) the provider's or organization's written policies

respecting the implementation of such rights;

(B) to document in the individual's medical record whether or

not the individual has executed an advance directive;

(C) not to condition the provision of care or otherwise

discriminate against an individual based on whether or not the

individual has executed an advance directive;

(D) to ensure compliance with requirements of State law

(whether statutory or as recognized by the courts of the State)

respecting advance directives; and

(E) to provide (individually or with others) for education for

staff and the community on issues concerning advance directives.

Subparagraph (C) shall not be construed as requiring the provision

of care which conflicts with an advance directive.

(2) The written information described in paragraph (1)(A) shall

be provided to an adult individual -

(A) in the case of a hospital, at the time of the individual's

admission as an inpatient,

(B) in the case of a nursing facility, at the time of the

individual's admission as a resident,

(C) in the case of a provider of home health care or personal

care services, in advance of the individual coming under the care

of the provider,

(D) in the case of a hospice program, at the time of initial

receipt of hospice care by the individual from the program, and

(E) in the case of a medicaid managed care organization, at the

time of enrollment of the individual with the organization.

(3) Nothing in this section shall be construed to prohibit the

application of a State law which allows for an objection on the

basis of conscience for any health care provider or any agent of

such provider which as a matter of conscience cannot implement an

advance directive.

(4) In this subsection, the term "advance directive" means a

written instruction, such as a living will or durable power of

attorney for health care, recognized under State law (whether

statutory or as recognized by the courts of the State) and relating

to the provision of such care when the individual is incapacitated.

(5) For construction relating to this subsection, see section

14406 of this title (relating to clarification respecting assisted

suicide, euthanasia, and mercy killing).

(x) Physician identifier system; establishment

The Secretary shall establish a system, for implementation by not

later than July 1, 1991, which provides for a unique identifier for

each physician who furnishes services for which payment may be made

under a State plan approved under this subchapter.

(y) Intermediate sanctions for psychiatric hospitals

(1) In addition to any other authority under State law, where a

State determines that a psychiatric hospital which is certified for

participation under its plan no longer meets the requirements for a

psychiatric hospital (referred to in section 1396d(h) of this

title) and further finds that the hospital's deficiencies -

(A) immediately jeopardize the health and safety of its

patients, the State shall terminate the hospital's participation

under the State plan; or

(B) do not immediately jeopardize the health and safety of its

patients, the State may terminate the hospital's participation

under the State plan, or provide that no payment will be made

under the State plan with respect to any individual admitted to

such hospital after the effective date of the finding, or both.

(2) Except as provided in paragraph (3), if a psychiatric

hospital described in paragraph (1)(B) has not complied with the

requirements for a psychiatric hospital under this subchapter -

(A) within 3 months after the date the hospital is found to be

out of compliance with such requirements, the State shall provide

that no payment will be made under the State plan with respect to

any individual admitted to such hospital after the end of such

3-month period, or

(B) within 6 months after the date the hospital is found to be

out of compliance with such requirements, no Federal financial

participation shall be provided under section 1396b(a) of this

title with respect to further services provided in the hospital

until the State finds that the hospital is in compliance with the

requirements of this subchapter.

(3) The Secretary may continue payments, over a period of not

longer than 6 months from the date the hospital is found to be out

of compliance with such requirements, if -

(A) the State finds that it is more appropriate to take

alternative action to assure compliance of the hospital with the

requirements than to terminate the certification of the hospital,

(B) the State has submitted a plan and timetable for corrective

action to the Secretary for approval and the Secretary approves

the plan of corrective action, and

(C) the State agrees to repay to the Federal Government

payments received under this paragraph if the corrective action

is not taken in accordance with the approved plan and timetable.

(z) Optional coverage of TB-related services

(1) Individuals described in this paragraph are individuals not

described in subsection (a)(10)(A)(i) of this section -

(A) who are infected with tuberculosis;

(B) whose income (as determined under the State plan under this

subchapter with respect to disabled individuals) does not exceed

the maximum amount of income a disabled individual described in

subsection (a)(10)(A)(i) of this section may have and obtain

medical assistance under the plan; and

(C) whose resources (as determined under the State plan under

this subchapter with respect to disabled individuals) do not

exceed the maximum amount of resources a disabled individual

described in subsection (a)(10)(A)(i) of this section may have

and obtain medical assistance under the plan.

(2) For purposes of subsection (a)(10) of this section, the term

"TB-related services" means each of the following services relating

to treatment of infection with tuberculosis:

(A) Prescribed drugs.

(B) Physicians' services and services described in section

1396d(a)(2) of this title.

(C) Laboratory and X-ray services (including services to

confirm the presence of infection).

(D) Clinic services and Federally-qualified health center

services.

(E) Case management services (as defined in section 1396n(g)(2)

of this title).

(F) Services (other than room and board) designed to encourage

completion of regimens of prescribed drugs by outpatients,

including services to observe directly the intake of prescribed

drugs.

(aa) Certain breast or cervical cancer patients

Individuals described in this subsection are individuals who -

(1) are not described in subsection (a)(10)(A)(i) of this

section;

(2) have not attained age 65;

(3) have been screened for breast and cervical cancer under the

Centers for Disease Control and Prevention breast and cervical

cancer early detection program established under title XV of the

Public Health Service Act (42 U.S.C. 300k et seq.) in accordance

with the requirements of section 1504 of that Act (42 U.S.C.

300n) and need treatment for breast or cervical cancer; and

(4) are not otherwise covered under creditable coverage, as

defined in section 2701(c) of the Public Health Service Act (42

U.S.C. 300gg(c)), but applied without regard to paragraph (1)(F)

of such section.

(bb) Payment for services provided by Federally-qualified health

centers and rural health clinics

(1) In general

Beginning with fiscal year 2001 with respect to services

furnished on or after January 1, 2001, and each succeeding fiscal

year, the State plan shall provide for payment for services

described in section 1396d(a)(2)(C) of this title furnished by a

Federally-qualified health center and services described in

section 1396d(a)(2)(B) of this title furnished by a rural health

clinic in accordance with the provisions of this subsection.

(2) Fiscal year 2001

Subject to paragraph (4), for services furnished on and after

January 1, 2001, during fiscal year 2001, the State plan shall

provide for payment for such services in an amount (calculated on

a per visit basis) that is equal to 100 percent of the average of

the costs of the center or clinic of furnishing such services

during fiscal years 1999 and 2000 which are reasonable and

related to the cost of furnishing such services, or based on such

other tests of reasonableness as the Secretary prescribes in

regulations under section 1395l(a)(3) of this title, or, in the

case of services to which such regulations do not apply, the same

methodology used under section 1395l(a)(3) of this title,

adjusted to take into account any increase or decrease in the

scope of such services furnished by the center or clinic during

fiscal year 2001.

(3) Fiscal year 2002 and succeeding fiscal years

Subject to paragraph (4), for services furnished during fiscal

year 2002 or a succeeding fiscal year, the State plan shall

provide for payment for such services in an amount (calculated on

a per visit basis) that is equal to the amount calculated for

such services under this subsection for the preceding fiscal year

-

(A) increased by the percentage increase in the MEI (as

defined in section 1395u(i)(3) of this title) applicable to

primary care services (as defined in section 1395u(i)(4) of

this title) for that fiscal year; and

(B) adjusted to take into account any increase or decrease in

the scope of such services furnished by the center or clinic

during that fiscal year.

(4) Establishment of initial year payment amount for new centers

or clinics

In any case in which an entity first qualifies as a

Federally-qualified health center or rural health clinic after

fiscal year 2000, the State plan shall provide for payment for

services described in section 1396d(a)(2)(C) of this title

furnished by the center or services described in section

1396d(a)(2)(B) of this title furnished by the clinic in the first

fiscal year in which the center or clinic so qualifies in an

amount (calculated on a per visit basis) that is equal to 100

percent of the costs of furnishing such services during such

fiscal year based on the rates established under this subsection

for the fiscal year for other such centers or clinics located in

the same or adjacent area with a similar case load or, in the

absence of such a center or clinic, in accordance with the

regulations and methodology referred to in paragraph (2) or based

on such other tests of reasonableness as the Secretary may

specify. For each fiscal year following the fiscal year in which

the entity first qualifies as a Federally-qualified health center

or rural health clinic, the State plan shall provide for the

payment amount to be calculated in accordance with paragraph (3).

(5) Administration in the case of managed care

(A) In general

In the case of services furnished by a Federally-qualified

health center or rural health clinic pursuant to a contract

between the center or clinic and a managed care entity (as

defined in section 1396u-2(a)(1)(B) of this title), the State

plan shall provide for payment to the center or clinic by the

State of a supplemental payment equal to the amount (if any) by

which the amount determined under paragraphs (2), (3), and (4)

of this subsection exceeds the amount of the payments provided

under the contract.

(B) Payment schedule

The supplemental payment required under subparagraph (A)

shall be made pursuant to a payment schedule agreed to by the

State and the Federally-qualified health center or rural health

clinic, but in no case less frequently than every 4 months.

(6) Alternative payment methodologies

Notwithstanding any other provision of this section, the State

plan may provide for payment in any fiscal year to a

Federally-qualified health center for services described in

section 1396d(a)(2)(C) of this title or to a rural health clinic

for services described in section 1396d(a)(2)(B) of this title in

an amount which is determined under an alternative payment

methodology that -

(A) is agreed to by the State and the center or clinic; and

(B) results in payment to the center or clinic of an amount

which is at least equal to the amount otherwise required to be

paid to the center or clinic under this section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1902, as added Pub. L.

89-97, title I, Sec. 121(a), July 30, 1965, 79 Stat. 344; amended

Pub. L. 90-248, title II, Secs. 210(a)(6), 223(a), 224(a), (c)(1),

227(a), 228(a), 229(a), 231, 234(a), 235(a), 236(a), 237, 238,

241(f)(1)-(4), title III, Sec. 302(b), Jan. 2, 1968, 81 Stat. 896,

901-906, 908, 911, 917, 929; Pub. L. 91-56, Sec. 2(c), (d), Aug. 9,

1969, 83 Stat. 99; Pub. L. 92-223, Sec. 4(b), Dec. 28, 1971, 85

Stat. 809; Pub. L. 92-603, title II, Secs. 208(a), 209(a), (b)(1),

221(c)(5), 231, 232(a), 236(b), 237(a)(2), 239(a), (b), 240,

246(a), 249(a), 255(a), 268(a), 274(a), 278(a)(18)-(20), (b)(14),

298, 299A, 299D(b), Oct. 30, 1972, 86 Stat. 1381, 1389, 1410,

1415-1418, 1424, 1426, 1446, 1450, 1452-1454, 1460, 1462; Pub. L.

93-233, Secs. 13(a)(2)-(10), 18(o)-(q), (x)(1)-(4), Dec. 31, 1973,

87 Stat. 960-962, 971, 972; Pub. L. 93-368, Sec. 9(a), Aug. 7,

1974, 88 Stat. 422; Pub. L. 94-48, Secs. 1, 2, July 1, 1975, 89

Stat. 247; Pub. L. 94-182, title I, Sec. 111(a), Dec. 31, 1975, 89

Stat. 1054; Pub. L. 94-552, Sec. 1, Oct. 18, 1976, 90 Stat. 2540;

Pub. L. 95-142, Secs. 2(a)(3), (b)(1), 3(c)(1), 7(b), (c), 9,

19(b)(2), 20(b), Oct. 25, 1977, 91 Stat. 1176, 1178, 1193, 1195,

1204, 1207; Pub. L. 95-210, Sec. 2(c), Dec. 13, 1977, 91 Stat.

1488; Pub. L. 95-559, Sec. 14(a)(1), Nov. 1, 1978, 92 Stat. 2140;

Pub. L. 96-272, title III, Sec. 308(c), June 17, 1980, 94 Stat.

531; Pub. L. 96-499, title IX, Secs. 902(b), 903(b), 905(a),

912(b), 913(c), (d), 914(b)(1), 916(b)(1), 918(b)(1), 962(a),

965(b), Dec. 5, 1980, 94 Stat. 2613, 2615, 2618-2621, 2624, 2626,

2650, 2652; Pub. L. 96-611, Sec. 5(b), Dec. 28, 1980, 94 Stat.

3568; Pub. L. 97-35, title XXI, Secs. 2105(c), 2113(m), 2171(a),

(b), 2172(a), 2173(a), (b)(1), 2174(a), 2175(a), (d)(1), 2178(b),

2181(a)(2), 2182, 2193(c)(9), Aug. 13, 1981, 95 Stat. 792, 795,

807-809, 811, 814-816, 828; Pub. L. 97-248, title I, Secs. 131(a),

(c), formerly (b), 132(a), (c), 134(a), 136(d), 137(a)(3),

(b)(7)-(10), (e), 146(a), Sept. 3, 1982, 96 Stat. 367, 369, 370,

373, 375-378, 381, 394; Pub. L. 97-448, title III, Sec. 309(a)(8),

Jan. 12, 1983, 96 Stat. 2408; Pub. L. 98-369, div. B, title III,

Secs. 2303(g)(1), 2314(b), 2335(e), 2361(a), 2362(a), 2363(a)(1),

2367(a), 2368(a), (b), 2373(b)(1)-(10), title VI, Sec. 2651(c),

July 18, 1984, 98 Stat. 1066, 1079, 1091, 1104, 1105, 1108, 1109,

1111, 1149; Pub. L. 98-378, Sec. 20(c), Aug. 16, 1984, 98 Stat.

1322; Pub. L. 98-617, Sec. 3(a)(7), (b)(10), Nov. 8, 1984, 98 Stat.

3295, 3296; Pub. L. 99-272, title IX, Secs. 9501(b), (c), 9503(a),

9505(b), (c)(1), (d), 9506(a), 9509(a), 9510(a), 9517(b),

9529(a)(1), (b)(1), title XII, Sec. 12305(b)(3), Apr. 7, 1986, 100

Stat. 201, 202, 205, 208-212, 216, 220, 293; Pub. L. 99-509, title

IX, Secs. 9320(h)(3), 9401(a)-(e)(1), 9402(a), (b), 9403(a), (c),

(e)-(g)(1), (4)(A), 9404(a), 9405, 9406(b), 9407(a), 9408(a), (b),

(c)(2), (3), 9431(a), (b)(1), 9433(a), 9435(b)(1), Oct. 21, 1986,

100 Stat. 2016, 2050-2058, 2060, 2061, 2066, 2068, 2069; Pub. L.

99-514, title XVIII, Sec. 1895(c)(1), (3)(B), (C), (7), Oct. 22,

1986, 100 Stat. 2935, 2936; Pub. L. 99-570, title XI, Sec.

11005(b), Oct. 27, 1986, 100 Stat. 3207-169; Pub. L. 99-643, Secs.

3(b), 7(b), Nov. 10, 1986, 100 Stat. 3575, 3579; Pub. L. 100-93,

Secs. 5(a), 7, 8(f), Aug. 18, 1987, 101 Stat. 689, 691, 694; Pub.

L. 100-203, title IV, Secs. 4072(d), 4101(a)(1), (2),

(b)(1)-(2)(B), (c)(2), (e)(1)-(5), 4102(b)(1), 4104, 4113(a)(2),

(b)(1), (2), (c)(1), (2), (d)(2), 4116, 4118(c)(1), (h)(1), (2),

(m)(1)(B), (p)(1)-(4), (6)-(8), 4211(b)(1), (h)(1)-(5), 4212(d)(2),

(3), (e)(1), 4213(b)(1), 4218(a), title IX, Secs. 9115(b),

9119(d)(1), Dec. 22, 1987, 101 Stat. 1330-117, 1330-140 to

1330-143, 1330-146, 1330-147, 1330-151, 1330-152, 1330-154 to

1330-157, 1330-159, 1330-203, 1330-205, 1330-213, 1330-219,

1330-220, 1330-305, as amended Pub. L. 100-360, title IV, Sec.

411(k)(5)(A), (7)(B)-(D), (10)(G)(ii), (iv), (l)(3)(H), (J),

(8)(C), (n)(2), (4), formerly (3), July 1, 1988, 102 Stat. 791,

794, 796, 803, 805, 807, as amended Pub. L. 100-485, title VI, Sec.

608(d)(14)(I), (15)(A), (27)(F)-(H), (28), Oct. 13, 1988, 102 Stat.

2416, 2423; Pub. L. 100-360, title II, Sec. 204(d)(3), title III,

Secs. 301(a)(1), (e)(2), 302(a), (b)(1), (c)(1), (2), (d)-(e)(3),

303(d), (e), title IV, Sec. 411(k)(5)(B), (17)(B), (l)(3)(E),

(6)(C), (D), July 1, 1988, 102 Stat. 729, 748-753, 762, 763, 792,

800, 803, 804; Pub. L. 100-485, title II, Sec. 202(c)(4), title

III, Sec. 303(a)(2), (b)(1), (d), title IV, Sec. 401(d)(1), title

VI, Sec. 608(d)(15)(B), (16)(C), Oct. 13, 1988, 102 Stat. 2378,

2391, 2392, 2396, 2416, 2418; Pub. L. 100-647, title VIII, Sec.

8434(b)(1), (2), Nov. 10, 1988, 102 Stat. 3805; Pub. L. 101-234,

title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L.

101-239, title VI, Secs. 6115(c), 6401(a), 6402(a), (c)(2),

6403(b), (d)(1), 6404(c), 6405(b), 6406(a), 6408(c)(1), (d)(1),

(4)(C), 6411(a)(1), (d)(3)(B), (e)(2), Dec. 19, 1989, 103 Stat.

2219, 2258, 2260, 2261, 2263-2265, 2268-2271; Pub. L. 101-508,

title IV, Secs. 4401(a)(2), 4402(a)(1), (c), (d)(1), 4501(b),

(e)(2), 4601(a)(1), 4602(a), 4603(a), 4604(a), (b), 4701(b)(1),

4704(a), (e)(1), 4708(a), 4711(c)(1), (d), 4713(a), 4715(a),

4723(b), 4724(a), 4732(b)(1), 4751(a), 4752(a)(1)(A), (c)(1),

4754(a), 4755(a)(2), (c)(1), 4801(e)(1)(A), (11)(A), Nov. 5, 1990,

104 Stat. 1388-143, 1388-161, 1388-163 to 1388-173, 1388-186,

1388-187, 1388-190, 1388-192, 1388-194, 1388-195, 1388-204,

1388-206, 1388-208 to 1388-210, 1388-215, 1388-217; Pub. L.

102-234, Secs. 2(b)(1), 3(a), Dec. 12, 1991, 105 Stat. 1799; Pub.

L. 103-66, title XIII, Sec. 13581(b)(2), 13601(b), 13602(c),

13603(a)-(c), 13611(d)(1), 13622(a)(1), (b), (c), 13623(a),

13625(a), 13631(a), (e)(1), (f)(1), Aug. 10, 1993, 107 Stat. 611,

613, 619, 620, 626, 632, 633, 636, 643, 644; Pub. L. 103-296, title

I, Sec. 108(d)(1), Aug. 15, 1994, 108 Stat. 1486; Pub. L. 103-448,

title II, Sec. 204(w)(2)(E), Nov. 2, 1994, 108 Stat. 4746; Pub. L.

104-193, title I, Secs. 108(k), 114(b)-(d)(1), title IX, Sec. 913,

Aug. 22, 1996, 110 Stat. 2169, 2180, 2354; Pub. L. 104-226, Sec.

1(b)(2), Oct. 2, 1996, 110 Stat. 3033; Pub. L. 104-248, Sec.

1(a)(1), Oct. 9, 1996, 110 Stat. 3148; Pub. L. 105-12, Sec.

9(b)(2), Apr. 30, 1997, 111 Stat. 26; Pub. L. 105-33, title IV,

Secs. 4106(c), 4454(b)(1), 4701(b)(2)(A)(i)-(iv), (d)(1),

4702(b)(2), 4709, 4711(a), 4712(a), (b)(1), (c)(1), 4714(a)(1),

4715(a), 4724(c)(1), (d), (f), (g)(1), 4731(a), (b), 4732(a), 4733,

4741(a), 4751(a), (b), 4752(a), 4753(b), 4911(b), 4912(b)(1),

4913(a), Aug. 5, 1997, 111 Stat. 368, 431, 493, 495, 506-510, 516,

517, 519, 520, 522-525, 571, 573; Pub. L. 106-113, div. B, Sec.

1000(a)(6) [title VI, Secs. 603(a)(1), 604(a)(1), (2)(A), (b)(1),

608(a)-(d), (y)(2), (aa)(1)], Nov. 29, 1999, 113 Stat. 1536,

1501A-394 to 1501A-398; Pub. L. 106-169, title I, Sec. 121(a)(1),

(c)(4), title II, Secs. 205(c), 206(b), Dec. 14, 1999, 113 Stat.

1829, 1830, 1834, 1837; Pub. L. 106-170, title II, Sec. 201(a)(1),

(2)(A), Dec. 17, 1999, 113 Stat. 1891, 1892; Pub. L. 106-354, Sec.

2(a)(1)-(3), (b)(2)(A), Oct. 24, 2000, 114 Stat. 1381-1383; Pub. L.

106-554, Sec. 1(a)(6) [title VII, Secs. 702(a)-(c)(1), 707(b)],

Dec. 21, 2000, 114 Stat. 2763, 2763A-572 to 2763A-574, 2763A-577;

Pub. L. 107-121, Sec. 2(a), (b)(1), (2), Jan. 15, 2002, 115 Stat.

2384.)

-STATAMEND-

REPEAL OF SUBSECTION (A)(29)

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, subsection (a)(29) of this section is repealed.

-REFTEXT-

REFERENCES IN TEXT

Parts A, D, and E of subchapter IV of this chapter, referred to

in subsecs. (a), (c), (e)(1), (10), and (l)(3), are classified to

sections 601 et seq., 651 et seq., and 670 et seq., respectively,

of this title.

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

subsec. (a)(10), (13)(B), are classified to sections 1395c et seq.

and 1395j et seq., respectively, of this title.

Section 602 of this title, referred to in subsecs.

(a)(10)(A)(i)(I) and (e)(10), was repealed and a new section 602

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 subsec.

(a)(37) or (a)(43).

Section 606 of this title, referred to in subsec.

(a)(10)(A)(i)(I), 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. (h).

Section 682 of this title, referred to in subsec.

(a)(10)(A)(i)(I), was repealed by Pub. L. 104-193, title I, Sec.

108(e), Aug. 22, 1996, 110 Stat. 2167.

The date of the enactment of section 211(a) of the Personal

Responsibility and Work Opportunity Reconciliation Act of 1996,

referred to in subsec. (a)(10)(A)(i)(II), is the date of enactment

of Pub. L. 104-193, which was approved Aug. 22, 1996. Section

211(a) of the Act amended section 1382c of this title.

Section 4611 of the Balanced Budget Act of 1997, referred to in

subsec. (a)(10)(E)(iv)(II), is section 4611 of Pub. L. 105-33,

which amended sections 1395d, 1395u, 1395x, and 1395ff of this

title. Subsec. (e)(3) of section 4611 of the Act is set out as a

note under section 1395d of this title. For complete classification

of section 4611 of the Act to the Code, see Tables.

Section 303(a)(4)(A) of this title, referred to in subsec.

(a)(20)(C), was amended generally by Pub. L. 97-35, title XXIII,

Sec. 2353(a)(1)(A), Aug. 13, 1981, 95 Stat. 871, and, as so

amended, no longer contained cls. (i) and (ii). Section 303(a)(4)

was amended by Pub. L. 103-66, title XIII, Sec. 13741(b), Aug. 10,

1993, 107 Stat. 663, and, as so amended, no longer contains

subparagraphs.

Section 1383(a)(4)(A)(i) and (ii) of this title, referred to in

subsec. (a)(20)(C), is a reference to section 1383(a)(4)(A)(i) and

(ii) existing prior to the general revision of subchapter XVI of

this chapter by Pub. L. 92-603, title III, Sec. 301, Oct. 30, 1972,

86 Stat. 1465, eff. Jan. 1, 1974. The prior section (which is set

out as a note under section 1383 of this title) continues in effect

for Puerto Rico, Guam, and the Virgin Islands. Subsec. (a)(4) of

the prior section was amended generally by Pub. L. 97-35, title

XXIII, Sec. 2353(m)(2)(B), Aug. 13, 1981, 95 Stat. 973, and, as so

amended, no longer contained clauses in subpar. (A). Subsec. (a)(4)

of the prior section was also amended by Pub. L. 103-66, title

XIII, Sec. 13741(b), Aug. 10, 1993, 107 Stat. 663, and, as so

amended, no longer contains subparagraphs.

Part B of subchapter XI of this chapter, referred to in subsec.

(d), is classified to section 1320c et seq. of this title.

Public Law 92-336, referred to in provisions following subsec.

(a)(52), is Pub. L. 92-336, July 1, 1972, 86 Stat. 406, which

amended sections 401, 403, 409, 411, 415, 427, 428, and 430 of this

title and sections 165, 1401, 1402, 3101, 3111, 3121, 3122, 3125,

6413, and 6654 of Title 26, Internal Revenue Code, and enacted

provisions set out as notes under sections 403, 409, 415, and 428

of this title and sections 165 and 1401 of Title 26.

The Public Health Service Act, referred to in subsecs. (u)(3) and

(aa)(3), is act July 1, 1944, ch. 373, 58 Stat. 682, as amended.

Titles XV and XXII of the Act are classified generally to

subchapters XIII (Sec. 300k et seq.) and XX (Sec. 300bb-1 et seq.),

respectively, 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 Internal Revenue Code of 1986, referred to in subsec. (u)(3),

is classified generally to Title 26.

The Employee Retirement Income Security Act of 1974, referred to

in subsec. (u)(3), 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-

AMENDMENTS

2002 - Subsec. (a)(15). Pub. L. 107-121, Sec. 2(b)(2),

substituted "subsection (bb)" for "subsection (aa)".

Subsec. (aa). Pub. L. 107-121, Sec. 2(b)(1), redesignated subsec.

(aa) relating to payment for services provided by

federally-qualified health centers and rural health clinics as

subsec. (bb).

Subsec. (aa)(4). Pub. L. 107-121, Sec. 2(a), inserted ", but

applied without regard to paragraph (1)(F) of such section" before

period at end.

Subsec. (bb). Pub. L. 107-121, Sec. 2(b)(1), redesignated subsec.

(aa) relating to payment for services provided by

federally-qualified health centers and rural health clinics as

subsec. (bb).

2000 - Subsec. (a)(10). Pub. L. 106-354, Sec. 2(a)(3), in

concluding provisions, substituted "(XIII)" for "and (XIII)" and

inserted before semicolon at end ", and (XIV) the medical

assistance made available to an individual described in subsection

(aa) of this section who is eligible for medical assistance only

because of subparagraph (A)(10)(ii)(XVIII) shall be limited to

medical assistance provided during the period in which such an

individual requires treatment for breast or cervical cancer".

Subsec. (a)(10)(A)(ii)(XVIII). Pub. L. 106-354, Sec. 2(a)(1),

added subcl. (XVIII).

Subsec. (a)(13)(A)(iv). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 702(a)(1)(A)], inserted "and" at end.

Subsec. (a)(13)(B). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 702(a)(1)(B)], struck out "and" at end.

Subsec. (a)(13)(C). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 702(c)(1)], repealed Pub. L. 105-33, Sec. 4712(c)(1). See 1997

Amendment note below.

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 702(a)(1)(C)],

struck out subpar. (C) which read as follows: "(C)(i) for payment

for services described in clause (B) or (C) of section 1396d(a)(2)

of this title under the plan of 100 percent (or 95 percent for

services furnished during fiscal year 2000, fiscal year 2001, or

fiscal year 2002, 90 percent for services furnished during fiscal

year 2003, or 85 percent for services furnished during fiscal year

2004) of costs which are reasonable and related to the cost of

furnishing such services or based on such other tests of

reasonableness, as the Secretary prescribes in regulations under

section 1395l(a)(3) of this title, or, in the case of services to

which those regulations do not apply, on the same methodology used

under section 1395l(a)(3) of this title and (ii) in carrying out

clause (i) in the case of services furnished by a

Federally-qualified health center or a rural health clinic pursuant

to a contract between the center and an organization under section

1396b(m) of this title, for payment to the center or clinic at

least quarterly by the State of a supplemental payment equal to the

amount (if any) by which the amount determined under clause (i)

exceeds the amount of the payments provided under such contract;".

Subsec. (a)(15). Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec.

702(a)(2)], added par. (15).

Subsec. (a)(47). Pub. L. 106-354, Sec. 2(b)(2)(A), inserted

before semicolon at end "and provide for making medical assistance

available to individuals described in subsection (a) of section

1396r-1b of this title during a presumptive eligibility period in

accordance with such section".

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

707(b)], substituted "2002" for "2001".

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

702(b)], added subsec. (aa) relating to payment for services

provided by Federally-qualified health centers and rural health

clinics.

Pub. L. 106-354, Sec. 2(a)(2), added subsec. (aa) relating to

certain breast or cervical cancer patients.

1999 - Subsec. (a)(10)(A)(ii)(XIV). Pub. L. 106-113, Sec.

1000(a)(6) [title VI, Sec. 608(aa)(1)], substituted "1396d(u)(2)(B)

of this title" for "1396d(u)(2)(C) of this title".

Subsec. (a)(10)(A)(ii)(XV). Pub. L. 106-169, Sec. 121(c)(4)(A),

redesignated subcl. (XV), related to individuals who are

independent foster care adolescents, as (XVII).

Pub. L. 106-169, Sec. 121(a)(1)(C), added subcl. (XV), related to

individuals who are independent foster care adolescents.

Pub. L. 106-169, Sec. 121(a)(1)(A), which directed striking out

of "or" at end of subcl. (XIII), was executed by amending subcl.

(XV), related to individuals who would be considered to be

receiving supplemental security income, etc. See Construction of

1999 Amendment note below.

Pub. L. 106-170, Sec. 201(a)(1), added subcl. (XV), related to

individuals who would be considered to be receiving supplemental

security income, etc.

Subsec. (a)(10)(A)(ii)(XVI). Pub. L. 106-169, Sec. 121(a)(1)(B),

which directed insertion of "or" at end of subcl. (XIV), was

executed to subcl. (XVI). See Construction of 1999 Amendment note

below.

Pub. L. 106-170, Sec. 201(a)(2)(A), added subcl. (XVI).

Subsec. (a)(10)(A)(ii)(XVII). Pub. L. 106-169, Sec. 121(c)(4),

redesignated subcl. (XV), related to individuals who are

independent foster care adolescents, as (XVII) and substituted

"section 1396d(w)(1)" for "section 1396d(v)(1)".

Subsec. (a)(10)(G). Pub. L. 106-169, Sec. 206(b), substituted

"subsections (c) and (e) of section 1382b" for "section 1382b(e)".

Pub. L. 106-169, Sec. 205(c), added subpar. (G).

Subsec. (a)(13)(C)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 603(a)(1)], substituted "fiscal year 2001, or fiscal year

2002, 90 percent for services furnished during fiscal year 2003, or

85 percent for services furnished during fiscal year 2004" for "90

percent for services furnished during fiscal year 2001, 85 percent

for services furnished during fiscal year 2002, or 70 percent for

services furnished during fiscal year 2003".

Subsec. (a)(30)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 604(b)(1)(A)], inserted "and" at end.

Subsec. (a)(30)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 604(b)(1)(B)], struck out "and" at end.

Subsec. (a)(30)(C). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 604(b)(1)(C)], struck out subpar. (C) which read as follows:

"use a utilization and quality control peer review organization

(under part B of subchapter XI of this chapter), an entity which

meets the requirements of section 1320c-1 of this title, as

determined by the Secretary, or a private accreditation body to

conduct (on an annual basis) an independent, external review of the

quality of services furnished under each contract under section

1396b(m) of this title, with the results of such review made

available to the State and, upon request, to the Secretary, the

Inspector General in the Department of Health and Human Services,

and the Comptroller General;".

Subsec. (a)(60). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(y)(2)], made technical amendment to reference in original act

which appears in text as reference to section 1396g-1 of this

title.

Subsec. (a)(64). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(a)], inserted "and" at end.

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

604(a)(2)(A)], struck out "(including quality review functions

described in subsection (a)(30)(C) of this section)" after "medical

or utilization review functions".

Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec. 604(a)(1)],

struck out "for the performance of the quality review functions

described in subsection (a)(30)(C) of this section," before "or a

utilization and quality control peer review organization".

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

608(b)], substituted "of" for "of of" after "numbered paragraph".

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

Sec. 608(c)(1)], substituted "children" for "children children".

Subsec. (l)(3). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(c)(2)], struck out first comma after "(a)(10)(A)(i)(VII)" in

introductory provisions.

Subsec. (l)(4)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(c)(3)], inserted comma after "(a)(10)(A)(i)(IV)".

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

608(d)], struck out par. (1) designation before "A State plan may

provide".

1997 - Subsec. (a). Pub. L. 105-33, Sec. 4454(b)(1), in second

sentence of flush concluding provisions, substituted "to a

religious nonmedical health care institution (as defined in section

1395x(ss)(1) of this title)." for "to a Christian Science

sanatorium operated, or listed and certified, by The Commission for

Accreditation of Christian Science Nursing

Organizations/Facilities, Inc.."

Subsec. (a)(4)(C), (D). Pub. L. 105-33, Sec. 4724(c)(1),

substituted "(C)" for "and (C)", "local officer, employee, or

independent contractor" for "local officer or employee", and "such

an officer, employee, or contractor" for "such an officer or

employee" in two places and added subpar. (D).

Subsec. (a)(9)(C). Pub. L. 105-33, Sec. 4106(c), substituted

"paragraphs (16) and (17)" for "paragraphs (15) and (16)".

Subsec. (a)(10)(A)(i)(II). Pub. L. 105-33, Sec. 4913(a), inserted

"(or were being paid as of the date of the enactment of section

211(a) of the Personal Responsibility and Work Opportunity

Reconciliation Act of 1996 (P.L. 104-193)) and would continue to be

paid but for the enactment of that section" after "subchapter XVI

of this chapter".

Subsec. (a)(10)(A)(ii)(XIII). Pub. L. 105-33, Sec. 4733, added

subcl. (XIII).

Subsec. (a)(10)(A)(ii)(XIV). Pub. L. 105-33, Sec. 4911(b), added

subcl. (XIV).

Subsec. (a)(10)(E)(iv). Pub. L. 105-33, Sec. 4732(a), added cl.

(iv).

Subsec. (a)(13)(A). Pub. L. 105-33, Sec. 4711(a)(1), added

subpar. (A) and struck out former subpar. (A) which related to

payment of hospital services, nursing facility services, and

services in intermediate care facilities for mentally retarded by

use of rates which account for various specified costs.

Subsec. (a)(13)(B). Pub. L. 105-33, Sec. 4711(a)(1)-(3),

redesignated subpar. (D) as (B), inserted "and" at end, and struck

out former subpar. (B) which read as follows: "that the State shall

provide assurances satisfactory to the Secretary that the payment

methodology utilized by the State for payments to hospitals can

reasonably be expected not to increase such payments, solely as a

result of a change of ownership, in excess of the increase which

would result from the application of section 1395x(v)(1)(O) of this

title;".

Subsec. (a)(13)(C). Pub. L. 105-33, Sec. 4712(c)(1), which

directed the repeal of subsec. (a)(13)(C), was repealed by Pub. L.

106-554, Sec. 1(a)(6) [title VII, Sec. 702(c)(1)]. See 2000

Amendment note above and Effective Date of 1997 Amendment note

below.

Pub. L. 105-33, Sec. 4712(b)(1), designated existing provisions

as cl. (i) and added cl. (ii).

Pub. L. 105-33, Sec. 4712(a), inserted "(or 95 percent for

services furnished during fiscal year 2000, 90 percent for services

furnished during fiscal year 2001, 85 percent for services

furnished during fiscal year 2002, or 70 percent for services

furnished during fiscal year 2003)" after "100 percent".

Pub. L. 105-33, Sec. 4711(a)(1), (2), (4), redesignated subpar.

(E) as (C), struck out "and" at end, and struck out former subpar.

(C) which read as follows: "that the State shall provide assurances

satisfactory to the Secretary that the valuation of capital assets,

for purposes of determining payment rates for nursing facilities

and for intermediate care facilities for the mentally retarded,

will not be increased (as measured from the date of acquisition by

the seller to the date of the change of ownership), solely as a

result of a change of ownership, by more than the lesser of -

"(i) one-half of the percentage increase (as measured over the

same period of time, or, if necessary, as extrapolated

retrospectively by the Secretary) in the Dodge Construction

Systems Costs for Nursing Homes, applied in the aggregate with

respect to those facilities which have undergone a change of

ownership during the fiscal year, or

"(ii) one-half of the percentage increase (as measured over the

same period of time) in the Consumer Price Index for All Urban

Consumers (United States city average);".

Subsec. (a)(13)(D), (E). Pub. L. 105-33, Sec. 4711(a)(2),

redesignated subpars. (D) and (E) as (B) and (C), respectively.

Subsec. (a)(13)(F). Pub. L. 105-33, Sec. 4711(a)(5), struck out

subpar. (F) which read as follows: "for payment for home and

community care (as defined in section 1396t(a) of this title and

provided under such section) through rates which are reasonable and

adequate to meet the costs of providing care, efficiently and

economically, in conformity with applicable State and Federal laws,

regulations, and quality and safety standards;".

Subsec. (a)(23). Pub. L. 105-33, Sec. 4724(d), struck out "except

as provided in subsection (g) of this section and in section 1396n

and except in the case of Puerto Rico, the Virgin Islands, and

Guam," after "(23)" and inserted before semicolon at end ", except

as provided in subsection (g) of this section and in section 1396n

of this title, except that this paragraph shall not apply in the

case of Puerto Rico, the Virgin Islands, and Guam, and except that

nothing in this paragraph shall be construed as requiring a State

to provide medical assistance for such services furnished by a

person or entity convicted of a felony under Federal or State law

for an offense which the State agency determines is inconsistent

with the best interests of beneficiaries under the State plan".

Subsec. (a)(23)(B). Pub. L. 105-33, Sec. 4701(d)(1), substituted

", in section 1396n of this title, and in section 1396u-2(a) of

this title" for "and in section 1396n of this title".

Pub. L. 105-33, Sec. 4701(b)(2)(A)(i), substituted "medicaid

managed care organization" for "health maintenance organization".

Subsec. (a)(25)(A)(ii). Pub. L. 105-33, Sec. 4753(b), substituted

"be integrated with, and be monitored as a part of the Secretary's

review of, the State's mechanized claims processing and information

retrieval systems required under section 1396b(r) of this title;"

for the dash that followed "which plan shall" and struck out

subcls. (I) and (II) which read as follows:

"(I) be integrated with, and be monitored as a part of the

Secretary's review of, the State's mechanized claims processing and

information retrieval system under section 1396b(r) of this title,

and

"(II) be subject to the provisions of section 1396b(r)(4) of this

title relating to reductions in Federal payments for failure to

meet conditions of approval, but shall not be subject to any other

financial penalty as a result of any other monitoring, quality

control, or auditing requirements;".

Subsec. (a)(25)(G) to (I). Pub. L. 105-33, Sec. 4741(a),

redesignated subpars. (H) and (I) as (G) and (H), respectively, and

struck out former subpar. (G) which read as follows: "that the

State plan shall meet the requirements of section 1396e of this

title (relating to enrollment of individuals under group health

plans in certain cases);".

Subsec. (a)(26). Pub. L. 105-33, Sec. 4751(a), substituted

"provide, with respect to each patient" for "provide -

"(A) with respect to each patient"

and struck out subpars. (B) and (C) which read as follows:

"(B) for periodic inspections to be made in all mental

institutions within the State by one or more medical review teams

(composed of physicians and other appropriate health and social

service personnel) of the care being provided to each person

receiving medical assistance, including (i) the adequacy of the

services available to meet his current health needs and promote his

maximum physical well-being, (ii) the necessity and desirability of

his continued placement in the institution, and (iii) the

feasibility of meeting his health care needs through alternative

institutional or noninstitutional services; and

"(C) for full reports to the State agency by each medical review

team of the findings of each inspection under subparagraph (B),

together with any recommendations;".

Subsec. (a)(31). Pub. L. 105-33, Sec. 4751(b), substituted

"provide, with respect to each patient" for "provide -

"(A) with respect to each patient"

and struck out subpars. (B) and (C) which read as follows:

"(B) with respect to each intermediate care facility for the

mentally retarded within the State, for periodic onsite inspections

of the care being provided to each person receiving medical

assistance, by one or more independent professional review teams

(composed of a physician or registered nurse and other appropriate

health and social service personnel), including with respect to

each such person (i) the adequacy of the services available to meet

his current health needs and promote his maximum physical

well-being, (ii) the necessity and desirability of his continued

placement in the facility, and (iii) the feasibility of meeting his

health care needs through alternative institutional or

noninstitutional services; and

"(C) for full reports to the State agency by each independent

professional review team of the findings of each inspection under

subparagraph (B), together with any recommendations;".

Subsec. (a)(47). Pub. L. 105-33, Sec. 4912(b)(1), inserted before

semicolon at end "and provide for making medical assistance for

items and services described in subsection (a) of section 1396r-1a

of this title available to children during a presumptive

eligibility period in accordance with such section".

Subsec. (a)(57). Pub. L. 105-33, Sec. 4701(b)(2)(A)(ii),

substituted "medicaid managed care organization" for "health

maintenance organization".

Subsec. (a)(63). Pub. L. 105-33, Sec. 4724(g)(1)(A), struck out

"and" at end.

Subsec. (a)(64). Pub. L. 105-33, Sec. 4724(g)(1)(B), which

directed the amendment of par. (64) by substituting "; and" for the

period at end, could not be executed because there was no period at

end.

Pub. L. 105-33, Sec. 4724(f), added par. (64).

Subsec. (a)(65). Pub. L. 105-33, Sec. 4724(g)(1)(C), added par.

(65).

Subsec. (e)(2)(A). Pub. L. 105-33, Sec. 4709(2), which directed

the amendment of subsec. (e)(2) by inserting "or by or through the

case manager" before period at end, was executed by making

insertion before period at end of subpar. (A) to reflect the

probable intent of Congress.

Pub. L. 105-33, Sec. 4709(1), substituted "who is enrolled with a

medicaid managed care organization (as defined in section

1396b(m)(1)(A) of this title), with a primary care case manager (as

defined in section 1396d(t) of this title)," for "who is enrolled

with a qualified health maintenance organization (as defined in

title XIII of the Public Health Service Act) or with an entity

described in paragraph (2)(B)(iii), (2)(E), (2)(G), or (6) of

section 1396b(m) of this title under a contract described in

section 1396b(m)(2)(A) of this title".

Subsec. (e)(12). Pub. L. 105-33, Sec. 4731(a), added par. (12).

Subsec. (i)(1)(B). Pub. L. 105-33, Sec. 4752(a), substituted

"establish alternative remedies if the State demonstrates to the

Secretary's satisfaction that the alternative remedies are

effective in deterring noncompliance and correcting deficiencies,

and may provide" for "provide".

Subsec. (j). Pub. L. 105-33, Sec. 4702(b)(2), substituted "a

numbered paragraph of" for "paragraphs (1) through (25)".

Subsec. (l)(1)(D). Pub. L. 105-33, Sec. 4731(b), inserted "(or,

at the option of a State, after any earlier date)" after "children

born after September 30, 1983".

Subsec. (n). Pub. L. 105-33, Sec. 4714(a)(1), designated existing

provisions as par. (1) and added pars. (2) and (3).

Subsec. (p)(2). Pub. L. 105-33, Sec. 4701(b)(2)(A)(iii),

substituted "medicaid managed care organization" for "health

maintenance organization" in introductory provisions.

Subsec. (r)(1). Pub. L. 105-33, Sec. 4715(a), designated existing

provisions as subpar. (A), inserted ", the treatment described in

subparagraph (B) shall apply," after "under such a waiver",

substituted ", and" for "and," after "Federal Republic of Germany",

and added subpar. (B).

Subsec. (w)(2)(E). Pub. L. 105-33, Sec. 4701(b)(2)(A)(iv),

substituted "medicaid managed care organization" for "health

maintenance organization".

Subsec. (w)(5). Pub. L. 105-12 added par. (5).

1996 - Subsec. (a). Pub. L. 104-193, Sec. 913, 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 third

sentence, was executed by making the substitution for "the First

Church of Christ, Scientist, Boston, Massachusetts" in first

undesignated closing par. to reflect the probable intent of

Congress.

Subsec. (a)(25)(A)(i). Pub. L. 104-226 struck out "including the

use of information collected by the Medicare and Medicaid Coverage

Data Bank under section 1320b-14 of this title and any additional

measures" before "as specified by the Secretary in regulations)".

Subsec. (a)(59). Pub. L. 104-248 substituted "subsection (x)" for

"subsection (v)".

Subsec. (a)(63). Pub. L. 104-193, Sec. 114(b), added par. (63).

Subsec. (c). Pub. L. 104-193, Sec. 114(d)(1), substituted "if the

State requires individuals described in subsection (l)(1) of this

section to apply for assistance under the State program funded

under part A of subchapter IV of this chapter as a condition of

applying for or receiving medical assistance under this

subchapter." for "if -

"(1) the State has in effect, under its plan established under

part A of subchapter IV of this chapter, payment levels that are

less than the payment levels in effect under such plan on May 1,

1988; or

"(2) the State requires individuals described in subsection

(l)(1) of this section to apply for benefits under such part as a

condition of applying for, or receiving, medical assistance under

this subchapter."

Subsec. (e)(1)(B). Pub. L. 104-193, Sec. 114(c), substituted

"2001" for "1998".

Subsec. (j). Pub. L. 104-193, Sec. 108(k), substituted "1308(f)"

for "1308(c)".

1994 - Subsec. (a)(10)(A)(ii)(XI). Pub. L. 103-296 substituted

"Commissioner of Social Security" for "Secretary".

Subsec. (a)(11)(C), (53)(A). Pub. L. 103-448 substituted "special

supplemental nutrition program" for "special supplemental food

program".

1993 - Subsec. (a)(10). Pub. L. 103-66, Sec. 13603(c), in

concluding provisions, substituted "services, or hospitals, (XI)"

for "services, or hospitals; and (XI)" and "other individuals,

(XII)" for "other individuals, and (XI)", and inserted ", and" and

subdiv. (XIII) before semicolon at end.

Subsec. (a)(10)(A)(ii)(XII). Pub. L. 103-66, Sec. 13603(a), added

subcl. (XII).

Subsec. (a)(1)(C)(iv). Pub. L. 103-66, Sec. 13601(b)(1),

substituted "paragraphs numbered (1) through (24)" for "paragraphs

numbered (1) through (21)".

Subsec. (a)(11). Pub. L. 103-66, Sec. 13631(f)(1)(A), (B), in

subpar. (B), struck out "effective July 1, 1969," after "(B)" and

"and" before "(ii)" and substituted "to the individual under

section 1396b of this title, and (iii) providing for coordination

of information and education on pediatric vaccinations and delivery

of immunization services" for "to him under section 1396b of this

title", and in subpar. (C), inserted ", including the provision of

information and education on pediatric vaccinations and the

delivery of immunization services," after "operations under this

subchapter".

Subsec. (a)(18). Pub. L. 103-66, Sec. 13611(d)(1)(A), substituted

", transfers of assets, and treatment of certain trusts" for "and

transfers of assets".

Subsec. (a)(25)(A). Pub. L. 103-66, Sec. 13622(a), substituted

"insurers, group health plans (as defined in section 607(1) of the

Employee Retirement Income Security Act of 1974), service benefit

plans, and health maintenance organizations)" for "insurers)" in

introductory provisions.

Subsec. (a)(25)(A)(i). Pub. L. 103-66, Sec. 13581(b)(2),

substituted "(including the use of information collected by the

Medicare and Medicaid Coverage Data Bank under section 1320b-14 of

this title and any additional measures as specified" for "(as

specified".

Subsec. (a)(25)(H). Pub. L. 103-66, Sec. 13622(b), added subpar.

(H).

Subsec. (a)(25)(I). Pub. L. 103-66, Sec. 13622(c), added subpar.

(I).

Subsec. (a)(32)(D). Pub. L. 103-66, Sec. 13631(e)(1), added

subpar. (D).

Subsec. (a)(43)(A). Pub. L. 103-66, Sec. 13631(f)(1)(C), inserted

before comma at end "and the need for age-appropriate immunizations

against vaccine-preventable diseases".

Subsec. (a)(51). Pub. L. 103-66, Sec. 13611(d)(1)(B), struck out

"(A)" before "meet the requirements" and ", and (B) meet the

requirement of section 1396p(c) of this title (relating to transfer

of assets)" after "community spouses)".

Subsec. (a)(54). Pub. L. 103-66, Sec. 13623(a)(1), which directed

amendment of par. (54) by striking "and" at end, could not be

executed because "and" did not appear at end subsequent to

amendment by Pub. L. 103-66, Sec. 13602(c). See below.

Pub. L. 103-66, Sec. 13602(c), amended par. (54) generally. Prior

to amendment, par. (54) read as follows:

"(A) provide that, any formulary or similar restriction (except

as provided in section 1396r-8(d) of this title) on the coverage of

covered outpatient drugs under the plan shall permit the coverage

of covered outpatient drugs of any manufacturer which has entered

into and complies with an agreement under section 1396r-8(a) of

this title, which are prescribed for a medically accepted

indication (as defined in subsection 1396r-8(k)(6) of this title),

and

"(B) comply with the reporting requirements of section

1396r-8(b)(2)(A) of this title and the requirements of subsections

(d) and (g) of section 1396r-8 of this title; and".

Subsec. (a)(55). Pub. L. 103-66, Sec. 13623(a)(3), redesignated

par. (55) relating to providing for adjusted payments as (56).

Pub. L. 103-66, Sec. 13623(a)(2), amended par. (55) relating to

providing for receipt and initial processing of applications by

substituting semicolon for period at end of subpar. (B).

Subsec. (a)(56). Pub. L. 103-66, Sec. 13623(a)(3), redesignated

par. (55) relating to providing for adjusted payments as (56),

transferred such par. to appear after par. (55) relating to

providing for receipt and initial processing of applications, and

substituted semicolon for period at end.

Subsec. (a)(57). Pub. L. 103-66, Sec. 13623(a)(4), transferred

par. (57) to appear after par. (56) as redesignated by Pub. L.

103-66, Sec. 13623(a)(3). See above.

Subsec. (a)(58). Pub. L. 103-66, Sec. 13623(a)(6), redesignated

par. (58) relating to maintaining a list as (59).

Pub. L. 103-66, Sec. 13623(a)(5), amended par. (58) relating to

providing that a State develop a written description of advance

directive laws by substituting a semicolon for period at end.

Pub. L. 103-66, Sec. 13623(a)(4), transferred par. (58) relating

to providing that a State develop a written description of advance

directive laws to follow par. (57) which was transferred by Pub. L.

103-66, Sec. 13623(a)(4), to appear after par. (56), as

redesignated by Pub. L. 103-66, Sec. 13623(a)(3). See above.

Subsec. (a)(59). Pub. L. 103-66, Sec. 13625(a)(1), struck out

"and" at end.

Pub. L. 103-66, Sec. 13623(a)(6), redesignated par. (58),

relating to maintaining a list, as (59), transferred such par. to

appear after par. (58) relating to providing that a State develop a

written description of advance directive laws, and substituted ";

and" for period at end.

Subsec. (a)(60). Pub. L. 103-66, Sec. 13623(a)(7), added par.

(60).

Subsec. (a)(61). Pub. L. 103-66, Sec. 13625(a), added par. (61).

Subsec. (a)(62). Pub. L. 103-66, Sec. 13631(a), added par. (62).

Subsec. (j). Pub. L. 103-66, Sec. 13601(b)(2), substituted

"paragraphs (1) through (25)" for "paragraphs (1) through (22)".

Subsec. (k). Pub. L. 103-66, Sec. 13611(d)(1)(C), struck out

subsec. (k) which read as follows:

"(k)(1) In the case of a medicaid qualifying trust (described in

paragraph (2)), the amounts from the trust deemed available to a

grantor, for purposes of subsection (a)(17) of this section, is the

maximum amount of payments that may be permitted under the terms of

the trust to be distributed to the grantor, assuming the full

exercise of discretion by the trustee or trustees for the

distribution of the maximum amount to the grantor. For purposes of

the previous sentence, the term 'grantor' means the individual

referred to in paragraph (2).

"(2) For purposes of this subsection, a 'medicaid qualifying

trust' is a trust, or similar legal device, established (other than

by will) by an individual (or an individual's spouse) under which

the individual may be the beneficiary of all or part of the

payments from the trust and the distribution of such payments is

determined by one or more trustees who are permitted to exercise

any discretion with respect to the distribution to the individual.

"(3) This subsection shall apply without regard to -

"(A) whether or not the medicaid qualifying trust is

irrevocable or is established for purposes other than to enable a

grantor to qualify for medical assistance under this subchapter;

or

"(B) whether or not the discretion described in paragraph (2)

is actually exercised.

"(4) The State may waive the application of this subsection with

respect to an individual where the State determines that such

application would work an undue hardship."

Subsec. (z). Pub. L. 103-66, Sec. 13603(b), added subsec. (z).

1991 - Subsec. (h). Pub. L. 102-234, Sec. 3(a), struck out "to

limit the amount of payment adjustments that may be made under a

plan under this subchapter with respect to hospitals that serve a

disproportionate number of low-income patients with special needs

or" after "Secretary".

Subsec. (t). Pub. L. 102-234, Sec. 2(b)(1), substituted "Nothing"

for "Except as provided in section 1396b(i) of this title, nothing"

and "taxes of general applicability" for "taxes (whether or not of

general applicability)".

1990 - Subsec. (a)(10). Pub. L. 101-508, Sec. 4713(a)(1)(D),

which directed amendment of par. (10) by adding subdiv. (XI),

relating to medical assistance available to an individual described

in subsection (u)(1), in the matter following subparagraph (E), was

executed in the matter following subpar. (F) to reflect the

probable intent of Congress and the intervening amendment by Pub.

L. 101-508, Sec. 4713(a)(1)(A)-(C), which added subpar. (F). See

below. Direction by section 4713(a)(1)(D) to strike "and" before

"(X)" could not be executed because "and" did not appear after

amendment by Pub. L. 101-508, Sec. 4402(d)(1). See below.

Pub. L. 101-508, Sec. 4402(d)(1), in closing provisions, struck

out "and" at end of subdiv. (IX), inserted "and" at end of subdiv.

(X), and added subdiv. (XI) relating to medical assistance to cover

costs of premiums, etc.

Subsec. (a)(10)(A)(i)(VII). Pub. L. 101-508, Sec. 4601(a)(1)(A),

added subcl. (VII).

Subsec. (a)(10)(A)(ii)(IX). Pub. L. 101-508, Sec. 4601(a)(1)(B),

substituted ", clause (i)(VI), or clause (i)(VII)" for "or clause

(i)(VI)".

Subsec. (a)(10)(C)(iv). Pub. L. 101-508, Secs. 4711(d)(2),

4755(c)(1)(A), amended cl. (iv) identically, substituting "through

(21)" for "through (20)".

Subsec. (a)(10)(E)(iii). Pub. L. 101-508, Sec. 4501(b), added cl.

(iii).

Subsec. (a)(10)(F). Pub. L. 101-508, Sec. 4713(a)(1)(A)-(C),

added subpar. (F).

Subsec. (a)(13)(A). Pub. L. 101-508, Sec. 4801(e)(1)(A), inserted

"(including the costs of services required to attain or maintain

the highest practicable physical, mental, and psychosocial

well-being of each resident eligible for benefits under this

subchapter)" after "take into account the costs".

Subsec. (a)(13)(E). Pub. L. 101-508, Sec. 4704(e)(1), repealed

Pub. L. 101-239, Sec. 6402(c)(2). See 1989 Amendment note below.

Pub. L. 101-508, Sec. 4704(a), substituted "prescribes" for "may

prescribe" and "on the same methodology used under section

1395l(a)(3) of this title" for "on such tests of reasonableness as

the Secretary may prescribe in regulations under this

subparagraph".

Subsec. (a)(13)(F). Pub. L. 101-508, Sec. 4711(c)(1)(A), added

subpar. (F).

Subsec. (a)(17). Pub. L. 101-508, Sec. 4723(b), inserted ",

payments made to the State under section 1396b(f)(2)(B) of this

title," after "insurance premiums".

Subsec. (a)(25)(G). Pub. L. 101-508, Sec. 4402(a)(1), added

subpar. (G).

Subsec. (a)(32)(C). Pub. L. 101-508, Sec. 4708(a), added subpar.

(C).

Subsec. (a)(41). Pub. L. 101-508, Sec. 4754(a), substituted

"shall promptly notify the Secretary and, in the case of a

physician and notwithstanding paragraph (7), the State medical

licensing board" for "shall promptly notify the Secretary".

Subsec. (a)(54). Pub. L. 101-508, Sec. 4401(a)(2), added par.

(54).

Subsec. (a)(55). Pub. L. 101-508, Sec. 4604(b), added par. (55)

relating to providing for adjusted payments.

Pub. L. 101-508, Sec. 4602(a), added par. (55) relating to

providing for receipt and initial processing of applications.

Subsec. (a)(57). Pub. L. 101-508, Sec. 4751(a)(1), added par.

(57).

Subsec. (a)(58). Pub. L. 101-508, Sec. 4752(c), added par. (58)

relating to maintaining a list.

Pub. L. 101-508, Sec. 4751(a)(1), added par. (58) relating to

providing that a State develop a written description of advance

directive laws.

Subsec. (e)(2)(A). Pub. L. 101-508, Sec. 4732(b)(1), inserted "or

with an eligible organization with a contract under section 1395mm

of this title" after "section 1396b(m)(2)(A) of this title".

Subsec. (e)(4). Pub. L. 101-508, Sec. 4603(a)(1), inserted "(or

would remain if pregnant)" after "remains".

Subsec. (e)(6). Pub. L. 101-508, Sec. 4603(a)(2), substituted

"In" for "At the option of a State, in", substituted "the woman

shall be deemed to continue to be" for "the State plan may

nonetheless treat the woman as being", and inserted at end "The

preceding sentence shall not apply in the case of a woman who has

been provided ambulatory prenatal care pursuant to section 1396r-1

of this title during a presumptive eligibility period and is then,

in accordance with such section, determined to be ineligible for

medical assistance under the State plan."

Subsec. (e)(11). Pub. L. 101-508, Sec. 4402(c), added par. (11).

Subsec. (h). Pub. L. 101-508, Sec. 4711(c)(1)(B), inserted before

period at end "or to limit the amount of payment that may be made

under a plan under this subchapter for home and community care".

Subsec. (j). Pub. L. 101-508, Secs. 4711(d)(1), 4755(c)(1)(B),

amended subsec. (j) identically substituting "through (22)" for

"through (21)".

Subsec. (l)(1)(C). Pub. L. 101-508, Sec. 4601(a)(1)(C)(i),

inserted "children" after "(C)".

Subsec. (l)(1)(D). Pub. L. 101-508, Sec. 4601(a)(1)(C)(ii), added

subpar. (D) and struck out former subpar. (D) which read as

follows: "at the option of the State, children born after September

30, 1983, who have attained 6 years of age but have not attained 7

or 8 years of age (as selected by the State),".

Subsec. (l)(2)(C). Pub. L. 101-508, Sec. 4601(a)(1)(C)(iii),

added subpar. (C) and struck out former subpar. (C) which read as

follows: "If a State elects, under subsection (a)(10)(A)(ii)(IX) of

this section, to cover individuals not described in subparagraph

(A) or (B) of paragraph (1), for purposes of that paragraph and

with respect to individuals not described in such subparagraphs the

State shall establish an income level which is a percentage (not

more than 100 percent) of the income official poverty line

described in subparagraph (A)."

Subsec. (l)(3). Pub. L. 101-508, Sec. 4601(a)(1)(C)(iv), inserted

", (a)(10)(A)(i)(VII)," after "(a)(10)(A)(i)(VI)".

Subsec. (l)(4)(A). Pub. L. 101-508, Sec. 4601(a)(1)(C)(v),

inserted "or subsection (a)(10)(A)(i)(VII) of this section" after

"(a)(10)(A)(i)(VI) of this section".

Subsec. (l)(4)(B). Pub. L. 101-508, Sec. 4601(a)(1)(C)(vi),

substituted "(a)(10)(A)(i)(VI), or (a)(10)(A)(i)(VII)" for "or

(a)(10)(A)(i)(VI)".

Subsec. (m)(1)(B). Pub. L. 101-508, Sec. 4501(e)(2)(A), inserted

", except as provided in paragraph (2)(C)" after "program".

Subsec. (m)(2)(C). Pub. L. 101-508, Sec. 4501(e)(2)(B), added

subpar. (C).

Subsec. (r)(1). Pub. L. 101-508, Sec. 4715(a), inserted "there

shall be disregarded reparation payments made by the Federal

Republic of Germany and" after "under such a waiver".

Subsec. (r)(2)(A). Pub. L. 101-508, Sec. 4601(a)(1)(D), inserted

"(a)(10)(A)(i)(VII)," after "(a)(10)(A)(i)(VI),".

Subsec. (s). Pub. L. 101-508, Sec. 4604(a), added subsec. (s).

Subsec. (t). Pub. L. 101-508, Sec. 4701(b)(1), added subsec. (t).

Subsec. (u). Pub. L. 101-508, Sec. 4713(a)(2), added subsec. (u).

Subsec. (v). Pub. L. 101-508, Sec. 4724(a), added subsec. (v).

Subsec. (w). Pub. L. 101-508, Sec. 4751(a)(2), added subsec. (w).

Subsec. (x). Pub. L. 101-508, Sec. 4752(a)(1)(A), added subsec.

(x).

Subsec. (y). Pub. L. 101-508, Sec. 4755(a)(2), added subsec. (y).

1989 - Subsec. (a)(9)(C). 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.(a)(10)(A). Pub. L. 101-239, Sec. 6405(b), substituted

"(1) through (5), (17) and (21)" for "(1) through (5) and (17)" in

introductory provisions.

Subsec. (a)(10)(A)(i)(VI). Pub. L. 101-239, Sec. 6401(a)(1),

added subcl. (VI).

Subsec. (a)(10)(A)(ii)(IX). Pub. L. 101-239, Sec. 6401(a)(2),

inserted "or clause (i)(VI)" after "clause (i)(IV)".

Subsec. (a)(10)(E). Pub. L. 101-239, Sec. 6408(d)(1), designated

existing provisions as cl. (i) and added cl. (ii).

Subsec. (a)(11)(C). Pub. L. 101-239, Sec. 6406(a)(1), added

subpar. (C).

Subsec. (a)(13)(D). Pub. L. 101-239, Sec. 6408(c)(1), substituted

"in amounts no lower than the amounts, using the same methodology,

used" for "in the same amounts, and using the same methodology, as

used", "in the case of" for "a separate rate may be paid for", and

"there shall be paid an additional amount, to take into account the

room and board furnished by the facility, equal to at least 95

percent of the rate that would have been paid by the State under

the plan for facility services in that facility for that

individual" for "to take into account the room and board furnished

by such facility".

Subsec. (a)(13)(E). Pub. L. 101-239, Sec. 6404(c), substituted

"clause (B) or (C) of section 1396d(a)(2) of this title" for

"section 1396d(a)(2)(B) of this title provided by a rural health

clinic".

Pub. L. 101-239, Sec. 6402(c)(2), which directed insertion of ",

and for payment for services described in section 1396d(a)(2)(C) of

this title under the plan," after "provided by a rural health

clinic under the plan", was repealed by Pub. L. 101-508, Sec.

4704(e)(1).

Subsec. (a)(30)(A). Pub. L. 101-239, Sec. 6402(a), inserted

before semicolon at end "and are sufficient to enlist enough

providers so that care and services are available under the plan at

least to the extent that such care and services are available to

the general population in the geographic area".

Subsec. (a)(43)(A). Pub. L. 101-239, Sec. 6403(d)(1), substituted

"section 1396d(r)" for "section 1396d(a)(4)(B)".

Subsec. (a)(43)(D). Pub. L. 101-239, Sec. 6403(b), added subpar.

(D).

Subsec. (a)(53). Pub. L. 101-239, Sec. 6406(a)(2)-(4), added par.

(53).

Subsec. (e)(7). Pub. L. 101-239, Sec. 6401(a)(8), substituted ",

(C), or (D)" for "or (C)" in introductory provisions.

Subsec. (f). Pub. L. 101-239, Sec. 6411(e)(2), inserted "and

section 1396r-5 of this title" after "section 1382h(b)(3) of this

title".

Pub. L. 101-239, Sec. 6411(a)(1), inserted "and except with

respect to qualified medicare beneficiaries, qualified severely

impaired individuals, and individuals described in subsection

(m)(1) of this subsection" before ", no State".

Pub. L. 101-239, Sec. 6408(d)(4)(C), inserted ", except with

respect to qualified disabled and working individuals (described in

section 1396d(s) of this title)," after "section 1382h(b)(3) of

this title".

Subsec. (l)(1)(C), (D). Pub. L. 101-239, Sec. 6401(a)(3), added

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

as follows: "at the option of the State, children born after

September 30, 1983, who have attained one year of age but have not

attained 2, 3, 4, 5, 6, 7, or 8 years of age (as selected by the

State),".

Subsec. (l)(2)(A)(ii)(II). Pub. L. 101-239, Sec. 6401(a)(4)(A),

amended subcl. (II) generally. Prior to amendment, subcl. (II) read

as follows: "July 1, 1990, is 100 percent."

Subsec. (l)(2)(A)(iv). Pub. L. 101-239, Sec. 6401(a)(4)(B), added

cl. (iv).

Subsec. (l)(2)(B), (C). Pub. L. 101-239, Sec. 6401(a)(5), (6),

added subpar. (B), struck out ", or, if less, the percentage

established under subparagraph (A)" after "not more than 100

percent" in former subpar. (B), and redesignated former subpar. (B)

as (C).

Subsec. (l)(3). Pub. L. 101-239, Sec. 6401(a)(6)(A), inserted ",

(a)(10)(A)(i)(VI)," after "(a)(10)(A)(i)(IV)" in introductory

provisions.

Subsec. (l)(3)(C). Pub. L. 101-239, Sec. 6401(a)(6)(B),

substituted "(C), or (D)" for "or (C)".

Subsec. (l)(4)(A). Pub. L. 101-239, Sec. 6401(a)(7)(A), inserted

"and for children described in subsection (a)(10)(A)(i)(VI) of this

section" after "(a)(10)(A)(i)(IV) of this section".

Subsec. (l)(4)(B). Pub. L. 101-239, Sec. 6401(a)(7)(B), inserted

"or (a)(10)(A)(i)(VI)" after "(a)(10)(A)(i)(IV)".

Subsec. (p)(2)(C). Pub. L. 101-239, Sec. 6411(d)(3)(B), added

subpar. (C).

Subsec. (r)(2)(A). Pub. L. 101-239, Sec. 6401(a)(9), inserted

"(a)(10)(A)(i)(VI)," after "(a)(10)(A)(i)(IV)," in introductory

provisions.

1988 - Subsec. (a)(9)(C). Pub. L. 100-360, Sec. 204(d)(3),

substituted "paragraphs (14) and (15)" for "paragraphs (13) and

(14)".

Subsec. (a)(10). Pub. L. 100-647, Sec. 8434(b)(1), inserted "who

is only entitled to medical assistance because the individual is

such a beneficiary" after "section 1396d(p)(1) of this title" in

subdiv. (VIII) of closing provisions.

Pub. L. 100-360, Sec. 302(a)(1)(C), inserted "(A)(i)(IV) or"

before "(A)(ii)(X)" in subdiv. (VII) of closing provisions.

Pub. L. 100-360, Sec. 302(b)(1), added subdiv. (X) in closing

provisions.

Subsec. (a)(10)(A)(i)(I). Pub. L. 100-485, Sec. 202(c)(4),

substituted "section 682(e)(6) of this title" for "section 614(g)

of this title".

Subsec. (a)(10)(A)(i)(IV). Pub. L. 100-360, Sec. 302(a)(1)(A),

added subcl. (IV).

Subsec. (a)(10)(A)(i)(V). Pub. L. 100-485, Sec. 401(d)(1), added

subcl. (V).

Subsec. (a)(10)(A)(ii)(VI). Pub. L. 100-360, Sec. 411(k)(17)(B),

substituted "(c), (d), or (e)" for "(c) or (d)" in two places.

Subsec. (a)(10)(A)(ii)(IX). Pub. L. 100-360, Sec. 302(a)(1)(B),

amended subcl. (IX) generally. Prior to amendment, subcl. (IX) read

as follows: "subject to subsection (l)(4) of this section, who are

described in subsection (l)(1) of this section;".

Subsec. (a)(10)(A)(ii)(X). Pub. L. 100-360, Sec. 301(e)(2)(A),

struck out "subject to subsection (m)(3) of this section," before

"who are described".

Subsec. (a)(10)(A)(ii)(XI). Pub. L. 100-360, Sec. 411(k)(5)(B),

substituted "may be more restrictive" for "are more restrictive"

and a semicolon for the period at end.

Pub. L. 100-360, Sec. 411(k)(5)(A), amended Pub. L. 100-203, Sec.

4104, see 1987 Amendment note below.

Subsec. (a)(10)(C)(i)(III). Pub. L. 100-360, Sec. 303(e)(1),

substituted "no more restrictive than the methodology" for "the

same methodology" in two places.

Subsec. (a)(10)(E). Pub. L. 100-360, Sec. 301(e)(2)(B), struck

out "subject to subsection (m)(3) of this section," before "for

making medical".

Pub. L. 100-360, Sec. 301(a)(1), struck out "at the option of a

State, but" after "(E)".

Subsec. (a)(13)(A). Pub. L. 100-360, Sec. 411(l)(3)(J), as added

by Pub. L. 100-485, Sec. 608(d)(27)(H), amended Pub. L. 100-203,

Sec. 4211(h)(2)(B), see 1987 Amendment note below.

Subsec. (a)(13)(C). Pub. L. 100-360, Sec. 411(l)(3)(H)(i), as

amended by Pub. L. 100-485, Sec. 608(d)(27)(F), amended Pub. L.

100-203, Sec. 4211(h)(2)(C), see 1987 Amendment note below.

Subsec. (a)(13)(D). Pub. L. 100-360, Sec. 411(l)(3)(H)(ii),

(iii), as amended by Pub. L. 100-485, Sec. 608(d)(27)(G), amended

Pub. L. 100-203, Sec. 4211(h)(2)(D), see 1987 Amendment note below.

Subsec. (a)(15). Pub. L. 100-360, Sec. 301(e)(2)(C), as added by

Pub. L. 100-485, Sec. 608(d)(14)(I)(iii), struck out par. (15)

which read as follows: "in the case of eligible individuals 65

years of age or older who are not qualified medicare beneficiaries

(as defined in section 1396d(p)(1) of this title) but are covered

by either or both of the insurance programs established by

subchapter XVIII of this chapter, provide where, under the plan,

all of any deductible, cost sharing, or similar charge imposed with

respect to such individual under the insurance program established

by such subchapter is not met, the portion thereof which is met

shall be determined on a basis reasonably related (as determined in

accordance with standards approved by the Secretary and included in

the plan) to such individual's income or his income and

resources;".

Subsec. (a)(17). Pub. L. 100-360, Sec. 411(k)(10)(G)(ii), amended

directory language of Pub. L. 100-203, Sec. 4118(h)(1), see 1987

Amendment note below.

Pub. L. 100-360, Sec. 301(e)(2)(D), formerly Sec. 301(e)(2)(C),

as redesignated and amended by Pub. L. 100-485, Sec.

608(d)(14)(I)(i), substituted "(m)(3), and (m)(4)" for "(m)(4), and

(m)(5)".

Subsec. (a)(28)(D)(i). Pub. L. 100-360, Sec. 411(l)(3)(E),

substituted "section 1396r(e) of this title" for "section 1396r(f)

of this title (relating to implementation of nursing facility

requirements, including paragraph (6)(B), relating to specification

of resident assessment instrument)".

Subsec. (a)(33)(B). Pub. L. 100-360, Sec. 411(l)(6)(C),

substituted "section 1396r(g) of this title" for "section 1396r(d)

of this title".

Subsec. (a)(44)(A). Pub. L. 100-360, Sec. 411(l)(6)(D), amended

Pub. L. 100-203, Sec. 4212(e)(1)(B), see 1987 Amendment note below.

Subsec. (a)(50). Pub. L. 100-360, Sec. 411(n)(4), formerly Sec.

411(n)(3), as redesignated by Pub. L. 100-485, Sec. 608(d)(28),

added Pub. L. 100-203, Sec. 9119(d)(1)(A), see 1987 Amendment note

below.

Subsec. (a)(51). Pub. L. 100-360, Sec. 303(e)(2)-(4), added par.

(51).

Subsec. (a)(52). Pub. L. 100-485, Sec. 303(a)(2), added par.

(52).

Subsec. (c). Pub. L. 100-360, Sec. 302(c)(1), amended subsec. (c)

generally. Prior to amendment, subsec. (c) read as follows:

"Notwithstanding subsection (b) of this section, the Secretary

shall not approve any State plan for medical assistance if he

determines that the approval and operation of the plan will result

in a reduction in aid or assistance in the form of money payments

(other than so much, if any, of the aid or assistance in such form

as was, immediately prior to the effective date of the State plan

under this subchapter, attributable to medical needs) provided for

eligible individuals under a plan of such State approved under

subchapter I, X, XIV, or XVI of this chapter, or part A of

subchapter IV of this chapter."

Subsec. (d). Pub. L. 100-360, Sec. 411(k)(7)(C), amended Pub. L.

100-203, Sec. 4113(b)(2)(ii), see 1987 Amendment note below.

Subsec. (e)(1). Pub. L. 100-485, Sec. 303(b)(1), designated

existing provisions as subpar. (A), inserted "subject to

subparagraph (B)" after "January 1, 1974,", and added subpar. (B).

Subsec. (e)(2)(A). Pub. L. 100-360, Sec. 411(k)(7)(D), repealed

Pub. L. 100-203, Sec. 4113(d)(2), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(k)(7)(B), amended Pub. L. 100-203, Sec.

4113(a)(2), see 1987 Amendment note below.

Subsec. (e)(6). Pub. L. 100-360, Sec. 302(e)(1), amended par. (6)

generally. Prior to amendment, par. (6) read as follows: "At the

option of a State, if a State plan provides medical assistance for

individuals under subsection (a)(10)(A)(ii)(IX) of this section,

the plan may provide that any woman described in such subsection

and subsection (l)(1)(A) of this section shall continue to be

treated as an individual described in subsection (a)(10)(A)(ii)(IX)

of this section without regard to any change in income of the

family of which she is a member until the end of the 60-day period

beginning on the last day of her pregnancy."

Subsec. (e)(7). Pub. L. 100-360, Sec. 302(e)(2), in introductory

provisions, substituted "In the case" for "If a State plan provides

medical assistance for individuals under subsection

(a)(10)(A)(ii)(IX) of this section, in the case" and inserted "or

paragraph (2) of section 1396d(n) of this title", and, in

concluding provisions, substituted "such respective provision" for

"subsection (a)(10)(A)(ii)(IX) of this section and subsection

(l)(1) of this section".

Subsec. (e)(10). Pub. L. 100-485, Sec. 303(d), added par. (10).

Subsec. (f). Pub. L. 100-360, Sec. 411(k)(10)(G)(iv), added Pub.

L. 100-203, Sec. 4118(h)(2), see 1987 Amendment note below.

Subsec. (i). Pub. L. 100-360, Sec. 411(l)(8)(C), amended Pub. L.

100-203, Sec. 4213(b)(1), see 1987 Amendment note below.

Subsec. (l)(1). Pub. L. 100-360, Sec. 302(e)(3)(A), inserted "any

of subclauses (I) through (III) of" after "described in" in

concluding provisions.

Subsec. (l)(1)(C). Pub. L. 100-360, Sec. 302(a)(2)(A), inserted

"at the option of the State," after "(C)" and struck out "and"

after "1983,".

Subsec. (l)(2)(A). Pub. L. 100-360, Sec. 302(a)(2)(B), as amended

by Pub. L. 100-485, Sec. 608(d)(15)(A), designated existing

provisions as cl. (i), substituted "(not less than the percentage

provided under clause (ii) and not more than 185 percent)" for

"(not more than 185 percent)", and added cls. (ii) and (iii).

Subsec. (l)(2)(A)(ii). Pub. L. 100-485, Sec. 608(d)(15)(B)(i), in

introductory provisions, substituted "The" for "Subject to clause

(iii), the", and in subcl. (I), inserted "or, if greater, the

percentage provided under clause (iii),".

Subsec. (l)(2)(A)(iii). Pub. L. 100-485, Sec. 608(d)(15)(B)(ii),

substituted "clause (ii)(I)" for "clause (ii)" in introductory

provisions and concluding provisions.

Subsec. (l)(3). Pub. L. 100-360, Sec. 302(e)(3)(B), inserted

"(a)(10)(A)(i)((IV) or" after "of subsection" in introductory

provisions.

Subsec. (l)(4). Pub. L. 100-360, Sec. 302(c)(2), (d), added par.

(4) and struck out former par. (4) which read as follows:

"(A) A State plan may not elect the option of furnishing medical

assistance to individuals described in subsection

(a)(10)(A)(ii)(IX) of this section unless the State has in effect,

under its plan established under part A of subchapter IV of this

chapter, payment levels that are not less than the payment levels

in effect under its plan on July 1, 1987.

"(B)(i) A State may not elect, under subsection

(a)(10)(A)(ii)(IX) of this section, to cover only individuals

described in paragraph (1)(A) or to cover only individuals

described in paragraph (1)(B).

"(ii) A State may not elect, under subsection (a)(10)(A)(ii)(IX)

of this section, to cover individuals described in subparagraph (C)

of paragraph (1) unless the State has elected, under such

subsection, to cover individuals described in the preceding

subparagraphs of such paragraph.

"(C) A State plan may not provide, in its election of the option

of furnishing medical assistance to individuals described in

paragraph (1), that such individuals must apply for benefits under

part A of subchapter IV of this chapter as a condition of applying

for, or receiving, medical assistance under this subchapter."

Subsec. (m)(3). Pub. L. 100-360, Sec. 301(e)(2)(E), formerly Sec.

301(e)(2)(D), as redesignated and amended by Pub. L. 100-485, Sec.

608(d)(14)(I)(ii), redesignated par. (4) as (3) and struck out

former par. (3) which read as follows: "A State plan may not

provide coverage for individuals under subsection (a)(10)(A)(ii)(X)

of this section or coverage under subsection (a)(10)(E) of this

section, unless the plan provides coverage of some or all of the

individuals described in subsection (l)(1) of this section."

Subsec. (m)(4). Pub. L. 100-360, Sec. 301(e)(2)(E), formerly Sec.

301(e)(2)(D), as redesignated and amended by Pub. L. 100-485, Sec.

608(d)(14)(I)(ii), redesignated par. (5) as (4). Former par. (4)

redesignated (3).

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

"section 1396d(p)(1)(B)" for "section 1396d(p)(1)(C)".

Subsec. (m)(5). Pub. L. 100-360, Sec. 301(e)(2)(E), formerly Sec.

301(e)(2)(D), as redesignated and amended by Pub. L. 100-485, Sec.

608(d)(14)(I)(ii), redesignated par. (5) as (4).

Subsec. (o). Pub. L. 100-360, Sec. 411(n)(2), made technical

correction to directory language of Pub. L. 100-203, Sec. 9115(b),

see 1987 Amendment note below.

Subsec. (q). Pub. L. 100-360, Sec. 411(n)(4), formerly Sec.

411(n)(3), as redesignated by Pub. L. 100-485, Sec. 608(d)(28),

added Pub. L. 100-203, Sec. 9119(d)(1)(B), see 1987 Amendment note

below.

Subsec. (r). Pub. L. 100-360, Sec. 303(e)(5), designated existing

provisions as par. (1), redesignated subpars. (A) and (B) as cls.

(i) and (ii), respectively, and added par. (2).

Pub. L. 100-360, Sec. 303(d), added subsec. (r).

Subsec. (r)(2)(A). Pub. L. 100-485, Sec. 608(d)(16)(C),

substituted ", or (f) of this section or under section 1396d(p) of

this title" for "of this section, or under subsection (f) of this

section" in introductory provisions.

1987 - Subsec. (a)(9)(C). Pub. L. 100-203, Sec. 4072(d),

substituted "paragraphs (13) and (14)" for "paragraphs (12) and

(13)".

Subsec. (a)(10). Pub. L. 100-203, Sec. 4101(e)(1), substituted

"postpartum, and family planning services" for "and postpartum

services" in subdiv. (VII) of closing provisions.

Subsec. (a)(10)(A)(ii)(VI). Pub. L. 100-203, Sec. 4211(h)(1)(A),

substituted "nursing facility or intermediate care facility for the

mentally retarded" for "skilled nursing facility or intermediate

care facility".

Pub. L. 100-203, Sec. 4102(b)(1), substituted "subsection (c) or

(d) of section 1396n of this title" for "section 1396n(c) of this

title" in two places.

Subsec. (a)(10)(A)(ii)(IX), (X). Pub. L. 100-203, Sec.

4118(p)(1), (2), realigned margin of subcls. (IX) and (X).

Subsec. (a)(10)(A)(ii)(XI). Pub. L. 100-203, Sec. 4104, as

amended by Pub. L. 100-360, Sec. 411(k)(5)(A), added subcl. (XI).

Subsec. (a)(10)(C)(iv). Pub. L. 100-203, Sec. 4211(h)(1)(B),

substituted "in an intermediate care facility" for "intermediate

care facility services".

Subsec. (a)(10)(D). Pub. L. 100-203, Sec. 4211(h)(1)(C), struck

out "skilled" before "nursing".

Subsec. (a)(13)(A). Pub. L. 100-203, Sec. 4211(h)(2)(B), as

amended by Pub. L. 100-360, Sec. 411(l)(3)(J), as added by Pub. L.

100-485, Sec. 608(d)(27)(H), substituted ", nursing facility, and

intermediate care facility for the mentally retarded and" for ",

skilled nursing facility, and intermediate care facility and".

Pub. L. 100-203, Sec. 4211(h)(2)(A), substituted "services,

nursing facility services, and services in an intermediate care

facility for the mentally retarded" for ", skilled nursing

facility, and intermediate care facility services".

Pub. L. 100-203, Sec. 4211(b)(1)(A), inserted "which, in the case

of nursing facilities, take into account the costs of complying

with subsections (b) (other than paragraph (3)(F) thereof), (c),

and (d) of section 1396r of this title and provide (in the case of

a nursing facility with a waiver under section 1396r(b)(4)(C)(ii)

of this title) for an appropriate reduction to take into account

the lower costs (if any) of the facility for nursing care," after

second reference to "State".

Subsec. (a)(13)(C). Pub. L. 100-203, Sec. 4211(h)(2)(C), as

amended by Pub. L. 100-360, Sec. 411(l)(3)(H)(i), as amended by

Pub. L. 100-485, Sec. 608(d)(27)(F), substituted "nursing

facilities and for intermediate care facilities for the mentally

retarded" for "skilled nursing facilities and intermediate care

facilities" in introductory provisions.

Subsec. (a)(13)(D). Pub. L. 100-203, Sec. 4211(h)(2)(D), as

amended by Pub. L. 100-360, Sec. 411(l)(3)(H)(ii), (iii), as

amended by Pub. L. 100-485, Sec. 608(d)(27)(G), substituted

"nursing facility or intermediate care facility for the mentally

retarded" for "skilled nursing facility or intermediate care

facility" and "nursing facility services or services in an

intermediate care facility for the mentally retarded" for "skilled

nursing facility services or intermediate care facility services".

Subsec. (a)(17). Pub. L. 100-203, Sec. 4118(p)(3), substituted

"subsections (l)(3), (m)(4), and (m)(5) of this section" for

"subsection (l)(3) of this section".

Pub. L. 100-203, Sec. 4118(h)(1), as amended by Pub. L. 100-360,

Sec. 411(k)(10)(G)(ii), substituted "(whether in the form of

insurance premiums or otherwise and regardless of whether such

costs are reimbursed under another public program of the State or

political subdivision thereof)" for "(whether in the form of

insurance premiums or otherwise)".

Subsec. (a)(23). Pub. L. 100-203, Sec. 4113(c)(1), designated

provision relating to the obtaining of medical assistance by an

eligible individual as cl. (A) and added cl. (B).

Pub. L. 100-93, Sec. 8(f)(1), inserted "subsection (g) of this

section and in" after "as provided in".

Subsec. (a)(28). Pub. L. 100-203, Sec. 4211(b)(1)(B), amended

par. (28) generally. Prior to amendment, par. (28) read as follows:

"provide that any skilled nursing facility receiving payments under

such plan must satisfy all of the requirements contained in section

1395x(j) of this title, except that the exclusion contained therein

with respect to institutions which are primarily for the care and

treatment of mental diseases shall not apply for purposes of this

subchapter;".

Subsec. (a)(30)(B)(i), (ii). Pub. L. 100-203, Sec. 4211(h)(3),

substituted "intermediate care facility for the mentally retarded"

for "skilled nursing facility, intermediate care facility".

Subsec. (a)(30)(C). Pub. L. 100-203, Sec. 4118(p)(4), substituted

"use" for "provide".

Pub. L. 100-203, Sec. 4113(b)(1), inserted ", an entity which

meets the requirements of section 1320c-1 of this title, as

determined by the Secretary," before "or a private accreditation

body".

Subsec. (a)(31). Pub. L. 100-203, Sec. 4212(d)(2), in

introductory provision substituted "services in an intermediate

care facility for the mentally retarded (where" for "skilled

nursing facility services (and with respect to intermediate care

facility services where" and in subpar. (B) substituted

"intermediate care facility for the mentally retarded" for "skilled

nursing or intermediate care facility".

Subsec. (a)(33)(B). Pub. L. 100-203, Sec. 4212(d)(3), inserted ",

except as provided in section 1396r(d) of this title," after "(B)

that".

Subsec. (a)(38). Pub. L. 100-93, Sec. 8(f)(2), substituted "the

information described in section 1320a-7(b)(9) of this title" for

"respectively, (A) full and complete information as to the

ownership of a subcontractor (as defined by the Secretary in

regulations) with whom such entity has had, during the previous

twelve months, business transactions in an aggregate amount in

excess of $25,000, and (B) full and complete information as to any

significant business transactions (as defined by the Secretary in

regulations), occurring during the five-year period ending on the

date of such request, between such entity and any wholly owned

supplier or between such entity and any subcontractor".

Subsec. (a)(39). Pub. L. 100-93, Sec. 8(f)(3), substituted

"exclude" for "bar", "individual or entity" for "person" in two

places, and inserted reference to section 1320a-7a of this title.

Subsec. (a)(42). Pub. L. 100-203, Sec. 4118(m)(1)(B), struck out

"(A)" after "provide", the comma after "under the plan", and cls.

(B) and (C) which read as follows: "(B) that such audits, for such

entities also providing services under subchapter XVIII of this

chapter, will be coordinated and conducted jointly (to such extent

and in such manner as the Secretary shall prescribe) with audits

conducted for purposes of such subchapter, and (C) for payment of

such proportion of costs of each such common audit as is determined

under methods specified by the Secretary under section 1320a-8(a)

of this title".

Subsec. (a)(44). Pub. L. 100-203, Sec. 4212(e)(1)(A), substituted

"services in an intermediate care facility for the mentally

retarded" for "skilled nursing facility services, intermediate care

facility services".

Subsec. (a)(44)(A). Pub. L. 100-203, Sec. 4218(a)(1), substituted

"physician (or, in the case of skilled nursing facility services or

intermediate care facility services, a physician, or a nurse

practitioner or clinical nurse specialist who is not an employee of

the facility but is working in collaboration with a physician)

certifies" for "physician certifies" and "a physician, a physician

assistant under the supervision of a physician, or, in the case of

skilled nursing facility services or intermediate care facility

services, a physician, or a nurse practitioner or clinical nurse

specialist who is not an employee of the facility but is working in

collaboration with a physician," for "the physician, or a physician

assistant or nurse practitioner under the supervision of a

physician,".

Pub. L. 100-203, Sec. 4212(e)(1)(B), as amended by Pub. L.

100-360, Sec. 411(l)(6)(D), substituted "that are services provided

in an intermediate care facility for the mentally retarded" for

"that are intermediate care facility services provided in an

institution for the mentally retarded".

Subsec. (a)(44)(B). Pub. L. 100-203, Sec. 4218(a)(2), substituted

"a physician, or, in the case of skilled nursing facility services

or intermediate care facility services, a physician, or a nurse

practitioner or clinical nurse specialist who is not an employee of

the facility but is working in collaboration with a physician;" for

"a physician;".

Subsec. (a)(46). Pub. L. 100-93, Sec. 5(a)(1), struck out "and"

after "title;".

Subsec. (a)(47). Pub. L. 100-93, Sec. 5(a)(2), (3), substituted

semicolon for period at end of par. (47), relating to ambulatory

prenatal care and redesignated par. (47), relating to cards

evidencing eligibility, as (48).

Subsec. (a)(48). Pub. L. 100-93, Sec. 5(a)(3), redesignated par.

(47), relating to cards evidencing eligibility for medical

assistance, as (48), and substituted "address; and" for "address."

Subsec. (a)(49). Pub. L. 100-93, Sec. 5(a)(4), added par. (49).

Subsec. (a)(50). Pub. L. 100-203, Sec. 9119(d)(1)(A), as added by

Pub. L. 100-360, Sec. 411(n)(4), formerly Sec. 411(n)(3), as

redesignated by Pub. L. 100-485, Sec. 608(d)(28), added par. (50).

Subsec. (d). Pub. L. 100-203, Sec. 4113(b)(2)(i), inserted "an

entity which meets the requirements of section 1320c-1 of this

title, as determined by the Secretary, for the performance of the

quality review functions described in subsection (a)(30)(C) of this

section, or" after "contracts with".

Pub. L. 100-203, Sec. 4113(b)(2)(ii), as amended by Pub. L.

100-360, Sec. 411(k)(7)(C), substituted "an entity or organization"

for "organization (or organizations)" in two places.

Subsec. (e)(2)(A). Pub. L. 100-203, Sec. 4113(d)(2), which

directed substitution of "subparagraph (B)(iii), (E), or (G) of

section 1396b(m)(2) of this title" for "section 1396a(m)(2)(G) of

this title", was repealed by Pub. L. 100-360, Sec. 411(k)(7)(D).

Pub. L. 100-203, Sec. 4113(a)(2), as amended by Pub. L. 100-360,

Sec. 411(k)(7)(B), substituted "paragraph (2)(B)(iii), (2)(E),

(2)(G), or (6) of section 1396b(m) of this title" for "section

1396b(m)(2)(G) of this title".

Pub. L. 100-203, Sec. 4113(c)(2), substituted "but, except for

benefits furnished under section 1396d(a)(4)(C) of this title,

only" for "but only".

Subsec. (e)(3)(B)(i). Pub. L. 100-203, Sec. 4211(h)(4),

substituted "nursing facility, or intermediate care facility for

the mentally retarded" for "skilled nursing facility, or

intermediate care facility".

Subsec. (e)(3)(C). Pub. L. 100-203, Sec. 4118(c)(1), substituted

"for medical assistance under the State plan under this subchapter"

for "to have a supplemental security income (or State supplemental)

payment made with respect to him under subchapter XVI of this

chapter".

Subsec. (e)(4). Pub. L. 100-203, Sec. 4101(a)(2), inserted

sentence at end relating to child's medical assistance eligibility

identification number and submission and payment of claims under

such number during period in which a child is eligible for

assistance.

Subsec. (e)(5). Pub. L. 100-203, Sec. 4101(e)(2), substituted

"through the end of the month in which the 60-day period (beginning

on the last day of her pregnancy) ends" for "until the end of the

60-day period beginning on the last day of her pregnancy".

Subsec. (e)(7). Pub. L. 100-203, Sec. 4101(b)(2)(B), substituted

"subparagraph (B) or (C)" for "subparagraph (B), (C), (D), (E), or

(F)".

Subsec. (e)(9). Pub. L. 100-203, Sec. 4118(p)(6), realigned

margins of par. (9).

Subsec. (e)(9)(A)(iii). Pub. L. 100-203, Sec. 4211(h)(5)(A),

substituted "nursing facility, or intermediate care facility for

the mentally retarded" for "skilled nursing facility, or

intermediate care facility,".

Subsec. (e)(9)(B). Pub. L. 100-203, Sec. 4211(h)(5)(B),

substituted "nursing facilities, or intermediate care facilities

for the mentally retarded" for "skilled nursing facilities, or

intermediate care facilities".

Subsec. (f). Pub. L. 100-203, Sec. 4118(h)(2), as added by Pub.

L. 100-360, Sec. 411(k)(10)(G)(iv), inserted "regardless of whether

such expenses are reimbursed under another public program of the

State or political subdivision thereof" after "State law" in first

sentence.

Subsec. (i). Pub. L. 100-203, Sec. 4213(b)(1), as amended by Pub.

L. 100-360, Sec. 411(l)(8)(C), in par. (1), substituted

"intermediate care facility for the mentally retarded" for "skilled

nursing facility or intermediate care facility" and "the

requirements for such a facility under this subchapter" for "the

provisions of section 1395x(j) of this title or section 1396d(c) of

this title, respectively,", and in pars. (2) and (3), substituted

"the requirements for such a facility under this subchapter" for

"the provisions of section 1395x(j) of this title or section

1396d(c) of this title (as the case may be)".

Subsec. (j). Pub. L. 100-203, Sec. 4116, inserted reference to

Northern Mariana Islands in two places.

Subsec. (l). Pub. L. 100-93, Sec. 7, redesignated subsec. (l),

relating to disregarding certain benefits for purposes of

determining post-eligibility contributions, as (o).

Subsec. (l)(1). Pub. L. 100-203, Sec. 4118(p)(7), made technical

corrections in introductory provisions and substituted "and whose"

for ", whose" in closing provisions.

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

"5, 6, 7, or 8 years of age" for "or 5 years of age".

Pub. L. 100-203, Sec. 4101(b)(1), added subpar. (C). Former

subpar. (C), which related to children who have attained one year

of age but have not attained two years of age, was struck out.

Subsec. (l)(1)(D) to (F). Pub. L. 100-203, Sec. 4101(b)(1)(B),

struck out subpars. (D) to (F) which related to children who have

attained two years of age but have not attained three years of age,

children who have attained three years of age but have not attained

four years of age, and children who have attained four years of age

but have not attained five years of age, respectively.

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

"nonfarm" after second reference to "income" in subpar. (A).

Pub. L. 100-203, Sec. 4101(a)(1)(A), designated existing

provisions as subpar. (A), inserted "with respect to individuals

described in subparagraph (A) or (B) of that paragraph",

substituted "185 percent" for "100 percent", and added subpar. (B).

Subsec. (l)(3)(C). Pub. L. 100-203, Sec. 4101(b)(2)(A)(i),

substituted "subparagraph (B) or (C)" for "subparagraph (B), (C),

(D), (E), or (F)".

Subsec. (l)(3)(D). Pub. L. 100-203, Sec. 4101(a)(1)(B), inserted

"appropriate" after "applied is the".

Subsec. (l)(3)(E). Pub. L. 100-203, Sec. 4101(e)(3), inserted

"(except to the extent such methodology is inconsistent with clause

(D) of subsection (a)(17) of this section)" after "subchapter IV of

this chapter".

Subsec. (l)(4)(A). Pub. L. 100-203, Sec. 4101(e)(4), substituted

"July 1, 1987" for "April 17, 1986".

Subsec. (l)(4)(B)(ii). Pub. L. 100-203, Sec. 4101(b)(2)(A)(ii),

substituted "subparagraph (C)" for "subparagraph (C), (D), (E), or

(F)".

Subsec. (l)(4)(C). Pub. L. 100-203, Sec. 4101(e)(5), added

subpar. (C).

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

"nonfarm" before "official".

Subsec. (o). Pub. L. 100-203, Sec. 9115(b), as amended by Pub. L.

100-360, Sec. 411(n)(2), substituted "subparagraph (E) or (G) of

section 1382(e)(1) of this title" for "section 1382(e)(1)(E) of

this title".

Pub. L. 100-93, Sec. 7, redesignated subsec. (l), relating to

disregarding certain benefits for purposes of determining

post-eligibility contributions, as (o).

Subsec. (p). Pub. L. 100-93, Sec. 7, added subsec. (p).

Subsec. (q). Pub. L. 100-203, Sec. 9119(d)(1)(B), as added by

Pub. L. 100-360, Sec. 411(n)(4), formerly Sec. 411(n)(3), as

redesignated by Pub. L. 100-485, Sec. 608(d)(28), added subsec.

(q).

1986 - Subsec. (a). Pub. L. 99-509, Sec. 9406(b), inserted at end

"Notwithstanding paragraph (10)(B) or any other provision of this

subsection, a State plan shall provide medical assistance with

respect to an alien who is not lawfully admitted for permanent

residence or otherwise permanently residing in the United States

under color of law only in accordance with section 1396b(v) of this

title."

Pub. L. 99-272, Sec. 9529(a)(1), inserted at end "For purposes of

this subchapter, any child who meets the requirements of paragraph

(1) or (2) of section 673(b) of this title shall be deemed to be a

dependent child as defined in section 606 of this title and shall

be deemed to be a recipient of aid to families with dependent

children under part A of subchapter IV of this chapter in the State

where such child resides."

Subsec. (a)(9)(C). Pub. L. 99-509, Sec. 9320(h)(3), substituted

"paragraphs (12) and (13)" for "paragraphs (11) and (12)".

Subsec. (a)(10). Pub. L. 99-509, Sec. 9408(b), added cl. (IX) at

end.

Pub. L. 99-509, Sec. 9403(c), added cl. (VIII) at end.

Pub. L. 99-509, Sec. 9401(c), added cl. (VII) at end.

Pub. L. 99-272, Sec. 9505(b)(1), added cl. (VI) at end.

Pub. L. 99-272, Sec. 9501(b), added cl. (V) at end.

Subsec. (a)(10)(A)(i)(I). Pub. L. 99-272, Sec. 12305(b)(3),

substituted ", 606(h), or 673(b) of this title" for "or 606(h) of

this title".

Subsec. (a)(10)(A)(i)(II). Pub. L. 99-509, Sec. 9404(a), inserted

"or who are qualified severely impaired individuals (as defined in

section 1396d(q) of this title)" after "subchapter XVI of this

chapter".

Subsec. (a)(10)(A)(ii)(V). Pub. L. 99-272, Sec. 9510(a), inserted

"for a period of not less than 30 consecutive days (with

eligibility by reason of this subclause beginning on the first day

of such period)" after "are in a medical institution".

Subsec. (a)(10)(A)(ii)(VII). Pub. L. 99-514, Sec. 1895(c)(7)(A),

realigned margin of subcl. (VII).

Pub. L. 99-272, Sec. 9505(b)(2), added subcl. (VII).

Subsec. (a)(10)(A)(ii)(VIII). Pub. L. 99-514, Sec. 1895(c)(7)(B),

realigned margins of subcl. (VIII).

Pub. L. 99-272, Sec. 9529(b)(1), added subcl. (VIII).

Subsec. (a)(10)(A)(ii)(IX). Pub. L. 99-509, Sec. 9401(a), added

subcl. (IX).

Subsec. (a)(10)(A)(ii)(X). Pub. L. 99-509, Sec. 9402(a)(1), added

subcl. (X).

Subsec. (a)(10)(C). Pub. L. 99-509, Sec. 9403(g)(1), inserted "or

(E)" after "subparagraph (A)" in introductory text.

Subsec. (a)(10)(C)(iv). Pub. L. 99-509, Sec. 9408(c)(3),

substituted "through (20)" for "through (19)".

Pub. L. 99-514, Sec. 1895(c)(3)(C), substituted "through (19)"

for "through (18)".

Pub. L. 99-272, Sec. 9505(d)(2), substituted "through (18)" for

"through (17)".

Subsec. (a)(10)(E). Pub. L. 99-509, Sec. 9403(a), added subpar.

(E).

Subsec. (a)(13)(B). Pub. L. 99-272, Sec. 9509(a)(1), substituted

"hospitals" for "hospitals, skilled nursing facilities, and

intermediate care facilities".

Subsec. (a)(13)(C). Pub. L. 99-272, Sec. 9509(a)(4), added

subpar. (C). Former subpar. (C) redesignated (D).

Pub. L. 99-272, Sec. 9505(c)(1), added subpar. (C). Former

subpar. (C) redesignated (D).

Subsec. (a)(13)(D). Pub. L. 99-514, Sec. 1895(c)(1), inserted

"and" after "facility;".

Pub. L. 99-509, Sec. 9435(b)(1), inserted "and for payment of

amounts under section 1396d(o)(3) of this title" before first

semicolon.

Pub. L. 99-272, Sec. 9509(a)(2), (3), redesignated former subpar.

(C) as (D), and struck out "and" at the end thereof. Former subpar.

(D) redesignated (E).

Pub. L. 99-272, Sec. 9505(c)(1)(B), redesignated former subpar.

(C) as (D).

Subsec. (a)(13)(E). Pub. L. 99-272, Sec. 9509(a)(3), redesignated

former subpar. (D) as (E).

Subsec. (a)(15). Pub. L. 99-509, Sec. 9403(g)(4)(A), inserted

"are not qualified medicare beneficiaries (as defined in section

1396d(p)(1) of this title) but" after "older who".

Subsec. (a)(17). Pub. L. 99-509, Sec. 9401(e)(1), inserted

"except as provided in subsection (l)(3) of this section" after

"(17)".

Subsec. (a)(25). Pub. L. 99-272, Sec. 9503(a)(1), amended par.

(25) generally. Prior to amendment, par. (25) read as follows:

"provide (A) that the State or local agency administering such plan

will take all reasonable measures to ascertain the legal liability

of third parties to pay for care and services (available under the

plan) arising out of injury, disease, or disability, (B) that where

the State or local agency knows that a third party has such a legal

liability such agency will treat such legal liability as a resource

of the individual on whose behalf the care and services are made

available for purposes of paragraph (17)(B), and (C) that in any

case where such a legal liability is found to exist after medical

assistance has been made available on behalf of the individual and

where the amount of reimbursement the State can reasonably expect

to recover exceeds the costs of such recovery, the State or local

agency will seek reimbursement for such assistance to the extent of

such legal liability;".

Subsec. (a)(30)(C). Pub. L. 99-509, Sec. 9431(a), added subpar.

(C).

Subsec. (a)(47). Pub. L. 99-570 added par. (47) relating to cards

evidencing eligibility for medical assistance.

Pub. L. 99-509, Sec. 9407(a), added par. (47) relating to

ambulatory prenatal care.

Subsec. (b)(2). Pub. L. 99-509, Sec. 9405, inserted before

semicolon ", regardless of whether or not the residence is

maintained permanently or at a fixed address".

Subsec. (d). Pub. L. 99-509, Sec. 9431(b)(1), inserted

"(including quality review functions described in subsection

(a)(30)(C) of this section)" after "medical or utilization review

functions".

Subsec. (e)(2)(A). Pub. L. 99-272, Sec. 9517(b)(1), inserted

reference to an entity described in section 1396b(m)(2)(G) of this

title, and substituted "such organization or entity" for "such

organization".

Subsec. (e)(2)(B). Pub. L. 99-272, Sec. 9517(b)(2), substituted

"an organization or entity" for "a health maintenance organization"

and "the organization or entity" for "the organization".

Subsec. (e)(5). Pub. L. 99-272, Sec. 9501(c), added par. (5).

Subsec. (e)(6), (7). Pub. L. 99-509, Sec. 9401(d), added pars.

(6) and (7).

Subsec. (e)(8). Pub. L. 99-509, Sec. 9403(f)(2), added par. (8).

Subsec. (e)(9). Pub. L. 99-509, Sec. 9408(a), added par. (9).

Subsec. (f). Pub. L. 99-643, Sec. 7(b), substituted "subsection

(e) of this section and section 1382h(b)(3) of this title" for

"subsection (e) of this section".

Subsec. (g). Pub. L. 99-272, Sec. 9503(a)(2), added subsec. (g).

Subsec. (h). Pub. L. 99-509, Sec. 9433(a), added subsec. (d) to

section 2173 of Pub. L. 97-35 in turn which added subsec. (h) of

this section. See 1981 Amendment note below.

Subsec. (j). Pub. L. 99-509, Sec. 9408(c)(2), substituted "(21)"

for "(20)".

Pub. L. 99-514, Sec. 1895(c)(3)(B), substituted "(20)" for

"(19)".

Pub. L. 99-272, Sec. 9505(d)(1), substituted "(19)" for "(18)".

Subsec. (k). Pub. L. 99-272, Sec. 9506(a), added subsec. (k).

Subsec. (l). Pub. L. 99-643, Sec. 3(b), added subsec. (l)

relating to disregarding of certain benefits for purposes of

determining post-eligibility contributions.

Pub. L. 99-509, Sec. 9401(b), added subsec. (l) relating to

description of group.

Subsec. (m). Pub. L. 99-509, Sec. 9402(a)(2), (b), added subsec.

(m).

Subsec. (m)(3). Pub. L. 99-509, Sec. 9403(f)(1)(A), which

directed insertion of "or coverage under subsection (a)(10)(E) of

this section" after "subsection (a)(10)(A)(ii)(IX) of this

section", was executed by making the insertion after "subsection

(a)(10)(A)(ii)(X) of this section" as the probable intent of

Congress.

Subsec. (m)(5). Pub. L. 99-509, Sec. 9403(f)(1)(B), added par.

(5).

Subsec. (n). Pub. L. 99-509, Sec. 9403(e), added subsec. (n).

1984 - Subsec. (a)(9)(C). Pub. L. 98-369, Sec. 2373(b)(1),

realigned margin of subpar. (C).

Subsec. (a)(10)(A). Pub. L. 98-369, Sec. 2373(b)(2), realigned

margins of subpar. (A).

Subsec. (a)(10)(A)(i). Pub. L. 98-369, Sec. 2361(a), amended cl.

(i) generally. Prior to the amendment cl. (i) read as follows: "all

individuals receiving aid or assistance under any plan of the State

approved under subchapter I, X, XIV, or XVI of this chapter, or

part A or part E of subchapter IV of this chapter (including

pregnant women deemed by the State to be receiving such aid as

authorized in section 606(g) of this title and individuals

considered by the State to be receiving such aid as authorized

under section 614(g) of this title), or with respect to whom

supplemental security income benefits are being paid under

subchapter XVI of this chapter; and".

Subsec. (a)(10(A)(i)(I). Pub. L. 98-378, Sec. 20(c), substituted

"section 602(a)(37) or 606(h) of this title" for "section

602(a)(37) of this title".

Subsec. (a)(13)(A). Pub. L. 98-369, Sec. 2373(b)(3), made

clarifying amendment by striking out "(A)" and all that follows

through "hospital" the first place it appears and inserting in lieu

thereof "(A) for payment (except where the State agency is subject

to an order under section 1396m of this title) of the hospital",

resulting in no change in text.

Subsec. (a)(13)(B), (C). Pub. L. 98-369, Sec. 2314(b), added

subpar. (B) and redesignated former subpar. (B) as (C).

Subsec. (a)(20)(B). Pub. L. 98-369, Sec. 2373(b)(4), substituted

"periodic" for "periodical".

Subsec. (a)(20)(C). Pub. L. 98-369, Sec. 2373(b)(5), struck out

reference to section 803(a)(1)(A)(i) and (ii) of this title.

Subsec. (a)(26). Pub. L. 98-369, Sec. 2368(b), in amending par.

(26) generally, revised existing provisions to continue their

application to review of inpatient mental hospital service

programs, and to sever provisions relating to review of skilled

nursing programs. See par. (31) of this section.

Subsec. (a)(26)(B)(ii). Pub. L. 98-617, Sec. 3(a)(7), repealed

the amendment made by Pub. L. 98-369, Sec. 2373(b)(6). See below.

Pub. L. 98-369, Sec. 2373(b)(6), provided that cl. (ii) is

amended by substituting "facilities" for "homes".

Subsec. (a)(26)(C). Pub. L. 98-617, Sec. 3(b)(10), realigned

margin of subpar. (C).

Subsec. (a)(28). Pub. L. 98-369, Sec. 2335(e), struck out "and

tuberculosis" after "mental diseases".

Subsec. (a)(30). Pub. L. 98-369, Sec. 2363(a)(1)(A), designated

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

Subsec. (a)(31). Pub. L. 98-369, Sec. 2368(a), in amending par.

(31) generally, revised existing provisions to cover review of

skilled nursing facilities.

Subsec. (a)(33)(A). Pub. L. 98-369, Sec. 2373(b)(7), substituted

"second sentence" for "penultimate sentence".

Subsec. (a)(42). Pub. L. 98-369, Sec. 2373(b)(8), substituted

"subchapter" for "part" after "audits conducted for purposes of

such".

Subsec. (a)(43). Pub. L. 98-369, Sec. 2303(g)(1), redesignated

par. (44) as (43), and struck out former par. (43) which provided

that if the State plan makes provision for payment to a physician

for laboratory services the performance of which such physician, or

other physician with whom he shares his practice, did not

personally perform or supervise, the plan include provision to

insure that payment for such services not exceed the payment

authorized by section 1395u(h) of this title.

Subsec. (a)(44). Pub. L. 98-369, Sec. 2363(a)(1)(B), added par.

(44).

Pub. L. 98-369, Sec. 2303(g)(1)(C), redesignated former par. (44)

as (43).

Subsec. (a)(45). Pub. L. 98-369, Sec. 2367(a), added par. (45).

Subsec. (a)(46). Pub. L. 98-369, Sec. 2651(c), added par. (46).

Subsec. (a), foll. par. (46). Pub. L. 98-369, Sec. 2373(b)(9),

substituted "The provisions of paragraph (9)(A), (31), and (33) and

of section 1396b(i)(4) of this title shall not apply to" for "For

purposes of paragraph (9)(A), (26), (31), and (33), and of section

1396b(i)(4) of this title, the term 'skilled nursing facility' and

'nursing home' do not include".

Subsec. (e)(4). Pub. L. 98-369, Sec. 2362(a), added par. (4).

Subsec. (f). Pub. L. 98-369, Sec. 2373(b)(10), substituted

"paragraph (10)(A)" and "paragraph (10)(C)" for "clause (10)(A)"

and "clause (10)(C)", respectively, wherever appearing.

1982 - Subsec. (a)(10)(A). Pub. L. 97-248, Sec. 137(b)(7),

redesignated existing provisions as provisions preceding cl. (i)

and cl. (i), and added cl. (ii).

Subsec. (a)(10)(C), (D). Pub. L. 97-248, Sec. 137(a)(3), amended

directory language of Pub. L. 97-35, Sec. 2171(a)(3), to correct an

error, and did not involve any change in text. See 1981 Amendment

note below.

Subsec. (a)(10)(C)(i). Pub. L. 97-248, Sec. 137(b)(8),

substituted ", (II)" for "and (II)", and added subcl. (III).

Subsec. (a)(10)(C)(ii)(I). Pub. L. 97-248, Sec. 137(b)(9),

substituted "under the age of 18 who (but for income and resources)

would be eligible for medical assistance as an individual described

in subparagraph (A)(i)" for "described in section 1396d(a)(i) of

this title".

Subsec. (a)(10). Pub. L. 97-248, Sec. 131(c), formerly Sec.

131(b), as redesignated by Pub. L. 97-448, Sec. 309(a)(8), in

provisions following subpar. (D) added cl. (IV).

Subsec. (a)(14). Pub. L. 97-248, Sec. 131(a), substituted

provisions that a State plan for medical assistance must provide

that enrollment fees, premiums, or similar charges, and deductions,

cost sharing, or similar charges, may be imposed only as provided

in section 1396o of this title for provisions that such plan must

provide that, with respect to individuals receiving assistance, no

enrollment fee, premium, or similar charge, and no deduction, cost

sharing, or similar charge with respect to the care and services

listed in pars. (1) through (5), (7), and (17) of section 1396d(a)

of this title, would be imposed under the plan, and any deduction,

cost sharing, or similar charge imposed under the plan with respect

to other care and services would be nominal in amount (as

determined in accordance with standards approved by the Secretary

and included in the plan), and with respect to individuals not

receiving assistance, there could be imposed an enrollment fee,

premium, or similar charge (as determined in accordance with

standards prescribed by the Secretary) related to the individual's

income, and any deductible, cost-sharing, or similar charge imposed

under the plan would be nominal.

Subsec. (a)(18). Pub. L. 97-248, Sec. 132(a), substituted

provisions that a State plan for medical assistance must comply

with the provisions of section 1396p of this title with respect to

liens, adjustments and recoveries of medical assistance correctly

paid, and transfers of assets for provisions that such plan must

provide that no lien could 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 plan (except pursuant to the

judgment of a court on account of benefits incorrectly paid on

behalf of such individual), and that there would be no adjustment

or recovery (except, in the case of an individual who was 65 years

of age or older when he received such assistance, from his estate,

and then only after the death of his surviving spouse, if any, and

only at a time when he had no surviving child who was under age 21

or (with respect to States eligible to participate in the State

program established under subchapter XVI of this chapter), was

blind or permanently and totally disabled, or was blind or disabled

as defined in section 1382c of this title with respect to States

which were not eligible to participate in such program) of any

medical assistance correctly paid on behalf of such individual

under the plan.

Subsec. (a). Pub. L. 97-248, Sec. 137(e), inserted ", (26)" after

"(9)(A)" in provisions following par. (44).

Subsec. (b)(2) to (4). Pub. L. 97-248, Sec. 137(b)(10), struck

out par. (2) which provided that the Secretary would not approve

any plan which imposed any age requirement which excluded any

individual who had not attained the age of 19 and was a dependent

child under part A of subchapter IV of this chapter, and

redesignated pars. (3) and (4) as (2) and (3), respectively.

Subsec. (d). Pub. L. 97-248, Sec. 146(a), substituted references

to utilization and quality control peer review organizations having

a contract with the Secretary, for references to conditionally or

otherwise designated Professional Standards Review Organizations,

wherever appearing.

Subsec. (e)(3). Pub. L. 97-248, Sec. 134(a), added par. (3).

Subsec. (j). Pub. L. 97-248, Secs. 132(c), 136(d), struck out

subsec. (j) which related to the denial of medical assistance under

a State plan because of an individual's disposal of resources for

less than fair market value, the period of ineligibility, and the

eligibility of certain individuals for medical assistance under a

State plan who would otherwise be ineligible because of the

provisions of section 1382b(c) of this title, and added a new

subsec. (j) relating to waiver or modification of requirements with

respect to American Samoa medical assistance program.

1981 - Subsec. (a)(9)(C). Pub. L. 97-35, Sec. 2175(d)(1)(C),

added subpar. (C).

Subsec. (a)(10)(A). Pub. L. 97-35, Sec. 2171(a)(1), substituted

"including at least the care and services listed in paragraphs (1)

through (5) and (17) of section 1396d(a) of this title, to all

individuals receiving aid or assistance under any plan of the State

approved under subchapter I, X, XIV, or XVI of this chapter, or

part A or part E of subchapter IV of this chapter (including

pregnant women deemed by the State to be receiving such aid as

authorized by section 606(g) of this title and individuals

considered by the State to be receiving such aid as authorized

under section 614(g) of this title)" for "to all individuals

receiving aid or assistance under any plan of the State approved

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

this chapter".

Subsec. (a)(10)(B). Pub. L. 97-35, Sec. 2171(a)(2), substituted

reference to subparagraph for reference to clause in two places.

Subsec. (a)(10)(C). Pub. L. 97-35, Sec. 2171(a)(3), as amended by

Pub. L. 97-248, Sec. 137(a)(3), substituted provisions relating to

plans for medical assistance included for any group of individuals

described in section 1396d(a) of this title who are not described

in subpar. (A) for provisions relating to medical assistance for

any group of individuals not described in subpar. (A) and who do

not meet the income and resources requirements of the appropriate

State plan, or the supplementary security income program under

subchapter XVI of this chapter, as the case may be, as determined

in accordance with standards prescribed by the Secretary.

Subsec. (a)(10)(D). Pub. L. 97-35, Sec. 2171(a)(3), as amended by

Pub. L. 97-248, Sec. 137(a)(3), added subpar. (D).

Subsec. (a)(11). Pub. L. 97-35, Sec. 2193(c)(9), substituted

"under or through an allotment under) subchapter V of this chapter,

(i) providing for utilizing such agency, institution, or

organization in furnishing care and services which are available

under such subchapter or allotment" for "for part or all of the

cost of plans or projects under subchapter V of this chapter, (i)

providing for utilizing such agency, institution, or organization

in furnishing care and services which are available under such plan

or project under subchapter V of this chapter".

Subsec. (a)(13)(A). Pub. L. 97-35, Secs. 2171(b), 2173(a)(1)(B),

(C), struck out subpar. (A) which provided that a State plan must

provide for the inclusion of some institutional and some

noninstitutional care and services and for the inclusion of home

health services for any individual who is entitled to skilled

nursing facility services, redesignated subpar. (E) as (A), and in

subpar. (A), as so redesignated, made the subsection applicable to

hospital facilities, inserted reference to rates which take into

account the situation of hospitals which serve a disproportionate

number of low income patients with special needs and provide, in

the case of hospital patients receiving services at an

inappropriate level of care under conditions similar to those

described in section 1395x(v)(1)(G) of this title, for lower

reimbursement rates reflecting the level of care actually received

in a manner consistent with such section, and substituted "safety

standards and to assure that individuals eligible for medical

assistance have reasonable access (taking into account geographic

location and reasonable travel time) to inpatient hospital services

of adequate quality" for "safety standards".

Subsec. (a)(13)(B). Pub. L. 97-35, Secs. 2171(b), 2173(a)(1)(C),

struck out subpar. (B) which provided that a State plan must

provide in the case of individuals 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, or with respect to

whom supplemental security income benefits are being paid under

subchapter XVI of this chapter, for the inclusion of at least the

care and services listed in paragraphs (1) through (5) and (17) of

section 1396d(a) of this title, and redesignated subpar. (F) as

(B).

Subsec. (a)(13)(C). Pub. L. 97-35, Sec. 2171(b), struck out

subpar. (C) which provided for care and services of individuals not

included in former subpar. (B).

Subsec. (a)(13)(D). Pub. L. 97-35, Sec. 2173(a)(1)(A), struck out

subpar. (D) which provided for payment of reasonable cost of

inpatient hospital services provided under the plan with provisions

for determination of such costs with certain maximum limitations

and for payment of reasonable cost of inappropriate inpatient

services described in subsec. (h)(1) of this section.

Subsec. (a)(13)(E), (F). Pub. L. 97-35, Sec. 2173(a)(1)(C),

redesignated subpars. (E) and (F) as (A) and (B), respectively.

Subsec. (a)(20)(D). Pub. L. 97-35, Sec. 2173(a)(2), struck out

subpar. (D) which required provision for methods of determining

reasonable cost of institutional care of such patients.

Subsec. (a)(23). Pub. L. 97-35, Sec. 2175(a), substituted "except

as provided in section 1396n and except in the case of" for "except

in the case of", and struck out provision that a State plan shall

not be deemed to be out of compliance with the requirements of this

paragraph or pars. (1) and (10) of this subsection solely by reason

of the fact that the State or any political subdivision thereof has

entered into 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.

Subsec. (a)(25)(C). Pub. L. 97-35, Sec. 2182, substituted "of the

individual and where the amount of reimbursement the State can

reasonably expect to recover exceeds the costs of such recovery,

the State" for "of the individual, the State".

Subsec. (a)(30). Pub. L. 97-35, Sec. 2174(a), substituted "that

payments are consistent" for "that payments (including payments for

any drugs provided under the plan) are not in excess of reasonable

charges consistent".

Subsec. (a)(39). Pub. L. 97-35, Sec. 2105(c), substituted

"person" for "individual" in two places.

Subsec. (a)(44). Pub. L. 97-35, Sec. 2181(a)(2)(C), added par.

(44).

Subsec. (b)(2). Pub. L. 97-35, Sec. 2172(a), substituted "any age

requirement which excludes any individual who has not attained the

age of 19 and is a dependent child under part A of subchapter IV of

this chapter;" for "effective July 1, 1967, any age requirement

which excludes any individual who has not attained the age of 21

and is or would, except for the provisions of section 606(a)(2) of

this title, be a dependent child under part A of subchapter IV of

this chapter; or".

Subsec. (d). Pub. L. 97-35, Sec. 2113(m), added subsec. (d).

Subsec. (e). Pub. L. 97-35, Sec. 2178(b), designated existing

provisions as par. (1) and added par. (2).

Subsec. (h). Pub. L. 97-35, Sec. 2173(b)(1), (d), as amended by

Pub. L. 99-509, Sec. 9433(a), added a new subsec. (h) and repealed

former subsec. (h) which related to skilled nursing and

intermediate care facility services.

1980 - Subsec. (a)(13)(B). Pub. L. 96-499, Sec. 965(b)(1),

substituted "paragraphs (1) through (5) and (17)" for "clauses (1)

through (5)".

Subsec. (a)(13)(C)(i). Pub. L. 96-499, Sec. 965(b)(2),

substituted "paragraphs (1) through (5) and (17)" for "clauses (1)

through (5)".

Subsec. (a)(13)(C)(ii). Pub. L. 96-499, Sec. 965(b)(3),

substituted "paragraphs numbered (1) through (17)" for "clauses

numbered (1) through (16)".

Subsec. (a)(13)(D). Pub. L. 96-499, Sec. 902(b)(1), designated

existing provisions as cl. (i) and added cl. (ii).

Subsec. (a)(13)(D)(i). Pub. L. 96-499, Secs. 903(b), 905(a),

inserted "(except where the State agency is subject to an order

under section 1396m of this title)" after "payment" and ", except

that in the case of hospitals reimbursed for services under part A

of subchapter XVIII of this chapter in accordance with section

1395f(b)(3) of this title, the plan must provide for payment of

inpatient hospital services provided in such hospitals under the

plan in accordance with the reimbursement system used under such

section" after "subchapter XVIII of this chapter".

Subsec. (a)(13)(E). Pub. L. 96-499, Sec. 905(a), inserted

"(except where the State agency is subject to an order under

section 1396m of this title)".

Pub. L. 96-499, Sec. 962(a), substituted provisions which

required a State plan for medical assistance to provide for payment

of skilled nursing facility and intermediate care facility services

provided under such plan through the use of rates determined in

accordance with methods and standards developed by the State rather

than on a reasonable cost related basis, required the filing of

uniform cost reports by each facility, and required periodic audits

of such reports by the State.

Subsec. (a)(14)(A)(i). Pub. L. 96-499, Sec. 965(b)(4),

substituted "paragraphs (1) through (5), (7), and (17)" for

"clauses (1) through (5) and (7)".

Subsec. (a)(33)(B). Pub. L. 96-499, Sec. 916(b)(1)(B), inserted

exception authorizing the Secretary where there was cause to

question the adequacy of participation determinations to make

independent determinations concerning the extent to which

individual institutions and agencies met the requirements for

participation.

Subsec. (a)(35). Pub. L. 96-499, Sec. 912(b), substituted

"disclosing entity (as defined in section 1320a-3(a)(2) of this

title)" for "intermediate care facility".

Subsec. (a)(39). Pub. L. 96-499, Sec. 913(c), substituted

provisions requiring that State plans for medical assistance

authorize the State agency to bar specified individuals from

participation in the program under the State plan when required by

the Secretary to do so pursuant to section 1320a-7 of this title

for provisions requiring that State plans for medical assistance

provide for the suspension of physicians or other individuals from

participation in the State plan upon notification by the Secretary

that such physician or other individual had been suspended from

participation in the plan under subchapter XVIII of this chapter.

Subsec. (a)(41). Pub. L. 96-272 added par. (41).

Subsec. (a)(42). Pub. L. 96-499, Sec. 914(b)(1), added par. (42).

Subsec. (a)(43). Pub. L. 96-499, Sec. 918(b)(1)(C), added par.

(43).

Subsec. (g). Pub. L. 96-499, Sec. 913(d), struck out subsec. (g)

which related to waiver of suspension of payments to physicians or

practitioners suspended from participation in approved State plans.

Subsec. (h). Pub. L. 96-499, Sec. 902(b)(2), added subsec. (h).

Subsec. (i). Pub. L. 96-499, Sec. 916(b)(1)(A), added subsec.

(i).

Subsec. (j). Pub. L. 96-611 added subsec. (j).

1978 - Subsec. (a)(4)(C). Pub. L. 95-559 added cl. (C).

1977 - Subsec. (a)(13)(F). Pub. L. 95-210, Sec. 2(c)(1), added

subpar. (F).

Subsec. (a)(23). Pub. L. 95-210, Sec. 2(c)(2), inserted ", 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" after "who elect to obtain such care and

services from such organization".

Subsec. (a)(26). Pub. L. 95-142, Sec. 20(b), inserted provision

relating to staff of skilled nursing facilities.

Subsec. (a)(27)(B). Pub. L. 95-142, Sec. 9, inserted "or the

Secretary" after "State agency" wherever appearing.

Subsec. (a)(32). Pub. L. 95-142, Sec. 2(a)(3), substituted

provisions relating to terms, conditions, etc., for payments under

an assignment or power of attorney, for provisions relating to

terms, conditions, etc., for payments to anyone other than the

individual receiving any care or service provided by a physician,

dentist, or other individual practitioner, or such physician,

dentist, or practitioner.

Subsec. (a)(35). Pub. L. 95-142, Sec. 3(c)(1)(A), substituted

provisions relating to requirements for intermediate care

facilities to comply with section 1320a-3 of this title for

provisions relating to disclosure requirements, effective Jan. 1,

1973, applicable to intermediate care facilities with respect to

ownership, corporate, status, etc.

Subsec. (a)(37). Pub. L. 95-142, Secs. 2(b)(1)(C), 3(c)(1)(C),

7(b)(1), added subsec. (a)(37) and made and struck out minor

changes in phraseology, necessitating no changes in text.

Subsec. (a)(38). Pub. L. 95-142, Secs. 3(c)(1)(D), 7(b)(2),

19(b)(2)(A), added par. (38) and made and struck out minor changes

in phraseology necessitating no changes in text.

Subsec. (a)(39). Pub. L. 95-142, Secs. 7(b)(3), 19(b)(2)(B),

added par. (39).

Subsec. (a)(40). Pub. L. 95-142, Sec. 19(b)(2)(C), added par.

(40).

Subsec. (a), foll. par. (40). Pub. L. 95-142, Sec. 2(b)(1)(D),

added paragraph relating to waiver of requirement of cl. (A) of

par. (37).

Subsec. (g). Pub. L. 95-142, Sec. 7(c), added subsec. (g).

1976 - Subsec. (g). Pub. L. 94-552 struck out provisions for

consent to suit and waiver of immunity by State.

1975 - Subsec. (a). Pub. L. 94-48, Sec. 1, added undesignated

paragraph at end of subsec. (a) relating to eligibility under this

subchapter of any individual who was eligible for the month of

August 1972, under a State plan approved under subchapters I, X,

XIV, XVI, or part A of subchapter IV of this chapter if such

individual would have been eligible for such month had the increase

in monthly insurance benefits under subchapter II of this chapter

resulting from enactment of Pub. L. 92-336 not been applicable to

such individual.

Subsec. (a)(23). Pub. L. 94-48, Sec. 2, inserted "except in the

case of Puerto Rico, the Virgin Islands, and Guam,".

Subsec. (g). Pub. L. 94-182 added subsec. (g).

1974 - Subsec. (a)(14)(B)(i). Pub. L. 93-368 substituted "may"

for "shall".

1973 - Subsec. (a)(5). Pub. L. 93-233, Sec. 13(a)(2)(A), (B),

substituted "to administer or to supervise the administration of

the plan" for "to administer the plan" and "to supervise the

administration of the plan" in that order and inserted after the

parenthetical phrase the conditional provision "if the State is

eligible to participate in the State plan program established under

subchapter XVI of this chapter, or by the agency or agencies

administering the supplemental security income program established

under subchapter XVI of this chapter or the State plan approved

under part A of subchapter IV of this chapter if the State is not

eligible to participate in the State plan program established under

subchapter XVI of this chapter".

Subsec. (a)(10). Pub. L. 93-233, Sec. 13(a)(3), incorporated

existing text in provisions designated as cl. (A), providing

therein for medical assistance to individuals with respect to whom

supplemental security income benefits are paid; incorporated

existing par. (A) in provisions designated as cl. (B); incorporated

existing par. (B) in provisions designated as cl. (C), providing

therein for individuals not meeting income and resources

requirements of the supplemental security income program;

substituted in cls. (B)(ii), (C), (C)(i)(ii) and "medical

assistance" for "medical or remedial care and services" appearing

in predecessor provisions and in cl. (C)(i) "except for income and

resources" for "if needy" appearing in predecessor provision; and

in the exception provisions included reference to par. (16) of

section 1396(a) of this title in item (I), substituted

"deductibles" for "the deductibles" in item (II), and added item

(III).

Subsec. (a)(13)(B). Pub. L. 93-233, Sec. 13(a)(4), substituted

"any plan of the State approved" for "the State's plan approved"

and inserted after "part A of subchapter IV of this chapter" text

reading ", or with respect to whom supplemental security income

benefits are being paid under subchapter XVI of this chapter".

Subsec. (a)(13)(C)(ii)(I). Pub. L. 93-233, Sec. 18(x)(1),

substituted reference to cl. "16" for "14".

Subsec. (a)(14)(A). Pub. L. 93-233, Sec. 13(a)(5), substituted

"any plan of the State approved" for "a State plan approved" and

"with respect to whom supplemental security income benefits are

being paid under subchapter XVI of this chapter, or who meet the

income and resources requirements of the appropriate State plan, or

the supplemental security income program under subchapter XVI of

this chapter, as the case may be, and 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

paragraph (10)(A)" for "who meet the income and resources

requirements of the one of such State plans which is appropriate".

Subsec. (a)(14)(B). Pub. L. 93-233, Sec. 13(a)(6)(A)-(D),

inserted after "with respect to individuals" the parenthetical

provision "(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 paragraph (10)(A))"; inserted

after "any such State plan" the clause "and with respect to whom

supplemental security income benefits are not being paid under

subchapter XVI of this chapter"; substituted "the appropriate State

plan, or the supplemental security income program under subchapter

XVI of this chapter, as the case may be," for "the one of such

State plans which is appropriate"; and struck out "or who, after

December 31, 1973, are included under the State plan for medical

assistance pursuant to subsection (a)(10)(B) of this section

approved under this subchapter" preceding the hyphen and cl. (i),

respectively.

Subsec. (a)(17). Pub. L. 93-233, Sec. 13(a)(7)(A)-(D), (8),

substituted: "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 "the State's plan

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

subchapter IV of this chapter"; "except for income and resources"

for "if he met the requirements as to need"; "any plan of the State

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

subchapter IV of this chapter, or to have paid with respect to him

supplemental security income benefits under subchapter XVI of this

chapter" for "a State plan approved under subchapter I, X, XIV, or

XVI, or part A of subchapter IV of this chapter"; "such aid,

assistance, or benefits" for "and amount of such aid or assistance

under such plan"; and "(with respect to States eligible to

participate in the State program established under subchapter XVI

of this chapter), is blind or permanently and totally disabled, or

is blind or disabled as defined in section 1382c of this title

(with respect to States which are not eligible to participate in

such program)" for "is blind or permanently and totally disabled".

Subsec. (a)(18). Pub. L. 93-233, Sec. 13(a)(8), substituted

"(with respect to States eligible to participate in the State

program established under subchapter XVI of this chapter), is blind

or permanently and totally disabled, or is blind or disabled as

defined in section 1382c of this title (with respect to States

which are not eligible to participate in such program)" for "is

blind or permanently and totally disabled".

Subsec. (a)(20)(C). Pub. L. 93-233, Sec. 13(a)(9), inserted

reference to section 803(a)(1)(A)(i) and (ii) of this title.

Subsec. (a)(21), (24). Pub. L. 93-233, Sec. 18(x)(4), provided

for substitution of "nursing facilities" for "nursing homes".

Subsec. (a)(26)(B). Pub. L. 93-233, Sec. 18(x)(4), provided for

substitution of "nursing facility" and "nursing facilities" for

"nursing home" and "nursing homes", changes already executed under

1972 Amendment by Pub. L. 92-603, Sec. 278(a)(19).

Subsec. (a)(33)(A). Pub. L. 93-233, Sec. 18(x)(2), substituted

"penultimate sentence" for "last sentence".

Subsec. (a)(34). Pub. L. 93-233, Sec. 18(o), inserted "(or

application was made on his behalf in the case of a deceased

individual)" after "he made application".

Subsec. (a)(35)(A). Pub. L. 93-233, Sec. 18(p), required the

intermediate care facility to supply full and complete information

respecting the person who is the owner (in whole or in part) of any

mortgage, deed of trust, note, or other obligation secured (in

whole or in part) by the intermediate care facility or any of the

property or assets of the intermediate care facility.

Subsec. (a)(35) to (37). Pub. L. 93-233, Sec. 18(x)(3)(A), (B),

substituted "; and" for "." at end of par. (35); and corrected

numerical sequence of paragraphs, redesignating par. (37) as (36),

the original subsec. (a) having been enacted without a par. (36).

Subsec. (e). Pub. L. 93-233, Sec. 18(q), substituted "each family

which was receiving aid pursuant to a plan of the State approved

under part A" for "each family which was eligible for assistance

pursuant to part A", "for such aid because of increased hours of,

or increased income from, employment" for "for such assistance

because of increased income from employment", and "remain eligible

for assistance under the plan approved under this subchapter (as

though the family was receiving aid under the plan approved under

part A of subchapter IV of this chapter) for 4 calendar months

beginning with the month in which such family became ineligible for

aid under the plan approved under part A of subchapter IV of this

chapter because of income and resources or hours of work

limitations" for "remain eligible for such assistance for 4

calendar months following the month in which such family would

otherwise be determined to be ineligible for such assistance

because of the income and resources limitations".

Subsec. (f). Pub. L. 93-233, Sec. 13(a)(10)(A)-(D), substituted:

"no State not eligible to participate in the State plan program

established under subchapter XVI of this chapter" for "no State"

and "any supplemental security income payment and State

supplementary payment made with respect to such individual" for

"such individual's payment under subchapter XVI of this chapter"

and "as recognized under State law" for "as defined in section 213

of Title 26" in parenthetical text; and inserted two end sentences

for consideration of certain individuals as eligible for medical

assistance under cl. (10)(A) or (C) of subsec. (a) of this section

or as eligible for such assistance under cl. (10)(A) in States not

providing such assistance under cl. (10)(C), respectively.

1972 - Subsec. (a). Pub. L. 92-603, Secs. 268(a), 278(b)(14),

inserted provisions exempting Christian Science sanatoriums from

certain nursing facility and nursing home requirements.

Subsec. (a)(9). Pub. L. 92-603, Sec. 239(a), inserted provisions

to utilize State health agency for establishing and maintaining

health standards for private or public institutions in which

recipients of medical assistance under the plan may receive care or

services.

Subsec. (a)(13)(A)(ii), (C). Pub. L. 92-603, Sec. 278(a)(18),

(b)(14), substituted "skilled nursing facility" for "skilled

nursing home".

Subsec. (a)(13)(D). Pub. L. 92-603, Secs. 221(c)(5), 232(a),

inserted provisions that the reasonable cost of inpatient hospital

services shall not exceed the amount determined under section

1395x(v) of this title and inserted reference to the consistency of

methods and standards with section 1320a-1 of this title for

determining the reasonable cost of inpatient hospital services.

Subsec. (a)(13)(E). Pub. L. 92-603, Sec. 249(a), added subpar.

(E).

Subsec. (a)(14). Pub. L. 92-603, Sec. 208(a), substituted a

nominal amount for an amount reasonably related to the recipient's

income as the amount of the deduction, cost sharing, or similar

charge imposed under the plan and inserted provisions covering

individuals who are not receiving aid or assistance under any state

plan and who do not meet the income and resources requirements and

covering individuals who are included under the state plan for

medical assistance pursuant to subsec. (a)(10)(B) of this section

approved under this subchapter.

Subsec. (a)(23). Pub. L. 92-603, Sec. 240, inserted provisions

allowing States to adopt comprehensive health care programs while

still complying with medicaid requirements.

Subsec. (a)(26). Pub. L. 92-603, Secs. 274(a), 278(a)(19),

(b)(14), substituted "evaluation)" for "evaluation" and "care" for

"care)" and substituted "skilled nursing facility" and "skilled

nursing facilities" for "skilled nursing home" and "skilled nursing

homes".

Subsec. (a)(28). Pub. L. 92-603, Secs. 246(a), 278(a)(20),

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

and substituted a simple reference to the requirements contained in

section 1395x(j) of this title with a specified exception for

provisions spelling out in detail the requirements for skilled

nursing homes receiving payments.

Subsec. (a)(30). Pub. L. 92-603, Sec. 237(a)(2), substituted

"under the plan (including but not limited to utilization review

plans as provided for in section 1396b(i)(4) of this title)" for

"under the plan".

Subsec. (a)(31)(A). Pub. L. 92-603, Sec. 298, struck out "which

provides more than a minimum level of health care services" after

"intermediate care facility".

Subsec. (a)(32). Pub. L. 92-603, Sec. 236(b)(3), added par. (32).

Subsec. (a)(33). Pub. L. 92-603, Sec. 239(b)(3), added par. (33).

Subsec. (a)(34). Pub. L. 92-603, Sec. 255(a)(3), added par. (34).

Subsec. (a)(35). Pub. L. 92-603, Sec. 299A(3), added par. (35).

Subsec. (a)(37). Pub. L. 92-603, Sec. 299D(b)(3), added par.

(37).

Subsec. (d). Pub. L. 92-603, Sec. 231, repealed subsec. (d) which

related to modification of state plans for medical assistance under

certain circumstances.

Subsec. (e). Pub. L. 92-603, Sec. 209(a), added subsec. (e).

Subsec. (f). Pub. L. 92-603, Sec. 209(b)(1), added subsec. (f).

1971 - Subsec. (a)(31). Pub. L. 92-223 added par. (31).

1969 - Subsec. (c). Pub. L. 91-56, Sec. 2(c), substituted "aid or

assistance in the form of money payments (other than so much, if

any, of the aid or assistance in such form as was, immediately

prior to the effective date of the State plan under this

subchapter, attributable to medical needs)" for "aid or assistance

(other than so much of the aid or assistance as is provided for

under the plan of the State approved under this subchapter)".

Subsec. (d). Pub. L. 91-56, Sec. 2(d), added subsec. (d).

1968 - Subsec. (a)(2). Pub. L. 90-248, Sec. 231, changed the date

on which State plans must meet certain financial participation

requirements by substituting "July 1, 1969" for "July 1, 1970".

Subsec. (a)(4). Pub. L. 90-248, Sec. 210(a)(6), designated

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

Subsec. (a)(10). Pub. L. 90-248, Secs. 223(a), 241(f)(1), struck

out "IV," after "I," and inserted ", and part A of subchapter IV of

this chapter" after "XVI of this chapter", and designated existing

provisions as item I and added item II.

Subsec. (a)(11). Pub. L. 90-248, Sec. 302(b), designated existing

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

Subsec. (a)(13). Pub. L. 90-248, Sec. 224(a), designated existing

provisions as subpar. (A), incorporated existing cl. (A) in

provisions designated as subpars. (B) and (C)(i), making subpar.

(B) and (C) applicable to individuals receiving aid or assistance

under an approved State plan and to individuals not covered under

subpar. (B), respectively, added cl. (ii) of subpar. (C),

redesignated former cl. (B) as subpar. (D), and deleted effective

date of July 1, 1967, for former cls. (A) and (B).

Subsec. (a)(13)(A). Pub. L. 90-248, Sec. 224(c)(1), designated

existing provisions as cl. (i) and added cl. (ii).

Subsec. (a)(14)(A). Pub. L. 90-248, Sec. 235(a)(1), inserted "in

the case of individuals receiving aid or assistance under State

plans approved under subchapters I, X, XIV, XVI, and part A of

subchapter IV of this chapter,".

Subsec. (a)(14)(B). Pub. L. 90-248, Sec. 235(a)(2), inserted

"inpatient hospital services or" after "respect to" and substituted

"to an individual" for "him".

Subsec. (a)(15). Pub. L. 90-248, Sec. 235(a)(3), struck out

subpar. (B) provision for meeting the full cost of any deductible

imposed with respect to any such individual under the insurance

program established by part A of such subchapter, deleted subpar.

(B) designation preceding "where, under the plan", and substituted

therein "established by such subchapter" for "established by part B

of such subchapter".

Subsec. (a)(17). Pub. L. 90-248, Sec. 238, inserted in

parenthetical expression "and may, in accordance with standards

prescribed by the Secretary, differ with respect to income levels,

but only in the case of applicants or recipients of assistance

under the plan who are not receiving aid or assistance under the

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

chapter, or part A of subchapter IV of this chapter, based on the

variations between shelter costs in urban areas and in rural areas"

after "all groups".

Pub. L. 90-248, Sec. 241(f)(2), in cl. (B) struck out "IV," after

"I," and inserted ", or part A of subchapter IV of this chapter"

after "XVI of this chapter".

Subsec. (a)(23) to (30). Pub. L. 90-248, Secs. 227(a), 228(a),

229(a), 234(a), 236(a), 237, added pars. (23), (24), (25), (26) to

(28), (29), (30), respectively.

Subsec. (b)(2). Pub. L. 90-248, Sec. 241(f)(3), inserted "part A

of" before "subchapter IV".

Subsec. (c). Pub. L. 90-248, Sec. 241(f)(4), struck out "IV,"

after "I," and inserted ", or part A of subchapter IV of this

chapter" after "XVI of this chapter".

EFFECTIVE DATE OF 2002 AMENDMENT

Pub. L. 107-121, Sec. 2(c), Jan. 15, 2002, 115 Stat. 2384,

provided that:

"(1) Bccpta technical amendment. - The amendment made by

subsection (a) [amending this section] shall take effect as if

included in the enactment of the Breast and Cervical Cancer

Prevention and Treatment Act of 2000 (Public Law 106-354; 114 Stat.

1381).

"(2) Bipa technical amendments. - The amendments made by

subsection (b) [amending this section and section 1396n of this

title] shall take effect as if included in the enactment of section

702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and

Protection Act of 2000 (114 Stat. 2763A-572) (as enacted into law

by section 1(a)(6) of Public Law 106-554)."

EFFECTIVE DATE OF 2000 AMENDMENTS

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 702(e)], Dec. 21,

2000, 114 Stat. 2763, 2763A-574, provided that: "The amendments

made by this section [amending this section and sections 1396b and

1396n of this title and repealing provisions set out as a note

under this section] take effect on January 1, 2001, and shall apply

to services furnished on or after such date."

Pub. L. 106-354, Sec. 2(d), Oct. 24, 2000, 114 Stat. 1384,

provided that: "The amendments made by this section [enacting

section 1396r-1b of this title and amending this section and

sections 1396b and 1396d of this title] apply to medical assistance

for items and services furnished on or after October 1, 2000,

without regard to whether final regulations to carry out such

amendments have been promulgated by such date."

EFFECTIVE DATE OF 1999 AMENDMENTS

Pub. L. 106-170, title II, Sec. 201(d), Dec. 17, 1999, 113 Stat.

1894, provided that: "The amendments made by this section [amending

this section and sections 1396b, 1396d, and 1396o of this title and

enacting provisions set out as a note below] apply to medical

assistance for items and services furnished on or after October 1,

2000."

Pub. L. 106-169, title II, Sec. 121(b), Dec. 14, 1999, 113 Stat.

1830, provided that: "The amendments made by subsection (a)

[amending this section and section 1396d of this title] apply to

medical assistance for items and services furnished on or after

October 1, 1999."

Amendment by section 205(c) of Pub. L. 106-169 effective Jan. 1,

2000, and applicable to trusts established on or after such date,

see section 205(d) of Pub. L. 106-169, set out as a note under

section 1382a of this title.

Amendment by section 206(b) of Pub. L. 106-169 effective with

respect to disposals made on or after Dec. 14, 1999, see section

206(c) of Pub. L. 106-169, set out as a note under section 1382b of

this title.

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

603(a)(3)], Nov. 29, 1999, 113 Stat. 1536, 1501A-395, provided

that: "The amendments made by this subsection [amending this

section and provisions set out as a note under this section] shall

take effect as if included in the enactment of section 4712 of BBA

(111 Stat. 508) [the Balanced Budget Act of 1997, Pub. L. 105-33]."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 604(c)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-395, provided that:

"(1) The amendment made by subsection (a)(1) [amending this

section] applies to expenditures made on and after the date of the

enactment of this Act [Nov. 29, 1999].

"(2) The amendments made by subsections (a)(2) and (b) [amending

this section and section 1396b of this title] apply as of such date

as the Secretary of Health and Human Services certifies to Congress

that the Secretary is fully implementing section 1932(c)(2) of the

Social Security Act (42 U.S.C. 1396u-2(c)(2))."

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)(1)] is effective as if included in the enactment of BBA

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

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

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

"Except as otherwise provided, the amendments made by this section

[amending this section and sections 1396b, 1396d, 1396g-1, 1396i,

1396n, 1396r, 1396r-1, 1396r-1a, 1396r-4, 1396r-6, 1396r-8, 1396t,

1396u-2, and 1396u-3 of this title] shall take effect on the date

of enactment of this Act [Nov. 29, 1999]."

EFFECTIVE DATE OF 1997 AMENDMENTS

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.

Amendment by section 4454(b)(1) of 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.

Amendment by section 4701(b)(2)(A)(i)-(iv), (d)(1) of Pub. L.

105-33 effective Aug. 5, 1997, and applicable to contracts entered

into or renewed on Oct. 1, 1997, except as otherwise provided, see

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

1396b of this title.

Amendment by section 4702(b)(2) 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 4709 of Pub. L. 105-33 effective 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)(7) of Pub. L. 105-33, set out as a note under

section 1396b of this title.

Section 4711(d) of Pub. L. 105-33 provided that: "This section

[amending this section and sections 1396d and 1396r-4 of this

title] shall take effect on the date of the enactment of this Act

[Aug. 5, 1997] and the amendments made by subsections (a) and (c)

[amending this section and sections 1396d and 1396r-4 of this

title] shall apply to payment for items and services furnished on

or after October 1, 1997."

Section 4712(b)(3) of Pub. L. 105-33 provided that: "The

amendments made by this subsection [amending this section and

section 1396b of this title] shall apply to services furnished on

or after October 1, 1997."

Pub. L. 105-33, title IV, Sec. 4712(c), Aug. 5, 1997, 111 Stat.

509, as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title

VI, Sec. 603(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-394,

which provided that the amendment made by section 4712(c) was

effective for services furnished on or after Oct. 1, 2004, was

repealed by Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec.

702(c)(1), (e)], Dec. 21, 2000, 114 Stat. 2763, 2763A-574,

effective Jan. 1, 2001, and applicable to services furnished on or

after such date.

Section 4714(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395w-4,

1395cc, 1396d of this title] shall apply to payment for (and with

respect to provider agreements with respect to) items and services

furnished on or after the date of the enactment of this Act [Aug.

5, 1997]. The amendments made by subsection (a) [amending this

section and section 1396d of this title] shall also apply to

payment by a State for items and services furnished before such

date if such payment is the subject of a law suit that is based on

the provisions of sections 1902(n) and 1905(p) of the Social

Security Act [subsec. (n) of this section and section 1396d(p) of

this title] and that is pending as of, or is initiated after, the

date of the enactment of this Act."

Section 4715(b) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section] shall apply on and

after October 1, 1997."

Section 4724(c)(2) of Pub. L. 105-33 provided that: "The

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

effect on January 1, 1998."

Section 4724(g)(2) of Pub. L. 105-33 provided that: "The

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

apply to suppliers of medical assistance consisting of durable

medical equipment furnished on or after January 1, 1998."

Section 4731(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section] shall apply to medical

assistance for items and services furnished on or after October 1,

1997."

Section 4741(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and section 1396e of

this title] shall take effect on the date of the enactment of this

Act [Aug. 5, 1997]."

Section 4751(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section] take effect on the

date of the enactment of this Act [Aug. 5, 1997]."

Section 4752(b) of Pub. L. 105-33 provided that: "The amendment

made by subsection (a) [amending this section] takes effect on the

date of the enactment of this Act [Aug. 5, 1997]."

Section 4753(c) of Pub. L. 105-33 provided that: "Except as

otherwise specifically provided, the amendments made by this

section [amending this section and section 1396b of this title]

shall take effect on January 1, 1998."

Section 4911(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall apply to medical assistance for items and

services furnished on or after October 1, 1997."

Section 4912(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [enacting section 1396r-1a and amending this

section and section 1396b of this title] shall take effect on the

date of the enactment of this Act [Aug. 5, 1997]."

Section 4913(b) of Pub. L. 105-33 provided that: "The amendment

made by subsection (a) [amending this section] applies to medical

assistance furnished on or after July 1, 1997."

Amendment by Pub. L. 105-12 effective Apr. 30, 1997, and

applicable to Federal payments made pursuant to obligations

incurred after Apr. 30, 1997, for items and services provided on or

after such date, subject to also being applicable with respect to

contracts entered into, renewed, or extended after Apr. 30, 1997,

as well as contracts entered into before Apr. 30, 1997, to the

extent permitted under such contracts, see section 11 of Pub. L.

105-12, set out as an Effective Date note under section 14401 of

this title.

EFFECTIVE DATE OF 1996 AMENDMENTS

Section 1(a)(2) of Pub. L. 104-248 provided that: "The amendment

made by paragraph (1) [amending this section] shall be effective as

if included in the enactment of the amendments made by section

4752(c)(1) of the Omnibus Budget Reconciliation Act of 1990 [Pub.

L. 101-508]."

Amendment by sections 108(k) and 114(b)-(d)(1), of Pub. L.

104-193 effective July 1, 1997, with transition rules relating to

State options to accelerate such date, rules relating to claims,

actions, and proceedings commenced before such date, rules relating

to closing out of accounts for terminated or substantially modified

programs and continuance in office of Assistant Secretary for

Family Support, and provisions relating to termination of

entitlement under AFDC program, see section 116 of Pub. L. 104-193,

as amended, set out as an Effective Date note under section 601 of

this title.

Section 913 of Pub. L. 104-193 provided that the amendment made

by that section is effective Jan. 1, 1997.

EFFECTIVE DATE OF 1994 AMENDMENTS

Amendment by Pub. L. 103-448 effective Oct. 1, 1994, see section

401 of Pub. L. 103-448, set out as a note under section 1755 of

this title.

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 13581(b)(2) of Pub. L. 103-66 effective Jan.

1, 1994, see section 13581(d) of Pub. L. 103-66, set out as a note

under section 1395y of this title.

Section 13601(c) of Pub. L. 103-66 provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1396d of this title] shall take effect as if included in the

enactment of section 4721(a) of OBRA-1990 [Pub. L. 101-508]."

Amendment by section 13602(c) of Pub. L. 103-66 applicable to

calendar quarters beginning on or after Oct. 1, 1993, without

regard to whether or not regulations to carry out the amendments by

section 13602(a)(1) and (c) of Pub. L. 103-66 have been promulgated

by such date, see section 13602(d)(2) of Pub. L. 103-66, set out as

a note under section 1396r-8 of this title.

Section 13603(f) of Pub. L. 103-66 provided that: "The amendments

made by this section [amending this section and sections 1396d and

1396n of this title] shall apply to medical assistance furnished on

or after January 1, 1994, without regard to whether or not final

regulations to carry out such amendments have been promulgated by

such date."

Amendment by section 13611(d)(1) of Pub. L. 103-66 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after Oct. 1, 1993, without

regard to whether or not final regulations to carry out the

amendments by section 13611 of Pub. L. 103-66 have been promulgated

by such date, see section 13611(e) of Pub. L. 103-66, set out as a

note under section 1396p of this title.

Section 13622(d) of Pub. L. 103-66 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

subsections (a)(1), (b), and (c) [amending this section] shall

apply to 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) 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

amendments made by subsections (a) and (b) [amending this section

and section 1396b of this title], 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

[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.

"(3) The amendment made by subsection (a)(2) [amending section

1396b of this title] shall apply to items and services furnished on

or after October 1, 1993."

Amendment by section 13623(a) of Pub. L. 103-66 applicable,

except as otherwise provided, to calendar quarters beginning on or

after Apr. 1, 1994, without regard to whether or not final

regulations to carry out the amendments by section 13623 of Pub. L.

103-66 have been promulgated by such date, see section 13623(c) of

Pub. L. 103-66, set out as an Effective Date note under section

1396g-1 of this title.

Section 13625(b) of Pub. L. 103-66 provided that: "Section

1902(a)(61) of the Social Security Act [subsec. (a)(61) of this

section] (as added by subsection (a)) shall take effect January 1,

1995, and the standards referred to in such section shall be

established not later than March 31, 1994."

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

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

effect on the date of the enactment of this Act [Aug. 10, 1993]."

Section 13631(f)(3) of Pub. L. 103-66 provided that:

"(A) Except as provided in subparagraph (B), the amendments made

by this subsection [amending this section and section 1396d of this

title] shall apply to 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 [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

amendments made by this subsection, 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

[Aug. 10, 1993]. For purposes of the previous 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 13631(i) of Pub. L. 103-66 provided that: "Except as

otherwise provided in this section, the amendments made by this

section [enacting section 1396s of this title, transferring former

section 1396s of this title to section 1396v of this title, and

amending this section and sections 1396b and 1396d of this title]

shall apply to payments under State plans approved under title XIX

of the Social Security Act [this subchapter] for calendar quarters

beginning on or after October 1, 1994."

EFFECTIVE DATE OF 1991 AMENDMENT

Section 2(c)(1) of Pub. L. 102-234 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] shall take effect January 1, 1992, without regard to

whether or not regulations have been promulgated to carry out such

amendments by such date."

Section 3(e)(1) of Pub. L. 102-234 provided that: "The amendments

made by this section [amending this section and sections 1396b and

1396r-4 of this title] shall take effect January 1, 1992."

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4402(e) of Pub. L. 101-508 provided that:

"(1) The amendments made by this section [enacting section 1396e

of this title and amending this section and sections 1396b and

1396d of this title] apply (except as provided under paragraph (2))

to payments under title XIX of the Social Security Act [this

subchapter] for calendar quarters beginning on or after January 1,

1991, 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 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 authorizing or appropriating funds) in order for

the plan to meet the additional requirements imposed by the

amendments made by subsection (a) [enacting section 1396e of this

title and amending 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 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

[Nov. 5, 1990]. For purposes of the previous 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 4501(f) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and sections 1395v and

1396d of this title] shall apply to calendar quarters beginning on

or after January 1, 1991, without regard to whether or not

regulations to implement such amendments are promulgated by such

date; except that the amendments made by subsection (e) [amending

this section and section 1396d of this title] shall apply to

determinations of income for months beginning with January 1991."

Section 4601(b) of Pub. L. 101-508 provided that:

"(1) The amendments made by this subsection [probably should be

"section", which amended this section and sections 1396b, 1396d,

and 1396r-6 of this title] apply (except as otherwise provided in

this subsection) 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) 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 authorizing or appropriating funds) in order for

the plan to meet the additional requirements imposed by the

amendments made by this subsection [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

[Nov. 5, 1990]. For purposes of the previous 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 4602(b) of Pub. L. 101-508 provided that: "The amendments

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

under title XIX of the Social Security Act [this subchapter] for

calenar [sic] 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."

Section 4603(b) of Pub. L. 101-508 provided that:

"(1) Infants. - The amendment made by subsection (a)(1) [amending

this section] shall apply to individuals born on or after January

1, 1991, without regard to whether or not final regulations to

carry out such amendment have been promulgated by such date.

"(2) Pregnant women. - The amendments made by subsection (a)(2)

[amending this section] shall apply with respect to determinations

to terminate the eligibility of women, based on change of income,

made on or after January 1, 1991, without regard to whether or not

final regulations to carry out such amendments have been

promulgated by such date."

Section 4604(d) of Pub. L. 101-508 provided that:

"(1) The amendments made by this subsection [probably should be

"section", which amended this section and section 1396n of this

title] shall become effective with respect 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) 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 authorizing or appropriating funds) in order for

the plan to meet the additional requirements imposed by the

amendments made by this subsection [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

[Nov. 5, 1990]. For purposes of the previous 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."

Amendment by section 4701(b)(1) of Pub. L. 101-508 effective Jan.

1, 1991, see section 4701(c) of Pub. L. 101-508, set out as a note

under section 1396b of this title.

Section 4704(f) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and sections 1396b,

1396d, and 1396n of this title] shall be effective as if included

in the enactment of the Omnibus Budget Reconciliation Act of 1989

[Pub. L. 101-239]."

Section 4708(b) of Pub. L. 101-508 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 [Nov. 5, 1990]."

Section 4711(e) of Pub. L. 101-508 provided that:

"(1) Except as provided in this subsection, the amendments made

by this section [enacting section 1396t of this title and amending

this section and sections 1396b and 1396d of this title] shall

apply to home and community care furnished 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)(A) The amendments made by subsection (c)(1) [amending this

section] shall apply to home and community care furnished on or

after July 1, 1991, or, if later, 30 days after the date of

publication of interim regulations under section 1929(k)(1)

[section 1396t(k)(1) of this title].

"(B) The amendment made by subsection (c)(2) [amending section

1396b of this title] shall apply to civil money penalties imposed

after the date of the enactment of this Act [Nov. 5, 1990]."

Section 4713(c) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall apply to medical assistance furnished on or after

January 1, 1991."

Section 4715(b) of Pub. L. 101-508 provided that: "The amendment

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

treatment of income for months beginning more than 30 days after

the date of the enactment of this Act [Nov. 5, 1990]."

Section 4732(e) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] shall take effect on the date of the enactment of this

Act [Nov. 5, 1990]."

Section 4751(c) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and sections 1396b and

1396r of this title] shall apply with respect to services furnished

on or after the first day of the first month beginning more than 1

year after the date of the enactment of this Act [Nov. 5, 1990]."

Section 4752(c)(2) of Pub. L. 101-508 provided that: "The

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

apply to medical assistance for calendar quarters beginning more

than 60 days after the date of establishment of the physician

identifier system under section 1902(x) of the Social Security Act

[subsec. (x) of this section]."

Section 4754(b) of Pub. L. 101-508 provided that: "The amendment

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

sanctions effected more than 60 days after the date of the

enactment of this Act [Nov. 5, 1990]."

Section 4755(c)(1) of Pub. L. 101-508 provided that the amendment

made by that section is effective July 1, 1990.

Section 4801(e)(11) of Pub. L. 101-508 provided that the

amendment made by that section is 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.

Section 4801(e)(19) of Pub. L. 101-508 provided that: "Except as

provided in paragraphs (7), (11), and (16), the amendments made by

this subsection [amending this section and sections 1396b and 1396r

of this title, repealing section 1396g of this title, and amending

provisions set out as a note under 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]."

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 6401(c) of Pub. L. 101-239 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and section 1396b of this

title] shall apply to payments under title XIX of the Social

Security Act [this subchapter] for calendar quarters beginning on

or after April 1, 1990, with respect to eligibility for medical

assistance on or after such date, 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 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 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 [Dec. 19, 1989]. For purposes

of the previous 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 6402(c), formerly Sec. 6402(d), of Pub. L. 101-239, as

renumbered and amended by Pub. L. 101-508, title IV, Sec.

4704(e)(2), Nov. 5, 1990, 104 Stat. 1388-172, provided that: "The

amendments made by this section [enacting section 1396r-7 of this

title and amending this section] (except as otherwise provided in

such amendments) shall take effect on the date of the enactment of

this Act [Dec. 19, 1989]."

Section 6403(e) of Pub. L. 101-239 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall take effect on April 1, 1990, without regard to

whether or not final regulations to carry out such amendments have

been promulgated by such date."

Section 6404(d) of Pub. L. 101-239 provided that:

"(1) The amendments made by this section [amending this section

and section 1396d of this title] apply (except as provided under

paragraph (2)) to payments under title XIX of the Social Security

Act [this subchapter] for calendar quarters beginning on or after

April 1, 1990, 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 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 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 [Dec. 19, 1989]. For purposes

of the previous 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 6405(c) of Pub. L. 101-239 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall become effective with respect to services

furnished by a certified pediatric nurse practitioner or certified

family nurse practitioner on or after July 1, 1990."

Section 6406(b) of Pub. L. 101-239 provided that: "The amendments

made by subsection (a) [amending this section] shall take effect on

July 1, 1990, without regard to whether regulations to carry out

such amendments have been promulgated by such date."

Section 6408(c)(2) of Pub. L. 101-239 provided that: "The

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

apply to services furnished on or after April 1, 1990, without

regard to whether or not final regulations have been promulgated by

such date to implement such amendments."

Section 6408(d)(5) of Pub. L. 101-239 provided that:

"(A) The amendments made by this subsection [amending this

section and sections 1396d and 1396o of this title] 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 July 1, 1990, 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

subsection, 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 [Dec. 19, 1989]. For purposes

of the previous 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 6411(a)(2) of Pub. L. 101-239 provided that: "The

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

as if it had been included in the enactment of the Medicare

Catastrophic Coverage Act of 1988 [Pub. L. 100-360]."

Amendment by section 6411(d)(3)(B) of Pub. L. 101-239 applicable

to employment and contracts as of 90 days after Dec. 19, 1989, see

section 6411(d)(4)(B) of Pub. L. 101-239, set out as a note under

section 1395mm of this title.

Section 6411(e)(4) of Pub. L. 101-239 provided that:

"(A) Spousal transfers. - The amendments made by paragraph (1)

[amending section 1396p of this title] shall apply to transfers

occurring after the date of the enactment of this Act [Dec. 19,

1989].

"(B) Other amendments. - Except as provided in subparagraph (A),

the amendments made by this subsection [amending this section and

sections 1396p and 1396r-5 of this title] shall apply as if

included in the enactment of section 303 of the Medicare

Catastrophic Coverage Act of 1988 [Pub. L. 100-360]."

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 8434(c) of Pub. L. 100-647 provided that: "The amendment

made by this section [amending this section and section 1396d of

this title] shall be effective as if included in the enactment of

section 301 of the Medicare Catastrophic Coverage Act of 1988 [Pub.

L. 100-360]."

Amendment by section 202(c)(4) of Pub. L. 100-485 effective Oct.

1, 1990, with provision for earlier effective dates in case of

States making certain changes in their State plans and formally

notifying the Secretary of Health and Human Services of their

desire to become subject to the amendments by title II of Pub. L.

100-485 at such earlier effective dates, see section 204(a),

(b)(1)(A) of Pub. L. 100-485, set out as a note under section 671

of this title.

Section 303(f) of Pub. L. 100-485, as amended by Pub. L. 101-239,

title VI, Sec. 6411(i)(2), Dec. 19, 1989, 103 Stat. 2273; Pub. L.

104-193, title I, Sec. 110(q), Aug. 22, 1996, 110 Stat. 2175,

provided that:

"(1) The amendments made by this section [enacting section

1396r-6 of this title, amending this section and section 1396d of

this title] (other than subsections (b)(3), (d), and (e) [amending

this section and section 602 of this title and provisions formerly

set out as a note under section 606 of this title]) shall apply to

payments under title XIX of the Social Security Act [this

subchapter] for calendar quarters beginning on or after April 1,

1990 (or, in the case of the Commonwealth of Kentucky, October 1,

1990) (without regard to whether regulations to implement such

amendments are promulgated by such date), with respect to families

that cease to be eligible for aid under part A of title IV of the

Social Security Act [part A of subchapter IV of this chapter] on or

after such date.

"(2) The amendment made by subsection (b)(3) [amending section

602 of this title] shall become effective on April 1, 1990, but

such amendment shall not apply with respect to families that cease

to be eligible for aid under part A of title IV of the Social

Security Act before such date.

"(3) The amendment made by subsection (d) [amending this section]

shall become effective on the effective date of section 402(a)(43)

of the Social Security Act, as inserted by section 403(a) of this

Act [the first day of the first calendar quarter to begin one year

or more after Oct. 13, 1988, see section 403(b) of Pub. L. 100-485,

102 Stat. 2398].

"(4) The amendment made by subsection (e) [amending provisions

formerly set out as a note under section 606 of this title] shall

take effect on October 1, 1988."

Section 401(g) of Pub. L. 100-485, as amended by Pub. L. 103-432,

title II, Sec. 234(a), Oct. 31, 1994, 108 Stat. 4466, provided

that:

"(1) Except as provided in paragraph (2), and in section

1905(m)(2) of the Social Security Act [section 1396d(m)(2) of this

title] (as added by subsection (d)(2) of this section), the

amendments made by this section [amending this section and sections

602, 607, and 1396d of this title] shall become effective on

October 1, 1990.

"(2) The amendments made by this section shall not become

effective with respect to Puerto Rico, American Samoa, Guam, or the

Virgin Islands, until the date of the repeal of the limitations

contained in section 1108(a) of the Social Security Act [section

1308(a) of this title] on payments to such jurisdictions for

purposes of making maintenance payments under parts A and E of

title IV of such Act [parts A and E of subchapter IV of this

chapter]."

[Section 234(b) of Pub. L. 103-432 provided that: "The amendment

made by subsection (a) [amending section 401(g)(2) of Pub. L.

100-485, set out above] shall take effect as if included in the

provision of the Family Support Act of 1988 [Pub. L. 100-485] to

which the amendment relates at the time such provision became

law."]

Amendment by section 608(d)(14)(I), (15)(A), (B), (16)(C),

(27)(F)-(H), (28) 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 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.

Amendment by section 301(e)(2) of Pub. L. 100-360 effective July

1, 1989, see section 301(e)(3) of Pub. L. 100-360, set out as a

note under section 1395v of this title.

Section 301(h) of Pub. L. 100-360, as amended by Pub. L. 100-485,

title VI, Sec. 608(d)(14)(K), Oct. 13, 1988, 102 Stat. 2416,

provided that:

"(1) The amendments made by this section [amending this section

and sections 1395v, 1396b, and 1396d of this title] apply (except

as provided in subsections (e) and (f) [set out as notes under

section 1395v and 1396b of this title] and under paragraph (2)) to

payments under title XIX of the Social Security Act [this

subchapter] for calendar quarters beginning on or after January 1,

1989, without regard to whether or not final regulations to carry

out such amendments have been promulgated by such date, with

respect to medical assistance for -

"(A) monthly premiums under title XVIII of such Act [subchapter

XVIII of this chapter] for months beginning with January 1989,

and

"(B) items and services furnished on and after January 1, 1989.

"(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 (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 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 session of the State

legislature that begins after the date of the enactment of this Act

[July 1, 1988]. For purposes of the previous 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 302(f) of Pub. L. 100-360 provided that:

"(1) In general. - The amendments made by this section [amending

this section and sections 1396b and 1396r-4 of this title] 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 July 1, 1989, with respect to eligibility for

medical assistance on or after such date, without regard to whether

or not final regulations to carry out such amendments have been

promulgated by such date.

"(2) Payment adjustment. - The amendments made by subsection

(b)(2) [amending section 1396r-4 of this title] shall take effect

on the date of the enactment of this Act [July 1, 1988].

"(3) Delay for state legislation. - 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 amendments made by this section (other

than subsection (b)(2)), 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. For purposes of

the previous sentence, in the case of a State that has a regular

legislative session of 2 years, each year of such session shall be

deemed to be a separate regular session of the State legislature."

Amendment by section 303(d) of Pub. L. 100-360 effective on and

after Apr. 8, 1988, with additional provision for supersedure of

certain administrative regulations, see section 303(g)(4) of Pub.

L. 100-360, set out as an Effective Date note under section 1396r-5

of this title.

Amendment by section 303(e)(1), (5) of Pub. L. 100-360 applicable

to medical assistance furnished on or after Oct. 1, 1982, see

section 303(g)(6) of Pub. L. 100-360, set out as an Effective Date

note under section 1396r-5 of this title.

Subsec. (a)(51)(A), as enacted by section 303(e)(2)-(4) of Pub.

L. 100-360, applicable 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 that

paragraph have been promulgated by that date, see section

303(g)(1)(A) of Pub. L. 100-360, set out as an Effective Date note

under section 1396r-5 of this title.

Subsec. (a)(51)(B), as enacted by section 303(e)(2)-(4) 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 that

paragraph have been promulgated by that date, with an exception for

resources disposed of before July 1, 1988, see section

303(g)(2)(A), (C), (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(k)(5), (7)(B)-(D), (10)(G)(ii),

(iv), (17)(B), (l)(3)(E), (H), (J), (6)(C), (D), (8)(C), and

(n)(2), (4) 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 4101(a)(3) of Pub. L. 100-203 provided that: "The

amendments made by this subsection [amending this section] shall

apply to medical assistance furnished on or after July 1, 1988."

Section 4101(b)(3) of Pub. L. 100-203 provided that: "The

amendments made by this subsection [amending this section and

provisions set out below] shall apply with respect to medical

assistance furnished on or after July 1, 1988."

Amendment by section 4101(c)(2) of Pub. L. 100-203 applicable to

medical assistance furnished on or after Oct. 1, 1988, see section

4101(c)(3) of Pub. L. 100-203, set out as a note under section

1396d of this title.

Section 4101(e)(6) of Pub. L. 100-203 provided that:

"(A) The amendment made by paragraph (1) [amending this section]

shall become effective on the date of enactment of this Act [Dec.

22, 1987].

"(B) The amendments made by paragraphs (2) and (3) [amending this

section] shall be effective as if they had been included in the

enactment of the Consolidated Omnibus Budget Reconciliation Act of

1985 [Pub. L. 99-272].

"(C) The amendment made by paragraph (4) [amending this section]

shall apply to elections made on or after the enactment of this

Act.

"(D) The amendment made by paragraph (5) [amending this section]

shall apply as if included in the enactment of section 9401 of the

Omnibus Budget Reconciliation Act of 1986 [Pub. L. 99-509]."

Section 4113(c)(3) of Pub. L. 100-203 provided that: "The

amendments made by this subsection [amending this section] shall

apply to services furnished on and after July 1, 1988."

Section 4118(c)(2) of Pub. L. 100-203 provided that: "The

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

effective as if it were included in section 134 of the Tax Equity

and Fiscal Responsibility Act of 1982 [Pub. L. 97-248]."

Section 4118(h)(3), formerly Sec. 4118(h)(2), of Pub. L. 100-203,

as renumbered and amended by Pub. L. 100-360, title IV, Sec.

411(k)(10)(G)(iii), July 1, 1988, 102 Stat. 796, provided that:

"The amendments made by this subsection [amending this section and

section 1396b of this title] shall apply to costs incurred after

the date of the enactment of this Act [Dec. 22, 1987]."

Section 4118(m)(2) of Pub. L. 100-203 provided that: "The

amendments made by paragraph (1) [amending this section and

repealing section 1320a-8 of this title] shall apply to audits

conducted after the date of the enactment of this Act [Dec. 22,

1987]."

Amendments by sections 4211(b)(1), (h)(1)-(5), 4212(d)(2), (3),

(e)(1) 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, and except that subsec. (a)(28)(B) of this section as

amended by section 4211(b) of Pub. L. 100-203 applicable to

calendar quarters beginning more than 6 months after Dec. 22, 1987,

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.

Section 4212(d)(4) of Pub. L. 100-203 provided that: "The

amendments made by this subsection [amending this section and

section 1396b of this title] shall not apply to a State until such

date (not earlier than October 1, 1990) as of which the Secretary

determines that -

"(A) the State has specified the resident assessment instrument

under section 1919(e)(5) of the Social Security Act [section

1396r(e)(5) of this title], and

"(B) the State has begun conducting surveys under section

1919(g)(2) of such Act."

Amendment by section 4213(b)(1) of Pub. L. 100-203 applicable to

payments under this subchapter for calendar quarters beginning on

or after Dec. 22, 1987, 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(b) of Pub. L. 100-203, as

amended, set out as an Effective Date note under section 1396r of

this title.

Section 4218(b) of Pub. L. 100-203 provided that: "The amendments

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

respect to certifications or recertifications during the period

beginning on July 1, 1988, and ending on October 1, 1990."

Amendment by section 9115(b) of Pub. L. 100-203 effective July 1,

1988, see section 9115(c) of Pub. L. 100-203, set out as a note

under section 1382 of this title.

Section 9119(d)(2) of Pub. L. 100-203, as added by Pub. L.

100-360, title IV, Sec. 411(n)(4), formerly Sec. 411(n)(3), July 1,

1988, 102 Stat. 807, and renumbered by Pub. L. 100-485, title VI,

Sec. 608(d)(28), Oct. 13, 1988, 102 Stat. 2423, provided that: "The

amendments made by paragraph (1) [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,

1988, without regard to whether or not final regulations to carry

out such amendments have been promulgated by such date."

Amendment by sections 5(a) and 8(f) of Pub. L. 100-93,

applicable, with certain exception, 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 such amendments have been published

by such date, see section 15(c) of Pub. L. 100-93, set out as a

note under section 1320a-7 of this title.

Amendment by section 7 of 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

Section 10(b) of Pub. L. 99-643 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

sections 3, 4, 5, 6, and 7 [amending this section and sections

1382, 1382c, 1382h, 1383, and 1396s of this title] shall become

effective on July 1, 1987.

"(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 requirements imposed

by the amendments made by section 3(b) [amending this section] and

section 7 of this Act [amending this section and section 1382h of

this title], 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 such additional requirements until 60 days

after the close of the first regular session of the State

legislature that begins after the date of the enactment of this Act

[Nov. 10, 1986]."

Section 11005(c)(2) of Pub. L. 99-570 provided that: "The

amendments made by subsection (b) [amending this section] shall

become effective on January 1, 1987, without regard to whether or

not final regulations to carry out such amendments have been

promulgated by such date."

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 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 9401(f) of Pub. L. 99-509, as amended by Pub. L. 100-203,

title IV, Sec. 4101(b)(2)(C), Dec. 22, 1987, 101 Stat. 1330-141,

provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and section 1396b of this

title] shall apply to medical assistance furnished in calendar

quarters beginning on or after April 1, 1987.

"(2) Subparagraph (C) of section 1902(l)(1) of the Social

Security Act [subsec. (l)(1)(C) of this section], as added by

subsection (b) of this section, shall apply to medical assistance

furnished in calendar quarters beginning on or after October 1,

1987.

"(3) An amendment made by this section shall become effective as

provided in paragraph (1) or (2) without regard to whether or not

final regulations to carry out such amendment have been promulgated

by the applicable date."

Section 9402(c) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section] shall apply to

payments to States 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."

Section 9403(h) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section and sections 1396b,

1396d, and 1396o of this title] apply to payments under title XIX

of the Social Security Act [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."

Section 9404(c) of Pub. L. 99-509 provided that:

"(1) The amendments made by this section [amending this section

and section 1396d of this title] apply (except as provided under

paragraph (2)) to payments under title XIX of the Social Security

Act [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.

"(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 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 [Oct. 21, 1986]."

Section 9406(c) of Pub. L. 99-509 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and section 1396b of this

title] shall apply to medical assistance furnished to aliens on or

after January 1, 1987, 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 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 requirement imposed by the

amendment made in subsection (b) [amending 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 such 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 [Oct. 21, 1986]."

Section 9407(d) of Pub. L. 99-509 provided that: "The amendments

made by this section [enacting section 1396r-1 of this title and

amending this section and sections 1396b and 1396s of this title]

shall apply to ambulatory prenatal care furnished in calendar

quarters beginning on or after April 1, 1987, without regard to

whether or not final regulations to carry out such amendments have

been promulgated by such date."

Section 9408(d) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall apply to services furnished on or after the date

of the enactment of this Act [Oct. 21, 1986]."

Section 9431(c) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] apply to payments under title XIX of the Social

Security Act [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."

Section 9433(b) of Pub. L. 99-509 provided that: "The amendment

made by subsection (a) [amending section 2173 of Pub. L. 97-35,

which amended this section] shall apply as though it was included

in the enactment of the Omnibus Budget Reconciliation Act of 1981

(Public Law 97-35)."

Section 9435(f) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title and provisions set out as notes under this section and

sections 1396d and 1396n of this title] shall be effective as if

included in the enactment of the Consolidated Omnibus Budget

Reconciliation Act of 1985 [Pub. L. 99-272]."

Section 9501(d)(2), (3) of Pub. L. 99-272 provided that:

"(2) Optional services. - The amendments made by subsection (b)

[amending this section] shall become effective on the date of the

enactment of this Act [Apr. 7, 1986].

"(3) Continued coverage. - The amendment made by subsection (c)

[amending this section] shall apply to medical assistance furnished

to a woman on or after the date of the enactment of this Act."

Section 9503(g) of Pub. L. 99-272 provided that:

"(1) Except as otherwise provided, the amendments made by this

section [amending this section and sections 1396b and 1396k of this

title and section 1144 of Title 29, Labor, and enacting provisions

set out as notes under this section and section 1144 of Title 29]

shall apply to calendar quarters beginning on or after the date of

the enactment of this Act [Apr. 7, 1986].

"(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 (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 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.

"(3) No penalty may be applied against any State for a violation

of section 1902(a)(25) of the Social Security Act [subsec. (a)(25)

of this section] occurring prior to the effective date of the

amendments made by this section.

"(4) The amendment made by subsection (c) [enacting provisions

set out below] shall become effective on the date of the enactment

of this Act [Apr. 7, 1986]."

Section 9505(e) 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

and sections 1396d and 1396o of this title] shall apply to medical

assistance provided for hospice care 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 9506(b), (c) of Pub. L. 99-272, as amended by Pub. L.

99-509, title IX, Sec. 9435(c), Oct. 21, 1986, 100 Stat. 2070,

provided that:

"(b) Effective Date. - The amendment made by subsection (a)

[amending this section] shall apply to medical assistance furnished

on or after the first day of the second month beginning after the

date of the enactment of this Act [Apr. 7, 1986].

"(c) Exception. - The amendment made by subsection (a) [amending

this section] shall not apply to any trust or initial trust decree

established prior to April 7, 1986, solely for the benefit of a

mentally retarded individual who resides in an intermediate care

facility for the mentally retarded."

Section 9509(b) of Pub. L. 99-272 provided that:

"(1) Except as provided in paragraphs (2) and (3), the amendments

made by this section [amending this section and enacting provisions

set out below] shall apply to medical assistance furnished on or

after October 1, 1985, but only with respect to changes of

ownership occurring on or after such date.

"(2) The amendments made by this section shall not apply with

respect to a change of ownership pursuant to an enforceable

agreement entered into prior to October 1, 1985.

"(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 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 the requirements imposed by the

amendments made by this section 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]."

Section 9510(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 with respect to payment for services furnished on or

after October 1, 1985, without regard to whether or not regulations

to carry out the amendment have been promulgated by that date."

Section 9529(a)(2) of Pub. L. 99-272 provided that: "The

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

to medical assistance furnished on or after the first calendar

quarter that begins more than 90 days after the date of the

enactment of this Act [Apr. 7, 1986]."

Section 9529(b)(3) of Pub. L. 99-272 provided that: "This

subsection, and the amendments made by this subsection [amending

this section and enacting provisions set out below], shall apply to

adoption assistance agreements entered into before, on, or after

the date of the enactment of this Act [Apr. 7, 1986]."

Amendment by section 12305(b)(3) of Pub. L. 99-272 applicable to

medical assistance furnished in or after first calendar quarter

beginning more than 90 days after Apr. 7, 1986, see section

12305(c) of Pub. L. 99-272, set out as a note under section 673 of

this title.

EFFECTIVE DATE OF 1984 AMENDMENTS

Amendment by Pub. L. 98-617 effective as if originally included

in the Deficit Reduction Act of 1984, Pub. L. 98-369, see section

3(c) of Pub. L. 98-617, set out as a note under section 1395f of

this title.

Amendment by section 2303(g)(1) of Pub. L. 98-369 applicable to

clinical diagnostic laboratory tests furnished on or after July 1,

1984, but not applicable to clinical diagnostic laboratory tests

furnished to inpatients of a provider operating under a waiver

granted pursuant to section 602(k) of Pub. L. 98-21, set out as a

note under section 1395y of this title, see section 2303(j)(1) and

(3) of Pub. L. 98-369, set out as a note under section 1395l of

this title.

Section 2314(c)(3) of Pub. L. 98-369 provided that:

"(A) Except as provided in subparagraph (B), the amendments made

by subsection (b) [amending this section] shall apply to medical

assistance furnished on or after October 1, 1984.

"(B) 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

requirement imposed by the amendments made by this section

[amending this section and section 1395x of this title and enacting

provisions set out as a note under section 1395x of this title],

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 [July 18, 1984]."

Amendment by section 2335(e) 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.

Section 2361(d) of Pub. L. 98-369 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and sections 606 and 1396d of

this title] shall apply to calendar quarters beginning on or after

October 1, 1984, 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 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 [July 18, 1984]."

Section 2362(b) of Pub. L. 98-369 provided that: "The amendment

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

children born on or after October 1, 1984."

Amendment by section 2363(a)(1) of Pub. L. 98-369 applicable to

calendar quarters beginning on or after July 18, 1984, except that,

in the case of individuals admitted to skilled nursing facilities

before that date, the amendment shall not require recertifications

sooner or more frequently than were required under the law in

effect before that date, see section 2363(c) of Pub. L. 98-369, set

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

Section 2367(c) of Pub. L. 98-369 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and section 1396k of this

title] shall become effective on October 1, 1984.

"(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

requirement 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 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 [July 18, 1984]."

Section 2368(c) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section] shall become effective

on the date of the enactment of this Act [July 18, 1984]."

Amendment by section 2651(c) of Pub. L. 98-369 effective Apr. 1,

1985, except as otherwise provided, see section 2651(l)(2) of Pub.

L. 98-369, set out as an Effective Date note under section 1320b-7

of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by section 131(a), (c) of Pub. L. 97-248 effective Oct.

1, 1982, see section 131(d) of Pub. L. 97-248, formerly Sec.

131(c), redesignated Pub. L. 97-448, title III, Sec. 309(a)(8),

Jan. 12, 1983, 96 Stat. 2408, set out as an Effective Date note

under section 1396o of this title.

Amendment by section 132(a), (c) of Pub. L. 97-248 effective

Sept. 3, 1982, see section 132(d) of Pub. L. 97-248, set out as an

Effective Date note under section 1396p of this title.

Section 134(b) of Pub. L. 97-248 provided that: "The amendment

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

effective on October 1, 1982."

Amendment by section 136(d) 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.

Section 137(d) of Pub. L. 97-248 provided that:

"(1) Except as otherwise provided in this section, any amendment

to the Omnibus Budget Reconciliation Act of 1981 [Pub. L. 97-35]

made by this section [amending this section and sections 1320a-1

and 1396b of this title and provisions set out as a note under

section 603 of this title] shall be effective as if it had been

originally included in the provision of the Omnibus Budget

Reconciliation Act of 1981 to which such amendment relates.

"(2) Except as otherwise provided in this section, any amendment

to the Social Security Act [this chapter] made by the preceding

provisions of this section [amending this section and sections 701,

705, 1320a-7a, 1320b-4, 1396b, 1396d, and 1396n of this title]

shall be effective as if it had been originally included as a part

of that provision of the Social Security Act to which it relates,

as such provision of the Social Security Act was amended by the

Omnibus Budget Reconciliation Act of 1981 [Pub. L. 97-35]."

Amendment by section 146(a) of Pub. L. 97-248 effective with

respect to contracts entered into or renewed on or after Sept. 3,

1982, see section 149 of Pub. L. 97-248, set out as an Effective

Date note under section 1320c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Section 2113(o) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and sections 1320c,

1320c-1, 1320c-3, 1320c-4, 1320c-7, 1320c-8, 1320c-9, 1320c-11,

1320c-17, 1320c-21, and 1396b of this title and repealing sections

1320c-13 and 1320c-20 of this title] apply to agreements with

Professional Standards Review Organizations entered into on or

after October 1, 1981."

Section 2171(c) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section] shall become effective

on the date of the enactment of this Act [Aug. 13, 1981]."

Section 2172(c) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall become effective on the date of the enactment of

this Act [Aug. 13, 1981]."

Section 2173(b)(2) of Pub. L. 97-35 provided that: "The amendment

made by paragraph (1) [amending this section] shall not apply with

respect to services furnished before the date the Secretary of

Health and Human Services first promulgates and has in effect final

regulations (on an interim or other basis) to carry out section

1902(a)(13)(A) of the Social Security Act [subsec. (a)(13)(A) of

this section] (as amended by this subtitle)."

Section 2174(c) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] shall apply to services furnished on or after October

1, 1981."

Section 2175(d)(2) of Pub. L. 97-35 provided that:

"(A) The amendments made by paragraph (1) [amending this section]

shall (except as provided under subparagraph (B)) be effective with

respect to payments under title XIX of the Social Security Act

[this subchapter] for calendar quarters beginning on or after

October 1, 1981.

"(B) 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

requirement imposed by the amendment made by paragraph (1)(C), 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 year 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. 13, 1981]."

Section 2178(c) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] shall apply with respect to services furnished, under a

State plan approved under title XIX of the Social Security Act

[this subchapter], on or after October 1, 1981; except that such

amendments shall not apply with respect to services furnished by a

health maintenance organization under a contract with a State

entered into under such title before October 1, 1981 unless the

organization requests that such amendments apply and the Secretary

of Health and Human Services and the single State agency

(administering or supervising the administration of the State plan

under such title) agree to such request."

Section 2181(b) of Pub. L. 97-35, as amended by Pub. L. 97-248,

title I, Sec. 137(a)(4), Sept. 3, 1982, 96 Stat. 376, provided

that: "The amendment made by subsection (a)(1) [amending section

603 of this title] shall apply to reductions for calendar quarters

beginning on or after June 30, 1974, and the amendments made by

subsection (a)(2) [amending this section] shall take effect on

October 1, 1981, except that, in the case of a State plan under

title XIX of the Social Security Act [this subchapter] which the

Secretary determines requires State legislation in order to

incorporate the provisions required to be included by this section

into such State plan, 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 include the provisions required to be

included in such State plan by subsection (a)(2) of this section

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. 13,

1981], but the requirements previously set forth in paragraphs (1)

through (3) of section 403(g) of the Social Security Act [section

603(g)(1)-(3) of this title] (prior to its repeal by this section)

shall apply under title XIX of such Act to such State on and after

October 1, 1981, whether or not the provisions required to be

included by this section in the State plan under title XIX have

been incorporated into such State plan."

For effective date, savings, and transitional provisions relating

to amendment by section 2193(c)(9) of Pub. L. 97-35, see section

2194 of Pub. L. 97-35, set out as a note under section 701 of this

title.

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by section 902(b) of Pub. L. 96-499 effective on date

on which final regulations to implement the amendment are first

issued, see section 902(c) of Pub. L. 96-499, set out as a note

under section 1395x of this title.

Section 914(b)(2) of Pub. L. 96-499, as amended by Pub. L.

97-248, title I, Sec. 137(c)(1), Sept. 3, 1982, 96 Stat. 381,

provided that:

"(A) The amendments made by paragraph (1) [amending this section]

shall (except as provided under subparagraph (B)) apply to cost

reporting periods, beginning on or after April 1, 1981, of an

entity providing services under a State plan approved under title

XIX of the Social Security Act [this subchapter]."

"(B) In the case of a State plan for medical assistance under

title XIX of the Social Security Act which the Secretary determines

requires State legislation in order for the plan to meet the

additional requirements imposed by the amendments made by paragraph

(1), 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."

Section 918(b)(2) of Pub. L. 96-499 provided that:

"(A) The amendments made by paragraph (1) [enacting this section]

shall (except as otherwise provided in subparagraph (B)) apply to

medical assistance provided, under a State plan approved under

title XIX of the Social Security Act [this subchapter], on and

after the first day of the first calendar quarter that begins more

than six months after the date of the enactment of this Act [Dec.

5, 1980].

"(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 in order

for the plan to meet the additional requirements imposed by the

amendments made by paragraph (1), 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."

Section 962(b) of Pub. L. 96-499 provided that: "The amendment

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

effective on October 1, 1980."

Section 965(c) of Pub. L. 96-499 provided that:

"(1) The amendments made by this section [amending this section

and section 1396d of this title] shall (except as provided under

paragraph (2)) be effective with respect to payments under title

XIX of the Social Security Act [this subchapter] for calendar

quarters beginning more than one hundred and twenty days after the

date of the enactment of this Act [Dec. 5, 1980].

"(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 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."

EFFECTIVE DATE OF 1978 AMENDMENT

Section 14(a)(2) of Pub. L. 95-559 provided that:

"(A) Except as provided in subparagraph (B), the amendments made

by paragraph (1) [amending this section] shall take effect one

hundred and eighty days after the date of the enactment of this Act

[Nov. 1, 1978].

"(B) In the case of a State plan for medical assistance under

title XIX of the Social Security Act [this subchapter] which the

Secretary determines requires State legislation in order for the

plan to meet the requirement added by the amendments made by

paragraph (1), such amendments shall not apply with respect to such

State plan before ninety days after the close of the first regular

session of the State legislature that begins after the date of the

enactment of this Act."

EFFECTIVE DATE OF 1977 AMENDMENTS

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.

Amendment by section 2(a)(3) of Pub. L. 95-142 applicable with

respect to care and services furnished on or after Oct. 25, 1977,

see section 2(a)(4) of Pub. L. 95-142, set out as a note under

section 1395g of this title.

Section 2(b)(2) of Pub. L. 95-142 provided that: "The amendments

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

calendar quarters beginning on and after July 1, 1978, with respect

to State plans approved under title XIX of the Social Security Act

[this subchapter]."

Amendment by section 3(c)(1) of Pub. L. 95-142 effective Jan. 1,

1978, see section 3(e) of Pub. L. 95-142, set out as an Effective

Date note under section 1320a-3 of this title.

Section 7(e)(2) of Pub. L. 95-142 provided that: "The amendment

made by subsection (b) [amending this section] shall become

effective on January 1, 1978."

Section 19(c)(2) of Pub. L. 95-142 provided that:

"(A) The amendments made by subsection (b) [amending this section

and section 1395x of this title] shall apply with respect to

operations of a hospital, skilled nursing facility, or intermediate

care facility, on and after the first day of its first fiscal year

which begins after the end of the six-month period beginning on the

date a uniform reporting system is established (under section

1121(a) of the Social Security Act) [section 1320a(a) of this

title] for that type of health services facility.

"(B) The amendments made by subsection (b) [amending this section

and section 1395x of this title] shall apply, with respect to the

operation of a health services facility or organization which is

neither a hospital, a skilled nursing facility, nor an intermediate

care facility, on and after the first day of its first fiscal year

which begins after such date as the Secretary of Health, Education,

and Welfare [now Health and Human Services] determines to be

appropriate for the implementation of the reporting requirement for

that type of facility or organization.

"(C) Except as provided in subparagraphs (A) and (B), the

amendments made by subsection (b)(2) [amending this section] shall

apply, with respect to State plans approved under title XIX of the

Social Security Act [this subchapter], on and after October 1,

1977."

Amendment by section 20(b) of Pub. L. 95-142 effective Oct. 1,

1977, and the Secretary to adjust payments made to States under

section 1396b of this title to reflect such amendment, see section

20(c) of Pub. L. 95-142, set out as a note under section 1396b of

this title.

EFFECTIVE DATE OF 1976 AMENDMENT

Section 2 of Pub. L. 94-552 provided that: "The amendments made

by the first section [amending this section and section 1396b of

this title] shall take effect as of January 1, 1976."

EFFECTIVE DATE OF 1975 AMENDMENT

Section 111(c) of Pub. L. 94-182 provided that: "The amendments

made by this section [amending this section and section 1396b of

this title] shall (except as otherwise provided for therein) become

effective January 1, 1976."

EFFECTIVE DATE OF 1974 AMENDMENT

Section 9(b) of Pub. L. 93-368 provided that: "The amendment made

by subsection (a) [amending this section] shall be effective

January 1, 1973."

EFFECTIVE DATE OF 1973 AMENDMENT

Section 13(d) of Pub. L. 93-233 provided that: "The amendments

made by subsection (a) [amending this section and sections 1396,

1396b, and 1396d of this title] shall be effective with respect to

payments under section 1903 of the Social Security Act [section

1396b of this title] for calendar quarters commencing after

December 31, 1973."

Section 18(z-3)(4) of Pub. L. 93-233 provided that: "The

amendments made by subsections (o) and (u) [amending this section

and section 1396b of this title] shall be effective July 1, 1973".

EFFECTIVE DATE OF 1972 AMENDMENT

Section 208(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall be effective

January 1, 1973 (or earlier if the State plan so provided)."

Section 209(b)(2) of Pub. L. 92-603 provided that: "The amendment

made by this subsection [amending this section] shall become

effective on January 1, 1974."

Section 232(c) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and section 705 of this

title] shall be effective July 1, 1972 (or earlier if the State

plan so provides)."

Amendment by section 236(b) of Pub. L. 92-603 effective Jan. 1,

1973, or earlier if the State plan so provides, see section 236(c)

of Pub. L. 92-603, set out as a note under section 1395u of this

title.

Section 237(d)(2) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a)(2) [amending this section] shall be

effective July 1, 1973."

Section 239(d) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and section 705 of this

title] shall be effective January 1, 1973 (or earlier if the State

plan so provides)."

Amendment by section 246(a) of Pub. L. 92-603 to be effective

July 1, 1973, see section 246(c) of Pub. L. 92-603, set out as a

note under section 1395x of this title.

Section 255(b) of Pub. L. 92-603 provided that: "The amendments

made by subsection (a) [amending this section] shall be effective

July 1, 1973."

Section 268(c) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and section 1396g of

this title] shall be effective on the date of the enactment of this

Act [Oct. 30, 1972]."

Amendment by section 299D(b) of Pub. L. 92-603 effective

beginning Jan. 1, 1973, or within 6 months following Oct. 30, 1972,

whichever is later, see section 299D(c) of Pub. L. 92-603, set out

as a note under section 1395aa of this title.

EFFECTIVE DATE OF 1971 AMENDMENT

Section 4(d) of Pub. L. 92-223, as amended by section 292 of Pub.

L. 92-603, provided that: "The amendments made by this section

[amending this section and section 1396d of this title and

repealing section 1320a of this title] shall become effective

January 1, 1972; except that the repeal made by subsection (c)

[repealing section 1320a of this title], shall not become effective

in the case of any State, which on January 1, 1972 did not have in

effect a State plan approved under title XIX of the Social Security

Act [this subchapter], until the first day of the first month

(occurring after such date) that such State does have in effect a

State plan approved under such title [this subchapter]."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by section 210(a)(6) of Pub. L. 90-248 effective July

1, 1969, or, if earlier (with respect to a State's plan approved

under this subchapter) on the date as of which the modification of

the State plan to comply with such amendment is approved, see

section 210(b) of Pub. L. 90-248, set out as a note under section

302 of this title.

Section 223(b) of Pub. L. 90-248 provided that: "The amendments

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

respect to calendar quarters beginning after June 30, 1967."

Section 224(b) of Pub. L. 90-248 provided that: "The amendment

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

respect to calendar quarters beginning after December 31, 1967."

Section 224(c)(2) of Pub. L. 90-248 provided that: "The amendment

made by paragraph (1) of this subsection [amending this section]

shall apply with respect to calendar quarters beginning after June

30, 1970."

Section 227(b) of Pub. L. 90-248, as amended by section 271A of

Pub. L. 92-603, effective from and after July 1, 1972, provided

that: "The amendments made by this section [amending this section]

shall apply with respect to calendar quarters beginning after June

30, 1969; except that such amendments shall apply in the case of

Puerto Rico, the Virgin Islands, and Guam only with respect to

calendar quarters beginning after June 30, 1975."

Section 229(b) of Pub. L. 90-248 provided that: "The amendment

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

respect to legal liabilities of third parties arising after March

31, 1968."

Section 234(b) of Pub. L. 90-248 provided that: "The amendments

made by subsection (a) of this section [amending this section]

(unless otherwise specified in the body of such amendments) shall

take effect on January 1, 1969."

Section 235(b) of Pub. L. 90-248 provided that: "The amendments

made by subsection (a) [amending this section] shall be effective

in the case of calendar quarters beginning after December 31,

1967."

Enactment by section 236(a) of Pub. L. 90-248 effective July 1,

1970, except as otherwise specified in the text thereof, see

section 236(c) of Pub. L. 90-248, set out as an Effective Date note

under section 1396g of this title.

Section 237 of Pub. L. 90-248 provided that the amendment made by

that section is effective Apr. 1, 1968.

Section 238 of Pub. L. 90-248 provided that the amendment made by

that section is effective July 1, 1969.

CONSTRUCTION OF 1999 AMENDMENT

Pub. L. 106-169, title I, Sec. 121(c), Dec. 14, 1999, 113 Stat.

1830, provided that: "If the Ticket to Work and Work Incentives

Improvement Act of 1999 [Pub. L. 106-170] is enacted (whether

before, on, or after the date of the enactment of this Act) -

"(1) the amendments made by that Act [see Tables for

classification] shall be executed as if this Act [see Short Title

of 1999 Amendment note under section 1305 of this title] had been

enacted after the enactment of such other Act;

"(2) with respect to subsection (a)(1)(A) of this section

[amending this section], any reference to subclause (XIII) is

deemed a reference to subclause (XV);

"(3) with respect to subsection (a)(1)(B) of this section

[amending this section], any reference to subclause (XIV) is

deemed a reference to subclause (XVI);

"(4) [Amended this section.]

"(5) [Amended section 1396d of this title.]"

-TRANS-

TRANSFER OF FUNCTIONS

Functions, powers, and duties of Secretary of Health and Human

Services under subsec. (a)(4)(A) of this section, insofar as

relates to the prescription of personnel standards on a merit

basis, transferred to Office of Personnel Management, see section

4728(a)(3)(D) of this title.

-MISC2-

STUDY REGARDING BARRIERS TO PARTICIPATION OF FARMWORKERS IN HEALTH

PROGRAMS

Pub. L. 107-251, title IV, Sec. 404, Oct. 26, 2002, 116 Stat.

1662, provided that:

"(a) In General. - The Secretary shall conduct a study of the

problems experienced by farmworkers (including their families)

under Medicaid and SCHIP. Specifically, the Secretary shall examine

the following:

"(1) Barriers to enrollment. - Barriers to their enrollment,

including a lack of outreach and outstationed eligibility

workers, complicated applications and eligibility determination

procedures, and linguistic and cultural barriers.

"(2) Lack of portability. - The lack of portability of Medicaid

and SCHIP coverage for farmworkers who are determined eligible in

one State but who move to other States on a seasonal or other

periodic basis.

"(3) Possible solutions. - The development of possible

solutions to increase enrollment and access to benefits for

farmworkers, because, in part, of the problems identified in

paragraphs (1) and (2), and the associated costs of each of the

possible solutions described in subsection (b).

"(b) Possible Solutions. - Possible solutions to be examined

shall include each of the following:

"(1) Interstate compacts. - The use of interstate compacts

among States that establish portability and reciprocity for

eligibility for farmworkers under the Medicaid and SCHIP and

potential financial incentives for States to enter into such

compacts.

"(2) Demonstration projects. - The use of multi-state

demonstration waiver projects under section 1115 of the Social

Security Act (42 U.S.C. 1315) to develop comprehensive migrant

coverage demonstration projects.

"(3) Use of current law flexibility. - Use of current law

Medicaid and SCHIP State plan provisions relating to coverage of

residents and out-of-State coverage.

"(4) National migrant family coverage. - The development of

programs of national migrant family coverage in which States

could participate.

"(5) Public-private partnerships. - The provision of incentives

for development of public-private partnerships to develop private

coverage alternatives for farmworkers.

"(6) Other possible solutions. - Such other solutions as the

Secretary deems appropriate.

"(c) Consultations. - In conducting the study, the Secretary

shall consult with the following:

"(1) Farmworkers affected by the lack of portability of

coverage under the Medicaid program or the State children's

health insurance program (under titles XIX and XXI of the Social

Security Act [this subchapter and subchapter XXI of this

chapter]).

"(2) Individuals with expertise in providing health care to

farmworkers, including designees of national and local

organizations representing migrant health centers and other

providers.

"(3) Resources with expertise in health care financing.

"(4) Representatives of foundations and other nonprofit

entities that have conducted or supported research on farmworker

health care financial issues.

"(5) Representatives of Federal agencies which are involved in

the provision or financing of health care to farmworkers,

including the Health Care Financing Administration and the Health

Research and Services Administration.

"(6) Representatives of State governments.

"(7) Representatives from the farm and agricultural industries.

"(8) Designees of labor organizations representing farmworkers.

"(d) Definitions. - For purposes of this section:

"(1) Farmworker. - The term 'farmworker' means a migratory

agricultural worker or seasonal agricultural worker, as such

terms are defined in section 330(g)(3) of the Public Health

Service Act (42 U.S.C. 254c(g)(3) [254b(g)(3)]), and includes a

family member of such a worker.

"(2) Medicaid. - The term 'Medicaid' means the program under

title XIX of the Social Security Act [this subchapter].

"(3) SCHIP. - The term 'SCHIP' means the State children's

health insurance program under title XXI of the Social Security

Act [subchapter XXI of this chapter].

"(e) Report. - Not later than one year after the date of the

enactment of this Act [Oct. 26, 2002], the Secretary shall transmit

a report to the President and the Congress on the study conducted

under this section. The report shall contain a detailed statement

of findings and conclusions of the study, together with its

recommendations for such legislation and administrative actions as

the Secretary considers appropriate."

STUDY ON LIMITATION ON STATE PAYMENT FOR MEDICARE COST-SHARING

AFFECTING ACCESS TO SERVICES FOR QUALIFIED MEDICARE BENEFICIARIES

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 125], Dec. 21, 2000,

114 Stat. 2763, 2763A-479, provided that:

"(a) In General. - The Secretary of Health and Human Services

shall conduct a study to determine if access to certain services

(including mental health services) for qualified medicare

beneficiaries has been affected by limitations on a State's payment

for medicare cost-sharing for such beneficiaries under section

1902(n) of the Social Security Act (42 U.S.C. 1396a(n)). As part of

such study, the Secretary shall analyze the effect of such payment

limitation on providers who serve a disproportionate share of such

beneficiaries.

"(b) Report. - Not later than 1 year after the date of the

enactment of this Act [Dec. 21, 2000], the Secretary shall submit

to Congress a report on the study under subsection (a). The report

shall include recommendations regarding any changes that should be

made to the State payment limits under section 1902(n) for

qualified medicare beneficiaries to ensure appropriate access to

services."

GAO STUDY OF FUTURE REBASING

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 702(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-574, provided that: "The Comptroller

General of the United States shall provide for a study on the need

for, and how to, rebase or refine costs for making payment under

the medicaid program for services provided by Federally-qualified

health centers and rural health clinics (as provided under the

amendments made by this section [amending this section and sections

1396b and 1396n of this title and repealing provisions set out as a

note under this section]). The Comptroller General shall provide

for submittal of a report on such study to Congress by not later

than 4 years after the date of the enactment of this Act [Dec. 21,

2000]."

GAO REPORTS

Pub. L. 106-170, title II, Sec. 201(c), Dec. 17, 1999, 113 Stat.

1893, provided that: "Not later than 3 years after the date of the

enactment of this Act [Dec. 17, 1999], the Comptroller General of

the United States shall submit a report to the Congress regarding

the amendments made by this section [amending this section and

sections 1396b, 1396d, and 1396o of this title] that examines -

"(1) the extent to which higher health care costs for

individuals with disabilities at higher income levels deter

employment or progress in employment;

"(2) whether such individuals have health insurance coverage or

could benefit from the State option established under such

amendments to provide a medicaid buy-in; and

"(3) how the States are exercising such option, including -

"(A) how such States are exercising the flexibility afforded

them with regard to income disregards;

"(B) what income and premium levels have been set;

"(C) the degree to which States are subsidizing premiums

above the dollar amount specified in section 1916(g)(2) of the

Social Security Act (42 U.S.C. 1396o(g)(2)); and

"(D) the extent to which there exists any crowd-out effect."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 603(b)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-395, provided that: "Not later

than 1 year after the date of the enactment of this Act [Nov. 29,

1999], the Comptroller General of the United States shall submit a

report to Congress that evaluates the effect on Federally-qualified

health centers and rural health clinics and on the populations

served by such centers and clinics of the phase-out and elimination

of the reasonable cost basis for payment for Federally-qualified

health center services and rural health clinic services provided

under section 1902(a)(13)(C)(i) of the Social Security Act (42

U.S.C. 1396a(a)(13)(C)(i)), as amended by section 4712 of BBA (111

Stat. 508) [the Balanced Budget Act of 1997, Pub. L. 105-33] and

subsection (a) of this section. Such report shall include an

analysis of the amount, method, and impact of payments made by

States that have provided for payment under title XIX of such Act

[this subchapter] for such services on a basis other than payment

of costs which are reasonable and related to the cost of furnishing

such services, together with any recommendations for legislation,

including whether a new payment system is needed, that the

Comptroller General determines to be appropriate as a result of the

study."

DEMONSTRATION OF COVERAGE UNDER THE MEDICAID PROGRAM OF WORKERS

WITH POTENTIALLY SEVERE DISABILITIES

Pub. L. 106-170, title II, Sec. 204, Dec. 17, 1999, 113 Stat.

1897, provided that:

"(a) State Application. - A State may apply to the Secretary of

Health and Human Services (in this section referred to as the

'Secretary') for approval of a demonstration project (in this

section referred to as a 'demonstration project') under which up to

a specified maximum number of individuals who are workers with a

potentially severe disability (as defined in subsection (b)(1)) are

provided medical assistance equal to -

"(1) that provided under section 1905(a) of the Social Security

Act (42 U.S.C. 1396d(a)) to individuals described in section

1902(a)(10)(A)(ii)(XIII) of that Act (42 U.S.C.

1396a(a)(10)(A)(ii)(XIII)); or

"(2) in the case of a State that has not elected to provide

medical assistance under that section to such individuals, such

medical assistance as the Secretary determines is an appropriate

equivalent to the medical assistance described in paragraph (1).

"(b) Worker With a Potentially Severe Disability Defined. - For

purposes of this section -

"(1) In general. - The term 'worker with a potentially severe

disability' means, with respect to a demonstration project, an

individual who -

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

"(B) has a specific physical or mental impairment that, as

defined by the State under the demonstration project, is

reasonably expected, but for the receipt of items and services

described in section 1905(a) of the Social Security Act (42

U.S.C. 1396d(a)), to become blind or disabled (as defined under

section 1614(a) of the Social Security Act (42 U.S.C.

1382c(a))); and

"(C) is employed (as defined in paragraph (2)).

"(2) Definition of employed. - An individual is considered to

be 'employed' if the individual -

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

requirement under section 6 of the Fair Labor Standards Act (29

U.S.C. 206) and working at least 40 hours per month; or

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

reasonable threshold criteria for hours of work, wages, or

other measures, as defined under the demonstration project and

approved by the Secretary.

"(c) Approval of Demonstration Projects. -

"(1) In general. - Subject to paragraph (3), the Secretary

shall approve applications under subsection (a) that meet the

requirements of paragraph (2) and such additional terms and

conditions as the Secretary may require. The Secretary may waive

the requirement of section 1902(a)(1) of the Social Security Act

(42 U.S.C. 1396a(a)(1)) to allow for sub-State demonstrations.

"(2) Terms and conditions of demonstration projects. - The

Secretary may not approve a demonstration project under this

section unless the State provides assurances satisfactory to the

Secretary that the following conditions are or will be met:

"(A) Maintenance of state effort. - Federal funds paid to a

State pursuant to this section must be used to supplement, but

not supplant, the level of State funds expended for workers

with potentially severe disabilities under programs in effect

for such individuals at the time the demonstration project is

approved under this section.

"(B) Independent evaluation. - The State provides for an

independent evaluation of the project.

"(3) Limitations on federal funding. -

"(A) Appropriation. -

"(i) In general. - Out of any funds in the Treasury not

otherwise appropriated, there is appropriated to carry out

this section -

"(I) $42,000,000 for each of fiscal years 2001 through 2004;

and

"(II) $41,000,000 for each of fiscal years 2005 and 2006.

"(ii) Budget authority. - Clause (i) constitutes budget

authority in advance of appropriations Acts and represents

the obligation of the Federal Government to provide for the

payment of the amounts appropriated under clause (i).

"(B) Limitation on payments. - In no case may -

"(i) the aggregate amount of payments made by the Secretary

to States under this section exceed $250,000,000;

"(ii) the aggregate amount of payments made by the

Secretary to States for administrative expenses relating to

annual reports required under subsection (d) exceed

$2,000,000 of such $250,000,000; or

"(iii) payments be provided by the Secretary for a fiscal

year after fiscal year 2009.

"(C) Funds allocated to states. - The Secretary shall

allocate funds to States based on their applications and the

availability of funds. Funds allocated to a State under a grant

made under this section for a fiscal year shall remain

available until expended.

"(D) Funds not allocated to States. - Funds not allocated to

States in the fiscal year for which they are appropriated shall

remain available in succeeding fiscal years for allocation by

the Secretary using the allocation formula established under

this section.

"(E) Payments to States. - The Secretary shall pay to each

State with a demonstration project approved under this section,

from its allocation under subparagraph (C), an amount for each

quarter equal to the Federal medical assistance percentage (as

defined in section 1905(b) of the Social Security Act (42

U.S.C. 1395d(b) [42 U.S.C. 1396d(b)]) of expenditures in the

quarter for medical assistance provided to workers with a

potentially severe disability.

"(d) Annual Report. - A State with a demonstration project

approved under this section shall submit an annual report to the

Secretary on the use of funds provided under the grant. Each report

shall include enrollment and financial statistics on -

"(1) the total population of workers with potentially severe

disabilities served by the demonstration project; and

"(2) each population of such workers with a specific physical

or mental impairment described in subsection (b)(1)(B) served by

such project.

"(e) Recommendation. - Not later than October 1, 2004, the

Secretary shall submit a recommendation to the Committee on

Commerce [now Committee on Energy and Commerce] of the House of

Representatives and the Committee on Finance of the Senate

regarding whether the demonstration project established under this

section should be continued after fiscal year 2006.

"(f) State Defined. - In this section, the term 'State' has the

meaning given such term for purposes of title XIX of the Social

Security Act (42 U.S.C. 1396 et seq.)."

MEDICAL ASSISTANCE PAYMENTS FOR ELIGIBLE PACE PROGRAM ENROLLEES

Pub. L. 105-277, div. A, Sec. 101(f) [title VII, Sec. 710], Oct.

21, 1998, 112 Stat. 2681-337, 2681-391, provided that: "For

purposes of payments to States for medical assistance under title

XIX of the Social Security Act [this subchapter] from amounts

appropriated to carry out such title for fiscal year 1999 and for

any subsequent fiscal year, individuals who are PACE program

eligible individuals under section 1934 of that Act [section

1396u-4 of this title] and who meet the income and resource

eligibility requirements of individuals who are eligible for

medical assistance under section 1902(a)(10)(A)(ii)(VI) of that Act

[subsec. (a)(10)(A)(ii)(VI) of this section] shall be treated as

individuals described in such section 1902(a)(10)(A)(ii)(VI) during

the period of their enrollment in the PACE program."

STUDY AND REPORT BY SECRETARY OF HEALTH AND HUMAN SERVICES

Section 4711(b) of Pub. L. 105-33 provided that:

"(1) Study. - The Secretary of Health and Human Services shall

study the effect on access to, and the quality of, services

provided to beneficiaries of the rate-setting methods used by

States pursuant to section 1902(a)(13)(A) of the Social Security

Act (42 U.S.C. 1396a(a)(13)(A)), as amended by subsection (a).

"(2) Report. - Not later than 4 years after the date of the

enactment of this Act [Aug. 5, 1997], the Secretary of Health and

Human Services shall submit a report to the appropriate committees

of Congress on the conclusions of the study conducted under

paragraph (1), together with any recommendations for legislation as

a result of such conclusions."

DUAL ELIGIBLES; MONITORING PAYMENTS

Section 4724(e) of Pub. L. 105-33 provided that: "The

Administrator of the Health Care Financing Administration shall

develop mechanisms to improve the monitoring of, and to prevent,

inappropriate payments under the medicaid program under title XIX

of the Social Security Act (42 U.S.C. 1396 et seq.) in the case of

individuals who are dually eligible for benefits under such program

and under the medicare program under title XVIII of such Act (42

U.S.C. 1395 et seq.)."

EXTENSION OF EFFECTIVE DATE FOR STATE LAW AMENDMENT

Section 4759 of title IV of Pub. L. 105-33 provided that: "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 a

provision of this subtitle [subtitle H (Secs. 4701-4759) of title

IV of Pub. L. 105-33, enacting sections 1396u-2 and 1396u-3 of this

title, amending this section and sections 1308, 1315, 1320a-3,

1320a-7b, 1395i-3, 1395w-4, 1395cc, 1396b, 1396d, 1396e, 1396n,

1396o, 1396r, 1396r-4, 1396r-6, 1396r-8, 1396u-2, and 1396v of this

title, and repealing section 1396r-7 of this title], 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 [Aug. 5, 1997]. For purposes of the previous sentence,

in the case of a State that has a 2-year legislative session, each

year of the session is considered to be a separate regular session

of the State legislature."

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.

DEMONSTRATION PROJECTS TO STUDY EFFECT OF ALLOWING STATES TO EXTEND

MEDICAID COVERAGE TO CERTAIN LOW-INCOME FAMILIES NOT OTHERWISE

QUALIFIED TO RECEIVE MEDICAID BENEFITS

Section 4745 of Pub. L. 101-508, as amended by Pub. L. 103-66,

title XIII, Sec. 13643(a), Aug. 10, 1993, 107 Stat. 647, provided

that:

"(a) Demonstration Projects. -

"(1) In general. - (A) The Secretary of Health and Human

Services (hereafter in this section referred to as the

'Secretary') shall enter into agreements with 3 and no more than

4 States submitting applications under this section for the

purpose of conducting demonstration projects to study the effect

on access to, and costs of, health care of eliminating the

categorical eligibility requirement for medicaid benefits for

certain low-income individuals.

"(B) In entering into agreements with States under this section

the Secretary shall provide that at least 1 and no more than 2 of

the projects are conducted on a substate basis.

"(2) Requirements. - (A) The Secretary may not enter into an

agreement with a State to conduct a project unless the Secretary

determines that -

"(i) the project can reasonably be expected to improve access

to health insurance coverage for the uninsured;

"(ii) with respect to projects for which the statewideness

requirement has not been waived, the State provides, under its

plan under title XIX of the Social Security Act [this

subchapter], for eligibility for medical assistance for all

individuals described in subparagraphs (A), (B), (C), and (D)

of paragraph (1) of section 1902(l) of such Act [subsec.

(l)(1)(A), (B), (C), (D) of this section] (based on the State's

election of certain eligibility options the highest income

standards and, based on the State's waiver of the application

of any resource standard);

"(iii) eligibility for benefits under the project is limited

to individuals in families with income below 150 percent of the

income official poverty line and who are not individuals

receiving benefits under title XIX of the Social Security Act;

"(iv) if the Secretary determines that it is cost-effective

for the project to utilize employer coverage (as described in

section 1925(b)(4)(D) of the Social Security Act [section

1396r-6(b)(4)(D) of this title]), the project must require an

employer contribution and benefits under the State plan under

title XIX of such Act will continue to be made available to the

extent they are not available under the employer coverage;

"(v) the project provides for coverage of benefits consistent

with subsection (b); and

"(vi) the project only imposes premiums, coinsurance, and

other cost-sharing consistent with subsection (c).

"(B) The Secretary may waive the requirements of clause (ii) of

this paragraph [probably means subparagraph (A)] with respect to

those projects described in subparagraph (B) of paragraph (1).

"(3) Permissible restrictions. - A project may limit

eligibility to individuals whose assets are valued below a level

specified by the State. For this purpose, any evaluation of such

assets shall be made in a manner consistent with the standards

for valuation of assets under the State plan under title XIX of

the Social Security Act for individuals entitled to assistance

under part A of title IV of such Act [part A of subchapter IV of

this chapter]. Nothing in this section shall be construed as

requiring a State to provide for eligibility for individuals for

months before the month in which such eligibility is first

established.

"(4) Extension of eligibility. - A project may provide for

extension of eligibility for medical assistance for individuals

covered under the project in a manner similar to that provided

under section 1925 of the Social Security Act to certain families

receiving aid pursuant to a plan of the State approved under part

A of title IV of such Act.

"(5) Waiver of requirements. -

"(A) In general. - Subject to subparagraph (B), the Secretary

may waive such requirements of title XIX of the Social Security

Act (except section 1903(m) of the Social Security Act [section

1396b(m) of this title]) as may be required to provide for

additional coverage of individuals under projects under this

section.

"(B) Nonwaivable provisions. - Except with respect to those

projects described in subparagraph (B) of paragraph (1), the

Secretary may not waive, under subparagraph (A), the

statewideness requirement of section 1902(a)(1) of the Social

Security Act [subsec. (a)(1) of this section] or the Federal

medical assistance percentage specified in section 1905(b) of

such Act [section 1396d(b) of this title].

"(b) Benefits. -

"(1) In general. - Except as provided in this subsection, the

amount, duration, and scope of medical assistance made available

under a project shall be the same as the amount, duration, and

scope of such assistance made available to individuals entitled

to medical assistance under the State plan under section

1902(a)(10)(A)(i) of the Social Security Act [subsec.

(a)(10)(A)(i) of this section].

"(2) Limits on benefits. -

"(A) Required. - Except with respect to those projects

described in subparagraph (B) of paragraph (1), no medical

assistance shall be made available under a project for nursing

facility services or community-based long-term care services

(as defined by the Secretary) or for pregnancy-related

services. No medical assistance shall be made available under a

project to individuals confined to a State correctional

facility, county jail, local or county detention center, or

other State institution.

"(B) Permissible. - A State, with the approval of the

Secretary, may limit or otherwise deny eligibility for medical

assistance under the project and may limit coverage of items

and services under the project, other than early and periodic

screening, diagnostic, and treatment services for children

under 18 years of age.

"(3) Use of utilization controls. - Nothing in this subsection

shall be construed as limiting a State's authority to impose

controls over utilization of services, including preadmission

requirements, managed care provisions, use of preferred

providers, and use of second opinions before surgical procedures.

"(c) Premiums and Cost-Sharing. -

"(1) None for those with income below the poverty line. - Under

a project, there shall be no premiums, coinsurance, or other

cost-sharing for individuals whose family income level does not

exceed 100 percent of the income official poverty line (as

defined in subsection (g)(1)) applicable to a family of the size

involved.

"(2) Limit for those with income above the poverty line. -

Under a project, for individuals whose family income level

exceeds 100 percent, but is less than 150 percent, of the income

official poverty line applicable to a family of the size

involved, the monthly average amount of premiums, coinsurance,

and other cost-sharing for covered items and services shall not

exceed 3 percent of the family's average gross monthly earnings.

"(3) Income determination. - Each project shall provide for

determinations of income in a manner consistent with the

methodology used for determinations of income under title XIX of

the Social Security Act [this subchapter] for individuals

entitled to benefits under part A of title IV of such Act [part A

of subchapter IV of this chapter].

"(d) Duration. - Each project under this section shall commence

not later than July 1, 1991 and shall be conducted for a 3-year

period; except that the Secretary may terminate such a project if

the Secretary determines that the project is not in substantial

compliance with the requirements of this section.

"(e) Limits on Expenditures and Funding. -

"(1) In general. - (A) The Secretary in conducting projects

shall limit the total amount of the Federal share of benefits

paid and expenses incurred under title XIX of the Social Security

Act [this subchapter] to no more than $40,000,000.

"(B) Of the amounts appropriated under subparagraph (A), the

Secretary shall provide that no more than one-third of such

amounts shall be used to carry out the projects described in

paragraph (1)(B) of subsection (a) (for which the statewideness

requirement has been waived).

"(2) No funding of current beneficiaries. - No funding shall be

available under a project with respect to medical assistance

provided to individuals who are otherwise eligible for medical

assistance under the plan without regard to the project.

"(3) No increase in federal medical assistance percentage. -

Payments to a State under a project with respect to expenditures

made for medical assistance made available under the project may

not exceed the Federal medical assistance percentage (as defined

in section 1905(b) of the Social Security Act [section 1396d(b)

of this title]) of such expenditures.

"(f) Evaluation and Report. -

"(1) Evaluations. - For each project the Secretary shall

provide for an evaluation to determine the effect of the project

with respect to -

"(A) access to, and costs of, health care,

"(B) private health care insurance coverage, and

"(C) premiums and cost-sharing.

"(2) Reports. - The Secretary shall prepare and submit to

Congress an interim report on the status of the projects not

later than January 1, 1993, and a final report containing such

summary together with such further recommendations as the

Secretary may determine appropriate not later than one year after

the termination of the projects.

"(g) Definitions. - In this section:

"(1) The term 'income official poverty line' means such line as

defined by the Office of Management and Budget and revised

annually in accordance with section 673(2) of the Omnibus Budget

Reconciliation Act of 1981 [section 9902(2) of this title].

"(2) The term 'project' refers to a demonstration project under

subsection (a)."

[Section 13643(a) of Pub. L. 103-66 provided in part that the

amendment made by that section to section 4745 of Pub. L. 101-508,

set out above, is effective as if included in enactment of Pub. L.

101-508.]

DEMONSTRATION PROJECT TO PROVIDE MEDICAID COVERAGE FOR HIV-POSITIVE

INDIVIDUALS

Section 4747 of Pub. L. 101-508 provided that:

"(a) In General. - Not later than 3 months after the date of the

enactment of this Act [Nov. 5, 1990], the Secretary of Health and

Human Services (hereafter in this section referred to as the

'Secretary') shall provide for 2 demonstration projects to be

administered by States that submit an application under this

section, through programs administered by the States under title

XIX of the Social Security Act [this subchapter]. Such

demonstration projects shall provide coverage for the services

described in subsection (c) to individuals whose income and

resources do not exceed the maximum allowable amount for

eligibility for any individual in any category of disability under

the State plan under section 1902 of the Social Security Act [this

section], and who have tested positive for the presence of HIV

virus (without regard to the presence of any symptoms of AIDS or

opportunistic diseases related to AIDS).

"(b) Services Available Under a Demonstration Project. - (1) The

medical assistance made available to individuals described in

section 1902(a)(10)(A) of the Social Security Act [subsec.

(a)(10)(A) of this section] shall be made available to individuals

described in subsection (a) who receive services under a

demonstration project under such paragraph.

"(2) A demonstration project under subsection (a) shall provide

services in addition to the services described in paragraph (1)

which shall be limited only on the basis of medical necessity or

the appropriateness of such services. To the extent not provided as

described in paragraph (1), such additional services shall include

-

"(A) general and preventative medical care services (including

inpatient, outpatient, residential care, physician visits, clinic

visits, and hospice care);

"(B) prescription drugs, including drugs for the purposes of

preventative health care services;

"(C) counseling and social services;

"(D) substance abuse treatment services (including services for

multiple substances abusers);

"(E) home care services (including assistance in carrying out

activities of daily living);

"(F) case management;

"(G) health education services;

"(H) respite care for caregivers;

"(I) dental services; and

"(J) diagnostic and laboratory services[.]

"(c) Agreements With States. - (1) Each State conducting a

demonstration project under subsection (a) shall enter into an

agreement with a hospital and at least one other nonprofit

organization submitting applications to the State. The State shall

require that such hospital and other entity have a demonstrated

record of case management of patients who have tested positive for

the presence of HIV virus and have access to a control group of

such type of patients who are not receiving State or Federal

payments for medical services (or other payments from private

insurance coverage) before developing symptoms of AIDS. Under such

agreement, the State shall agree to pay each such entity for the

services provided under subsection (b) and not later than 12 months

after the commencement of a demonstration project, institute a

system of monthly payment to each such entity based on the average

per capita cost of the services described in subsection (c)

provided to individuals described in paragraphs (1) and (2) of

subsection (a).

"(2) A demonstration project described in subsection (a) shall be

limited to an enrollment of not more than 200 individuals.

"(3) A demonstration project conducted under subsection (a) shall

commence not later than 9 months after the date of the enactment of

this Act [Nov. 5, 1990] and shall terminate on the date that is 3

years after the date of commencement.

"(4)(A) The Secretary shall provide for an evaluation of the

comparative costs of providing services to individuals who have

tested positive for the presence of HIV virus at an early stage

after detection of such virus and those that are treated at a later

stage after such detection.

"(B) The Secretary shall report to Congress on the results of the

evaluation conducted under subparagraph (A) no later than 6 months

after the date of termination of the demonstration projects

described in this section.

"(d) Federal Share of Costs. - The Federal share of the cost of

services described in paragraph (3) furnished under a demonstration

project conducted under paragraph (1) shall be determined by the

otherwise applicable Federal matching assistance percentage

pursuant to section 1905(b) of the Social Security Act [section

1396d(b) of this title].

"(e) Waiver of Requirements of the Social Security Act. - The

Secretary may waive such requirements of the Social Security Act

[this chapter] as the Secretary determines to be necessary to carry

out the purposes of this section.

"(f) Limitation on Amount of Expenditures. - The amount of funds

that may be expended as medical assistance to carry out the

purposes of this section shall be $5,000,000 for fiscal year 1991,

$12,000,000 for fiscal year 1992, and $13,000,000 for fiscal year

1993."

PUBLIC EDUCATION CAMPAIGN

Section 4751(d) of Pub. L. 101-508 provided that:

"(1) In general. - The Secretary, no later than 6 months after

the date of enactment of this section [Nov. 5, 1990], shall develop

and implement a national campaign to inform the public of the

option to execute advance directives and of a patient's right to

participate and direct health care decisions.

"(2) Development and distribution of information. - The Secretary

shall develop or approve nationwide informational materials that

would be distributed by providers under the requirements of this

section [amending this section and sections 1396b and 1396r of this

title and enacting provisions set out above], to inform the public

and the medical and legal profession of each person's right to make

decisions concerning medical care, including the right to accept or

refuse medical or surgical treatment, and the existence of advance

directives.

"(3) Providing assistance to states. - The Secretary shall assist

appropriate State agencies, associations, or other private entities

in developing the State-specific documents that would be

distributed by providers under the requirements of this section.

The Secretary shall further assist appropriate State agencies,

associations, or other private entities in ensuring that providers

are provided a copy of the documents that are to be distributed

under the requirements of the section.

"(4) Duties of secretary. - The Secretary shall mail information

to Social Security recipients, [and] add a page to the medicare

handbook with respect to the provisions of this section."

PHYSICIAN IDENTIFIER SYSTEM; DEADLINE AND CONSIDERATIONS

Section 4752(a)(1)(B) of Pub. L. 101-508 provided that: "The

system established under the amendment made by subparagraph (A)

[amending this section] may be the same as, or different from, the

system established under section 9202(g) of the Consolidated

Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99-272, formerly

set out in a note under section 1395ww of this title]."

FOREIGN MEDICAL GRADUATE CERTIFICATION

Section 4752(d) of Pub. L. 101-508 provided that:

"(1) Passage of fmgems examination in order to obtain identifier.

- The Secretary of Health and Human Service[s] shall provide, in

the identifier system established under section 1902(x) of the

Social Security Act [subsec. (x) of this section], that no foreign

medical graduate (as defined in section 1886(h)(5)(D) of such Act

[section 1395ww(h)(5)(D) of this title]) shall be issued an

identifier under such system unless the individual -

"(A) has passed the FMGEMS examination (as defined in section

1886(h)(5)(E) of such Act);

"(B) has previously received certification from, or has

previously passed the examination of, the Educational Commission

for Foreign Medical Graduates; or

"(C) has held a license from 1 or more States continuously

since 1958.

"(2) Effective date. - Paragraph (1) shall apply with respect to

issuance of an identifier applicable to services furnished on or

after January 1, 1992."

EXCLUSIONS IN DETERMINATION OF INCOME AND RESOURCES UNDER THIS

SUBCHAPTER

Section 11115(c) of Pub. L. 101-508 provided that: "Pursuant to

section 1902(a)(17) of the Social Security Act (42 U.S.C.

1396a(a)(17)), the Secretary of Health and Human Services shall

promulgate regulations to exempt from any determination of income

and resources (for the month of receipt and the following month)

under title XIX of the Social Security Act [this subchapter] any

refund of Federal income taxes made to an individual by reason of

section 32 of the Internal Revenue Code of 1986 [26 U.S.C. 32]

(relating to earned income tax credit), and any payment made to an

individual by an employer under section 3507 of such Code [26

U.S.C. 3507] (relating to advance payment of earned income

credit)."

DEVELOPMENT OF MODEL APPLICATIONS FOR MEDICAID PROGRAM

Section 6506(b) of Pub. L. 101-239 provided that:

"(1) In general. - The Secretary of Health and Human Services

shall, by not later than 1 year after the date of the enactment of

this Act [Dec. 19, 1989], develop a model application form for use

in applying for benefits under title XIX of the Social Security Act

[this subchapter] for individuals who are not receiving cash

assistance under part A of title IV of the Social Security Act

[part A of subchapter IV of this chapter], and who are not

institutionalized. In developing such model application form, the

Secretary is not authorized to require that such form be adopted by

States as part of their State medicaid plan.

"(2) Dissemination of model form. - The Secretary shall provide

for publication in the Federal Register of the model application

form developed under paragraph (1), and shall send a copy of such

form to each State agency responsible for administering a State

medicaid plan."

CLARIFICATION OF FEDERAL FINANCIAL PARTICIPATION FOR

CASE-MANAGEMENT SERVICES

Section 8435 of Pub. L. 100-647 provided that: "The Secretary of

Health and Human Services may not fail or refuse to approve an

amendment to a State plan under title XIX of the Social Security

Act [this subchapter] that provides for coverage of case-management

services described in section 1915(g)(2) of such Act [section

1396n(g)(2) of this title], or to deny payment to a State for such

services under section 1903(a)(1) of such Act [section 1396b(a)(1)

of this title] on the basis that a State is required to provide

such services under State law or on the basis that the State had

paid or is paying for such services from non-Federal funds before

or after April 7, 1986. Nothing in this section shall be construed

as requiring the Secretary to make payment to a State under section

1903(a)(1) of such Act for such case-management services which are

provided without charge to the users of such services."

TREATMENT OF STATES OPERATING UNDER DEMONSTRATION PROJECTS

Section 301(g)(1) of Pub. L. 100-360 provided that: "In the case

of any State which is providing medical assistance to its residents

under a waiver granted under section 1115(a) of the Social Security

Act [section 1315(a) of this title], the Secretary of Health and

Human Services shall require the State to meet the requirement of

section 1902(a)(10)(E) of the Social Security Act [subsec.

(a)(10)(E) 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 title XIX of such Act [this subchapter]."

ADJUSTMENT IN MEDICAID PAYMENT FOR INPATIENT HOSPITAL SERVICES

FURNISHED BY DISPROPORTIONATE SHARE HOSPITALS

Pub. L. 100-203, title IV, Sec. 4112, Dec. 22, 1987, 101 Stat.

1330-148, which related to adjustment in medicaid payment for

inpatient hospital services furnished by disproportionate share

hospitals was amended by Pub. L. 100-360, title IV, Sec.

411(k)(6)(A)-(B)(i), July 1, 1988, 102 Stat. 792, 793, and so

amended, Sec. 4112 enacts the provisions of former section 4112 as

section 1396r-4 of this title and amends sections 1396b and 1396s

of this title.

AMENDMENT TO STATE PLAN TO PROVIDE ADJUSTMENT FOR SERVICES

FURNISHED DURING FISCAL YEAR 1990

Section 4211(b)(2) of Pub. L. 100-203, as amended by Pub. L.

101-508, title IV, Sec. 4801(e)(1)(B), Nov. 5, 1990, 104 Stat.

1388-215, provided that: "A plan of a State under title XIX of the

Social Security Act [this subchapter] shall not be considered to

have met the requirement of section 1902(a)(13)(A) of the Social

Security Act [subsec. (a)(13)(A) of this section] (as amended by

paragraph (1)(A) of this subsection), as of the first day of a

Federal fiscal year (beginning on or after October 1, 1990), unless

the State has submitted to the Secretary of Health and Human

Services, as of April 1 before the fiscal year, an amendment to

such State plan to provide for an appropriate adjustment in payment

amounts for nursing facility services furnished during the Federal

fiscal year. Each such amendment shall include a detailed

description of the specific methodology to be used in determining

the appropriate adjustment in payment amounts for nursing facility

services. The Secretary shall, not later than September 30 before

the fiscal year concerned, review each such plan 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. The absence of approval of

such a plan amendment does not relieve the State or any nursing

facility of any obligation or requirement under title XIX of the

Social Security Act (as amended by this Act)."

TECHNICAL ASSISTANCE WITH RESPECT TO FACILITIES THAT TAKE INTO

ACCOUNT CASE MIX OF RESIDENTS

Section 4211(j) of Pub. L. 100-203 provided that: "The Secretary

of Health and Human Services shall, upon request by a State,

furnish technical assistance with respect to the development and

implementation of reimbursement methods for nursing facilities that

take into account the case mix of residents in the different

facilities."

STATE UTILIZATION REVIEW SYSTEMS

Section 9432 of Pub. L. 99-509, as amended by Pub. L. 100-203,

title IV, Sec. 4118(p)(11), as added by Pub. L. 100-360, title IV,

Sec. 411(k)(10)(M), July 1, 1988, 102 Stat. 797; Pub. L. 101-508,

title IV, Sec. 4755(b), Nov. 5, 1990, 104 Stat. 1388-210, provided

that:

"(a) In General. - (1) The Secretary of Health and Human Services

(in this section referred to as the 'Secretary') may not publish

final or interim final regulations requiring a State plan approved

under title XIX of the Social Security Act [this subchapter] to

include a program requiring second surgical opinions or a program

of inpatient hospital preadmission review.

"(2) The Secretary may not, during the period beginning on the

date of the enactment of the Omnibus Budget Reconciliation Act of

1990 [Nov. 5, 1990] and ending on the date that is 180 days after

the date on which the report required by subsection (d) is

submitted to the Congress, publish final or interim final

regulations requiring a State plan approved under title XIX of the

Social Security Act [this subchapter] to include a program for

ambulatory surgery, preadmission testing, or same-day surgery.

"(b) Report. -

"(1) The Secretary shall report to Congress, by not later than

October 1, 1988, for each State in a representative sample of

States -

"(A) the identity of those procedures which are high volume

or high cost procedures among patients who are covered under

the State medicaid plan,

"(B) the payment rates under those plans for such procedures,

and the aggregate annual payment amounts made under such plans

for such procedures (including the Federal share of such

payment amounts),

"(C) the rate at which each such procedure is performed on

medicaid patients and (to the extent that data are available)

comparisons to the rate at which such procedure is performed on

patients of comparable age who are not medicaid patients,

"(D) with respect to each such procedure -

"(i) the number of board certified or board eligible

physicians in the State who provide care and services to

medicaid patients and who perform the procedure, and

"(ii) in the case of a State with a mandatory second

surgical opinion program in operation, the number of

physicians described in clause (i) who provide second

opinions (of the type described in section 1164 of the Social

Security Act [section 1320c-13 of this title]) for the

procedure at prevailing payment rates under the State

medicaid plan, and

"(E) in the case of a State with a mandatory second surgical

opinion program or a program of inpatient hospital preadmission

review in operation, a description of -

"(i) the extent to which such program impedes access to

necessary care and services, and

"(ii) the measures that the State has taken to address such

impediments, particularly in rural areas.

"(2) Such report shall also include a list of those surgical

procedures which the Secretary believes meet the following

criteria and for which a mandatory second opinion program under

medicaid plans may be appropriate:

"(A) The procedure is one which generally can be postponed

without undue risk to the patient.

"(B) The procedure is a high volume procedure among patients

who are covered under State medicaid plans or is a high cost

procedure.

"(C) The procedure has a comparatively high rate of

nonconfirmation upon examination by another qualified

physician, there is substantial geographic variation in the

rates of performance of the procedure, or there are other

reasons why requiring second opinions for 100 percent of such

procedures would be cost effective.

"(3) The representative sample of States required to be

included in the report shall include States with mandatory second

surgical opinion programs in operation, States with programs of

inpatient hospital preadmission review in operation, and States

with neither such program in operation.

"(4) In this subsection and subsection (d), the term 'medicaid

plan' means a State plan approved under title XIX of the Social

Security Act [this subchapter].

"(c) Study. -

"(1) The Secretary shall conduct a study of the utilization of

selected medical treatments and surgical procedures by medicaid

beneficiaries in order to assess the appropriateness, necessity,

and effectiveness of such treatments and procedures.

"(2) The study shall analyze the extent to which there is

significant variation in the rate of utilization by medicaid

beneficiaries of selected treatments and procedures for different

geographic areas within States and among States.

"(3) The study shall also identify underutilized, medically

necessary treatments and procedures for which -

"(A) a failure to furnish could have an adverse effect on

health status, and

"(B) the rate of utilization by medicaid beneficiaries is

significantly less than the rate for comparable, age-adjusted

populations.

"(4) The study shall be coordinated, to the extent practicable,

with the research program established pursuant to section 1875(c)

of the Social Security Act [section 1395ll(c) of this title],

with particular regard to the relationship of the variations

described in paragraph (2) to patient outcomes.

"(5) The Secretary shall submit an interim report on the

results of the study, including an analysis of the geographic

variations under paragraph (2), to the Congress not later than

January 1, 1990, and shall report the final results of the study

to the Congress not later than January 1, 1992.

"(d) Report. - The Secretary shall report to Congress, by not

later than January 1, 1993, for each State in a representative

sample of States -

"(1) an analysis of the procedures for which programs for

ambulatory surgery, preadmission testing, and same-day surgery

are appropriate for patients who are covered under the State

medicaid plan, and

"(2) the effects of such programs on access of such patients to

necessary care, quality of care, and costs of care.

In selecting such a sample of States, the Secretary shall include

some States with medicaid plans that include such programs."

PROMULGATION OF REGULATIONS

Section 9503(c) of Pub. L. 99-272 provided that: "The Secretary

of Health and Human Services shall promulgate final regulations

necessary to carry out sections 1902(a)(25) and 1903(r)(6)(J) of

the Social Security Act [subsec. (a)(25) of this section and

section 1396b(r)(6)(J) of this title] within 6 months after the

date of the enactment of this Act [Apr. 7, 1986]."

STUDY BY COMPTROLLER GENERAL OF EFFECT OF AMENDMENT TO SUBSECTION

(A)(13)

Section 9509(c) of Pub. L. 99-272 directed Comptroller General to

conduct a study of effects of the amendments made by this section

and report results of such study to Congress two years after Apr.

7, 1986.

TASK FORCE ON TECHNOLOGY-DEPENDENT CHILDREN

Section 9520 of Pub. L. 99-272 directed Secretary of Health and

Human Services, within six months after Apr. 7, 1986, to establish

a task force concerning alternatives to institutional care for

technology-dependent children, such task force to (1) include

representatives of Federal and State agencies with responsibilities

relating to child health, health insurers, large employers

(including those that self-insure for health care costs), providers

of health care to technology-dependent children, and parents of

technology-dependent children, (2) identify barriers that prevent

the provision of appropriate care in a home or community setting to

meet special needs of technology-dependent children, (3) recommend

changes in the provision and financing of health care in private

and public health care programs (including appropriate joint

public-private initiatives) so as to provide home and

community-based alternatives to the institutionalization of

technology-dependent children, and (4) make a final report to

Secretary and to Congress on its activities not later than two

years after Apr. 7, 1986.

MEDICAID COVERAGE RELATING TO ADOPTION ASSISTANCE AGREEMENTS

ENTERED INTO BEFORE APRIL 7, 1986

Section 9529(b)(2) of Pub. L. 99-272 provided that: "In the case

of an adoption assistance agreement (other than an agreement under

part E of title IV of the Social Security Act [part E of subchapter

IV of this chapter]) entered into before the date of the enactment

of this Act [Apr. 7, 1986] -

"(A) the requirements of subdivisions (aa) and (bb) of section

1902(a)(10)(A)(ii)(VIII) of the Social Security Act [subsec.

(a)(10)(A)(ii)(VIII)(aa), (bb) of this section] shall be deemed

to be met if the State agency responsible for adoption assistance

agreements determines that -

"(i) at the time of adoptive placement the child had special

needs for medical or rehabilitative care that made the child

difficult to place; and

"(ii) there is in effect with respect to such child an

adoption assistance agreement between the State and an adoptive

parent or parents; and

"(B) the requirement of subdivision (cc) of such section shall

be deemed to be met if the child was found by the State to be

eligible for medical assistance prior to such agreement being

entered into."

PAYMENT FOR PSYCHIATRIC HOSPITAL SERVICES

Section 2366 of Pub. L. 98-369 provided that: "The provisions of

section 1902(a)(13) of the Social Security Act [subsec. (a)(13) of

this section], in so far as they require a reduction of the amount

of payment otherwise to be made to a public psychiatric hospital

due to the level of care received in such hospital, shall not apply

to payments to hospitals before July 1, 1985, and such a reduction

made for payments during the 12-month period ending June 30, 1986,

and during the 12-month period ending June 30, 1987, shall be

one-third and two-thirds, respectively, of the amount of the

reduction which would have been made without regard to this

section."

MORATORIUM ON REGULATORY ACTIONS BY SECRETARY

Section 2373(c) of Pub. L. 98-369, as amended by Pub. L. 100-93,

Sec. 9, Aug. 18, 1987, 101 Stat. 695, provided that:

"(1) The Secretary of Health and Human Services shall not take

any compliance, disallowance, penalty, or other regulatory action

against a State with respect to the moratorium period described in

paragraph (2) by reason of such State's plan described in paragraph

(5) under title XIX of the Social Security Act [this subchapter]

(including any part of the plan operating pursuant to section

1902(f) of such Act [subsec. (f) of this section]), or the

operation thereunder, being determined to be in violation of clause

(IV), (V), or (VI) of section 1902(a)(10)(A)(ii) or section

1902(a)(10)(C)(i)(III) of such Act on account of such plan's (or

its operation) having a standard or methodology which the Secretary

interprets as being less restrictive than the standard or

methodology required under such section, provided that such plan

(or its operation) does not make ineligible any individual who

would be eligible but for the provisions of this subsection.

"(2) The moratorium period is the period beginning on October 1,

1981, and ending 18 months after the date on which the Secretary

submits the report required under paragraph (3).

"(3) The Secretary shall report to the Congress within 12 months

after the date of the enactment of this Act [July 18, 1984] with

respect to the appropriateness, and impact on States and recipients

of medical assistance, of applying standards and methodologies

utilized in cash assistance programs to those recipients of medical

assistance who do not receive cash assistance, and any

recommendations for changes in such requirements.

"(4) No provision of law shall repeal or suspend the moratorium

imposed by this subsection unless such provision specifically

amends or repeals this subsection.

"(5) In this subsection, a State plan is considered to include -

"(A) any amendment or other change in the plan which is

submitted by a State, or

"(B) any policy or guideline delineated in the Medicaid

operation or program manuals of the State which are submitted by

the State to the Secretary,

whether before or after the date of enactment of this Act [July 18,

1984] and whether or not the amendment or change, or the operating

or program manual was approved, disapproved, acted upon, or not

acted upon by the Secretary.

"(6) During the moratorium period, the Secretary shall implement

(and shall not change by any administrative action) the policy in

effect at the beginning of such moratorium period with respect to -

"(A) the point in time at which an institutionalized individual

must sell his home (in order that it not be counted as a

resource); and

"(B) the time period allowed for sale of a home of any such

individual,

who is an applicant for or recipient of medical assistance under

the State plan as a medically needy individual (described in

section 1902(a)(10)(C) of the Social Security Act [subsec.

(a)(10)(C) of this section]) or as an optional categorically needy

individual (described in section 1902(a)(10)(A)(ii) of such Act)."

[Amendment of section 2373(c) of Pub. L. 98-369, set out above,

by section 9 of Pub. L. 100-93 applicable as though originally

included in Pub. L. 98-369, Sec. 2373(c), see section 15(e) of Pub.

L. 100-93, set out as an Effective Date of 1987 Amendment note

under section 1320a-7 of this title.]

EVALUATION AND STUDY OF REASONS FOR TERMINATION BY MEDICAID

BENEFICIARIES OF MEMBERSHIP IN HEALTH MAINTENANCE ORGANIZATIONS

Section 2178(d) of Pub. L. 97-35 directed Secretary of Health and

Human Services to conduct a study evaluating extent of, and reasons

for, termination by medicaid beneficiaries of their memberships in

health maintenance organizations, placing special emphasis on

quantity and quality of medical care provided in health maintenance

organizations and quality of such care when provided on a

fee-for-service basis, with Secretary to submit an interim report

to Congress, within two years after Aug. 13, 1981, and a final

report within five years from such date containing, respectively,

the interim and final findings and conclusions made as a result of

such study.

CONTINUING MEDICAID ELIGIBILITY FOR CERTAIN RECIPIENTS OF VETERANS'

ADMINISTRATION PENSIONS

Section 310(b)(1) of Pub. L. 96-272 provided that:

"(A) For purposes of section 1902(a)(10)(A) of the Social

Security Act [subsec. (a)(10)(A) of this section], any individual

who, prior to the date of enactment of this Act [June 17, 1980] and

for the month of December 1978, was eligible for and received aid

or assistance under a State plan approved under title I, X, XIV, or

XVI, or part A of title IV of such Act [subchapter I, X, XIV, or

XVI, or part A of subchapter IV of this chapter], or was eligible

for and received supplemental security income benefits under title

XVI of such Act [subchapter XVI of this chapter] (or a

supplementary payment described in section 13(c) of Public Law

93-233) [set out as a note under this section], and was also in

receipt of (or was a dependent, for purposes of chapter 15 of title

38, United States Code, as in effect on December 31, 1978, of an

individual in receipt of) pension from the Veterans' Administration

for the month of December 1978 shall (subject to subparagraph (B))

be deemed to have been receiving such aid, assistance, supplemental

security income, or supplementary payment, for each calendar month

thereafter (prior to the month in which the provisions of this

subparagraph cease to be effective with respect to him as

determined under subparagraph (B)), if such individual would have

been eligible therefor in December 1978 and in the month in which

the provisions of this subparagraph cease to be effective with

respect to him as determined under subparagraph (B) had the

increase in income of such individual (or of the family of which

such individual is a member), attributable to an election (made by

such individual or another member of such individual's family)

under section 306 of the Veterans' and Survivors' Pension

Improvement Act of 1978 [section 306 of Pub. L. 95-588, set out as

a note under section 521 of Title 38, Veterans' Benefits], not

occurred.

"(B)(i) The provisions of subparagraph (A) shall take effect on

January 1, 1979, and shall cease to be effective, in the case of

any individual, for and after the first calendar month beginning

more than 10 days after an 'informed election' (as defined in

subdivision (ii) of this subparagraph) has been made by such

individual (or, if such individual is not eligible to make such an

election, by a member of such individual's family who is eligible

to make such an election which affects such individual's

eligibility for aid, assistance, or benefits under a plan or

program referred to in subparagraph (A)).

"(ii) The term 'informed election' means an election made under

section 306 of the Veterans' and Survivors' Pension Improvement Act

of 1978 [section 306 of Pub. L. 95-588, set out as a note under

section 521 of Title 38] (or a reaffirmation of such an election

which previously was made under such section 306) after the date of

compliance by the Administrator of Veterans' Affairs (hereinafter

in this section referred to as the 'Administrator') with the

provisions of paragraph (2)(A) with respect to the individual

concerned. An individual who fails, within the time limits

prescribed in paragraph (2)(B), to disaffirm an election previously

made by such individual under such section 306 shall be deemed, for

purposes of this section and such section 306, to have reaffirmed

such election."

PRESERVATION OF MEDICAID ELIGIBILITY FOR INDIVIDUALS WHO CEASE TO

BE ELIGIBLE FOR SUPPLEMENTAL SECURITY INCOME BENEFITS ON ACCOUNT OF

COST-OF-LIVING INCREASES IN SOCIAL SECURITY BENEFITS

Pub. L. 94-566, title V, Sec. 503, Oct. 20, 1976, 90 Stat. 2685,

provided that: "In addition to other requirements imposed by law as

a condition for the approval of any State plan under title XIX of

the Social Security Act [this subchapter], there is hereby imposed

the requirement (and each such State plan shall be deemed to

require) that medical assistance under such plan shall be provided

to any individual, for any month after June 1977 for which such

individual is entitled to a monthly insurance benefit under title

II of such Act [subchapter II of this chapter] but is not eligible

for benefits under title XVI of such Act [subchapter XVI of this

chapter], in like manner and subject to the same terms and

conditions as are applicable under such State plan in the case of

individuals who are eligible for and receiving benefits under such

title XVI [subchapter XVI of this chapter] for such month, if for

such month such individual would be (or could become) eligible for

benefits under such title XVI [subchapter XVI of this chapter]

except for amounts of income received by such individual and his

spouse (if any) which are attributable to increases in the level of

monthly insurance benefits payable under title II of such Act

[subchapter II of this chapter] which have occurred pursuant to

section 215(i) of such Act [section 415(i) of this title], in the

case of such individual, since the last month after April 1977 for

which such individual was both eligible for (and received) benefits

under such title XVI [subchapter XVI of this chapter] and was

entitled to a monthly insurance benefit under such title II

[subchapter II of this chapter], and, in the case of such

individual's spouse (if any), since the last such month for which

such spouse was both eligible for (and received) benefits under

such title XVI [subchapter XVI of this chapter] and was entitled to

a monthly insurance benefit under such title II [subchapter II of

this chapter]. Solely for purposes of this section, payments of the

type described in section 1616(a) of the Social Security Act

[section 1382e(a) of this title] or of the type described in

section 212(a) of Public Law 93-66 [set out as note under section

1382 of this title] shall be deemed to be benefits under title XVI

of the Social Security Act [subchapter XVI of this chapter]."

MEDICAID ELIGIBILITY FOR INDIVIDUALS RECEIVING MANDATORY STATE

SUPPLEMENTARY PAYMENTS; EFFECTIVE DATE

Section 13(c) of Pub. L. 93-233 provided that: "In addition to

other requirements imposed by law as conditions for the approval of

any State plan under title XIX of the Social Security Act [this

subchapter], there is hereby imposed (effective January 1, 1974)

the requirement (and each such State plan shall be deemed to

require) that medical assistance under such plan shall be provided

to any individual -

"(1) for any month for which there (A) is payable with respect

to such individual a supplementary payment pursuant to an

agreement entered into between the State and the Secretary of

Health, Education, and Welfare [now Health and Human Services]

under section 212(a) of Public Law 93-66 [set out as note under

section 1382 of this title], and (B) would be payable with

respect to such individual such a supplementary payment, if the

amount of the supplementary payments payable pursuant to such

agreement were established without regard to paragraph (3)(A)(ii)

of such section 212(a) [set out as note under section 1382 of

this title], and

"(2) in like manner, and subject to the same terms and

conditions, as medical assistance is provided under such plan to

individuals with respect to whom benefits are payable for such

month under the supplementary security income program established

by title XVI of the Social Security Act [subchapter XVI of this

chapter].

Federal matching under title XIX of the Social Security Act [this

subchapter] shall be available for the medical assistance furnished

to individuals who are eligible for such assistance under this

subsection."

COVERAGE OF ESSENTIAL PERSONS UNDER MEDICAID

Section 230 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat.

159, provided that: "In the case of any State plan (approved under

title XIX of the Social Security Act [this subchapter]) which for

December 1973 provided medical assistance to persons described in

section 1905(a)(vi) of such Act [section 1396d(a)(vi) of this

title], there is hereby imposed the requirement (and such State

plan shall be deemed to require) that medical assistance under such

plan be provided to each such person (who for December 1973 was

eligible for medical assistance under such plan) for each month

(after December 1973) that -

"(1) the individual (referred to in the last sentence of

section 1905(a) of such Act [section 1396d(a) of this title])

with whom such person is living continues to meet the criteria

(as in effect for December 1973) for aid or assistance under a

State plan (referred to in such sentence), and

"(2) such person continues to have the relationship with such

individual described in such sentence and meets the other

criteria (referred to in such sentence) with respect to a State

plan (so referred to) as such plan was in effect for December

1973.

Federal matching under title XIX of the Social Security Act [this

subchapter] shall be available for the medical assistance furnished

to individuals eligible for such assistance under this section."

PERSONS IN MEDICAL INSTITUTIONS

Section 231 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat.

159, as amended by Pub. L. 93-233, Sec. 13(b)(1), Dec. 31, 1973, 87

Stat. 964, provided that: "For purposes of section 1902(a)(10) of

the Social Security Act [subsec. (a)(10) of this section], any

individual who, for all (or any part of) the month of December 1973

-

"(1) was an inpatient in an institution qualified for

reimbursement under title XIX of the Social Security Act [this

subchapter], and

"(2)(A) received or would (except for his being an inpatient in

such institution) have been eligible to receive aid or assistance

under a State plan approved under title I, X, XIV, or XVI of such

Act [subchapter I, X, XIV, or XVI of this chapter], and

"(B), [sic] on the basis of his status as described in

subparagraph (A), was included as an individual eligible for

medical assistance under a State plan approved under title XIX of

such Act [this subchapter] (whether or not such individual

actually received aid or assistance under a State plan referred

to in subparagraph (A)),

shall be deemed to be receiving such aid or assistance for such

month and for each succeeding month in a continuous period of

months if, for each month in such period -

"(3) such individual continues to be (for all of such month) an

inpatient in such an institution and would (except for his being

an inpatient in such institution) continue to meet the conditions

of eligibility to receive aid or assistance under such plan (as

such plan was in effect for December 1973), and

"(4) such individual is determined (under the utilization

review and other professional audit procedures applicable to

State plans approved under title XIX of the Social Security Act

[this subchapter]) to be in need of care in such an institution.

Federal matching under title XIX of the Social Security Act [this

subchapter] shall be available for the medical assistance furnished

to individuals eligible for such assistance under this section."

BLIND AND DISABLED MEDICALLY INDIGENT PERSONS

Section 232 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat.

160, as amended by Pub. L. 93-233, Sec. 13(b)(2), Dec. 31, 1973, 87

Stat. 964, provided that: "For purposes of section 1902(a)(10) of

the Social Security Act [subsec. (a)(10) of this section], any

individual who, for the month of December 1973 was eligible

[subsec. (a)(10) of this section] for medical assistance by reason

of his having been determined to meet the criteria for blindness or

disability (established by a State plan approved under title I, X,

XIV, or XVI of such Act [subchapter I, X, XIV, or XVI of this

chapter]), shall be deemed for purposes of title XIX [this

subchapter] to be an individual who is blind or disabled within the

meaning of section 1614(a) of the Social Security Act [section

1382c(a) of this title] for each month in a continuous period of

months (beginning with the month of January 1974), if, for each

month in such period, such individual continues to meet the

criteria for blindness or disability so established by such a State

plan (as it was in effect for December 1973), and the other

conditions of eligibility contained in the plan of the State

approved under title XIX [this subchapter] (as it was in effect in

December 1973). Federal matching under title XIX of the Social

Security Act [this subchapter] shall be available for the medical

assistance furnished to individuals eligible for such assistance

under this section."

IMPACT OF 1972 SOCIAL SECURITY BENEFITS INCREASE UNDER PUB. L.

92-336 UPON ELIGIBILITY FOR ASSISTANCE UNDER THIS SUBCHAPTER

Section 249E of Pub. L. 92-603, as amended by section 233 of Pub.

L. 93-66, title II, July 9, 1973, 87 Stat. 160, provided that: "For

purposes of section 1902(a)(10) of the Social Security Act [subsec.

(a)(10) of this section] any individual who, for the month of

August 1972, was eligible for or receiving aid or assistance under

a State plan approved under title I, X, XIV, or XVI, or part A of

title IV of such Act [subchapter I, X, XIV, or XVI, or part A of

subchapter IV of this chapter] and who for such month was entitled

to monthly insurance benefits under title II of such Act

[subchapter II of this chapter] shall be deemed to be eligible for

such aid or assistance for any month thereafter prior to July 1975

if such individual would have been eligible for such aid or

assistance for such month had the increase in monthly insurance

benefits under title II of such Act [subchapter II of this chapter]

resulting from enactment of Pub. L. 92-336 [see Tables] not been

applicable to such individual."

NURSING HOMES ELIGIBLE FOR MATCHING FUNDS FOR HOME SERVICES WHEN

MEETING STATE LICENSURE REQUIREMENTS AFTER JUNE 30, 1968

Section 234(c) of Pub. L. 90-248 provided that: "Notwithstanding

any other provision of law, after June 30, 1968, no Federal funds

shall be paid to any State as Federal matching under title I, X,

XIV, XVI, or XIX of the Social Security Act [subchapter I, X, XIV,

XVI, or XIX of this chapter] for payments made to any nursing home

for or on account of any nursing home services provided by such

nursing home for any period during which such nursing home is

determined not to meet fully all requirements of the State for

licensure as a nursing home, except that the Secretary may

prescribe a reasonable period or periods of time during which a

nursing home which has formerly met such requirements will be

eligible for payments which include Federal participation if during

such period or periods such home promptly takes all necessary steps

to again meet such requirements."

DISTRICT OF COLUMBIA; PLAN FOR MEDICAL ASSISTANCE

Pub. L. 90-227, Sec. 1, Dec. 27, 1967, 81 Stat. 744, provided:

"That (a) the Commissioner of the District of Columbia [now Mayor]

(hereafter in this Act [enacting this note and provisions set out

as a note under section 1395v of this title] referred to as the

'Commissioner') may submit under title XIX of the Social Security

Act [this subchapter] to the Secretary of Health, Education, and

Welfare [now Health and Human Services] (hereafter in this Act

referred to as the 'Secretary') a plan for medical assistance (and

any modifications of such plan) to enable the District of Columbia

to receive Federal financial assistance under such title for a

medical assistance program established by the Commissioner under

such plan.

"(b)(1) Notwithstanding any other provision of law, the

Commissioner may take such action as may be necessary to submit

such plan to the Secretary and to establish and carry out such

medical assistance program, except that in prescribing the

standards for determining eligibility for and the extent of medical

assistance under the District of Columbia's plan for medical

assistance, the Commissioner may not (except to the extent required

by title XIX of the Social Security Act [this subchapter]) -

"(A) prescribe maximum income levels for recipients of medical

assistance under such plan which exceed (i) the title XIX maximum

income levels if such levels are in effect, or (ii) the

Commissioner's maximum income levels for the local medical

assistance program if there are no title XIX maximum income

levels in effect; or

"(B) prescribe criteria which would permit an individual or

family to be eligible for such assistance if such individual or

family would be ineligible, solely by reason of his or its

resources, for medical assistance both under the plan of the

State of Maryland approved under title XIX of the Social Security

Act [this subchapter] and under the plan of the State of Virginia

approved under such title.

"(2) For purposes of subparagraph (A) of paragraph (1) of this

subsection -

"(A) the term 'title XIX maximum income levels' means any

maximum income levels which may be specified by title XIX of the

Social Security Act [this subchapter] for recipients of medical

assistance under State plans approved under that title;

"(B) the term 'the Commissioner's maximum income levels for the

local medical assistance program' means the maximum income levels

prescribed for recipients of medical assistance under the

District of Columbia's medical assistance program in effect in

the fiscal year ending June 30, 1967; and

"(C) during any of the first four calendar quarters in which

medical assistance is provided under such plan there shall be

deemed to be no title XIX maximum income levels in effect if the

title XIX maximum income levels in effect during such quarter are

higher than the Commissioner's maximum income levels for the

local medical assistance program."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 256b, 300e-17, 608, 671,

705, 1315, 1320a-7, 1320a-7a, 1320b-14, 1320b-22, 1382c, 1382h,

1382i, 1395v, 1395w-4, 1395w-21, 1395cc, 1396b, 1396c, 1396d,

1396e, 1396g, 1396g-1, 1396i, 1396k, 1396l, 1396n, 1396o, 1396p,

1396r, 1396r-1, 1396r-1a, 1396r-1b, 1396r-2, 1396r-4, 1396r-5,

1396r-6, 1396r-8, 1396s, 1396t, 1396u-1, 1396u-2, 1396u-3, 1396u-4,

1397gg, 1397hh, 1397jj, 4728, 6006, 6022, 6042, 14406, 15024, 15043

of this title; title 8 section 1255a; title 38 section 5503.

-FOOTNOTE-

(!1) See References in Text note below.

(!2) So in original. The semicolon probably should be a comma.

(!3) So in original. Probably should be followed by "and".

(!4) So in original. The word "to" probably should not appear.

(!5) So in original. The semicolon probably should be a comma.

(!6) So in original. Probably should be followed by a comma.

(!7) So in original.

(!8) See References in Text note below.

(!9) So in original. Probably should be section

"1396d(l)(2)(B)".

(!10) See References in Text note below.

(!11) So in original. Probably should be "an".

(!12) So in original. Probably should be "this subsection".

(!13) So in original. Probably should be subsection "(a)(56)".

(!14) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1396b 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. 1396b. Payment to States

-STATUTE-

(a) Computation of amount

From the sums appropriated therefor, the Secretary (except as

otherwise provided in this section) shall pay to each State which

has a plan approved under this subchapter, for each quarter,

beginning with the quarter commencing January 1, 1966 -

(1) an amount equal to the Federal medical assistance

percentage (as defined in section 1396d(b) of this title, subject

to subsections (g) and (j) of this section and section 1396r-4(f)

of this title) of the total amount expended during such quarter

as medical assistance under the State plan; plus

(2)(A) an amount equal to 75 per centum of so much of the sums

expended during such quarter (as found necessary by the Secretary

for the proper and efficient administration of the State plan) as

are attributable to compensation or training of skilled

professional medical personnel, and staff directly supporting

such personnel, of the State agency or any other public agency;

plus

(B) notwithstanding paragraph (1) or subparagraph (A), with

respect to amounts expended for nursing aide training and

competency evaluation programs, and competency evaluation

programs, described in section 1396r(e)(1) of this title

(including the costs for nurse aides to complete such competency

evaluation programs), regardless of whether the programs are

provided in or outside nursing facilities or of the skill of the

personnel involved in such programs, an amount equal to 50

percent (or, for calendar quarters beginning on or after July 1,

1988, and before October 1, 1990, the lesser of 90 percent or the

Federal medical assistance percentage plus 25 percentage points)

of so much of the sums expended during such quarter (as found

necessary by the Secretary for the proper and efficient

administration of the State plan) as are attributable to such

programs; plus

(C) an amount equal to 75 percent of so much of the sums

expended during such quarter (as found necessary by the Secretary

for the proper and efficient administration of the State plan) as

are attributable to preadmission screening and resident review

activities conducted by the State under section 1396r(e)(7) of

this title; plus

(D) for each calendar quarter during -

(i) fiscal year 1991, an amount equal to 90 percent,

(ii) fiscal year 1992, an amount equal to 85 percent,

(iii) fiscal year 1993, an amount equal to 80 percent, and

(iv) fiscal year 1994 and thereafter, an amount equal to 75

percent,

of so much of the sums expended during such quarter (as found

necessary by the Secretary for the proper and efficient

administration of the State plan) as are attributable to State

activities under section 1396r(g) of this title; plus

(3) an amount equal to -

(A)(i) 90 per centum of so much of the sums expended during

such quarter as are attributable to the design, development, or

installation of such mechanized claims processing and

information retrieval systems as the Secretary determines are

likely to provide more efficient, economical, and effective

administration of the plan and to be compatible with the claims

processing and information retrieval systems utilized in the

administration of subchapter XVIII of this chapter, including

the State's share of the cost of installing such a system to be

used jointly in the administration of such State's plan and the

plan of any other State approved under this chapter, and

(ii) 90 per centum of so much of the sums expended during any

such quarter in the fiscal year ending June 30, 1972, or the

fiscal year ending June 30, 1973, as are attributable to the

design, development, or installation of cost determination

systems for State-owned general hospitals (except that the

total amount paid to all States under this clause for either

such fiscal year shall not exceed $150,000), and

(B) 75 per centum of so much of the sums expended during such

quarter as are attributable to the operation of systems

(whether such systems are operated directly by the State or by

another person under a contract with the State) of the type

described in subparagraph (A)(i) (whether or not designed,

developed, or installed with assistance under such

subparagraph) which are approved by the Secretary and which

include provision for prompt written notice to each individual

who is furnished services covered by the plan, or to each

individual in a sample group of individuals who are furnished

such services, of the specific services (other than

confidential services) so covered, the name of the person or

persons furnishing the services, the date or dates on which the

services were furnished, and the amount of the payment or

payments made under the plan on account of the services; and

(C)(i) 75 per centum of the sums expended with respect to

costs incurred during such quarter (as found necessary by the

Secretary for the proper and efficient administration of the

State plan) as are attributable to the performance of medical

and utilization review by a utilization and quality control

peer review organization or by an entity which meets the

requirements of section 1320c-1 of this title, as determined by

the Secretary, under a contract entered into under section

1396a(d) of this title; and

(ii) 75 percent of the sums expended with respect to costs

incurred during such quarter (as found necessary by the

Secretary for the proper and efficient administration of the

State plan) as are attributable to the performance of

independent external reviews conducted under section

1396u-2(c)(2) of this title; and

(D) 75 percent of so much of the sums expended by the State

plan during a quarter in 1991, 1992, or 1993, as the Secretary

determines is attributable to the statewide adoption of a drug

use review program which conforms to the requirements of

section 1396r-8(g) of this title; plus

(4) an amount equal to 100 percent of the sums expended during

the quarter which are attributable to the costs of the

implementation and operation of the immigration status

verification system described in section 1320b-7(d) of this

title; plus

(5) an amount equal to 90 per centum of the sums expended

during such quarter which are attributable to the offering,

arranging, and furnishing (directly or on a contract basis) of

family planning services and supplies;

(6) subject to subsection (b)(3) of this section, an amount

equal to -

(A) 90 per centum of the sums expended during such a quarter

within the twelve-quarter period beginning with the first

quarter in which a payment is made to the State pursuant to

this paragraph, and

(B) 75 per centum of the sums expended during each succeeding

calendar quarter,

with respect to costs incurred during such quarter (as found

necessary by the Secretary for the elimination of fraud in the

provision and administration of medical assistance provided under

the State plan) which are attributable to the establishment and

operation of (including the training of personnel employed by) a

State medicaid fraud control unit (described in subsection (q) of

this section); plus

(7) subject to section 1396r(g)(3)(B) of this title, an amount

equal to 50 per centum of the remainder of the amounts expended

during such quarter as found necessary by the Secretary for the

proper and efficient administration of the State plan.

(b) Quarterly expenditures beginning after December 31, 1969

(1) Notwithstanding the preceding provisions of this section, the

amount determined under subsection (a)(1) of this section for any

State for any quarter beginning after December 31, 1969, shall not

take into account any amounts expended as medical assistance with

respect to individuals aged 65 or over and disabled individuals

entitled to hospital insurance benefits under subchapter XVIII of

this chapter which would not have been so expended if the

individuals involved had been enrolled in the insurance program

established by part B of subchapter XVIII of this chapter, other

than amounts expended under provisions of the plan of such State

required by section 1396a(a)(34) of this title.

(2) For limitation on Federal participation for capital

expenditures which are out of conformity with a comprehensive plan

of a State or areawide planning agency, see section 1320a-1 of this

title.

(3) The amount of funds which the Secretary is otherwise

obligated to pay a State during a quarter under subsection (a)(6)

of this section may not exceed the higher of -

(A) $125,000, or

(B) one-quarter of 1 per centum of the sums expended by the

Federal, State, and local governments during the previous quarter

in carrying out the State's plan under this subchapter.

(4) Amounts expended by a State for the use of an enrollment

broker in marketing medicaid managed care organizations and other

managed care entities to eligible individuals under this subchapter

shall be considered, for purposes of subsection (a)(7) of this

section, to be necessary for the proper and efficient

administration of the State plan but only if the following

conditions are met with respect to the broker:

(A) The broker is independent of any such entity and of any

health care providers (whether or not any such provider

participates in the State plan under this subchapter) that

provide coverage of services in the same State in which the

broker is conducting enrollment activities.

(B) No person who is an owner, employee, consultant, or has a

contract with the broker either has any direct or indirect

financial interest with such an entity or health care provider or

has been excluded from participation in the program under this

subchapter or subchapter XVIII of this chapter or debarred by any

Federal agency, or subject to a civil money penalty under this

chapter.

(5) Notwithstanding the preceding provisions of this section, the

amount determined under subsection (a)(1) of this section for any

State shall be decreased in a quarter by the amount of any health

care related taxes (described in subsection (w)(3)(A) of this

section) (!1) that are imposed on a hospital described in

subsection (w)(3)(F) of this section in that quarter.

(c) Treatment of educationally-related services

Nothing in this subchapter shall be construed as prohibiting or

restricting, or authorizing the Secretary to prohibit or restrict,

payment under subsection (a) of this section for medical assistance

for covered services furnished to a child with a disability because

such services are included in the child's individualized education

program established pursuant to part B of the Individuals with

Disabilities Education Act [20 U.S.C. 1411 et seq.] or furnished to

an infant or toddler with a disability because such services are

included in the child's individualized family service plan adopted

pursuant to part H (!1) of such Act.

(d) Estimates of State entitlement; installments; adjustments to

reflect overpayments or underpayments; time for recovery or

adjustment; uncollectable or discharged debts; obligated

appropriations; disputed claims

(1) Prior to the beginning of each quarter, the Secretary shall

estimate the amount to which a State will be entitled under

subsections (a) and (b) of this section for such quarter, such

estimates to be based on (A) a report filed by the State containing

its estimate of the total sum to be expended in such quarter in

accordance with the provisions of such subsections, and stating the

amount appropriated or made available by the State and its

political subdivisions for such expenditures in such quarter, and

if such amount is less than the State's proportionate share of the

total sum of such estimated expenditures, the source or sources

from which the difference is expected to be derived, and (B) such

other investigation as the Secretary may find necessary.

(2)(A) The Secretary shall then pay to the State, in such

installments as he may determine, the amount so estimated, reduced

or increased to the extent of any overpayment or underpayment which

the Secretary determines was made under this section to such State

for any prior quarter and with respect to which adjustment has not

already been made under this subsection.

(B) Expenditures for which payments were made to the State under

subsection (a) of this section shall be treated as an overpayment

to the extent that the State or local agency administering such

plan has been reimbursed for such expenditures by a third party

pursuant to the provisions of its plan in compliance with section

1396a(a)(25) of this title.

(C) For purposes of this subsection, when an overpayment is

discovered, which was made by a State to a person or other entity,

the State shall have a period of 60 days in which to recover or

attempt to recover such overpayment before adjustment is made in

the Federal payment to such State on account of such overpayment.

Except as otherwise provided in subparagraph (D), the adjustment in

the Federal payment shall be made at the end of the 60 days,

whether or not recovery was made.

(D) In any case where the State is unable to recover a debt which

represents an overpayment (or any portion thereof) made to a person

or other entity on account of such debt having been discharged in

bankruptcy or otherwise being uncollectable, no adjustment shall be

made in the Federal payment to such State on account of such

overpayment (or portion thereof).

(3)(A) The pro rata share to which the United States is equitably

entitled, as determined by the Secretary, of the net amount

recovered during any quarter by the State or any political

subdivision thereof with respect to medical assistance furnished

under the State plan shall be considered an overpayment to be

adjusted under this subsection.

(B)(i) Subparagraph (A) and paragraph (2)(B) shall not apply to

any amount recovered or paid to a State as part of the

comprehensive settlement of November 1998 between manufacturers of

tobacco products, as defined in section 5702(d) of the Internal

Revenue Code of 1986, and State Attorneys General, or as part of

any individual State settlement or judgment reached in litigation

initiated or pursued by a State against one or more such

manufacturers.

(ii) Except as provided in subsection (i)(19) of this section, a

State may use amounts recovered or paid to the State as part of a

comprehensive or individual settlement, or a judgment, described in

clause (i) for any expenditures determined appropriate by the

State.

(4) Upon the making of any estimate by the Secretary under this

subsection, any appropriations available for payments under this

section shall be deemed obligated.

(5) In any case in which the Secretary estimates that there has

been an overpayment under this section to a State on the basis of a

claim by such State that has been disallowed by the Secretary under

section 1316(d) of this title, and such State disputes such

disallowance, the amount of the Federal payment in controversy

shall, at the option of the State, be retained by such State or

recovered by the Secretary pending a final determination with

respect to such payment amount. If such final determination is to

the effect that any amount was properly disallowed, and the State

chose to retain payment of the amount in controversy, the Secretary

shall offset, from any subsequent payments made to such State under

this subchapter, an amount equal to the proper amount of the

disallowance plus interest on such amount disallowed for the period

beginning on the date such amount was disallowed and ending on the

date of such final determination at a rate (determined by the

Secretary) based on the average of the bond equivalent of the

weekly 90-day treasury bill auction rates during such period.

(6)(A) Each State (as defined in subsection (w)(7)(D) of this

section) shall include, in the first report submitted under

paragraph (1) after the end of each fiscal year, information

related to -

(i) provider-related donations made to the State or units of

local government during such fiscal year, and

(ii) health care related taxes collected by the State or such

units during such fiscal year.

(B) Each State shall include, in the first report submitted under

paragraph (1) after the end of each fiscal year, information

related to the total amount of payment adjustments made, and the

amount of payment adjustments made to individual providers (by

provider), under section 1396r-4(c) of this title during such

fiscal year.

(e) Transition costs of closures or conversions permitted

A State plan approved under this subchapter may include, as a

cost with respect to hospital services under the plan under this

subchapter, periodic expenditures made to reflect transitional

allowances established with respect to a hospital closure or

conversion under section 1395uu of this title.

(f) Limitation on Federal participation in medical assistance

(1)(A) Except as provided in paragraph (4), payment under the

preceding provisions of this section shall not be made with respect

to any amount expended as medical assistance in a calendar quarter,

in any State, for any member of a family the annual income of which

exceeds the applicable income limitation determined under this

paragraph.

(B)(i) Except as provided in clause (ii) of this subparagraph,

the applicable income limitation with respect to any family is the

amount determined, in accordance with standards prescribed by the

Secretary, to be equivalent to 133 1/3 percent of the highest

amount which would ordinarily be paid to a family of the same size

without any income or resources, in the form of money payments,

under the plan of the State approved under part A of subchapter IV

of this chapter.

(ii) If the Secretary finds that the operation of a uniform

maximum limits payments to families of more than one size, he may

adjust the amount otherwise determined under clause (i) to take

account of families of different sizes.

(C) The total amount of any applicable income limitation

determined under subparagraph (B) shall, if it is not a multiple of

$100 or such other amount as the Secretary may prescribe, be

rounded to the next higher multiple of $100 or such other amount,

as the case may be.

(2)(A) In computing a family's income for purposes of paragraph

(1), there shall be excluded any costs (whether in the form of

insurance premiums or otherwise and regardless of whether such

costs are reimbursed under another public program of the State or

political subdivision thereof) incurred by such family for medical

care or for any other type of remedial care recognized under State

law or, (B) notwithstanding section 1396o of this title at State

option, an amount paid by such family, at the family's option, to

the State, provided that the amount, when combined with costs

incurred in prior months, is sufficient when excluded from the

family's income to reduce such family's income below the applicable

income limitation described in paragraph (1). The amount of State

expenditures for which medical assistance is available under

subsection (a)(1) of this section will be reduced by amounts paid

to the State pursuant to this subparagraph.

(3) For purposes of paragraph (1)(B), in the case of a family

consisting of only one individual, the "highest amount which would

ordinarily be paid" to such family under the State's plan approved

under part A of subchapter IV of this chapter shall be the amount

determined by the State agency (on the basis of reasonable

relationship to the amounts payable under such plan to families

consisting of two or more persons) to be the amount of the aid

which would ordinarily be payable under such plan to a family

(without any income or resources) consisting of one person if such

plan provided for aid to such a family.

(4) The limitations on payment imposed by the preceding

provisions of this subsection shall not apply with respect to any

amount expended by a State as medical assistance for any individual

described in section 1396a(a)(10)(A)(i)(III),

1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V),

1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII),

1396a(a)(10)(A)(ii)(IX), 1396a(a)(10)(A)(ii)(X),

1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or (!2)

1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI),

1396a(a)(10)(A)(ii)(XVII), 1396a(a)(10)(A)(ii)(XVIII), 1396d(p)(1)

of this title or for any individual -

(A) who is receiving aid or assistance under any plan of the

State approved under subchapter I, X, XIV or XVI, or part A of

subchapter IV, or with respect to whom supplemental security

income benefits are being paid under subchapter XVI of this

chapter, or

(B) who is not receiving such aid or assistance, and with

respect to whom such benefits are not being paid, but (i) is

eligible to receive such aid or assistance, or to have such

benefits paid with respect to him, or (ii) would be eligible to

receive such aid or assistance, or to have such benefits paid

with respect to him if he were not in a medical institution, or

(C) with respect to whom there is being paid, or who is

eligible, or would be eligible if he were not in a medical

institution, to have paid with respect to him, a State

supplementary payment and is 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, or who is a PACE program eligible

individual enrolled in a PACE program under section 1396u-4 of

this title, but only if the income of such individual (as

determined under section 1382a of this title, but without regard

to subsection (b) thereof) does not exceed 300 percent of the

supplemental security income benefit rate established by section

1382(b)(1) of this title,

at the time of the provision of the medical assistance giving rise

to such expenditure.

(g) Decrease in Federal medical assistance percentage of amounts

paid for services furnished under State plan after June 30, 1973

(1) Subject to paragraph (3), with respect to amounts paid for

the following services furnished under the State plan after June

30, 1973 (other than services furnished pursuant to a contract with

a health maintenance organization as defined in section 1395mm of

this title or which is a qualified health maintenance organization

(as defined in section 300e-9(d) (!3) of this title)), the Federal

medical assistance percentage shall be decreased as follows: After

an individual has received inpatient hospital services or services

in an intermediate care facility for the mentally retarded for 60

days or inpatient mental hospital services for 90 days (whether or

not such days are consecutive), during any fiscal year, the Federal

medical assistance percentage with respect to amounts paid for any

such care furnished thereafter to such individual shall be

decreased by a per centum thereof (determined under paragraph (5))

unless the State agency responsible for the administration of the

plan makes a showing satisfactory to the Secretary that, with

respect to each calendar quarter for which the State submits a

request for payment at the full Federal medical assistance

percentage for amounts paid for inpatient hospital services or

services in an intermediate care facility for the mentally retarded

furnished beyond 60 days (or inpatient mental hospital services

furnished beyond 90 days), such State has an effective program of

medical review of the care of patients in mental hospitals and

intermediate care facilities for the mentally retarded pursuant to

paragraphs (26) and (31) of section 1396a(a) of this title whereby

the professional management of each case is reviewed and evaluated

at least annually by independent professional review teams. In

determining the number of days on which an individual has received

services described in this subsection, there shall not be counted

any days with respect to which such individual is entitled to have

payments made (in whole or in part) on his behalf under section

1395d of this title.

(2) The Secretary shall, as part of his validation procedures

under this subsection, conduct timely sample onsite surveys of

private and public institutions in which recipients of medical

assistance may receive care and services under a State plan

approved under this subchapter, and his findings with respect to

such surveys (as well as the showings of the State agency required

under this subsection) shall be made available for public

inspection.

(3)(A) No reduction in the Federal medical assistance percentage

of a State otherwise required to be imposed under this subsection

shall take effect -

(i) if such reduction is due to the State's unsatisfactory or

invalid showing made with respect to a calendar quarter beginning

before January 1, 1977;

(ii) before January 1, 1978;

(iii) unless a notice of such reduction has been provided to

the State at least 30 days before the date such reduction takes

effect; or

(iv) due to the State's unsatisfactory or invalid showing made

with respect to a calendar quarter beginning after September 30,

1977, unless notice of such reduction has been provided to the

State no later than the first day of the fourth calendar quarter

following the calendar quarter with respect to which such showing

was made.

(B) The Secretary shall waive application of any reduction in the

Federal medical assistance percentage of a State otherwise required

to be imposed under paragraph (1) because a showing by the State,

made under such paragraph with respect to a calendar quarter ending

after January 1, 1977, and before January 1, 1978, is determined to

be either unsatisfactory under such paragraph or invalid under

paragraph (2), if the Secretary determines that the State's showing

made under paragraph (1) with respect to any calendar quarter

ending on or before December 31, 1978, is satisfactory under such

paragraph and is valid under paragraph (2).

(4)(A) The Secretary may not find the showing of a State, with

respect to a calendar quarter under paragraph (1), to be

satisfactory if the showing is submitted to the Secretary later

than the 30th day after the last day of the calendar quarter,

unless the State demonstrates to the satisfaction of the Secretary

good cause for not meeting such deadline.

(B) The Secretary shall find a showing of a State, with respect

to a calendar quarter under paragraph (1), to be satisfactory under

such paragraph with respect to the requirement that the State

conduct annual onsite inspections in mental hospitals and

intermediate care facilities for the mentally retarded under

paragraphs (26) and (31) of section 1396a(a) of this title, if the

showing demonstrates that the State has conducted such an onsite

inspection during the 12-month period ending on the last date of

the calendar quarter -

(i) in each of not less than 98 per centum of the number of

such hospitals and facilities requiring such inspection, and

(ii) in every such hospital or facility which has 200 or more

beds,

and that, with respect to such hospitals and facilities not

inspected within such period, the State has exercised good faith

and due diligence in attempting to conduct such inspection, or if

the State demonstrates to the satisfaction of the Secretary that it

would have made such a showing but for failings of a technical

nature only.

(5) In the case of a State's unsatisfactory or invalid showing

made with respect to a type of facility or institutional services

in a calendar quarter, the per centum amount of the reduction of

the State's Federal medical assistance percentage for that type of

services under paragraph (1) is equal to 33 1/3 per centum

multiplied by a fraction, the denominator of which is equal to the

total number of patients receiving that type of services in that

quarter under the State plan in facilities or institutions for

which a showing was required to be made under this subsection, and

the numerator of which is equal to the number of such patients

receiving such type of services in that quarter in those facilities

or institutions for which a satisfactory and valid showing was not

made for that calendar quarter.

(6)(A) Recertifications required under section 1396a(a)(44) of

this title shall be conducted at least every 60 days in the case of

inpatient hospital services.

(B) Such recertifications in the case of services in an

intermediate care facility for the mentally retarded shall be

conducted at least -

(i) 60 days after the date of the initial certification,

(ii) 180 days after the date of the initial certification,

(iii) 12 months after the date of the initial certification,

(iv) 18 months after the date of the initial certification,

(v) 24 months after the date of the initial certification, and

(vi) every 12 months thereafter.

(C) For purposes of determining compliance with the schedule

established by this paragraph, a recertification shall be

considered to have been done on a timely basis if it was performed

not later than 10 days after the date the recertification was

otherwise required and the State establishes good cause why the

physician or other person making such recertification did not meet

such schedule.

(h) Repealed. Pub. L. 100-203, title IV, Sec. 4211(g)(1), Dec. 22,

1987, 101 Stat. 1330-205

(i) Payment for organ transplants; item or service furnished by

excluded individual, entity, or physician; other restrictions

Payment under the preceding provisions of this section shall not

be made -

(1) for organ transplant procedures unless the State plan

provides for written standards respecting the coverage of such

procedures and unless such standards provide that -

(A) similarly situated individuals are treated alike; and

(B) any restriction, on the facilities or practitioners which

may provide such procedures, is consistent with the

accessibility of high quality care to individuals eligible for

the procedures under the State plan; or

(2) with respect to any amount expended for an item or service

(other than an emergency item or service, not including items or

services furnished in an emergency room of a hospital) furnished

-

(A) under the plan by any individual or entity during any

period when the individual or entity is excluded from

participation under subchapter V, XVIII, or XX of this chapter

or under this subchapter pursuant to section 1320a-7, 1320a-7a,

1320c-5, or 1395u(j)(2) of this title, or

(B) at the medical direction or on the prescription of a

physician, during the period when such physician is excluded

from participation under subchapter V, XVIII, or XX of this

chapter or under this subchapter pursuant to section 1320a-7,

1320a-7a, 1320c-5, or 1395u(j)(2) of this title and when the

person furnishing such item or service knew or had reason to

know of the exclusion (after a reasonable time period after

reasonable notice has been furnished to the person); or

(3) with respect to any amount expended for inpatient hospital

services furnished under the plan (other than amounts

attributable to the special situation of a hospital which serves

a disproportionate number of low income patients with special

needs) to the extent that such amount exceeds the hospital's

customary charges with respect to such services or (if such

services are furnished under the plan by a public institution

free of charge or at nominal charges to the public) exceeds an

amount determined on the basis of those items (specified in

regulations prescribed by the Secretary) included in the

determination of such payment which the Secretary finds will

provide fair compensation to such institution for such services;

or

(4) with respect to any amount expended for care or services

furnished under the plan by a hospital unless such hospital has

in effect a utilization review plan which meets the requirements

imposed by section 1395x(k) of this title for purposes of

subchapter XVIII of this chapter; and if such hospital has in

effect such a utilization review plan for purposes of subchapter

XVIII of this chapter, such plan shall serve as the plan required

by this subsection (with the same standards and procedures and

the same review committee or group) as a condition of payment

under this subchapter; the Secretary is authorized to waive the

requirements of this paragraph if the State agency demonstrates

to his satisfaction that it has in operation utilization review

procedures which are superior in their effectiveness to the

procedures required under section 1395x(k) of this title; or

(5) with respect to any amount expended for any drug product

for which payment may not be made under part B of subchapter

XVIII of this chapter because of section 1395y(c) of this title;

or

(6) with respect to any amount expended for inpatient hospital

tests (other than in emergency situations) not specifically

ordered by the attending physician or other responsible

practitioner; or

(7) with respect to any amount expended for clinical diagnostic

laboratory tests performed by a physician, independent

laboratory, or hospital, to the extent such amount exceeds the

amount that would be recognized under section 1395l(h) of this

title for such tests performed for an individual enrolled under

part B of subchapter XVIII of this chapter; or

(8) with respect to any amount expended for medical assistance

(A) for nursing facility services to reimburse (or otherwise

compensate) a nursing facility for payment of a civil money

penalty imposed under section 1396r(h) of this title or (B) for

home and community care to reimburse (or otherwise compensate) a

provider of such care for payment of a civil money penalty

imposed under this subchapter or subchapter XI of this chapter or

for legal expenses in defense of an exclusion or civil money

penalty under this subchapter or subchapter XI of this chapter if

there is no reasonable legal ground for the provider's case; or

(9) Repealed. Pub. L. 104-193, title I, Sec. 114(d)(2), Aug.

22, 1996, 110 Stat. 2180.

(10)(A) with respect to covered outpatient drugs unless there

is a rebate agreement in effect under section 1396r-8 of this

title with respect to such drugs or unless section 1396r-8(a)(3)

of this title applies, and

(B) with respect to any amount expended for an innovator

multiple source drug (as defined in section 1396r-8(k) of this

title) dispensed on or after July 1, 1991, if, under applicable

State law, a less expensive multiple source drug could have been

dispensed, but only to the extent that such amount exceeds the

upper payment limit for such multiple source drug; or

(11) with respect to any amount expended for physicians'

services furnished on or after the first day of the first quarter

beginning more than 60 days after the date of establishment of

the physician identifier system under section 1396a(x) of this

title, unless the claim for the services includes the unique

physician identifier provided under such system; or

(12) Repealed. Pub. L. 105-33, title IV, Sec. 4742(a), Aug. 5,

1997, 111 Stat. 523.

(13) with respect to any amount expended to reimburse (or

otherwise compensate) a nursing facility for payment of legal

expenses associated with any action initiated by the facility

that is dismissed on the basis that no reasonable legal ground

existed for the institution of such action; or

(14) with respect to any amount expended on administrative

costs to carry out the program under section 1396s of this title;

or

(15) with respect to any amount expended for a single-antigen

vaccine and its administration in any case in which the

administration of a combined-antigen vaccine was medically

appropriate (as determined by the Secretary); or

(16) with respect to any amount expended for which funds may

not be used under the Assisted Suicide Funding Restriction Act of

1997 [42 U.S.C. 14401 et seq.]; or

(17) with respect to any amount expended for roads, bridges,

stadiums, or any other item or service not covered under a State

plan under this subchapter; or

(18) with respect to any amount expended for home health care

services provided by an agency or organization unless the agency

or organization provides the State agency on a continuing basis a

surety bond in a form specified by the Secretary under paragraph

(7) of section 1395x(o) of this title and in an amount that is

not less than $50,000 or such comparable surety bond as the

Secretary may permit under the last sentence of such section; or

(19) with respect to any amount expended on administrative

costs to initiate or pursue litigation described in subsection

(d)(3)(B) of this section; or

(20) with respect to amounts expended for medical assistance

provided to an individual described in subclause (XV) or (XVI) of

section 1396a(a)(10)(A)(ii) of this title for a fiscal year

unless the State demonstrates to the satisfaction of the

Secretary that the level of State funds expended for such fiscal

year for programs to enable working individuals with disabilities

to work (other than for such medical assistance) is not less than

the level expended for such programs during the most recent State

fiscal year ending before December 17, 1999.

Nothing in paragraph (1) shall be construed as permitting a State

to provide services under its plan under this subchapter that are

not reasonable in amount, duration, and scope to achieve their

purpose. Paragraphs (1), (2), (16), (17), and (18) shall apply with

respect to items or services furnished and amounts expended by or

through a managed care entity (as defined in section

1396u-2(a)(1)(B) of this title) in the same manner as such

paragraphs apply to items or services furnished and amounts

expended directly by the State.

(j) Adjustment of amount

Notwithstanding the preceding provisions of this section, the

amount determined under subsection (a)(1) of this section for any

State for any quarter shall be adjusted in accordance with section

1396m of this title.

(k) Technical assistance to States

The Secretary is authorized to provide at the request of any

State (and without cost to such State) such technical and actuarial

assistance as may be necessary to assist such State to contract

with any medicaid managed care organization which meets the

requirements of subsection (m) of this section for the purpose of

providing medical care and services to individuals who are entitled

to medical assistance under this subchapter.

(l) Repealed. Pub. L. 94-552, Sec. 1, Oct. 18, 1976, 90 Stat. 2540

(m) "Medicaid managed care organization" defined; duties and

functions of Secretary; payments to States; reporting

requirements; remedies

(1)(A) The term "medicaid managed care organization" means a

health maintenance organization, an eligible organization with a

contract under section 1395mm of this title or a Medicare+Choice

organization with a contract under part C of subchapter XVIII of

this chapter, a provider sponsored organization, or any other

public or private organization, which meets the requirement of

section 1396a(w) of this title and -

(i) makes services it provides to individuals eligible for

benefits under this subchapter accessible to such individuals,

within the area served by the organization, to the same extent as

such services are made accessible to individuals (eligible for

medical assistance under the State plan) not enrolled with the

organization, and

(ii) has made adequate provision against the risk of

insolvency, which provision is satisfactory to the State, meets

the requirements of subparagraph (C)(i) (if applicable), and

which assures that individuals eligible for benefits under this

subchapter are in no case held liable for debts of the

organization in case of the organization's insolvency.

An organization that is a qualified health maintenance organization

(as defined in section 300e-9(d) (!4) of this title) is deemed to

meet the requirements of clauses (i) and (ii).

(B) The duties and functions of the Secretary, insofar as they

involve making determinations as to whether an organization is a

medicaid managed care organization within the meaning of

subparagraph (A), shall be integrated with the administration of

section 300e-11(a) and (b) of this title.

(C)(i) Subject to clause (ii), a provision meets the requirements

of this subparagraph for an organization if the organization meets

solvency standards established by the State for private health

maintenance organizations or is licensed or certified by the State

as a risk-bearing entity.

(ii) Clause (i) shall not apply to an organization if -

(I) the organization is not responsible for the provision

(directly or through arrangements with providers of services) of

inpatient hospital services and physicians' services;

(II) the organization is a public entity;

(III) the solvency of the organization is guaranteed by the

State; or

(IV) the organization is (or is controlled by) one or more

Federally-qualified (!5) health centers and meets solvency

standards established by the State for such an organization.

For purposes of subclause (IV), the term "control" means the

possession, whether direct or indirect, of the power to direct or

cause the direction of the management and policies of the

organization through membership, board representation, or an

ownership interest equal to or greater than 50.1 percent.

(2)(A) Except as provided in subparagraphs (B), (C), and (G), no

payment shall be made under this subchapter to a State with respect

to expenditures incurred by it for payment (determined under a

prepaid capitation basis or under any other risk basis) for

services provided by any entity (including a health insuring

organization) which is responsible for the provision (directly or

through arrangements with providers of services) of inpatient

hospital services and any other service described in paragraph (2),

(3), (4), (5), or (7) of section 1396d(a) of this title or for the

provision of any three or more of the services described in such

paragraphs unless -

(i) the Secretary has determined that the entity is a medicaid

managed care organization as defined in paragraph (1);

(ii) Repealed. Pub. L. 105-33, title IV, Sec. 4703(a), Aug. 5,

1997, 111 Stat. 495.

(iii) such services are provided for the benefit of individuals

eligible for benefits under this subchapter in accordance with a

contract between the State and the entity under which prepaid

payments to the entity are made on an actuarially sound basis and

under which the Secretary must provide prior approval for

contracts providing for expenditures in excess of $1,000,000 for

1998 and, for a subsequent year, the amount established under

this clause for the previous year increased by the percentage

increase in the consumer price index for all urban consumers over

the previous year;

(iv) such contract provides that the Secretary and the State

(or any person or organization designated by either) shall have

the right to audit and inspect any books and records of the

entity (and of any subcontractor) that pertain (I) to the ability

of the entity to bear the risk of potential financial losses, or

(II) to services performed or determinations of amounts payable

under the contract;

(v) such contract provides that in the entity's enrollment,

reenrollment, or disenrollment of individuals who are eligible

for benefits under this subchapter and eligible to enroll,

reenroll, or disenroll with the entity pursuant to the contract,

the entity will not discriminate among such individuals on the

basis of their health status or requirements for health care

services;

(vi) such contract (I) permits individuals who have elected

under the plan to enroll with the entity for provision of such

benefits to terminate such enrollment in accordance with section

1396u-2(a)(4) of this title, and (II) provides for notification

in accordance with such section of each such individual, at the

time of the individual's enrollment, of such right to terminate

such enrollment;

(vii) such contract provides that, in the case of medically

necessary services which were provided (I) to an individual

enrolled with the entity under the contract and entitled to

benefits with respect to such services under the State's plan and

(II) other than through the organization because the services

were immediately required due to an unforeseen illness, injury,

or condition, either the entity or the State provides for

reimbursement with respect to those services,(!6)

(viii) such contract provides for disclosure of information in

accordance with section 1320a-3 of this title and paragraph (4)

of this subsection;

(ix) such contract provides, in the case of an entity that has

entered into a contract for the provision of services with a

Federally-qualified (!5) health center or a rural health clinic,

that the entity shall provide payment that is not less than the

level and amount of payment which the entity would make for the

services if the services were furnished by a provider which is

not a Federally-qualified health center or a rural health clinic;

(x) any physician incentive plan that it operates meets the

requirements described in section 1395mm(i)(8) of this title;

(xi) such contract provides for maintenance of sufficient

patient encounter data to identify the physician who delivers

services to patients; and

(xii) such contract, and the entity complies with the

applicable requirements of section 1396u-2 of this title.

(B) Subparagraph (A) (!7) except with respect to clause (ix) of

subparagraph (A), does not apply with respect to payments under

this subchapter to a State with respect to expenditures incurred by

it for payment for services provided by an entity which -

(i)(I) received a grant of at least $100,000 in the fiscal year

ending June 30, 1976, under section 254b(d)(1)(A) or 254c(d)(1)

of this title,(!8) and for the period beginning July 1, 1976, and

ending on the expiration of the period for which payments are to

be made under this subchapter has been the recipient of a grant

under either such section; and

(II) provides to its enrollees, on a prepaid capitation risk

basis or on any other risk basis, all of the services and

benefits described in paragraphs (1), (2), (3), (4)(C), and (5)

of section 1396d(a) of this title and, to the extent required by

section 1396a(a)(10)(D) of this title to be provided under a

State plan for medical assistance, the services and benefits

described in paragraph (7) of section 1396d(a) of this title; or

(ii) is a nonprofit primary health care entity located in a

rural area (as defined by the Appalachian Regional Commission) -

(I) which received in the fiscal year ending June 30, 1976,

at least $100,000 (by grant, subgrant, or subcontract) under

the Appalachian Regional Development Act of 1965,(!8) and

(II) for the period beginning July 1, 1976, and ending on the

expiration of the period for which payments are to be made

under this subchapter either has been the recipient of a grant,

subgrant, or subcontract under such Act or has provided

services under a contract (initially entered into during a year

in which the entity was the recipient of such a grant,

subgrant, or subcontract) with a State agency under this

subchapter on a prepaid capitation risk basis or on any other

risk basis; or

(iii) which has contracted with the single State agency for the

provision of services (but not including inpatient hospital

services) to persons eligible under this subchapter on a prepaid

risk basis prior to 1970.

(C) to (E) Repealed. Pub. L. 105-33, title IV, Sec.

4703(b)(1)(A), Aug. 5, 1997, 111 Stat. 495.

(F) Repealed. Pub. L. 105-33, title IV, Sec. 4701(d)(2)(B), Aug.

5, 1997, 111 Stat. 494.

(G) In the case of an entity which is receiving (and has received

during the previous two years) a grant of at least $100,000 under

section 254b(d)(1)(A) or 254c(d)(1) of this title (!8) or is

receiving (and has received during the previous two years) at least

$100,000 (by grant, subgrant, or subcontract) under the Appalachian

Regional Development Act of 1965,(!8) clause (i) of subparagraph

(A) shall not apply.

(H) In the case of an individual who -

(i) in a month is eligible for benefits under this subchapter

and enrolled with a medicaid managed care organization with a

contract under this paragraph or with a primary care case manager

with a contract described in section 1396d(t)(3) of this title,

(ii) in the next month (or in the next 2 months) is not

eligible for such benefits, but

(iii) in the succeeding month is again eligible for such

benefits,

the State plan, subject to subparagraph (A)(vi), may enroll the

individual for that succeeding month with the organization

described in clause (i) if the organization continues to have a

contract under this paragraph with the State or with the manager

described in such clause if the manager continues to have a

contract described in section 1396d(t)(3) of this title with the

State.

(3) Repealed. Pub. L. 101-508, title IV, Sec. 4732(d)(2), Nov. 5,

1990, 104 Stat. 1388-196.

(4)(A) Each medicaid managed care organization which is not a

qualified health maintenance organization (as defined in section

300e-9(d) (!8) of this title) must report to the State and, upon

request, to the Secretary, the Inspector General of the Department

of Health and Human Services, and the Comptroller General a

description of transactions between the organization and a party in

interest (as defined in section 300e-17(b) of this title),

including the following transactions:

(i) Any sale or exchange, or leasing of any property between

the organization and such a party.

(ii) Any furnishing for consideration of goods, services

(including management services), or facilities between the

organization and such a party, but not including salaries paid to

employees for services provided in the normal course of their

employment.

(iii) Any lending of money or other extension of credit between

the organization and such a party.

The State or Secretary may require that information reported

respecting an organization which controls, or is controlled by, or

is under common control with, another entity be in the form of a

consolidated financial statement for the organization and such

entity.

(B) Each organization shall make the information reported

pursuant to subparagraph (A) available to its enrollees upon

reasonable request.

(5)(A) If the Secretary determines that an entity with a contract

under this subsection -

(i) fails substantially to provide medically necessary items

and services that are required (under law or under the contract)

to be provided to an individual covered under the contract, if

the failure has adversely affected (or has substantial likelihood

of adversely affecting) the individual;

(ii) imposes premiums on individuals enrolled under this

subsection in excess of the premiums permitted under this

subchapter;

(iii) acts to discriminate among individuals in violation of

the provision of paragraph (2)(A)(v), including expulsion or

refusal to re-enroll an individual or engaging in any practice

that would reasonably be expected to have the effect of denying

or discouraging enrollment (except as permitted by this

subsection) by eligible individuals with the organization whose

medical condition or history indicates a need for substantial

future medical services;

(iv) misrepresents or falsifies information that is furnished -

(I) to the Secretary or the State under this subsection, or

(II) to an individual or to any other entity under this

subsection,(!9) or

(v) fails to comply with the requirements of section

1395mm(i)(8) of this title,

the Secretary may provide, in addition to any other remedies

available under law, for any of the remedies described in

subparagraph (B).

(B) The remedies described in this subparagraph are -

(i) civil money penalties of not more than $25,000 for each

determination under subparagraph (A), or, with respect to a

determination under clause (iii) or (iv)(I) of such subparagraph,

of not more than $100,000 for each such determination, plus, with

respect to a determination under subparagraph (A)(ii), double the

excess amount charged in violation of such subparagraph (and the

excess amount charged shall be deducted from the penalty and

returned to the individual concerned), and plus, with respect to

a determination under subparagraph (A)(iii), $15,000 for each

individual not enrolled as a result of a practice described in

such subparagraph, or

(ii) denial of payment to the State for medical assistance

furnished under the contract under this subsection for

individuals enrolled after the date the Secretary notifies the

organization of a determination under subparagraph (A) and until

the Secretary is satisfied that the basis for such determination

has been corrected and is not likely to recur.

The provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to a civil money penalty under

clause (i) in the same manner as such provisions apply to a penalty

or proceeding under section 1320a-7a(a) of this title.

(6)(A) For purposes of this subsection and section 1396a(e)(2)(A)

of this title, in the case of the State of New Jersey, the term

"contract" shall be deemed to include an undertaking by the State

agency, in the State plan under this subchapter, to operate a

program meeting all requirements of this subsection.

(B) The undertaking described in subparagraph (A) must provide -

(i) for the establishment of a separate entity responsible for

the operation of a program meeting the requirements of this

subsection, which entity may be a subdivision of the State agency

administering the State plan under this subchapter;

(ii) for separate accounting for the funds used to operate such

program; and

(iii) for setting the capitation rates and any other payment

rates for services provided in accordance with this subsection

using a methodology satisfactory to the Secretary designed to

ensure that total Federal matching payments under this subchapter

for such services will be lower than the matching payments that

would be made for the same services, if provided under the State

plan on a fee for service basis to an actuarially equivalent

population.

(C) The undertaking described in subparagraph (A) shall be

subject to approval (and annual re-approval) by the Secretary in

the same manner as a contract under this subsection.

(D) The undertaking described in subparagraph (A) shall not be

eligible for a waiver under section 1396n(b) of this title.

(n) Repealed. Pub. L. 100-93, Sec. 8(h)(1), Aug. 18, 1987, 101

Stat. 694

(o) Restrictions on authorized payments to States

Notwithstanding the preceding provisions of this section, no

payment shall be made to a State under the preceding provisions of

this section for expenditures for medical assistance provided for

an individual under its State plan approved under this subchapter

to the extent that a private insurer (as defined by the Secretary

by regulation and including a group health plan (as defined in

section 1167(1) of title 29), a service benefit plan, and a health

maintenance organization) would have been obligated to provide such

assistance but for a provision of its insurance contract which has

the effect of limiting or excluding such obligation because the

individual is eligible for or is provided medical assistance under

the plan.

(p) Assignment of rights of payment; incentive payments for

enforcement and collection

(1) When a political subdivision of a State makes, for the State

of which it is a political subdivision, or one State makes, for

another State, the enforcement and collection of rights of support

or payment assigned under section 1396k of this title, pursuant to

a cooperative arrangement under such section (either within or

outside of such State), there shall be paid to such political

subdivision or such other State from amounts which would otherwise

represent the Federal share of payments for medical assistance

provided to the eligible individuals on whose behalf such

enforcement and collection was made, an amount equal to 15 percent

of any amount collected which is attributable to such rights of

support or payment.

(2) Where more than one jurisdiction is involved in such

enforcement or collection, the amount of the incentive payment

determined under paragraph (1) shall be allocated among the

jurisdictions in a manner to be prescribed by the Secretary.

(q) "State medicaid fraud control unit" defined

For the purposes of this section, the term "State medicaid fraud

control unit" means a single identifiable entity of the State

government which the Secretary certifies (and annually recertifies)

as meeting the following requirements:

(1) The entity (A) is a unit of the office of the State

Attorney General or of another department of State government

which possesses statewide authority to prosecute individuals for

criminal violations, (B) is in a State the constitution of which

does not provide for the criminal prosecution of individuals by a

statewide authority and has formal procedures, approved by the

Secretary, that (i) assure its referral of suspected criminal

violations relating to the program under this subchapter to the

appropriate authority or authorities in the State for prosecution

and (ii) assure its assistance of, and coordination with, such

authority or authorities in such prosecutions, or (C) has a

formal working relationship with the office of the State Attorney

General and has formal procedures (including procedures for its

referral of suspected criminal violations to such office) which

are approved by the Secretary and which provide effective

coordination of activities between the entity and such office

with respect to the detection, investigation, and prosecution of

suspected criminal violations relating to the program under this

subchapter.

(2) The entity is separate and distinct from the single State

agency that administers or supervises the administration of the

State plan under this subchapter.

(3) The entity's function is conducting a statewide program for

the investigation and prosecution of violations of all applicable

State laws regarding any and all aspects of fraud in connection

with (A) any aspect of the provision of medical assistance and

the activities of providers of such assistance under the State

plan under this subchapter; and (B) upon the approval of the

Inspector General of the relevant Federal agency, any aspect of

the provision of health care services and activities of providers

of such services under any Federal health care program (as

defined in section 1320a-7b(f)(1) of this title), if the

suspected fraud or violation of law in such case or investigation

is primarily related to the State plan under this subchapter.

(4)(A) The entity has -

(i) procedures for reviewing complaints of abuse or neglect

of patients in health care facilities which receive payments

under the State plan under this subchapter;

(ii) at the option of the entity, procedures for reviewing

complaints of abuse or neglect of patients residing in board

and care facilities; and

(iii) procedures for acting upon such complaints under the

criminal laws of the State or for referring such complaints to

other State agencies for action.

(B) For purposes of this paragraph, the term "board and care

facility" means a residential setting which receives payment

(regardless of whether such payment is made under the State plan

under this subchapter) from or on behalf of two or more unrelated

adults who reside in such facility, and for whom one or both of

the following is provided:

(i) Nursing care services provided by, or under the

supervision of, a registered nurse, licensed practical nurse,

or licensed nursing assistant.

(ii) A substantial amount of personal care services that

assist residents with the activities of daily living, including

personal hygiene, dressing, bathing, eating, toileting,

ambulation, transfer, positioning, self-medication, body care,

travel to medical services, essential shopping, meal

preparation, laundry, and housework.

(5) The entity provides for the collection, or referral for

collection to a single State agency, of overpayments that are

made under the State plan or under any Federal health care

program (as so defined) to health care facilities and that are

discovered by the entity in carrying out its activities. All

funds collected in accordance with this paragraph shall be

credited exclusively to, and available for expenditure under, the

Federal health care program (including the State plan under this

subchapter) that was subject to the activity that was the basis

for the collection.

(6) The entity employs such auditors, attorneys, investigators,

and other necessary personnel and is organized in such a manner

as is necessary to promote the effective and efficient conduct of

the entity's activities.

(7) The entity submits to the Secretary an application and

annual reports containing such information as the Secretary

determines, by regulation, to be necessary to determine whether

the entity meets the other requirements of this subsection.

(r) Mechanized claims processing and information retrieval systems;

operational, etc., requirements

(1) In order to receive payments under subsection (a) of this

section for use of automated data systems in administration of the

State plan under this subchapter, a State must have in operation

mechanized claims processing and information retrieval systems that

meet the requirements of this subsection and that the Secretary has

found -

(A) are adequate to provide efficient, economical, and

effective administration of such State plan;

(B) are compatible with the claims processing and information

retrieval systems used in the administration of subchapter XVIII

of this chapter, and for this purpose -

(i) have a uniform identification coding system for

providers, other payees, and beneficiaries under this

subchapter or subchapter XVIII of this chapter;

(ii) provide liaison between States and carriers and

intermediaries with agreements under subchapter XVIII of this

chapter to facilitate timely exchange of appropriate data; and

(iii) provide for exchange of data between the States and the

Secretary with respect to persons sanctioned under this

subchapter or subchapter XVIII of this chapter;

(C) are capable of providing accurate and timely data;

(D) are complying with the applicable provisions of part C of

subchapter XI of this chapter;

(E) are designed to receive provider claims in standard formats

to the extent specified by the Secretary; and

(F) effective for claims filed on or after January 1, 1999,

provide for electronic transmission of claims data in the format

specified by the Secretary and consistent with the Medicaid

Statistical Information System (MSIS) (including detailed

individual enrollee encounter data and other information that the

Secretary may find necessary).

(2) In order to meet the requirements of this paragraph,

mechanized claims processing and information retrieval systems must

meet the following requirements:

(A) The systems must be capable of developing provider,

physician, and patient profiles which are sufficient to provide

specific information as to the use of covered types of services

and items, including prescribed drugs.

(B) The State must provide that information on probable fraud

or abuse which is obtained from, or developed by, the systems, is

made available to the State's medicaid fraud control unit (if

any) certified under subsection (q) of this section.

(C) The systems must meet all performance standards and other

requirements for initial approval developed by the Secretary.

(s) Limitations on certain physician referrals

Notwithstanding the preceding provisions of this section, no

payment shall be made to a State under this section for

expenditures for medical assistance under the State plan consisting

of a designated health service (as defined in subsection (h)(6) of

section 1395nn of this title) furnished to an individual on the

basis of a referral that would result in the denial of payment for

the service under subchapter XVIII of this chapter if such

subchapter provided for coverage of such service to the same extent

and under the same terms and conditions as under the State plan,

and subsections (f) and (g)(5) of such section shall apply to a

provider of such a designated health service for which payment may

be made under this subchapter in the same manner as such

subsections apply to a provider of such a service for which payment

may be made under such subchapter.

(t) Repealed. Pub. L. 97-35, title XXI, Sec. 2161(c)(2), Aug. 13,

1981, 95 Stat. 805, as amended by Pub. L. 97-248, title I, Sec.

137(a)(2), Sept. 3, 1982, 96 Stat. 376

(u) Limitation of Federal financial participation in erroneous

medical assistance expenditures

(1)(A) Notwithstanding subsection (a)(1) of this section, if the

ratio of a State's erroneous excess payments for medical assistance

(as defined in subparagraph (D)) to its total expenditures for

medical assistance under the State plan approved under this

subchapter exceeds 0.03, for the period consisting of the third and

fourth quarters of fiscal year 1983, or for any full fiscal year

thereafter, then the Secretary shall make no payment for such

period or fiscal year with respect to so much of such erroneous

excess payments as exceeds such allowable error rate of 0.03.

(B) The Secretary may waive, in certain limited cases, all or

part of the reduction required under subparagraph (A) with respect

to any State if such State is unable to reach the allowable error

rate for a period or fiscal year despite a good faith effort by

such State.

(C) In estimating the amount to be paid to a State under

subsection (d) of this section, the Secretary shall take into

consideration the limitation on Federal financial participation

imposed by subparagraph (A) and shall reduce the estimate he makes

under subsection (d)(1) of this section, for purposes of payment to

the State under subsection (d)(3) of this section, in light of any

expected erroneous excess payments for medical assistance

(estimated in accordance with such criteria, including sampling

procedures, as he may prescribe and subject to subsequent

adjustment, if necessary, under subsection (d)(2) of this section).

(D)(i) For purposes of this subsection, the term "erroneous

excess payments for medical assistance" means the total of -

(I) payments under the State plan with respect to ineligible

individuals and families, and

(II) overpayments on behalf of eligible individuals and

families by reason of error in determining the amount of

expenditures for medical care required of an individual or family

as a condition of eligibility.

(ii) In determining the amount of erroneous excess payments for

medical assistance to an ineligible individual or family under

clause (i)(I), if such ineligibility is the result of an error in

determining the amount of the resources of such individual or

family, the amount of the erroneous excess payment shall be the

smaller of (I) the amount of the payment with respect to such

individual or family, or (II) the difference between the actual

amount of such resources and the allowable resource level

established under the State plan.

(iii) In determining the amount of erroneous excess payments for

medical assistance to an individual or family under clause (i)(II),

the amount of the erroneous excess payment shall be the smaller of

(I) the amount of the payment on behalf of the individual or

family, or (II) the difference between the actual amount incurred

for medical care by the individual or family and the amount which

should have been incurred in order to establish eligibility for

medical assistance.

(iv) In determining the amount of erroneous excess payments,

there shall not be included any error resulting from a failure of

an individual to cooperate or give correct information with respect

to third-party liability as required under section 1396k(a)(1)(C)

or 602(a)(26)(C) (!10) of this title or with respect to payments

made in violation of section 1396e of this title.

(v) In determining the amount of erroneous excess payments, there

shall not be included any erroneous payments made for ambulatory

prenatal care provided during a presumptive eligibility period (as

defined in section 1396r-1(b)(1) of this title), for items and

services described in subsection (a) of section 1396r-1a of this

title provided to a child during a presumptive eligibility period

under such section, or for medical assistance provided to an

individual described in subsection (a) of section 1396r-1b of this

title during a presumptive eligibility period under such section.

(E) For purposes of subparagraph (D), there shall be excluded, in

determining both erroneous excess payments for medical assistance

and total expenditures for medical assistance -

(i) payments with respect to any individual whose eligibility

therefor was determined exclusively by the Secretary under an

agreement pursuant to section 1383c of this title and such other

classes of individuals as the Secretary may by regulation

prescribe whose eligibility was determined in part under such an

agreement; and

(ii) payments made as the result of a technical error.

(2) The State agency administering the plan approved under this

subchapter shall, at such times and in such form as the Secretary

may specify, provide information on the rates of erroneous excess

payments made (or expected, with respect to future periods

specified by the Secretary) in connection with its administration

of such plan, together with any other data he requests that are

reasonably necessary for him to carry out the provisions of this

subsection.

(3)(A) If a State fails to cooperate with the Secretary in

providing information necessary to carry out this subsection, the

Secretary, directly or through contractual or such other

arrangements as he may find appropriate, shall establish the error

rates for that State on the basis of the best data reasonably

available to him and in accordance with such techniques for

sampling and estimating as he finds appropriate.

(B) In any case in which it is necessary for the Secretary to

exercise his authority under subparagraph (A) to determine a

State's error rates for a fiscal year, the amount that would

otherwise be payable to such State under this subchapter for

quarters in such year shall be reduced by the costs incurred by the

Secretary in making (directly or otherwise) such determination.

(4) This subsection shall not apply with respect to Puerto Rico,

Guam, the Virgin Islands, the Northern Mariana Islands, or American

Samoa.

(v) Medical assistance to aliens not lawfully admitted for

permanent residence

(1) Notwithstanding the preceding provisions of this section,

except as provided in paragraph (2), no payment may be made to a

State under this section for medical assistance furnished to an

alien who is not lawfully admitted for permanent residence or

otherwise permanently residing in the United States under color of

law.

(2) Payment shall be made under this section for care and

services that are furnished to an alien described in paragraph (1)

only if -

(A) such care and services are necessary for the treatment of

an emergency medical condition of the alien,

(B) such alien otherwise meets the eligibility requirements for

medical assistance under the State plan approved under this

subchapter (other than the requirement of the receipt of aid or

assistance under subchapter IV of this chapter, supplemental

security income benefits under subchapter XVI of this chapter, or

a State supplementary payment), and

(C) such care and services are not related to an organ

transplant procedure.

(3) For purposes of this subsection, the term "emergency medical

condition" means a medical condition (including emergency labor and

delivery) manifesting itself by acute symptoms of sufficient

severity (including severe pain) such that the absence of immediate

medical attention could reasonably be expected to result in -

(A) placing the patient's health in serious jeopardy,

(B) serious impairment to bodily functions, or

(C) serious dysfunction of any bodily organ or part.

(w) Prohibition on use of voluntary contributions, and limitation

on use of provider-specific taxes to obtain Federal financial

participation under medicaid

(1)(A) Notwithstanding the previous provisions of this section,

for purposes of determining the amount to be paid to a State (as

defined in paragraph (7)(D)) under subsection (a)(1) of this

section for quarters in any fiscal year, the total amount expended

during such fiscal year as medical assistance under the State plan

(as determined without regard to this subsection) shall be reduced

by the sum of any revenues received by the State (or by a unit of

local government in the State) during the fiscal year -

(i) from provider-related donations (as defined in paragraph

(2)(A)), other than -

(I) bona fide provider-related donations (as defined in

paragraph (2)(B)), and

(II) donations described in paragraph (2)(C);

(ii) from health care related taxes (as defined in paragraph

(3)(A)), other than broad-based health care related taxes (as

defined in paragraph (3)(B));

(iii) from a broad-based health care related tax, if there is

in effect a hold harmless provision (described in paragraph (4))

with respect to the tax; or

(iv) only with respect to State fiscal years (or portions

thereof) occurring on or after January 1, 1992, and before

October 1, 1995, from broad-based health care related taxes to

the extent the amount of such taxes collected exceeds the limit

established under paragraph (5).

(B) Notwithstanding the previous provisions of this section, for

purposes of determining the amount to be paid to a State under

subsection (a)(7) of this section for all quarters in a Federal

fiscal year (beginning with fiscal year 1993), the total amount

expended during the fiscal year for administrative expenditures

under the State plan (as determined without regard to this

subsection) shall be reduced by the sum of any revenues received by

the State (or by a unit of local government in the State) during

such quarters from donations described in paragraph (2)(C), to the

extent the amount of such donations exceeds 10 percent of the

amounts expended under the State plan under this subchapter during

the fiscal year for purposes described in paragraphs (2), (3), (4),

(6), and (7) of subsection (a) of this section.

(C)(i) Except as otherwise provided in clause (ii), subparagraph

(A)(i) shall apply to donations received on or after January 1,

1992.

(ii) Subject to the limits described in clause (iii) and

subparagraph (E), subparagraph (A)(i) shall not apply to donations

received before the effective date specified in subparagraph (F) if

such donations are received under programs in effect or as

described in State plan amendments or related documents submitted

to the Secretary by September 30, 1991, and applicable to State

fiscal year 1992, as demonstrated by State plan amendments, written

agreements, State budget documentation, or other documentary

evidence in existence on that date.

(iii) In applying clause (ii) in the case of donations received

in State fiscal year 1993, the maximum amount of such donations to

which such clause may be applied may not exceed the total amount of

such donations received in the corresponding period in State fiscal

year 1992 (or not later than 5 days after the last day of the

corresponding period).

(D)(i) Except as otherwise provided in clause (ii), subparagraphs

(A)(ii) and (A)(iii) shall apply to taxes received on or after

January 1, 1992.

(ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to

impermissible taxes (as defined in clause (iii)) received before

the effective date specified in subparagraph (F) to the extent the

taxes (including the tax rate or base) were in effect, or the

legislation or regulations imposing such taxes were enacted or

adopted, as of November 22, 1991.

(iii) In this subparagraph and subparagraph (E), the term

"impermissible tax" means a health care related tax for which a

reduction may be made under clause (ii) or (iii) of subparagraph

(A).

(E)(i) In no case may the total amount of donations and taxes

permitted under the exception provided in subparagraphs (C)(ii) and

(D)(ii) for the portion of State fiscal year 1992 occurring during

calendar year 1992 exceed the limit under paragraph (5) minus the

total amount of broad-based health care related taxes received in

the portion of that fiscal year.

(ii) In no case may the total amount of donations and taxes

permitted under the exception provided in subparagraphs (C)(ii) and

(D)(ii) for State fiscal year 1993 exceed the limit under paragraph

(5) minus the total amount of broad-based health care related taxes

received in that fiscal year.

(F) In this paragraph in the case of a State -

(i) except as provided in clause (iii), with a State fiscal

year beginning on or before July 1, the effective date is October

1, 1992,

(ii) except as provided in clause (iii), with a State fiscal

year that begins after July 1, the effective date is January 1,

1993, or

(iii) with a State legislature which is not scheduled to have a

regular legislative session in 1992, with a State legislature

which is not scheduled to have a regular legislative session in

1993, or with a provider-specific tax enacted on November 4,

1991, the effective date is July 1, 1993.

(2)(A) In this subsection (except as provided in paragraph (6)),

the term "provider-related donation" means any donation or other

voluntary payment (whether in cash or in kind) made (directly or

indirectly) to a State or unit of local government by -

(i) a health care provider (as defined in paragraph (7)(B)),

(ii) an entity related to a health care provider (as defined in

paragraph (7)(C)), or

(iii) an entity providing goods or services under the State

plan for which payment is made to the State under paragraph (2),

(3), (4), (6), or (7) of subsection (a) of this section.

(B) For purposes of paragraph (1)(A)(i)(I), the term "bona fide

provider-related donation" means a provider-related donation that

has no direct or indirect relationship (as determined by the

Secretary) to payments made under this subchapter to that provider,

to providers furnishing the same class of items and services as

that provider, or to any related entity, as established by the

State to the satisfaction of the Secretary. The Secretary may by

regulation specify types of provider-related donations described in

the previous sentence that will be considered to be bona fide

provider-related donations.

(C) For purposes of paragraph (1)(A)(i)(II), donations described

in this subparagraph are funds expended by a hospital, clinic, or

similar entity for the direct cost (including costs of training and

of preparing and distributing outreach materials) of State or local

agency personnel who are stationed at the hospital, clinic, or

entity to determine the eligibility of individuals for medical

assistance under this subchapter and to provide outreach services

to eligible or potentially eligible individuals.

(3)(A) In this subsection (except as provided in paragraph (6)),

the term "health care related tax" means a tax (as defined in

paragraph (7)(F)) that -

(i) is related to health care items or services, or to the

provision of, the authority to provide, or payment for, such

items or services, or

(ii) is not limited to such items or services but provides for

treatment of individuals or entities that are providing or paying

for such items or services that is different from the treatment

provided to other individuals or entities.

In applying clause (i), a tax is considered to relate to health

care items or services if at least 85 percent of the burden of such

tax falls on health care providers.

(B) In this subsection, the term "broad-based health care related

tax" means a health care related tax which is imposed with respect

to a class of health care items or services (as described in

paragraph (7)(A)) or with respect to providers of such items or

services and which, except as provided in subparagraphs (D), (E),

and (F) -

(i) is imposed at least with respect to all items or services

in the class furnished by all non-Federal, nonpublic providers in

the State (or, in the case of a tax imposed by a unit of local

government, the area over which the unit has jurisdiction) or is

imposed with respect to all non-Federal, nonpublic providers in

the class; and

(ii) is imposed uniformly (in accordance with subparagraph

(C)).

(C)(i) Subject to clause (ii), for purposes of subparagraph

(B)(ii), a tax is considered to be imposed uniformly if -

(I) in the case of a tax consisting of a licensing fee or

similar tax on a class of health care items or services (or

providers of such items or services), the amount of the tax

imposed is the same for every provider providing items or

services within the class;

(II) in the case of a tax consisting of a licensing fee or

similar tax imposed on a class of health care items or services

(or providers of such services) on the basis of the number of

beds (licensed or otherwise) of the provider, the amount of the

tax is the same for each bed of each provider of such items or

services in the class;

(III) in the case of a tax based on revenues or receipts with

respect to a class of items or services (or providers of items or

services) the tax is imposed at a uniform rate for all items and

services (or providers of such items or services) in the class on

all the gross revenues or receipts, or net operating revenues,

relating to the provision of all such items or services (or all

such providers) in the State (or, in the case of a tax imposed by

a unit of local government within the State, in the area over

which the unit has jurisdiction); or

(IV) in the case of any other tax, the State establishes to the

satisfaction of the Secretary that the tax is imposed uniformly.

(ii) Subject to subparagraphs (D) and (E), a tax imposed with

respect to a class of health care items and services is not

considered to be imposed uniformly if the tax provides for any

credits, exclusions, or deductions which have as their purpose or

effect the return to providers of all or a portion of the tax paid

in a manner that is inconsistent with subclauses (I) and (II) of

subparagraph (E)(ii) or provides for a hold harmless provision

described in paragraph (4).

(D) A tax imposed with respect to a class of health care items

and services is considered to be imposed uniformly -

(i) notwithstanding that the tax is not imposed with respect to

items or services (or the providers thereof) for which payment is

made under a State plan under this subchapter or subchapter XVIII

of this chapter, or

(ii) in the case of a tax described in subparagraph

(C)(i)(III), notwithstanding that the tax provides for exclusion

(in whole or in part) of revenues or receipts from a State plan

under this subchapter or subchapter XVIII of this chapter.

(E)(i) A State may submit an application to the Secretary

requesting that the Secretary treat a tax as a broad-based health

care related tax, notwithstanding that the tax does not apply to

all health care items or services in class (or all providers of

such items and services), provides for a credit, deduction, or

exclusion, is not applied uniformly, or otherwise does not meet the

requirements of subparagraph (B) or (C). Permissible waivers may

include exemptions for rural or sole-community providers.

(ii) The Secretary shall approve such an application if the State

establishes to the satisfaction of the Secretary that -

(I) the net impact of the tax and associated expenditures under

this subchapter as proposed by the State is generally

redistributive in nature, and

(II) the amount of the tax is not directly correlated to

payments under this subchapter for items or services with respect

to which the tax is imposed.

The Secretary shall by regulation specify types of credits,

exclusions, and deductions that will be considered to meet the

requirements of this subparagraph.

(F) In no case shall a tax not qualify as a broad-based health

care related tax under this paragraph because it does not apply to

a hospital that is described in section 501(c)(3) of the Internal

Revenue Code of 1986 and exempt from taxation under section 501(a)

of such Code and that does not accept payment under the State plan

under this subchapter or under subchapter XVIII of this chapter.

(4) For purposes of paragraph (1)(A)(iii), there is in effect a

hold harmless provision with respect to a broad-based health care

related tax imposed with respect to a class of items or services if

the Secretary determines that any of the following applies:

(A) The State or other unit of government imposing the tax

provides (directly or indirectly) for a payment (other than under

this subchapter) to taxpayers and the amount of such payment is

positively correlated either to the amount of such tax or to the

difference between the amount of the tax and the amount of

payment under the State plan.

(B) All or any portion of the payment made under this

subchapter to the taxpayer varies based only upon the amount of

the total tax paid.

(C) The State or other unit of government imposing the tax

provides (directly or indirectly) for any payment, offset, or

waiver that guarantees to hold taxpayers harmless for any portion

of the costs of the tax.

The provisions of this paragraph shall not prevent use of the tax

to reimburse health care providers in a class for expenditures

under this subchapter nor preclude States from relying on such

reimbursement to justify or explain the tax in the legislative

process.

(5)(A) For purposes of this subsection, the limit under this

subparagraph with respect to a State is an amount equal to 25

percent (or, if greater, the State base percentage, as defined in

subparagraph (B)) of the non-Federal share of the total amount

expended under the State plan during a State fiscal year (or

portion thereof), as it would be determined pursuant to paragraph

(1)(A) without regard to paragraph (1)(A)(iv).

(B)(i) In subparagraph (A), the term "State base percentage"

means, with respect to a State, an amount (expressed as a

percentage) equal to -

(I) the total of the amount of health care related taxes

(whether or not broad-based) and the amount of provider-related

donations (whether or not bona fide) projected to be collected

(in accordance with clause (ii)) during State fiscal year 1992,

divided by

(II) the non-Federal share of the total amount estimated to be

expended under the State plan during such State fiscal year.

(ii) For purposes of clause (i)(I), in the case of a tax that is

not in effect throughout State fiscal year 1992 or the rate (or

base) of which is increased during such fiscal year, the Secretary

shall project the amount to be collected during such fiscal year as

if the tax (or increase) were in effect during the entire State

fiscal year.

(C)(i) The total amount of health care related taxes under

subparagraph (B)(i)(I) shall be determined by the Secretary based

on only those taxes (including the tax rate or base) which were in

effect, or for which legislation or regulations imposing such taxes

were enacted or adopted, as of November 22, 1991.

(ii) The amount of provider-related donations under subparagraph

(B)(i)(I) shall be determined by the Secretary based on programs in

effect on September 30, 1991, and applicable to State fiscal year

1992, as demonstrated by State plan amendments, written agreements,

State budget documentation, or other documentary evidence in

existence on that date.

(iii) The amount of expenditures described in subparagraph

(B)(i)(II) shall be determined by the Secretary based on the best

data available as of December 12, 1991.

(6)(A) Notwithstanding the provisions of this subsection, the

Secretary may not restrict States' use of funds where such funds

are derived from State or local taxes (or funds appropriated to

State university teaching hospitals) transferred from or certified

by units of government within a State as the non-Federal share of

expenditures under this subchapter, regardless of whether the unit

of government is also a health care provider, except as provided in

section 1396a(a)(2) of this title, unless the transferred funds are

derived by the unit of government from donations or taxes that

would not otherwise be recognized as the non-Federal share under

this section.

(B) For purposes of this subsection, funds the use of which the

Secretary may not restrict under subparagraph (A) shall not be

considered to be a provider-related donation or a health care

related tax.

(7) For purposes of this subsection:

(A) Each of the following shall be considered a separate class

of health care items and services:

(i) Inpatient hospital services.

(ii) Outpatient hospital services.

(iii) Nursing facility services (other than services of

intermediate care facilities for the mentally retarded).

(iv) Services of intermediate care facilities for the

mentally retarded.

(v) Physicians' services.

(vi) Home health care services.

(vii) Outpatient prescription drugs.

(viii) Services of a medicaid managed care organization with

a contract under subsection (m) of this section.

(ix) Such other classification of health care items and

services consistent with this subparagraph as the Secretary may

establish by regulation.

(B) The term "health care provider" means an individual or

person that receives payments for the provision of health care

items or services.

(C) An entity is considered to be "related" to a health care

provider if the entity -

(i) is an organization, association, corporation or

partnership formed by or on behalf of health care providers;

(ii) is a person with an ownership or control interest (as

defined in section 1320a-3(a)(3) of this title) in the

provider;

(iii) is the employee, spouse, parent, child, or sibling of

the provider (or of a person described in clause (ii)); or

(iv) has a similar, close relationship (as defined in

regulations) to the provider.

(D) The term "State" means only the 50 States and the District

of Columbia but does not include any State whose entire program

under this subchapter is operated under a waiver granted under

section 1315 of this title.

(E) The "State fiscal year" means, with respect to a specified

year, a State fiscal year ending in that specified year.

(F) The term "tax" includes any licensing fee, assessment, or

other mandatory payment, but does not include payment of a

criminal or civil fine or penalty (other than a fine or penalty

imposed in lieu of or instead of a fee, assessment, or other

mandatory payment).

(G) The term "unit of local government" means, with respect to

a State, a city, county, special purpose district, or other

governmental unit in the State.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1903, as added Pub. L.

89-97, title I, Sec. 121(a), July 30, 1965, 79 Stat. 349; amended

Pub. L. 90-248, title II, Secs. 220(a), 222(c), (d), 225(a),

229(c), 241(f)(5), Jan. 2, 1968, 81 Stat. 898, 901, 902, 904, 917;

Pub. L. 90-364, title III, Sec. 303(a)(1), June 28, 1968, 82 Stat.

274; Pub. L. 91-56, Sec. 2(a), Aug. 9, 1969, 83 Stat. 99; Pub. L.

92-603, title II, Secs. 207(a), 221(c)(6), 224(c), 225, 226(e),

229(c), 230, 233(c), 235(a), 237(a)(1), 249B, 278(b)(1), (5), (7),

(16), 290, 295, 299E(a), Oct. 30, 1972, 86 Stat. 1379, 1389, 1395,

1396, 1404, 1410, 1411, 1414, 1415, 1428, 1453, 1454, 1457, 1459,

1462; Pub. L. 93-66, title II, Sec. 234(a), July 9, 1973, 87 Stat.

160; Pub. L. 93-233, Secs. 13(a)(11), (12), 18(r)-(v), (x)(5), (6),

(y)(1), Dec. 31, 1973, 87 Stat. 963, 971-973; Pub. L. 94-182, title

I, Secs. 110(a), 111(b), Dec. 31, 1975, 89 Stat. 1054; Pub. L.

94-460, title II, Sec. 202(a), Oct. 8, 1976, 90 Stat. 1957; Pub. L.

94-552, Sec. 1, Oct. 18, 1976, 90 Stat. 2540; Pub. L. 95-83, title

I, Sec. 105(a)(1), (2), Aug. 1, 1977, 91 Stat. 384; Pub. L. 95-142,

Secs. 3(c)(2), 8(c), 10(a), 11(a), 17(a)-(c), 20(a), Oct. 25, 1977,

91 Stat. 1179, 1195, 1196, 1201, 1205; Pub. L. 95-559, Sec. 14(c),

Nov. 1, 1978, 92 Stat. 2141; Pub. L. 95-626, title I, Sec.

102(b)(3), Nov. 10, 1978, 92 Stat. 3551; Pub. L. 96-79, title I,

Sec. 128, Oct. 4, 1979, 93 Stat. 629; Pub. L. 96-398, title IX,

Sec. 901, Oct. 7, 1980, 94 Stat. 1609; Pub. L. 96-499, title IX,

Secs. 905(b), (c), 961(a), 963, 964, Dec. 5, 1980, 94 Stat. 2618,

2650, 2651; Pub. L. 97-35, title XXI, Secs. 2101(a)(2), 2103(b)(1),

2106(b)(3), 2113(n), 2161, 2163, 2164(a), 2174(b), 2178(a),

2183(a), Aug. 13, 1981, 95 Stat. 786, 788, 792, 795, 803-806, 809,

813, 816; Pub. L. 97-248, title I, Secs. 133(a), 137(a)(1), (2),

(b)(11)-(16), (27), (g), 146(b), Sept. 3, 1982, 96 Stat. 373, 376,

378, 379, 381, 394; Pub. L. 97-448, title III, Sec. 309(b)(16),

Jan. 12, 1983, 96 Stat. 2409; Pub. L. 98-369, div. B, title III,

Secs. 2303(g)(2), 2363(a)(2), (4), (b), 2364, 2373(b)(11)-(14),

July 18, 1984, 98 Stat. 1066, 1106, 1107, 1111, 1112; Pub. L.

98-617, Sec. 3(a)(6), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99-272,

title IX, Secs. 9503(b), (f), 9507(a), 9512(a), 9517(a), (c)(1),

9518(a), Apr. 7, 1986, 100 Stat. 206, 207, 210, 212, 215, 216; Pub.

L. 99-509, title IX, Secs. 9401(e)(2), 9403(g)(2), 9406(a),

9407(c), 9431(b)(2), 9434(a)(1), (2), (b), Oct. 21, 1986, 100 Stat.

2052, 2055, 2057, 2060, 2066, 2068, 2069; Pub. L. 99-514, title

XVIII, Sec. 1895(c)(2), Oct. 22, 1986, 100 Stat. 2935; Pub. L.

99-603, title I, Sec. 121(b)(2), Nov. 6, 1986, 100 Stat. 3390; Pub.

L. 100-93, Sec. 8(g), (h)(1), Aug. 18, 1987, 101 Stat. 694; Pub. L.

100-203, title IV, Secs. 4112(b), 4113(a)(1), (b)(3), (d)(1),

4118(d)(1), (e)(11), (h)(1), (p)(5), 4211(d)(1), (g), (i),

4212(c)(1), (2), (d)(1), (e)(2), 4213(b)(2), Dec. 22, 1987, 101

Stat. 1330-149, 1330-150, 1330-152, 1330-155, 1330-159, 1330-204,

1330-205, 1330-207, 1330-212, 1330-213, 1330-219, as amended Pub.

L. 100-360, title IV, Sec. 411(a)(3)(A), (B)(iii), (k)(6)(B)(x),

(7)(A), (D), (10)(D), (G)(ii), July 1, 1988, 102 Stat. 768, 794,

796; Pub. L. 100-360, title II, Sec. 202(h)(2), title III, Secs.

301(f), 302(c)(3), (e)(4), title IV, Sec. 411(k)(12)(A), (13)(A),

July 1, 1988, 102 Stat. 718, 750, 752, 753, 797, 798; Pub. L.

100-485, title VI, Sec. 608(d)(26)(K)(ii), (f)(4), Oct. 13, 1988,

102 Stat. 2422, 2424; Pub. L. 101-234, title II, Sec. 201(a), Dec.

13, 1989, 103 Stat. 1981; Pub. L. 101-239, title VI, Secs. 6401(b),

6411(d)(2), 6901(b)(5)(A), Dec. 19, 1989, 103 Stat. 2259, 2271,

2299; Pub. L. 101-508, title IV, Secs. 4401(a)(1), (b)(1), 4402(b),

(d)(3), 4601(a)(3)(A), 4701(b)(2), 4704(b)(1), (2), 4711(c)(2),

4723(a), 4731(a), (b)(2), 4732(a), (b)(2), (c), (d), 4751(b)(1),

4752(a)(2), (b)(1), (e), 4801(a)(8), (e)(16)(A), Nov. 5, 1990, 104

Stat. 1388-143, 1388-159, 1388-163, 1388-164, 1388-166, 1388-170,

1388-172, 1388-187, 1388-194 to 1388-196, 1388-205 to 1388-207,

1388-212, 1388-218; Pub. L. 102-119, Sec. 26(i)(1), Oct. 7, 1991,

105 Stat. 607; Pub. L. 102-234, Secs. 2(a), (b)(2), 3(b)(2)(B),

4(a), Dec. 12, 1991, 105 Stat. 1793, 1799, 1803, 1804; Pub. L.

103-66, title XIII, Secs. 13602(b), 13604(a), 13622(a)(2),

13624(a), 13631(c), (h)(1), Aug. 10, 1993, 107 Stat. 619, 621, 632,

636, 643, 645; Pub. L. 104-193, title I, Sec. 114(d)(2), Aug. 22,

1996, 110 Stat. 2180; Pub. L. 104-248, Sec. 1(b)(1), Oct. 9, 1996,

110 Stat. 3148; Pub. L. 105-12, Sec. 9(b)(1), Apr. 30, 1997, 111

Stat. 26; Pub. L. 105-33, title IV, Secs. 4701(b)(1),

(2)(A)(v)-(viii), (B), (C), (c), (d)(2), 4702(b)(1), 4703(a),

(b)(1), 4705(b), 4706, 4707(b), 4708(a), (d), 4712(b)(2), (c)(2),

4722(a), (b), 4724(a), (b)(1), 4742(a), 4753(a), 4802(b)(2),

4912(b)(2), Aug. 5, 1997, 111 Stat. 492, 493, 495, 500, 501, 505,

506, 509, 514-516, 523, 525, 549, 573; Pub. L. 105-100, title I,

Sec. 162(4), Nov. 19, 1997, 111 Stat. 2189; Pub. L. 106-31, title

III, Sec. 3031(a), (b), May 21, 1999, 113 Stat. 103, 104; Pub. L.

106-113, div. B, Sec. 1000(a)(6) [title VI, Secs. 604(a)(2)(B),

(b)(2), 608(e)-(k), (aa)(2)], Nov. 29, 1999, 113 Stat. 1536,

1501A-395, 1501A-397, 1501A-398; Pub. L. 106-170, title II, Sec.

201(a)(4), (b), title IV, Sec. 407(a)-(c), Dec. 17, 1999, 113 Stat.

1893, 1913; Pub. L. 106-354, Sec. 2(b)(2)(B), Oct. 24, 2000, 114

Stat. 1383; Pub. L. 106-554, Sec. 1(a)(6) [title VII, Secs.

702(c)(1), 710(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-574,

2763A-578.)

-REFTEXT-

REFERENCES IN TEXT

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

subsecs. (b) and (i), are classified to sections 1395c et seq. and

1395j et seq., respectively, of this title.

Subsection (w)(3)(A) of this section, referred to in subsec.

(b)(5), was in the original "section 1902(w)(3)(A)", and was

translated as reading "section 1903(w)(3)(A)", meaning section

1903(w)(3)(A) of the Social Security Act, to reflect the probable

intent of Congress, because section 1902(w)(3), which is classified

to section 1396a(w)(3) of this title, does not contain a subpar.

(A), and subsec. (w)(3)(A) of this section relates to health care

related taxes.

The Individuals with Disabilities Education Act, referred to in

subsec. (c), is title VI of Pub. L. 91-230, Apr. 13, 1970, 84 Stat.

175, as amended. Part B of the Act is classified generally to

subchapter II (Sec. 1411 et seq.) of chapter 33 of Title 20,

Education. Part H of the Act was classified generally to subchapter

VIII (Sec. 1471 et seq.) of chapter 33 of Title 20, prior to repeal

by Pub. L. 105-17, title II, Sec. 203(b), June 4, 1997, 111 Stat.

157, effective July 1, 1998. For complete classification of this

Act to the Code, see section 1400 of Title 20 and Tables.

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

(f), is classified to section 601 et seq. of this title.

Section 300e-9(d) of this title, referred to in subsecs. (g)(1)

and (m)(1)(A), (4)(A), was redesignated section 300e-9(c) of this

title by Pub. L. 100-517, Sec. 7(b), Oct. 24, 1988, 102 Stat. 2580.

The Assisted Suicide Funding Restriction Act of 1997, referred to

in subsec. (i)(16), is Pub. L. 105-12, Apr. 30, 1997, 111 Stat. 23,

which is classified principally to chapter 138 (Sec. 14401 et seq.)

of this title. For complete classification of this Act to the Code,

see Short Title note set out under section 14401 of this title and

Tables.

Part C of subchapter XVIII of this chapter, referred to in

subsec. (m)(1)(A), is classified to section 1395w-21 et seq. of

this title.

Sections 254b and 254c of this title, referred to in subsec.

(m)(2)(B)(i)(I), (G), were in the original references to sections

329 and 330 of the Public Health Service Act, act July 1, 1944,

which were omitted in the general amendment of subpart I (Sec. 254b

et seq.) of part D of subchapter II of chapter 6A of this title by

Pub. L. 104-299, Sec. 2, Oct. 11, 1996, 110 Stat. 3626. Sections 2

and 3(a) of Pub. L. 104-299 enacted new sections 330 and 330A of

act July 1, 1944, which are classified, respectively, to sections

254b and 254c of this title.

The Appalachian Regional Development Act of 1965, referred to in

subsec. (m)(2)(B)(ii), (G), is Pub. L. 89-4, Mar. 9, 1965, 79 Stat.

5, as amended, which was set out in the Appendix to former Title

40, Public Buildings, Property, and Works, and was repealed and

reenacted as subtitle IV (Sec. 14101 et seq.) of Title 40, Public

Buildings, Property, and Works, by Pub. L. 107-217, Secs. 1, 6(b),

Aug. 21, 2002, 116 Stat. 1062, 1304.

Part C of subchapter XI of this chapter, referred to in subsec.

(r)(1)(D), is classified to section 1320d et seq. of this title.

Section 602 of this title, referred to in subsec. (u)(1)(D)(iv),

was repealed and a new section 602 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. (a)(26)(C).

The Internal Revenue Code of 1986, referred to in subsecs.

(d)(3)(B)(i) and (w)(3)(F), is classified generally to Title 26,

Internal Revenue Code.

-MISC1-

AMENDMENTS

2000 - Subsec. (f)(4). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 710(a)], inserted "1396a(a)(10)(A)(ii)(XVII),

1396a(a)(10)(A)(ii)(XVIII)," after "1396a(a)(10)(A)(ii)(XVI),".

Subsec. (m)(2)(A)(ix). Pub. L. 106-554, Sec. 1(a)(6) [title VII,

Sec. 702(c)(1)], repealed Pub. L. 105-33, Sec. 4712(c)(2). See 1997

Amendment note below.

Subsec. (u)(1)(D)(v). Pub. L. 106-354 substituted ", for items"

for "or for items" and inserted before period at end ", or for

medical assistance provided to an individual described in

subsection (a) of section 1396r-1b of this title during a

presumptive eligibility period under such section".

1999 - Subsec. (a)(3)(C)(i). Pub. L. 106-113, Sec. 1000(a)(6)

[title VI, Sec. 604(a)(2)(B)], struck out "or quality review" after

"medical and utilization review".

Subsec. (b)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(e)], inserted "of" after "for the use" in introductory

provisions.

Subsec. (d)(3). Pub. L. 106-31, Sec. 3031(a), designated existing

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

Subsec. (d)(3)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(f)], realigned margins.

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

608(g)], struck out second period at end.

Subsec. (f)(4). Pub. L. 106-170, Sec. 201(b), inserted

"1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI)," before

"1396d(p)(1)" in introductory provisions.

Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec. 608(aa)(2)],

substituted "1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV),

or 1396d(p)(1) of this title" for "1396d(p)(1), or 1396d(u) of this

title" in introductory provisions.

Subsec. (i)(14). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec.

608(h)], inserted "or" after semicolon.

Subsec. (i)(19). Pub. L. 106-31, Sec. 3031(b), added par. (19).

Subsec. (i)(20). Pub. L. 106-170, Sec. 201(a)(4), added par.

(20).

Subsec. (m)(2)(A)(vi). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 608(i)(1)], struck out semicolon after "section

1396u-2(a)(4) of this title".

Subsec. (m)(2)(A)(xi), (xii). Pub. L. 106-113, Sec. 1000(a)(6)

[title VI, Sec. 608(i)(2)], redesignated cl. (xi), relating to

section 1396u-2, as (xii).

Subsec. (m)(6)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 604(b)(2)(A)], inserted "and" at end.

Subsec. (m)(6)(B)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 604(b)(2)(B)], substituted a period for "; and" at end.

Subsec. (m)(6)(B)(iv). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 604(b)(2)(C)], struck out cl. (iv) which read as follows:

"that the State agency will contract, for purposes of meeting the

requirement under section 1396a(a)(30)(C) of this title, with an

organization or entity that under section 1320c-3 of this title

reviews services provided by an eligible organization pursuant to a

contract under section 1395mm of this title for the purpose of

determining whether the quality of services meets professionally

recognized standards of health care."

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

608(j)], struck out second closing parenthesis after "section

1167(1) of title 29".

Subsec. (q)(3). Pub. L. 106-170, Sec. 407(a), inserted "(A)"

after "in connection with" and added subpar. (B).

Subsec. (q)(4). Pub. L. 106-170, Sec. 407(c), amended par. (4)

generally. Prior to amendment, par. (4) read as follows: "The

entity has procedures for reviewing complaints of the abuse and

neglect of patients of health care facilities which receive

payments under the State plan under this subchapter, and, where

appropriate, for acting upon such complaints under the criminal

laws of the State or for referring them to other State agencies for

action."

Subsec. (q)(5). Pub. L. 106-170, Sec. 407(b), inserted "or under

any Federal health care program (as so defined)" before "to health

care facilities" and inserted at end "All funds collected in

accordance with this paragraph shall be credited exclusively to,

and available for expenditure under, the Federal health care

program (including the State plan under this subchapter) that was

subject to the activity that was the basis for the collection."

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

Sec. 608(k)(1)], substituted "purposes" for "puroses".

Subsec. (w)(3)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI,

Sec. 608(k)(2)], inserted a comma after "(D)" in introductory

provisions.

Subsec. (w)(7)(A)(viii). Pub. L. 106-113, Sec. 1000(a)(6) [title

VI, Sec. 608(k)(3)], realigned margins.

1997 - Subsec. (a)(3)(C). Pub. L. 105-33, Sec. 4705(b),

designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (b)(4). Pub. L. 105-33, Sec. 4707(b), added par. (4).

Subsec. (b)(5). Pub. L. 105-33, Sec. 4722(b), added par. (5).

Subsec. (f)(4). Pub. L. 105-100 substituted "1396d(p)(1), or

1396d(u) of this title" for "or 1396d(p)(1) of this title" in

introductory provisions.

Subsec. (f)(4)(C). Pub. L. 105-33, Sec. 4802(b)(2), inserted "or

who is a PACE program eligible individual enrolled in a PACE

program under section 1396u-4 of this title," after "section

1396a(a)(10)(A) of this title,".

Subsec. (i). Pub. L. 105-33, Sec. 4708(d), inserted at end of

closing provisions "Paragraphs (1), (2), (16), (17), and (18) shall

apply with respect to items or services furnished and amounts

expended by or through a managed care entity (as defined in section

1396u-2(a)(1)(B) of this title) in the same manner as such

paragraphs apply to items or services furnished and amounts

expended directly by the State."

Subsec. (i)(2). Pub. L. 105-33, Sec. 4724(a)(1), substituted ";

or" for the period at end.

Subsec. (i)(10)(B), (11). Pub. L. 105-33, Sec. 4724(a)(2),

inserted "or" at end.

Subsec. (i)(12). Pub. L. 105-33, Sec. 4742(a), struck out par.

(12) which related to restrictions on payments, on or after Jan. 1,

1992, for physicians' services to children under 21 years of age

and to pregnant women.

Subsec. (i)(13). Pub. L. 105-33, Sec. 4724(a)(2), inserted "or"

at end.

Subsec. (i)(16). Pub. L. 105-12 added par. (16).

Subsec. (i)(17). Pub. L. 105-33, Sec. 4724(a)(1), (3), added par.

(17).

Subsec. (i)(18). Pub. L. 105-33, Sec. 4724(b)(1), added par.

(18).

Subsec. (k). Pub. L. 105-33, Sec. 4701(b)(2)(A)(v), substituted

"medicaid managed care organization" for "health maintenance

organization".

Subsec. (m)(1)(A). Pub. L. 105-33, Sec. 4701(b)(1), in

introductory provisions, substituted "The term 'medicaid managed

care organization' means a health maintenance organization, an

eligible organization with a contract under section 1395mm of this

title or a Medicare+Choice organization with a contract under part

C of subchapter XVIII of this chapter, a provider sponsored

organization, or any other public or private organization, which

meets the requirement of section 1396a(w) of this title and - " for

"The term 'health maintenance organization' means a public or

private organization, organized under the laws of any State, which

meets the requirement of section 1396a(w) of this title is a

qualified health maintenance organization (as defined in section

300e-9(d) of this title) or which meets the requirement of section

1396a(a) of this title and - " and inserted as closing provisions

"An organization that is a qualified health maintenance

organization (as defined in section 300e-9(d) of this title) is

deemed to meet the requirements of clauses (i) and (ii)."

Subsec. (m)(1)(A)(ii). Pub. L. 105-33, Sec. 4706(1), inserted ",

meets the requirements of subparagraph (C)(i) (if applicable),"

after "provision is satisfactory to the State".

Subsec. (m)(1)(B). Pub. L. 105-33, Sec. 4701(b)(2)(A)(vi),

substituted "medicaid managed care organization" for "health

maintenance organization".

Subsec. (m)(1)(C). Pub. L. 105-33, Sec. 4706(2), added subpar.

(C).

Subsec. (m)(2)(A)(i). Pub. L. 105-33, Sec. 4701(b)(2)(A)(vii),

substituted "medicaid managed care organization" for "health

maintenance organization".

Subsec. (m)(2)(A)(ii). Pub. L. 105-33, Sec. 4703(a), struck out

cl. (ii) which read as follows: "less than 75 percent of the

membership of the entity which is enrolled on a prepaid basis

consists of individuals who (I) are insured for benefits under part

B of subchapter XVIII of this chapter or for benefits under both

parts A and B of such subchapter, or (II) are eligible to receive

benefits under this subchapter;".

Subsec. (m)(2)(A)(iii). Pub. L. 105-33, Sec. 4708(a), substituted

"$1,000,000 for 1998 and, for a subsequent year, the amount

established udner this clause for the previous year increased by

the percentage increase in the consumer price index for all urban

consumers over the previous year" for "$100,000".

Subsec. (m)(2)(A)(vi). Pub. L. 105-33, Sec. 4701(d)(2)(A), struck

out "except as provided under subparagraph (F)," after "such

contract (I)", substituted "in accordance with section

1396u-2(a)(4) of this title;" for "without cause as of the

beginning of the first calendar month following a full calendar

month after the request is made for such termination", and inserted

"in accordance with such section" after "provides for

notification".

Subsec. (m)(2)(A)(ix). Pub. L. 105-33, Sec. 4712(c)(2), which

directed the repeal of subsec. (m)(2)(A)(ix), was repealed by Pub.

L. 106-554, Sec. 1(a)(6) [title VII, Sec. 702(c)(1)]. See 2000

Amendment note above and Effective Date of 1997 Amendment note

below.

Pub. L. 105-33, Sec. 4712(b)(2), amended cl. (ix) generally.

Prior to amendment, cl. (ix) read as follows: "such contract

provides, in the case of an entity that has entered into a contract

for the provision of services of such center with a federally

qualified health center, that (I) rates of prepayment from the

State are adjusted to reflect fully the rates of payment specified

in section 1396a(a)(13)(E) of this title, and (II) at the election

of such center payments made by the entity to such a center for

services described in 1396d(a)(2)(C) of this title are made at the

rates of payment specified in section 1396a(a)(13)(E) of this

title;".

Subsec. (m)(2)(A)(xi). Pub. L. 105-33, Sec. 4701(c), added cl.

(xi) relating to section 1396u-2.

Subsec. (m)(2)(C) to (E). Pub. L. 105-33, Sec. 4703(b)(1)(A),

struck out subpars. (C) to (E) which read as follows:

"(C) Subparagraph (A)(ii) shall not apply with respect to

payments under this subchapter to a State with respect to

expenditures incurred by it for payment for services by an entity

during the three-year period beginning on October 8, 1976, or

beginning on the date the entity qualifies as a health maintenance

organization (as determined by the Secretary), whichever occurs

later, but only if the entity demonstrates to the satisfaction of

the Secretary by the submission of plans for each year of such

three-year period that it is making continuous efforts and progress

toward achieving compliance with subparagraph (A)(ii).

"(D) In the case of a health maintenance organization that is a

public entity, the Secretary may modify or waive the requirement

described in subparagraph (A)(ii) but only if the Secretary

determines that the organization has taken and is taking reasonable

efforts to enroll individuals who are not entitled to benefits

under the State plan approved under this subchapter or under

subchapter XVIII of this chapter.

"(E) In the case of a health maintenance organization that -

"(i) is a nonprofit organization with at least 25,000 members,

"(ii) is and has been a qualified health maintenance

organization (as defined in section 300e-9(d) of this title) for

a period of at least four years,

"(iii) provides basic health services through members of the

staff of the organization,

"(iv) is located in an area designated as medically underserved

under section 300e-1(7) of this title, and

"(v) previously received a waiver of the requirement described

in subparagraph (A)(ii) under section 1315 of this title,

the Secretary may modify or waive the requirement described in

subparagraph (A)(ii) but only if the Secretary determines that

special circumstances warrant such modification or waiver and that

the organization has taken and is taking reasonable efforts to

enroll individuals who are not entitled to benefits under the State

plan approved under this subchapter or under subchapter XVIII of

this chapter."

Subsec. (m)(2)(F). Pub. L. 105-33, Sec. 4701(d)(2)(B), struck out

subpar. (F) which read as follows: "In the case of -

"(i) a contract with an entity described in subparagraph (E) or

(G), with a qualified health maintenance organization (as defined

in section 300e-9(d) of this title) which meets the requirement

of subparagraph (A)(ii), or or with an eligible organization with

a contract under section 1395mm of this title which meets the

requirement of subparagraph (A)(ii), or

"(ii) a program pursuant to an undertaking described in

paragraph (6) in which at least 25 percent of the membership

enrolled on a prepaid basis are individuals who (I) are not

insured for benefits under part B of subchapter XVIII of this

chapter or eligible for benefits under this subchapter, and (II)

(in the case of such individuals whose prepayments are made in

whole or in part by any government entity) had the opportunity at

the time of enrollment in the program to elect other coverage of

health care costs that would have been paid in whole or in part

by any governmental entity,

a State plan may restrict the period in which requests for

termination of enrollment without cause under subparagraph

(A)(vi)(I) are permitted to the first month of each period of

enrollment, each such period of enrollment not to exceed six months

in duration, but only if the State provides notification, at least

twice per year, to individuals enrolled with such entity or

organization of the right to terminate such enrollment and the

restriction on the exercise of this right. Such restriction shall

not apply to requests for termination of enrollment for cause."

Subsec. (m)(2)(G). Pub. L. 105-33, Sec. 4703(b)(1)(B),

substituted "clause (i)" for "clauses (i) and (ii)".

Subsec. (m)(2)(H). Pub. L. 105-33, Sec. 4702(b)(1)(B), in

concluding provisions, inserted before period at end "or with the

manager described in such clause if the manager continues to have a

contract described in section 1396d(t)(3) of this title with the

State".

Pub. L. 105-33, Sec. 4701(b)(2)(B), struck out "health

maintenance" before "organization described" in concluding

provisions.

Subsec. (m)(2)(H)(i). Pub. L. 105-33, Sec. 4702(b)(1)(A),

inserted "or with a primary care case manager with a contract

described in section 1396d(t)(3) of this title" before comma at

end.

Pub. L. 105-33, Sec. 4701(b)(2)(A)(vii), substituted "medicaid

managed care organization" for "health maintenance organization".

Subsec. (m)(4)(A). Pub. L. 105-33, Sec. 4701(b)(2)(A)(viii),

substituted "Each medicaid managed care organization" for "Each

health maintenance organization".

Subsec. (r)(1). Pub. L. 105-33, Sec. 4753(a)(1), added par. (1)

and struck out former par. (1) which read as follows:

"(1)(A) In order to receive payments under paragraphs (2)(A) and

(7) of subsection (a) of this section without being subject to per

centum reductions set forth in subparagraph (C) of this paragraph,

a State must provide that mechanized claims processing and

information retrieval systems of the type described in subsection

(a)(3)(B) of this section and detailed in an advance planning

document approved by the Secretary are operational on or before the

deadline established under subparagraph (B).

"(B) The deadline for operation of such systems for a State is

September 30, 1985.

"(C) If a State fails to meet the deadline established under

subparagraph (B), the per centums specified in paragraphs (2)(A)

and (7) of subsection (a) of this section with respect to that

State shall each be reduced by 5 percentage points for the first

two quarters beginning on or after such deadline, and shall be

further reduced by an additional 5 percentage points after each

period consisting of two quarters during which the Secretary

determines the State fails to meet the requirements of subparagraph

(A); except that -

"(i) neither such per centum may be reduced by more than 25

percentage points by reason of this paragraph; and

"(ii) no reduction shall be made under this paragraph for any

quarter following the quarter during which such State meets the

requirements of subparagraph (A)."

Subsec. (r)(2). Pub. L. 105-33, Sec. 4753(a)(1), (2)(B), (D),

inserted introductory provisions, redesignated par. (5)(A)(i) to

(iii) as par. (2)(A) to (C), and struck out former par. (2) which

read as follows:

"(2)(A) In order to receive payments under paragraphs (2)(A) and

(7) of subsection (a) of this section without being subject to the

per centum reductions set forth in subparagraph (C) of this

paragraph, a State must have its mechanized claims processing and

information retrieval systems, of the type required to be

operational under paragraph (1), initially approved by the

Secretary in accordance with paragraph (5)(A) on or before the

deadline established under subparagraph (B).

"(B) The deadline for approval of such systems for a State is the

last day of the fourth quarter that begins after the date on which

the Secretary determines that such systems became operational as

required under paragraph (1).

"(C) If a State fails to meet the deadline established under

subparagraph (B), the per centums specified in paragraphs (2)(A)

and (7) of subsection (a) of this section with respect to that

State shall each be reduced by 5 percentage points for the first

two quarters beginning after such deadline, and shall be further

reduced by an additional 5 percentage points at the end of each

period consisting of two quarters during which the State fails to

meet the requirements of subparagraph (A); except that -

"(i) neither such per centum may be reduced by more than 25

percentage points by reason of this paragraph, and

"(ii) no reduction shall be made under this paragraph for any

quarter following the quarter during which such State's systems

are approved by the Secretary as provided in subparagraph (A).

"(D) Any State's systems which are approved by the Secretary for

purposes of subsection (a)(3)(B) of this section on or before

October 7, 1980, shall be deemed to be initially approved for

purposes of this subsection."

Subsec. (r)(3), (4). Pub. L. 105-33, Sec. 4753(a)(1), struck out

pars. (3) and (4) which related to Federal matching funds and

Secretary's periodic review of approved retrieval systems.

Subsec. (r)(5). Pub. L. 105-33, Sec. 4753(a)(2), struck out

introductory provisions relating to requirements for Secretary's

initial approval of mechanized claims processing and information

retrieval systems and struck out "under paragraph (6)" before

period at end of subpar. (A)(iii), redesignated subpar. (A)(i) to

(iii) as par. (2)(A) to (C), and struck out subpar. (B) which

related to requirements for Secretary's reapproval of mechanized

claims processing and information retrieval systems.

Subsec. (r)(6) to (8). Pub. L. 105-33, Sec. 4753(a)(3), struck

out pars. (6) to (8) which related to Secretary's development of

performance standards for approval of State mechanized processing

claims and information retrieval systems, waiver of certain

requirements for initial operation, and applicability of per centum

reductions in certain situations.

Subsec. (u)(1)(D)(v). Pub. L. 105-33, Sec. 4912(b)(2), inserted

before period at end "or for items and services described in

subsection (a) of section 1396r-1a of this title provided to a

child during a presumptive eligibility period under such section".

Subsec. (w)(3)(B). Pub. L. 105-33, Sec. 4722(a)(1), substituted

"(E), and (F)" for "and (E)" in introductory provisions.

Subsec. (w)(3)(F). Pub. L. 105-33, Sec. 4722(a)(2), added subpar.

(F).

Subsec. (w)(7)(A)(viii). Pub. L. 105-33, Sec. 4701(b)(2)(C),

amended cl. (viii) generally. Prior to amendment, cl. (viii) read

as follows: "Services of health maintenance organizations (and

other organizations with contracts under subsection (m) of this

section)."

1996 - Subsec. (i)(9). Pub. L. 104-193 struck out par. (9) which

read as follows: "with respect to any amount of medical assistance

for pregnant women and children described in section

1396a(a)(10)(A)(ii)(IX) of this title, if the State has in effect,

under its plan established under part A of subchapter IV of this

chapter, payment levels that are less than the payment levels in

effect under such plan on July 1, 1987;".

Subsec. (i)(12)(A)(i). Pub. L. 104-248, Sec. 1(b)(1)(A), inserted

"or is certified in family practice or pediatrics by the medical

specialty board recognized by the American Osteopathic Association"

before comma at end.

Subsec. (i)(12)(A)(vi). Pub. L. 104-248, Sec. 1(b)(1)(C)(i),

(iii), (iv), added cl. (vi) and redesignated former cl. (vi) as

(vii).

Pub. L. 104-248, Sec. 1(b)(1)(C)(ii), inserted "(or certified by

the State in accordance with policies of the Secretary)" after

"Secretary".

Subsec. (i)(12)(A)(vii). Pub. L. 104-248, Sec. 1(b)(1)(C)(iii),

redesignated cl. (vi) as (vii).

Subsec. (i)(12)(B)(i). Pub. L. 104-248, Sec. 1(b)(1)(B), inserted

"or is certified in family practice or obstetrics by the medical

specialty board recognized by the American Osteopathic Association"

before comma at end.

Subsec. (i)(12)(B)(vi). Pub. L. 104-248, Sec. 1(b)(1)(C)(i),

(iii), (iv), added cl. (vi) and redesignated former cl. (vi) as

(vii).

Pub. L. 104-248, Sec. 1(b)(1)(C)(ii), inserted "(or certified by

the State in accordance with policies of the Secretary)" after

"Secretary".

Subsec. (i)(12)(B)(vii). Pub. L. 104-248, Sec. 1(b)(1)(C)(iii),

redesignated cl. (vi) as (vii).

1993 - Subsec. (i)(10). Pub. L. 103-66, Sec. 13631(c)(1), which

directed the amendment of par. (10) by striking all that follows

"1396r-8(g) of this title" and inserting a semicolon, could not be

executed because "1396r-8(g) of this title" did not appear

subsequent to the general amendment of par. (10) by Pub. L. 103-66,

Sec. 13602(b). See below.

Pub. L. 103-66, Sec. 13602(b), amended par. (10) generally. Prior

to amendment, par. (10) read as follows: "with respect to covered

outpatient drugs of a manufacturer dispensed in any State unless,

(A) except as provided in section 1396r-8(a)(3) of this title, the

manufacturer complies with the rebate requirements of section

1396r-8(a) of this title with respect to the drugs so dispensed in

all States, and (B) effective January 1, 1993, the State provides

for drug use review in accordance with section 1396r-8(g) of this

title; or".

Subsec. (i)(11). Pub. L. 103-66, Sec. 13631(c)(2), redesignated

par. (12) as (11), transferred such par. to appear after par. (10),

and substituted semicolon for period at end. Former par. (11)

redesignated (13).

Subsec. (i)(12). Pub. L. 103-66, Sec. 13631(c)(3), redesignated

par. (14) as (12), transferred such par. to appear after par. (11),

as redesignated by Pub. L. 103-66, Sec. 13631(c)(2), and

substituted semicolon for period at end. Former par. (12)

redesignated (11).

Subsec. (i)(13). Pub. L. 103-66, Sec. 13631(c)(4), redesignated

par. (11) as (13), transferred such par. to appear after par. (12),

as redesignated by Pub. L. 103-66, Sec. 13631(c)(3), and directed

substitution of "; or" for period at end.

Subsec. (i)(14). Pub. L. 103-66, Sec. 13631(c)(5), added par.

(14).

Subsec. (i)(15). Pub. L. 103-66, Sec. 13631(h)(1), added par.

(15).

Subsec. (o). Pub. L. 103-66, Sec. 13622(a)(2), substituted

"regulation and including a group health plan (as defined in

section 1167(1) of title 29)), a service benefit plan, and a health

maintenance organization)" for "regulation)".

Subsec. (s). Pub. L. 103-66, Sec. 13624(a), added subsec. (s).

Subsec. (v)(2)(C). Pub. L. 103-66, Sec. 13604(a), added subpar.

(C).

1991 - Subsec. (a)(1). Pub. L. 102-234, Sec. 3(b)(2)(B), inserted

"and section 1396r-4(f) of this title" after "of this section".

Subsec. (c). Pub. L. 102-119 substituted "child with a

disability" for "handicapped child", "Individuals with Disabilities

Education Act" for "Education of the Handicapped Act", and "an

infant or toddler with a disability" for "a handicapped infant or

toddler".

Subsec. (d)(6). Pub. L. 102-234, Sec. 4(a), added par. (6).

Subsec. (i)(10). Pub. L. 102-234, Sec. 2(b)(2), struck out par.

(10) added by Pub. L. 101-508, Sec. 4701(b)(2)(B), which read as

follows: "with respect to any amount expended for medical

assistance for care or services furnished by a hospital, nursing

facility, or intermediate care facility for the mentally retarded

to reimburse the hospital or facility for the costs attributable to

taxes imposed by the State soley [sic] with respect to hospitals or

facilities."

Subsec. (w). Pub. L. 102-234, Sec. 2(a), added subsec. (w).

1990 - Subsec. (a)(1). Pub. L. 101-508, Sec. 4402(d)(3), struck

out before semicolon "(including expenditures for medicare

cost-sharing and including expenditures 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, or part A of subchapter IV, 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 sixty-five years of age or older and

disabled individuals entitled to hospital 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)(2)(B). Pub. L. 101-508, Sec. 4801(a)(8), substituted

"October 1, 1990" for "July 1, 1990".

Subsec. (a)(3)(C), (D). Pub. L. 101-508, Sec. 4401(b)(1),

substituted "and" for "plus" at end of subpar. (C) and added

subpar. (D).

Subsec. (f)(2). Pub. L. 101-508, Sec. 4723(a), inserted "(A)"

after "(2)" and added cl. (B).

Subsec. (f)(4). Pub. L. 101-508, Sec. 4601(a)(3)(A), substituted

"1396a(a)(10)(A)(i)(III), 1396a(a)(10) (A)(i)(IV),

1396a(a)(10)(A)(i)(V), 1396a(a)(10) (A)(i)(VI),

1396a(a)(10)(A)(i)(VII)" for "1396a(a)(10) (A)(i)(IV),

1396a(a)(10)(A)(i)(VI)".

Subsec. (i)(8). Pub. L. 101-508, Sec. 4711(c)(2), inserted "(A)"

after "medical assistance" and added cl. (B).

Subsec. (i)(10). Pub. L. 101-508, Sec. 4701(b)(2), added par.

(10) relating to any amount expended for medical assistance for

care or services.

Pub. L. 101-508, Sec. 4401(a)(1), added par. (10) relating to

covered outpatient drugs.

Subsec. (i)(11). Pub. L. 101-508, Sec. 4801(e)(16)(A), added par.

(11).

Subsec. (i)(12). Pub. L. 101-508, Sec. 4752(a)(2), added par.

(12).

Subsec. (i)(14). Pub. L. 101-508, Sec. 4752(e), added par. (14).

Subsec. (m)(1)(A). Pub. L. 101-508, Sec. 4751(b)(1), inserted

"meets the requirement of section 1396a(w) of this title" after

"State, which" and "meets the requirement of section 1396a(a) of

this title and" after "or which".

Subsec. (m)(2)(A)(i). Pub. L. 101-508, Sec. 4732(d)(1), struck

out "(or the State as authorized by paragraph (3))" after "the

Secretary".

Subsec. (m)(2)(A)(ix). Pub. L. 101-508, Sec. 4704(b)(1), added

cl. (ix).

Subsec. (m)(2)(A)(x). Pub. L. 101-508, Sec. 4731(a), added cl.

(x).

Subsec. (m)(2)(A)(xi). Pub. L. 101-508, Sec. 4752(b)(1), added

cl. (xi).

Subsec. (m)(2)(B). Pub. L. 101-508, Sec. 4704(b)(2), inserted

"except with respect to clause (ix) of subparagraph (A)," after

"Subparagraph (A)".

Subsec. (m)(2)(D). Pub. L. 101-508, Sec. 4732(a), struck out "(i)

special circumstances warrant such modification or waiver, and

(ii)" after "the Secretary determines that".

Subsec. (m)(2)(F)(i). Pub. L. 101-508, Sec. 4732(b)(2),

substituted "(G)," for "(G) or" and inserted at end "or with an

eligible organization with a contract under section 1395mm of this

title which meets the requirement of subparagraph (A)(ii), or".

Subsec. (m)(2)(H). Pub. L. 101-508, Sec. 4732(c), added subpar.

(H).

Subsec. (m)(3). Pub. L. 101-508, Sec. 4732(d)(2), struck out par.

(3) which read as follows: "A State may, in the case of an entity

which has submitted an application to the Secretary for

determination that it is a health maintenance organization within

the meaning of paragraph (1) and for which no such determination

has been made within 90 days of the submission of the application,

make a provisional determination for the purposes of this

subchapter that such entity is such a health maintenance

organization. Such provisional determination shall remain in force

until such time as the Secretary makes a determination regarding

the entity's qualification under paragraph (1)."

Subsec. (m)(5)(A)(v). Pub. L. 101-508, Sec. 4731(b)(2), added cl.

(v).

Subsec. (u)(1)(D)(iv). Pub. L. 101-508, Sec. 4402(b), which

directed amendment of subpar. (C)(iv) by inserting before period at

end "or with respect to payments made in violation of section 1396e

of this title", was executed to subpar. (D)(iv) to reflect the

probable intent of Congress because subpar. (C) does not have a cl.

(iv).

1989 - Subsec. (a)(2)(B). Pub. L. 101-239, Sec. 6901(b)(5)(A),

inserted "(including the costs for nurse aides to complete such

competency evaluation programs)" after "1396r(e)(1) of this title"

and "(or, for calendar quarters beginning on or after July 1, 1988,

and before July 1, 1990, the lesser of 90 percent or the Federal

medical assistance percentage plus 25 percentage points)" after "50

percent".

Subsec. (f)(4). Pub. L. 101-239, Sec. 6401(b), inserted

"1396a(a)(10)(A)(i)(VI)," after "1396a(a)(10)(A) (i)(IV),".

Subsec. (i)(2). Pub. L. 101-239, Sec. 6411(d)(2), inserted ", not

including items or services furnished in an emergency room of a

hospital" after "emergency item or service".

Subsec. (i)(5). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.

202(h)(2), 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.

1988 - Subsec. (a)(1). Pub. L. 100-360, Sec. 301(f), amended Pub.

L. 99-509, Sec. 9403(g)(2), see 1986 Amendment note below.

Subsec. (c). Pub. L. 100-360, Sec. 411(k)(13)(A), added subsec.

(c).

Subsec. (f)(2). Pub. L. 100-360, Sec. 411(k)(10)(G)(ii), amended

Pub. L. 100-203, Sec. 4118(h)(1), see 1987 Amendment note below.

Subsec. (f)(4). Pub. L. 100-360, Sec. 302(e)(4), inserted

"1396a(a)(10)(A)(i)(IV)," before "1396a(a)(10)(A)(ii)(IX)" in

introductory provisions.

Subsec. (i)(2)(A). Pub. L. 100-360, Sec. 411(k)(10)(D), as

amended by Pub. L. 100-485, Sec. 608(d)(26)(K)(ii), added Pub. L.

100-203, Sec. 4118(e)(11)(A), see 1987 Amendment note below.

Subsec. (i)(2)(B). Pub. L. 100-360, Sec. 411(k)(10)(D), as

amended by Pub. L. 100-485, Sec. 608(d)(26)(K)(ii), added Pub. L.

100-203, Sec. 4118(e)(11)(B), see 1987 Amendment note below.

Subsec. (i)(3). Pub. L. 100-360, Sec. 411(k)(6)(B)(x), added Pub.

L. 100-203, Sec. 4112(b), see 1987 Amendment note below.

Subsec. (i)(5). Pub. L. 100-360, Sec. 202(h)(2), substituted

"section 1395y(c)(1)" for "section 1395y(c)".

Subsec. (i)(9). Pub. L. 100-360, Sec. 302(c)(3), added par. (9).

Subsec. (m)(2)(B)(i)(II). Pub. L. 100-485, Sec. 608(f)(4),

substituted "1396a(a)(10)(D) of this title" for

"1396a(a)(13)(A)(ii) of this title".

Subsec. (m)(2)(F). Pub. L. 100-360, Sec. 411(k)(7)(D), repealed

Pub. L. 100-203, Sec. 4113(d)(1), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(iii), (k)(7)(A), amended

Pub. L. 100-203, Sec. 4113(a)(1)(B), see 1987 Amendment note below.

Subsec. (m)(5). Pub. L. 100-360, Sec. 411(k)(12)(A), amended par.

(5) generally. Prior to amendment, par. (5) read as follows:

"(A) Any entity with a contract under this subsection that fails

substantially to provide medically necessary items and services

that are required (under law or such contract) to be provided to

individuals covered under such contract, if the failure has

adversely affected (or has a substantial likelihood of adversely

affecting) these individuals, is subject to a civil money penalty

of not more than $10,000 for each such failure.

"(B) The provisions of section 1320a-7a of this title (other than

subsection (a)) shall apply to a civil money penalty under

subparagraph (A) in the same manner as they apply to a civil money

penalty under that section."

1987 - Subsec. (a)(1). Pub. L. 100-203, Sec. 4211(g)(2),

substituted "and (j)" for ", (h), and (j)".

Subsec. (a)(2)(A) to (C). Pub. L. 100-203, Sec. 4211(d)(1),

designated existing provisions as subpar. (A) and added subpars.

(B) and (C).

Subsec. (a)(2)(D). Pub. L. 100-203, Sec. 4212(c)(1), added

subpar. (D).

Subsec. (a)(3)(C). Pub. L. 100-203, Sec. 4113(b)(3), inserted "or

by an entity which meets the requirements of section 1320c-1 of

this title, as determined by the Secretary," after "organization".

Subsec. (a)(7). Pub. L. 100-203, Sec. 4212(e)(2), inserted

"subject to section 1396r(g)(3)(B) of this title," after "(7)".

Subsec. (f)(2). Pub. L. 100-203, Sec. 4118(h)(1), as amended by

Pub. L. 100-360, Sec. 411(k)(10)(G)(ii), substituted "(whether in

the form of insurance premiums or otherwise and regardless of

whether such costs are reimbursed under another public program of

the State or political subdivision thereof)" for "(whether in the

form of insurance premiums or otherwise)".

Subsec. (f)(4). Pub. L. 100-203, Sec. 4118(p)(5), inserted ",

1396a(a)(10)(A)(ii)(X), or 1396d(p)(1)" after

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

Subsec. (g)(1). Pub. L. 100-203, Sec. 4212(d)(1)(A), substituted

"or services in an intermediate care facility for the mentally

retarded" for first reference to "or intermediate care facility

services", struck out ", skilled nursing facility services for 30

days," after first reference to "60 days", substituted "or services

in an intermediate care facility for the mentally retarded" for ",

skilled nursing facility services, or intermediate care facility

services", and substituted "and intermediate care facilities for

the mentally retarded" for ", skilled nursing facilities, and

intermediate care facilities".

Subsec. (g)(4)(B). Pub. L. 100-203, Sec. 4212(d)(1)(B),

substituted "and intermediate care facilities for the mentally

retarded" for ", skilled nursing facilities, and intermediate care

facilities".

Subsec. (g)(6)(B) to (D). Pub. L. 100-203, Sec. 4212(d)(1)(C),

redesignated subpar. (C) as (B) and substituted "services in an

intermediate care facility for the mentally retarded" for

"intermediate care facility services", redesignated subpar. (D) as

(C), and struck out former subpar. (B) which read as follows: "Such

recertifications in the case of skilled nursing facility services

shall be conducted at least -

"(i) 30 days after the date of the initial certification,

"(ii) 60 days after the date of the initial certification,

"(iii) 90 days after the date of the initial certification, and

"(iv) every 60 days thereafter."

Subsec. (g)(7). Pub. L. 100-203, Sec. 4212(d)(1)(D), struck out

par. (7) which read as follows: "It is the duty and responsibility

of the Secretary to assure that standards which govern the

provision of care in skilled nursing facilities and intermediate

care facilities under plans approved under this subchapter, and the

enforcement of such standards, are adequate to protect the health

and safety of residents and to promote the effective and efficient

use of public moneys."

Subsec. (h). Pub. L. 100-203, Sec. 4211(g)(1), struck out subsec.

(h) which related to reduction by Secretary of amount otherwise

considered as expenditures under State plan where reasonable cost

differential between statewide average cost of skilled nursing

facility services and statewide average cost of intermediate care

facility services does not exist for any calendar quarter beginning

after June 30, 1973.

Subsec. (i). Pub. L. 100-203, Sec. 4118(d)(1)(B), inserted

sentence at end that nothing in par. (1) be construed as permitting

a State to provide services under its plan under this subchapter

that are not reasonable in amount, duration, and scope to achieve

their purpose.

Subsec. (i)(1). Pub. L. 100-203, Sec. 4118(d)(1)(A), substituted

"; or" for period at end.

Subsec. (i)(2). Pub. L. 100-93, Sec. 8(g), amended par. (2)

generally. Prior to amendment, par. (2) read as follows: "with

respect to any amount paid for services furnished under the plan

after December 31, 1972, by a provider or other person during any

period of time, if payment may not be made under subchapter XVIII

of this chapter with respect to services furnished by such provider

or person during such period of time solely by reason of a

determination by the Secretary under section 1395y(d)(1) of this

title or under clause (D), (E), or (F) of section 1395cc(b)(2) of

this title, or by reason of noncompliance with a request made by

the Secretary under clause (C)(ii) of such section 1395cc(b)(2) or

under section 1396a(a)(38) of this title; or".

Subsec. (i)(2)(A). Pub. L. 100-203, Sec. 4118(e)(11)(A), as added

by Pub. L. 100-360, Sec. 411(k)(10)(D), as amended by Pub. L.

100-485, Sec. 608(d)(26)(K)(ii), substituted "under subchapter V,

XVIII, or XX of this chapter or under this subchapter pursuant to

section 1320a-7, 1320a-7a, 1320c-5, or 1395u(j)(2) of this title"

for "in the State plan under this subchapter pursuant to section

1320a-7 of this title or section 1320a-7a of this title".

Subsec. (i)(2)(B). Pub. L. 100-203, Sec. 4118(e)(11)(B), as added

by Pub. L. 100-360, Sec. 411(k)(10)(D), as amended by Pub. L.

100-485, Sec. 608(d)(26)(K)(ii), substituted "from participation

under subchapter V, XVIII, or XX of this chapter or under this

subchapter pursuant to section 1320a-7, 1320a-7a, 1320c-5, or

1395u(j)(2) of this title" for "pursuant to section 1320a-7 of this

title or section 1320a-7a of this title from participation in the

program under this subchapter".

Subsec. (i)(3). Pub. L. 100-203, Sec. 4112(b), as added by Pub.

L. 100-360, Sec. 411(k)(6)(B)(x), inserted "(other than amounts

attributable to the special situation of a hospital which serves a

disproportionate number of low income patients with special needs)"

before "to the extent".

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

skilled nursing facility" after "hospital" in three places.

Subsec. (i)(8). Pub. L. 100-203, Sec. 4213(b)(2), added par. (8).

Subsec. (m)(2)(F). Pub. L. 100-203, Sec. 4113(d)(1), which

directed the substitution of "subparagraphs (E) or (G)" for

"subparagraph (G)", was repealed by Pub. L. 100-360, Sec.

411(k)(7)(D).

Pub. L. 100-203, Sec. 4113(a)(1)(B), as amended by Pub. L.

100-360, Sec. 411(a)(3)(A), (B)(iii), (k)(7)(A), substituted "(F)

In the case of - " and cls. (i) and (ii) for "(F) In the case of a

contract with an entity described in subparagraph (G) or with a

qualified health maintenance organization (as defined in section

300e-9(d) of this title) which meets the requirement of

subparagraph (A)(ii),".

Subsec. (m)(6). Pub. L. 100-203, Sec. 4113(a)(1)(A), added par.

(6).

Subsec. (n). Pub. L. 100-93, Sec. 8(h)(1), struck out subsec. (n)

which related to State agency action upon disclosure or failure to

disclose required information by institution, organization, etc.

Subsec. (r). Pub. L. 100-203, Sec. 4212(c)(2), substituted

"paragraphs (2)(A)" for "paragraphs (2)" in pars. (1)(A), (C) and

(2)(A), (C).

1986 - Subsec. (a)(1). Pub. L. 99-509, Sec. 9403(g)(2), as

amended by Pub. L. 100-360, Sec. 301(f), inserted "including

expenditures for medicare cost-sharing and" before "including

expenditures".

Subsec. (a)(3)(C). Pub. L. 99-509, Sec. 9431(b)(2), inserted "or

quality review" after "medical and utilization review".

Subsec. (a)(4). Pub. L. 99-603 added par. (4).

Subsec. (d)(2). Pub. L. 99-272, Sec. 9512(a), designated first

sentence as subpar. (A), designated second sentence as subpar. (B),

properly indented and aligned below subpar. (A), and added subpars.

(C) and (D).

Subsec. (f)(4). Pub. L. 99-509, Sec. 9401(e)(2), inserted "for

any individual described in section 1396a(a)(10)(A)(ii)(IX) of this

title or" after "as medical assistance".

Subsec. (i)(1). Pub. L. 99-272, Sec. 9507(a), added par. (1).

Subsec. (m)(2)(A). Pub. L. 99-272, Sec. 9517(a)(1), substituted

"subparagraphs (B), (C), and (G)" for "subparagraphs (B) and (C)"

in introductory text.

Pub. L. 99-272, Sec. 9517(c)(1), inserted "(including a health

insuring organization)" after "any entity" and "(directly or

through arrangements with providers of services)" after

"responsible for the provision" in introductory text.

Subsec. (m)(2)(A)(iii). Pub. L. 99-509, Sec. 9434(a)(2), inserted

before the semicolon "and under which the Secretary must provide

prior approval for contracts providing for expenditures in excess

of $100,000".

Subsec. (m)(2)(A)(viii). Pub. L. 99-509, Sec. 9434(a)(1)(A),

added cl. (viii).

Subsec. (m)(2)(F). Pub. L. 99-514, Sec. 1895(c)(2), substituted

"In the case" for "in the case".

Pub. L. 99-272, Sec. 9517(a)(2), struck out designation "(i)" at

beginning of subpar. (F), substituted "in the case of a contract

with an entity described in subparagraph (G) or with a qualified

health maintenance organization (as defined in section 300e-9(d) of

this title) which meets the requirement of subparagraph (A)(ii)"

for "In the case of a contract with a health maintenance

organization described in clause (ii)", substituted "such entity or

organization" for "such organization", and struck out cl. (ii)

which defined a health maintenance organization.

Subsec. (m)(2)(G). Pub. L. 99-272, Sec. 9517(a)(3), added subpar.

(G).

Subsec. (m)(4). Pub. L. 99-509, Sec. 9434(a)(1)(B), added par.

(4).

Subsec. (m)(5). Pub. L. 99-509, Sec. 9434(b), added par. (5).

Subsec. (r)(1)(B). Pub. L. 99-272, Sec. 9518(a), substituted

"September 30, 1985" for "the earlier of (i) September 30, 1982, or

(ii) the last day of the sixth month following the date specified

for operation of such systems in the State's most recently approved

advance planning document submitted before October 7, 1980".

Subsec. (r)(4)(A). Pub. L. 99-272, Sec. 9503(b)(2), substituted

"once every three years" for "once each fiscal year" and inserted

at end "Reviews may, at the Secretary's discretion, constitute

reviews of the entire system or of only those standards, systems

requirements, and other conditions which have demonstrated weakness

in previous reviews."

Subsec. (r)(6)(J). Pub. L. 99-272, Sec. 9503(b)(1), amended

subpar. (J) generally. Prior to amendment, subsec. (J) read as

follows: "report on or before October 1, 1981, to the Congress on

the extent to which States have developed and operated effective

mechanized claims processing and information retrieval systems."

Subsec. (u)(1)(D)(iv). Pub. L. 99-272, Sec. 9503(f), added cl.

(iv).

Subsec. (u)(1)(D)(v). Pub. L. 99-509, Sec. 9407(c), added cl.

(v).

Subsec. (v). Pub. L. 99-509, Sec. 9406(a), added subsec. (v).

1984 - Subsec. (g)(1). Pub. L. 98-369, Sec. 2363(a)(2)(A), (B),

in provision preceding subpar. (A), substituted "inpatient hospital

services or intermediate care facility services for 60 days,

skilled nursing facility services for 30 days, or inpatient mental

hospital services for" for "care as an inpatient in a hospital

(including an institution for tuberculosis), skilled nursing

facility or intermediate care facility on 60 days, or in a hospital

for mental diseases on", and struck out "which for purposes of this

section means the four calendar quarters ending with June 30,"

before "the Federal medical assistance percentage", and struck out

"in the same fiscal year" before "shall be decreased by a per

centum thereof".

Pub. L. 98-369, Sec. 2363(a)(2)(C), substituted ", skilled

nursing facility services, or intermediate care facility services

furnished beyond 60 days (or inpatient mental hospital services

furnished beyond 90 days), such State has an effective program of

medical review of the care of patients in mental hospitals, skilled

nursing facilities, and intermediate care facilities pursuant to

paragraphs (26) and (31) of section 1396a(a) of this title whereby

the professional management of each case is reviewed and evaluated

at least annually by independent professional review teams" for

"(including tuberculosis hospitals), skilled nursing facility

services, or intermediate care facility services furnished beyond

60 days (or inpatient mental hospital services furnished beyond 90

days), there is in operation in the State an effective program of

control over utilization of such services; such a showing must

include evidence that - " and former subpars. (A) through (D)

requirement for evidence concerning an effective program of

utilization of certain medical services.

Subsec. (g)(4)(B). Pub. L. 98-369, Sec. 2373(b)(11), substituted

"paragraphs (26)" for "paragraph (26)" and "diligence" for

"deligence".

Subsec. (g)(6). Pub. L. 98-369, Sec. 2363(a)(4), in amending par.

(6) generally, substituted provisions relating to recertifications

for provisions relating to reports to Congress concerning

Secretary's determination and review of showing respecting any

decrease of Federal medical assistance percentage of amounts paid

for services.

Subsec. (g)(7). Pub. L. 98-369, Sec. 2363(b), as amended by Pub.

L. 98-617, Sec. 3(a)(6), added par. (7).

Subsec. (i)(7). Pub. L. 98-369, Sec. 2303(g)(2), added par. (7).

Subsec. (m)(2)(A)(vi). Pub. L. 98-369, Sec. 2364(1), inserted

"except as provided under subparagraph (F)," after "(I)".

Subsec. (m)(2)(B)(i)(I). Pub. L. 98-369, Sec. 2373(b)(12)(A),

(C), struck out "(II)" before "for the period" and substituted

"period" for "peroid".

Subsec. (m)(2)(B)(i)(II). Pub. L. 98-369, Sec. 2373(b)(12)(B),

substituted "of section 1396d(a) of this title" for "of such

section".

Subsec. (m)(2)(C). Pub. L. 98-369, Sec. 2373(b)(13), realigned

margin of subpar. (C).

Subsec. (m)(2)(E), (F). Pub. L. 98-369, Sec. 2364(2), added

subpars. (E) and (F).

Subsec. (s)(3)(B). Pub. L. 98-369, Sec. 2373(b)(14), substituted

"non-Federal" for "nonfederal".

1983 - Subsec. (t)(3). Pub. L. 97-448 substituted "purposes" for

"purpose" and "the lower of the Federal medical assistance

percentage for the State in effect for fiscal year 1981, or the

Federal medical assistance percentage for the State in effect for

fiscal year 1982" for "the Federal medical assistance percentage

for States in effect for fiscal year 1981, disregarding any change

in such percentage after fiscal year 1981".

1982 - Subsec. (a)(3)(C). Pub. L. 97-248, Sec. 146(b),

substituted "utilization and quality control peer review

organization" for "Professional Standards Review Organization".

Subsec. (f)(3). Pub. L. 97-248, Sec. 137(g), struck out "(without

regard to section 608 of this title)" after "consisting of one

person if such plan".

Subsec. (g)(1). Pub. L. 97-248, Sec. 137(b)(11), inserted "or

which is a qualified health maintenance organization (as defined in

section 300e-9(d) of this title)".

Subsec. (g)(1)(A). Pub. L. 97-248, Sec. 137(b)(12), substituted

"provided in an institution for the mentally retarded" for

"described in section 1396d(d) of this title".

Subsec. (k). Pub. L. 97-248, Sec. 137(b)(13), substituted

"subsection (m) of this section" for "section 1395mm of this

title".

Subsec. (m)(2)(A). Pub. L. 97-248, Sec. 137(b)(14), substituted

"or" for "and" before "(II)" in cl. (iv), and substituted

"unforeseen" for "unforseen" in cl. (vii)(II).

Subsec. (s). Pub. L. 97-248, Sec. 137(a)(2), amended directory

language of Pub. L. 97-35, Sec. 2161(c)(1), to correct an error,

and did not involve any change in text. See 1981 Amendment note

below.

Subsec. (s)(1)(A). Pub. L. 97-248, Sec. 137(b)(15)(A), (B), in

provisions following cl. (iii), substituted "fiscal year 1982" for

"fiscal year 1981", and "subsections (a)(6) and (t) of this

section, without regard to payments for claims relating to

expenditures made for medical assistance for services received

through a facility of the Indian Health Service," for "subsection

(t) of this section".

Subsec. (s)(1)(C). Pub. L. 97-248, Sec. 137(b)(15)(C), inserted

"a program in operation under", before "a plan approved".

Subsec. (s)(3)(D). Pub. L. 97-248, Sec. 137(b)(15)(D),

substituted "must determine that" for "determines that", "most

recent year (which shall consist of a 12-month period determined by

the Secretary for this purpose)" for "most recent calendar year",

and "2- or 3-year period" for "2 or 3 calendar year period", and

struck out "calendar" wherever appearing.

Subsec. (s)(4)(B). Pub. L. 97-248, Sec. 137(b)(15)(E), inserted

"and paragraph (3)(D)".

Subsec. (s)(5)(A)(i). Pub. L. 97-248, Sec. 137(b)(15)(F),

inserted "(including amounts saved, to the extent such amounts can

be documented to the satisfaction of the Secretary, by reason of

the suspension or termination of a provider or other person for

fraud or abuse, but only during the period of such suspension or

termination or, if shorter, the 1-year period beginning on the date

of such termination or suspension)" after "recovered or diverted".

Subsec. (s)(5)(B). Pub. L. 97-248, Sec. 137(b)(27), inserted "or

quarters" after "carried forward to the following quarter".

Subsec. (t). Pub. L. 97-248, Sec. 137(a)(1), (2), amended

directory language of Pub. L. 97-35, Sec. 2161(b), (c)(2), to

correct an error, and did not involve any change in text. See 1981

Amendment note below.

Subsec. (t)(1)(A). Pub. L. 97-248, Sec. 137(b)(16)(A),

substituted "payments under subsection (a)(6) of this section,

interest paid under subsection (d)(5) of this section, and payments

for claims relating to expenditures made for medical assistance for

services received through a facility of the Indian Health Service"

for "interest paid under subsection (d)(5) of this section".

Subsec. (t)(1)(B). Pub. L. 97-248, Sec. 137(b)(16)(B), (D),

substituted "Consumer Price Index for all urban consumers (U.S.

city average) published by the Bureau of Labor Statistics" for

"consumer price index for all urban consumers (published by the

Bureau of Labor Statistics)" and "for the 12-month period ending on

September 30, 1983" for "between September 1982 and September

1983".

Subsec. (t)(1)(C). Pub. L. 97-248, Sec. 137(b)(16)(C), (D),

substituted "Consumer Price Index for all urban consumers (U.S.

city average) published by the Bureau of Labor Statistics" for

"consumer price index for all urban consumers (published by the

Bureau of Labor Statistics)" and "for the 24-month period ending on

September 30, 1984" for "between September 1982 and September

1984".

Subsec. (t)(2)(A). Pub. L. 97-248, Sec. 137(b)(16)(A),

substituted "payments under subsection (a)(6) of this section,

interest paid under subsection (d)(5) of this section, and payments

for claims relating to expenditures made for medical assistance for

services received through a facility of the Indian Health Service"

for "interest paid under subsection (d)(5) of this section".

Subsec. (t)(3). Pub. L. 97-248, Sec. 137(b)(16)(E), substituted

"for fiscal years 1982, 1983, and 1984" for "for fiscal year 1984"

wherever appearing, "years 1983, 1984, and 1985, respectively" for

"year 1985", "in effect for fiscal year 1981" for "in effect for

fiscal year 1983", and "after fiscal year 1981" for "between fiscal

year 1983 and fiscal year 1984".

Subsec. (u). Pub. L. 97-248, Sec. 133(a), added subsec. (u).

1981 - Subsec. (a)(3)(B). Pub. L. 97-35, Sec. 2113(n),

substituted "and" for "plus" at the end of subpar. (B) and added

subpar. (C).

Subsec. (d)(5). Pub. L. 97-35, Sec. 2163, substituted

"determination at a rate" for "determination (but not to exceed a

period of twelve months with respect to disallowances made prior to

October 1, 1981, or six months with respect to disallowances made

thereafter) at a rate".

Subsec. (e). Pub. L. 97-35, Sec. 2101(a)(2), added subsec. (e).

Subsec. (g)(1)(A). Pub. L. 97-35, Sec. 2183(a), inserted "and the

physician, or a physician assistant or nurse practitioner under the

supervision of a physician" and "or, in the case of services that

are intermediate care facility services described in section

1396d(d) of this title, every year" in parenthetical text.

Subsec. (i)(1). Pub. L. 97-35, Sec. 2174(b), struck out par. (1)

which provided that payments shall not be made with respect to any

amount paid for items or services furnished under the plan after

Dec. 31, 1972, to the extent that such amount exceeds the charge

which would be determined to be reasonable for such items or

services under fourth and fifth sentences of section 1395u(b)(3) of

this title.

Subsec. (i)(5). Pub. L. 97-35, Sec. 2103(b)(1), added par. (5).

Subsec. (i)(6). Pub. L. 97-35, Sec. 2164(a), added par. (6).

Subsec. (m)(1)(A). Pub. L. 97-35, Sec. 2178(a)(1), redefined

"Health Maintenance Organization" substantially, and substituted

reference to public and private organizations making services to

individuals eligible for benefits under this subchapter and which

makes adequate provision against the risk of insolvency for

reference to a legal entity which provides health services to

individuals enrolled in such organization and providing services

and benefits to individuals eligible for benefits under specified

provisions of this subchapter.

Subsec. (m)(2)(A). Pub. L. 97-35, Sec. 2178(a)(2), in cl. (ii),

substituted "75 percent of the membership of the entity which is

enrolled on a prepaid basis" for "one-half of the membership of the

entity", and added cls. (iii) to (vii).

Subsec. (m)(2)(D). Pub. L. 97-35, Sec. 2178(a)(3), added subpar.

(D).

Subsec. (n). Pub. L. 97-35, Sec. 2106(b)(3), struck out "of this

section" after "section 1395cc of this title" thereby perfecting

the amendment made by Pub. L. 96-499, Sec. 905(c)(2).

Subsec. (s). Pub. L. 97-35, Sec. 2161(c)(1), as amended by Pub.

L. 97-248, Sec. 137(a)(2), repealed subsec. (s) which provided for

reduction in medicaid payments to States, limitations on

reductions, States included, and percentage reductions reduced

under certain circumstances. See Effective Date of 1981 Amendment

note below.

Pub. L. 97-35, Sec. 2161(a), added subsec. (s).

Subsec. (t). Pub. L. 97-35, Sec. 2161(c)(2), as amended by Pub.

L. 97-248, Sec. 137(a)(2), repealed subsec. (t) which provided for

offset for meeting Federal medicaid expenditure targets, and

computation for meeting expenditure targets. See Effective Date of

1981 Amendment note below.

Pub. L. 97-35, Sec. 2161(b), as amended by Pub. L. 97-248, Sec.

137(a)(1), added subsec. (t).

1980 - Subsec. (a)(1). Pub. L. 96-499, Sec. 905(b), inserted

reference to subsection (j) of this section.

Subsec. (a)(6). Pub. L. 96-499, Sec. 963, substituted "such a

quarter within the twelve-quarter period beginning with the first

quarter in which a payment is made to the State pursuant to this

paragraph, and (B) 75 per centum of the sums expended during each

succeeding calendar quarter" for "each quarter beginning on or

after October 1, 1977, and ending before October 1, 1980".

Subsec. (d)(5). Pub. L. 96-499, Sec. 961(a), added par. (5).

Subsec. (g)(3)(B). Pub. L. 96-499, Sec. 964, substituted "January

1, 1978" for "October 1, 1977" and "any calendar quarter ending on

or before December 31, 1978" for "the calendar quarter ending on

December 31, 1977".

Subsec. (j). Pub. L. 96-499, Sec. 905(c)(1), substituted

provisions relating to the adjustment of amounts determined under

subsec. (a)(1) of this section in accordance with section 1396m of

this title for provisions relating to orders for suspension of

payment.

Subsec. (n). Pub. L. 96-499, Sec. 905(c)(2), struck out "or is

subject to a suspension of payment order issued under subsection

(j)" after "section 1395cc of this title".

Subsec. (r). Pub. L. 96-398 added subsec. (r).

1979 - Subsec. (m)(2)(C). Pub. L. 96-79 substituted "the date the

entity qualifies as a health maintenance organization (as

determined by the Secretary)" for "the date the entity enters into

a contract with the State under this subchapter for the provision

of health services on a prepaid risk basis".

1978 - Subsec. (m)(1)(B). Pub. L. 95-559 struck out "shall be

administered through the Assistant Secretary for Health and in the

Office of the Assistant Secretary for Health, and the

administration of such duties and functions" after "subparagraph

(A),".

Subsec. (m)(2)(B)(i)(I). Pub. L. 95-626 substituted "section

254b(d)(1)(A)" for "section 247d(d)(1)(A)".

1977 - Subsec. (a)(3)(B). Pub. L. 95-142, Sec. 10(a), inserted

provisions relating to notice to individuals in a sample group and

provisions exempting notice respecting confidential services from

notice requirements.

Subsec. (a)(6), (7). Pub. L. 95-142, Sec. 17(a), added par. (6)

and redesignated former par. (6) as (7).

Subsec. (b)(3). Pub. L. 95-142, Sec. 17(b), added par. (3).

Subsec. (g). Pub. L. 95-142, Sec. 20(a), in par. (1) substituted

"Subject to paragraph (3), with respect to" for "With respect to"

and "by a per centum thereof (determined under paragraph (5))" for

"by 33 1/3 per centum thereof", in par. (2) inserted "timely"

before "sample onsite surveys", and added pars. (3) to (6).

Subsec. (i)(2). Pub. L. 95-142, Sec. 3(c)(2), inserted provisions

relating to noncompliance under sections 1395cc(b)(2) and

1396a(a)(38) of this title.

Subsec. (m)(2)(A). Pub. L. 95-83, Sec. 105(a)(1), in revising

text, incorporated former cl. (i) (I) and (II) provisions in

introductory text relating to responsibility for providing

inpatient hospital services and other described services,

substituting "capitation basis" for "capitation risk basis" and

inserting "unless"; redesignated as cl. (i) former cl. (ii),

substituting "has determined that the entity is a health

maintenance organization" for "has not determined to be a health

maintenance organization"; and redesignated as cl. (ii) former cl.

(iii), substituting "less than one-half of the membership of the

entity consists of individuals who (I) are insured for benefits

under part B of subchapter XVIII of this chapter or for benefits

under both parts A and B of such subchapter, or (II) are eligible

to receive benefits under this subchapter" for "more than one-half

of the membership of which consists of individuals who are insured

under parts A and B of subchapter XVIII of this chapter or

recipients of benefits under this subchapter."

Subsec. (m)(2)(C). Pub. L. 95-83, Sec. 105(a)(2), substituted

reference to subpar. "(A)(ii)" for "(A)(iii)" wherever appearing.

Subsec. (n). Pub. L. 95-142, Sec. 8(c), added subsec. (n).

Subsecs. (o), (p). Pub. L. 95-142, Sec. 11(a), added subsecs. (o)

and (p).

Subsec. (q). Pub. L. 95-142, Sec. 17(c), added subsec. (q).

1976 - Subsec. (l). Pub. L. 94-552 repealed subsec. (l) which

provided for reduction of amount of payments to States found not to

be in compliance with section 1396a(g) of this title.

Subsec. (m). Pub. L. 94-460 added subsec. (m).

1975 - Subsec. (g)(1)(C). Pub. L. 94-182, Sec. 110(a), inserted

provisions specifying the method by which the size and composition

of the sample of admissions subject to review is to be established.

Subsec. (l). Pub. L. 94-182, Sec. 111(b), added subsec. (l).

1973 - Subsec. (a). Pub. L. 93-233, Sec. 18(x)(5), struck out

reference to section 1317 of this title in introductory

parenthetical phrase.

Subsec. (a)(1). Pub. L. 93-233, Secs. 13(a)(11), 18(r)(1),

substituted "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 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" for "individuals who are recipients of money payments

under a State plan approved under subchapter I, X, XIV, or XVI, or

part A of subchapter IV of this chapter" and inserted "and disabled

individuals entitled to hospital insurance benefits under

subchapter XVIII of this chapter," after "individuals sixty-five

years of age or older".

Subsec. (a)(4). Pub. L. 93-233, Sec. 18(s), substituted "sums

expended with respect to costs incurred" for "sums expended".

Subsec. (a)(5). Pub. L. 93-233, Sec. 18(t), struck out "(as found

necessary by the Secretary for the proper and efficient

administration of the plan)" after "such quarter".

Subsec. (b). Pub. L. 93-233, Secs. 18(r)(2), (u), (x)(6),

inserted in par. (2) after "individuals sixty-five years of age or

older" text reading "and disabled individuals entitled to hospital

insurance benefits under subchapter XVIII of this chapter" and end

text reading ", other than amounts expended under provisions of the

plan of such State required by section 1396a(a)(34) of this title,"

and redesignated pars. (2) and (3) as (1) and (2), respectively.

Subsec. (c). Pub. L. 93-233, Sec. 18(y)(1)(A), struck out subsec.

(c) which provided for Federal medical assistance percentage and

Federal share of State medical expenses during fiscal year ending

June 30, 1965.

Subsec. (d)(1). Pub. L. 93-233, Sec. 18(y)(1)(B), struck out

reference to subsec. (c) of this section.

Subsec. (f)(4). Pub. L. 93-233, Sec. 13(a)(12), in subpar. (A),

made payment limitations inapplicable to individual with respect to

whom supplemental security income benefits are being paid under

subchapter XVI of this chapter; in subpar. (B), made payment

limitations inapplicable to individual with respect to whom such

benefits are not being paid, and in cls. (i) and (ii) inserted "to

have such benefits paid with respect to him", and added subpar.

(C).

Subsec. (g)(1)(C). Pub. L. 93-233, Sec. 18(v), substituted

"directly responsible for the care of the patient or financially

interested in any such institution or, except in the case of

hospitals, employed by the institution" for "directly responsible

for the care of the patient and who are not employed by or

financially interested in any such institution".

Subsec. (j). Pub. L. 93-66 struck out provisions respecting

skilled nursing facility services and intermediate care facility

services.

1972 - Subsec. (a)(1). Pub. L. 92-603, Sec. 207(a)(2), inserted

reference to subsecs. (g) and (h) and of this section.

Subsec. (a)(3). Pub. L. 92-603, Sec. 235(a), added par. (3).

Former par. (3) redesignated (4).

Subsec. (a)(4). Pub. L. 92-603, Sec. 249B, temporarily added par.

(4) which provided for payments to States of 100 per centum of sums

expended for costs incurred during a quarter attributable to

compensation or training of personnel responsible for inspecting

public or private institutions providing long-term care to

recipients of medical assistance to determine compliance with

health or safety standards. Former par. 4 redesignated (5). See

Effective Date of 1972 Amendment note below.

Pub. L. 92-603, Sec. 235(a), redesignated former par. (3) as (4).

Subsec. (a)(5). Pub. L. 92-603, Sec. 299E(a), added par. (5).

Former par. (5) redesignated (6).

Pub. L. 92-603, Sec. 249B, redesignated former par. (4) as (5).

Subsec. (a)(6). Pub. L. 92-603, Sec. 299E, redesignated former

par. (5) as (6).

Subsec. (b)(1). Pub. L. 92-603, Sec. 295, struck out par. (1)

which related to amount of quarterly expenditures exceeding average

of total expenditures for each quarter of fiscal year ending June

30, 1965.

Subsec. (b)(3). Pub. L. 92-603, Sec. 221(c)(6), added par. (3).

Subsec. (e). Pub. L. 92-603, Sec. 230, repealed subsec. (e) which

related to furnishing for comprehensive care and services by July

1, 1977.

Subsec. (g). Pub. L. 92-603, Secs. 207(a)(1), 278(b)(1), added

subsec. (g) and substituted "skilled nursing facility" for "skilled

nursing home" and "skilled nursing facilities" for "skilled nursing

homes" wherever appearing.

Subsec. (h). Pub. L. 92-603, Secs. 207(a)(1), 278(b)(1)(5), added

subsec. (h) and substituted "skilled nursing facility" for "skilled

nursing home" wherever appearing.

Subsec. (i). Pub. L. 92-603, Secs. 224(c), 229(c), 233(c),

237(a)(1), 278(b)(7), added subsec. (i) and substituted "skilled

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

Subsec. (j). Pub. L. 92-603, Sec. 290, added subsec. (j) relating

to orders for suspension of payment.

Pub. L. 92-603, Secs. 225, 278(b)(16), added subsec. (j) relating

to skilled nursing facilities services, and substituted "skilled

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

Subsec. (k). Pub. L. 92-603, Sec. 226(e), added subsec. (k).

1969 - Subsec. (e). Pub. L. 91-56 extended from July 1, 1975, to

July 1, 1977, the date by which comprehensive care and services for

eligible individuals must be made available for a State to be

eligible for payments.

1968 - Subsec. (a)(1). Pub. L. 90-248, Sec. 222(d), substituted

"and, except in the case of individuals sixty-five years of age or

older who are not enrolled under part B of subchapter XVIII of this

chapter, other insurance premiums" for "and other insurance

premiums".

Pub. L. 90-248, Sec. 241(f)(5), struck out "IV," after "I," and

inserted "or part A of subchapter IV of this chapter," after "XVI

of this chapter,".

Subsec. (a)(2). Pub. L. 90-248, Sec. 225(a), substituted "of the

State agency or any other public agency" for "of the State agency

(or of the local agency administering the State plan in the

political subdivision)".

Subsec. (b). Pub. L. 90-248, Sec. 222(c), designated existing

provisions as par. (1) and added par. (2).

Subsec. (b)(2). Pub. L. 90-364 substituted "1969" for "1967".

Subsec. (d)(2). Pub. L. 90-248, Sec. 229(c), provided for

treatment of expenditures for which payments were made to the State

under subsec. (a) as an overpayment to the extent that the State or

local agency administering the plan has been reimbursed for such

expenditures by a third party pursuant to the provisions of its

plan in compliance with section 1396a(a)(25) of this title.

Subsec. (f). Pub. L. 90-248, Sec. 220(a), added subsec. (f).

EFFECTIVE DATE OF 2000 AMENDMENTS

Amendment by section 702(c)(1) of 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.

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 710(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-578, provided that:

"(1) The amendment made by subsection (a)(1) [amending this

section] shall be effective as if included in the enactment of

section 121 of the Foster Care Independence Act of 1999 (Public Law

106-169 [amending sections 1396a and 1396d of this title and

enacting provisions set out as notes under section 1396a of this

title]).

"(2) The amendment made by subsection (a)(2) [amending this

section] shall be effective as if included in the enactment of the

Breast and Cervical Cancer Prevention and Treatment Act of 2000

(Public Law 106-354)."

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 section 201(a)(4), (b) of 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.

Pub. L. 106-170, title IV, Sec. 407(d), Dec. 17, 1999, 113 Stat.

1914, provided that: "The amendments made by this section [amending

this section] take effect on the date of the enactment of this Act

[Dec. 17, 1999]."

Amendment by section 1000(a)(6) [title VI, Sec. 604(a)(2)(B),

(b)(2)] of Pub. L. 106-113 applicable as of such date as the

Secretary of Health and Human Services certifies to Congress that

the Secretary is fully implementing section 1396u-2(c)(2) of this

title, see section 1000(a)(6) [title VI, Sec. 604(c)(2)] of Pub. L.

106-113, set out as a note under section 1396a of this title.

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)(2)] 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(e)-(k)] 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.

Pub. L. 106-31, title III, Sec. 3031(c), May 21, 1999, 113 Stat.

104, provided that: "This section [amending this section] and the

amendments made by this section shall apply to amounts paid to a

State prior to, on, or after the date of the enactment of this Act

[May 21, 1999]."

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.

Section 4710 of title IV of Pub. L. 105-33 provided that:

"(a) General Effective Date. - Except as otherwise provided in

this chapter [chapter 1 (Secs. 4701-4710) of subtitle H of title IV

of Pub. L. 105-33, enacting section 1396u-2 of this title, amending

this section and sections 1320a-3, 1320a-7b, 1396a, 1396d, 1396o,

1396r-6, 1396r-8, 1396u-2, and 1396v of this title, and enacting

provisions set out as a note under section 1396u-2 of this title]

and section 4759 [enacting provisions set out as a note under

section 1396a of this title], the amendments made by this chapter

shall take effect on the date of the enactment of this Act [Aug. 5,

1997] and shall apply to contracts entered into or renewed on or

after October 1, 1997.

"(b) Specific Effective Dates. - Subject to subsection (c) and

section 4759 -

"(1) PCCM option. - The amendments made by section 4702

[amending this section and sections 1396a and 1396d of this

title] shall apply to primary care case management services

furnished on or after October 1, 1997.

"(2) 75:25 rule. - The amendments made by section 4703

[amending this section and section 1396r-6 of this title] apply

to contracts under section 1903(m) of the Social Security Act (42

U.S.C. 1396b(m)) on and after June 20, 1997.

"(3) Quality standards. - Section 1932(c)(1) of the Social

Security Act [section 1396u-2(c)(1) of this title], as added by

section 4705(a), shall take effect on January 1, 1999.

"(4) Solvency standards. -

"(A) In general. - The amendments made by section 4706

[amending this section] shall apply to contracts entered into

or renewed on or after October 1, 1998.

"(B) Transition rule. - In the case of an organization that

as of the date of the enactment of this Act [Aug. 5, 1997] has

entered into a contract under section 1903(m) of the Social

Security Act [subsec. (m) of this section] with a State for the

provision of medical assistance under title XIX of such Act

[this subchapter] under which the organization assumes full

financial risk and is receiving capitation payments, the

amendment made by section 4706 shall not apply to such

organization until 3 years after the date of the enactment of

this Act.

"(5) Sanctions for noncompliance. - Section 1932(e) of the

Social Security Act [section 1396u-2(e) of this title], as added

by section 4707(a), shall apply to contracts entered into or

renewed on or after April 1, 1998.

"(6) Limitation on ffp for enrollment brokers. - The amendment

made by section 4707(b) [amending this section] shall apply to

amounts expended on or after October 1, 1997.

"(7) 6-month guaranteed eligibility. - The amendments made by

section 4709 [amending section 1396a of this title] shall take

effect on October 1, 1997.

"(c) Nonapplication to Waivers. - Nothing in this chapter (or the

amendments made by this chapter) shall be construed as affecting

the terms and conditions of any waiver, or the authority of the

Secretary of Health and Human Services with respect to any such

waiver, under section 1115 or 1915 of the Social Security Act (42

U.S.C. 1315, 1396n)."

Amendment by section 4712(b)(2) of Pub. L. 105-33 applicable to

services furnished on or after Oct. 1, 1997, see section 4712(b)(3)

of Pub. L. 105-33, set out as a note under section 1396a of this

title.

Pub. L. 105-33, title IV, Sec. 4712(c), Aug. 5, 1997, 111 Stat.

509, as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title

VI, Sec. 603(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-394,

which provided that the amendment made by section 4712(c) was

effective for services furnished on or after Oct. 1, 2004, was

repealed by Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec.

702(c)(1), (e)], Dec. 21, 2000, 114 Stat. 2763, 2763A-574,

effective Jan. 1, 2001, and applicable to services furnished on or

after such date.

Section 4722(d) of Pub. L. 105-33 provided that: "The amendments

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

imposed before, on, or after the date of the enactment of this Act

[Aug. 5, 1997] and the amendment made by subsection (b) [amending

this section] shall apply to taxes imposed on or after such date."

Section 4724(b)(2) of Pub. L. 105-33 provided that: "The

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

apply to home health care services furnished on or after January 1,

1998."

Section 4742(b) of Pub. L. 105-33 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 [Aug. 5, 1997]."

Amendment by section 4753(a) of Pub. L. 105-33 effective Jan. 1,

1998, except as otherwise specifically provided, see section

4753(c) of Pub. L. 105-33, set out as a note under section 1396a of

this title.

Amendment by section 4912(b)(2) of Pub. L. 105-33 effective Aug.

5, 1997, see section 4912(c) of Pub. L. 105-33, set out as a note

under section 1396a of this title.

Amendment by Pub. L. 105-12 effective Apr. 30, 1997, and

applicable to Federal payments made pursuant to obligations

incurred after Apr. 30, 1997, for items and services provided on or

after such date, subject to also being applicable with respect to

contracts entered into, renewed, or extended after Apr. 30, 1997,

as well as contracts entered into before Apr. 30, 1997, to the

extent permitted under such contracts, see section 11 of Pub. L.

105-12, set out as an Effective Date note under section 14401 of

this title.

EFFECTIVE DATE OF 1996 AMENDMENTS

Section 1(b)(2) of Pub. L. 104-248 provided that: "The amendments

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

physicians' services furnished on or after January 1, 1992."

Amendment by Pub. L. 104-193 effective July 1, 1997, with

transition rules relating to State options to accelerate such date,

rules relating to claims, actions, and proceedings commenced before

such date, rules relating to closing out of accounts for terminated

or substantially modified programs and continuance in office of

Assistant Secretary for Family Support, and provisions relating to

termination of entitlement under AFDC program, see section 116 of

Pub. L. 104-193, as amended, set out as an Effective Date note

under section 601 of this title.

EFFECTIVE DATE OF 1993 AMENDMENT

Amendment by section 13602(b) of Pub. L. 103-66 effective as if

included in enactment of the Omnibus Budget Reconciliation Act of

1990, Pub. L. 101-508, see section 13602(d)(1) of Pub. L. 103-66,

set out as a note under section 1396r-8 of this title.

Section 13604(b) of Pub. L. 103-66 provided that:

"(1) Subject to paragraph (2), the amendments made by subsection

(a) [amending this section] shall apply as if included in the

enactment of OBRA-1986 [Pub. L. 99-509].

"(2) The Secretary of Health and Human Services shall not

disallow expenditures made for the care and services described in

section 1903(v)(2)(C) of the Social Security Act [subsec. (v)(2)(C)

of this section], as added by subsection (a), furnished before the

date of the enactment of this Act [Aug. 10, 1993]."

Amendment by section 13622(a)(2) of Pub. L. 103-66 applicable to

items and services furnished on or after Oct. 1, 1993, see section

13622(d)(3) of Pub. L. 103-66, set out as a note under section

1396a of this title.

Section 13624(b) of Pub. L. 103-66 provided that: "The amendment

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

referrals made on or after December 31, 1994."

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

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

apply to amounts expended for vaccines administered on or after

October 1, 1993."

Amendment by section 13631(c) of Pub. L. 103-66 applicable to

payments under State plans approved under this subchapter for

calendar quarters beginning on or after Oct. 1, 1994, see section

13631(i) of Pub. L. 103-66, set out as a note under section 1396a

of this title.

EFFECTIVE DATE OF 1991 AMENDMENT

Amendments by section 2(a), (b)(2) of Pub. L. 102-234 effective

Jan. 1, 1992, without regard to whether or not regulations have

been promulgated to carry out such amendments by such date, see

section 2(c)(1) of Pub. L. 102-234, set out as a note under section

1396a of this title.

Amendment by section 3(b)(2)(B) of Pub. L. 102-234 effective Jan.

1, 1992, see section 3(e)(1) of Pub. L. 102-234, set out as a note

under section 1396a of this title.

Section 4(b) of Pub. L. 102-234 provided that: "The amendment

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

fiscal years ending after the date of the enactment of this Act

[Dec. 12, 1991]."

EFFECTIVE DATE OF 1990 AMENDMENTS

Amendment by section 4402(b), (d)(3) 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 4601(a)(3)(A) 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.

Section 4701(c) of Pub. L. 101-508 provided that: "The amendment

made by subsection (b) [amending this section and section 1396a of

this title] shall take effect on January 1, 1991."

Amendment by section 4704(b)(1), (2) 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.

Amendment by section 4711(c)(2) of Pub. L. 101-508 applicable to

civil money penalties imposed after Nov. 5, 1990, see section

4711(e)(2)(B) of Pub. L. 101-508, set out as a note under section

1396a of this title.

Section 4731(c) of Pub. L. 101-508 provided that: "The amendments

made by subsections (a) and (b)(2) [amending this section] shall

apply with respect to contract years beginning on or after January

1, 1992, and the amendments made by subsection (b)(1) [amending

section 1320a-7a of this title] shall take effect on the date of

the enactment of this Act [Nov. 5, 1990]."

Amendment by section 4751(b)(1) of Pub. L. 101-508 applicable

with respect to services furnished on or after first day of 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 4752(b)(2) of Pub. L. 101-508 provided that: "The

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

apply to contract years beginning after the date of the

establishment of the system described in section 1902(x) of the

Social Security Act [section 1396a(x) of this title]."

Section 4801(a)(9) of Pub. L. 101-508 provided that: "Except as

provided in paragraph (6), the amendments made by this subsection

[amending this section and section 1396r of this title] shall take

effect as if they were included in the enactment of the Omnibus

Budget Reconciliation Act of 1987 [Pub. L. 100-203]."

Section 4801(e)(16)(B) of Pub. L. 101-508 provided that: "The

amendments made by subparagraph (A) [amending this section] shall

apply with respect to actions initiated on or after the date of the

enactment of this Act [Nov. 5, 1990]."

EFFECTIVE DATE OF 1989 AMENDMENTS

Amendment by section 6401(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, with respect

to eligibility for medical assistance on or after such date,

without regard to whether or not final regulations to carry out the

amendments by section 6401 of Pub. L. 101-239 have been promulgated

by such date, see section 6401(c) of Pub. L. 101-239, set out as a

note under section 1396a of this title.

Amendment by section 6901(b)(5)(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, see section 6901(b)(6)

of Pub. L. 101-239, set out as a note under section 1395i-3 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 section 608(d)(26)(K)(ii) 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)(4) 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 202(h)(2) of Pub. L. 100-360 applicable to

items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of

Pub. L. 100-360, set out as a note under section 1395u of this

title.

Section 301(f) of Pub. L. 100-360 provided that the amendment

made by that section is effective as though included in the

enactment of the Omnibus Budget Reconciliation Act of 1986, Pub. L.

99-509.

Amendment by section 302(c)(3) of Pub. L. 100-360 applicable,

except as otherwise provided, to payments under this subchapter for

calendar quarters beginning on or after July 1, 1989, with respect

to eligibility for medical assistance on or after that date,

without regard to whether or not final regulations to carry out

such amendment have been promulgated by such date, see section

302(f) 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(a)(3)(A), (B)(iii), (k)(6)(B)(x),

(7)(A), (D), (10)(D), (G)(ii) 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)(12)(B) of Pub. L. 100-360 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

apply to actions occurring on or after the date of the enactment of

this Act [July 1, 1988]."

Section 411(k)(13)(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 AMENDMENTS

Section 4118(d)(2) of Pub. L. 100-203 provided that: "The

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

effective as if included in the enactment of section 9507 of the

Consolidated Omnibus Budget Reconciliation Act of 1985 [Pub. L.

99-272]."

Amendment by section 4118(h)(1) of Pub. L. 100-203 applicable to

costs incurred after Dec. 22, 1987, see section 4118(h)(3) of Pub.

L. 100-203, as amended, set out as a note under section 1396a of

this title.

Amendments by sections 4211(d)(1), (g), (i), 4212(c)(1), (2),

(d)(1), (e)(2) 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.

Amendment by section 4212(d)(1) of Pub. L. 100-203 not applicable

until such date as of which the State has specified the resident

assessment instrument under section 1396r(e)(5) of this title, and

the State has begun conducting surveys under section 1396r(g)(2) of

this title, see section 4212(d)(4) of Pub. L. 100-203, set out as a

note under section 1396a of this title.

Amendment by section 4213(b)(2) of Pub. L. 100-203 applicable to

payments under this subchapter for calendar quarters beginning on

or after Dec. 22, 1987, without regard to whether regulations

implementing such amendment are promulgated by such date, except as

otherwise specifically provided in section 1396r of this title, see

section 4214(b)(1) 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 Pub. L. 99-603 effective Oct. 1, 1987, see section

121(c)(2) of Pub. L. 99-603, set out as a note under section 502 of

this title.

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 9401(e)(2) of Pub. L. 99-509 applicable to

medical assistance furnished in calendar quarters beginning on or

after Apr. 1, 1987, without regard to whether of not final

regulations to carry out such amendment have been promulgated by

such date, see section 9401(f) of Pub. L. 99-509, set out as a note

under section 1396a of this title.

Amendment by section 9403(g)(2) 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 9406(a) of Pub. L. 99-509 applicable, except

as otherwise provided, to medical assistance furnished to aliens on

or after Jan. 1, 1987, without regard to whether or not final

regulations to carry out such amendments have been promulgated by

such date, see section 9406(c) of Pub. L. 99-509, set out as a note

under section 1396a of this title.

Amendment by section 9407(c) of Pub. L. 99-509 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 amendments have been promulgated by

such date, see section 9407(d) of Pub. L. 99-509, set out as a note

under section 1396a of this title.

Amendment by section 9431(b)(2) 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 9431(c) of Pub. L. 99-509, set out as a note

under section 1396a of this title.

Section 9434(a)(3) of Pub. L. 99-509 provided that:

"(A) The amendments made by paragraph (1) [amending this section]

shall take effect 6 months after the date of the enactment of this

Act [Oct. 21, 1986].

"(B) The amendment made by paragraph (2) [amending this section]

shall take effect on the date of the enactment of this Act and

shall apply to contracts entered into, renewed, or extended after

the end of the 30-day period beginning on the date of the enactment

of this Act."

Amendment by section 9503(b), (f) of 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.

Section 9507(b) of Pub. L. 99-272 provided that: "The amendments

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

medical assistance furnished on or after January 1, 1987."

Section 9512(b) of Pub. L. 99-272 provided that: "The amendments

made by this section [amending this section] shall apply to

overpayments identified for quarters beginning on or after October

1, 1985."

Section 9517(c)(2), (3) of Pub. L. 99-272, as amended by Pub. L.

99-509, title IX, Sec. 9435(e), Oct. 21, 1986, 100 Stat. 2070; Pub.

L. 99-514, title XVIII, Sec. 1895(c)(4), Oct. 22, 1986, 100 Stat.

2935; Pub. L. 101-508, title IV, Sec. 4734, Nov. 5, 1990, 104 Stat.

1388-196; Pub. L. 104-240, Sec. 1(a), Oct. 8, 1996, 110 Stat. 3140;

Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 704(a)], Dec. 21,

2000, 114 Stat. 2763, 2763A-575, provided that:

"(2)(A) Except as provided in subparagraph (B) and in paragraph

(3), the amendments made by paragraph (1) [amending this section]

shall apply to expenditures incurred for health insuring

organizations which first become operational on or after January 1,

1986. For purposes of this paragraph, a health insuring

organization is not considered to be operational until the date on

which it first enrolls patients.

"(B) In the case of a health insuring organization -

"(i) which first becomes operational on or after January 1,

1986, but

"(ii) for which the Secretary of Health and Human Services has

waived, under section 1915(b) of the Social Security Act [section

1396n(b) of this title] and before such date, certain

requirements of section 1902 of such Act [section 1396a of this

title],

clauses (ii) and (vi) of section 1903(m)(2)(A) of such Act [subsec.

(m)(2)(A)(ii) and (vi) of this section] shall not apply during the

period for which such waiver is effective.

"(C) In the case of the Hartford Health Network, Inc., clauses

(ii) and (vi) of section 1903(m)(2)(A) of the Social Security Act

shall not apply during the period for which a waiver by the

Secretary of Health and Human Services, under section 1915(b) of

such Act, of certain requirements of section 1902 of such Act is in

effect (pursuant to a request for a waiver under section 1915(b) of

such Act submitted before January 1, 1986).

"(D) Nothing in section 1903(m)(1)(A) of the Social Security Act

shall be construed as requiring a health-insuring organization to

be organized under the health maintenance organization laws of a

State.

"(3)(A) Subject to subparagraph (C), in the case of up to 3

health insuring organizations which are described in subparagraph

(B), which first become operational on or after January 1, 1986,

and which are designated by the Governor, and approved by the

Legislature, of California, the amendments made by paragraph (1)

shall not apply.

"(B) A health insuring organization described in this

subparagraph is one that -

"(i) is operated directly by a public entity established by a

county government in the State of California under a State

enabling statute;

"(ii) enrolls all medicaid beneficiaries residing in the county

or counties in which it operates;

"(iii) meets the requirements for health maintenance

organizations under the Knox-Keene Act (Cal. Health and Safety

Code, section 1340 et seq.) and the Waxman-Duffy Act (Cal.

Welfare and Institutions Code, section 14450 et seq.);

"(iv) assures a reasonable choice of providers, which includes

providers that have historically served medicaid beneficiaries

and which does not impose any restriction which substantially

impairs access to covered services of adequate quality where

medically necessary;

"(v) provides for a payment adjustment for a disproportionate

share hospital (as defined under State law consistent with

section 1923 of the Social Security Act [section 1396r-4 of this

title]) in a manner consistent with the requirements of such

section; and

"(vi) provides for payment, in the case of childrens' hospital

services provided to medicaid beneficiaries who are under 21

years of age, who are children with special health care needs

under title V of the Social Security Act [subchapter V of this

chapter], and who are receiving care coordination services under

such title, at rates determined by the California Medical

Assistance Commission.

"(C) Subparagraph (A) shall not apply with respect to any period

for which the Secretary of Health and Human Services determines

that the number of medicaid beneficiaries enrolled with health

insuring organizations described in subparagraph (B) exceeds 14

percent of the number of such beneficiaries in the State of

California.

"(D) In this paragraph, the term 'medicaid beneficiary' means an

individual who is entitled to medical assistance under the State

plan under title XIX of the Social Security Act [this subchapter],

other than a qualified medicare beneficiary who is only entitled to

such assistance because of section 1902(a)(10)(E) of such title

[section 1396a(a)(10)(E) of this title]."

[Pub. L. 106-554, Sec. 1(a)(6) [title VII, Sec. 704(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-575, provided that: "The amendment made

by subsection (a) [amending section 9517(c)(3)(C) of Pub. L.

99-272, set out above] takes effect on the date of the enactment of

this Act [Dec. 21, 2000]."]

[Pub. L. 104-240, Sec. 1(b), Oct. 8, 1996, 110 Stat. 3140,

provided that: "The amendment made by subsection (a) [amending

section 9517(c)(3)(B)(ii) of Pub. L. 99-272, set out above] shall

apply to quarters beginning on or after October 1, 1996."]

Section 9518(b) of Pub. L. 99-272 provided that: "The amendment

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

payment under section 1903(a) of the Social Security Act [subsec.

(a) of this section] for calendar quarters beginning on or after

October 1, 1982."

EFFECTIVE DATE OF 1984 AMENDMENTS

Amendment by Pub. L. 98-617 effective as if originally included

in the Deficit Reduction Act of 1984, Pub. L. 98-369, see section

3(c) of Pub. L. 98-617, set out as a note under section 1395f of

this title.

Amendment by section 2303(g)(2) of Pub. L. 98-369 applicable to

payments for calendar quarters beginning on or after Oct. 1, 1984,

but not applicable to clinical diagnostic laboratory tests

furnished to inpatients of a provider operating under a waiver

granted pursuant to section 602(k) of Pub. L. 98-21, set out as a

note under section 1395y of this title, see section 2303(j)(2) and

(3) of Pub. L. 98-369, set out as a note under section 1395l of

this title.

Section 2363(c) of Pub. L. 98-369 provided that: "The amendments

made by subsection (a) [amending this section and section 1396a of

this title] apply to calendar quarters beginning on or after the

date of the enactment of this Act [July 18, 1984], except that, in

the case of individuals admitted to skilled nursing facilities

before such date, the amendments made by such subsection shall not

require recertifications sooner or more frequently than were

required under the law in effect before such date."

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 133(b) of Pub. L. 97-248 provided that: "The amendment

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

effective on the date of the enactment of this Act [Sept. 3,

1982]."

Amendment by section 137(a)(1), (2) of Pub. L. 97-248 effective

as if originally included in the provision of the Omnibus Budget

Reconciliation Act of 1981, Pub. L. 97-35, to which such amendment

relates, see section 137(d)(1) of Pub. L. 97-248, set out as a note

under section 1396a of this title.

Amendment by section 137(b)(11)-(16), (27) 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.

Section 137(g) of Pub. L. 97-248 provided that the amendment made

by that section is effective Oct. 1, 1982.

Amendment by section 146(b) of Pub. L. 97-248 effective with

respect to contracts entered into or renewed on or after Sept. 3,

1982, see section 149 of Pub. L. 97-248, set out as an Effective

Date note under section 1320c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by section 2101(a)(2) of Pub. L. 97-35 applicable only

to services furnished by a hospital during any accounting year

beginning on or after Oct. 1, 1981, see section 2101(c) of Pub. L.

97-35, set out as an Effective Date note under section 1395uu of

this title.

Section 2103(b)(2) of Pub. L. 97-35 provided that: "The amendment

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

amounts expended on or after October 1, 1981."

Amendment by section 2113(n) of Pub. L. 97-35 applicable to

agreements with Professional Standards Review Organizations entered

into on or after Oct. 1, 1981, see section 2113(o) of Pub. L.

97-35, set out as a note under section 1396a of this title.

Section 2161(c)(1) of Pub. L. 97-35, as amended by Pub. L.

97-248, title I, Sec. 137(a)(2), Sept. 3, 1982, 96 Stat. 376,

provided that the amendment made by such section 2161(c)(1) is

effective for calendar quarters beginning on or after Oct. 1, 1984.

Section 2161(c)(2) of Pub. L. 97-35, as amended by Pub. L.

97-248, title I, Sec. 137(a)(2), Sept. 3, 1982, 96 Stat. 376,

provided that the amendment made by such section 2161(c)(2) is

effective after payments for the first quarter of fiscal year 1985.

Section 2164(b) of Pub. L. 97-35 provided that: "The amendments

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

occurring on or after October 1, 1981."

Amendment by section 2174(b) of Pub. L. 97-35 applicable to

services furnished on or after Oct. 1, 1981, see section 2174(c) of

Pub. L. 97-35, set out as a note under section 1396a of this title.

Amendment by section 2178(a) of Pub. L. 97-35 applicable with

respect to services furnished, under a State plan approved under

this subchapter, on or before Oct. 1, 1981, except that such

amendments not applicable with respect to services furnished by a

health maintenance organization under a contract with a State

entered into under this subchapter before Oct. 1, 1981, unless the

organization requests that such amendments apply and the Secretary

and the State agency agree to such request, see section 2178(c) of

Pub. L. 97-35, set out as a note under section 1396a of this title.

Section 2183(b) of Pub. L. 97-35 provided that: "The amendments

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

payments made to States for calendar quarters beginning on or after

October 1, 1981."

EFFECTIVE DATE OF 1980 AMENDMENT

Section 961(b) of Pub. L. 96-499 provided that: "The amendment

made by subsection (a) [amending this section] shall be effective

with respect to expenditures for services furnished on or after

October 1, 1980."

EFFECTIVE DATE OF 1977 AMENDMENTS

Amendment by section 3(c)(2) of Pub. L. 95-142 effective Jan. 1,

1978, see section 3(e) of Pub. L. 95-142, set out as an Effective

Date note under section 1320a-3 of this title.

Amendment by section 8(c) of Pub. L. 95-142 effective with

respect to contracts, agreements, etc., made on and after the first

day of the fourth month beginning after Oct. 25, 1977, see section

8(e) of Pub. L. 95-142, set out as an Effective Date note under

section 1320a-5 of this title.

Section 10(b) of Pub. L. 95-142 provided that: "The amendment

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

respect to calendar quarters beginning after the date of the

enactment of this Act [Oct. 25, 1977]."

Section 11(c) of Pub. L. 95-142 provided that: "The amendment

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

respect to medical assistance provided, under a State plan approved

under title XIX of the Social Security Act [this subchapter], on

and after January 1, 1978."

Section 17(e)(1) of Pub. L. 95-142 provided that: "The amendment

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

respect to calendar quarters beginning after September 30, 1977."

Section 20(c) of Pub. L. 95-142, as amended by Pub. L. 95-292,

Sec. 8(e), June 13, 1978, 92 Stat. 316, provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this section [amending this section and section 1396a of this

title] shall be effective on October 1, 1977, and the Secretary of

Health, Education, and Welfare shall promptly adjust payments made

to States under section 1903 of the Social Security Act [this

section] to reflect the changes made by such amendments.

"(2) The amount of any reduction in the Federal medical

assistance percentage of a State, otherwise required to be imposed

under section 1903(g)(1) of the Social Security Act [subsec. (g)(1)

of this section] because of an unsatisfactory or invalid showing

made by the State with respect to a calendar quarter beginning on

or after January 1, 1977, shall be determined under such section as

amended by this section. Subparagraph (B) of paragraph (4) of

section 1903(g) of such Act [subsec. (g)(4)(B) of this section], as

added by this section, shall apply to any showing made by a State

under such section with respect to a calendar quarter beginning on

or after January 1, 1977."

Section 105(a)(3) of Pub. L. 95-83 provided that: "The amendments

made by paragraphs (1) and (2) [amending this section] shall apply

with respect to payments under title XIX of the Social Security Act

[this subchapter] to States for services provided -

"(A) after October 8, 1976, under contracts under such title

[this subchapter] entered into or renegotiated after such date,

or

"(B) after the expiration of the one-year period beginning on

such date,

whichever occurs first."

EFFECTIVE DATE OF 1976 AMENDMENTS

Amendment by Pub. L. 94-552 effective Jan. 1, 1976, see section 2

of Pub. L. 94-552, set out as a note under section 1396a of this

title.

Section 202(b) of Pub. L. 94-460 provided that: "The amendment

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

respect to payments under title XIX of the Social Security Act

[this subchapter] to States for services provided -

"(1) after the date of enactment of subsection (a) [Oct. 8,

1976] under contracts under such title entered into or

renegotiated after such date, or

"(2) after the expiration of the 1-year period beginning on

such date of enactment,

whichever occurs first."

EFFECTIVE DATE OF 1975 AMENDMENT

Section 110(b) of Pub. L. 94-182 provided that: "The amendment

made by subsection (a) [amending this section] shall take effect on

the first day of the first calendar month which begins not less

than 90 days after the date of enactment of this Act [Dec. 31,

1975]."

Amendment by section 111(b) of Pub. L. 94-182 effective January

1, 1976, except as otherwise provided therein, see section 111(c)

of Pub. L. 94-182, set out as a note under section 1396a of this

title.

EFFECTIVE DATE OF 1973 AMENDMENTS

Amendment by section 13(a)(11), (12) of Pub. L. 93-233 effective

with respect to payments under this section 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.

Amendment by section 18(u) of Pub. L. 93-233 effective July 1,

1973, see section 18(z-3)(4) of Pub. L. 93-233, set out as a note

under section 1396a of this title.

Section 234(b) of Pub. L. 93-66 provided that: "The amendment

made by subsection (a) [amending this section] shall be applicable

in the case of expenditures for skilled nursing services and for

intermediate care facility services furnished in calendar quarters

which begin after December 31, 1972."

EFFECTIVE DATE OF 1972 AMENDMENT

Section 207(b) of Pub. L. 92-603 provided that: "The amendments

made by subsection (a) [amending this section] shall, except as

otherwise provided therein, be effective July 1, 1973."

Amendment by section 226(e) of Pub. L. 92-603 effective with

respect to services provided on or after July 1, 1973, see section

226(f) of Pub. L. 92-603, set out as an Effective Date note under

section 1395mm of this title.

Amendment by section 233(c) of Pub. L. 92-603 applicable with

respect to services furnished by hospitals in accounting periods

beginning after Dec. 31, 1972, see section 233(f) of Pub. L.

92-603, set out as a note under section 1395f of this title. See,

also, section 16 of Pub. L. 93-233, set out as an Effective Date

note under section 1395f of this title.

Section 235(b) of Pub. L. 92-603 provided that: "The amendments

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

respect to expenditures under State plans approved under title XIX

of the Social Security Act [this subchapter], made after June 30,

1971."

Section 237(d)(1) of Pub. L. 92-603 provided that: "The

amendments made by subsections (a)(1) and (b) [amending this

section and section 706 of this title] shall apply with respect to

services furnished in calendar quarters beginning after June 30,

1973."

Section 249B of Pub. L. 92-603, as amended by Pub. L. 93-368,

Sec. 8, Aug. 7, 1974, 88 Stat. 422; Pub. L. 95-83, title III, Sec.

309(b), Aug. 1, 1977, 91 Stat. 396, provided that the amendment

made by that section is effective for period beginning Oct. 1,

1972, and ending Sept. 30, 1980.

EFFECTIVE DATE OF 1968 AMENDMENTS

Section 220(b) of Pub. L. 90-248 provided that:

"(b)(1) In the case of any State whose plan under title XIX of

the Social Security Act [this subchapter] is approved by the

Secretary of Health, Education, and Welfare under section 1902

[section 1396a of this title] after July 25, 1967, the amendment

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

respect to calendar quarters beginning after the date of enactment

of this Act [Jan. 2, 1968].

"(2) In the case of any State whose plan under title XIX of the

Social Security Act [this subchapter] was approved by the Secretary

of Health, Education, and Welfare under section 1902 of the Social

Security Act [section 1396a of this title] prior to July 26, 1967,

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

apply with respect to calendar quarters beginning after June 30,

1968, except that -

"(A) with respect to the third and fourth calendar quarters of

1968, such subsection shall be applied by substituting in

subsection (f) of section 1903 of the Social Security Act

[subsec. (f) of this section] 150 percent for 133 1/2 percent

each time such latter figure appears in such subsection (f), and

"(B) with respect to all calendar quarters during 1969, such

subsection shall be applied by substituting in subsection (f) of

section 1903 of such Act [subsec. (f) of this section] 140

percent for 133 1/2 percent each time such latter figure appears

in such subsection (f)."

Section 222(d) of Pub. L. 90-248, as amended by section 303(a)(2)

of Pub. L. 90-364, provided that the amendment made by such section

222(d) is effective with respect to calendar quarters beginning

after December 31, 1969.

Section 225(b) of Pub. L. 90-248 provided that: "The amendment

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

respect to expenditures made after December 31, 1967."

Section 303(b) of Pub. L. 90-364 provided that: "The amendments

made by subsection (a) [amending this section] shall be effective

with respect to calendar quarters beginning after December 31,

1967."

REGULATIONS

Section 5 of Pub. L. 102-234 provided that:

"(a) In General. - Subject to subsection (b), the Secretary of

Health and Human Services shall issue such regulations (on an

interim final or other basis) as may be necessary to implement this

Act [see Short Title of 1991 Amendment note set out under section

1305 of this title] and the amendments made by this Act.

"(b) Regulations Changing Treatment of Intergovernmental

Transfers. - The Secretary may not issue any interim final

regulation that changes the treatment (specified in section

433.45(a) of title 42, Code of Federal Regulations) of public funds

as a source of State share of financial participation under title

XIX of the Social Security Act [this subchapter], except as may be

necessary to permit the Secretary to deny Federal financial

participation for public funds described in section 1903(w)(6)(A)

of such Act [subsection (w)(6)(A) of this section] (as added by

section 2(a) of this Act) that are derived from donations or taxes

that would not otherwise be recognized as the non-Federal share

under section 1903(w) of such Act.

"(c) Consultation With States. - The Secretary shall consult with

the States before issuing any regulations under this Act."

Secretary of Health and Human Services to promulgate final

regulations necessary to carry out subsec. (r)(6)(j) of this

section within 6 months after Apr. 7, 1986, see section 9503(c) of

Pub. L. 99-272, set out as a note under section 1396a of this

title.

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.

TREATMENT OF DONATION OR TAX PROCEEDS PRIOR TO EFFECTIVE DATE OF

SUBSECTION (W)

Section 2(c)(2) of Pub. L. 102-234 provided that: "Except as

specifically provided in section 1903(w) of the Social Security Act

[subsec. (w) of this section] and notwithstanding any other

provision of such Act [this chapter], the Secretary of Health and

Human Services shall not, with respect to expenditures prior to the

effective date specified in section 1903(w)(1)(F) of such Act,

disallow any claim submitted by a State for, or otherwise withhold

Federal financial participation with respect to, amounts expended

for medical assistance under title XIX of the Social Security Act

[this subchapter] by reason of the fact that the source of the

funds used to constitute the non-Federal share of such expenditures

is a tax imposed on, or a donation received from, a health care

provider, or on the ground that the amount of any donation or tax

proceeds must be credited against the amount of the expenditure."

TEMPORARY INCREASE IN FEDERAL MATCH FOR ADMINISTRATIVE COSTS

Section 4401(b)(2) of Pub. L. 101-508 provided that: "The per

centum to be applied under section 1903(a)(7) of the Social

Security Act [subsec. (a)(7) of this section] for amounts expended

during calendar quarters in fiscal year 1991 which are attributable

to administrative activities necessary to carry out section 1927

(other than subsection (g)) of such Act [section 1396r-8 of this

title] shall be 75 percent, rather than 50 percent; after fiscal

year 1991, the match shall revert back to 50 percent."

REPORT ON ERRORS IN ELIGIBILITY DETERMINATIONS; ERROR RATE

TRANSITION RULES

Section 4607 of Pub. L. 101-508 directed Secretary of Health and

Human Services to report to Congress, by not later than July 1,

1991, on error rates by States in determining eligibility of

individuals described in subparagraph (A) or (B) of section

1396a(l)(1) of this title for medical assistance under plans

approved under this subchapter, and directed that there should not

be taken into account, for purposes of subsec. (u) of this section,

payments and expenditures for medical assistance attributable to

medical assistance for individuals described in such subparagraph

(A) or (B), and made on or after July 1, 1989, and before the first

calendar quarter that begins more than 12 months after the date of

submission of the Secretary's report.

MEDICALLY NEEDY INCOME LEVELS FOR CERTAIN 1-MEMBER FAMILIES

Section 4718 of Pub. L. 101-508 provided that:

"(a) In General. - For purposes of section 1903(f)(1)(B)

[probably means subsec. (f)(1)(B) of this section], for payments

made before, on, or after the date of the enactment of this Act

[Nov. 5, 1990], a State described in subparagraph (B) may use, in

determining the 'highest amount which would ordinarily be paid to a

family of the same size' (under the State's plan approved under

part A of title IV of such Act [probably means part A of subchapter

IV of this chapter]) in the case of a family consisting only of one

individual and without regard to whether or not such plan provides

for aid to families consisting only of one individual, an amount

reasonably related to the highest money payment which would

ordinarily be made under such a plan to a family of two without

income or resources.

"(b) States Covered. - Subsection (a) shall only apply to a State

the State plan of which (under title XIX of the Social Security Act

[this subchapter]) as of June 1, 1989, provided for the policy

described in such paragraph. For purposes of the previous sentence,

a State plan includes all the matter included in a State plan under

section 2373(c)(5) of the Deficit Reduction Act of 1984 [Pub. L.

98-369, set out as a note under section 1396a of this title] (as

amended by section 9 of the Medicare and Medicaid Patient and

Program Protection Act of 1987 [Pub. L. 100-93])."

DAY HABILITATION AND RELATED SERVICES

Section 6411(g) of Pub. L. 101-239 provided that:

"(1) Prohibition of disallowance pending issuance of regulations.

- Except as specifically permitted under paragraph (3), the

Secretary of Health and Human Services may not -

"(A) withhold, suspend, disallow, or deny Federal financial

participation under section 1903(a) of the Social Security Act

[subsec. (a) of this section] for day habilitation and related

services under paragraph (9) or (13) of section 1905(a) of such

Act [section 1396d(a)(9), (13) of this title] on behalf of

persons with mental retardation or with related conditions

pursuant to a provision of its State plan as approved on or

before June 30, 1989, or

"(B) withdraw Federal approval of any such State plan

provision.

"(2) Requirements for regulation. - A final regulation described

in this paragraph is a regulation, promulgated after a notice of

proposed rule-making and a period of at least 60 days for public

comment, that -

"(A) specifies the types of day habilitation and related

services that a State may cover under paragraph (9) or (13) of

section 1905(a) of the Social Security Act on behalf of persons

with mental retardation or with related conditions, and

"(B) any requirements respecting such coverage.

"(3) Prospective application of regulation. - If the Secretary

promulgates a final regulation described in paragraph (2) and the

Secretary determines that a State plan under title XIX of the

Social Security Act [this subchapter] does not comply with such

regulation, the Secretary shall notify the State of the

determination and its basis, and such determination shall not apply

to day habilitation and related services furnished before the first

day of the first calendar quarter beginning after the date of the

notice to the State."

NURSE AIDE TRAINING AND EVALUATION PROGRAMS; ALLOCATION OF COSTS

BEFORE OCTOBER 1, 1990

Section 6901(b)(5)(B) of Pub. L. 101-239 provided that: "In

making payments under section 1903(a)(2)(B) of the Social Security

Act [subsec. (a)(2)(B) of this section] for amounts expended for

nurse aide training and competency evaluation programs, and

competency evaluation programs, described in section 1919(e)(1) of

such Act [section 1396r(e)(1) of this title], in the case of

activities conducted before October 1, 1990, the Secretary of

Health and Human Services shall not take into account, or allocate

amounts on the basis of, the proportion of residents of nursing

facilities that is entitled to benefits under title XVIII or XIX of

such Act [this subchapter and subchapter XVIII of this chapter]."

CLARIFICATION OF FEDERAL MATCHING RATE FOR SURVEY AND CERTIFICATION

ACTIVITIES

Section 6901(d)(2) of Pub. L. 101-239 provided that: "During the

period before October 1, 1990, the Federal percentage matching

payment rate under section 1903(a) of the Social Security Act

[subsec. (a) of this section] for so much of the sums expended

under a State plan under title XIX of such Act [this subchapter] as

are attributable to compensation or training of personnel

responsible for inspecting public or private skilled nursing or

intermediate care facilities to individuals receiving medical

assistance to determine compliance with health or safety standards

shall be 75 percent."

QUALITY CONTROL TRANSITION PROVISIONS

Section 608(h) of Pub. L. 100-485 provided that: "There shall not

be taken into account, for purposes of section 1903(u) of the

Social Security Act [subsec. (u) of this section], payments and

expenditures for medical assistance which are made on or after

January 1, 1989, and before July 1, 1989, and which are

attributable to medicare-cost [sic] sharing for qualified medicare

beneficiaries (as defined in section 1905(p) of such Act [section

1396d(p) of this title])."

DELAY QUALITY CONTROL SANCTIONS FOR MEDICAID

Section 4117 of Pub. L. 100-203 provided that: "The Secretary of

Health and Human Services shall not, prior to July 1, 1988,

implement any reductions in payments to States pursuant to section

1903(u) of the Social Security Act [subsec. (u) of this section]

(or any provision of law described in subsection (c) of section 133

of the Tax Equity and Fiscal Responsibility Act of 1982 [section

133(c) of Pub. L. 97-248, set out below])."

TEMPORARY TECHNICAL ERROR DEFINITION

Section 4118(n) of Pub. L. 100-203 provided that: "For purposes

of section 1903(u)(1)(E)(ii) of the Social Security Act [subsec.

(u)(1)(E)(ii) of this section], effective for the period beginning

on the date of enactment of this Act [Dec. 22, 1987] and ending

December 31, 1988, a 'technical error' is an error in eligibility

condition (such as assignment of social security numbers and

assignment of rights to third-party benefits as a condition of

eligibility) that, if corrected, would not result in a difference

in the amount of medical assistance paid."

ENHANCED FUNDING FOR NURSE AIDE TRAINING

Section 4211(d)(2) of Pub. L. 100-203, as amended by Pub. L.

100-360, title IV, Sec. 411(l)(3)(F), July 1, 1988, 102 Stat. 803,

provided that: "For the 8 calendar quarters (beginning with the

calendar quarter that begins on July 1, 1988), with respect to

payment under section 1903(a)(2)(B) of the Social Security Act

[subsec. (a)(2)(B) of this section] to a State for additional

amounts expended by the State under its plan approved under title

XIX of such Act [this subchapter] for nursing aide training and

competency evaluation programs, and competency evaluation programs,

described in section 1919(e)(1) of such title [section 1396r(e)(1)

of this title], any reference to '50 percent' is deemed a reference

to the sum of the Federal medical assistance percentage (determined

under section 1905(b) of such Act [section 1396d(b) of this title])

plus 25 percentage points, but not to exceed 90 percent."

EXPENSES INCURRED FOR REVIEW OF CARE PROVIDED TO RESIDENTS OF

NURSING FACILITIES

Section 4212(c)(3) of Pub. L. 100-203 provided that: "For

purposes of section 1903(a) of the Social Security Act [subsec. (a)

of this section], proper expenses incurred by a State for medical

review by independent professionals of the care provided to

residents of nursing facilities who are entitled to medical

assistance under title XIX of such Act [this subchapter] shall be

reimbursable as expenses necessary for the proper and efficient

administration of the State plan under that title."

QUALITY CONTROL STUDIES AND PENALTY MORATORIUM

Section 12301 of Pub. L. 99-272, as amended by Pub. L. 99-514,

title XVII, Sec. 1710, Oct. 22, 1986, 100 Stat. 2783; Pub. L.

100-485, title VI, Sec. 609(b), Oct. 13, 1988, 102 Stat. 2425,

provided that:

"(a) Studies. - (1) The Secretary of Health and Human Services

(hereafter referred to in this section as the 'Secretary') shall

conduct a study of quality control systems for the Aid to Families

with Dependent Children Program under title IV-A of the Social

Security Act [part A of subchapter IV of this chapter] and for the

Medicaid Program under title XIX of such Act [this subchapter]. The

study shall examine how best to operate such systems in order to

obtain information which will allow program managers to improve the

quality of administration, and provide reasonable data on the basis

of which Federal funding may be withheld for States with excessive

levels of erroneous payments.

"(2) The Secretary shall also contract with the National Academy

of Sciences to conduct a concurrent independent study for the

purpose described in paragraph (1). For purposes of such study, the

Secretary shall provide to the National Academy of Sciences any

relevant data available to the Secretary at the onset of the study

and on an ongoing basis.

"(3) The Secretary and the National Academy of Sciences shall

report the results of their respective studies to the Congress

within one year after the date the Secretary and the National

Academy of Sciences enter into the contract required under

paragraph (2).

"(b) Moratorium on Penalties. - (1) During the 24-month period

beginning with the first calendar quarter which begins after the

date of the enactment of this Act [Apr. 7, 1986] (hereafter in this

section referred to as the 'moratorium period'), the Secretary

shall not impose any reductions in payments to States pursuant to

section 403(i) of the Social Security Act [section 603(i) of this

title] (or prior regulations), or pursuant to any comparable

provision of law relating to the programs under title IV-A of such

Act [part A of subchapter IV of this chapter] in Puerto Rico, Guam,

the Virgin Islands, American Samoa, or the Northern Mariana

Islands.

"(2) During the moratorium period, the Secretary and the States

shall continue to operate the quality control systems in effect

under title IV-A of the Social Security Act, and to calculate the

error rates under the provisions referred to in paragraph (1).

"(c) Restructured Quality Control Systems. - (1) Not later than 6

months after the date on which the results of both studies required

under subsection (a)(3) have been reported, the Secretary shall

publish regulations which shall -

"(A) restructure the quality control systems under title XIX of

the Social Security Act [this subchapter] to the extent the

Secretary determines to be appropriate, taking into account the

studies conducted under subsection (a); and

"(B) establish, taking into account the studies conducted under

subsection (a), criteria for adjusting the reductions which shall

be made for quarters prior to the implementation of the

restructured quality control systems so as to eliminate

reductions for those quarters which would not be required if the

restructured quality control systems had been in effect during

those quarters.

"(2) Beginning with the first calendar quarter after the

moratorium period, the Secretary shall implement the revised

quality control systems under title XIX, and shall reduce payments

to States -

"(A) for quarters after the moratorium period in accordance

with the restructured quality control systems; and

"(B) for quarters in and before the moratorium period, as

provided under the regulations described in paragraph (1)(B).

"(d) Effective Date. - This section shall become effective on the

date of the enactment of this Act [Apr. 7, 1986]."

EFFECTIVENESS OF LAWS LIMITING FEDERAL FINANCIAL PARTICIPATION WITH

RESPECT TO ERRONEOUS PAYMENTS MADE BY STATES UNDER A STATE PLAN

APPROVED UNDER THIS SUBCHAPTER

Section 133(c) of Pub. L. 97-248 provided that: "No provision of

law limiting Federal financial participation with respect to

erroneous payments made by States under a State plan approved under

title XIX of the Social Security Act [this subchapter] (including

any provision contained in, or incorporated by reference into, any

appropriation Act or resolution making continuing appropriations),

other than the limitations contained in section 1903 of such Act

[this section], shall be effective with respect to payments to

States under such section 1903 for quarters beginning on or after

October 1, 1982, unless such provision of law is enacted after the

date of the date of the enactment of this Act [Sept. 3, 1982] and

expressly provides that such limitation is in addition to or in

lieu of the limitations contained in section 1903 of the Social

Security Act."

MEDICAID PAYMENTS FOR INDIAN HEALTH SERVICE FACILITIES TO BE PAID

ENTIRELY BY FEDERAL FUNDS; EXCLUSION OF PAYMENTS TO STATES IN

COMPUTATION OF TARGET AMOUNT OF FEDERAL MEDICAID EXPENDITURES

Pub. L. 97-92, Secs. 102, 118, Dec. 15, 1981, 95 Stat. 1193,

1197, as amended by Pub. L. 97-161, Mar. 31, 1982, 96 Stat. 22,

provided, for the period Dec. 15, 1981, to not later than Sept. 30,

1982, that: "Notwithstanding section 1903(s) of the Social Security

Act [subsec. (s) of this section], all medicaid payments to the

States for Indian health service facilities as defined by section

1911 of the Social Security Act [section 1396j of this title] shall

be paid entirely by Federal funds, and notwithstanding section

1903(t) of the Social Security Act [subsec. (t) of this section],

all medicaid payments to the States for Indian health service

facilities shall not be included in the computation of the target

amount of Federal medicaid expenditures."

PROMULGATION OF REGULATIONS FOR IMPLEMENTATION OF AMENDMENTS BY

SECTION 17 OF PUB. L. 95-142

Section 17(e)(2) of Pub. L. 95-142 required Secretary of Health,

Education, and Welfare to establish regulations, not later than 90

days after Oct. 25, 1977, to carry out amendments made by section

17 (amending sections 1395b-1 and 1396b of this title). See section

1302 of this title.

DEFERRAL OF IMPLEMENTATION OF DECREASES IN MATCHING FUNDS

Section 6 of Pub. L. 95-59, June 30, 1977, 91 Stat. 255, provided

that: "Notwithstanding the provisions of subsection (g) of section

1903 of the Social Security Act [subsec. (g) of this section], the

amount payable to any State for the calendar quarters during the

period commencing April 1, 1977, and ending September 30, 1977, on

account of expenditures made under a State plan approved under

title XIX of such Act [this subchapter], shall not be decreased by

reason of the application of the provisions of such subsection with

respect to any period for which such State plan was in operation

prior to April 1, 1977."

COMPREHENSIVE CARE AND SERVICES FOR ELIGIBLE INDIVIDUALS BY JULY 1,

1977; REQUIREMENT INAPPLICABLE FOR ANY PERIOD PRIOR TO JULY 1,

1971; REGULATIONS; ADVICE TO STATES

Section 2(b) of Pub. L. 91-56, which provided that subsection (e)

of this section was inapplicable to the period prior to July 1,

1971, and which authorized the Secretary to issue regulations, was

repealed by Pub. L. 92-603, title II, Sec. 230, Oct. 30, 1972, 86

Stat. 1410.

EXEMPTION OF PUERTO RICO, THE VIRGIN ISLANDS, AND GUAM FROM

LIMITATIONS ON FEDERAL PAYMENTS FOR MEDICAL ASSISTANCE

Section 248(d) of Pub. L. 90-248 provided that: "The amendment

made by section 220(a) of this Act [amending this section] shall

not apply in the case of Puerto Rico, the Virgin Islands, or Guam."

NONDUPLICATION OF PAYMENTS TO STATES; LIMITATION ON INSTITUTIONAL

CARE

Section 121(b) of Pub. L. 89-97, as amended by section 249D of

Pub. L. 92-603, provided that: "No payment may be made to any State

under title I, IV, X, XIV, or XVI of the Social Security Act

[subchapter I, IV, X, XIV, or XVI of this chapter] with respect to

aid or assistance in the form of medical or any other type of

remedial care for any period for which such State receives payments

under title XIX of such Act [this subchapter], or for any period

after December 31, 1969. After the date of enactment of the Social

Security Amendments of 1972 [Oct. 30, 1972], Federal matching shall

not be available for any portion of any payment by any State under

title I, X, XIV, or XVI, or part A of title IV, of the Social

Security Act [subchapter I, X, XIV, or XVI, or part A of subchapter

IV of this chapter] for or on account of any medical or any other

type of remedial care provided by an institution to any individual

as an inpatient thereof, in the case of any State which has a plan

approved under title XIX of such Act [this subchapter], if such

care is (or could be) provided under a State plan approved under

title XIX of such Act [this subchapter] by an institution certified

under such title XIX [this subchapter]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1315, 1320a-7, 1320a-7b,

1320b-7, 1320c-7, 1395i-3, 1395eee, 1396a, 1396d, 1396e, 1396n,

1396r, 1396r-1, 1396r-1a, 1396r-2, 1396r-4, 1396r-6, 1396r-8,

1396t, 1396u-1, 1396u-2, 1396u-3, 1396u-4, 1397ee, 1397gg, 1786,

3058i of this title; title 7 section 2025; title 8 sections 1611,

1621; title 18 section 506.

-FOOTNOTE-

(!1) See References in Text note below.

(!2) So in original. The word "or" probably should precede

"1396(p)(1)".

(!3) See References in Text note below.

(!4) See References in Text note below.

(!5) So in original. Probably should not be capitalized.

(!6) So in original. The comma probably should be a semicolon.

(!7) So in original. Probably should be followed by a comma.

(!8) See References in Text note below.

(!9) So in original. The comma probably should be a semicolon.

(!10) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1396c 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. 1396c. Operation of State plans

-STATUTE-

If the Secretary, after reasonable notice and opportunity for

hearing to the State agency administering or supervising the

administration of the State plan approved under this subchapter,

finds -

(1) that the plan has been so changed that it no longer

complies with the provisions of section 1396a of this title; or

(2) that in the administration of the plan there is a failure

to comply substantially with any such provision;

the Secretary shall notify such State agency that further payments

will not be made to the State (or, in his discretion, that payments

will be limited to categories under or parts of the State plan not

affected by such failure), until the Secretary is satisfied that

there will no longer be any such failure to comply. Until he is so

satisfied he shall make no further payments to such State (or shall

limit payments to categories under or parts of the State plan not

affected by such failure).

-SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1904, as added Pub. L.

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

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1316 of this title.

-End-

-CITE-

42 USC Sec. 1396d 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. 1396d. Definitions

-STATUTE-

For purposes of this subchapter -

(a) Medical assistance

The term "medical assistance" means payment of part or all of the

cost of the following care and services (if provided in or after

the third month before the month in which the recipient makes

application for assistance or, in the case of medicare cost-sharing

with respect to a qualified medicare beneficiary described in

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

which the individual becomes such a beneficiary) for individuals,

and, with respect to physicians' or dentists' services, at the

option of the State, to individuals (other than individuals with

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

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

with respect to them a State supplementary payment and are eligible

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

medical assistance made available to individuals described in

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

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

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

chapter, and with respect to whom supplemental security income

benefits are not being paid under subchapter XVI of this chapter,

who are -

(i) under the age of 21, or, at the option of the State, under

the age of 20, 19, or 18 as the State may choose,

(ii) relatives specified in section 606(b)(1) (!1) of this

title with whom a child is living if such child is (or would, if

needy, be) a dependent child under part A of subchapter IV of

this chapter,

(iii) 65 years of age or older,

(iv) blind, with respect to States eligible to participate in

the State plan program established under subchapter XVI of this

chapter,

(v) 18 years of age or older and permanently and totally

disabled, with respect to States eligible to participate in the

State plan program established under subchapter XVI of this

chapter,

(vi) persons essential (as described in the second sentence of

this subsection) to individuals receiving aid or assistance under

State plans approved under subchapter I, X, XIV, or XVI of this

chapter,

(vii) blind or disabled as defined in section 1382c of this

title, with respect to States not eligible to participate in the

State plan program established under subchapter XVI of this

chapter,

(viii) pregnant women,

(ix) individuals provided extended benefits under section

1396r-6 of this title,

(x) individuals described in section 1396a(u)(1) of this title,

(xi) individuals described in section 1396a(z)(1) of this

title,

(xii) employed individuals with a medically improved disability

(as defined in subsection (v) of this section), or

(xiii) individuals described in section 1396a(aa) (!2) of this

title,

but whose income and resources are insufficient to meet all of such

cost -

(1) inpatient hospital services (other than services in an

institution for mental diseases);

(2)(A) outpatient hospital services, (B) consistent with State

law permitting such services, rural health clinic services (as

defined in subsection (l)(1) of this section) and any other

ambulatory services which are offered by a rural health clinic

(as defined in subsection (l)(1) of this section) and which are

otherwise included in the plan, and (C) Federally-qualified

health center services (as defined in subsection (l)(2) of this

section) and any other ambulatory services offered by a

Federally-qualified health center and which are otherwise

included in the plan;

(3) other laboratory and X-ray services;

(4)(A) nursing facility services (other than services in an

institution for mental diseases) for individuals 21 years of age

or older; (B) early and periodic screening, diagnostic, and

treatment services (as defined in subsection (r) of this section)

for individuals who are eligible under the plan and are under the

age of 21; and (C) family planning services and supplies

furnished (directly or under arrangements with others) to

individuals of child-bearing age (including minors who can be

considered to be sexually active) who are eligible under the

State plan and who desire such services and supplies;

(5)(A) physicians' services furnished by a physician (as

defined in section 1395x(r)(1) of this title), whether furnished

in the office, the patient's home, a hospital, or a nursing

facility, or elsewhere, and (B) medical and surgical services

furnished by a dentist (described in section 1395x(r)(2) of this

title) to the extent such services may be performed under State

law either by a doctor of medicine or by a doctor of dental

surgery or dental medicine and would be described in clause (A)

if furnished by a physician (as defined in section 1395x(r)(1) of

this title);

(6) medical care, or any other type of remedial care recognized

under State law, furnished by licensed practitioners within the

scope of their practice as defined by State law;

(7) home health care services;

(8) private duty nursing services;

(9) clinic services furnished by or under the direction of a

physician, without regard to whether the clinic itself is

administered by a physician, including such services furnished

outside the clinic by clinic personnel to an eligible individual

who does not reside in a permanent dwelling or does not have a

fixed home or mailing address;

(10) dental services;

(11) physical therapy and related services;

(12) prescribed drugs, dentures, and prosthetic devices; and

eyeglasses prescribed by a physician skilled in diseases of the

eye or by an optometrist, whichever the individual may select;

(13) other diagnostic, screening, preventive, and

rehabilitative services, including any medical or remedial

services (provided in a facility, a home, or other setting)

recommended by a physician or other licensed practitioner of the

healing arts within the scope of their practice under State law,

for the maximum reduction of physical or mental disability and

restoration of an individual to the best possible functional

level;

(14) inpatient hospital services and nursing facility services

for individuals 65 years of age or over in an institution for

mental diseases;

(15) services in an intermediate care facility for the mentally

retarded (other than in an institution for mental diseases) for

individuals who are determined, in accordance with section

1396a(a)(31) of this title, to be in need of such care;

(16) effective January 1, 1973, inpatient psychiatric hospital

services for individuals under age 21, as defined in subsection

(h) of this section;

(17) services furnished by a nurse-midwife (as defined in

section 1395x(gg) of this title) which the nurse-midwife is

legally authorized to perform under State law (or the State

regulatory mechanism provided by State law), whether or not the

nurse-midwife is under the supervision of, or associated with, a

physician or other health care provider, and without regard to

whether or not the services are performed in the area of

management of the care of mothers and babies throughout the

maternity cycle;

(18) hospice care (as defined in subsection (o) of this

section);

(19) case management services (as defined in section

1396n(g)(2) of this title) and TB-related services described in

section 1396a(z)(2)(F) of this title;

(20) respiratory care services (as defined in section

1396a(e)(9)(C) of this title);

(21) services furnished by a certified pediatric nurse

practitioner or certified family nurse practitioner (as defined

by the Secretary) which the certified pediatric nurse

practitioner or certified family nurse practitioner is legally

authorized to perform under State law (or the State regulatory

mechanism provided by State law), whether or not the certified

pediatric nurse practitioner or certified family nurse

practitioner is under the supervision of, or associated with, a

physician or other health care provider;

(22) home and community care (to the extent allowed and as

defined in section 1396t of this title) for functionally disabled

elderly individuals;

(23) community supported living arrangements services (to the

extent allowed and as defined in section 1396u of this title);

(24) personal care services furnished to an individual who is

not an inpatient or resident of a hospital, nursing facility,

intermediate care facility for the mentally retarded, or

institution for mental disease that are (A) authorized for the

individual by a physician in accordance with a plan of treatment

or (at the option of the State) otherwise authorized for the

individual in accordance with a service plan approved by the

State, (B) provided by an individual who is qualified to provide

such services and who is not a member of the individual's family,

and (C) furnished in a home or other location;

(25) primary care case management services (as defined in

subsection (t) of this section);

(26) services furnished under a PACE program under section

1396u-4 of this title to PACE program eligible individuals

enrolled under the program under such section; and

(27) any other medical care, and any other type of remedial

care recognized under State law, specified by the Secretary,

except as otherwise provided in paragraph (16), such term does not

include -

(A) any such payments with respect to care or services for any

individual who is an inmate of a public institution (except as a

patient in a medical institution); or

(B) any such payments with respect to care or services for any

individual who has not attained 65 years of age and who is a

patient in an institution for mental diseases.

For purposes of clause (vi) of the preceding sentence, a person

shall be considered essential to another individual if such person

is the spouse of and is living with such individual, the needs of

such person are taken into account in determining the amount of aid

or assistance furnished to such individual (under a State plan

approved under subchapter I, X, XIV, or XVI of this chapter), and

such person is determined, under such a State plan, to be essential

to the well-being of such individual. The payment described in the

first sentence may include expenditures for medicare cost-sharing

and for premiums under part B of subchapter XVIII of this chapter

for individuals who are eligible for medical assistance under the

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

State approved under subchapter I, X, XIV, or XVI of this chapter,

or part A of subchapter IV of this chapter, or with respect to whom

supplemental security income benefits are being paid under

subchapter XVI of this chapter, or (B) with respect to whom there

is being paid a State supplementary payment and are eligible for

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

medical assistance made available to individuals described in

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

individuals 65 years of age or older and disabled individuals

entitled to health insurance benefits under subchapter XVIII of

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

of this chapter, other insurance premiums for medical or any other

type of remedial care or the cost thereof. No service (including

counseling) shall be excluded from the definition of "medical

assistance" solely because it is provided as a treatment service

for alcoholism or drug dependency.

(b) Federal medical assistance percentage; State percentage; Indian

health care percentage

Subject to section 1396u-3(d) of this title, the term "Federal

medical assistance percentage" for any State shall be 100 per

centum less the State percentage; and the State percentage shall be

that percentage which bears the same ratio to 45 per centum as the

square of the per capita income of such State bears to the square

of the per capita income of the continental United States

(including Alaska) and Hawaii; except that (1) the Federal medical

assistance percentage shall in no case be less than 50 per centum

or more than 83 per centum, (2) the Federal medical assistance

percentage for Puerto Rico, the Virgin Islands, Guam, the Northern

Mariana Islands, and American Samoa shall be 50 per centum, (3) for

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

Federal medical assistance percentage for the District of Columbia

shall be 70 percent, and (4) the Federal medical assistance

percentage shall be equal to the enhanced FMAP described in section

1397ee(b) of this title with respect to medical assistance provided

to individuals who are eligible for such assistance only on the

basis of section 1396a(a)(10)(A)(ii)(XVIII) of this title. The

Federal medical assistance percentage for any State shall be

determined and promulgated in accordance with the provisions of

section 1301(a)(8)(B) of this title. Notwithstanding the first

sentence of this section, the Federal medical assistance percentage

shall be 100 per centum with respect to amounts expended as medical

assistance for services which are received through an Indian Health

Service facility whether operated by the Indian Health Service or

by an Indian tribe or tribal organization (as defined in section

1603 of title 25). Notwithstanding the first sentence of this

subsection, in the case of a State plan that meets the condition

described in subsection (u)(1) of this section, with respect to

expenditures (other than expenditures under section 1396r-4 of this

title) described in subsection (u)(2)(A) of this section or

subsection (u)(3) of this section for the State for a fiscal year,

and that do not exceed the amount of the State's available

allotment under section 1397dd of this title, the Federal medical

assistance percentage is equal to the enhanced FMAP described in

section 1397ee(b) of this title.

(c) Nursing facility

For definition of the term "nursing facility", see section

1396r(a) of this title.

(d) Intermediate care facility for mentally retarded

The term "intermediate care facility for the mentally retarded"

means an institution (or distinct part thereof) for the mentally

retarded or persons with related conditions if -

(1) the primary purpose of such institution (or distinct part

thereof) is to provide health or rehabilitative services for

mentally retarded individuals and the institution meets such

standards as may be prescribed by the Secretary;

(2) the mentally retarded individual with respect to whom a

request for payment is made under a plan approved under this

subchapter is receiving active treatment under such a program;

and

(3) in the case of a public institution, the State or political

subdivision responsible for the operation of such institution has

agreed that the non-Federal expenditures in any calendar quarter

prior to January 1, 1975, with respect to services furnished to

patients in such institution (or distinct part thereof) in the

State will not, because of payments made under this subchapter,

be reduced below the average amount expended for such services in

such institution in the four quarters immediately preceding the

quarter in which the State in which such institution is located

elected to make such services available under its plan approved

under this subchapter.

(e) Physicians' services

In the case of any State the State plan of which (as approved

under this subchapter) -

(1) does not provide for the payment of services (other than

services covered under section 1396a(a)(12) of this title)

provided by an optometrist; but

(2) at a prior period did provide for the payment of services

referred to in paragraph (1);

the term "physicians' services" (as used in subsection (a)(5) of

this section) shall include services of the type which an

optometrist is legally authorized to perform where the State plan

specifically provides that the term "physicians' services", as

employed in such plan, includes services of the type which an

optometrist is legally authorized to perform, and shall be

reimbursed whether furnished by a physician or an optometrist.

(f) Nursing facility services

For purposes of this subchapter, the term "nursing facility

services" means services which are or were required to be given an

individual who needs or needed on a daily basis nursing care

(provided directly by or requiring the supervision of nursing

personnel) or other rehabilitation services which as a practical

matter can only be provided in a nursing facility on an inpatient

basis.

(g) Chiropractors' services

If the State plan includes provision of chiropractors' services,

such services include only -

(1) services provided by a chiropractor (A) who is licensed as

such by the State and (B) who meets uniform minimum standards

promulgated by the Secretary under section 1395x(r)(5) of this

title; and

(2) services which consist of treatment by means of manual

manipulation of the spine which the chiropractor is legally

authorized to perform by the State.

(h) Inpatient psychiatric hospital services for individuals under

age 21

(1) For purposes of paragraph (16) of subsection (a) of this

section, the term "inpatient psychiatric hospital services for

individuals under age 21" includes only -

(A) inpatient services which are provided in an institution (or

distinct part thereof) which is a psychiatric hospital as defined

in section 1395x(f) of this title or in another inpatient setting

that the Secretary has specified in regulations;

(B) inpatient services which, in the case of any individual (i)

involve active treatment which meets such standards as may be

prescribed in regulations by the Secretary, and (ii) a team,

consisting of physicians and other personnel qualified to make

determinations with respect to mental health conditions and the

treatment thereof, has determined are necessary on an inpatient

basis and can reasonably be expected to improve the condition, by

reason of which such services are necessary, to the extent that

eventually such services will no longer be necessary; and

(C) inpatient services which, in the case of any individual,

are provided prior to (i) the date such individual attains age

21, or (ii) in the case of an individual who was receiving such

services in the period immediately preceding the date on which he

attained age 21, (I) the date such individual no longer requires

such services, or (II) if earlier, the date such individual

attains age 22;

(2) Such term does not include services provided during any

calendar quarter under the State plan of any State if the total

amount of the funds expended, during such quarter, by the State

(and the political subdivisions thereof) from non-Federal funds for

inpatient services included under paragraph (1), and for active

psychiatric care and treatment provided on an outpatient basis for

eligible mentally ill children, is less than the average quarterly

amount of the funds expended, during the 4-quarter period ending

December 31, 1971, by the State (and the political subdivisions

thereof) from non-Federal funds for such services.

(i) Institution for mental diseases

The term "institution for mental diseases" means a hospital,

nursing facility, or other institution of more than 16 beds, that

is primarily engaged in providing diagnosis, treatment, or care of

persons with mental diseases, including medical attention, nursing

care, and related services.

(j) State supplementary payment

The term "State supplementary payment" means any cash payment

made by a State on a regular basis to an individual who is

receiving supplemental security income benefits under subchapter

XVI of this chapter or who would but for his income be eligible to

receive such benefits, as assistance based on need in

supplementation of such benefits (as determined by the Commissioner

of Social Security), but only to the extent that such payments are

made with respect to an individual with respect to whom

supplemental security income benefits are payable under subchapter

XVI of this chapter, or would but for his income be payable under

that subchapter.

(k) Supplemental security income benefits

Increased supplemental security income benefits payable pursuant

to section 211 of Public Law 93-66 shall not be considered

supplemental security income benefits payable under subchapter XVI

of this chapter.

(l) Rural health clinics

(1) The terms "rural health clinic services" and "rural health

clinic" have the meanings given such terms in section 1395x(aa) of

this title, except that (A) clause (ii) of section 1395x(aa)(2) of

this title shall not apply to such terms, and (B) the physician

arrangement required under section 1395x(aa)(2)(B) of this title

shall only apply with respect to rural health clinic services and,

with respect to other ambulatory care services, the physician

arrangement required shall be only such as may be required under

the State plan for those services.

(2)(A) The term "Federally-qualified health center services"

means services of the type described in subparagraphs (A) through

(C) of section 1395x(aa)(1) of this title when furnished to an

individual as an (!3) patient of a Federally-qualified health

center and, for this purpose, any reference to a rural health

clinic or a physician described in section 1395x(aa)(2)(B) of this

title is deemed a reference to a Federally-qualified health center

or a physician at the center, respectively.

(B) The term "Federally-qualified health center" means an entity

which -

(i) is receiving a grant under section 254b of this title,

(ii)(I) is receiving funding from such a grant under a contract

with the recipient of such a grant, and

(II) meets the requirements to receive a grant under section

254b of this title,

(iii) based on the recommendation of the Health Resources and

Services Administration within the Public Health Service, is

determined by the Secretary to meet the requirements for

receiving such a grant, including requirements of the Secretary

that an entity may not be owned, controlled, or operated by

another entity, or

(iv) was treated by the Secretary, for purposes of part B of

subchapter XVIII of this chapter, as a comprehensive Federally

funded health center as of January 1, 1990;

and includes an outpatient health program or facility operated by a

tribe or tribal organization under the Indian Self-Determination

Act (Public Law 93-638) [25 U.S.C. 450f et seq.] or by an urban

Indian organization receiving funds under title V of the Indian

Health Care Improvement Act [25 U.S.C. 1651 et seq.] for the

provision of primary health services. In applying clause (ii),(!4)

the Secretary may waive any requirement referred to in such clause

for up to 2 years for good cause shown.

(m) Qualified family member

(1) Subject to paragraph (2), the term "qualified family member"

means an individual (other than a qualified pregnant woman or

child, as defined in subsection (n) of this section) who is a

member of a family that would be receiving aid under the State plan

under part A of subchapter IV of this chapter pursuant to section

607 (!5) of this title if the State had not exercised the option

under section 607(b)(2)(B)(i) (!5) of this title.

(2) No individual shall be a qualified family member for any

period after September 30, 1998.

(n) "Qualified pregnant woman or child" defined

The term "qualified pregnant woman or child" means -

(1) a pregnant woman who -

(A) would be eligible for aid to families with dependent

children under part A of subchapter IV of this chapter (or

would be eligible for such aid if coverage under the State plan

under part A of subchapter IV of this chapter included aid to

families with dependent children of unemployed parents pursuant

to section 607 of this title) if her child had been born and

was living with her in the month such aid would be paid, and

such pregnancy has been medically verified;

(B) is a member of a family which would be eligible for aid

under the State plan under part A of subchapter IV of this

chapter pursuant to section 607 of this title if the plan

required the payment of aid pursuant to such section; or

(C) otherwise meets the income and resources requirements of

a State plan under part A of subchapter IV of this chapter; and

(2) a child who has not attained the age of 19, who was born

after September 30, 1983 (or such earlier date as the State may

designate), and who meets the income and resources requirements

of the State plan under part A of subchapter IV of this chapter.

(o) Optional hospice benefits

(1)(A) Subject to subparagraph (B), the term "hospice care" means

the care described in section 1395x(dd)(1) of this title furnished

by a hospice program (as defined in section 1395x(dd)(2) of this

title) to a terminally ill individual who has voluntarily elected

(in accordance with paragraph (2)) to have payment made for hospice

care instead of having payment made for certain benefits described

in section 1395d(d)(2)(A) of this title and for which payment may

otherwise be made under subchapter XVIII of this chapter and

intermediate care facility services under the plan. For purposes of

such election, hospice care may be provided to an individual while

such individual is a resident of a skilled nursing facility or

intermediate care facility, but the only payment made under the

State plan shall be for the hospice care.

(B) For purposes of this subchapter, with respect to the

definition of hospice program under section 1395x(dd)(2) of this

title, the Secretary may allow an agency or organization to make

the assurance under subparagraph (A)(iii) of such section without

taking into account any individual who is afflicted with acquired

immune deficiency syndrome (AIDS).

(2) An individual's voluntary election under this subsection -

(A) shall be made in accordance with procedures that are

established by the State and that are consistent with the

procedures established under section 1395d(d)(2) of this title;

(B) shall be for such a period or periods (which need not be

the same periods described in section 1395d(d)(1) of this title)

as the State may establish; and

(C) may be revoked at any time without a showing of cause and

may be modified so as to change the hospice program with respect

to which a previous election was made.

(3) In the case of an individual -

(A) who is residing in a nursing facility or intermediate care

facility for the mentally retarded and is receiving medical

assistance for services in such facility under the plan,

(B) who is entitled to benefits under part A of subchapter

XVIII of this chapter and has elected, under section 1395d(d) of

this title, to receive hospice care under such part, and

(C) with respect to whom the hospice program under such

subchapter and the nursing facility or intermediate care facility

for the mentally retarded have entered into a written agreement

under which the program takes full responsibility for the

professional management of the individual's hospice care and the

facility agrees to provide room and board to the individual,

instead of any payment otherwise made under the plan with respect

to the facility's services, the State shall provide for payment to

the hospice program of an amount equal to the additional amount

determined in section 1396a(a)(13)(B) of this title and, if the

individual is an individual described in section 1396a(a)(10)(A) of

this title, shall provide for payment of any coinsurance amounts

imposed under section 1395e(a)(4) of this title.

(p) Qualified medicare beneficiary; medicare cost-sharing

(1) The term "qualified medicare beneficiary" means an individual

-

(A) who is entitled to hospital insurance benefits under part A

of subchapter XVIII of this chapter (including an individual

entitled to such benefits pursuant to an enrollment under section

1395i-2 of this title, but not including an individual entitled

to such benefits only pursuant to an enrollment under section

1395i-2a of this title), (B) whose income (as determined under section 1382a of this

title for purposes of the supplemental security income program,

except as provided in paragraph (2)(D)) does not exceed an income

level established by the State consistent with paragraph (2), and

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

title for purposes of the supplemental security income program)

do not exceed twice the maximum amount of resources that an

individual may have and obtain benefits under that program.

(2)(A) The income level established under paragraph (1)(B) shall

be at least the percent provided under subparagraph (B) (but not

more than 100 percent) of the official poverty line (as defined by

the Office of Management and Budget, and revised annually in

accordance with section 9902(2) of this title) applicable to a

family of the size involved.

(B) Except as provided in subparagraph (C), the percent provided

under this clause, with respect to eligibility for medical

assistance on or after -

(i) January 1, 1989, is 85 percent,

(ii) January 1, 1990, is 90 percent, and

(iii) January 1, 1991, is 100 percent.

(C) In the case of a State which has elected treatment under

section 1396a(f) of this title and which, as of January 1, 1987,

used an income standard for individuals age 65 or older which was

more restrictive than the income standard established under the

supplemental security income program under subchapter XVI of this

chapter, the percent provided under subparagraph (B), with respect

to eligibility for medical assistance on or after -

(i) January 1, 1989, is 80 percent,

(ii) January 1, 1990, is 85 percent,

(iii) January 1, 1991, is 95 percent, and

(iv) January 1, 1992, is 100 percent.

(D)(i) In determining under this subsection the income of an

individual who is entitled to monthly insurance benefits under

subchapter II of this chapter for a transition month (as defined in

clause (ii)) in a year, such income shall not include any amounts

attributable to an increase in the level of monthly insurance

benefits payable under such subchapter which have occurred pursuant

to section 415(i) of this title for benefits payable for months

beginning with December of the previous year.

(ii) For purposes of clause (i), the term "transition month"

means each month in a year through the month following the month in

which the annual revision of the official poverty line, referred to

in subparagraph (A), is published.

(3) The term "medicare cost-sharing" means (subject to section

1396a(n)(2) of this title) the following costs incurred with

respect to a qualified medicare beneficiary, without regard to

whether the costs incurred were for items and services for which

medical assistance is otherwise available under the plan:

(A)(i) premiums under section 1395i-2 or 1395i-2a of this

title, and

(ii) premiums under section 1395r of this title,(!6)