((a)) ** Contents** A State plan for medical assistance must—

((1)) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;

((2)) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under are authorized by this subchapter; and, effective , provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan;

((3)) provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness;

((4)) provide (A) such methods of administration (including methods relating to the establishment and maintenance of personnel standards on a merit basis, except that the Secretary shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods, including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan, and, subject to , including a specification that the single State agency described in paragraph (5) will ensure necessary transportation for beneficiaries under the State plan to and from providers and a description of the methods that such agency will use to ensure such transportation) as are found by the Secretary to be necessary for the proper and efficient operation of the plan, (B) for the training and effective use of paid subprofessional staff, with particular emphasis on the full-time or part-time employment of recipients and other persons of low income, as community service aides, in the administration of the plan and for the use of nonpaid or partially paid volunteers in a social service volunteer program in providing services to applicants and recipients and in assisting any advisory committees established by the State agency, (C) that each State or local officer, employee, or independent contractor who is responsible for the expenditure of substantial amounts of funds under the State plan, each individual who formerly was such an officer, employee, or contractor, and each partner of such an officer, employee, or contractor shall be prohibited from committing any act, in relation to any activity under the plan, the commission of which, in connection with any activity concerning the United States Government, by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee is prohibited by section 207 or 208 of title 18, and (D) that each State or local officer, employee, or independent contractor who is responsible for selecting, awarding, or otherwise obtaining items and services under the State plan shall be subject to safeguards against conflicts of interest that are at least as stringent as the safeguards that apply under chapter 21 of title 41 to persons described in ;

((5)) either provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan; or provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan, except that the determination of eligibility for medical assistance under the plan shall be made by the State or local agency administering the State plan approved under subchapter I or XVI (insofar as it relates to the aged) if the State is eligible to participate in the State plan program established under subchapter XVI, or by the agency or agencies administering the supplemental security income program established under subchapter XVI or the State plan approved under part A of subchapter IV if the State is not eligible to participate in the State plan program established under subchapter XVI;

((6)) provide that the State agency will make such reports, in such form and containing such information, as the Secretary may from time to time require, and comply with such provisions as the Secretary may from time to time find necessary to assure the correctness and verification of such reports;

((7)) provide—

((A)) safeguards which restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with—

((i)) the administration of the plan; and

((ii)) the exchange of information necessary to certify or verify the certification of eligibility of children for free or reduced price breakfasts under the Child Nutrition Act of 1966 [ et seq.] and free or reduced price lunches under the Richard B. Russell National School Lunch Act [ et seq.], in accordance with section 9(b) of that Act [], using data standards and formats established by the State agency; and

((B)) that, notwithstanding the Express Lane option under subsection (e)(13), the State may enter into an agreement with the State agency administering the school lunch program established under the Richard B. Russell National School Lunch Act under which the State shall establish procedures to ensure that—

((i)) a child receiving medical assistance under the State plan under this subchapter whose family income does not exceed 133 percent of the poverty line (as defined in , including any revision required by such section), as determined without regard to any expense, block, or other income disregard, applicable to a family of the size involved, may be certified as eligible for free lunches under the Richard B. Russell National School Lunch Act and free breakfasts under the Child Nutrition Act of 1966 without further application; and

((ii)) the State agencies responsible for administering the State plan under this subchapter, and for carrying out the school lunch program established under the Richard B. Russell National School Lunch Act ( et seq.) or the school breakfast program established by section 4 of the Child Nutrition Act of 1966 (), cooperate in carrying out paragraphs (3)(F) and (15) of section 9(b) of that Act [];

((8)) provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals;

((9)) provide—

((A)) that the State health agency, or other appropriate State medical agency (whichever is utilized by the Secretary for the purpose specified in the first sentence of ), shall be responsible for establishing and maintaining health standards for private or public institutions in which recipients of medical assistance under the plan may receive care or services,

((B)) for the establishment or designation of a State authority or authorities which shall be responsible for establishing and maintaining standards, other than those relating to health, for such institutions,

((C)) that any laboratory services paid for under such plan must be provided by a laboratory which meets the applicable requirements of or paragraphs (16) and (17) of , or, in the case of a laboratory which is in a rural health clinic, of , and

((D)) that the State maintain a consumer-oriented website providing useful information to consumers regarding all skilled nursing facilities and all nursing facilities in the State, including for each facility, Form 2567 State inspection reports (or a successor form), complaint investigation reports, the facility’s plan of correction, and such other information that the State or the Secretary considers useful in assisting the public to assess the quality of long term care options and the quality of care provided by individual facilities;

((10)) provide—

((A)) for making medical assistance available, including at least the care and services listed in paragraphs (1) through (5), (13)(B), (17), (21), (28), (29), and (30) of , to—

((i)) all individuals—

((I)) who are receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A or part E of subchapter IV (including individuals eligible under this subchapter by reason of section 602(a)(37), 606(h), or 673(b) of this title, or considered by the State to be receiving such aid as authorized under section 682(e)(6) of this title),

((II))

((aa)) with respect to whom supplemental security income benefits are being paid under subchapter XVI (or were being paid as of the date of the enactment of section 211(a) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 () and would continue to be paid but for the enactment of that section), (bb) who are qualified severely impaired individuals (as defined in ), or (cc) who are under 21 years of age and with respect to whom supplemental security income benefits would be paid under subchapter XVI if subparagraphs (A) and (B) of were applied without regard to the phrase “the first day of the month following”,

((III)) who are qualified pregnant women or children as defined in ,

((IV)) who are described in subparagraph (A) or (B) of subsection ()(1) and whose family income does not exceed the minimum income level the State is required to establish under subsection ()(2)(A) for such a family;

((V)) who are qualified family members as defined in ,

((VI)) who are described in subparagraph (C) of subsection ()(1) and whose family income does not exceed the income level the State is required to establish under subsection ()(2)(B) for such a family,

((VII)) who are described in subparagraph (D) of subsection ()(1) and whose family income does not exceed the income level the State is required to establish under subsection ()(2)(C) for such a family;

((VIII)) beginning , who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in ) applicable to a family of the size involved, subject to subsections (k) and (xx);  or

((IX)) who—

((aa)) are under 26 years of age;

((bb)) are not described in and are not enrolled under any of subclauses (I) through (VII) of this clause or are described in any of such subclauses but have income that exceeds the level of income applicable under the State plan for eligibility to enroll for medical assistance under such subclause;

((cc)) were in foster care under the responsibility of a State on the date of attaining 18 years of age or such higher age as the State has elected under ; and

((dd)) were enrolled in a State plan under this subchapter or under a waiver of such a plan while in such foster care;

((ii)) at the option of the State, to  any group or groups of individuals described in (or, in the case of individuals described in , to  any reasonable categories of such individuals) who are not individuals described in clause (i) of this subparagraph but—

((I)) who meet the income and resources requirements of the appropriate State plan described in clause (i) or the supplemental security income program (as the case may be),

((II)) who would meet the income and resources requirements of the appropriate State plan described in clause (i) if their work-related child care costs were paid from their earnings rather than by a State agency as a service expenditure,

((III)) who would be eligible to receive aid under the appropriate State plan described in clause (i) if coverage under such plan was as broad as allowed under Federal law,

((IV)) with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them, aid or assistance under the appropriate State plan described in clause (i), supplemental security income benefits under subchapter XVI, or a State supplementary payment;

((V)) who are in a medical institution for a period of not less than 30 consecutive days (with eligibility by reason of this subclause beginning on the first day of such period), who meet the resource requirements of the appropriate State plan described in clause (i) or the supplemental security income program, and whose income does not exceed a separate income standard established by the State which is consistent with the limit established under ,

((VI)) who would be eligible under the State plan under this subchapter if they were in a medical institution, with respect to whom there has been a determination that but for the provision of home or community-based services described in subsection (c), (d), or (e) of they would require the level of care provided in a hospital, nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan, and who will receive home or community-based services pursuant to a waiver granted by the Secretary under subsection (c), (d), or (e) of ,

((VII)) who would be eligible under the State plan under this subchapter if they were in a medical institution, who are terminally ill, and who will receive hospice care pursuant to a voluntary election described in section 1396d() of this title;

((VIII)) who is a child described in —

((aa)) for whom there is in effect an adoption assistance agreement (other than an agreement under part E of subchapter IV) between the State and an adoptive parent or parents,

((bb)) who the State agency responsible for adoption assistance has determined cannot be placed with adoptive parents without medical assistance because such child has special needs for medical or rehabilitative care, and

((cc)) who was eligible for medical assistance under the State plan prior to the adoption assistance agreement being entered into, or who would have been eligible for medical assistance at such time if the eligibility standards and methodologies of the State’s foster care program under part E of subchapter IV were applied rather than the eligibility standards and methodologies of the State’s aid to families with dependent children program under part A of subchapter IV;

((IX)) who are described in subsection ()(1) and are not described in clause (i)(IV), clause (i)(VI), or clause (i)(VII);

((X)) who are described in subsection (m)(1);

((XI)) who receive only an optional State supplementary payment based on need and paid on a regular basis, equal to the difference between the individual’s countable income and the income standard used to determine eligibility for such supplementary payment (with countable income being the income remaining after deductions as established by the State pursuant to standards that may be more restrictive than the standards for supplementary security income benefits under subchapter XVI), which are available to all individuals in the State (but which may be based on different income standards by political subdivision according to cost of living differences), and which are paid by a State that does not have an agreement with the Commissioner of Social Security under section 1382e or 1383c of this title;

((XII)) who are described in subsection (z)(1) (relating to certain TB-infected individuals);

((XIII)) who are in families whose income is less than 250 percent of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with ) applicable to a family of the size involved, and who but for earnings in excess of the limit established under , would be considered to be receiving supplemental security income (subject, notwithstanding section 1396 of this title, to payment of premiums or other cost-sharing charges (set on a sliding scale based on income) that the State may determine);

((XIV)) who are optional targeted low-income children described in ;

((XV)) who, but for earnings in excess of the limit established under , would be considered to be receiving supplemental security income, who is at least 16 years of age, and whose assets, resources, and earned or unearned income (or both) do not exceed such limitations (if any) as the State may establish, including at least the group described in ;

((XVI)) who are employed individuals with a medically improved disability described in and whose assets, resources, and earned or unearned income (or both) do not exceed such limitations (if any) as the State may establish, including at least the group described in , but only if the State provides medical assistance to individuals described in subclause (XV);

((XVII)) who are independent foster care adolescents (as defined in ), or who are within any reasonable categories of such adolescents specified by the State;

((XVIII)) who are described in subsection (aa) (relating to certain breast or cervical cancer patients);

((XIX)) who are disabled children described in subsection (cc)(1);

((XX)) beginning , who are under 65 years of age and are not described in or enrolled under a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) exceeds 133 percent of the poverty line (as defined in ) applicable to a family of the size involved but does not exceed the highest income eligibility level established under the State plan or under a waiver of the plan, subject to subsection (hh);

((XXI)) who are described in subsection (ii) (relating to individuals who meet certain income standards);

((XXII)) who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of , or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection;  or

((XXIII)) during any portion of the emergency period defined in paragraph (1)(B) of beginning on or after , who are uninsured individuals (as defined in subsection (ss));

((B)) that the medical assistance made available to any individual described in subparagraph (A)—

((i)) shall not be less in amount, duration, or scope than the medical assistance made available to any other such individual, and

((ii)) shall not be less in amount, duration, or scope than the medical assistance made available to individuals not described in subparagraph (A);

((C)) that if medical assistance is included for any group of individuals described in who are not described in subparagraph (A) or (E), then—

((i)) the plan must include a description of (I) the criteria for determining eligibility of individuals in the group for such medical assistance, (II) the amount, duration, and scope of medical assistance made available to individuals in the group, and (III) the single standard to be employed in determining income and resource eligibility for all such groups, and the methodology to be employed in determining such eligibility, which shall be no more restrictive than the methodology which would be employed under the supplemental security income program in the case of groups consisting of aged, blind, or disabled individuals in a State in which such program is in effect, and which shall be no more restrictive than the methodology which would be employed under the appropriate State plan (described in subparagraph (A)(i)) to which such group is most closely categorically related in the case of other groups;

((ii)) the plan must make available medical assistance—

((I)) to individuals under the age of 18 who (but for income and resources) would be eligible for medical assistance as an individual described in subparagraph (A)(i), and

((II)) to pregnant women, during the course of their pregnancy, who (but for income and resources) would be eligible for medical assistance as an individual described in subparagraph (A);

((iii)) such medical assistance must include (I) with respect to children under 18 and individuals entitled to institutional services, ambulatory services, and (II) with respect to pregnant women, prenatal care and delivery services; and

((iv)) if such medical assistance includes services in institutions for mental diseases or in an intermediate care facility for the mentally retarded (or both) for any such group, it also must include for all groups covered at least the care and services listed in paragraphs (1) through (5), (13)(B), and (17) of or the care and services listed in any 7 of the paragraphs numbered (1) through (24) of such section;

((D)) for the inclusion of home health services for any individual who, under the State plan, is entitled to nursing facility services;

((E))

((i)) for making medical assistance available for medicare cost-sharing (as defined in ) for qualified medicare beneficiaries described in ;

((ii)) for making medical assistance available for payment of medicare cost-sharing described in for qualified disabled and working individuals described in ;

((iii)) for making medical assistance available for medicare cost sharing described in subject to , for individuals who would be qualified medicare beneficiaries described in (including such individuals enrolled under section 1395(b) of this title) but for the fact that their income exceeds the income level established by the State under but is less than 110 percent in 1993 and 1994, and 120 percent in 1995 and years thereafter of the official poverty line (referred to in such section) for a family of the size involved; and

((iv)) subject to sections 1396u–3 and 1396d(p)(4) of this title, for making medical assistance available for medicare cost-sharing described in for individuals who would be qualified medicare beneficiaries described in (including such individuals enrolled under section 1395(b) of this title) but for the fact that their income exceeds the income level established by the State under and is at least 120 percent, but less than 135 percent, of the official poverty line (referred to in such section) for a family of the size involved and who are not otherwise eligible for medical assistance under the State plan;

((F)) at the option of a State, for making medical assistance available for COBRA premiums (as defined in subsection (u)(2)) for qualified COBRA continuation beneficiaries described in subsection (u)(1); and

((G)) that, in applying eligibility criteria of the supplemental security income program under subchapter XVI for purposes of determining eligibility for medical assistance under the State plan of an individual who is not receiving supplemental security income, the State will disregard the provisions of subsections (c) and (e) of ;

((11))

((A)) provide for entering into cooperative arrangements with the State agencies responsible for administering or supervising the administration of health services and vocational rehabilitation services in the State looking toward maximum utilization of such services in the provision of medical assistance under the plan, (B) provide, to the extent prescribed by the Secretary, for entering into agreements, with any agency, institution, or organization receiving payments under (or through an allotment under) subchapter V, (i) providing for utilizing such agency, institution, or organization in furnishing care and services which are available under such subchapter or allotment and which are included in the State plan approved under this section  (ii) making such provision as may be appropriate for reimbursing such agency, institution, or organization for the cost of any such care and services furnished any individual for which payment would otherwise be made to the State with respect to the individual under , and (iii) providing for coordination of information and education on pediatric vaccinations and delivery of immunization services, and (C) provide for coordination of the operations under this subchapter, including the provision of information and education on pediatric vaccinations and the delivery of immunization services, with the State’s operations under the special supplemental nutrition program for women, infants, and children under section 17 of the Child Nutrition Act of 1966 [];

((12)) provide that, in determining whether an individual is blind, there shall be an examination by a physician skilled in the diseases of the eye or by an optometrist, whichever the individual may select;

((13)) provide—

((A)) for a public process for determination of rates of payment under the plan for hospital services, nursing facility services, and services of intermediate care facilities for the mentally retarded under which—

((i)) proposed rates, the methodologies underlying the establishment of such rates, and justifications for the proposed rates are published,

((ii)) providers, beneficiaries and their representatives, and other concerned State residents are given a reasonable opportunity for review and comment on the proposed rates, methodologies, and justifications,

((iii)) final rates, the methodologies underlying the establishment of such rates, and justifications for such final rates are published, and

((iv)) in the case of hospitals, such rates take into account (in a manner consistent with ) the situation of hospitals which serve a disproportionate number of low-income patients with special needs;

((B)) for payment for hospice care in amounts no lower than the amounts, using the same methodology, used under part A of subchapter XVIII and for payment of amounts under section 1396d()(3) of this title; except that in the case of hospice care which is furnished to an individual who is a resident of a nursing facility or intermediate care facility for the mentally retarded, and who would be eligible under the plan for nursing facility services or services in an intermediate care facility for the mentally retarded if he had not elected to receive hospice care, there shall be paid an additional amount, to take into account the room and board furnished by the facility, equal to at least 95 percent of the rate that would have been paid by the State under the plan for facility services in that facility for that individual; and

((C)) payment for primary care services (as defined in subsection (jj)) furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a rate not less than 100 percent of the payment rate that applies to such services and physician under part B of subchapter XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under for the year involved were the conversion factor under such section for 2009);

((14)) provide that enrollment fees, premiums, or similar charges, and deductions, cost sharing, or similar charges, may be imposed only as provided in section 1396 of this title and provide for imposition of such deductions, cost sharing, or similar charges for care, items, or services furnished to specified individuals (as defined in paragraph (3) of section 1396(k) of this title) in accordance with paragraph (2) of such section;

((15)) provide for payment for services described in clause (B) or (C) of under the plan in accordance with subsection (bb);

((16)) provide for inclusion, to the extent required by regulations prescribed by the Secretary, of provisions (conforming to such regulations) with respect to the furnishing of medical assistance under the plan to individuals who are residents of the State but are absent therefrom;

((17)) except as provided in subsections (e)(14), (e)(15), ()(3), (m)(3), and (m)(4), include reasonable standards (which shall be comparable for all groups and may, in accordance with standards prescribed by the Secretary, differ with respect to income levels, but only in the case of applicants or recipients of assistance under the plan who are not receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, and with respect to whom supplemental security income benefits are not being paid under subchapter XVI, based on the variations between shelter costs in urban areas and in rural areas) for determining eligibility for and the extent of medical assistance under the plan which (A) are consistent with the objectives of this subchapter, (B) provide for taking into account only such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient and (in the case of any applicant or recipient who would, except for income and resources, be eligible for aid or assistance in the form of money payments under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, or to have paid with respect to him supplemental security income benefits under subchapter XVI) as would not be disregarded (or set aside for future needs) in determining his eligibility for such aid, assistance, or benefits, (C) provide for reasonable evaluation of any such income or resources, and (D) do not take into account the financial responsibility of any individual for any applicant or recipient of assistance under the plan unless such applicant or recipient is such individual’s spouse or such individual’s child who is under age 21 or (with respect to States eligible to participate in the State program established under subchapter XVI), is blind or permanently and totally disabled, or is blind or disabled as defined in (with respect to States which are not eligible to participate in such program); and provide for flexibility in the application of such standards with respect to income by taking into account, except to the extent prescribed by the Secretary, the costs (whether in the form of insurance premiums, payments made to the State under , or otherwise and regardless of whether such costs are reimbursed under another public program of the State or political subdivision thereof) incurred for medical care or for any other type of remedial care recognized under State law;

((18)) comply with the provisions of with respect to liens, adjustments and recoveries of medical assistance correctly paid,, transfers of assets, and treatment of certain trusts;

((19)) provide such safeguards as may be necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided, in a manner consistent with simplicity of administration and the best interests of the recipients;

((20)) if the State plan includes medical assistance in behalf of individuals 65 years of age or older who are patients in institutions for mental diseases—

((A)) provide for having in effect such agreements or other arrangements with State authorities concerned with mental diseases, and, where appropriate, with such institutions, as may be necessary for carrying out the State plan, including arrangements for joint planning and for development of alternate methods of care, arrangements providing assurance of immediate readmittance to institutions where needed for individuals under alternate plans of care, and arrangements providing for access to patients and facilities, for furnishing information, and for making reports;

((B)) provide for an individual plan for each such patient to assure that the institutional care provided to him is in his best interests, including, to that end, assurances that there will be initial and periodic review of his medical and other needs, that he will be given appropriate medical treatment within the institution, and that there will be a periodic determination of his need for continued treatment in the institution; and

((C)) provide for the development of alternate plans of care, making maximum utilization of available resources, for recipients 65 years of age or older who would otherwise need care in such institutions, including appropriate medical treatment and other aid or assistance; for services referred to in section 303(a)(4)(A)(i) and (ii)  or section 1383(a)(4)(A)(i) and (ii)  of this title which are appropriate for such recipients and for such patients; and for methods of administration necessary to assure that the responsibilities of the State agency under the State plan with respect to such recipients and such patients will be effectively carried out;

((21)) if the State plan includes medical assistance in behalf of individuals 65 years of age or older who are patients in public institutions for mental diseases, show that the State is making satisfactory progress toward developing and implementing a comprehensive mental health program, including provision for utilization of community mental health centers, nursing facilities, and other alternatives to care in public institutions for mental diseases;

((22)) include descriptions of (A) the kinds and numbers of professional medical personnel and supporting staff that will be used in the administration of the plan and of the responsibilities they will have, (B) the standards, for private or public institutions in which recipients of medical assistance under the plan may receive care or services, that will be utilized by the State authority or authorities responsible for establishing and maintaining such standards, (C) the cooperative arrangements with State health agencies and State vocational rehabilitation agencies entered into with a view to maximum utilization of and coordination of the provision of medical assistance with the services administered or supervised by such agencies, and (D) other standards and methods that the State will use to assure that medical or remedial care and services provided to recipients of medical assistance are of high quality;

((23)) provide that (A) any individual eligible for medical assistance (including drugs) may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required (including an organization which provides such services, or arranges for their availability, on a prepayment basis), who undertakes to provide him such services, and (B) an enrollment of an individual eligible for medical assistance in a primary care case-management system (described in ), a medicaid managed care organization, or a similar entity shall not restrict the choice of the qualified person from whom the individual may receive services under , except as provided in subsection (g), in , and in , except that this paragraph shall not apply in the case of Puerto Rico, the Virgin Islands, and Guam, and except that nothing in this paragraph shall be construed as requiring a State to provide medical assistance for such services furnished by a person or entity convicted of a felony under Federal or State law for an offense which the State agency determines is inconsistent with the best interests of beneficiaries under the State plan or by a provider or supplier to which a moratorium under subsection (kk)(4) is applied during the period of such moratorium;

((24)) effective , provide for consultative services by health agencies and other appropriate agencies of the State to hospitals, nursing facilities, home health agencies, clinics, laboratories, and such other institutions as the Secretary may specify in order to assist them (A) to qualify for payments under this chapter, (B) to establish and maintain such fiscal records as may be necessary for the proper and efficient administration of this chapter, and (C) to provide information needed to determine payments due under this chapter on account of care and services furnished to individuals;

((25)) provide—

((A)) that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties (including health insurers, self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 []), service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service) to pay for care and services available under the plan, including—

((i)) the collection of sufficient information (as specified by the Secretary in regulations) to enable the State to pursue claims against such third parties, with such information being collected at the time of any determination or redetermination of eligibility for medical assistance, and

((ii)) the submission to the Secretary of a plan (subject to approval by the Secretary) for pursuing claims against such third parties, which plan shall be integrated with, and be monitored as a part of the Secretary’s review of, the State’s mechanized claims processing and information retrieval systems required under ;

((B)) that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual and where the amount of reimbursement the State can reasonably expect to recover exceeds the costs of such recovery, the State or local agency will seek reimbursement for such assistance to the extent of such legal liability;

((C)) that in the case of an individual who is entitled to medical assistance under the State plan with respect to a service for which a third party is liable for payment, the person furnishing the service may not seek to collect from the individual (or any financially responsible relative or representative of that individual) payment of an amount for that service (i) if the total of the amount of the liabilities of third parties for that service is at least equal to the amount payable for that service under the plan (disregarding section 1396 of this title), or (ii) in an amount which exceeds the lesser of (I) the amount which may be collected under section 1396 of this title, or (II) the amount by which the amount payable for that service under the plan (disregarding section 1396 of this title) exceeds the total of the amount of the liabilities of third parties for that service;

((D)) that a person who furnishes services and is participating under the plan may not refuse to furnish services to an individual (who is entitled to have payment made under the plan for the services the person furnishes) because of a third party’s potential liability for payment for the service;

((E)) that in the case of preventive pediatric care (including early and periodic screening and diagnosis services under ) covered under the State plan, the State shall—

((i)) make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to the liability of a third party for payment for such services, except that the State may, if the State determines doing so is cost-effective and will not adversely affect access to care, only make such payment if a third party so liable has not made payment within 90 days after the date the provider of such services has initially submitted a claim to such third party for payment for such services; and

((ii)) seek reimbursement from such third party in accordance with subparagraph (B);

((F)) that in the case of any services covered under such plan which are provided to an individual on whose behalf child support enforcement is being carried out by the State agency under part D of subchapter IV of this chapter, the State shall—

((i)) make payment for such service in accordance with the usual payment schedule under such plan for such services without regard to any third-party liability for payment for such services, if such third-party liability is derived (through insurance or otherwise) from the parent whose obligation to pay support is being enforced by such agency, if payment has not been made by such third party within 100 days after the date the provider of such services has initially submitted a claim to such third party for payment for such services, except that the State may make such payment within 30 days after such date if the State determines doing so is cost-effective and necessary to ensure access to care.;  and

((ii)) seek reimbursement from such third party in accordance with subparagraph (B);

((G)) that the State prohibits any health insurer (including a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 [], a self-insured plan, a service benefit plan, a managed care organization, a pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service), in enrolling an individual or in making any payments for benefits to the individual or on the individual’s behalf, from taking into account that the individual is eligible for or is provided medical assistance under a plan under this subchapter for such State, or any other State;

((H)) that to the extent that payment has been made under the State plan for medical assistance in any case where a third party has a legal liability to make payment for such assistance, the State has in effect laws under which, to the extent that payment has been made under the State plan for medical assistance for health care items or services furnished to an individual, the State is considered to have acquired the rights of such individual to payment by any other party for such health care items or services; and

((I)) that the State shall provide assurances satisfactory to the Secretary that the State has in effect laws requiring health insurers, including self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 []), service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, as a condition of doing business in the State, to—

((i)) provide, with respect to individuals who are eligible (and, at State option, individuals who apply or whose eligibility for medical assistance is being evaluated in accordance with ) for, or are provided, medical assistance under a State plan (or under a waiver of the plan) under this subchapter and child health assistance under subchapter XXI, upon the request of the State, information to determine during what period the individual or their spouses or their dependents may be (or may have been) covered by a health insurer and the nature of the coverage that is or was provided by the health insurer (including the name, address, and identifying number of the plan) in a manner prescribed by the Secretary;

((ii))

((I)) accept the State’s right of recovery and the assignment to the State of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the State plan (or under a waiver of such plan); and

((II)) in the case of a responsible third party (other than the original medicare fee-for-service program under parts A and B of subchapter XVIII, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under , a health care prepayment plan under section 1395 of this title, or a prescription drug plan offered by a PDP sponsor under part D of such subchapter) that requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under this subchapter, accept authorization provided by the State that the item or service is covered under the State plan (or waiver of such plan) for such individual, as if such authorization were the prior authorization made by the third party for such item or service;

((iii)) not later than 60 days after receiving any inquiry by the State regarding a claim for payment for any health care item or service that is submitted not later than 3 years after the date of the provision of such health care item or service, respond to such inquiry; and

((iv)) agree not to deny a claim submitted by the State solely on the basis of the date of submission of the claim, the type or format of the claim form, a failure to present proper documentation at the point-of-sale that is the basis of the claim, or in the case of a responsible third party (other than the original medicare fee-for-service program under parts A and B of subchapter XVIII, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under , a health care prepayment plan under section 1395 of this title, or a prescription drug plan offered by a PDP sponsor under part D of such subchapter) a failure to obtain a prior authorization for the item or service for which the claim is being submitted, if—

((I)) the claim is submitted by the State within the 3-year period beginning on the date on which the item or service was furnished; and

((II)) any action by the State to enforce its rights with respect to such claim is commenced within 6 years of the State’s submission of such claim;

((26)) if the State plan includes medical assistance for inpatient mental hospital services, provide, with respect to each patient receiving such services, for a regular program of medical review (including medical evaluation) of his need for such services, and for a written plan of care;

((27)) provide for agreements with every person or institution providing services under the State plan under which such person or institution agrees (A) to keep such records as are necessary fully to disclose the extent of the services provided to individuals receiving assistance under the State plan, and (B) to furnish the State agency or the Secretary with such information, regarding any payments claimed by such person or institution for providing services under the State plan, as the State agency or the Secretary may from time to time request;

((28)) provide—

((A)) that any nursing facility receiving payments under such plan must satisfy all the requirements of subsections (b) through (d) of as they apply to such facilities;

((B)) for including in “nursing facility services” at least the items and services specified (or deemed to be specified) by the Secretary under and making available upon request a description of the items and services so included;

((C)) for procedures to make available to the public the data and methodology used in establishing payment rates for nursing facilities under this subchapter; and

((D)) for compliance (by the date specified in the respective sections) with the requirements of—

((i)) ;

((ii)) (relating to responsibility for survey and certification of nursing facilities); and

((iii)) sections 1396r(h)(2)(B) and 1396r(h)(2)(D) of this title (relating to establishment and application of remedies);

((29)) include a State program which meets the requirements set forth in , for the licensing of administrators of nursing homes;

((30))

((A)) provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan (including but not limited to utilization review plans as provided for in ) as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area; and

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

((i)) each admission to a hospital, intermediate care facility for the mentally retarded, or hospital for mental diseases is reviewed or screened in accordance with criteria established by medical and other professional personnel who are not themselves directly responsible for the care of the patient involved, and who do not have a significant financial interest in any such institution and are not, except in the case of a hospital, employed by the institution providing the care involved, and

((ii)) the information developed from such review or screening, along with the data obtained from prior reviews of the necessity for admission and continued stay of patients by such professional personnel, shall be used as the basis for establishing the size and composition of the sample of admissions to be subject to review and evaluation by such personnel, and any such sample may be of any size up to 100 percent of all admissions and must be of sufficient size to serve the purpose of (I) identifying the patterns of care being provided and the changes occurring over time in such patterns so that the need for modification may be ascertained, and (II) subjecting admissions to early or more extensive review where information indicates that such consideration is warranted to a hospital, intermediate care facility for the mentally retarded, or hospital for mental diseases;

((31)) with respect to services in an intermediate care facility for the mentally retarded (where the State plan includes medical assistance for such services) provide, with respect to each patient receiving such services, for a written plan of care, prior to admission to or authorization of benefits in such facility, in accordance with regulations of the Secretary, and for a regular program of independent professional review (including medical evaluation) which shall periodically review his need for such services;

((32)) provide that no payment under the plan for any care or service provided to an individual shall be made to anyone other than such individual or the person or institution providing such care or service, under an assignment or power of attorney or otherwise; except that—

((A)) in the case of any care or service provided by a physician, dentist, or other individual practitioner, such payment may be made (i) to the employer of such physician, dentist, or other practitioner if such physician, dentist, or practitioner is required as a condition of his employment to turn over his fee for such care or service to his employer, or (ii) (where the care or service was provided in a hospital, clinic, or other facility) to the facility in which the care or service was provided if there is a contractual arrangement between such physician, dentist, or practitioner and such facility under which such facility submits the bill for such care or service;

((B)) nothing in this paragraph shall be construed (i) to prevent the making of such a payment in accordance with an assignment from the person or institution providing the care or service involved if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or (ii) to preclude an agent of such person or institution from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such person or institution under the plan is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment;

((C)) in the case of services furnished (during a period that does not exceed 14 continuous days in the case of an informal reciprocal arrangement or 90 continuous days (or such longer period as the Secretary may provide) in the case of an arrangement involving per diem or other fee-for-time compensation) by, or incident to the services of, one physician to the patients of another physician who submits the claim for such services, payment shall be made to the physician submitting the claim (as if the services were furnished by, or incident to, the physician’s services), but only if the claim identifies (in a manner specified by the Secretary) the physician who furnished the services; and

((D)) in the case of payment for a childhood vaccine administered before , to individuals entitled to medical assistance under the State plan, the State plan may make payment directly to the manufacturer of the vaccine under a voluntary replacement program agreed to by the State pursuant to which the manufacturer (i) supplies doses of the vaccine to providers administering the vaccine, (ii) periodically replaces the supply of the vaccine, and (iii) charges the State the manufacturer’s price to the Centers for Disease Control and Prevention for the vaccine so administered (which price includes a reasonable amount to cover shipping and the handling of returns);

((33)) provide—

((A)) that the State health agency, or other appropriate State medical agency, shall be responsible for establishing a plan, consistent with regulations prescribed by the Secretary, for the review by appropriate professional health personnel of the appropriateness and quality of care and services furnished to recipients of medical assistance under the plan in order to provide guidance with respect thereto in the administration of the plan to the State agency established or designated pursuant to paragraph (5) and, where applicable, to the State agency described in the second sentence of this subsection; and

((B)) that, except as provided in , the State or local agency utilized by the Secretary for the purpose specified in the first sentence of , or, if such agency is not the State agency which is responsible for licensing health institutions, the State agency responsible for such licensing, will perform for the State agency administering or supervising the administration of the plan approved under this subchapter the function of determining whether institutions and agencies meet the requirements for participation in the program under such plan, except that, if the Secretary has cause to question the adequacy of such determinations, the Secretary is authorized to validate State determinations and, on that basis, make independent and binding determinations concerning the extent to which individual institutions and agencies meet the requirements for participation;

((34)) provide that in the case of any individual who has been determined to be eligible for medical assistance under the plan, such assistance will be made available to him for care and services included under the plan and furnished in or after the third month before the month in which he made application (or application was made on his behalf in the case of a deceased individual) for such assistance if such individual was (or upon application would have been) eligible for such assistance at the time such care and services were furnished;

((35)) provide that any disclosing entity (as defined in ) receiving payments under such plan complies with the requirements of ;

((36)) provide that within 90 days following the completion of each survey of any health care facility, laboratory, agency, clinic, or organization, by the appropriate State agency described in paragraph (9), such agency shall (in accordance with regulations of the Secretary) make public in readily available form and place the pertinent findings of each such survey relating to the compliance of each such health care facility, laboratory, clinic, agency, or organization with (A) the statutory conditions of participation imposed under this subchapter, and (B) the major additional conditions which the Secretary finds necessary in the interest of health and safety of individuals who are furnished care or services by any such facility, laboratory, clinic, agency, or organization;

((37)) provide for claims payment procedures which (A) ensure that 90 per centum of claims for payment (for which no further written information or substantiation is required in order to make payment) made for services covered under the plan and furnished by health care practitioners through individual or group practices or through shared health facilities are paid within 30 days of the date of receipt of such claims and that 99 per centum of such claims are paid within 90 days of the date of receipt of such claims, and (B) provide for procedures of prepayment and postpayment claims review, including review of appropriate data with respect to the recipient and provider of a service and the nature of the service for which payment is claimed, to ensure the proper and efficient payment of claims and management of the program;

((38)) require that an entity (other than an individual practitioner or a group of practitioners) that furnishes, or arranges for the furnishing of, items or services under the plan, shall supply (within such period as may be specified in regulations by the Secretary or by the single State agency which administers or supervises the administration of the plan) upon request specifically addressed to such entity by the Secretary or such State agency, the information described in ;

((39)) provide that the State agency shall exclude any specified individual or entity from participation in the program under the State plan for the period specified by the Secretary, when required by him to do so pursuant to or , terminate the participation of any individual or entity in such program if (subject to such exceptions as are permitted with respect to exclusion under sections 1320a–7(c)(3)(B) and 1320a–7(d)(3)(B) of this title) participation of such individual or entity is terminated under subchapter XVIII, any other State plan under this subchapter (or waiver of the plan), or any State child health plan under subchapter XXI (or waiver of the plan) and such termination is included by the Secretary in any database or similar system developed pursuant to section 6401(b)(2) of the Patient Protection and Affordable Care Act, and provide that no payment may be made under the plan with respect to any item or service furnished by such individual or entity during such period;

((40)) require each health services facility or organization which receives payments under the plan and of a type for which a uniform reporting system has been established under to make reports to the Secretary of information described in such section in accordance with the uniform reporting system (established under such section) for that type of facility or organization;

((41)) provide, in accordance with subsection (kk)(8) (as applicable), that whenever a provider of services or any other person is terminated, suspended, or otherwise sanctioned or prohibited from participating under the State plan, the State agency shall promptly notify the Secretary and, in the case of a physician and notwithstanding paragraph (7), the State medical licensing board of such action;

((42)) provide that—

((A)) the records of any entity participating in the plan and providing services reimbursable on a cost-related basis will be audited as the Secretary determines to be necessary to insure that proper payments are made under the plan; and

((B)) not later than , the State shall—

((i)) establish a program under which the State contracts (consistent with State law and in the same manner as the Secretary enters into contracts with recovery audit contractors under , subject to such exceptions or requirements as the Secretary may require for purposes of this subchapter or a particular State) with 1 or more recovery audit contractors for the purpose of identifying underpayments and overpayments and recouping overpayments under the State plan and under any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver; and

((ii)) provide assurances satisfactory to the Secretary that—

((I)) under such contracts, payment shall be made to such a contractor only from amounts recovered;

((II)) from such amounts recovered, payment—

((aa)) shall be made on a contingent basis for collecting overpayments; and

((bb)) may be made in such amounts as the State may specify for identifying underpayments;

((III)) the State has an adequate process for entities to appeal any adverse determination made by such contractors; and

((IV)) such program is carried out in accordance with such requirements as the Secretary shall specify, including—

((aa)) for purposes of , that amounts expended by the State to carry out the program shall be considered amounts expended as necessary for the proper and efficient administration of the State plan or a waiver of the plan;

((bb)) that shall apply to amounts recovered under the program; and

((cc)) that the State and any such contractors under contract with the State shall coordinate such recovery audit efforts with other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, including efforts with Federal and State law enforcement with respect to the Department of Justice, including the Federal Bureau of Investigations, the Inspector General of the Department of Health and Human Services, and the State medicaid fraud control unit; and

((43)) provide for—

((A)) informing all persons in the State who are under the age of 21 and who have been determined to be eligible for medical assistance including services described in , of the availability of early and periodic screening, diagnostic, and treatment services as described in and the need for age-appropriate immunizations against vaccine-preventable diseases,

((B)) providing or arranging for the provision of such screening services in all cases where they are requested,

((C)) arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services, and

((D)) reporting to the Secretary (in a uniform form and manner established by the Secretary, by age group and by basis of eligibility for medical assistance, and by not later than April 1 after the end of each fiscal year, beginning with fiscal year 1990) the following information relating to early and periodic screening, diagnostic, and treatment services provided under the plan during each fiscal year:

((i)) the number of children provided child health screening services,

((ii)) the number of children referred for corrective treatment (the need for which is disclosed by such child health screening services),

((iii)) the number of children receiving dental services, and other information relating to the provision of dental services to such children described in section 1397hh(e)  of this title and

((iv)) the State’s results in attaining the participation goals set for the State under ;

((44)) in each case for which payment for inpatient hospital services, services in an intermediate care facility for the mentally retarded, or inpatient mental hospital services is made under the State plan—

((A)) a physician (or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician) certifies at the time of admission, or, if later, the time the individual applies for medical assistance under the State plan (and a physician, a physician assistant under the supervision of a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, recertifies, where such services are furnished over a period of time, in such cases, at least as often as required under (or, in the case of services that are services provided in an intermediate care facility for the mentally retarded, every year), and accompanied by such supporting material, appropriate to the case involved, as may be provided in regulations of the Secretary), that such services are or were required to be given on an inpatient basis because the individual needs or needed such services, and

((B)) such services were furnished under a plan established and periodically reviewed and evaluated by a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician;

((45)) provide for mandatory assignment of rights of payment for medical support and other medical care owed to recipients, in accordance with ;

((46))

((A)) provide that information is requested and exchanged for purposes of income and eligibility verification in accordance with a State system which meets the requirements of ; and

((B)) provide, with respect to an individual declaring to be a citizen or national of the United States for purposes of establishing eligibility under this subchapter, that the State shall satisfy the requirements of—

((i)) ; or

((ii)) subsection (ee);

((47)) provide—

((A)) at the option of the State, for making ambulatory prenatal care available to pregnant women during a presumptive eligibility period in accordance with and provide for making medical assistance for items and services described in subsection (a) of available to children during a presumptive eligibility period in accordance with such section and provide for making medical assistance available to individuals described in subsection (a) of during a presumptive eligibility period in accordance with such section and provide for making medical assistance available to individuals described in subsection (a) of during a presumptive eligibility period in accordance with such section; and

((B)) that any hospital that is a participating provider under the State plan may elect to be a qualified entity for purposes of determining, on the basis of preliminary information, whether any individual is eligible for medical assistance under the State plan or under a waiver of the plan for purposes of providing the individual with medical assistance during a presumptive eligibility period, in the same manner, and subject to the same requirements, as apply to the State options with respect to populations described in section 1396r–1, 1396r–1a, 1396r–1b, or 1396r–1c of this title (but without regard to whether the State has elected to provide for a presumptive eligibility period under any such sections), subject to such guidance as the Secretary shall establish;

((48)) provide a method of making cards evidencing eligibility for medical assistance available to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address;

((49)) provide that the State will provide information and access to certain information respecting sanctions taken against health care practitioners and providers by State licensing authorities in accordance with ;

((50)) provide, in accordance with subsection (q), for a monthly personal needs allowance for certain institutionalized individuals and couples;

((51)) meet the requirements of (relating to protection of community spouses);

((52)) meet the requirements of (relating to extension of eligibility for medical assistance);

((53)) provide—

((A)) for notifying in a timely manner all individuals in the State who are determined to be eligible for medical assistance and who are pregnant women, breastfeeding or postpartum women (as defined in section 17 of the Child Nutrition Act of 1966 []), or children below the age of 5, of the availability of benefits furnished by the special supplemental nutrition program under such section, and

((B)) for referring any such individual to the State agency responsible for administering such program;

((54)) in the case of a State plan that provides medical assistance for covered outpatient drugs (as defined in ), comply with the applicable requirements of ;

((55)) provide for receipt and initial processing of applications of individuals for medical assistance under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), (a)(10)(A)(ii)(IX), or (a)(10)(A)(ii)(XXIII)—

((A)) at locations which are other than those used for the receipt and processing of applications for aid under part A of subchapter IV and which include facilities defined as disproportionate share hospitals under and Federally-qualified health centers described in section 1396d(1)(2)(B)  of this title, and

((B)) using applications which are other than those used for applications for aid under such part;

((56)) provide, in accordance with subsection (s), for adjusted payments for certain inpatient hospital services;

((57)) provide that each hospital, nursing facility, provider of home health care or personal care services, hospice program, or medicaid managed care organization (as defined in ) receiving funds under the plan shall comply with the requirements of subsection (w);

((58)) provide that the State, acting through a State agency, association, or other private nonprofit entity, develop a written description of the law of the State (whether statutory or as recognized by the courts of the State) concerning advance directives that would be distributed by providers or organizations under the requirements of subsection (w);

((59)) maintain a list (updated not less often than monthly, and containing each physician’s unique identifier provided under the system established under subsection (x)) of all physicians who are certified to participate under the State plan;

((60)) provide that the State agency shall provide assurances satisfactory to the Secretary that the State has in effect the laws relating to medical child support required under ;

((61)) provide that the State must demonstrate that it operates a medicaid fraud and abuse control unit described in that effectively carries out the functions and requirements described in such section, as determined in accordance with standards established by the Secretary, unless the State demonstrates to the satisfaction of the Secretary that the effective operation of such a unit in the State would not be cost-effective because minimal fraud exists in connection with the provision of covered services to eligible individuals under the State plan, and that beneficiaries under the plan will be protected from abuse and neglect in connection with the provision of medical assistance under the plan without the existence of such a unit;

((62)) provide for a program for the distribution of pediatric vaccines to program-registered providers for the immunization of vaccine-eligible children in accordance with ;

((63)) provide for administration and determinations of eligibility with respect to individuals who are (or seek to be) eligible for medical assistance based on the application of ;

((64)) provide, not later than 1 year after , a mechanism to receive reports from beneficiaries and others and compile data concerning alleged instances of waste, fraud, and abuse relating to the operation of this subchapter;

((65)) provide that the State shall issue provider numbers for all suppliers of medical assistance consisting of durable medical equipment, as defined in , and the State shall not issue or renew such a supplier number for any such supplier unless—

((A))

((i)) full and complete information as to the identity of each person with an ownership or control interest (as defined in ) in the supplier or in any subcontractor (as defined by the Secretary in regulations) in which the supplier directly or indirectly has a 5 percent or more ownership interest; and

((ii)) to the extent determined to be feasible under regulations of the Secretary, the name of any disclosing entity (as defined in ) with respect to which a person with such an ownership or control interest in the supplier is a person with such an ownership or control interest in the disclosing entity; and

((B)) a surety bond in a form specified by the Secretary under and in an amount that is not less than $50,000 or such comparable surety bond as the Secretary may permit under the second sentence of such section;

((66)) provide for making eligibility determinations under ;

((67)) provide, with respect to services covered under the State plan (but not under subchapter XVIII) that are furnished to a PACE program eligible individual enrolled with a PACE provider by a provider participating under the State plan that does not have a contract or other agreement with the PACE provider that establishes payment amounts for such services, that such participating provider may not require the PACE provider to pay the participating provider an amount greater than the amount that would otherwise be payable for the service to the participating provider under the State plan for the State where the PACE provider is located (in accordance with regulations issued by the Secretary);

((68)) provide that any entity that receives or makes annual payments under the State plan of at least $5,000,000, as a condition of receiving such payments, shall—

((A)) establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, administrative remedies for false claims and statements established under chapter 38 of title 31, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in );

((B)) include as part of such written policies, detailed provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse; and

((C)) include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse;

((69)) provide that the State must comply with any requirements determined by the Secretary to be necessary for carrying out the Medicaid Integrity Program established under ;

((70)) at the option of the State and notwithstanding paragraphs (1), (10)(B), and (23), provide for the establishment of a non-emergency medical transportation brokerage program in order to more cost-effectively provide transportation for individuals eligible for medical assistance under the State plan who need access to medical care or services and have no other means of transportation which—

((A)) may include a wheelchair van, taxi, stretcher car, bus passes and tickets, secured transportation, and such other transportation as the Secretary determines appropriate; and

((B)) may be conducted under contract with a broker who—

((i)) is selected through a competitive bidding process based on the State’s evaluation of the broker’s experience, performance, references, resources, qualifications, and costs;

((ii)) has oversight procedures to monitor beneficiary access and complaints and ensure that transport personnel are licensed, qualified, competent, and courteous;

((iii)) is subject to regular auditing and oversight by the State in order to ensure the quality of the transportation services provided and the adequacy of beneficiary access to medical care and services; and

((iv)) complies with such requirements related to prohibitions on referrals and conflict of interest as the Secretary shall establish (based on the prohibitions on physician referrals under and such other prohibitions and requirements as the Secretary determines to be appropriate);

((71)) provide that the State will implement an asset verification program as required under ;

((72)) provide that the State will not prevent a Federally-qualified health center from entering into contractual relationships with private practice dental providers in the provision of Federally-qualified health center services;

((73)) in the case of any State in which 1 or more Indian Health Programs or Urban Indian Organizations furnishes health care services, provide for a process under which the State seeks advice on a regular, ongoing basis from designees of such Indian Health Programs and Urban Indian Organizations on matters relating to the application of this subchapter that are likely to have a direct effect on such Indian Health Programs and Urban Indian Organizations and that—

((A)) shall include solicitation of advice prior to submission of any plan amendments, waiver requests, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs, or Urban Indian Organizations; and

((B)) may include appointment of an advisory committee and of a designee of such Indian Health Programs and Urban Indian Organizations to the medical care advisory committee advising the State on its State plan under this subchapter;

((74)) provide for maintenance of effort under the State plan or under any waiver of the plan in accordance with subsection (gg);

((75)) provide that, beginning January 2015, and annually thereafter, the State shall submit a report to the Secretary that contains—

((A)) the total number of enrolled and newly enrolled individuals in the State plan or under a waiver of the plan for the fiscal year ending on September 30 of the preceding calendar year, disaggregated by population, including children, parents, nonpregnant childless adults, disabled individuals, elderly individuals, and such other categories or sub-categories of individuals eligible for medical assistance under the State plan or under a waiver of the plan as the Secretary may require;

((B)) a description, which may be specified by population, of the outreach and enrollment processes used by the State during such fiscal year; and

((C)) any other data reporting determined necessary by the Secretary to monitor enrollment and retention of individuals eligible for medical assistance under the State plan or under a waiver of the plan;

((76)) provide that any data collected under the State plan meets the requirements of section 3101 of the Public Health Service Act [];

((77)) provide that the State shall comply with provider and supplier screening, oversight, and reporting requirements in accordance with subsection (kk);

((78)) provide that, not later than , in the case of a State that pursuant to its State plan or waiver of the plan for medical assistance pays for medical assistance on a fee-for-service basis, the State shall require each provider furnishing items and services to, or ordering, prescribing, referring, or certifying eligibility for, services for individuals eligible to receive medical assistance under such plan to enroll with the State agency and provide to the State agency the provider’s identifying information, including the name, specialty, date of birth, Social Security number, national provider identifier (if applicable), Federal taxpayer identification number, and the State license or certification number of the provider (if applicable);

((79)) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;

((80)) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;

((81)) provide for implementation of the payment models specified by the Secretary under for implementation on a nationwide basis unless the State demonstrates to the satisfaction of the Secretary that implementation would not be administratively feasible or appropriate to the health care delivery system of the State;

((82)) provide that the State agency responsible for administering the State plan under this subchapter provides assurances to the Secretary that the State agency is in compliance with subparagraphs (A), (B), and (C) of ;

((83)) provide that in the case of a State plan (or waiver of the plan) that provides medical assistance on a fee-for-service basis or through a primary care case-management system described in , the State shall publish (and update on at least a quarterly basis or more frequently as required by the Secretary) on the public website of the State agency administering the State plan, a searchable directory of the providers described in subsection (mm) that, in addition to such other requirements as the Secretary may specify, such as making paper directories available to enrollees, includes with respect to each such provider—

((A)) the name of the provider;

((B)) the specialty of the provider;

((C)) the address at which the provider provides services;

((D)) the telephone number of the provider;

((E)) information regarding—

((i)) the provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or by a skilled medical interpreter who provides interpretation services at the provider’s office;

((ii)) whether the provider is accepting as new patients individuals who receive medical assistance under this subchapter;

((iii)) whether the provider’s office or facility has accommodations for individuals with physical disabilities, including offices, exam rooms, and equipment;

((iv)) the Internet website of such provider, if applicable; and

((v)) whether the provider offers covered services via telehealth; and

((F)) other relevant information as required by the Secretary;

((84)) provide that—

((A)) the State shall not terminate eligibility for medical assistance under the State plan (or waiver of such plan) for an individual because the individual is an inmate of a public institution (as defined in subsection (nn)(3)), but, subject to subparagraph (D), may suspend coverage during the period the individual is such an inmate (or in the case of such an individual who is an eligible juvenile (as defined in subsection (nn)(2)) and a State electing the option described in the subdivision (A) following the last numbered paragraph of , during such period beginning after the disposition of charges with respect to such individual);

((B)) in the case of an individual who is an eligible juvenile described in paragraph (2)(A) of subsection (nn), the State shall, prior to the individual’s release from such a public institution, conduct a redetermination of eligibility for such individual with respect to such medical assistance (without requiring a new application from the individual) and, if the State determines pursuant to such redetermination that the individual continues to meet the eligibility requirements for such medical assistance, the State shall restore coverage for such medical assistance to such an individual upon the individual’s release from such public institution;

((C)) in the case of an individual who is an eligible juvenile described in paragraph (2)(B) of subsection (nn), the State shall process any application for medical assistance submitted by, or on behalf of, such individual such that the State makes a determination of eligibility for such individual with respect to such medical assistance upon release of such individual from such public institution; and

((D)) in the case of an individual who is an eligible juvenile described in subsection (nn)(2) and is within 30 days of the date on which such eligible juvenile is scheduled to be released from a public institution following adjudication, the State shall have in place a plan, and in accordance with such plan, provide for—

((i)) in the 30 days prior to the release of such eligible juvenile from such public institution (or not later than one week, or as soon as practicable, after release from the public institution), and in coordination with such institution, any screening or diagnostic service which meets reasonable standards of medical and dental practice, as determined by the State, or as indicated as medically necessary, in accordance with paragraphs (1)(A) and (5) of , including a behavioral health screening or diagnostic service; and

((ii)) in the 30 days prior to the release of such eligible juvenile from such public institution, and for at least 30 days following the release of such eligible juvenile from such institution, targeted case management services, including referrals for such eligible juvenile to the appropriate care and services available in the geographic region of the home or residence of such eligible juvenile (where feasible) under the State plan (or waiver of such plan);

((85)) provide that the State is in compliance with the drug review and utilization requirements under subsection ()(1);

((86)) provide, at the option of the State, for making medical assistance available on an inpatient or outpatient basis at a residential pediatric recovery center (as defined in subsection (pp)) to infants with neonatal abstinence syndrome;

((87)) provide for a mechanism, which may include attestation, that ensures that, with respect to any provider (including a transportation network company) or individual driver of nonemergency transportation to medically necessary services receiving payments under such plan (but excluding any public transit authority), at a minimum—

((A)) each such provider and individual driver is not excluded from participation in any Federal health care program (as defined in ) and is not listed on the exclusion list of the Inspector General of the Department of Health and Human Services;

((B)) each such individual driver has a valid driver’s license;

((C)) each such provider has in place a process to address any violation of a State drug law; and

((D)) each such provider has in place a process to disclose to the State Medicaid program the driving history, including any traffic violations, of each such individual driver employed by such provider, including any traffic violations;

((88)) provide—

((A)) beginning not later than , in the case of 1 of the 50 States and the District of Columbia, for a process to regularly obtain address information for individuals enrolled under such plan (or a waiver of such plan) in accordance with subsection (vv); and

((B)) beginning not later than —

((i)) for the State to submit to the system established by the Secretary under subsection (uu), with respect to an individual enrolled or seeking to enroll under such plan, not less frequently than once each month and during each determination or redetermination of the eligibility of such individual for medical assistance under such plan (or waiver of such plan)—

((I)) the social security number of such individual, if such individual has a social security number and is required to provide such number to enroll under such plan (or waiver); and

((II)) such other information with respect to such individual as determined necessary by the Secretary for purposes of preventing individuals from simultaneously being enrolled under State plans (or waivers of such plans) of multiple States;

((ii)) for the use of such system to prevent such simultaneous enrollment; and

((iii)) in the case that such system indicates that an individual enrolled or seeking to enroll under such plan (or waiver of such plan) is enrolled under a State plan (or waiver of such a plan) of another State, for the taking of appropriate action (as determined by the Secretary) to identify whether such an individual resides in the State and disenroll an individual from the State plan of such State if such individual does not reside in such State (unless such individual meets such an exception as the Secretary may specify);

((89)) provide that the State shall comply with the eligibility verification requirements under subsection (ww), except that this paragraph shall apply only in the case of the 50 States and the District of Columbia; and

((90)) beginning , provide, with respect to an active duty relocated individual (as defined in subsection (yy)(1))—

((A)) that, for purposes of determining eligibility for medical assistance under the State plan (or waiver of such plan), such active duty relocated individual is treated as a resident of the State unless such individual voluntarily elects not to be so treated for such purposes;

((B)) that if, at the time of relocation (as described in subsection (yy)(1)), such active duty relocated individual is on a home and community-based services waiting list (as defined in subsection (yy)(2)), such individual remains on such list until—

((i)) the State completes an assessment and renders a decision with respect to the eligibility of such individual to receive the relevant home and community-based services at the time a slot for such services becomes available and, in the case such decision is a denial of such eligibility, such individual has exhausted the individual’s opportunity for a fair hearing; or

((ii)) such individual elects to be removed from such list; and

((C)) payment for medical assistance furnished under the State plan (or a waiver of the plan) on behalf of such active duty relocated individual in the military service relocation State (as referred to in subsection (yy)(1)(B)(i)), to the extent that such assistance is available in such military service relocation State in accordance with such guidance as the Secretary may issue to ensure access to such assistance.

((b)) ** Approval by Secretary** The Secretary shall approve any plan which fulfills the conditions specified in subsection (a), except that he shall not approve any plan which imposes, as a condition of eligibility for medical assistance under the plan—

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

((2)) any residence requirement which excludes any individual who resides in the State, regardless of whether or not the residence is maintained permanently or at a fixed address; or

((3)) any citizenship requirement which excludes any citizen of the United States.

((c)) ** Lower payment levels or applying for benefits as condition of applying for, or receiving, medical assistance** Notwithstanding subsection (b), the Secretary shall not approve any State plan for medical assistance if the State requires individuals described in subsection ()(1) to apply for assistance under the State program funded under part A of subchapter IV as a condition of applying for or receiving medical assistance under this subchapter.l

((d)) ** Performance of medical or utilization review functions** If a State contracts with an entity which meets the requirements of , as determined by the Secretary, or a utilization and quality control peer review organization  having a contract with the Secretary under part B of subchapter XI for the performance of medical or utilization review functions required under this subchapter of a State plan with respect to specific services or providers (or services or providers in a geographic area of the State), such requirements shall be deemed to be met for those services or providers (or services or providers in that area) by delegation to such an entity or organization under the contract of the State’s authority to conduct such review activities if the contract provides for the performance of activities not inconsistent with part B of subchapter XI and provides for such assurances of satisfactory performance by such an entity or organization as the Secretary may prescribe.section 1320c–1 of this title10

((e)) ** Continuation and extension of eligibility of certain individuals; Express Lane option for children**

((1)) Beginning , for provisions relating to the extension of eligibility for medical assistance for certain families who have received aid pursuant to a State plan approved under part A of subchapter IV and have earned income, see .

((2))

((A)) In the case of an individual who is enrolled with a medicaid managed care organization (as defined in ), with a primary care case manager (as defined in ), or with an eligible organization with a contract under and who would (but for this paragraph) lose eligibility for benefits under this subchapter before the end of the minimum enrollment period (defined in subparagraph (B)), the State plan may provide, notwithstanding any other provision of this subchapter, that the individual shall be deemed to continue to be eligible for such benefits until the end of such minimum period, but, except for benefits furnished under , only with respect to such benefits provided to the individual as an enrollee of such organization or entity or by or through the case manager.

((B)) For purposes of subparagraph (A), the term “minimum enrollment period” means, with respect to an individual’s enrollment with an organization or entity under a State plan, a period, established by the State, of not more than six months beginning on the date the individual’s enrollment with the organization or entity becomes effective.

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

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

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

((i)) the individual requires a level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded,

((ii)) it is appropriate to provide such care for the individual outside such an institution, and

((iii)) the estimated amount which would be expended for medical assistance for the individual for such care outside an institution is not greater than the estimated amount which would otherwise be expended for medical assistance for the individual within an appropriate institution; and

((C)) if the individual were in a medical institution, would be eligible for medical assistance under the State plan under this subchapter,

((4)) A child born to a woman eligible for and receiving medical assistance under a State plan on the date of the child’s birth shall be deemed to have applied for medical assistance and to have been found eligible for such assistance under such plan on the date of such birth and to remain eligible for such assistance for a period of one year. During the period in which a child is deemed under the preceding sentence to be eligible for medical assistance, the medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires). Notwithstanding the preceding sentence, in the case of a child who is born in the United States to an alien mother for whom medical assistance for the delivery of the child is made available pursuant to , the State immediately shall issue a separate identification number for the child upon notification by the facility at which such delivery occurred of the child’s birth.

((5)) A woman who, while pregnant, is eligible for, has applied for, and has received medical assistance under the State plan, shall continue to be eligible under the plan, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan, through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends.

((6)) In the case of a pregnant woman described in subsection (a)(10) who, because of a change in income of the family of which she is a member, would not otherwise continue to be described in such subsection, the woman shall be deemed to continue to be an individual described in subsection (a)(10)(A)(i)(IV) and subsection ()(1)(A) without regard to such change of income through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends. The preceding sentence shall not apply in the case of a woman who has been provided ambulatory prenatal care pursuant to during a presumptive eligibility period and is then, in accordance with such section, determined to be ineligible for medical assistance under the State plan.

((7)) In the case of an infant or child described in subparagraph (B), (C), or (D) of subsection ()(1) or paragraph (2) of —

((A)) who is receiving inpatient services for which medical assistance is provided on the date the infant or child attains the maximum age with respect to which coverage is provided under the State plan for such individuals, and

((B)) who, but for attaining such age, would remain eligible for medical assistance under such subsection,

((8)) If an individual is determined to be a qualified medicare beneficiary (as defined in ), such determination shall apply to services furnished after the end of the month in which the determination first occurs. For purposes of payment to a State under , such determination shall be considered to be valid for an individual for a period of 12 months, except that a State may provide for such determinations more frequently, but not more frequently than once every 6 months for an individual.

((9))

((A)) At the option of the State, the plan may include as medical assistance respiratory care services for any individual who—

((i)) is medically dependent on a ventilator for life support at least six hours per day;

((ii)) has been so dependent for at least 30 consecutive days (or the maximum number of days authorized under the State plan, whichever is less) as an inpatient;

((iii)) but for the availability of respiratory care services, would require respiratory care as an inpatient in a hospital, nursing facility, or intermediate care facility for the mentally retarded and would be eligible to have payment made for such inpatient care under the State plan;

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

((v)) wishes to be cared for at home.

((B)) The requirements of subparagraph (A)(ii) may be satisfied by a continuous stay in one or more hospitals, nursing facilities, or intermediate care facilities for the mentally retarded.

((C)) For purposes of this paragraph, respiratory care services means services provided on a part-time basis in the home of the individual by a respiratory therapist or other health care professional trained in respiratory therapy (as determined by the State), payment for which is not otherwise included within other items and services furnished to such individual as medical assistance under the plan.

((10))

((A)) The fact that an individual, child, or pregnant woman may be denied aid under part A of subchapter IV pursuant to section 602(a)(43)  of this title shall not be construed as denying (or permitting a State to deny) medical assistance under this subchapter to such individual, child, or woman who is eligible for assistance under this subchapter on a basis other than the receipt of aid under such part.

((B)) If an individual, child, or pregnant woman is receiving aid under part A of subchapter IV and such aid is terminated pursuant to section 602(a)(43)  of this title, the State may not discontinue medical assistance under this subchapter for the individual, child, or woman until the State has determined that the individual, child, or woman is not eligible for assistance under this subchapter on a basis other than the receipt of aid under such part.

((11))

((A)) In the case of an individual who is enrolled with a group health plan under and who would (but for this paragraph) lose eligibility for benefits under this subchapter before the end of the minimum enrollment period (defined in subparagraph (B)), the State plan may provide, notwithstanding any other provision of this subchapter, that the individual shall be deemed to continue to be eligible for such benefits until the end of such minimum period, but only with respect to such benefits provided to the individual as an enrollee of such plan.

((B)) For purposes of subparagraph (A), the term “minimum enrollment period” means, with respect to an individual’s enrollment with a group health plan, a period established by the State, of not more than 6 months beginning on the date the individual’s enrollment under the plan becomes effective.

((12)) ** 1 .—** The State plan (or waiver of such State plan) shall provide that an individual who is under the age of 19 and who is determined to be eligible for benefits under a State plan (or waiver of such plan) approved under this subchapter under subsection (a)(10)(A) shall remain eligible for such benefits until the earlier of—

((A)) the end of the 12-month period beginning on the date of such determination;

((B)) the time that such individual attains the age of 19; or

((C)) the date that such individual ceases to be a resident of such State.

((13))

((A))

((i)) ** .—** At the option of the State, the State plan may provide that in determining eligibility under this subchapter for a child (as defined in subparagraph (G)), the State may rely on a finding made within a reasonable period (as determined by the State) from an Express Lane agency (as defined in subparagraph (F)) when it determines whether a child satisfies one or more components of eligibility for medical assistance under this subchapter. The State may rely on a finding from an Express Lane agency notwithstanding sections 1396a(a)(46)(B) and 1320b–7(d) of this title or any differences in budget unit, disregard, deeming or other methodology, if the following requirements are met:

((I)) ** .—** If a finding from an Express Lane agency would result in a determination that a child does not satisfy an eligibility requirement for medical assistance under this subchapter and for child health assistance under subchapter XXI, the State shall determine eligibility for assistance using its regular procedures.

((II)) ** .—** For any child who is found eligible for medical assistance under the State plan under this subchapter or child health assistance under subchapter XXI and who is subject to premiums based on an Express Lane agency’s finding of such child’s income level, the State shall provide notice that the child may qualify for lower premium payments if evaluated by the State using its regular policies and of the procedures for requesting such an evaluation.

((III)) ** .—** The State shall satisfy the requirements under subparagraphs (A) and (B) of (relating to screen and enroll) before enrolling a child in child health assistance under subchapter XXI. At its option, the State may fulfill such requirements in accordance with either option provided under subparagraph (C) of this paragraph.

((IV)) ** .—** The State shall satisfy the requirements of section 1396a(a)(46)(B) or 1397ee(c)(9) of this title, as applicable for verifications of citizenship or nationality status.

((V)) ** .—** The State meets the requirements of subparagraph (E).

((ii)) ** .—** The State may apply the provisions of this paragraph when conducting initial determinations of eligibility, redeterminations of eligibility, or both, as described in the State plan.

((B)) ** .—** Nothing in this paragraph shall be construed—

((i)) to limit or prohibit a State from taking any actions otherwise permitted under this subchapter or subchapter XXI in determining eligibility for or enrolling children into medical assistance under this subchapter or child health assistance under subchapter XXI; or

((ii)) to modify the limitations in concerning the agencies that may make a determination of eligibility for medical assistance under this subchapter.

((C))

((i)) ** .—** With respect to a child whose eligibility for medical assistance under this subchapter or for child health assistance under subchapter XXI has been evaluated by a State agency using an income finding from an Express Lane agency, a State may carry out its duties under subparagraphs (A) and (B) of (relating to screen and enroll) in accordance with either clause (ii) or clause (iii).

((ii))

((I)) ** .—** Under this clause, the State establishes a screening threshold set as a percentage of the Federal poverty level that exceeds the highest income threshold applicable under this subchapter to the child by a minimum of 30 percentage points or, at State option, a higher number of percentage points that reflects the value (as determined by the State and described in the State plan) of any differences between income methodologies used by the program administered by the Express Lane agency and the methodologies used by the State in determining eligibility for medical assistance under this subchapter.

((II)) ** .—** If the income of a child does not exceed the screening threshold, the child is deemed to satisfy the income eligibility criteria for medical assistance under this subchapter regardless of whether such child would otherwise satisfy such criteria.

((III)) ** .—** If the income of a child exceeds the screening threshold, the child shall be considered to have an income above the Medicaid applicable income level described in and to satisfy the requirement under (relating to the requirement that CHIP matching funds be used only for children not eligible for Medicaid). If such a child is enrolled in child health assistance under subchapter XXI, the State shall provide the parent, guardian, or custodial relative with the following:

((aa)) Notice that the child may be eligible to receive medical assistance under the State plan under this subchapter if evaluated for such assistance under the State’s regular procedures and notice of the process through which a parent, guardian, or custodial relative can request that the State evaluate the child’s eligibility for medical assistance under this subchapter using such regular procedures.

((bb)) A description of differences between the medical assistance provided under this subchapter and child health assistance under subchapter XXI, including differences in cost-sharing requirements and covered benefits.

((iii))

((I)) ** .—** Under this clause, a State enrolls a child in child health assistance under subchapter XXI for a temporary period if the child appears eligible for such assistance based on an income finding by an Express Lane agency.

((II)) ** .—** During such temporary enrollment period, the State shall determine the child’s eligibility for child health assistance under subchapter XXI or for medical assistance under this subchapter in accordance with this clause.

((III)) ** .—** In making such a determination, the State shall take prompt action to determine whether the child should be enrolled in medical assistance under this subchapter or child health assistance under subchapter XXI pursuant to subparagraphs (A) and (B) of (relating to screen and enroll).

((IV)) ** .—** In making such a determination, the State shall use procedures that, to the maximum feasible extent, reduce the burden imposed on the individual of such determination. Such procedures may not require the child’s parent, guardian, or custodial relative to provide or verify information that already has been provided to the State agency by an Express Lane agency or another source of information unless the State agency has reason to believe the information is erroneous.

((V)) ** .—** Medical assistance for items and services that are provided to a child enrolled in subchapter XXI during a temporary enrollment period under this clause shall be treated as child health assistance under such subchapter.

((D))

((i)) ** .—** The State may initiate and determine eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan without a program application from, or on behalf of, the child based on data obtained from sources other than the child (or the child’s family), but a child can only be automatically enrolled in the State Medicaid plan or the State CHIP plan if the child or the family affirmatively consents to being enrolled through affirmation in writing, by telephone, orally, through electronic signature, or through any other means specified by the Secretary or by signature on an Express Lane agency application, if the requirement of clause (ii) is met.

((ii)) ** .—** The requirement of this clause is that the State informs the parent, guardian, or custodial relative of the child of the services that will be covered, appropriate methods for using such services, premium or other cost sharing charges (if any) that apply, medical support obligations (under ) created by enrollment (if applicable), and the actions the parent, guardian, or relative must take to maintain enrollment and renew coverage.

((E))

((i)) ** .—** For purposes of subparagraph (A)(iv), the requirement of this subparagraph for a State is that the State agrees to—

((I)) assign such codes as the Secretary shall require to the children who are enrolled in the State Medicaid plan or the State CHIP plan through reliance on a finding made by an Express Lane agency for the duration of the State’s election under this paragraph;

((II)) annually provide the Secretary with a statistically valid sample (that is approved by Secretary) of the children enrolled in such plans through reliance on such a finding by conducting a full Medicaid eligibility review of the children identified for such sample for purposes of determining an eligibility error rate (as described in clause (iv)) with respect to the enrollment of such children (and shall not include such children in any data or samples used for purposes of complying with a Medicaid Eligibility Quality Control (MEQC) review or a payment error rate measurement (PERM) requirement);

((III)) submit the error rate determined under subclause (II) to the Secretary;

((IV)) if such error rate exceeds 3 percent for either of the first 2 fiscal years in which the State elects to apply this paragraph, demonstrate to the satisfaction of the Secretary the specific corrective actions implemented by the State to improve upon such error rate; and

((V)) if such error rate exceeds 3 percent for any fiscal year in which the State elects to apply this paragraph, a reduction in the amount otherwise payable to the State under for quarters for that fiscal year, equal to the total amount of erroneous excess payments determined for the fiscal year only with respect to the children included in the sample for the fiscal year that are in excess of a 3 percent error rate with respect to such children.

((ii)) ** .—** The Secretary shall not apply the error rate derived from the sample under clause (i) to the entire population of children enrolled in the State Medicaid plan or the State CHIP plan through reliance on a finding made by an Express Lane agency, or to the population of children enrolled in such plans on the basis of the State’s regular procedures for determining eligibility, or penalize the State on the basis of such error rate in any manner other than the reduction of payments provided for under clause (i)(V).

((iii)) ** .—** Nothing in this paragraph shall be construed as relieving a State that elects to apply this paragraph from being subject to a penalty under , for payments made under the State Medicaid plan with respect to ineligible individuals and families that are determined to exceed the error rate permitted under that section (as determined without regard to the error rate determined under clause (i)(II)).

((iv)) ** .—** In this subparagraph, the term “error rate” means the rate of erroneous excess payments for medical assistance (as defined in ) for the period involved, except that such payments shall be limited to individuals for which eligibility determinations are made under this paragraph and except that in applying this paragraph under subchapter XXI, there shall be substituted for references to provisions of this subchapter corresponding provisions within subchapter XXI.

((F))

((i)) ** .—** In this paragraph, the term “Express Lane agency” means a public agency that—

((I)) is determined by the State Medicaid agency or the State CHIP agency (as applicable) to be capable of making the determinations of one or more eligibility requirements described in subparagraph (A)(i);

((II)) is identified in the State Medicaid plan or the State CHIP plan; and

((III)) notifies the child’s family—

((aa)) of the information which shall be disclosed in accordance with this paragraph;

((bb)) that the information disclosed will be used solely for purposes of determining eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan; and

((cc)) that the family may elect to not have the information disclosed for such purposes; and

((IV)) enters into, or is subject to, an interagency agreement to limit the disclosure and use of the information disclosed.

((ii)) ** .—** Such term includes the following:

((I)) A public agency that determines eligibility for assistance under any of the following:

((aa)) The temporary assistance for needy families program funded under part A of subchapter IV.

((bb)) A State program funded under part D of subchapter IV.

((cc)) The State Medicaid plan.

((dd)) The State CHIP plan.

((ee)) The Food and Nutrition Act of 2008 ( et seq.).

((ff)) The Head Start Act [ et seq.].

((gg)) The Richard B. Russell National School Lunch Act ( et seq.).

((hh)) The Child Nutrition Act of 1966 ( et seq.).

((ii)) The Child Care and Development Block Grant Act of 1990 [ et seq.].

((jj)) The Stewart B. McKinney Homeless Assistance Act  ( et seq.).

((kk)) The United States Housing Act of 1937 ( et seq.).

((ll)) The Native American Housing Assistance and Self-Determination Act of 1996 ( et seq.).

((II)) A State-specified governmental agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the State.

((III)) A public agency that is subject to an interagency agreement limiting the disclosure and use of the information disclosed for purposes of determining eligibility under the State Medicaid plan or the State CHIP plan.

((IV)) The Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (as defined in ).

((iii)) ** .—** Such term does not include an agency that determines eligibility for a program established under the Social Services Block Grant established under subchapter XX or a private, for-profit organization.

((iv)) ** .—** Nothing in this paragraph shall be construed as—

((I)) exempting a State Medicaid agency from complying with the requirements of relating to merit-based personnel standards for employees of the State Medicaid agency and safeguards against conflicts of interest);  or

((II)) authorizing a State Medicaid agency that elects to use Express Lane agencies under this subparagraph to use the Express Lane option to avoid complying with such requirements for purposes of making eligibility determinations under the State Medicaid plan.

((v)) ** .—** In this paragraph:

((I)) ** .—** The term “State” means 1 of the 50 States or the District of Columbia.

((II)) ** .—** The term “State CHIP agency” means the State agency responsible for administering the State CHIP plan.

((III)) ** .—** The term “State CHIP plan” means the State child health plan established under subchapter XXI and includes any waiver of such plan.

((IV)) ** .—** The term “State Medicaid agency” means the State agency responsible for administering the State Medicaid plan.

((V)) ** .—** The term “State Medicaid plan” means the State plan established under subchapter XIX and includes any waiver of such plan.

((G)) ** .—** For purposes of this paragraph, the term “child” means an individual under 19 years of age, or, at the option of a State, such higher age, not to exceed 21 years of age, as the State may elect.

((H)) ** .—** At the option of the State, a finding from an Express Lane agency may include gross income or adjusted gross income shown by State income tax records or returns.

((I)) ** .—** This paragraph shall not apply with respect to eligibility determinations made after .

((14))

((A)) ** .—** Notwithstanding subsection (r) or any other provision of this subchapter, except as provided in subparagraph (D), for purposes of determining income eligibility for medical assistance under the State plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect to the imposition of premiums and cost-sharing, a State shall use the modified adjusted gross income of an individual and, in the case of an individual in a family greater than 1, the household income of such family. A State shall establish income eligibility thresholds for populations to be eligible for medical assistance under the State plan or a waiver of the plan using modified adjusted gross income and household income that are not less than the effective income eligibility levels that applied under the State plan or waiver on . For purposes of complying with the maintenance of effort requirements under subsection (gg) during the transition to modified adjusted gross income and household income, a State shall, working with the Secretary, establish an equivalent income test that ensures individuals eligible for medical assistance under the State plan or under a waiver of the plan on , do not lose coverage under the State plan or under a waiver of the plan. The Secretary may waive such provisions of this subchapter and subchapter XXI as are necessary to ensure that States establish income and eligibility determination systems that protect beneficiaries.

((B)) ** .—** Subject to subparagraph (I), no type of expense, block, or other income disregard shall be applied by a State to determine income eligibility for medical assistance under the State plan or under any waiver of such plan or for any other purpose applicable under the plan or waiver for which a determination of income is required.

((C)) ** .—** A State shall not apply any assets or resources test for purposes of determining eligibility for medical assistance under the State plan or under a waiver of the plan.

((D))

((i)) ** .—** Subparagraphs (A), (B), and (C) shall not apply to the determination of eligibility under the State plan or under a waiver for medical assistance for the following:

((I)) Individuals who are eligible for medical assistance under the State plan or under a waiver of the plan on a basis that does not require a determination of income by the State agency administering the State plan or waiver, including as a result of eligibility for, or receipt of, other Federal or State aid or assistance, individuals who are eligible on the basis of receiving (or being treated as if receiving) supplemental security income benefits under subchapter XVI, and individuals who are eligible as a result of being or being deemed to be a child in foster care under the responsibility of the State.

((II)) Individuals who have attained age 65.

((III)) Individuals who qualify for medical assistance under the State plan or under any waiver of such plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits under subchapter XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of paragraph (3).

((IV)) Individuals described in subsection (a)(10)(C).

((V)) Individuals described in any clause of subsection (a)(10)(E).

((ii)) ** .—** In the case of a State that elects the Express Lane option under paragraph (13), notwithstanding subparagraphs (A), (B), and (C), the State may rely on a finding made by an Express Lane agency in accordance with that paragraph relating to the income of an individual for purposes of determining the individual’s eligibility for medical assistance under the State plan or under a waiver of the plan.

((iii)) ** .—** Subparagraphs (A), (B), and (C) shall not apply to any determinations of eligibility for premium and cost-sharing subsidies under and in accordance with made by the State pursuant to .

((iv))

((I)) ** .—** Subparagraphs (A), (B), and (C) shall not apply to any determinations of eligibility of individuals for purposes of medical assistance for nursing facility services, a level of care in any institution equivalent to that of nursing facility services, home or community-based services furnished under a waiver or State plan amendment under or a waiver under , and services described in .

((II)) ** .—** shall apply for purposes of determining the eligibility of an individual for medical assistance with respect to nursing facility services or other long-term care services.

((v)) ** .—** An individual who, on , is enrolled in the State plan or under a waiver of the plan and who would be determined ineligible for medical assistance solely because of the application of the modified adjusted gross income or household income standard described in subparagraph (A), shall remain eligible for medical assistance under the State plan or waiver (and subject to the same premiums and cost-sharing as applied to the individual on that date) through , or the date on which the individual’s next regularly scheduled redetermination of eligibility is to occur, whichever is later.

((E)) ** .—** Each State shall submit to the Secretary for the Secretary’s approval the income eligibility thresholds proposed to be established using modified adjusted gross income and household income, the methodologies and procedures to be used to determine income eligibility using modified adjusted gross income and household income and, if applicable, a State plan amendment establishing an optional eligibility category under subsection (a)(10)(A)(ii)(XX). To the extent practicable, the State shall use the same methodologies and procedures for purposes of making such determinations as the State used on . The Secretary shall ensure that the income eligibility thresholds proposed to be established using modified adjusted gross income and household income, including under the eligibility category established under subsection (a)(10)(A)(ii)(XX), and the methodologies and procedures proposed to be used to determine income eligibility, will not result in children who would have been eligible for medical assistance under the State plan or under a waiver of the plan on , no longer being eligible for such assistance.

((F)) ** .—** The Secretary shall not waive compliance with the requirements of this paragraph except to the extent necessary to permit a State to coordinate eligibility requirements for dual eligible individuals (as defined in ) under the State plan or under a waiver of the plan and under subchapter XVIII and individuals who require the level of care provided in a hospital, a nursing facility, or an intermediate care facility for the mentally retarded.

((G)) ** .—** In this paragraph, the terms “modified adjusted gross income” and “household income” have the meanings given such terms in section 36B(d)(2) of the Internal Revenue Code of 1986.

((H)) ** .—** The requirement under this paragraph for States to use modified adjusted gross income and household income to determine income eligibility for medical assistance under the State plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required shall not be construed as affecting or limiting the application of—

((i)) the requirement under this subchapter and under the State plan or a waiver of the plan to determine an individual’s income as of the point in time at which an application for medical assistance under the State plan or a waiver of the plan is processed; or

((ii)) any rules established under this subchapter or under the State plan or a waiver of the plan regarding sources of countable income.

((I)) ** .—** For purposes of determining the income eligibility of an individual for medical assistance whose eligibility is determined based on the application of modified adjusted gross income under subparagraph (A), the State shall—

((i)) determine the dollar equivalent of the difference between the upper income limit on eligibility for such an individual (expressed as a percentage of the poverty line) and such upper income limit increased by 5 percentage points; and

((ii)) notwithstanding the requirement in subparagraph (A) with respect to use of modified adjusted gross income, utilize as the applicable income of such individual, in determining such income eligibility, an amount equal to the modified adjusted gross income applicable to such individual reduced by such dollar equivalent amount.

((J)) ** .—** Any nominal amount received by an individual as compensation, including a stipend, for participation as a parent mentor (as defined in paragraph (5) of ) in an activity or program funded through a grant under such section shall be disregarded for purposes of determining the income eligibility of such individual for medical assistance under the State plan or any waiver of such plan.

((K))

((i)) ** .—** In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after ) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received—

((I)) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000;

((II)) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000;

((III)) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and

((IV)) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000.

((ii)) ** .—** For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause.

((iii)) ** .—** An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, shall continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State (in accordance with standards specified by the Secretary), that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary.

((iv)) ** .—** A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i)—

((I)) before the date on which the individual loses such eligibility, inform the individual—

((aa)) of the individual’s opportunity to enroll in a qualified health plan offered through an Exchange established under title I of the Patient Protection and Affordable Care Act during the special enrollment period specified in section 9801(f)(3) of the Internal Revenue Code of 1986 (relating to loss of Medicaid or CHIP coverage); and

((bb)) of the date on which the individual would no longer be considered ineligible by reason of clause (i) to receive medical assistance under the State plan or under any waiver of such plan and be eligible to reapply to receive such medical assistance; and

((II)) provide technical assistance to the individual seeking to enroll in such a qualified health plan.

((v)) ** .—** In this subparagraph, the term “qualified lottery winnings” means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment.

((vi)) ** .—** In this subparagraph, the term “qualified lump sum income” means income that is received as a lump sum from monetary winnings from gambling (as defined by the Secretary and including gambling activities described in ).

((L))

((i)) ** .—** Subject to clause (ii), with respect to redeterminations of eligibility for medical assistance under a State plan (or waiver of such plan) scheduled on or after the first day of the first quarter that begins after , a State shall make such a redetermination once every 6 months for the following individuals:

((I)) Individuals enrolled under subsection (a)(10)(A)(i)(VIII).

((II)) Individuals described in such subsection who are otherwise enrolled under a waiver of such plan that provides coverage that is equivalent to minimum essential coverage (as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and determined in accordance with standards prescribed by the Secretary in regulations) to all individuals described in subsection (a)(10)(A)(i)(VIII).

((ii)) ** .—** The requirements described in clause (i) shall not apply to any individual described in subsection (xx)(9)(A)(ii)(II).

((iii)) ** .—** For purposes of this subparagraph, the term “State” means 1 of the 50 States or the District of Columbia.

((15)) ** .—** The first $2,000 received by an individual (who has attained 19 years of age) as compensation for participation in a clinical trial meeting the requirements of shall be disregarded for purposes of determining the income eligibility of such individual for medical assistance under the State plan or any waiver of such plan.

((16))

((A)) ** .—** At the option of the State, the State plan (or waiver of such State plan) may provide, that an individual who, while pregnant, is eligible for and has received medical assistance under the State plan approved under this subchapter (or a waiver of such plan) (including during a period of retroactive eligibility under subsection (a)(34)) shall, in addition to remaining eligible under paragraph (5) for all pregnancy-related and postpartum medical assistance available under the State plan (or waiver) through the last day of the month in which the 60-day period (beginning on the last day of her pregnancy) ends, remain eligible under the State plan (or waiver) for medical assistance for the period beginning on the first day occurring after the end of such 60-day period and ending on the last day of the month in which the 12-month period (beginning on the last day of her pregnancy) ends.

((B)) ** .—** The medical assistance provided for a pregnant or postpartum individual by a State making an election under this paragraph, without regard to the basis on which the individual is eligible for medical assistance under the State plan (or waiver), shall—

((i)) include all items and services covered under the State plan (or waiver) that are not less in amount, duration, or scope, or are determined by the Secretary to be substantially equivalent, to the medical assistance available for an individual described in subsection (a)(10)(A)(i); and

((ii)) be provided for the individual while pregnant and during the 12-month period that begins on the last day of the individual’s pregnancy and ends on the last day of the month in which such 12-month period ends.

((C)) ** .—** A State making an election under this paragraph that covers under subchapter XXI child health assistance for targeted low-income children who are pregnant or targeted low-income pregnant women, as applicable, shall also make the election under section 1397gg(e)(1)(J)  of this title.

((f)) ** Effective date of State plan as determinative of duty of State to provide medical assistance to aged, blind, or disabled individuals** Notwithstanding any other provision of this subchapter, except as provided in subsection (e) and and , except with respect to qualified disabled and working individuals (described in ), and except with respect to qualified medicare beneficiaries, qualified severely impaired individuals, and individuals described in subsection (m)(1), no State not eligible to participate in the State plan program established under subchapter XVI shall be required to provide medical assistance to any aged, blind, or disabled individual (within the meaning of subchapter XVI) for any month unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this subchapter and in effect on , been in effect in such month, except that for this purpose any such individual shall be deemed eligible for medical assistance under such State plan if (in addition to meeting such other requirements as are or may be imposed under the State plan) the income of any such individual as determined in accordance with (after deducting any supplemental security income payment and State supplementary payment made with respect to such individual, and incurred expenses for medical care as recognized under State law regardless of whether such expenses are reimbursed under another public program of the State or political subdivision thereof) is not in excess of the standard for medical assistance established under the State plan as in effect on . In States which provide medical assistance to individuals pursuant to paragraph (10)(C) of subsection (a) of this section, an individual who is eligible for medical assistance by reason of the requirements of this section concerning the deduction of incurred medical expenses from income shall be considered an individual eligible for medical assistance under paragraph (10)(A) of that subsection if that individual is, or is eligible to be (1) an individual with respect to whom there is payable a State supplementary payment on the basis of which similarly situated individuals are eligible to receive medical assistance equal in amount, duration, and scope to that provided to individuals eligible under paragraph (10)(A), or (2) an eligible individual or eligible spouse, as defined in subchapter XVI, with respect to whom supplemental security income benefits are payable; otherwise that individual shall be considered to be an individual eligible for medical assistance under paragraph (10)(C) of that subsection. In States which do not provide medical assistance to individuals pursuant to paragraph (10)(C) of that subsection, an individual who is eligible for medical assistance by reason of the requirements of this section concerning the deduction of incurred medical expenses from income shall be considered an individual eligible for medical assistance under paragraph (10)(A) of that subsection.section 1382h(b)(3) of this titlesection 1396r–5 of this titlesection 1396d(s) of this titlesection 1396b(f) of this titleJanuary 1, 19721972-01-01January 1, 19721972-01-01

((g)) ** Reduction of aid or assistance to providers of services attempting to collect from beneficiary in violation of third-party provisions** In addition to any other sanction available to a State, a State may provide for a reduction of any payment amount otherwise due with respect to a person who furnishes services under the plan in an amount equal to up to three times the amount of any payment sought to be collected by that person in violation of subsection (a)(25)(C).

((h)) ** Payments for hospitals serving disproportionate number of low-income patients and for home and community care**

((1)) Nothing in this subchapter (including subsections (a)(13) and (a)(30) of this section) shall be construed as authorizing the Secretary to limit the amount of payment that may be made under a plan under this subchapter for home and community care, home and community-based services provided under subsection (c), (d), or (i) of or under a waiver or demonstration project under , self-directed personal assistance services provided pursuant to a written plan of care under , and home and community-based attendant services and supports under .

((2)) Nothing in this subchapter, subchapter XVIII, or subchapter XI shall be construed as prohibiting receipt of any care or services specified in paragraph (1) in an acute care hospital that are—

((A)) identified in an individual’s person-centered service plan (or comparable plan of care);

((B)) provided to meet needs of the individual that are not met through the provision of hospital services;

((C)) not a substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and

((D)) designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

((i)) ** Termination of certification for participation of and suspension of State payments to intermediate care facilities for the mentally retarded**

((1)) In addition to any other authority under State law, where a State determines that a  intermediate care facility for the mentally retarded which is certified for participation under its plan no longer substantially meets the requirements for such a facility under this subchapter and further determines that the facility’s deficiencies—

((A)) immediately jeopardize the health and safety of its patients, the State shall provide for the termination of the facility’s certification for participation under the plan and may provide, or

((B)) do not immediately jeopardize the health and safety of its patients, the State may, in lieu of providing for terminating the facility’s certification for participation under the plan, establish alternative remedies if the State demonstrates to the Secretary’s satisfaction that the alternative remedies are effective in deterring noncompliance and correcting deficiencies, and may provide

((2)) The State shall not make such a decision with respect to a facility until the facility has had a reasonable opportunity, following the initial determination that it no longer substantially meets the requirements for such a facility under this subchapter, to correct its deficiencies, and, following this period, has been given reasonable notice and opportunity for a hearing.

((3)) The State’s decision to deny payment may be made effective only after such notice to the public and to the facility as may be provided for by the State, and its effectiveness shall terminate (A) when the State finds that the facility is in substantial compliance (or is making good faith efforts to achieve substantial compliance) with the requirements for such a facility under this subchapter, or (B) in the case described in paragraph (1)(B), with the end of the eleventh month following the month such decision is made effective, whichever occurs first. If a facility to which clause (B) of the previous sentence applies still fails to substantially meet the provisions of the respective section on the date specified in such clause, the State shall terminate such facility’s certification for participation under the plan effective with the first day of the first month following the month specified in such clause.

((j)) ** Waiver or modification of subchapter requirements with respect to medical assistance program in American Samoa** Notwithstanding any other requirement of this subchapter, the Secretary may waive or modify any requirement of this subchapter with respect to the medical assistance program in American Samoa and the Northern Mariana Islands, other than a waiver of the Federal medical assistance percentage, the limitation in ,, the requirement that payment may be made for medical assistance only with respect to amounts expended by American Samoa or the Northern Mariana Islands for care and services described in a numbered paragraph of , or the requirement under subsection (qq)(1) (relating to data reporting).section 1308(f) of this titlesection 1396d(a) of this title21

((k)) ** Minimum coverage for individuals with income at or below 133 percent of the poverty line**

((1)) The medical assistance provided to an individual described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of benchmark coverage described in or benchmark equivalent coverage described in . Such medical assistance shall be provided subject to the requirements of , without regard to whether a State otherwise has elected the option to provide medical assistance through coverage under that section, unless an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is also an individual for whom, under subparagraph (B) of , the State may not require enrollment in benchmark coverage described in subsection (b)(1) of or benchmark equivalent coverage described in subsection (b)(2) of that section.

((2)) Beginning with the first day of any fiscal year quarter that begins on or after , and before , a State may elect through a State plan amendment to provide medical assistance to individuals who would be described in subclause (VIII) of subsection (a)(10)(A)(i) if that subclause were effective before . A State may elect to phase-in the extension of eligibility for medical assistance to such individuals based on income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.

((3)) If an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected) who is eligible for medical assistance under the State plan or under a waiver of such plan (under that subclause or under a State plan amendment under paragraph (2), the individual may not be enrolled under the State plan unless the individual’s child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term “parent” includes an individual treated as a caretaker relative for purposes of carrying out .

((l)) ** Description of group**

((1)) Individuals described in this paragraph are—

((A)) women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy),

((B)) infants under one year of age,

((C)) children who have attained one year of age but have not attained 6 years of age, and

((D)) children born after (or, at the option of a State, after any earlier date), who have attained 6 years of age but have not attained 19 years of age,

((2))

((A))

((i)) For purposes of paragraph (1) with respect to individuals described in subparagraph (A) or (B) of that paragraph, the State shall establish an income level which is a percentage (not less than the percentage provided under clause (ii) and not more than 185 percent) of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with ) applicable to a family of the size involved.

((ii)) The percentage provided under this clause, with respect to eligibility for medical assistance on or after—

((I)) , is 75 percent, or, if greater, the percentage provided under clause (iii), and

((II)) , 133 percent, or, if greater, the percentage provided under clause (iv).

((iii)) In the case of a State which, as of , has elected to provide, and provides, medical assistance to individuals described in this subsection or has enacted legislation authorizing, or appropriating funds, to provide such assistance to such individuals before , the percentage provided under clause (ii)(I) shall not be less than—

((I)) the percentage specified by the State in an amendment to its State plan (whether approved or not) as of , or

((II)) if no such percentage is specified as of , the percentage established under the State’s authorizing legislation or provided for under the State’s appropriations;

((iv)) In the case of a State which, as of , has established under clause (i), or has enacted legislation authorizing, or appropriating funds, to provide for, a percentage (of the income official poverty line) that is greater than 133 percent, the percentage provided under clause (ii) for medical assistance on or after , shall not be less than—

((I)) the percentage specified by the State in an amendment to its State plan (whether approved or not) as of , or

((II)) if no such percentage is specified as of , the percentage established under the State’s authorizing legislation or provided for under the State’s appropriations.

((B)) For purposes of paragraph (1) with respect to individuals described in subparagraph (C) of such paragraph, the State shall establish an income level which is equal to 133 percent of the income official poverty line described in subparagraph (A) applicable to a family of the size involved.

((C)) For purposes of paragraph (1) with respect to individuals described in subparagraph (D) of that paragraph, the State shall establish an income level which is equal to 100 percent (or, beginning , 133 percent) of the income official poverty line described in subparagraph (A) applicable to a family of the size involved.

((3)) Notwithstanding subsection (a)(17), for individuals who are eligible for medical assistance because of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10) (A)(i)(VII), or (a)(10)(A)(ii)(IX)—

((A)) application of a resource standard shall be at the option of the State;

((B)) any resource standard or methodology that is applied with respect to an individual described in subparagraph (A) of paragraph (1) may not be more restrictive than the resource standard or methodology that is applied under subchapter XVI;

((C)) any resource standard or methodology that is applied with respect to an individual described in subparagraph (B), (C), or (D) of paragraph (1) may not be more restrictive than the corresponding methodology that is applied under the State plan under part A of subchapter IV;

((D)) the income standard to be applied is the appropriate income standard established under paragraph (2); and

((E)) family income shall be determined in accordance with the methodology employed under the State plan under part A or E of subchapter IV (except to the extent such methodology is inconsistent with clause (D) of subsection (a)(17)), and costs incurred for medical care or for any other type of remedial care shall not be taken into account.

((4))

((A)) In the case of any State which is providing medical assistance to its residents under a waiver granted under , the Secretary shall require the State to provide medical assistance for pregnant women and infants under age 1 described in subsection (a)(10)(A)(i)(IV) and for children described in subsection (a)(10)(A)(i)(VI) or subsection (a)(10)(A)(i)(VII) in the same manner as the State would be required to provide such assistance for such individuals if the State had in effect a plan approved under this subchapter.

((B)) In the case of a State which is not one of the 50 States or the District of Columbia, the State need not meet the requirement of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), or (a)(10)(A)(i)(VII) and, for purposes of paragraph (2)(A), the State may substitute for the percentage provided under clause (ii) of such paragraph any percentage.

((m)) ** Description of individuals**

((1)) Individuals described in this paragraph are individuals—

((A)) who are 65 years of age or older or are disabled individuals (as determined under ),

((B)) whose income (as determined under for purposes of the supplemental security income program, except as provided in paragraph (2)(C)) does not exceed an income level established by the State consistent with paragraph (2)(A), and

((C)) whose resources (as determined under for purposes of the supplemental security income program) do not exceed (except as provided in paragraph (2)(B)) the maximum amount of resources that an individual may have and obtain benefits under that program.

((2))

((A)) The income level established under paragraph (1)(B) may not exceed a percentage (not more than 100 percent) of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with ) applicable to a family of the size involved.

((B)) In the case of a State that provides medical assistance to individuals not described in subsection (a)(10)(A) and at the State’s option, the State may use under paragraph (1)(C) such resource level (which is higher than the level described in that paragraph) as may be applicable with respect to individuals described in paragraph (1)(A) who are not described in subsection (a)(10)(A).

((C)) The provisions of shall apply to determinations of income under this subsection in the same manner as they apply to determinations of income under .

((3)) Notwithstanding subsection (a)(17), for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(X)—

((A)) the income standard to be applied is the income standard described in paragraph (1)(B), and

((B)) except as provided in , costs incurred for medical care or for any other type of remedial care shall not be taken into account in determining income.

((4)) Notwithstanding subsection (a)(17), for qualified medicare beneficiaries described in —

((A)) the income standard to be applied is the income standard described in , and

((B)) except as provided in , costs incurred for medical care or for any other type of remedial care shall not be taken into account in determining income.

((n)) ** Payment amounts**

((1)) In the case of medical assistance furnished under this subchapter for medicare cost-sharing respecting the furnishing of a service or item to a qualified medicare beneficiary, the State plan may provide payment in an amount with respect to the service or item that results in the sum of such payment amount and any amount of payment made under subchapter XVIII with respect to the service or item exceeding the amount that is otherwise payable under the State plan for the item or service for eligible individuals who are not qualified medicare beneficiaries.

((2)) In carrying out paragraph (1), a State is not required to provide any payment for any expenses incurred relating to payment for deductibles, coinsurance, or copayments for medicare cost-sharing to the extent that payment under subchapter XVIII for the service would exceed the payment amount that otherwise would be made under the State plan under this subchapter for such service if provided to an eligible recipient other than a medicare beneficiary.

((3)) In the case in which a State’s payment for medicare cost-sharing for a qualified medicare beneficiary with respect to an item or service is reduced or eliminated through the application of paragraph (2)—

((A)) for purposes of applying any limitation under subchapter XVIII on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under subchapter XVIII plus the amount of payment (if any) under the State plan shall be considered to be payment in full for the service;

((B)) the beneficiary shall not have any legal liability to make payment to a provider or to an organization described in for the service; and

((C)) any lawful sanction that may be imposed upon a provider or such an organization for excess charges under this subchapter or subchapter XVIII shall apply to the imposition of any charge imposed upon the individual in such case.

((o)) ** Certain benefits disregarded for purposes of determining post-eligibility contributions** Notwithstanding any provision of subsection (a) to the contrary, a State plan under this subchapter shall provide that any supplemental security income benefits paid by reason of subparagraph (E) or (G) of to an individual who—

((1)) is eligible for medical assistance under the plan, and

((2)) is in a hospital, skilled nursing facility, or intermediate care facility at the time such benefits are paid,

((p)) ** Exclusion power of State; exclusion as prerequisite for medical assistance payments; “exclude” defined**

((1)) In addition to any other authority, a State may exclude any individual or entity for purposes of participating under the State plan under this subchapter for any reason for which the Secretary could exclude the individual or entity from participation in a program under subchapter XVIII under section 1320a–7, 1320a–7a, or 1395cc(b)(2) of this title.

((2)) In order for a State to receive payments for medical assistance under , with respect to payments the State makes to a medicaid managed care organization (as defined in ) or to an entity furnishing services under a waiver approved under , the State must provide that it will exclude from participation, as such an organization or entity, any organization or entity that—

((A)) could be excluded under (relating to owners and managing employees who have been convicted of certain crimes or received other sanctions),

((B)) has, directly or indirectly, a substantial contractual relationship (as defined by the Secretary) with an individual or entity that is described in , or

((C)) employs or contracts with any individual or entity that is excluded from participation under this subchapter under section 1320a–7 or 1320a–7a of this title for the provision of health care, utilization review, medical social work, or administrative services or employs or contracts with any entity for the provision (directly or indirectly) through such an excluded individual or entity of such services.

((3)) As used in this subsection, the term “exclude” includes the refusal to enter into or renew a participation agreement or the termination of such an agreement.

((q)) ** Minimum monthly personal needs allowance deduction; “institutionalized individual or couple” defined**

((1))

((A)) In order to meet the requirement of subsection (a)(50), the State plan must provide that, in the case of an institutionalized individual or couple described in subparagraph (B), in determining the amount of the individual’s or couple’s income to be applied monthly to payment for the cost of care in an institution, there shall be deducted from the monthly income (in addition to other allowances otherwise provided under the State plan) a monthly personal needs allowance—

((i)) which is reasonable in amount for clothing and other personal needs of the individual (or couple) while in an institution, and

((ii)) which is not less (and may be greater) than the minimum monthly personal needs allowance described in paragraph (2).

((B)) In this subsection, the term “institutionalized individual or couple” means an individual or married couple—

((i)) who is an inpatient (or who are inpatients) in a medical institution or nursing facility for which payments are made under this subchapter throughout a month, and

((ii)) who is or are determined to be eligible for medical assistance under the State plan.

((2)) The minimum monthly personal needs allowance described in this paragraph  is $30 for an institutionalized individual and $60 for an institutionalized couple (if both are aged, blind, or disabled, and their incomes are considered available to each other in determining eligibility).

((r)) ** Disregarding payments for certain medical expenses by institutionalized individuals**

((1))

((A)) For purposes of sections 1396a(a)(17) and 1396r–5(d)(1)(D) of this title and for purposes of a waiver under , with respect to the post-eligibility treatment of income of individuals who are institutionalized or receiving home or community-based services under such a waiver, the treatment described in subparagraph (B) shall apply, there shall be disregarded reparation payments made by the Federal Republic of Germany, and there shall be taken into account amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including—

((i)) medicare and other health insurance premiums, deductibles, or coinsurance, and

((ii)) necessary medical or remedial care recognized under State law but not covered under the State plan under this subchapter, subject to reasonable limits the State may establish on the amount of these expenses.

((B))

((i)) In the case of a veteran who does not have a spouse or a child, if the veteran—

((I)) receives, after the veteran has been determined to be eligible for medical assistance under the State plan under this subchapter, a veteran’s pension in excess of $90 per month, and

((II)) resides in a State veterans home with respect to which the Secretary of Veterans Affairs makes per diem payments for nursing home care pursuant to ,

((ii)) The provisions of clause (i) shall apply with respect to a surviving spouse of a veteran who does not have a child in the same manner as they apply to a veteran described in such clause.

((2))

((A)) The methodology to be employed in determining income and resource eligibility for individuals under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) or under may be less restrictive, and shall be no more restrictive, than the methodology—

((i)) in the case of groups consisting of aged, blind, or disabled individuals, under the supplemental security income program under subchapter XVI, or

((ii)) in the case of other groups, under the State plan most closely categorically related.

((B)) For purposes of this subsection and subsection (a)(10), methodology is considered to be “no more restrictive” if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.

((C)) This paragraph shall not be construed as permitting a State to determine the eligibility of an individual for medical assistance with respect to nursing facility services or other long-term care services without application of the limit under .

((s)) ** Adjustment in payment for hospital services furnished to low-income children under age of 6 years** In order to meet the requirements of subsection (a)(55)  , the State plan must provide that payments to hospitals under the plan for inpatient hospital services furnished to infants who have not attained the age of 1 year, and to children who have not attained the age of 6 years and who receive such services in a disproportionate share hospital described in , shall—

((1)) if made on a prospective basis (whether per diem, per case, or otherwise) provide for an outlier adjustment in payment amounts for medically necessary inpatient hospital services involving exceptionally high costs or exceptionally long lengths of stay,

((2)) not be limited by the imposition of day limits with respect to the delivery of such services to such individuals, and

((3)) not be limited by the imposition of dollar limits (other than such limits resulting from prospective payments as adjusted pursuant to paragraph (1)) with respect to the delivery of such services to any such individual who has not attained their first birthday (or in the case of such an individual who is an inpatient on his first birthday until such individual is discharged).

((t)) ** Limitation on payments to States for expenditures attributable to taxes** Nothing in this subchapter (including sections 1396b(a) and 1396d(a) of this title) shall be construed as authorizing the Secretary to deny or limit payments to a State for expenditures, for medical assistance for items or services, attributable to taxes of general applicability imposed with respect to the provision of such items or services.

((u)) ** Qualified COBRA continuation beneficiaries**

((1)) Individuals described in this paragraph are individuals—

((A)) who are entitled to elect COBRA continuation coverage (as defined in paragraph (3)),

((B)) whose income (as determined under for purposes of the supplemental security income program) does not exceed 100 percent of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with ) applicable to a family of the size involved,

((C)) whose resources (as determined under for purposes of the supplemental security income program) do not exceed twice the maximum amount of resources that an individual may have and obtain benefits under that program, and

((D)) with respect to whose enrollment for COBRA continuation coverage the State has determined that the savings in expenditures under this subchapter resulting from such enrollment is likely to exceed the amount of payments for COBRA premiums made.

((2)) For purposes of subsection (a)(10)(F) and this subsection, the term “COBRA premiums” means the applicable premium imposed with respect to COBRA continuation coverage.

((3)) In this subsection, the term “COBRA continuation coverage” means coverage under a group health plan provided by an employer with 75 or more employees provided pursuant to title XXII of the Public Health Service Act [ et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI  of the Employee Retirement Income Security Act of 1974.

((4)) Notwithstanding subsection (a)(17), for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(XI)—

((A)) the income standard to be applied is the income standard described in paragraph (1)(B), and

((B)) except as provided in , costs incurred for medical care or for any other type of remedial care shall not be taken into account in determining income.

((v)) ** State agency disability and blindness determinations for medical assistance eligibility** A State plan may provide for the making of determinations of disability or blindness for the purpose of determining eligibility for medical assistance under the State plan by the single State agency or its designee, and make medical assistance available to individuals whom it finds to be blind or disabled and who are determined otherwise eligible for such assistance during the period of time prior to which a final determination of disability or blindness is made by the Social Security Administration with respect to such an individual. In making such determinations, the State must apply the definitions of disability and blindness found in .section 1382c(a) of this title

((w)) ** Maintenance of written policies and procedures respecting advance directives**

((1)) For purposes of subsection (a)(57) and sections 1396b(m)(1)(A) and 1396r(c)(2)(E) of this title, the requirement of this subsection is that a provider or organization (as the case may be) maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization—

((A)) to provide written information to each such individual concerning—

((i)) an individual’s rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives (as defined in paragraph (3)), and

((ii)) the provider’s or organization’s written policies respecting the implementation of such rights;

((B)) to document in the individual’s medical record whether or not the individual has executed an advance directive;

((C)) not to condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive;

((D)) to ensure compliance with requirements of State law (whether statutory or as recognized by the courts of the State) respecting advance directives; and

((E)) to provide (individually or with others) for education for staff and the community on issues concerning advance directives.

((2)) The written information described in paragraph (1)(A) shall be provided to an adult individual—

((A)) in the case of a hospital, at the time of the individual’s admission as an inpatient,

((B)) in the case of a nursing facility, at the time of the individual’s admission as a resident,

((C)) in the case of a provider of home health care or personal care services, in advance of the individual coming under the care of the provider,

((D)) in the case of a hospice program, at the time of initial receipt of hospice care by the individual from the program, and

((E)) in the case of a medicaid managed care organization, at the time of enrollment of the individual with the organization.

((3)) Nothing in this section shall be construed to prohibit the application of a State law which allows for an objection on the basis of conscience for any health care provider or any agent of such provider which as a matter of conscience cannot implement an advance directive.

((4)) In this subsection, the term “advance directive” means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provision of such care when the individual is incapacitated.

((5)) For construction relating to this subsection, see (relating to clarification respecting assisted suicide, euthanasia, and mercy killing).

((x)) ** Physician identifier system; establishment** The Secretary shall establish a system, for implementation by not later than , which provides for a unique identifier for each physician who furnishes services for which payment may be made under a State plan approved under this subchapter.July 1, 19911991-07-01

((y)) ** Intermediate sanctions for psychiatric hospitals**

((1)) In addition to any other authority under State law, where a State determines that a psychiatric hospital which is certified for participation under its plan no longer meets the requirements for a psychiatric hospital (referred to in ) and further finds that the hospital’s deficiencies—

((A)) immediately jeopardize the health and safety of its patients, the State shall terminate the hospital’s participation under the State plan; or

((B)) do not immediately jeopardize the health and safety of its patients, the State may terminate the hospital’s participation under the State plan, or provide that no payment will be made under the State plan with respect to any individual admitted to such hospital after the effective date of the finding, or both.

((2)) Except as provided in paragraph (3), if a psychiatric hospital described in paragraph (1)(B) has not complied with the requirements for a psychiatric hospital under this subchapter—

((A)) within 3 months after the date the hospital is found to be out of compliance with such requirements, the State shall provide that no payment will be made under the State plan with respect to any individual admitted to such hospital after the end of such 3-month period, or

((B)) within 6 months after the date the hospital is found to be out of compliance with such requirements, no Federal financial participation shall be provided under with respect to further services provided in the hospital until the State finds that the hospital is in compliance with the requirements of this subchapter.

((3)) The Secretary may continue payments, over a period of not longer than 6 months from the date the hospital is found to be out of compliance with such requirements, if—

((A)) the State finds that it is more appropriate to take alternative action to assure compliance of the hospital with the requirements than to terminate the certification of the hospital,

((B)) the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and

((C)) the State agrees to repay to the Federal Government payments received under this paragraph if the corrective action is not taken in accordance with the approved plan and timetable.

((z)) ** Optional coverage of TB-related services**

((1)) Individuals described in this paragraph are individuals not described in subsection (a)(10)(A)(i)—

((A)) who are infected with tuberculosis;

((B)) whose income (as determined under the State plan under this subchapter with respect to disabled individuals) does not exceed the maximum amount of income a disabled individual described in subsection (a)(10)(A)(i) may have and obtain medical assistance under the plan; and

((C)) whose resources (as determined under the State plan under this subchapter with respect to disabled individuals) do not exceed the maximum amount of resources a disabled individual described in subsection (a)(10)(A)(i) may have and obtain medical assistance under the plan.

((2)) For purposes of subsection (a)(10), the term “TB-related services” means each of the following services relating to treatment of infection with tuberculosis:

((A)) Prescribed drugs.

((B)) Physicians’ services and services described in .

((C)) Laboratory and X-ray services (including services to confirm the presence of infection).

((D)) Clinic services and Federally-qualified health center services.

((E)) Case management services (as defined in ).

((F)) Services (other than room and board) designed to encourage completion of regimens of prescribed drugs by outpatients, including services to observe directly the intake of prescribed drugs.

((aa)) ** Certain breast or cervical cancer patients** Individuals described in this subsection are individuals who—

((1)) are not described in subsection (a)(10)(A)(i);

((2)) have not attained age 65;

((3)) have been screened for breast and cervical cancer under the Centers for Disease Control and Prevention breast and cervical cancer early detection program established under title XV of the Public Health Service Act ( et seq.) in accordance with the requirements of section 1504 of that Act () and need treatment for breast or cervical cancer; and

((4)) are not otherwise covered under creditable coverage, as defined in section 2701(c)  of the Public Health Service Act (), but applied without regard to paragraph (1)(F) of such section.

((bb)) ** Payment for services provided by Federally-qualified health centers and rural health clinics**

((1)) ** In general** Beginning with fiscal year 2001 with respect to services furnished on or after , and each succeeding fiscal year, the State plan shall provide for payment for services described in furnished by a Federally-qualified health center and services described in furnished by a rural health clinic in accordance with the provisions of this subsection.section 1396d(a)(2)(C) of this titlesection 1396d(a)(2)(B) of this titleJanuary 1, 20012001-01-01

((2)) ** Fiscal year 2001** Subject to paragraph (4), for services furnished on and after , during fiscal year 2001, the State plan shall provide for payment for such services in an amount (calculated on a per visit basis) that is equal to 100 percent of the average of the costs of the center or clinic of furnishing such services during fiscal years 1999 and 2000 which are reasonable and related to the cost of furnishing such services, or based on such other tests of reasonableness as the Secretary prescribes in regulations under section 1395(a)(3) of this title, or, in the case of services to which such regulations do not apply, the same methodology used under section 1395(a)(3) of this title, adjusted to take into account any increase or decrease in the scope of such services furnished by the center or clinic during fiscal year 2001.January 1, 20012001-01-01ll

((3)) ** Fiscal year 2002 and succeeding fiscal years** Subject to paragraph (4), for services furnished during fiscal year 2002 or a succeeding fiscal year, the State plan shall provide for payment for such services in an amount (calculated on a per visit basis) that is equal to the amount calculated for such services under this subsection for the preceding fiscal year—

((A)) increased by the percentage increase in the MEI (as defined in ) applicable to primary care services (as defined in ) for that fiscal year; and

((B)) adjusted to take into account any increase or decrease in the scope of such services furnished by the center or clinic during that fiscal year.

((4)) ** Establishment of initial year payment amount for new centers or clinics** In any case in which an entity first qualifies as a Federally-qualified health center or rural health clinic after fiscal year 2000, the State plan shall provide for payment for services described in furnished by the center or services described in furnished by the clinic in the first fiscal year in which the center or clinic so qualifies in an amount (calculated on a per visit basis) that is equal to 100 percent of the costs of furnishing such services during such fiscal year based on the rates established under this subsection for the fiscal year for other such centers or clinics located in the same or adjacent area with a similar case load or, in the absence of such a center or clinic, in accordance with the regulations and methodology referred to in paragraph (2) or based on such other tests of reasonableness as the Secretary may specify. For each fiscal year following the fiscal year in which the entity first qualifies as a Federally-qualified health center or rural health clinic, the State plan shall provide for the payment amount to be calculated in accordance with paragraph (3).section 1396d(a)(2)(C) of this titlesection 1396d(a)(2)(B) of this title

((5)) ** Administration in the case of managed care**

((A)) ** In general** In the case of services furnished by a Federally-qualified health center or rural health clinic pursuant to a contract between the center or clinic and a managed care entity (as defined in ), the State plan shall provide for payment to the center or clinic by the State of a supplemental payment equal to the amount (if any) by which the amount determined under paragraphs (2), (3), and (4) of this subsection exceeds the amount of the payments provided under the contract.section 1396u–2(a)(1)(B) of this title

((B)) ** Payment schedule** The supplemental payment required under subparagraph (A) shall be made pursuant to a payment schedule agreed to by the State and the Federally-qualified health center or rural health clinic, but in no case less frequently than every 4 months.

((6)) ** Alternative payment methodologies** Notwithstanding any other provision of this section, the State plan may provide for payment in any fiscal year to a Federally-qualified health center for services described in or to a rural health clinic for services described in in an amount which is determined under an alternative payment methodology that—

((A)) is agreed to by the State and the center or clinic; and

((B)) results in payment to the center or clinic of an amount which is at least equal to the amount otherwise required to be paid to the center or clinic under this section.

((cc)) ** Disabled children eligible to receive medical assistance at option of State**

((1)) Individuals described in this paragraph are individuals—

((A)) who are children who have not attained 19 years of age and are born—

((i)) on or after (or, at the option of a State, on or after an earlier date), in the case of the second, third, and fourth quarters of fiscal year 2007;

((ii)) on or after (or, at the option of a State, on or after an earlier date), in the case of each quarter of fiscal year 2008; and

((iii)) after , in the case of each quarter of fiscal year 2009 and each quarter of any fiscal year thereafter;

((B)) who would be considered disabled under (as determined under subchapter XVI for children but without regard to any income or asset eligibility requirements that apply under such subchapter with respect to children); and

((C)) whose family income does not exceed such income level as the State establishes and does not exceed—

((i)) 300 percent of the poverty line (as defined in ) applicable to a family of the size involved; or

((ii)) such higher percent of such poverty line as a State may establish, except that—

((I)) any medical assistance provided to an individual whose family income exceeds 300 percent of such poverty line may only be provided with State funds; and

((II)) no Federal financial participation shall be provided under for any medical assistance provided to such an individual.

((2))

((A)) If an employer of a parent of an individual described in paragraph (1) offers family coverage under a group health plan (as defined in section 2791(a) of the Public Health Service Act []), the State shall—

((i)) notwithstanding , require such parent to apply for, enroll in, and pay premiums for such coverage as a condition of such parent’s child being or remaining eligible for medical assistance under subsection (a)(10)(A)(ii)(XIX) if the parent is determined eligible for such coverage and the employer contributes at least 50 percent of the total cost of annual premiums for such coverage; and

((ii)) if such coverage is obtained—

((I)) subject to paragraph (2) of section 1396(h)  of this title, reduce the premium imposed by the State under that section in an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and

((II)) treat such coverage as a third party liability under subsection (a)(25).

((B)) In the case of a parent to which subparagraph (A) applies, a State, notwithstanding but subject to paragraph (1)(C)(ii), may provide for payment of any portion of the annual premium for such family coverage that the parent is required to pay. Any payments made by the State under this subparagraph shall be considered, for purposes of , to be payments for medical assistance.

((dd)) ** Electronic transmission of information** If the State agency determining eligibility for medical assistance under this subchapter or child health assistance under subchapter XXI verifies an element of eligibility based on information from an Express Lane Agency  (as defined in subsection (e)(13)(F)), or from another public agency, then the applicant’s signature under penalty of perjury shall not be required as to such element. Any signature requirement for an application for medical assistance may be satisfied through an electronic signature, as defined in section 1710(1) of the Government Paperwork Elimination Act ( note). The requirements of subparagraphs (A) and (B) of may be met through evidence in digital or electronic form.1844 U.S.C. 3504section 1320b–7(d)(2) of this title

((ee)) ** Alternate State process for verification of citizenship or nationality declaration**

((1)) For purposes of subsection (a)(46)(B)(ii), the requirements of this subsection with respect to an individual declaring to be a citizen or national of the United States for purposes of establishing eligibility under this subchapter, are, in lieu of requiring the individual to present satisfactory documentary evidence of citizenship or nationality under (if the individual is not described in paragraph (2) of that section), as follows:

((A)) The State submits the name and social security number of the individual to the Commissioner of Social Security as part of the program established under paragraph (2).

((B)) If the State receives notice from the Commissioner of Social Security that the name or social security number, or the declaration of citizenship or nationality, of the individual is inconsistent with information in the records maintained by the Commissioner—

((i)) the State makes a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the individual to confirm the accuracy of the name or social security number submitted or declaration of citizenship or nationality and by taking such additional actions as the Secretary, through regulation or other guidance, or the State may identify, and continues to provide the individual with medical assistance while making such effort; and

((ii)) in the case such inconsistency is not resolved under clause (i), the State—

((I)) notifies the individual of such fact;

((II)) provides the individual with a period of 90 days from the date on which the notice required under subclause (I) is received by the individual to either present satisfactory documentary evidence of citizenship or nationality (as defined in ) or resolve the inconsistency with the Commissioner of Social Security (and continues to provide the individual with medical assistance during such 90-day period); and

((III)) disenrolls the individual from the State plan under this subchapter within 30 days after the end of such 90-day period if no such documentary evidence is presented or if such inconsistency is not resolved.

((2))

((A)) Each State electing to satisfy the requirements of this subsection for purposes of shall establish a program under which the State submits at least monthly to the Commissioner of Social Security for comparison of the name and social security number, of each individual newly enrolled in the State plan under this subchapter that month who is not described in and who declares to be a United States citizen or national, with information in records maintained by the Commissioner.

((B)) In establishing the State program under this paragraph, the State may enter into an agreement with the Commissioner of Social Security—

((i)) to provide, through an on-line system or otherwise, for the electronic submission of, and response to, the information submitted under subparagraph (A) for an individual enrolled in the State plan under this subchapter who declares to be  citizen or national on at least a monthly basis; or

((ii)) to provide for a determination of the consistency of the information submitted with the information maintained in the records of the Commissioner through such other method as agreed to by the State and the Commissioner and approved by the Secretary, provided that such method is no more burdensome for individuals to comply with than any burdens that may apply under a method described in clause (i).

((C)) The program established under this paragraph shall provide that, in the case of any individual who is required to submit a social security number to the State under subparagraph (A) and who is unable to provide the State with such number, shall be provided with at least the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality (as defined in ) as is provided under clauses (i) and (ii) of to an individual for the submittal to the State of evidence indicating a satisfactory immigration status.

((3))

((A)) The State agency implementing the plan approved under this subchapter shall, at such times and in such form as the Secretary may specify, provide information on the percentage each month that the inconsistent submissions bears to the total submissions made for comparison for such month. For purposes of this subparagraph, a name, social security number, or declaration of citizenship or nationality of an individual shall be treated as inconsistent and included in the determination of such percentage only if—

((i)) the information submitted by the individual is not consistent with information in records maintained by the Commissioner of Social Security;

((ii)) the inconsistency is not resolved by the State;

((iii)) the individual was provided with a reasonable period of time to resolve the inconsistency with the Commissioner of Social Security or provide satisfactory documentation of citizenship status and did not successfully resolve such inconsistency; and

((iv)) payment has been made for an item or service furnished to the individual under this subchapter.

((B)) If, for any fiscal year, the average monthly percentage determined under subparagraph (A) is greater than 3 percent—

((i)) the State shall develop and adopt a corrective plan to review its procedures for verifying the identities of individuals seeking to enroll in the State plan under this subchapter and to identify and implement changes in such procedures to improve their accuracy; and

((ii)) pay to the Secretary an amount equal to the amount which bears the same ratio to the total payments under the State plan for the fiscal year for providing medical assistance to individuals who provided inconsistent information as the number of individuals with inconsistent information in excess of 3 percent of such total submitted bears to the total number of individuals with inconsistent information.

((C)) The Secretary may waive, in certain limited cases, all or part of the payment under subparagraph (B)(ii) if the State is unable to reach the allowable error rate despite a good faith effort by such State.

((D)) Subparagraphs (A) and (B) shall not apply to a State for a fiscal year if there is an agreement described in paragraph (2)(B) in effect as of the close of the fiscal year that provides for the submission on a real-time basis of the information described in such paragraph.

((4)) Nothing in this subsection shall affect the rights of any individual under this subchapter to appeal any disenrollment from a State plan.

((ff)) ** Disregard of certain property in determination of eligibility of Indians** Notwithstanding any other requirement of this subchapter or any other provision of Federal or State law, a State shall disregard the following property from resources for purposes of determining the eligibility of an individual who is an Indian for medical assistance under this subchapter:

((1)) Property, including real property and improvements, that is held in trust, subject to Federal restrictions, or otherwise under the supervision of the Secretary of the Interior, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act [ et seq.], and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior.

((2)) For any federally recognized Tribe not described in paragraph (1), property located within the most recent boundaries of a prior Federal reservation.

((3)) Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally protected rights.

((4)) Ownership interests in or usage rights to items not covered by paragraphs (1) through (3) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.

((gg)) ** Maintenance of effort**

((1)) ** General requirement to maintain eligibility standards until State exchange is fully operational** Subject to the succeeding paragraphs of this subsection, during the period that begins on , and ends on the date on which the Secretary determines that an Exchange established by the State under is fully operational, as a condition for receiving any Federal payments under for calendar quarters occurring during such period, a State shall not have in effect eligibility standards, methodologies, or procedures under the State plan under this subchapter or under any waiver of such plan that is in effect during that period, that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under the plan or waiver that are in effect on .section 18031 of this titlesection 1396b(a) of this titleMarch 23, 20102010-03-23March 23, 20102010-03-23

((2)) ** Continuation of eligibility standards for children through ** The requirement under paragraph (1) shall continue to apply to a State through , (but during the period that begins on , and ends on , only with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in ) applicable to a family of the size involved) with respect to the eligibility standards, methodologies, and procedures under the State plan under this subchapter or under any waiver of such plan that are applicable to determining the eligibility for medical assistance of any child who is under 19 years of age (or such higher age as the State may have elected).section 1397jj(c)(5) of this titleSeptember 30, 20292029-09-30October 1, 20192019-10-01September 30, 20292029-09-30

((3)) ** Nonapplication** During the period that begins on , and ends on , the requirement under paragraph (1) shall not apply to a State with respect to nonpregnant, nondisabled adults who are eligible for medical assistance under the State plan or under a waiver of the plan at the option of the State and whose income exceeds 133 percent of the poverty line (as defined in ) applicable to a family of the size involved if, on or after , the State certifies to the Secretary that, with respect to the State fiscal year during which the certification is made, the State has a budget deficit, or with respect to the succeeding State fiscal year, the State is projected to have a budget deficit. Upon submission of such a certification to the Secretary, the requirement under paragraph (1) shall not apply to the State with respect to any remaining portion of the period described in the preceding sentence.section 1397jj(c)(5) of this titleJanuary 1, 20112011-01-01December 31, 20132013-12-31December 31, 20102010-12-31

((4)) ** Determination of compliance**

((A)) ** States shall apply modified adjusted gross income** A State’s determination of income in accordance with subsection (e)(14) shall not be considered to be eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on , for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).March 23, 20102010-03-23

((B)) ** States may expand eligibility or move waivered populations into coverage under the State plan** With respect to any period applicable under paragraph (1), (2), or (3), a State that applies eligibility standards, methodologies, or procedures under the State plan under this subchapter or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, applied under the State plan or under a waiver of the plan on , or that makes individuals who, on , are eligible for medical assistance under a waiver of the State plan, after , eligible for medical assistance through a State plan amendment with an income eligibility level that is not less than the income eligibility level that applied under the waiver, or as a result of the application of subclause (VIII) of subsection (a)(10)(A)(i), shall not be considered to have in effect eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on , for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).March 23, 20102010-03-23March 23, 20102010-03-23March 23, 20102010-03-23March 23, 20102010-03-23

((hh)) ** State option for coverage for individuals with income that exceeds 133 percent of the poverty line**

((1)) A State may elect to phase-in the extension of eligibility for medical assistance to individuals described in subclause (XX) of subsection (a)(10)(A)(ii) based on the categorical group (including nonpregnant childless adults) or income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.

((2)) If an individual described in subclause (XX) of subsection (a)(10)(A)(ii) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected) who is eligible for medical assistance under the State plan or under a waiver of such plan, the individual may not be enrolled under the State plan unless the individual’s child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term “parent” includes an individual treated as a caretaker relative for purposes of carrying out .

((ii)) ** State eligibility option for family planning services**

((1)) Individuals described in this subsection are individuals—

((A)) whose income does not exceed an income eligibility level established by the State that does not exceed the highest income eligibility level established under the State plan under this subchapter (or under its State child health plan under subchapter XXI) for pregnant women; and

((B)) who are not pregnant.

((2)) At the option of a State, individuals described in this subsection may include individuals who, had individuals applied on or before , would have been made eligible pursuant to the standards and processes imposed by that State for benefits described in clause (XVI) of the matter following subparagraph (G) of section  subsection (a)(10) pursuant to a waiver granted under .

((3)) At the option of a State, for purposes of subsection (a)(17)(B), in determining eligibility for services under this subsection, the State may consider only the income of the applicant or recipient.

((jj)) ** Primary care services defined** For purposes of subsection (a)(13)(C), the term “primary care services” means—

((1)) evaluation and management services that are procedure codes (for services covered under subchapter XVIII) for services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System (established by the Secretary under as of , and as subsequently modified); and

((2)) services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such System.

((kk)) ** Provider and supplier screening, oversight, and reporting requirements** For purposes of subsection (a)(77), the requirements of this subsection are the following:

((1)) ** Screening**

((A)) ** In general** The State complies with the process for screening providers and suppliers under this subchapter, as established by the Secretary under .section 1395cc(j)(2) of this title

((B)) ** Provider screening against Death Master File** Beginning , as part of the enrollment (or reenrollment or revalidation of enrollment) of a provider or supplier under this subchapter, and not less frequently than quarterly during the period that such provider or supplier is so enrolled, the State conducts a check of the Death Master File (as such term is defined in ) to determine whether such provider or supplier is deceased.section 1306c(d) of this titleJanuary 1, 20282028-01-01

((2)) ** Provisional period of enhanced oversight for new providers and suppliers** The State complies with procedures to provide for a provisional period of enhanced oversight for new providers and suppliers under this subchapter, as established by the Secretary under .section 1395cc(j)(3) of this title

((3)) ** Disclosure requirements** The State requires providers and suppliers under the State plan or under a waiver of the plan to comply with the disclosure requirements established by the Secretary under .section 1395cc(j)(5) of this title

((4)) ** Temporary moratorium on enrollment of new providers or suppliers**

((A)) ** Temporary moratorium imposed by the Secretary**

((i)) ** In general** Subject to clause (ii), the State complies with any temporary moratorium on the enrollment of new providers or suppliers imposed by the Secretary under .section 1395cc(j)(7) of this title

((ii)) ** Exceptions**

((I)) ** Compliance with moratorium** A State shall not be required to comply with a temporary moratorium described in clause (i) if the State determines that the imposition of such temporary moratorium would adversely impact beneficiaries’ access to medical assistance.

((II)) ** FFP available** Notwithstanding , payment may be made to a State under this subchapter with respect to amounts expended for items and services described in such section if the Secretary, in consultation with the State agency administering the State plan under this subchapter (or a waiver of the plan), determines that denying payment to the State pursuant to such section would adversely impact beneficiaries’ access to medical assistance.section 1396b(i)(2)(E) of this title

((iii)) ** Limitation on charges to beneficiaries** With respect to any amount expended for items or services furnished during calendar quarters beginning on or after , the State prohibits, during the period of a temporary moratorium described in clause (i), a provider meeting the requirements specified in subparagraph (C)(iii) of from charging an individual or other person eligible to receive medical assistance under the State plan under this subchapter (or a waiver of the plan) for an item or service described in furnished to such an individual.section 1395cc(j)(7) of this titlesection 1396b(i)(2)(E) of this titleOctober 1, 20172017-10-01

((B)) ** Moratorium on enrollment of providers and suppliers** At the option of the State, the State imposes, for purposes of entering into participation agreements with providers or suppliers under the State plan or under a waiver of the plan, periods of enrollment moratoria, or numerical caps or other limits, for providers or suppliers identified by the Secretary as being at high-risk for fraud, waste, or abuse as necessary to combat fraud, waste, or abuse, but only if the State determines that the imposition of any such period, cap, or other limits would not adversely impact beneficiaries’ access to medical assistance.

((5)) ** Compliance programs** The State requires providers and suppliers under the State plan or under a waiver of the plan to establish, in accordance with the requirements of section 1395cc(j)(7)  of this title, a compliance program that contains the core elements established under subparagraph (B) of that section 1395cc(j)(7)  of this title for providers or suppliers within a particular industry or category.11

((6)) ** Reporting of adverse provider actions** The State complies with the national system for reporting criminal and civil convictions, sanctions, negative licensure actions, and other adverse provider actions to the Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, in accordance with regulations of the Secretary.

((7)) ** Enrollment and NPI of ordering or referring providers** The State requires—

((A)) all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the plan as a participating provider; and

((B)) the national provider identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional.

((8)) ** Provider terminations**

((A)) ** In general** Beginning on , in the case of a notification under subsection (a)(41) with respect to a termination for a reason specified in section 455.101 of title 42, Code of Federal Regulations (as in effect on ) or for any other reason specified by the Secretary, of the participation of a provider of services or any other person under the State plan (or under a waiver of the plan), the State, not later than 30 days after the effective date of such termination, submits to the Secretary with respect to any such provider or person, as appropriate—

((i)) the name of such provider or person;

((ii)) the provider type of such provider or person;

((iii)) the specialty of such provider’s or person’s practice;

((iv)) the date of birth, Social Security number, national provider identifier (if applicable), Federal taxpayer identification number, and the State license or certification number of such provider or person (if applicable);

((v)) the reason for the termination;

((vi)) a copy of the notice of termination sent to the provider or person;

((vii)) the date on which such termination is effective, as specified in the notice; and

((viii)) any other information required by the Secretary.

((B)) ** Effective date defined** For purposes of this paragraph, the term “effective date” means, with respect to a termination described in subparagraph (A), the later of—

((i)) the date on which such termination is effective, as specified in the notice of such termination; or

((ii)) the date on which all appeal rights applicable to such termination have been exhausted or the timeline for any such appeal has expired.

((9)) ** Other State oversight** Nothing in this subsection shall be interpreted to preclude or limit the ability of a State to engage in provider and supplier screening or enhanced provider and supplier oversight activities beyond those required by the Secretary.

((ll)) ** Termination notification database** In the case of a provider of services or any other person whose participation under this subchapter or subchapter XXI is terminated (as described in subsection (kk)(8)), the Secretary shall, not later than 30 days after the date on which the Secretary is notified of such termination under subsection (a)(41) (as applicable), review such termination and, if the Secretary determines appropriate, include such termination in any database or similar system developed pursuant to section 6401(b)(2) of the Patient Protection and Affordable Care Act ( note; ).42 U.S.C. 1395ccPublic Law 111–148

((mm)) ** Directory provider described**

((1)) ** In general** A provider described in this subsection, at a minimum, includes physicians, hospitals, pharmacies, providers of mental health services, providers of substance use disorder services, providers of long term services and supports as appropriate, and such other providers as required by the Secretary, and—

((A)) in the case of a provider or a provider type for which the State agency, as a condition of receiving payment for items and services furnished by the provider to individuals eligible to receive medical assistance under the State plan (or a waiver of the plan), requires the enrollment of the provider with the State agency, includes a provider that—

((i)) is enrolled with the agency as of the date on which the directory is published or updated (as applicable) under subsection (a)(83); and

((ii)) received payment under the State plan in the 12-month period preceding such date; and

((B)) in the case of a provider or a provider type for which the State agency does not require such enrollment, includes a provider that received payment under the State plan (or a waiver of the plan) in the 12-month period preceding the date on which the directory is published or updated (as applicable) under subsection (a)(83).

((2)) ** State option to include other participating providers** At State option, a provider described in this subsection may include any provider who furnishes services and is participating under the State plan under this subchapter or under a waiver of such plan.

((nn)) ** Juvenile; eligible juvenile; public institution** For purposes of subsection (a)(84) and this subsection:

((1)) ** Juvenile** The term “juvenile” means an individual who is—

((A)) under 21 years of age; or

((B)) described in subsection (a)(10)(A)(i)(IX).

((2)) ** Eligible juvenile** The term “eligible juvenile” means a juvenile who is an inmate of a public institution and who—

((A)) was determined eligible for medical assistance under the State plan (or waiver of such plan) immediately before becoming an inmate of such a public institution; or

((B)) is determined eligible for such medical assistance while an inmate of a public institution.

((3)) ** Inmate of a public institution** The term “inmate of a public institution” has the meaning given such term for purposes of applying the subdivision (A) following the last numbered paragraph of , taking into account the exception in such subdivision for a patient of a medical institution.section 1396d(a) of this title

((oo)) ** Drug review and utilization requirements**

((1)) ** In general** For purposes of subsection (a)(85), the drug review and utilization requirements under this subsection are, subject to paragraph (3) and beginning , the following:

((A)) ** Claims review limitations**

((i)) ** In general** The State has in place—

((I)) safety edits (as specified by the State) for subsequent fills for opioids and a claims review automated process (as designed and implemented by the State) that indicates when an individual enrolled under the State plan (or under a waiver of the State plan) is prescribed a subsequent fill of opioids in excess of any limitation that may be identified by the State;

((II)) safety edits (as specified by the State) on the maximum daily morphine equivalent that can be prescribed to an individual enrolled under the State plan (or under a waiver of the State plan) for treatment of chronic pain and a claims review automated process (as designed and implemented by the State) that indicates when an individual enrolled under the plan (or waiver) is prescribed the morphine equivalent for such treatment in excess of any limitation that may be identified by the State; and

((III)) a claims review automated process (as designed and implemented by the State) that monitors when an individual enrolled under the State plan (or under a waiver of the State plan) is concurrently prescribed opioids and—

((aa)) benzodiazepines; or

((bb)) antipsychotics.

((ii)) ** Managed care entities** The State requires each managed care entity (as defined in ) with respect to which the State has a contract under or under to have in place, subject to paragraph (3), with respect to individuals who are eligible for medical assistance under the State plan (or under a waiver of the State plan) and who are enrolled with the entity, the limitations described in subclauses (I) and (II) of clause (i) and a claims review automated process described in subclause (III) of such clause.section 1396u–2(a)(1)(B) of this titlesection 1396b(m) of this titlesection 1396d(t)(3) of this title

((iii)) ** Rules of construction** Nothing in this subparagraph may be construed as prohibiting a State or managed care entity from designing and implementing a claims review automated process under this subparagraph that provides for prospective or retrospective reviews of claims. Nothing in this subparagraph shall be understood as prohibiting the exercise of clinical judgment from a provider enrolled as a participating provider in a State plan (or waiver of the State plan) or contracting with a managed care entity regarding the best items and services for an individual enrolled under such State plan (or waiver).

((B)) ** Program to monitor antipsychotic medications by children** The State has in place a program (as designed and implemented by the State) to monitor and manage the appropriate use of antipsychotic medications by children enrolled under the State plan (or under a waiver of the State plan) and submits annually to the Secretary such information as the Secretary may require on activities carried out under such program for individuals not more than the age of 18 years generally and children in foster care specifically.

((C)) ** Fraud and abuse identification** The State has in place a process (as designed and implemented by the State) that identifies potential fraud or abuse of controlled substances by individuals enrolled under the State plan (or under a waiver of the State plan), health care providers prescribing drugs to individuals so enrolled, and pharmacies dispensing drugs to individuals so enrolled.

((D)) ** Reports** The State shall include in the annual report submitted to the Secretary under information on the limitations, requirement, program, and processes applied by the State under subparagraphs (A) through (C) in accordance with such manner and time as specified by the Secretary.section 1396r–8(g)(3)(D) of this title

((E)) ** Clarification** Nothing shall prevent a State from satisfying the requirement—

((i)) described in subparagraph (A) by having safety edits or a claims review automated process described in such subparagraph that was in place before ;

((ii)) described in subparagraph (B) by having a program described in such subparagraph that was in place before such date; or

((iii)) described in subparagraph (C) by having a process described in such subparagraph that was in place before such date.

((2)) ** Annual report by Secretary** For each fiscal year beginning with fiscal year 2020, the Secretary shall submit to Congress a report on the most recent information submitted by States under paragraph (1)(D).

((3)) ** Exceptions**

((A)) ** Certain individuals exempted** The drug review and utilization requirements under this subsection shall not apply with respect to an individual who—

((i)) is receiving—

((I)) hospice or palliative care; or

((II)) treatment for cancer;

((ii)) is a resident of a long-term care facility, of a facility described in , or of another facility for which frequently abused drugs are dispensed for residents through a contract with a single pharmacy; or

((iii)) the State elects to treat as exempted from such requirements.

((B)) ** Exception relating to ensuring access** In order to ensure reasonable access to health care, the Secretary shall waive the drug review and utilization requirements under this subsection, with respect to a State, in the case of natural disasters and similar situations, and in the case of the provision of emergency services (as defined for purposes of ).section 1395w–104(c)(5)(D)(ii)(II) of this title

((pp)) ** Residential pediatric recovery center defined**

((1)) ** In general** For purposes of , the term “residential pediatric recovery center” means a center or facility that furnishes items and services for which medical assistance is available under the State plan to infants with the diagnosis of neonatal abstinence syndrome without any other significant medical risk factors.section 1396a(a)(86) of this title

((2)) ** Counseling and services** A residential pediatric recovery center may offer counseling and other services to mothers (and other appropriate family members and caretakers) of infants receiving treatment at such centers if such services are otherwise covered under the State plan under this subchapter or under a waiver of such plan. Such other services may include the following:

((A)) Counseling or referrals for services.

((B)) Activities to encourage caregiver-infant bonding.

((C)) Training on caring for such infants.

((qq)) ** Application of certain data reporting and program integrity requirements to Northern Mariana Islands, American Samoa, and Guam**

((1)) ** In general** Not later than , the Northern Mariana Islands, American Samoa, and Guam shall—

((A)) demonstrate progress in implementing methods, satisfactory to the Secretary, for the collection and reporting of reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system); and

((B)) demonstrate progress in establishing a State medicaid fraud control unit described in .

((2)) ** Determination of progress** For purposes of paragraph (1), the Secretary shall deem that a territory described in such paragraph has demonstrated satisfactory progress in implementing methods for the collection and reporting of reliable data or establishing a State medicaid fraud control unit if the territory has made a good faith effort to implement such methods or establish such a unit, given the circumstances of the territory.

((rr)) ** Program integrity requirements for Puerto Rico**

((1)) ** System for tracking Federal Medicaid funding provided to Puerto Rico**

((A)) ** In general** Puerto Rico shall establish and maintain a system, which may include the use of a quarterly Form CMS–64, for tracking any amounts paid by the Federal Government to Puerto Rico with respect to the State plan of Puerto Rico (or a waiver of such plan). Under such system, Puerto Rico shall ensure that information is available, with respect to each quarter in a fiscal year (beginning with the first quarter beginning on or after the date that is 1 year after ), on the following:

((i)) In the case of a quarter other than the first quarter of such fiscal year—

((I)) the total amount expended by Puerto Rico during any previous quarter of such fiscal year under the State plan of Puerto Rico (or a waiver of such plan); and

((II)) a description of how such amount was so expended.

((ii)) The total amount that Puerto Rico expects to expend during the quarter under the State plan of Puerto Rico (or a waiver of such plan), and a description of how Puerto Rico expects to expend such amount.

((B)) ** Report to CMS** For each quarter with respect to which Puerto Rico is required under subparagraph (A) to ensure that information described in such subparagraph is available, Puerto Rico shall submit to the Administrator of the Centers for Medicare & Medicaid Services a report on such information for such quarter, which may include the submission of a quarterly Form CMS–37.

((2)) ** Submission of documentation on contracts upon request** Puerto Rico shall, upon request, submit to the Administrator of the Centers for Medicare & Medicaid Services all documentation requested with respect to contracts awarded under the State plan of Puerto Rico (or a waiver of such plan).

((3)) ** Reporting on Medicaid and CHIP Scorecard measures** Beginning 12 months after , Puerto Rico shall begin to report to the Administrator of the Centers for Medicare & Medicaid Services on selected measures included in the Medicaid and CHIP Scorecard developed by the Centers for Medicare & Medicaid Services.December 20, 20192019-12-20

((ss)) ** Uninsured individual defined** For purposes of this section, the term “uninsured individual” means, notwithstanding any other provision of this subchapter, any individual who is—

((1)) not described in subsection (a)(10)(A)(i) (excluding subclause (VIII) of such subsection if the individual is a resident of a State which does not furnish medical assistance to individuals described in such subclause); and

((2)) not enrolled in a Federal health care program (as defined in ), a group health plan, group or individual health insurance coverage offered by a health insurance issuer (as such terms are defined in ), or a health plan offered under chapter 89 of title 5, except that individuals who are eligible for medical assistance under subsection (a)(10)(A)(ii)(XII), subsection (a)(10)(A)(ii)(XVIII), subsection (a)(10)(A)(ii)(XXI), or subsection (a)(10)(C) (but only to the extent such an individual is considered to not have minimum essential coverage under section 5000A(f)(1) of the Internal Revenue Code of 1986), or who are described in subsection ()(1)(A) and are eligible for medical assistance only because of subsection (a)(10)(A)(i)(IV) or (a)(10)(A)(ii)(IX) and whose eligibility for such assistance is limited by the State under clause (VII) in the matter following subsection (a)(10)(G), shall not be treated as enrolled in a Federal health care program for purposes of this paragraph.

((tt)) ** Requirements relating to transition from Families First Coronavirus Response Act FMAP increase requirements; enforcement and corrective action**

((1)) ** Reporting requirements** For each month occurring during the period that begins on , and ends on , each State shall submit to the Secretary, on a timely basis, a report, that the Secretary shall make publicly available, on the activities of the State relating to eligibility redeterminations conducted during such period, and which include, with respect to the month for which the report is submitted, the following information:

((A)) The number of eligibility renewals initiated, beneficiaries renewed on a total and ex parte basis, and individuals whose coverage for medical assistance, child health assistance, or pregnancy-related assistance was terminated.

((B)) The number of individuals whose coverage for medical assistance, child health assistance, or pregnancy-related assistance was so terminated for procedural reasons.

((C)) Where applicable, the number of individuals who were enrolled in a State child health plan or waiver in the form described in paragraph (1) of .

((D)) Unless the Administrator of the Centers for Medicare & Medicaid Services reports such information on behalf of the State:

((i)) In a State with a Federal or State American Health Benefit Exchange established under title I of the Patient Protection and Affordable Care Act in which the systems used to determine eligibility for assistance under this subchapter or subchapter XXI are not integrated with the systems used to determine eligibility for coverage under a qualified health plan with advance payment under section 1412(a) of the Patient Protection and Affordable Care Act [] of any premium tax credit allowed under section 36B of the Internal Revenue Code of 1986—

((I)) the number of individuals whose accounts were received via secure electronic transfer by the Federal or State American Health Benefit Exchange, or a basic health program established under section 1331 of the Patient Protection and Affordable Care Act [];

((II)) the number of individuals identified in subclause (I) who were determined eligible for a qualified health plan, as defined in section 1301(a)(1) of the Patient Protection and Affordable Care Act [], or (if applicable) the basic health program established under section 1331 of such Act []; and

((III)) the number of individuals identified in subclause (II) who made a qualified health plan selection or were enrolled in a basic health program plan (if applicable).

((ii)) In a State with a State American Health Benefit Exchange established under title I of the Patient Protection and Affordable Care Act in which the systems used to determine eligibility for assistance under this subchapter or subchapter XXI are integrated with the systems used to determine eligibility for coverage under a qualified health plan with advance payment under section 1412(a) of the Patient Protection and Affordable Care Act [] of any premium tax credit allowed under section 36B of the Internal Revenue Code of 1986—

((I)) the number of individuals who were determined eligible for a qualified health plan, as defined in section 1301(a)(1) of the Patient Protection and Affordable Care Act [], or (if applicable) the basic health program established under section 1331 of such Act []; and

((II)) the number of individuals identified in subclause (I) who made a qualified health plan selection or were enrolled in a basic health program plan (if applicable).

((E)) The total call center volume, average wait times, and average abandonment rate (as determined by the Secretary) for each call center of the State agency responsible for administering the State plan under this subchapter (or a waiver of such plan) during such month.

((F)) Such other information related to eligibility redeterminations and renewals during the period described in paragraph (1), as identified by the Secretary.

((2)) ** Enforcement and corrective action**

((A)) ** In general** For each fiscal quarter that occurs during the period that begins on , and ends on , if a State does not satisfy the requirements of paragraph (1), the Federal medical assistance percentage determined for the State for the quarter under shall be reduced by the number of percentage points (not to exceed 1 percentage point) equal to the product of 0.25 percentage points and the number of fiscal quarters during such period for which the State has failed to satisfy such requirements.section 1396d(b) of this titleJuly 1, 20232023-07-01June 30, 20242024-06-30

((B)) ** Corrective action plan; additional authority**

((i)) ** In general** The Secretary may assess a State’s compliance with all Federal requirements applicable to eligibility redeterminations and the reporting requirements described in paragraph (1), and, if the Secretary determines that a State did not comply with any such requirements during the period that begins on , and ends on , the Secretary may require the State to submit and implement a corrective action plan in accordance with clause (ii).April 1, 20232023-04-01June 30, 20242024-06-30

((ii)) ** Corrective action plan** A State that receives a written notice from the Secretary that the Secretary has determined that the State is not in compliance with a requirement described in clause (i) shall—

((I)) not later than 14 days after receiving such notice, submit a corrective action plan to the Secretary;

((II)) not later than 21 days after the date on which such corrective action plan is submitted to the Secretary, receive approval for the plan from the Secretary; and

((III)) begin implementation of such corrective action plan not later than 14 days after such approval.

((iii)) ** Effect of failure to submit or implement a corrective action plan** If a State fails to submit or implement an approved corrective action plan in accordance with clause (ii), the Secretary may, in addition to any reduction applied under subparagraph (A) to the Federal medical assistance percentage determined for the State and any other remedy available to the Secretary for the purpose of carrying out this subchapter, require the State to suspend making all or some terminations of eligibility for medical assistance from the State plan under this subchapter (including any waiver of such plan) that are for procedural reasons until the State takes appropriate corrective action, as determined by the Secretary, and may impose a civil money penalty of not more than $100,000 for each day a State is not in compliance.

((uu)) ** Prevention of enrollment under multiple State plans**

((1)) ** In general** Not later than , the Secretary shall establish a system to be utilized by the Secretary and States to prevent an individual from being simultaneously enrolled under the State plans (or waivers of such plans) of multiple States. Such system shall—

((A)) provide for the receipt of information submitted by a State under subsection (a)(88)(B)(i); and

((B)) not less than once each month, transmit information to a State (or allow the Secretary to transmit information to a State) regarding whether an individual enrolled or seeking to enroll under the State plan of such State (or waiver of such plan) is enrolled under the State plan (or waiver of such plan) of another State.

((2)) ** Standards** The Secretary shall establish such standards as determined necessary by the Secretary to limit and protect information submitted under such system and ensure the privacy of such information, consistent with subsection (a)(7).

((3)) ** Implementation funding** There are appropriated to the Administrator of the Centers for Medicare & Medicaid Services, out of amounts in the Treasury not otherwise appropriated, in addition to amounts otherwise available—

((A)) for fiscal year 2026, $10,000,000 for purposes of establishing the system and standards required under this subsection, to remain available until expended; and

((B)) for fiscal year 2029, $20,000,000 for purposes of maintaining such system, to remain available until expended.

((vv)) ** Process to obtain enrollee address information**

((1)) ** In general** For purposes of subsection (a)(88)(A), a process to regularly obtain address information for individuals enrolled under a State plan (or a waiver of such plan) shall obtain address information from reliable data sources described in paragraph (2) and take such actions as the Secretary shall specify with respect to any changes to such address based on such information.

((2)) ** Reliable data sources described** For purposes of paragraph (1), the reliable data sources described in this paragraph are the following:

((A)) Mail returned to the State by the United States Postal Service with a forwarding address.

((B)) The National Change of Address Database maintained by the United States Postal Service.

((C)) A managed care entity (as defined in ) or prepaid inpatient health plan or prepaid ambulatory health plan (as such terms are defined in ) that has a contract under the State plan if the address information is provided to such entity or plan directly from, or verified by such entity or plan directly with, such individual.

((D)) Other data sources as identified by the State and approved by the Secretary.

((ww)) ** Verification of certain eligibility criteria**

((1)) ** In general** For purposes of subsection (a)(89), the eligibility verification requirements, beginning , are as follows:

((A)) ** Quarterly screening to verify enrollee status** The State shall, not less frequently than quarterly, review the Death Master File (as such term is defined in ) or a successor system that provides such information needed to determine whether any individuals enrolled for medical assistance under the State plan (or waiver of such plan) are deceased.section 1306c(d) of this title

((B)) ** Disenrollment under State plan** If the State determines, based on information obtained from the Death Master File, that an individual enrolled for medical assistance under the State plan (or waiver of such plan) is deceased, the State shall—

((i)) treat such information as factual information confirming the death of a beneficiary;

((ii)) disenroll such individual from the State plan (or waiver of such plan) in accordance with subsection (a)(3); and

((iii)) discontinue any payments for medical assistance under this subchapter made on behalf of such individual (other than payments for any items or services furnished to such individual prior to the death of such individual).

((C)) ** Reinstatement of coverage in the event of error** If a State determines that an individual was misidentified as deceased based on information obtained from the Death Master File and was erroneously disenrolled from medical assistance under the State plan (or waiver of such plan) based on such misidentification, the State shall immediately re-enroll such individual under the State plan (or waiver of such plan), retroactive to the date of such disenrollment.

((2)) ** Rule of construction** Nothing under this subsection shall be construed to preclude the ability of a State to use other electronic data sources to timely identify potentially deceased beneficiaries, so long as the State is also in compliance with the requirements of this subsection (and all other requirements under this subchapter relating to Medicaid eligibility determination and redetermination).

((xx)) ** Community engagement requirement for applicable individuals**

((1)) ** In general** Except as provided in paragraph (11), beginning not later than the first day of the first quarter that begins after , or, at the option of the State under a waiver or demonstration project under or the State plan, such earlier date as the State may specify, subject to the succeeding provisions of this subsection, a State shall provide, as a condition of eligibility for medical assistance for an applicable individual, that such individual is required to demonstrate community engagement under paragraph (2)—

((A)) in the case of an applicable individual who has filed an application for medical assistance under a State plan (or a waiver of such plan) under this subchapter, for 1 or more but not more than 3 (as specified by the State) consecutive months immediately preceding the month during which such individual applies for such medical assistance; and

((B)) in the case of an applicable individual enrolled and receiving medical assistance under a State plan (or under a waiver of such plan) under this subchapter, for 1 or more (as specified by the State) months, whether or not consecutive—

((i)) during the period between such individual’s most recent determination (or redetermination, as applicable) of eligibility and such individual’s next regularly scheduled redetermination of eligibility (as verified by the State as part of such regularly scheduled redetermination of eligibility); or

((ii)) in the case of a State that has elected under paragraph (4) to conduct more frequent verifications of compliance with the requirement to demonstrate community engagement, during the period between the most recent and next such verification with respect to such individual.

((2)) ** Community engagement compliance described** Subject to paragraph (3), an applicable individual demonstrates community engagement under this paragraph for a month if such individual meets 1 or more of the following conditions with respect to such month, as determined in accordance with criteria established by the Secretary through regulation:

((A)) The individual works not less than 80 hours.

((B)) The individual completes not less than 80 hours of community service.

((C)) The individual participates in a work program for not less than 80 hours.

((D)) The individual is enrolled in an educational program at least half-time.

((E)) The individual engages in any combination of the activities described in subparagraphs (A) through (D), for a total of not less than 80 hours.

((F)) The individual has a monthly income that is not less than the applicable minimum wage requirement under , multiplied by 80 hours.

((G)) The individual had an average monthly income over the preceding 6 months that is not less than the applicable minimum wage requirement under multiplied by 80 hours, and is a seasonal worker, as described in section 45R(d)(5)(B) of the Internal Revenue Code of 1986 .

((3)) ** Exceptions**

((A)) ** Mandatory exception for certain individuals** The State shall deem an applicable individual to have demonstrated community engagement under paragraph (2) for a month, and may elect to not require an individual to verify information resulting in such deeming, if—

((i)) for part or all of such month, the individual—

((I)) was a specified excluded individual (as defined in paragraph (9)(A)(ii)); or

((II)) was—

((aa)) under the age of 19;

((bb)) entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII; or

((cc)) described in any of subclauses (I) through (VII) of subsection (a)(10)(A)(i); or

((ii)) at any point during the 3-month period ending on the first day of such month, the individual was an inmate of a public institution.

((B)) ** Optional exception for short-term hardship events**

((i)) ** In general** The State plan (or waiver of such plan) may provide, in the case of an applicable individual who experiences a short-term hardship event during a month, that the State shall, under procedures established by the State (in accordance with standards specified by the Secretary), in the case of a short-term hardship event described in clause (ii)(II) and, upon the request of such individual, a short-term hardship event described in subclause (I) or (III) of clause (ii), deem such individual to have demonstrated community engagement under paragraph (2) for such month.

((ii)) ** Short-term hardship event defined** For purposes of this subparagraph, an applicable individual experiences a short-term hardship event during a month if, for part or all of such month—

((I)) such individual receives inpatient hospital services, nursing facility services, services in an intermediate care facility for individuals with intellectual disabilities, inpatient psychiatric hospital services, or such other services of similar acuity (including outpatient care relating to other services specified in this subclause) as the Secretary determines appropriate;

((II)) such individual resides in a county (or equivalent unit of local government)—

((aa)) in which there exists an emergency or disaster declared by the President pursuant to the National Emergencies Act [ et seq.] or the Robert T. Stafford Disaster Relief and Emergency Assistance Act [ et seq.]; or

((bb)) that, subject to a request from the State to the Secretary, made in such form, at such time, and containing such information as the Secretary may require, has an unemployment rate that is at or above the lesser of—

((AA)) 8 percent; or

((BB)) 1.5 times the national unemployment rate; or

((III)) such individual or their dependent must travel outside of their community for an extended period of time to receive medical services necessary to treat a serious or complex medical condition (as described in paragraph (9)(A)(ii)(V)(ee)) that are not available within their community of residence.

((4)) ** Option to conduct more frequent compliance verifications** With respect to an applicable individual enrolled and receiving medical assistance under a State plan (or a waiver of such plan) under this subchapter, the State shall verify (in accordance with procedures specified by the Secretary) that each such individual has met the requirement to demonstrate community engagement under paragraph (1) during each such individual’s regularly scheduled redetermination of eligibility, except that a State may provide for such verifications more frequently.

((5)) ** Ex parte verifications** For purposes of verifying that an applicable individual has met the requirement to demonstrate community engagement under paragraph (1), or determining such individual to be deemed to have demonstrated community engagement under paragraph (3), or that an individual is a specified excluded individual under paragraph (9)(A)(ii), the State shall, in accordance with standards established by the Secretary, establish processes and use reliable information available to the State (such as payroll data or payments or encounter data under this subchapter for individuals and data on payments to such individuals for the provision of services covered under this subchapter) without requiring, where possible, the applicable individual to submit additional information.

((6)) ** Procedure in the case of noncompliance**

((A)) ** In general** If a State is unable to verify that an applicable individual has met the requirement to demonstrate community engagement under paragraph (1) (including, if applicable, by verifying that such individual was deemed to have demonstrated community engagement under paragraph (3)) the State shall (in accordance with standards specified by the Secretary)—

((i)) provide such individual with the notice of noncompliance described in subparagraph (B);

((ii))

((I)) provide such individual with a period of 30 calendar days, beginning on the date on which such notice of noncompliance is received by the individual, to—

((aa)) make a satisfactory showing to the State of compliance with such requirement (including, if applicable, by showing that such individual was or should be deemed to have demonstrated community engagement under paragraph (3)); or

((bb)) make a satisfactory showing to the State that such requirement does not apply to such individual on the basis that such individual does not meet the definition of applicable individual under paragraph (9)(A); and

((II)) if such individual is enrolled under the State plan (or a waiver of such plan) under this subchapter, continue to provide such individual with medical assistance during such 30-calendar-day period; and

((iii)) if no such satisfactory showing is made and the individual is not a specified excluded individual described in paragraph (9)(A)(ii), deny such individual’s application for medical assistance under the State plan (or waiver of such plan) or, as applicable, disenroll such individual from the plan (or waiver of such plan) not later than the end of the month following the month in which such 30-calendar-day period ends, provided that—

((I)) the State first determines whether, with respect to the individual, there is any other basis for eligibility for medical assistance under the State plan (or waiver of such plan) or for another insurance affordability program; and

((II)) the individual is provided written notice and granted an opportunity for a fair hearing in accordance with subsection (a)(3).

((B)) ** Notice** The notice of noncompliance provided to an applicable individual under subparagraph (A)(i) shall include information (in accordance with standards specified by the Secretary) on—

((i)) how such individual may make a satisfactory showing of compliance with such requirement (as described in subparagraph (A)(ii)) or make a satisfactory showing that such requirement does not apply to such individual on the basis that such individual does not meet the definition of applicable individual under paragraph (9)(A); and

((ii)) how such individual may reapply for medical assistance under the State plan (or a waiver of such plan) under this subchapter in the case that such individuals’ application is denied or, as applicable, in the case that such individual is disenrolled from the plan (or waiver).

((7)) ** Treatment of noncompliant individuals in relation to certain other provisions**

((A)) ** Certain FMAP increases** A State shall not be treated as not providing medical assistance to all individuals described in , or as not expending amounts for all such individuals under the State plan (or waiver of such plan), solely because such an individual is determined ineligible for medical assistance under the State plan (or waiver) on the basis of a failure to meet the requirement to demonstrate community engagement under paragraph (1).section 1396a(a)(10)(A)(i)(VIII) of this title

((B)) ** Other provisions** For purposes of section 36B(c)(2)(B) of the Internal Revenue Code of 1986, an individual shall be deemed to be eligible for minimum essential coverage described in section 5000A(f)(1)(A)(ii) of such Code for a month if such individual would have been eligible for medical assistance under a State plan (or a waiver of such plan) under this subchapter but for a failure to meet the requirement to demonstrate community engagement under paragraph (1).

((8)) ** Outreach**

((A)) ** In general** In accordance with standards specified by the Secretary, beginning not later than the date that precedes (or, if the State elects under paragraph (1) to specify an earlier date, such earlier date) by the number of months specified by the State under paragraph (1)(A) plus 3 months, and periodically thereafter, the State shall notify applicable individuals enrolled under a State plan (or waiver) under this subchapter of the requirement to demonstrate community engagement under this subsection. Such notice shall include information on—

((i)) how to comply with such requirement, including an explanation of the exceptions to such requirement under paragraph (3) and the definition of the term “applicable individual” under paragraph (9)(A);

((ii)) the consequences of noncompliance with such requirement; and

((iii)) how to report to the State any change in the individual’s status that could result in—

((I)) the applicability of an exception under paragraph (3) (or the end of the applicability of such an exception); or

((II)) the individual qualifying as a specified excluded individual under paragraph (9)(A)(ii).

((B)) ** Form of outreach notice** A notice required under subparagraph (A) shall be delivered—

((i)) by regular mail (or, if elected by the individual, in an electronic format); and

((ii)) in 1 or more additional forms, which may include telephone, text message, an internet website, other commonly available electronic means, and such other forms as the Secretary determines appropriate.

((9)) ** Definitions** In this subsection:

((A)) ** Applicable individual**

((i)) ** In general** The term “applicable individual” means an individual (other than a specified excluded individual (as defined in clause (ii)))—

((I)) who is eligible to enroll (or is enrolled) under the State plan under subsection (a)(10)(A)(i)(VIII); or

((II)) who—

((aa)) is otherwise eligible to enroll (or is enrolled) under a waiver of such plan that provides coverage that is equivalent to minimum essential coverage (as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and as determined in accordance with standards prescribed by the Secretary in regulations); and

((bb)) has attained the age of 19 and is under 65 years of age, is not pregnant, is not entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and is not otherwise eligible to enroll under such plan.

((ii)) ** Specified excluded individual** For purposes of clause (i), the term “specified excluded individual” means an individual, as determined by the State (in accordance with standards specified by the Secretary)—

((I)) who is described in subsection (a)(10)(A)(i)(IX);

((II)) who—

((aa)) is an Indian or an Urban Indian (as such terms are defined in paragraphs (13) and (28) of );

((bb)) is a California Indian described in section 1679(a) of such title; or

((cc)) has otherwise been determined eligible as an Indian for the Indian Health Service under regulations promulgated by the Secretary;

((III)) who is the parent, guardian, caretaker relative, or family caregiver (as defined in section 2 of the RAISE Family Caregivers Act) of a dependent child 13 years of age and under or a disabled individual;

((IV)) who is a veteran with a disability rated as total under ;

((V)) who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual—

((aa)) who is blind or disabled (as defined in );

((bb)) with a substance use disorder;

((cc)) with a disabling mental disorder;

((dd)) with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; or

((ee)) with a serious or complex medical condition;

((VI)) who—

((aa)) is in compliance with any requirements imposed by the State pursuant to ; or

((bb)) is a member of a household that receives supplemental nutrition assistance program benefits under the Food and Nutrition Act of 2008 and is not exempt from a work requirement under such Act;

((VII)) who is participating in a drug addiction or alcoholic treatment and rehabilitation program (as defined in section 3(h) of the Food and Nutrition Act of 2008 []);

((VIII)) who is an inmate of a public institution; or

((IX)) who is pregnant or entitled to postpartum medical assistance under paragraph (5) or (16) of subsection (e).

((B)) ** Educational program** The term “educational program” includes—

((i)) an institution of higher education (as defined in ); and

((ii)) a program of career and technical education (as defined in ).

((C)) ** State** The term “State” means 1 of the 50 States or the District of Columbia.

((D)) ** Work program** The term “work program” has the meaning given such term in section 6()(1) of the Food and Nutrition Act of 2008 [()(1)].7 U.S.C. 2015oo

((10)) ** Prohibiting waiver of community engagement requirements** Notwithstanding , the provisions of this subsection may not be waived.section 1315(a) of this title

((11)) ** Special implementation rule**

((A)) ** In general** Subject to subparagraph (C), the Secretary may exempt a State from compliance with the requirements of this subsection if—

((i)) the State submits to the Secretary a request for such exemption, made in such form and at such time as the Secretary may require, and including the information specified in subparagraph (B); and

((ii)) the Secretary determines that based on such request, the State is demonstrating a good faith effort to comply with the requirements of this subsection.

((B)) ** Good faith effort determination** In determining whether a State is demonstrating a good faith effort for purposes of subparagraph (A)(ii), the Secretary shall consider—

((i)) any actions taken by the State toward compliance with the requirements of this subsection;

((ii)) any significant barriers to or challenges in meeting such requirements, including related to funding, design, development, procurement, or installation of necessary systems or resources;

((iii)) the State’s detailed plan and timeline for achieving full compliance with such requirements, including any milestones of such plan (as defined by the Secretary); and

((iv)) any other criteria determined appropriate by the Secretary.

((C)) ** Duration of exemption**

((i)) ** In general** An exemption granted under subparagraph (A) shall expire not later than , and may not be renewed beyond such date.December 31, 20282028-12-31

((ii)) ** Early termination** The Secretary may terminate an exemption granted under subparagraph (A) prior to the expiration date of such exemption if the Secretary determined that the State has—

((I)) failed to comply with the reporting requirements described in subparagraph (D); or

((II)) based on the information provided pursuant to subparagraph (D), failed to make continued good faith efforts toward compliance with the requirements of this subsection.

((D)) ** Reporting requirements** A State granted an exemption under subparagraph (A) shall submit to the Secretary—

((i)) quarterly progress reports on the State’s status in achieving the milestones toward full compliance described in subparagraph (B)(iii); and

((ii)) information on specific risks or newly identified barriers or challenges to full compliance, including the State’s plan to mitigate such risks, barriers, or challenges.

((yy)) ** Active duty relocated individual; home and community-based services waiting list** For purposes of subsection (a)(90) and this subsection:

((1)) ** Active duty relocated individual** The term “active duty relocated individual” means an individual—

((A)) who—

((i)) is enrolled under the State plan (or waiver of such plan); or

((ii)) with respect to an individual described in subparagraph (C)(ii), would be so enrolled pursuant to subsection (a)(10)(A)(ii)(VI) if such individual began receiving home and community-based services;

((B)) who—

((i)) is a member of the Armed Forces engaged in active duty service and is relocated to another State (in this subsection referred to as the “military service relocation State”) by reason of such service;

((ii)) would be described in clause (i) except that the individual stopped being engaged in active duty service (including by reason of retirement from such service) and the last day on which the individual was engaged in active duty service occurred not more than 12 months ago; or

((iii)) is a dependent (as defined by the Secretary) of a member described in clause (i) or (ii) who relocates to the military service relocation State with such member; and

((C)) who—

((i)) was receiving home and community-based services (as defined in section 9817(a)(2)(B) of the American Rescue Plan Act of 2021) at the time of such relocation; or

((ii)) if the State maintains a home and community-based services waiting list, was on such home and community-based services waiting list at the time of such relocation.

((2)) ** Home and community-based services waiting list** The term “home and community-based services waiting list” means, in the case of a State that has a limit on the number of individuals who may receive home and community-based services under or , a list maintained by such State of individuals who are requesting to receive such services under 1 or more such sections but for whom the State has not yet completed an assessment and rendered a decision with respect to the eligibility of such individuals to receive the relevant home and community-based services at the time a slot for such services becomes available due to such limit.section 1315(a) of this titlesection 1396n(c) of this title