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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 |
§ 1396r–6. Extension of eligibility for medical assistance
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(a) Initial 6-month extension (1) Requirement (A) In general Notwithstanding any other provision of this subchapter but subject to subparagraph (B) and paragraph (5), each State plan approved under this subchapter must provide that each family which was receiving aid pursuant to a plan of the State approved under part A of subchapter IV of this chapter in at least 3 of the 6 months immediately preceding the month in which such family becomes ineligible for such aid, because of hours of, or income from, employment of the caretaker relative (as defined in subsection (e) of this section) or because of section 602(a)(8)(B)(ii)(II) of this title. Instead of terminating a family’s extension under clause (iii)(I), a State, at its option, may provide for suspension of the extension until the month after the month in which the family reports information required under paragraph (2)(B)(ii), but only if the family’s extension has not otherwise been terminated under subclause (II) or (III) of clause (iii). The State shall make determinations under clause (iii)(III) for a family each time a report under paragraph (2)(B)(ii) for the family is received.
(B) Notice before termination No termination of assistance shall become effective under subparagraph (A) until the State has provided the family with notice of the grounds for the termination, which notice shall include (in the case of termination under subparagraph (A)(iii)(II), relating to no continued earnings) a description of how the family may reestablish eligibility for medical assistance under the State plan. No such termination shall be effective earlier than 10 days after the date of mailing of such notice.
(C) Continuation in certain cases until redetermination (i) Dependent children With respect to a child who would cease to receive medical assistance because of subparagraph (A)(i) but who may be eligible for assistance under the State plan because the child is described in clause (i) of section 1396d(a) of this title or clause (i)(IV), (i)(VI), (i)(VII), or (ii)(IX) of section 1396a(a)(10)(A) of this title, the State may not discontinue such assistance under such subparagraph until the State has determined that the child is not eligible for assistance under the plan.
(ii) Medically needy With respect to an individual who would cease to receive medical assistance because of clause (ii) or (iii) of subparagraph (A) but who may be eligible for assistance under the State plan because the individual is within a category of person for which medical assistance under the State plan is available under section 1396a(a)(10)(C) of this title (relating to medically needy individuals), the State may not discontinue such assistance under such subparagraph until the State has determined that the individual is not eligible for assistance under the plan.
(4) Coverage (A) In general During the extension period under this subsection— (i) the State plan shall offer to each family medical assistance which (subject to subparagraphs (B) and (C)) is the same amount, duration, and scope as would be made available to the family if it were still receiving aid under the plan approved under part A of subchapter IV of this chapter; and (ii) the State plan may offer alternative coverage described in subparagraph (D). (B) Elimination of most non-acute care benefits At a State’s option and notwithstanding any other provision of this subchapter, a State may choose not to provide medical assistance under this subsection with respect to any (or all) of the items and services described in paragraphs (4)(A), (6), (7), (8), (11), (13), (14), (15), (16), (18), (20), and (21) 2 of section 1396d(a) of this title.
(C) State medicaid “wrap-around” option At a State’s option, the State may elect to apply the option described in subsection (a)(4)(B) of this section (relating to “wrap-around” coverage) for families electing medical assistance under this subsection in the same manner as such option applies to families provided extended eligibility for medical assistance under subsection (a) of this section.
(D) Alternative assistance At a State’s option, the State may offer families a choice of health care coverage under one or more of the following, instead of the medical assistance otherwise made available under this subsection: (i) Enrollment in family option of employer plan Enrollment of the caretaker relative and dependent children in a family option of the group health plan offered to the caretaker relative.
(ii) Enrollment in family option of State employee plan Enrollment of the caretaker relative and dependent children in a family option within the options of the group health plan or plans offered by the State to State employees.
(iii) Enrollment in State uninsured plan Enrollment of the caretaker relative and dependent children in a basic State health plan offered by the State to individuals in the State (or areas of the State) otherwise unable to obtain health insurance coverage.
(iv) Enrollment in medicaid managed care organization Enrollment of the caretaker relative and dependent children in a medicaid managed care organization (as defined in section 1396b(m)(1)(A) of this title).
If a State elects to offer an option to enroll a family under this subparagraph, the State shall pay any premiums and other costs for such enrollment imposed on the family and may pay deductibles and coinsurance imposed on the family. A State’s payment of premiums for the enrollment of families under this subparagraph (not including any premiums otherwise payable by an employer and less the amount of premiums collected from such families under paragraph (5)) and payment of any deductibles and coinsurance shall be considered, for purposes of section 1396b(a)(1) of this title, to be payments for medical assistance. (E) Prohibition on cost-sharing for maternity and preventive pediatric care (i) In general If a State offers any alternative option under subparagraph (D) for families, under each such option the State must assure that care described in clause (ii) is available without charge to the families through— (I) payment of any deductibles, coinsurance, and other cost-sharing respecting such care, or (II) providing coverage under the State plan for such care without any cost-sharing, or any combination of such mechanisms. (ii) Care described The care described in this clause consists of— (I) services related to pregnancy (including prenatal, delivery, and post partum services), and (II) ambulatory preventive pediatric care (including ambulatory early and periodic screening, diagnosis, and treatment services under section 1396d(a)(4)(B) of this title) for each child who meets the age and date of birth requirements to be a qualified child under section 1396d(n)(2) of this title. (5) Premium (A) Permitted Notwithstanding any other provision of this subchapter (including section 1396o of this title), a State may impose a premium for a family for additional extended coverage under this subsection for a premium payment period (as defined in subparagraph (D)(i)), but only if the family’s average gross monthly earnings (less the average monthly costs for such child care as is necessary for the employment of the caretaker relative) for the premium base period exceed 100 percent of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 9902(2) of this title) applicable to a family of the size involved.
(B) Level may vary by option offered The level of such premium may vary, for the same family, for each option offered by a State under paragraph (4)(D).
(C) Limit on premium In no case may the amount of any premium under this paragraph for a family for a month in either of the premium payment periods described in subparagraph (D)(i) exceed 3 percent of the family’s average gross monthly earnings (less the average monthly costs for such child care as is necessary for the employment of the caretaker relative) during the premium base period (as defined in subparagraph (D)(ii)).
(D) Definitions In this paragraph: (i) A “premium payment period” described in this clause is a 3-month period beginning with the 1st or 4th month of the 6-month additional extension period provided under this subsection. (ii) The term “premium base period” means, with respect to a particular premium payment period, the period of 3 consecutive months the last of which is 4 months before the beginning of that premium payment period. (c) Applicability in States and territories (1) States operating under demonstration projects In the case of any State which is providing medical assistance to its residents under a waiver granted under section 1315(a) of this title, the Secretary shall require the State to meet the requirements of this section in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this subchapter.
(2) Inapplicability in commonwealths and territories The provisions of this section shall only apply to the 50 States and the District of Columbia.
(d) General disqualification for fraud (1) Ineligibility for aid This section shall not apply to an individual who is a member of a family which has received aid under part A of subchapter IV of this chapter if the State makes a finding that, at any time during the last 6 months in which the family was receiving such aid before otherwise being provided extended eligibility under this section, the individual was ineligible for such aid because of fraud.
(2) General disqualifications For additional provisions relating to fraud and program abuse, see sections 1320a–7, 1320a–7a, and 1320a–7b of this title.
(e) “Caretaker relative” defined In this section, the term “caretaker relative” has the meaning of such term as used in part A of subchapter IV of this chapter.
(f) Sunset This section shall not apply with respect to families that cease to be eligible for aid under part A of subchapter IV of this chapter after
March 31, 2015 .(g) Collection and reporting of participation information (1) Collection of information from States Each State shall collect and submit to the Secretary (and make publicly available), in a format specified by the Secretary, information on average monthly enrollment and average monthly participation rates for adults and children under this section and of the number and percentage of children who become ineligible for medical assistance under this section whose medical assistance is continued under another eligibility category or who are enrolled under the State’s child health plan under subchapter XXI. Such information shall be submitted at the same time and frequency in which other enrollment information under this subchapter is submitted to the Secretary.
(2) Annual reports to Congress Using the information submitted under paragraph (1), the Secretary shall submit to Congress annual reports concerning enrollment and participation rates described in such paragraph.
References In Text
Section 602 of this title, referred to in subsecs. (a)(1)(A) and (b)(3)(A), was repealed and a new section 602 enacted by Pub. L. 104–193, title I, § 103(a)(1),
Paragraph (21) of section 1396d(a) of this title, referred to in subsec. (b)(4)(B), was redesignated paragraph (22) by Pub. L. 101–239, title VI, § 6405(a)(2),
Prior Provisions
A prior section 1925 of act
Amendments
2014—Subsec. (f). Pub. L. 113–93 substituted “
2013—Subsec. (f). Pub. L. 113–67 substituted “
Pub. L. 112–240 substituted “2013” for “2012”.
2012—Subsec. (f). Pub. L. 112–96 substituted “December 31” for “February 29”.
2011—Subsec. (f). Pub. L. 112–78 substituted “
2010—Subsec. (f). Pub. L. 111–309 substituted “
2009—Subsec. (a)(1). Pub. L. 111–5, § 5004(c)(2), (3), designated existing provisions as subpar. (A), inserted heading, added subpar. (B), and realigned margins.
Pub. L. 111–5, § 5004(b)(1), (c)(1), inserted “but subject to subparagraph (B) and paragraph (5)” after “Notwithstanding any other provision of this subchapter”.
Subsec. (a)(5). Pub. L. 111–5, § 5004(b)(2), added par. (5).
Subsec. (b)(1). Pub. L. 111–5, § 5004(b)(3), inserted “but subject to subsection (a)(5)” after “Notwithstanding any other provision of this subchapter”.
Subsec. (f). Pub. L. 111–5, § 5004(a)(1), substituted “
Subsec. (g). Pub. L. 111–5, § 5004(d), added subsec. (g).
2003—Subsec. (f). Pub. L. 108–40 substituted “2003” for “2002”.
2000—Subsec. (f). Pub. L. 106–554 substituted “2002” for “2001”.
1999—Subsec. (a)(3)(C). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(t)(1)], substituted “(i)(VI), (i)(VII),” for “(i)(VI)(i)(VII),,”.
Subsec. (b)(3)(C)(i). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(t)(2)], which directed substitution of “(i)(IV), (i)(VI), (i)(VII),” for “(i)(IV) (i)(VI) (i)(VII),,”, was executed by making the substitution for “(i)(IV), (i)(VI) (i)(VII),,” to reflect the probable intent of Congress.
1997—Subsec. (b)(4)(D)(iv). Pub. L. 105–33, § 4703(b)(2), struck out “less than 50 percent of the membership (enrolled on a prepaid basis) of which consists of individuals who are eligible to receive benefits under this subchapter (other than because of the option offered under this clause). The option of enrollment under this clause is in addition to, and not in lieu of, any enrollment option that the State might offer under subparagraph (A)(i) with respect to receiving services through a medicaid managed care organization in accordance with section 1396b(m) of this title and the applicable requirements of section 1396u–2 of this title” after “(as defined in section 1396b(m)(1)(A) of this title)”.
Pub. L. 105–33, § 4701(b)(2)(A)(ix), substituted “medicaid managed care organization” for “health maintenance organization” in two places.
Pub. L. 105–33, § 4701(b)(2)(D), substituted “medicaid managed care organization” for “HMO” in heading and inserted “and the applicable requirements of section 1396u–2 of this title” before period at end of text.
1996—Subsec. (f). Pub. L. 104–193 substituted “2001” for “1998”.
1990—Subsec. (a)(3)(C). Pub. L. 101–508, § 4601(a)(3)(B), inserted “(i)(VII),” after “(i)(VI)”.
Subsec. (b)(2)(B)(i). Pub. L. 101–508, § 4716(a)(1), which directed amendment of subsection (f) of this section in subsection (b)(2)(B)(i) by inserting at the end “A State may permit such additional extended assistance under this subsection notwithstanding a failure to report under this clause if the family has established, to the satisfaction of the State, good cause for the failure to report on a timely basis.”, was executed by making the insertion at the end of subsec. (b)(2)(B)(i) to reflect the probable intent of Congress.
Subsec. (b)(2)(B)(iii). Pub. L. 101–508, § 4716(a)(2), which directed amendment of subsection (f) of this section in subsection (b)(2)(B) by adding cl. (iii) at the end, was executed by adding cl. (iii) at the end of subsec. (b)(2)(B) to reflect the probable intent of Congress.
Subsec. (b)(3)(B). Pub. L. 101–508, § 4716(a)(3), which directed amendment of subsection (f) of this section in subsection (b)(3)(B) by inserting at the end “No such termination shall be effective earlier than 10 days after the date of mailing of such notice.”, was executed by making the insertion at the end of subsec. (b)(3)(B) to reflect the probable intent of Congress.
Subsec. (b)(3)(C)(i). Pub. L. 101–508, § 4601(a)(3)(B), inserted “(i)(VII),” after “(i)(VI)”.
1989—Subsec. (a)(3)(A). Pub. L. 101–239, § 6411(i)(1), substituted “a child, whether or not the child is” for “a child who is”.
Subsec. (a)(3)(C). Pub. L. 101–239, § 6411(i)(3), substituted “of section 1396d(a) of this title or clause (i)(IV), (i)(VI), or (ii)(IX) of section 1396a(a)(10)(A) of this title” for “or (v) of section 1396d(a) of this title”.
Subsec. (b)(3)(A)(i). Pub. L. 101–239, § 6411(i)(1), substituted “a child, whether or not the child is” for “a child who is”.
Subsec. (b)(3)(C)(i). Pub. L. 101–239, § 6411(i)(3), substituted “of section 1396d(a) of this title or clause (i)(IV), (i)(VI), or (ii)(IX) of section 1396a(a)(10)(A) of this title” for “or (v) of section 1396d(a) of this title”.
1988—Subsec. (b)(5)(C). Pub. L. 100–647, which directed the amendment of subsec. (d)(5)(C) by inserting “(less the average monthly costs for such child care as is necessary for the employment of the caretaker relative)” after “gross monthly earnings”, was executed to subsec. (b)(5)(C) to reflect the probable intent of Congress.
Effective Date Of Amendment
Amendment by section 5004(a)(1) of Pub. L. 111–5 effective
Pub. L. 111–5, div. B, title V, § 5004(e),
Amendment by Pub. L. 108–40 effective
Amendment by section 4701(b)(2)(A)(ix), (D) of Pub. L. 105–33 effective
Amendment by section 4703(b)(2) of Pub. L. 105–33 applicable to contracts under section 1396b(m) of this title on and after
Amendment by Pub. L. 104–193 effective
Amendment by section 4601(a)(3)(B) 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, § 4716(b),
Pub. L. 101–239, title VI, § 6411(i)(4),
Pub. L. 100–647, title VIII, § 8436(b),
Effective Date
Section applicable to payments under this subchapter for calendar quarters beginning on or after
Miscellaneous
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. 100–485, title III, § 303(c),