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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XIX. GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS |
§ 1396b. Payment to States
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(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 beforeOctober 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 (E) 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 translation or interpretation services in connection with the enrollment of, retention of, and use of services under this subchapter by, children of families for whom English is not the primary language; 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, (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 endingJune 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(iii) an amount equal to the Federal medical assistance percentage (as defined in section 1396d(b) of this title) 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 developments or modifications of systems of the type described in clause (i) as are necessary for the efficient collection and reporting on child health measures; 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 of this title), or networks of such providers. (2) Limitation The total amount of payments under this subsection shall not exceed $50,000,000 during the 4-year period beginning with 2006. This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this subsection.
(3) Preference In providing for payments to States under this subsection, the Secretary shall provide preference to States that establish, or provide for, alternate non-emergency services providers or networks of such providers that— (A) serve rural or underserved areas where beneficiaries under this subchapter may not have regular access to providers of primary care services; or (B) are in partnership with local community hospitals. (4) Form and manner of payment Payment to a State under this subsection shall be made only upon the filing of such application in such form and in such manner as the Secretary shall specify. Payment to a State under this subsection shall be made in the same manner as other payments under subsection (a).
(z) Medicaid transformation payments (1) In general In addition to the payments provided under subsection (a), subject to paragraph (4), the Secretary shall provide for payments to States for the adoption of innovative methods to improve the effectiveness and efficiency in providing medical assistance under this subchapter.
(2) Permissible uses of funds The following are examples of innovative methods for which funds provided under this subsection may be used: (A) Methods for reducing patient error rates through the implementation and use of electronic health records, electronic clinical decision support tools, or e-prescribing programs. (B) Methods for improving rates of collection from estates of amounts owed under this subchapter. (C) Methods for reducing waste, fraud, and abuse under the program under this subchapter, such as reducing improper payment rates as measured by annual payment error rate measurement (PERM) project rates. (D) Implementation of a medication risk management program as part of a drug use review program under section 1396r–8(g) of this title. (E) Methods in reducing, in clinically appropriate ways, expenditures under this subchapter for covered outpatient drugs, particularly in the categories of greatest drug utilization, by increasing the utilization of generic drugs through the use of education programs and other incentives to promote greater use of generic drugs. (F) Methods for improving access to primary and specialty physician care for the uninsured using integrated university-based hospital and clinic systems. (3) Application; terms and conditions (A) In general No payments shall be made to a State under this subsection unless the State applies to the Secretary for such payments in a form, manner, and time specified by the Secretary.
(B) Terms and conditions Such payments are made under such terms and conditions consistent with this subsection as the Secretary prescribes.
(C) Annual report Payment to a State under this subsection is conditioned on the State submitting to the Secretary an annual report on the programs supported by such payment. Such report shall include information on— (i) the specific uses of such payment; (ii) an assessment of quality improvements and clinical outcomes under such programs; and (iii) estimates of cost savings resulting from such programs. (4) Funding (A) Limitation on funds The total amount of payments under this subsection shall be equal to, and shall not exceed— (i) $75,000,000 for fiscal year 2007; and (ii) $75,000,000 for fiscal year 2008. This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this subsection. (B) Allocation of funds The Secretary shall specify a method for allocating the funds made available under this subsection among States. Such method shall provide preference for States that design programs that target health providers that treat significant numbers of Medicaid beneficiaries. Such method shall provide that not less than 25 percent of such funds shall be allocated among States the population of which (as determined according to data collected by the United States Census Bureau) as of
July 1, 2004 , was more than 105 percent of the population of the respective State (as so determined) as ofApril 1, 2000 .(C) Form and manner of payment Payment to a State under this subsection shall be made in the same manner as other payments under subsection (a). There is no requirement for State matching funds to receive payments under this subsection.
(5) Medication risk management program (A) In general For purposes of this subsection, the term “medication risk management program” means a program for targeted beneficiaries that ensures that covered outpatient drugs are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events.
(B) Elements Such program may include the following elements: (i) The use of established principles and standards for drug utilization review and best practices to analyze prescription drug claims of targeted beneficiaries and identify outlier physicians. (ii) On an ongoing basis provide outlier physicians— (I) a comprehensive pharmacy claims history for each targeted beneficiary under their care; (II) information regarding the frequency and cost of relapses and hospitalizations of targeted beneficiaries under the physician’s care; and (III) applicable best practice guidelines and empirical references. (iii) Monitor outlier physician’s prescribing, such as failure to refill, dosage strengths, and provide incentives and information to encourage the adoption of best clinical practices. (C) Targeted beneficiaries For purposes of this paragraph, the term “targeted beneficiaries” means Medicaid eligible beneficiaries who are identified as having high prescription drug costs and medical costs, such as individuals with behavioral disorders or multiple chronic diseases who are taking multiple medications.
References In Text
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,
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.
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, § 7(b),
The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (i)(16), is Pub. L. 105–12,
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
The Appalachian Regional Development Act of 1965, referred to in subsec. (m)(2)(B)(ii), (G), is Pub. L. 89–4,
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, § 103(a)(1),
The Deficit Reduction Act of 2005, referred to in subsec. (x)(5), is Pub. L. 109–171,
Amendments
2010—Subsec. (a)(3)(E). Pub. L. 111–148, § 2102(a)(8)(A), amended Pub. L. 111–3, § 211(a)(1)(B). See 2009 Amendment note below.
Subsec. (a)(3)(H). Pub. L. 111–148, § 2102(a)(8)(B), amended Pub. L. 111–3, § 211(a)(1)(B). See 2009 Amendment note below.
Subsec. (d)(2)(C). Pub. L. 111–148, § 6506(a)(1)(A), substituted “1 year” for “60 days” in first sentence and “1-year period” for “60 days” in second sentence.
Subsec. (d)(2)(D). Pub. L. 111–148, § 6506(a)(1)(B), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (f)(4). Pub. L. 111–148, § 2402(d)(2)(A), inserted “1396a(a)(10)(A)(ii)(XXII),” after “1396a(a)(10)(A)(ii)(XXI),”.
Pub. L. 111–148, § 2303(a)(4)(B), inserted “1396a(a)(10)(A)(ii)(XXI),” after “1396a(a)(10)(A)(ii)(XX),”.
Pub. L. 111–148, § 2004(c)(1), inserted “1396a(a)(10)(A)(i)(IX),” after “1396a(a)(10)(A)(i)(VIII),”.
Pub. L. 111–148, § 2001(e)(2)(B), inserted “1396a(a)(10)(A)(ii)(XX),” after “1396a(a)(10)(A)(ii)(XIX),”.
Pub. L. 111–148, § 2001(a)(5)(D), inserted “1396a(a)(10)(A)(i)(VIII),” after “1396a(a)(10)(A)(i)(VII),”.
Subsec. (i)(2)(C). Pub. L. 111–148, § 6402(h)(2), added subpar. (C).
Subsec. (i)(25). Pub. L. 111–148, § 6402(c), added par. (25).
Subsec. (i)(26). Pub. L. 111–148, § 2001(a)(2)(B), added par. (26).
Subsec. (m)(2)(A)(xi). Pub. L. 111–148, § 6504(b)(1), inserted “and for the provision of such data to the State at a frequency and level of detail to be specified by the Secretary” after “patients”.
Subsec. (m)(2)(A)(xiii). Pub. L. 111–148, § 2501(c)(1), added cl. (xiii).
Subsec. (r)(1)(B)(iv). Pub. L. 111–148, § 6507(1), added cl. (iv).
Subsec. (r)(1)(F). Pub. L. 111–148, § 6504(a), inserted “and including, for data submitted to the Secretary on or after
Subsec. (r)(4). Pub. L. 111–148, § 6507(2), added par. (4).
Subsec. (t)(3)(D). Pub. L. 111–157 substituted “inpatient or emergency room setting” for “setting (whether inpatient or outpatient)”.
Subsec. (t)(3)(E). Pub. L. 111–309, § 205(e)(1), substituted “reduced by the average payment the Secretary estimates will be made to such Medicaid providers (determined on a percentage or other basis for such classes or types of providers as the Secretary may specify) from other sources (other than under this subsection, or by the Federal government or a State or local government)” for “reduced by any payment that is made to such Medicaid provider from any other source (other than under this subsection or by a State or local government)”.
Subsec. (t)(6)(B). Pub. L. 111–309, § 205(e)(2), inserted “and shall be determined to have met such responsibility to the extent that the payment to the Medicaid provider is not in excess of 85 percent of the net average allowable cost” before period at end.
Subsec. (u)(1)(D)(v). Pub. L. 111–148, § 2303(b)(2)(B), inserted “or for medical assistance provided to an individual described in subsection (a) of section 1396r–1C of this title during a presumptive eligibility period under such section,” after “section 1396r–1b of this title during a presumptive eligibility period under such section,”.
Pub. L. 111–148, § 2202(b), substituted “section, for medical” for “section, or for medical” and inserted before period at end “, or for medical assistance provided to an individual during a presumptive eligibility period resulting from a determination of presumptive eligibility made by a hospital that elects under section 1396a(a)(47)(B) of this title to be a qualified entity for such purpose”.
2009—Subsec. (a)(2)(E). Pub. L. 111–3, § 201(b)(2)(A), added subpar. (E).
Subsec. (a)(3)(A)(iii). Pub. L. 111–3, § 401(b), added cl. (iii).
Subsec. (a)(3)(D). Pub. L. 111–5, § 4201(a)(1)(A), struck out “and” at end.
Subsec. (a)(3)(E)(ii). Pub. L. 111–5, § 4201(a)(1)(B), substituted “and” for “plus” at end.
Pub. L. 111–3, § 211(a)(1)(B)(i), which directed substitution of “and” for “plus” at end and could not be executed, was struck out by Pub. L. 111–148, § 2102(a)(8)(A).
Subsec. (a)(3)(F). Pub. L. 111–5, § 4201(a)(1)(C), added subpar. (F).
Subsec. (a)(3)(H). Pub. L. 111–3, § 211(a)(1)(B), as amended by Pub. L. 111–148, § 2102(a)(8)(B), added subpar. (H).
Subsec. (i)(22). Pub. L. 111–3, § 211(a)(3)(A), substituted “section 1396a(a)(46)(B) of this title” for “subsection (x)”.
Subsec. (t). Pub. L. 111–5, § 4201(a)(2), added subsec. (t).
Subsec. (v)(1). Pub. L. 111–3, § 214(a)(1), substituted “paragraphs (2) and (4)” for “paragraph (2)”.
Subsec. (v)(4). Pub. L. 111–3, § 214(a)(2), added par. (4).
Subsec. (x)(1). Pub. L. 111–3, § 211(a)(3)(B), substituted “section 1396a(a)(46)(B)(i) of this title” for “subsection (i)(22)”.
Subsec. (x)(2)(B), (C). Pub. L. 111–3, § 211(b)(4), realigned margins.
Subsec. (x)(2)(D), (E). Pub. L. 111–3, § 211(b)(3)(A)(i), added subpar. (D) and redesignated former subpar. (D) as (E).
Subsec. (x)(3)(B)(v), (vi). Pub. L. 111–3, § 211(b)(1), added cl. (v) and redesignated former cl. (v) as (vi).
Subsec. (x)(4), (5). Pub. L. 111–3, § 211(b)(2), (3)(A)(ii), added pars. (4) and (5).
2008—Subsec. (i)(24). Pub. L. 110–252 added par. (24).
Subsec. (r)(1). Pub. L. 110–379, § 3(a)(1), inserted “, in addition to meeting the requirements of paragraph (3),” after “a State must” in introductory provisions.
Subsec. (r)(3). Pub. L. 110–379, § 3(a)(2), added par. (3).
2007—Subsec. (i)(23). Pub. L. 110–28 added par. (23).
2006—Subsec. (f)(4). Pub. L. 109–171, § 6062(c)(1), inserted “1396a(a)(10)(A)(ii)(XIX),” after “1396a(a)(10)(A)(ii)(XVIII),” in introductory provisions.
Subsec. (i)(10)(C). Pub. L. 109–171, § 6002(b), added subpar. (C).
Subsec. (i)(10)(D). Pub. L. 109–171, § 6033(a), added subpar. (D).
Subsec. (i)(22). Pub. L. 109–171, § 6036(a)(1), added par. (22).
Subsec. (w)(4)(C). Pub. L. 109–432, § 403, designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (w)(7)(A)(viii). Pub. L. 109–171, § 6051(a), amended cl. (viii) generally. Prior to amendment, cl. (viii) read as follows: “Services of a medicaid managed care organization with a contract under subsection (m) of this section.”
Subsec. (x). Pub. L. 109–171, § 6036(a)(2), added subsec. (x).
Subsec. (x)(1). Pub. L. 109–432, § 405(c)(1)(A)(i), substituted “(i)(22)” for “(i)(23)”.
Subsec. (x)(2). Pub. L. 109–432, § 405(c)(1)(A)(ii)(I), substituted “individual declaring to be a citizen or national of the United States” for “alien” in introductory provisions.
Subsec. (x)(2)(B). Pub. L. 109–432, § 405(c)(1)(A)(ii)(II), added subpar. (B) and struck out former subpar. (B) which read as follows: “on the basis of receiving supplemental security income benefits under subchapter XVI; or”.
Subsec. (x)(2)(C). Pub. L. 109–432, § 405(c)(1)(A)(ii)(V), added subpar. (C). Former subpar. (C) redesignated (D).
Pub. L. 109–432, § 405(c)(1)(A)(ii)(III), struck out “other” before “basis” and substituted “has” for “had”.
Subsec. (x)(2)(D). Pub. L. 109–432, § 405(c)(1)(A)(ii)(IV), redesignated subpar. (C) as (D).
Subsec. (x)(3)(C)(iii). Pub. L. 109–432, § 405(c)(1)(A)(iii), substituted “I–197” for “I–97”.
Subsec. (y). Pub. L. 109–171, § 6043(b), added subsec. (y).
Subsec. (z). Pub. L. 109–171, § 6081, added subsec. (z).
2005—Subsec. (i)(21). Pub. L. 109–91 added par. (21).
2004—Subsec. (a)(3)(D). Pub. L. 108–357, § 712(b)(1), substituted “and” for “plus”.
Subsec. (a)(3)(E). Pub. L. 108–357, § 712(b)(2), added subpar. (E).
Subsec. (c). Pub. L. 108–446 substituted “part C” for “part H”.
2000—Subsec. (f)(4). Pub. L. 106–554, § 1(a)(6) [title VII, § 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, § 1(a)(6) [title VII, § 702(c)(1)], repealed Pub. L. 105–33, § 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, § 1000(a)(6) [title VI, § 604(a)(2)(B)], struck out “or quality review” after “medical and utilization review”.
Subsec. (b)(4). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(e)], inserted “of” after “for the use” in introductory provisions.
Subsec. (d)(3). Pub. L. 106–31, § 3031(a), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (d)(3)(B). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(f)], realigned margins.
Subsec. (f)(2). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(g)], struck out second period at end.
Subsec. (f)(4). Pub. L. 106–170, § 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, § 1000(a)(6) [title VI, § 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, § 1000(a)(6) [title VI, § 608(h)], inserted “or” after semicolon.
Subsec. (i)(19). Pub. L. 106–31, § 3031(b), added par. (19).
Subsec. (i)(20). Pub. L. 106–170, § 201(a)(4), added par. (20).
Subsec. (m)(2)(A)(vi). Pub. L. 106–113, § 1000(a)(6) [title VI, § 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, § 1000(a)(6) [title VI, § 608(i)(2)], redesignated cl. (xi), relating to section 1396u–2, as (xii).
Subsec. (m)(6)(B)(ii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(b)(2)(A)], inserted “and” at end.
Subsec. (m)(6)(B)(iii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(b)(2)(B)], substituted a period for “; and” at end.
Subsec. (m)(6)(B)(iv). Pub. L. 106–113, § 1000(a)(6) [title VI, § 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, § 1000(a)(6) [title VI, § 608(j)], struck out second closing parenthesis after “section 1167(1) of title 29”.
Subsec. (q)(3). Pub. L. 106–170, § 407(a), inserted “(A)” after “in connection with” and added subpar. (B).
Subsec. (q)(4). Pub. L. 106–170, § 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, § 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, § 1000(a)(6) [title VI, § 608(k)(1)], substituted “purposes” for “puroses”.
Subsec. (w)(3)(B). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(k)(2)], inserted a comma after “(D)” in introductory provisions.
Subsec. (w)(7)(A)(viii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(k)(3)], realigned margins.
1997—Subsec. (a)(3)(C). Pub. L. 105–33, § 4705(b), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (b)(4). Pub. L. 105–33, § 4707(b), added par. (4).
Subsec. (b)(5). Pub. L. 105–33, § 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, § 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, § 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, § 4724(a)(1), substituted “; or” for the period at end.
Subsec. (i)(10)(B), (11). Pub. L. 105–33, § 4724(a)(2), inserted “or” at end.
Subsec. (i)(12). Pub. L. 105–33, § 4742(a), struck out par. (12) which related to restrictions on payments, on or after
Subsec. (i)(13). Pub. L. 105–33, § 4724(a)(2), inserted “or” at end.
Subsec. (i)(16). Pub. L. 105–12 added par. (16).
Subsec. (i)(17). Pub. L. 105–33, § 4724(a)(1), (3), added par. (17).
Subsec. (i)(18). Pub. L. 105–33, § 4724(b)(1), added par. (18).
Subsec. (k). Pub. L. 105–33, § 4701(b)(2)(A)(v), substituted “medicaid managed care organization” for “health maintenance organization”.
Subsec. (m)(1)(A). Pub. L. 105–33, § 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, § 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, § 4701(b)(2)(A)(vi), substituted “medicaid managed care organization” for “health maintenance organization”.
Subsec. (m)(1)(C). Pub. L. 105–33, § 4706(2), added subpar. (C).
Subsec. (m)(2)(A)(i). Pub. L. 105–33, § 4701(b)(2)(A)(vii), substituted “medicaid managed care organization” for “health maintenance organization”.
Subsec. (m)(2)(A)(ii). Pub. L. 105–33, § 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, § 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, § 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, § 4712(c)(2), which directed the repeal of subsec. (m)(2)(A)(ix), was repealed by Pub. L. 106–554, § 1(a)(6) [title VII, § 702(c)(1)]. See 2000 Amendment note above and Effective Date of 1997 Amendment note below.
Pub. L. 105–33, § 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, § 4701(c), added cl. (xi) relating to section 1396u–2.
Subsec. (m)(2)(C) to (E). Pub. L. 105–33, § 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
“(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, § 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, § 4703(b)(1)(B), substituted “clause (i)” for “clauses (i) and (ii)”.
Subsec. (m)(2)(H). Pub. L. 105–33, § 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, § 4701(b)(2)(B), struck out “health maintenance” before “organization described” in concluding provisions.
Subsec. (m)(2)(H)(i). Pub. L. 105–33, § 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, § 4701(b)(2)(A)(vii), substituted “medicaid managed care organization” for “health maintenance organization”.
Subsec. (m)(4)(A). Pub. L. 105–33, § 4701(b)(2)(A)(viii), substituted “Each medicaid managed care organization” for “Each health maintenance organization”.
Subsec. (r)(1). Pub. L. 105–33, § 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
“(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, § 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
Subsec. (r)(3), (4). Pub. L. 105–33, § 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, § 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, § 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, § 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, § 4722(a)(1), substituted “(E), and (F)” for “and (E)” in introductory provisions.
Subsec. (w)(3)(F). Pub. L. 105–33, § 4722(a)(2), added subpar. (F).
Subsec. (w)(7)(A)(viii). Pub. L. 105–33, § 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
Subsec. (i)(12)(A)(i). Pub. L. 104–248, § 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, § 1(b)(1)(C)(i), (iii), (iv), added cl. (vi) and redesignated former cl. (vi) as (vii).
Pub. L. 104–248, § 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, § 1(b)(1)(C)(iii), redesignated cl. (vi) as (vii).
Subsec. (i)(12)(B)(i). Pub. L. 104–248, § 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, § 1(b)(1)(C)(i), (iii), (iv), added cl. (vi) and redesignated former cl. (vi) as (vii).
Pub. L. 104–248, § 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, § 1(b)(1)(C)(iii), redesignated cl. (vi) as (vii).
1993—Subsec. (i)(10). Pub. L. 103–66, § 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, § 13602(b). See below.
Pub. L. 103–66, § 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
Subsec. (i)(11). Pub. L. 103–66, § 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, § 13631(c)(3), redesignated par. (14) as (12), transferred such par. to appear after par. (11), as redesignated by Pub. L. 103–66, § 13631(c)(2), and substituted semicolon for period at end. Former par. (12) redesignated (11).
Subsec. (i)(13). Pub. L. 103–66, § 13631(c)(4), redesignated par. (11) as (13), transferred such par. to appear after par. (12), as redesignated by Pub. L. 103–66, § 13631(c)(3), and directed substitution of “; or” for period at end.
Subsec. (i)(14). Pub. L. 103–66, § 13631(c)(5), added par. (14).
Subsec. (i)(15). Pub. L. 103–66, § 13631(h)(1), added par. (15).
Subsec. (o). Pub. L. 103–66, § 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, § 13624(a), added subsec. (s).
Subsec. (v)(2)(C). Pub. L. 103–66, § 13604(a), added subpar. (C).
1991—Subsec. (a)(1). Pub. L. 102–234, § 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, § 4(a), added par. (6).
Subsec. (i)(10). Pub. L. 102–234, § 2(b)(2), struck out par. (10) added by Pub. L. 101–508, § 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, § 2(a), added subsec. (w).
1990—Subsec. (a)(1). Pub. L. 101–508, § 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, § 4801(a)(8), substituted “
Subsec. (a)(3)(C), (D). Pub. L. 101–508, § 4401(b)(1), substituted “and” for “plus” at end of subpar. (C) and added subpar. (D).
Subsec. (f)(2). Pub. L. 101–508, § 4723(a), inserted “(A)” after “(2)” and added cl. (B).
Subsec. (f)(4). Pub. L. 101–508, § 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, § 4711(c)(2), inserted “(A)” after “medical assistance” and added cl. (B).
Subsec. (i)(10). Pub. L. 101–508, § 4701(b)(2), added par. (10) relating to any amount expended for medical assistance for care or services.
Pub. L. 101–508, § 4401(a)(1), added par. (10) relating to covered outpatient drugs.
Subsec. (i)(11). Pub. L. 101–508, § 4801(e)(16)(A), added par. (11).
Subsec. (i)(12). Pub. L. 101–508, § 4752(a)(2), added par. (12).
Subsec. (i)(14). Pub. L. 101–508, § 4752(e), added par. (14).
Subsec. (m)(1)(A). Pub. L. 101–508, § 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, § 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, § 4704(b)(1), added cl. (ix).
Subsec. (m)(2)(A)(x). Pub. L. 101–508, § 4731(a), added cl. (x).
Subsec. (m)(2)(A)(xi). Pub. L. 101–508, § 4752(b)(1), added cl. (xi).
Subsec. (m)(2)(B). Pub. L. 101–508, § 4704(b)(2), inserted “except with respect to clause (ix) of subparagraph (A),” after “Subparagraph (A)”.
Subsec. (m)(2)(D). Pub. L. 101–508, § 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, § 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, § 4732(c), added subpar. (H).
Subsec. (m)(3). Pub. L. 101–508, § 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, § 4731(b)(2), added cl. (v).
Subsec. (u)(1)(D)(iv). Pub. L. 101–508, § 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, § 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
Subsec. (f)(4). Pub. L. 101–239, § 6401(b), inserted “1396a(a)(10)(A)(i)(VI),” after “1396a(a)(10)(A) (i)(IV),”.
Subsec. (i)(2). Pub. L. 101–239, § 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, § 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, § 301(f), amended Pub. L. 99–509, § 9403(g)(2), see 1986 Amendment note below.
Subsec. (c). Pub. L. 100–360, § 411(k)(13)(A), added subsec. (c).
Subsec. (f)(2). Pub. L. 100–360, § 411(k)(10)(G)(ii), amended Pub. L. 100–203, § 4118(h)(1), see 1987 Amendment note below.
Subsec. (f)(4). Pub. L. 100–360, § 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, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), added Pub. L. 100–203, § 4118(e)(11)(A), see 1987 Amendment note below.
Subsec. (i)(2)(B). Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), added Pub. L. 100–203, § 4118(e)(11)(B), see 1987 Amendment note below.
Subsec. (i)(3). Pub. L. 100–360, § 411(k)(6)(B)(x), added Pub. L. 100–203, § 4112(b), see 1987 Amendment note below.
Subsec. (i)(5). Pub. L. 100–360, § 202(h)(2), substituted “section 1395y(c)(1)” for “section 1395y(c)”.
Subsec. (i)(9). Pub. L. 100–360, § 302(c)(3), added par. (9).
Subsec. (m)(2)(B)(i)(II). Pub. L. 100–485, § 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, § 411(k)(7)(D), repealed Pub. L. 100–203, § 4113(d)(1), see 1987 Amendment note below.
Pub. L. 100–360, § 411(a)(3)(A), (B)(iii), (k)(7)(A), amended Pub. L. 100–203, § 4113(a)(1)(B), see 1987 Amendment note below.
Subsec. (m)(5). Pub. L. 100–360, § 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, § 4211(g)(2), substituted “and (j)” for “, (h), and (j)”.
Subsec. (a)(2)(A) to (C). Pub. L. 100–203, § 4211(d)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (a)(2)(D). Pub. L. 100–203, § 4212(c)(1), added subpar. (D).
Subsec. (a)(3)(C). Pub. L. 100–203, § 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, § 4212(e)(2), inserted “subject to section 1396r(g)(3)(B) of this title,” after “(7)”.
Subsec. (f)(2). Pub. L. 100–203, § 4118(h)(1), as amended by Pub. L. 100–360, § 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, § 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, § 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, § 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, § 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, § 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, § 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
Subsec. (i). Pub. L. 100–203, § 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, § 4118(d)(1)(A), substituted “; or” for period at end.
Subsec. (i)(2). Pub. L. 100–93, § 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
Subsec. (i)(2)(A). Pub. L. 100–203, § 4118(e)(11)(A), as added by Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 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, § 4118(e)(11)(B), as added by Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 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, § 4112(b), as added by Pub. L. 100–360, § 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, § 4211(i), struck out “or skilled nursing facility” after “hospital” in three places.
Subsec. (i)(8). Pub. L. 100–203, § 4213(b)(2), added par. (8).
Subsec. (m)(2)(F). Pub. L. 100–203, § 4113(d)(1), which directed the substitution of “subparagraphs (E) or (G)” for “subparagraph (G)”, was repealed by Pub. L. 100–360, § 411(k)(7)(D).
Pub. L. 100–203, § 4113(a)(1)(B), as amended by Pub. L. 100–360, § 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, § 4113(a)(1)(A), added par. (6).
Subsec. (n). Pub. L. 100–93, § 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, § 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, § 9403(g)(2), as amended by Pub. L. 100–360, § 301(f), inserted “including expenditures for medicare cost-sharing and” before “including expenditures”.
Subsec. (a)(3)(C). Pub. L. 99–509, § 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, § 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, § 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, § 9507(a), added par. (1).
Subsec. (m)(2)(A). Pub. L. 99–272, § 9517(a)(1), substituted “subparagraphs (B), (C), and (G)” for “subparagraphs (B) and (C)” in introductory text.
Pub. L. 99–272, § 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, § 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, § 9434(a)(1)(A), added cl. (viii).
Subsec. (m)(2)(F). Pub. L. 99–514, § 1895(c)(2), substituted “In the case” for “in the case”.
Pub. L. 99–272, § 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, § 9517(a)(3), added subpar. (G).
Subsec. (m)(4). Pub. L. 99–509, § 9434(a)(1)(B), added par. (4).
Subsec. (m)(5). Pub. L. 99–509, § 9434(b), added par. (5).
Subsec. (r)(1)(B). Pub. L. 99–272, § 9518(a), substituted “
Subsec. (r)(4)(A). Pub. L. 99–272, § 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, § 9503(b)(1), amended subpar. (J) generally. Prior to amendment, subsec. (J) read as follows: “report on or before
Subsec. (u)(1)(D)(iv). Pub. L. 99–272, § 9503(f), added cl. (iv).
Subsec. (u)(1)(D)(v). Pub. L. 99–509, § 9407(c), added cl. (v).
Subsec. (v). Pub. L. 99–509, § 9406(a), added subsec. (v).
1984—Subsec. (g)(1). Pub. L. 98–369, § 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, § 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, § 2373(b)(11), substituted “paragraphs (26)” for “paragraph (26)” and “diligence” for “deligence”.
Subsec. (g)(6). Pub. L. 98–369, § 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, § 2363(b), as amended by Pub. L. 98–617, § 3(a)(6), added par. (7).
Subsec. (i)(7). Pub. L. 98–369, § 2303(g)(2), added par. (7).
Subsec. (m)(2)(A)(vi). Pub. L. 98–369, § 2364(1), inserted “except as provided under subparagraph (F),” after “(I)”.
Subsec. (m)(2)(B)(i)(I). Pub. L. 98–369, § 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, § 2373(b)(12)(B), substituted “of section 1396d(a) of this title” for “of such section”.
Subsec. (m)(2)(C). Pub. L. 98–369, § 2373(b)(13), realigned margin of subpar. (C).
Subsec. (m)(2)(E), (F). Pub. L. 98–369, § 2364(2), added subpars. (E) and (F).
Subsec. (s)(3)(B). Pub. L. 98–369, § 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, § 146(b), substituted “utilization and quality control peer review organization” for “Professional Standards Review Organization”.
Subsec. (f)(3). Pub. L. 97–248, § 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, § 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, § 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, § 137(b)(13), substituted “subsection (m) of this section” for “section 1395mm of this title”.
Subsec. (m)(2)(A). Pub. L. 97–248, § 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, § 137(a)(2), amended directory language of Pub. L. 97–35, § 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, § 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, § 137(b)(15)(C), inserted “a program in operation under”, before “a plan approved”.
Subsec. (s)(3)(D). Pub. L. 97–248, § 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, § 137(b)(15)(E), inserted “and paragraph (3)(D)”.
Subsec. (s)(5)(A)(i). Pub. L. 97–248, § 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, § 137(b)(27), inserted “or quarters” after “carried forward to the following quarter”.
Subsec. (t). Pub. L. 97–248, § 137(a)(1), (2), amended directory language of Pub. L. 97–35, § 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, § 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, § 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
Subsec. (t)(1)(C). Pub. L. 97–248, § 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
Subsec. (t)(2)(A). Pub. L. 97–248, § 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, § 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, § 133(a), added subsec. (u).
1981—Subsec. (a)(3)(B). Pub. L. 97–35, § 2113(n), substituted “and” for “plus” at the end of subpar. (B) and added subpar. (C).
Subsec. (d)(5). Pub. L. 97–35, § 2163, substituted “determination at a rate” for “determination (but not to exceed a period of twelve months with respect to disallowances made prior to
Subsec. (e). Pub. L. 97–35, § 2101(a)(2), added subsec. (e).
Subsec. (g)(1)(A). Pub. L. 97–35, § 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, § 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
Subsec. (i)(5). Pub. L. 97–35, § 2103(b)(1), added par. (5).
Subsec. (i)(6). Pub. L. 97–35, § 2164(a), added par. (6).
Subsec. (m)(1)(A). Pub. L. 97–35, § 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, § 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, § 2178(a)(3), added subpar. (D).
Subsec. (n). Pub. L. 97–35, § 2106(b)(3), struck out “of this section” after “section 1395cc of this title” thereby perfecting the amendment made by Pub. L. 96–499, § 905(c)(2).
Subsec. (s). Pub. L. 97–35, § 2161(c)(1), as amended by Pub. L. 97–248, § 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, § 2161(a), added subsec. (s).
Subsec. (t). Pub. L. 97–35, § 2161(c)(2), as amended by Pub. L. 97–248, § 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, § 2161(b), as amended by Pub. L. 97–248, § 137(a)(1), added subsec. (t).
1980—Subsec. (a)(1). Pub. L. 96–499, § 905(b), inserted reference to subsection (j) of this section.
Subsec. (a)(6). Pub. L. 96–499, § 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
Subsec. (d)(5). Pub. L. 96–499, § 961(a), added par. (5).
Subsec. (g)(3)(B). Pub. L. 96–499, § 964, substituted “
Subsec. (j). Pub. L. 96–499, § 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, § 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, § 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, § 17(a), added par. (6) and redesignated former par. (6) as (7).
Subsec. (b)(3). Pub. L. 95–142, § 17(b), added par. (3).
Subsec. (g). Pub. L. 95–142, § 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 33⅓ 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, § 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, § 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, § 105(a)(2), substituted reference to subpar. “(A)(ii)” for “(A)(iii)” wherever appearing.
Subsec. (n). Pub. L. 95–142, § 8(c), added subsec. (n).
Subsecs. (o), (p). Pub. L. 95–142, § 11(a), added subsecs. (o) and (p).
Subsec. (q). Pub. L. 95–142, § 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, § 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, § 111(b), added subsec. (l).
1973—Subsec. (a). Pub. L. 93–233, § 18(x)(5), struck out reference to section 1317 of this title in introductory parenthetical phrase.
Subsec. (a)(1). Pub. L. 93–233, §§ 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, § 18(s), substituted “sums expended with respect to costs incurred” for “sums expended”.
Subsec. (a)(5). Pub. L. 93–233, § 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, §§ 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, § 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
Subsec. (d)(1). Pub. L. 93–233, § 18(y)(1)(B), struck out reference to subsec. (c) of this section.
Subsec. (f)(4). Pub. L. 93–233, § 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, § 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, § 207(a)(2), inserted reference to subsecs. (g) and (h) and of this section.
Subsec. (a)(3). Pub. L. 92–603, § 235(a), added par. (3). Former par. (3) redesignated (4).
Subsec. (a)(4). Pub. L. 92–603, § 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, § 235(a), redesignated former par. (3) as (4).
Subsec. (a)(5). Pub. L. 92–603, § 299E(a), added par. (5). Former par. (5) redesignated (6).
Pub. L. 92–603, § 249B, redesignated former par. (4) as (5).
Subsec. (a)(6). Pub. L. 92–603, § 299E, redesignated former par. (5) as (6).
Subsec. (b)(1). Pub. L. 92–603, § 295, struck out par. (1) which related to amount of quarterly expenditures exceeding average of total expenditures for each quarter of fiscal year ending
Subsec. (b)(3). Pub. L. 92–603, § 221(c)(6), added par. (3).
Subsec. (e). Pub. L. 92–603, § 230, repealed subsec. (e) which related to furnishing for comprehensive care and services by
Subsec. (g). Pub. L. 92–603, §§ 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, §§ 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, §§ 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, § 290, added subsec. (j) relating to orders for suspension of payment.
Pub. L. 92–603, §§ 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, § 226(e), added subsec. (k).
1969—Subsec. (e). Pub. L. 91–56 extended from
1968—Subsec. (a)(1). Pub. L. 90–248, § 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, § 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, § 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, § 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, § 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, § 220(a), added subsec. (f).
Change Of Name
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Pub. L. 108–173, set out as a note under section 1395w–21 of this title.
Effective Date Of Amendment
Pub. L. 111–309, title II, § 205(e),
Amendment by Pub. L. 111–157 effective as if included in the enactment of the HITECH Act (Pub. L. 111–5, div. A, title XIII, div. B, title IV), see section 5(b) of Pub. L. 111–157, set out as a note under section 1395w–4 of this title.
Amendment by section 2004(c)(1) of Pub. L. 111–148 effective
Pub. L. 111–148, title II, § 2102(a),
Amendment by section 2202(b) of Pub. L. 111–148 effective
Amendment by section 2303(a)(4)(B), (b)(2)(B) of Pub. L. 111–148 effective
Amendment by section 2402(d)(2)(A) of Pub. L. 111–148 effective on the first day of the first fiscal year quarter that begins after
Pub. L. 111–148, title VI, § 6504(b)(2),
Pub. L. 111–148, title VI, § 6506(a)(2),
Amendment by sections 6504(a) and 6507 of Pub. L. 111–148 effective
Amendment by sections 201(b)(2)(A), 214(a), and 401(b) of Pub. L. 111–3 effective
Amendment by section 211 of Pub. L. 111–3 effective
Pub. L. 110–379, § 3(b),
Pub. L. 110–28, title VII, § 7002(b)(2),
[Pub. L. 110–90, § 5,
Pub. L. 109–432, div. B, title IV, § 405(c)(1)(A),
Pub. L. 109–171, title VI, § 6033(b),
Pub. L. 109–171, title VI, § 6036(b),
Pub. L. 109–171, title VI, § 6043(c),
Pub. L. 109–171, title VI, § 6051(b),
Amendment by section 6062(c)(1) of Pub. L. 109–171 applicable to medical assistance for items and services furnished on or after
Pub. L. 109–91, title I, § 104(d),
Pub. L. 108–357, title VII, § 712(d),
Amendment by section 702(c)(1) of Pub. L. 106–554 effective
Pub. L. 106–554, § 1(a)(6) [title VII, § 710(b)],
Amendment by Pub. L. 106–354 applicable to medical assistance for items and services furnished on or after
Amendment by section 201(a)(4), (b) of Pub. L. 106–170 applicable to medical assistance for items and services furnished on or after
Pub. L. 106–170, title IV, § 407(d),
Amendment by section 1000(a)(6) [title VI, § 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, § 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, § 1000(a)(6) [title VI, § 608(aa)],
Amendment by section 1000(a)(6) [title VI, § 608(e)–(k)] of Pub. L. 106–113 effective
Pub. L. 106–31, title III, § 3031(c),
Pub. L. 105–100, title I, § 162,
Pub. L. 105–33, title IV, § 4710,
Amendment by section 4712(b)(2) of Pub. L. 105–33 applicable to services furnished on or after
Pub. L. 105–33, title IV, § 4712(c),
Pub. L. 105–33, title IV, § 4722(d),
Pub. L. 105–33, title IV, § 4724(b)(2),
Pub. L. 105–33, title IV, § 4742(b),
Amendment by section 4753(a) of Pub. L. 105–33 effective
Amendment by section 4912(b)(2) of Pub. L. 105–33 effective
Amendment by Pub. L. 105–12 effective
Pub. L. 104–248, § 1(b)(2),
Amendment by Pub. L. 104–193 effective
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.
Pub. L. 103–66, title XIII, § 13604(b),
Amendment by section 13622(a)(2) of Pub. L. 103–66 applicable to items and services furnished on or after
Pub. L. 103–66, title XIII, § 13624(b),
Pub. L. 103–66, title XIII, § 13631(h)(2),
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
Amendments by section 2(a), (b)(2) of Pub. L. 102–234 effective
Amendment by section 3(b)(2)(B) of Pub. L. 102–234 effective
Pub. L. 102–234, § 4(b),
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
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
Pub. L. 101–508, title IV, § 4701(c),
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
Pub. L. 101–508, title IV, § 4731(c),
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
Pub. L. 101–508, title IV, § 4752(b)(2),
Pub. L. 101–508, title IV, § 4801(a)(9),
Pub. L. 101–508, title IV, § 4801(e)(16)(B),
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
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
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
Amendment by section 202(h)(2) of Pub. L. 100–360 applicable to items dispensed on or after
Pub. L. 100–360, title III, § 301(f),
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
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.
Pub. L. 100–360, title IV, § 411(k)(12)(B),
Pub. L. 100–360, title IV, § 411(k)(13)(B),
Pub. L. 100–203, title IV, § 4118(d)(2),
Amendment by section 4118(h)(1) of Pub. L. 100–203 applicable to costs incurred after
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
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
Amendment by Pub. L. 100–93 effective at end of fourteen-day period beginning
Amendment by Pub. L. 99–603 effective
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
Amendment by section 9403(g)(2) of Pub. l. 99–509 applicable to payments under this subchapter for calendar quarters beginning on or after
Amendment by section 9406(a) of Pub. L. 99–509 applicable, except as otherwise provided, to medical assistance furnished to aliens on or after
Amendment by section 9407(c) of Pub. L. 99–509 applicable to ambulatory prenatal care furnished in calendar quarters beginning on or after
Amendment by section 9431(b)(2) of Pub. L. 99–509 applicable to payments under this subchapter for calendar quarters beginning on or after
Pub. L. 99–509, title IX, § 9434(a)(3),
Amendment by section 9503(b), (f) of Pub. L. 99–272 applicable to calendar quarters beginning on or after
Pub. L. 99–272, title IX, § 9507(b),
Pub. L. 99–272, title IX, § 9512(b),
Pub. L. 99–272, title IX, § 9517(c)(2), (3),
[Pub. L. 110–275, title II, § 205(b),
[Pub. L. 106–554, § 1(a)(6) [title VII, § 704(b)],
[Pub. L. 104–240, § 1(b),
Pub. L. 99–272, title IX, § 9518(b),
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
Pub. L. 98–369, div. B, title III, § 2363(c),
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.
Pub. L. 97–248, title I, § 133(b),
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.
Pub. L. 97–248, title I, § 137(g),
Amendment by section 146(b) of Pub. L. 97–248 effective with respect to contracts entered into or renewed on or after
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
Pub. L. 97–35, title XXI, § 2103(b)(2),
Amendment by section 2113(n) of Pub. L. 97–35 applicable to agreements with Professional Standards Review Organizations entered into on or after
Pub. L. 97–35, title XXI, § 2161(c)(1),
Pub. L. 97–35, title XXI, § 2161(c)(2),
Pub. L. 97–35, title XXI, § 2164(b),
Amendment by section 2174(b) of Pub. L. 97–35 applicable to services furnished on or after
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
Pub. L. 97–35, title XXI, § 2183(b),
Pub. L. 96–499, title IX, § 961(b),
Amendment by section 3(c)(2) of Pub. L. 95–142 effective
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
Pub. L. 95–142, § 10(b),
Pub. L. 95–142, § 11(c),
Pub. L. 95–142, § 17(e)(1),
Pub. L. 95–142, § 20(c),
Pub. L. 95–83, title I, § 105(a)(3),
Amendment by Pub. L. 94–552 effective
Pub. L. 94–460, title II, § 202(b),
Pub. L. 94–182, title I, § 110(b),
Amendment by section 111(b) of Pub. L. 94–182 effective
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
Amendment by section 18(u) of Pub. L. 93–233 effective
Pub. L. 93–66, title II, § 234(b),
Pub. L. 92–603, title II, § 207(b),
Amendment by section 226(e) of Pub. L. 92–603 effective with respect to services provided on or after
Amendment by section 233(c) of Pub. L. 92–603 applicable with respect to services furnished by hospitals in accounting periods beginning after
Pub. L. 92–603, title II, § 235(b),
Pub. L. 92–603, title II, § 237(d)(1),
Pub. L. 92–603, title II, § 249B,
Pub. L. 90–248, title II, § 220(b),
Pub. L. 90–248, title II, § 222(d),
Pub. L. 90–248, title II, § 225(b),
Pub. L. 90–364, title III, § 303(b),
Miscellaneous
Pub. L. 111–148, title VI, § 6506(b),
Pub. L. 102–234, § 5,
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
For provisions that certain references to provisions of part A (§ 601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect
Pub. L. 109–171, title VI, § 6036(c),
Pub. L. 111–3, title VI, § 615,
Pub. L. 108–173, title X, § 1001(e),
Pub. L. 102–234, § 2(c)(2),
Pub. L. 101–508, title IV, § 4401(b)(2),
Pub. L. 101–508, title IV, § 4607,
Pub. L. 101–508, title IV, § 4718,
Pub. L. 101–239, title VI, § 6411(g),
Pub. L. 101–239, title VI, § 6901(b)(5)(B),
Pub. L. 101–239, title VI, § 6901(d)(2),
Pub. L. 100–485, title VI, § 608(h),
Pub. L. 100–203, title IV, § 4117,
Pub. L. 100–203, title IV, § 4118(n),
Pub. L. 100–203, title IV, § 4211(d)(2),
Pub. L. 100–203, title IV, § 4212(c)(3),
Pub. L. 99–272, title XII, § 12301,
Pub. L. 97–248, title I, § 133(c),
Pub. L. 97–92, §§ 102, 118,
Pub. L. 95–142, § 17(e)(2),
Pub. L. 95–59, § 6,
Pub. L. 91–56, § 2(b),
Pub. L. 90–248, title II, § 248(d),
Pub. L. 89–97, title I, § 121(b),