---
kind: "section"
citation: "42 U.S.C. § 1396b"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1396b"
heading: "Payment to States"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1396b"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XIX — Grants to States for Medical Assistance Programs"
---

# §1396b. Payment to States

- (a) **Computation of amount—** From the sums appropriated therefor, the [Secretary](/usc/42/1301.md?p=a-6) (except as otherwise provided in this section) shall pay to each [State](/usc/42/619.md?p=5) which has a plan approved under this subchapter, for each quarter, beginning with the quarter commencing January 1, 1966—
  - (1) an amount equal to the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) (as defined in [section 1396d(b) of this title](/usc/42/1396d.md?p=b), subject to subsections [(g)](#g) and [(j)](#j) of this section and [section 1396r–4(f) of this title](/usc/42/1396r–4.md?p=f)) of the total amount expended during such quarter as [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan; plus
  - (2)
    - (A) an amount equal to 75 per centum of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the [State agency](/usc/42/629a.md?p=a-3) or any other [public agency](/usc/42/11851.md?p=8); plus
    - (B) notwithstanding [paragraph (1)](#a-1) or [subparagraph (A)](#a-2-A), with respect to amounts expended for nursing aide training and competency evaluation programs, and competency evaluation programs, described in [section 1396r(e)(1) of this title](/usc/42/1396r.md?p=e-1) ([including](/usc/42/1301.md?p=b) the costs for nurse aides to complete such competency evaluation programs), regardless of whether the programs are provided in or outside [nursing facilities](/usc/42/1396d.md?p=c) or of the skill of the personnel involved in such programs, an amount equal to 50 percent (or, for calendar quarters beginning on or after July 1, 1988, and before October 1, 1990, the lesser of 90 percent or the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) plus 25 percentage points) of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to such programs; plus
    - (C) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to preadmission screening and resident review activities conducted by the [State](/usc/42/619.md?p=5) under [section 1396r(e)(7) of this title](/usc/42/1396r.md?p=e-7); plus
    - (D) for each calendar quarter during—
      - (i) [fiscal year](/usc/42/619.md?p=3) 1991, an amount equal to 90 percent,
      - (ii) [fiscal year](/usc/42/619.md?p=3) 1992, an amount equal to 85 percent,
      - (iii) [fiscal year](/usc/42/619.md?p=3) 1993, an amount equal to 80 percent, and
      - (iv) [fiscal year](/usc/42/619.md?p=3) 1994 and thereafter, an amount equal to 75 percent,

      of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to [State](/usc/42/619.md?p=5) activities under [section 1396r(g) of this title](/usc/42/1396r.md?p=g); plus

    - (E) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to translation or interpretation services in connection with the enrollment of, retention of, and use of services under this subchapter by, children of families for whom English is not the primary language; plus
  - (3) an amount equal to—
    - (A)
      - (i) 90 per centum of so much of the sums expended during such quarter as are attributable to the design, development, or installation of such mechanized claims processing and information retrieval systems as the [Secretary](/usc/42/1301.md?p=a-6) determines are likely to provide more efficient, economical, and effective [administration](/usc/42/1301.md?p=a-10) of the plan and to be compatible with the claims processing and information retrieval systems utilized in the [administration](/usc/42/1301.md?p=a-10) of subchapter XVIII, [including](/usc/42/1301.md?p=b) the [State](/usc/42/619.md?p=5)’s share of the cost of installing such a system to be used jointly in the [administration](/usc/42/1301.md?p=a-10) of such [State](/usc/42/619.md?p=5)’s plan and the plan of any other [State](/usc/42/619.md?p=5) approved under this subchapter,
      - (ii) 90 per centum of so much of the sums expended during any such quarter in the [fiscal year](/usc/42/619.md?p=3) ending June 30, 1972, or the [fiscal year](/usc/42/619.md?p=3) ending June 30, 1973, as are attributable to the design, development, or installation of cost determination systems for [State](/usc/42/619.md?p=5)-owned general [hospitals](/usc/42/300s–3.md?p=1) (except that the total amount paid to all [States](/usc/42/619.md?p=5) under this clause for either such [fiscal year](/usc/42/619.md?p=3) shall not exceed $150,000), and
      - (iii) an amount equal to the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) (as defined in [section 1396d(b) of this title](/usc/42/1396d.md?p=b)) of so much of the sums expended during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to such developments or modifications of systems of the type described in [clause (i)](#a-3-A-i) as are necessary for the efficient collection and reporting on [child](/usc/42/1382c.md?p=c) health measures; and
    - (B) 75 per centum of so much of the sums expended during such quarter as are attributable to the operation of systems (whether such systems are operated directly by the [State](/usc/42/619.md?p=5) or by another [person](/usc/42/1301.md?p=a-3) under a contract with the [State](/usc/42/619.md?p=5)) of the type described in [subparagraph (A)(i)](#a-3-A-i) (whether or not designed, developed, or installed with assistance under such subparagraph) which are approved by the [Secretary](/usc/42/1301.md?p=a-6) and which include provision for prompt written notice to each individual who is furnished services covered by the plan, or to each individual in a sample group of individuals who are furnished such services, of the specific services (other than confidential services) so covered, the name of the [person](/usc/42/1301.md?p=a-3) or [persons](/usc/42/1301.md?p=a-3) furnishing the services, the date or dates on which the services were furnished, and the amount of the payment or payments made under the plan on account of the services; and
    - (C)
      - (i) 75 per centum of the sums expended with respect to costs incurred during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to the performance of medical and utilization review by a utilization and quality control peer review organization[^1] or by an entity which meets the requirements of [section 1320c–1 of this title](/usc/42/1320c–1.md), as determined by the [Secretary](/usc/42/1301.md?p=a-6), under a contract entered into under [section 1396a(d) of this title](/usc/42/1396a.md?p=d); and
      - (ii) 75 percent of the sums expended with respect to costs incurred during such quarter (as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan) as are attributable to the performance of independent external reviews conducted under [section 1396u–2(c)(2) of this title](/usc/42/1396u–2.md?p=c-2); and
    - (D) 75 percent of so much of the sums expended by the [State](/usc/42/619.md?p=5) plan during a quarter in 1991, 1992, or 1993, as the [Secretary](/usc/42/1301.md?p=a-6) determines is attributable to the statewide adoption of a [drug](/usc/42/11851.md?p=4) use review program which conforms to the requirements of [section 1396r–8(g) of this title](/usc/42/1396r–8.md?p=g);
    - (E) 50 percent of the sums expended with respect to costs incurred during such quarter as are attributable to providing—
      - (i) services to identify and educate individuals who are likely to be eligible for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter and who have Sickle Cell Disease or who are carriers of the sickle cell gene, [including](/usc/42/1301.md?p=b) education regarding how to identify such individuals; or
      - (ii) education regarding the risks of stroke and other complications, as well as the prevention of stroke and other complications, in individuals who are likely to be eligible for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter and who have Sickle Cell Disease; and
    - (F)
      - (i) 100 percent of so much of the sums expended during such quarter as are attributable to payments to Medicaid providers described in [subsection (t)(1)](#t-1) to encourage the adoption and use of certified EHR technology; and
      - (ii) 90 percent of so much of the sums expended during such quarter as are attributable to payments for reasonable administrative expenses related to the [administration](/usc/42/1301.md?p=a-10) of payments described in [clause (i)](#a-3-F-i) if the [State](/usc/42/619.md?p=5) meets the condition described in [subsection (t)(9)](#t-9); plus
    - (H)
      - (i) [^2] 90 percent of the sums expended during the quarter as are attributable to the design, development, or installation of such mechanized verification and information retrieval systems as the [Secretary](/usc/42/1301.md?p=a-6) determines are necessary to implement [section 1396a(ee) of this title](/usc/42/1396a.md?p=ee) ([including](/usc/42/1301.md?p=b) a system described in [paragraph (2)(B)](#a-2-B) thereof),[^3] and
      - (ii) 75 percent of the sums expended during the quarter as are attributable to the operation of systems to which [clause (i)](#a-3-H-i) applies,[^3] plus
  - (4) an amount equal to 100 percent of the sums expended during the quarter which are attributable to the costs of the implementation and operation of the immigration status verification system described in [section 1320b–7(d) of this title](/usc/42/1320b–7.md?p=d); plus
  - (5) an amount equal to 90 per centum of the sums expended during such quarter which are attributable to the offering, arranging, and furnishing (directly or on a contract basis) of family planning services and supplies;
  - (6) subject to [subsection (b)(3)](#b-3), an amount equal to—
    - (A) 90 per centum of the sums expended during such a quarter within the twelve-quarter period beginning with the first quarter in which a payment is made to the [State](/usc/42/619.md?p=5) pursuant to this paragraph, and
    - (B) 75 per centum of the sums expended during each succeeding calendar quarter,

    with respect to costs incurred during such quarter which are attributable to the establishment and operation of ([including](/usc/42/1301.md?p=b) the training of personnel employed by) a [State](/usc/42/619.md?p=5) medicaid fraud control unit (described in [subsection (q)](#q)); plus

  - (7) subject to [section 1396r(g)(3)(B) of this title](/usc/42/1396r.md?p=g-3-B), an amount equal to 50 per centum of the remainder of the amounts expended during such quarter as found necessary by the [Secretary](/usc/42/1301.md?p=a-6) for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan.
- (b) **Quarterly expenditures beginning after December 31, 1969—**
  - (1) Notwithstanding the preceding provisions of this section, the amount determined under [subsection (a)(1)](#a-1) for any [State](/usc/42/619.md?p=5) for any quarter beginning after December 31, 1969, shall not take into account any amounts expended as [medical assistance](/usc/42/1396d.md?p=a) with respect to individuals aged 65 or over and disabled individuals entitled to [hospital](/usc/42/300s–3.md?p=1) insurance benefits under subchapter XVIII which would not have been so expended if the individuals involved had been enrolled in the insurance program established by part B of subchapter XVIII, other than amounts expended under provisions of the plan of such [State](/usc/42/619.md?p=5) required by [section 1396a(a)(34) of this title](/usc/42/1396a.md?p=a-34).
  - (2) For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a [State](/usc/42/619.md?p=5) or areawide planning [agency](/usc/42/1397n–12.md?p=1), see [section 1320a–1 of this title](/usc/42/1320a–1.md).
  - (3) The amount of funds which the [Secretary](/usc/42/1301.md?p=a-6) is otherwise obligated to pay a [State](/usc/42/619.md?p=5) during a quarter under [subsection (a)(6)](#a-6) may not exceed the higher of—
    - (A) $125,000, or
    - (B) one-quarter of 1 per centum of the sums expended by the Federal, [State](/usc/42/619.md?p=5), and local governments during the previous quarter in carrying out the [State](/usc/42/619.md?p=5)’s plan under this subchapter.
  - (4) Amounts expended by a [State](/usc/42/619.md?p=5) for the use of an enrollment broker in marketing medicaid managed care organizations and other managed care entities to eligible individuals under this subchapter shall be considered, for purposes of [subsection (a)(7)](#a-7), to be necessary for the proper and efficient [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan but only if the following conditions are met with respect to the broker:
    - (A) The broker is independent of any such entity and of any [health care providers](/usc/42/1320d.md?p=3) (whether or not any such provider participates in the [State](/usc/42/619.md?p=5) plan under this subchapter) that provide coverage of services in the same [State](/usc/42/619.md?p=5) in which the broker is conducting enrollment activities.
    - (B) No [person](/usc/42/1301.md?p=a-3) who is an [owner](/usc/42/13641.md?p=4), employee, consultant, or has a contract with the broker either has any direct or indirect financial interest with such an entity or [health care provider](/usc/42/1320d.md?p=3) or has been excluded from participation in the program under this subchapter or subchapter XVIII or debarred by any Federal [agency](/usc/42/1397n–12.md?p=1), or subject to a civil money penalty under this chapter.
  - (5) Notwithstanding the preceding provisions of this section, the amount determined under [subsection (a)(1)](#a-1) for any [State](/usc/42/619.md?p=5) shall be decreased in a quarter by the amount of any health care related taxes (described in [subsection (w)(3)(A)](#w-3-A))[^4] that are imposed on a [hospital](/usc/42/300s–3.md?p=1) described in [subsection (w)(3)(F)](#w-3-F) in that quarter.
- (c) **Treatment of educationally-related services—** Nothing in this subchapter shall be construed as prohibiting or restricting, or authorizing the [Secretary](/usc/42/1301.md?p=a-6) to prohibit or restrict, payment under [subsection (a)](#a) for [medical assistance](/usc/42/1396d.md?p=a) for covered services furnished to a [child](/usc/42/1382c.md?p=c) with a disability because such services are included in the [child](/usc/42/1382c.md?p=c)’s individualized education program established pursuant to part B of the Individuals with Disabilities Education Act [[20 U.S.C. 1411](/usc/20/1411.md) et seq.] or furnished to an infant or toddler with a disability because such services are included in the [child](/usc/42/1382c.md?p=c)’s individualized family service plan adopted pursuant to part C of such Act [[20 U.S.C. 1431](/usc/20/1431.md) et seq.].
- (d) **Estimates of State entitlement; installments; adjustments to reflect overpayments or underpayments; time for recovery or adjustment; uncollectable or discharged debts; obligated appropriations; disputed claims—**
  - (1) Prior to the beginning of each quarter, the [Secretary](/usc/42/1301.md?p=a-6) shall estimate the amount to which a [State](/usc/42/619.md?p=5) will be entitled under subsections [(a)](#a) and [(b)](#b) for such quarter, such estimates to be based on (A) a report filed by the [State](/usc/42/619.md?p=5) containing its estimate of the total sum to be expended in such quarter in accordance with the provisions of such subsections, and stating the amount appropriated or made available by the [State](/usc/42/619.md?p=5) and its political subdivisions for such expenditures in such quarter, and if such amount is less than the [State](/usc/42/619.md?p=5)’s proportionate share of the total sum of such estimated expenditures, the source or sources from which the difference is expected to be derived, and (B) such other investigation as the [Secretary](/usc/42/1301.md?p=a-6) may find necessary.
  - (2)
    - (A) The [Secretary](/usc/42/1301.md?p=a-6) shall then pay to the [State](/usc/42/619.md?p=5), in such installments as he may determine, the amount so estimated, reduced or increased to the extent of any overpayment or underpayment which the [Secretary](/usc/42/1301.md?p=a-6) determines was made under this section to such [State](/usc/42/619.md?p=5) for any prior quarter and with respect to which adjustment has not already been made under this subsection.
    - (B) Expenditures for which payments were made to the [State](/usc/42/619.md?p=5) under [subsection (a)](#a) shall be treated as an overpayment to the extent that the [State](/usc/42/619.md?p=5) or local [agency](/usc/42/1397n–12.md?p=1) administering such plan has been reimbursed for such expenditures by a third party pursuant to the provisions of its plan in compliance with [section 1396a(a)(25) of this title](/usc/42/1396a.md?p=a-25).
    - (C) For purposes of this subsection, when an overpayment is discovered, which was made by a [State](/usc/42/619.md?p=5) to a [person](/usc/42/1301.md?p=a-3) or other entity, the [State](/usc/42/619.md?p=5) shall have a period of 1 year in which to recover or attempt to recover such overpayment before adjustment is made in the Federal payment to such [State](/usc/42/619.md?p=5) on account of such overpayment. Except as otherwise provided in [subparagraph (D)](#d-2-D), the adjustment in the Federal payment shall be made at the end of the 1-year period, whether or not recovery was made.
    - (D)
      - (i) In any case where the [State](/usc/42/619.md?p=5) is unable to recover a debt which represents an overpayment (or any portion thereof) made to a [person](/usc/42/1301.md?p=a-3) or other entity on account of such debt having been discharged in bankruptcy or otherwise being uncollectable, no adjustment shall be made in the Federal payment to such [State](/usc/42/619.md?p=5) on account of such overpayment (or portion thereof).
      - (ii) In any case where the [State](/usc/42/619.md?p=5) is unable to recover a debt which represents an overpayment (or any portion thereof) made to a [person](/usc/42/1301.md?p=a-3) or other entity due to fraud within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), [including](/usc/42/1301.md?p=b) as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such [State](/usc/42/619.md?p=5) on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment ([including](/usc/42/1301.md?p=b), if applicable, a final determination on an appeal) is made.
  - (3)
    - (A) The pro rata share to which the [United States](/usc/42/1301.md?p=a-2) is equitably entitled, as determined by the [Secretary](/usc/42/1301.md?p=a-6), of the net amount recovered during any quarter by the [State](/usc/42/619.md?p=5) or any political subdivision thereof with respect to [medical assistance](/usc/42/1396d.md?p=a) furnished under the [State](/usc/42/619.md?p=5) plan shall be considered an overpayment to be adjusted under this subsection.
    - (B)
      - (i) [Subparagraph (A)](#d-3-A) and [paragraph (2)(B)](#d-2-B) shall not apply to any amount recovered or paid to a [State](/usc/42/619.md?p=5) as part of the comprehensive settlement of November 1998 between manufacturers of tobacco products, as defined in section 5702(d) of the Internal Revenue Code of 1986, and [State](/usc/42/619.md?p=5) Attorneys General, or as part of any individual [State](/usc/42/619.md?p=5) settlement or judgment reached in litigation initiated or pursued by a [State](/usc/42/619.md?p=5) against one or more such manufacturers.
      - (ii) Except as provided in [subsection (i)(19)](#i-19), a [State](/usc/42/619.md?p=5) may use amounts recovered or paid to the [State](/usc/42/619.md?p=5) as part of a comprehensive or individual settlement, or a judgment, described in [clause (i)](#d-3-B-i) for any expenditures determined appropriate by the [State](/usc/42/619.md?p=5).
  - (4) Upon the making of any estimate by the [Secretary](/usc/42/1301.md?p=a-6) under this subsection, any appropriations available for payments under this section shall be deemed obligated.
  - (5) In any case in which the [Secretary](/usc/42/1301.md?p=a-6) estimates that there has been an overpayment under this section to a [State](/usc/42/619.md?p=5) on the basis of a claim by such [State](/usc/42/619.md?p=5) that has been disallowed by the [Secretary](/usc/42/1301.md?p=a-6) under [section 1316(d) of this title](/usc/42/1316.md?p=d), and such [State](/usc/42/619.md?p=5) disputes such disallowance, the amount of the Federal payment in controversy shall, at the option of the [State](/usc/42/619.md?p=5), be retained by such [State](/usc/42/619.md?p=5) or recovered by the [Secretary](/usc/42/1301.md?p=a-6) pending a final determination with respect to such payment amount. If such final determination is to the effect that any amount was properly disallowed, and the [State](/usc/42/619.md?p=5) chose to retain payment of the amount in controversy, the [Secretary](/usc/42/1301.md?p=a-6) shall offset, from any subsequent payments made to such [State](/usc/42/619.md?p=5) under this subchapter, an amount equal to the proper amount of the disallowance plus interest on such amount disallowed for the period beginning on the date such amount was disallowed and ending on the date of such final determination at a rate (determined by the [Secretary](/usc/42/1301.md?p=a-6)) based on the average of the bond equivalent of the weekly 90-day treasury bill auction rates during such period.
  - (6)
    - (A) Each [State](/usc/42/619.md?p=5) (as defined in [subsection (w)(7)(D)](#w-7-D)) shall include, in the first report submitted under [paragraph (1)](#d-1) after the end of each [fiscal year](/usc/42/619.md?p=3), information related to—
      - (i) provider-related donations made to the [State](/usc/42/619.md?p=5) or units of local government during such [fiscal year](/usc/42/619.md?p=3), and
      - (ii) health care related taxes collected by the [State](/usc/42/619.md?p=5) or such units during such [fiscal year](/usc/42/619.md?p=3).
    - (B) Each [State](/usc/42/619.md?p=5) shall include, in the first report submitted under [paragraph (1)](#d-1) after the end of each [fiscal year](/usc/42/619.md?p=3), information related to the total amount of payment adjustments made, and the amount of payment adjustments made to individual providers (by provider), under [section 1396r–4(c) of this title](/usc/42/1396r–4.md?p=c) during such [fiscal year](/usc/42/619.md?p=3).
- (e) **Transition costs of closures or conversions permitted—** A [State](/usc/42/619.md?p=5) plan approved under this subchapter may include, as a cost with respect to [hospital](/usc/42/300s–3.md?p=1) services under the plan under this subchapter, periodic expenditures made to reflect transitional allowances established with respect to a [hospital](/usc/42/300s–3.md?p=1) closure or conversion under [section 1395uu of this title](/usc/42/1395uu.md).
- (f) **Limitation on Federal participation in medical assistance—**
  - (1)
    - (A) Except as provided in [paragraph (4)](#f-4), payment under the preceding provisions of this section shall not be made with respect to any amount expended as [medical assistance](/usc/42/1396d.md?p=a) in a calendar quarter, in any [State](/usc/42/619.md?p=5), for any member of a family the annual income of which exceeds the applicable income limitation determined under this paragraph.
    - (B)
      - (i) Except as provided in clause (ii) of this subparagraph, the applicable income limitation with respect to any family is the amount determined, in accordance with [standards](/usc/42/1320d.md?p=7) prescribed by the [Secretary](/usc/42/1301.md?p=a-6), to be equivalent to 133⅓ percent of the highest amount which would ordinarily be paid to a family of the same size without any income or resources, in the form of money payments, under the plan of the [State](/usc/42/619.md?p=5) approved under part A of subchapter IV of this chapter.
      - (ii) If the [Secretary](/usc/42/1301.md?p=a-6) finds that the operation of a uniform maximum limits payments to families of more than one size, he may adjust the amount otherwise determined under [clause (i)](#f-1-B-i) to take account of families of different sizes.
    - (C) The total amount of any applicable income limitation determined under [subparagraph (B)](#f-1-B) shall, if it is not a multiple of $100 or such other amount as the [Secretary](/usc/42/1301.md?p=a-6) may prescribe, be rounded to the next higher multiple of $100 or such other amount, as the case may be.
  - (2)
    - (A) In computing a family’s income for purposes of [paragraph (1)](#f-1), there shall be excluded any costs (whether in the form of insurance premiums or otherwise and regardless of whether such costs are reimbursed under another public program of the [State](/usc/42/619.md?p=5) or political subdivision thereof) incurred by such family for [medical care](/usc/42/1301.md?p=a-7) or for any other type of remedial care recognized under [State](/usc/42/619.md?p=5) law or, (B) notwithstanding [section 1396o](/usc/42/1396o.md) of this title at [State](/usc/42/619.md?p=5) option, an amount paid by such family, at the family’s option, to the [State](/usc/42/619.md?p=5), provided that the amount, when combined with costs incurred in prior months, is sufficient when excluded from the family’s income to reduce such family’s income below the applicable income limitation described in [paragraph (1)](#f-1). The amount of [State](/usc/42/619.md?p=5) expenditures for which [medical assistance](/usc/42/1396d.md?p=a) is available under [subsection (a)(1)](#a-1) will be reduced by amounts paid to the [State](/usc/42/619.md?p=5) pursuant to this subparagraph.
  - (3) For purposes of [paragraph (1)(B)](#f-1-B), in the case of a family consisting of only one individual, the “highest amount which would ordinarily be paid” to such family under the [State](/usc/42/619.md?p=5)’s plan approved under part A of subchapter IV of this chapter shall be the amount determined by the [State agency](/usc/42/629a.md?p=a-3) (on the basis of reasonable relationship to the amounts payable under such plan to families consisting of two or more [persons](/usc/42/1301.md?p=a-3)) to be the amount of the aid which would ordinarily be payable under such plan to a family (without any income or resources) consisting of one [person](/usc/42/1301.md?p=a-3) if such plan provided for aid to such a family.
  - (4) The limitations on payment imposed by the preceding provisions of this subsection shall not apply with respect to any amount expended by a [State](/usc/42/619.md?p=5) as [medical assistance](/usc/42/1396d.md?p=a) for any individual described in section 1396a(a)(10)(A)(i)(III), 1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V), 1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII), 1396a(a)(10)(A)(i)(VIII), 1396a(a)(10)(A)(i)(IX), 1396a(a)(10)(A)(ii)(IX), 1396a(a)(10)(A)(ii)(X), 1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or[^5] 1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI), 1396a(a)(10)(A)(ii)(XVII), 1396a(a)(10)(A)(ii)(XVIII), 1396a(a)(10)(A)(ii)(XIX), 1396a(a)(10)(A)(ii)(XX), 1396a(a)(10)(A)(ii)(XXI), 1396a(a)(10)(A)(ii)(XXII), [1396d(p)(1)](/usc/42/1396d.md?p=p-1) of this title or for any individual—
    - (A) who is receiving aid or assistance under any plan of the [State](/usc/42/619.md?p=5) approved under subchapter I, X, XIV or XVI, or part A of subchapter IV, or with respect to whom supplemental security income benefits are being paid under subchapter XVI, or
    - (B) who is not receiving such aid or assistance, and with respect to whom such benefits are not being paid, but (i) is eligible to receive such aid or assistance, or to have such benefits paid with respect to him, or (ii) would be eligible to receive such aid or assistance, or to have such benefits paid with respect to him if he were not in a medical institution, or
    - (C) with respect to whom there is being paid, or who is eligible, or would be eligible if he were not in a medical institution, to have paid with respect to him, a [State supplementary payment](/usc/42/1396d.md?p=j) and is eligible for [medical assistance](/usc/42/1396d.md?p=a) equal in amount, duration, and scope to the [medical assistance](/usc/42/1396d.md?p=a) made available to individuals described in [section 1396a(a)(10)(A) of this title](/usc/42/1396a.md?p=a-10-A), or who is a PACE program eligible individual enrolled in a PACE program under [section 1396u–4 of this title](/usc/42/1396u–4.md), but only if the income of such individual (as determined under [section 1382a of this title](/usc/42/1382a.md), but without regard to [subsection (b)](#b) thereof) does not exceed 300 percent of the supplemental security income benefit rate established by [section 1382(b)(1) of this title](/usc/42/1382.md?p=b-1),

    at the time of the provision of the [medical assistance](/usc/42/1396d.md?p=a) giving rise to such expenditure.

- (g) **Decrease in Federal medical assistance percentage of amounts paid for services furnished under State plan after June 30, 1973—**
  - (1) Subject to [paragraph (3)](#g-3), with respect to amounts paid for the following services furnished under the [State](/usc/42/619.md?p=5) plan after June 30, 1973 (other than services furnished pursuant to a contract with a health maintenance organization as defined in [section 1395mm of this title](/usc/42/1395mm.md) or which is a qualified health maintenance organization (as defined in [section 300e–9(d)](/usc/42/300e–9.md?p=d)[^4] of this title)), the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) shall be decreased as follows: After an individual has received inpatient [hospital](/usc/42/300s–3.md?p=1) services or services in an [intermediate care facility for the mentally retarded](/usc/42/1396d.md?p=d) for 60 days or inpatient mental [hospital](/usc/42/300s–3.md?p=1) services for 90 days (whether or not such days are consecutive), during any [fiscal year](/usc/42/619.md?p=3), the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) with respect to amounts paid for any such care furnished thereafter to such individual shall be decreased by a per centum thereof (determined under [paragraph (5)](#g-5)) unless the [State agency](/usc/42/629a.md?p=a-3) responsible for the [administration](/usc/42/1301.md?p=a-10) of the plan makes a showing satisfactory to the [Secretary](/usc/42/1301.md?p=a-6) that, with respect to each calendar quarter for which the [State](/usc/42/619.md?p=5) submits a request for payment at the full [Federal medical assistance percentage](/usc/42/1396d.md?p=b) for amounts paid for inpatient [hospital](/usc/42/300s–3.md?p=1) services or services in an [intermediate care facility for the mentally retarded](/usc/42/1396d.md?p=d) furnished beyond 60 days (or inpatient mental [hospital](/usc/42/300s–3.md?p=1) services furnished beyond 90 days), such [State](/usc/42/619.md?p=5) has an effective program of medical review of the care of patients in mental [hospitals](/usc/42/300s–3.md?p=1) and intermediate care [facilities](/usc/42/1320a–3.md?p=c-5-B) for the mentally retarded pursuant to paragraphs (26) and (31) of [section 1396a(a) of this title](/usc/42/1396a.md?p=a) whereby the professional management of each case is reviewed and evaluated at least annually by independent professional review teams. In determining the number of days on which an individual has received services described in this subsection, there shall not be counted any days with respect to which such individual is entitled to have payments made (in whole or in part) on his behalf under [section 1395d of this title](/usc/42/1395d.md).
  - (2) The [Secretary](/usc/42/1301.md?p=a-6) shall, as part of his validation procedures under this subsection, conduct timely sample onsite surveys of private and public institutions in which recipients of [medical assistance](/usc/42/1396d.md?p=a) may receive care and services under a [State](/usc/42/619.md?p=5) plan approved under this subchapter, and his findings with respect to such surveys (as well as the showings of the [State agency](/usc/42/629a.md?p=a-3) required under this subsection) shall be made available for public inspection.
  - (3)
    - (A) No reduction in the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) of a [State](/usc/42/619.md?p=5) otherwise required to be imposed under this subsection shall take effect—
      - (i) if such reduction is due to the [State](/usc/42/619.md?p=5)’s unsatisfactory or invalid showing made with respect to a calendar quarter beginning before January 1, 1977;
      - (ii) before January 1, 1978;
      - (iii) unless a notice of such reduction has been provided to the [State](/usc/42/619.md?p=5) at least 30 days before the date such reduction takes effect; or
      - (iv) due to the [State](/usc/42/619.md?p=5)’s unsatisfactory or invalid showing made with respect to a calendar quarter beginning after September 30, 1977, unless notice of such reduction has been provided to the [State](/usc/42/619.md?p=5) no later than the first day of the fourth calendar quarter following the calendar quarter with respect to which such showing was made.
    - (B) The [Secretary](/usc/42/1301.md?p=a-6) shall waive application of any reduction in the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) of a [State](/usc/42/619.md?p=5) otherwise required to be imposed under [paragraph (1)](#g-1) because a showing by the [State](/usc/42/619.md?p=5), made under such paragraph with respect to a calendar quarter ending after January 1, 1977, and before January 1, 1978, is determined to be either unsatisfactory under such paragraph or invalid under [paragraph (2)](#g-2), if the [Secretary](/usc/42/1301.md?p=a-6) determines that the [State](/usc/42/619.md?p=5)’s showing made under [paragraph (1)](#g-1) with respect to any calendar quarter ending on or before December 31, 1978, is satisfactory under such paragraph and is valid under [paragraph (2)](#g-2).
  - (4)
    - (A) The [Secretary](/usc/42/1301.md?p=a-6) may not find the showing of a [State](/usc/42/619.md?p=5), with respect to a calendar quarter under [paragraph (1)](#g-1), to be satisfactory if the showing is submitted to the [Secretary](/usc/42/1301.md?p=a-6) later than the 30th day after the last day of the calendar quarter, unless the [State](/usc/42/619.md?p=5) demonstrates to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) good cause for not meeting such deadline.
    - (B) The [Secretary](/usc/42/1301.md?p=a-6) shall find a showing of a [State](/usc/42/619.md?p=5), with respect to a calendar quarter under [paragraph (1)](#g-1), to be satisfactory under such paragraph with respect to the requirement that the [State](/usc/42/619.md?p=5) conduct annual onsite inspections in mental [hospitals](/usc/42/300s–3.md?p=1) and intermediate care [facilities](/usc/42/1320a–3.md?p=c-5-B) for the mentally retarded under paragraphs (26) and (31) of [section 1396a(a) of this title](/usc/42/1396a.md?p=a), if the showing demonstrates that the [State](/usc/42/619.md?p=5) has conducted such an onsite inspection during the 12-month period ending on the last date of the calendar quarter—
      - (i) in each of not less than 98 per centum of the number of such [hospitals](/usc/42/300s–3.md?p=1) and [facilities](/usc/42/1320a–3.md?p=c-5-B) requiring such inspection, and
      - (ii) in every such [hospital](/usc/42/300s–3.md?p=1) or [facility](/usc/42/1320a–3.md?p=c-5-B) which has 200 or more beds,

      and that, with respect to such [hospitals](/usc/42/300s–3.md?p=1) and [facilities](/usc/42/1320a–3.md?p=c-5-B) not inspected within such period, the [State](/usc/42/619.md?p=5) has exercised good faith and due diligence in attempting to conduct such inspection, or if the [State](/usc/42/619.md?p=5) demonstrates to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that it would have made such a showing but for failings of a technical nature only.

  - (5) In the case of a [State](/usc/42/619.md?p=5)’s unsatisfactory or invalid showing made with respect to a type of [facility](/usc/42/1320a–3.md?p=c-5-B) or institutional services in a calendar quarter, the per centum amount of the reduction of the [State](/usc/42/619.md?p=5)’s [Federal medical assistance percentage](/usc/42/1396d.md?p=b) for that type of services under [paragraph (1)](#g-1) is equal to 33⅓ per centum multiplied by a fraction, the denominator of which is equal to the total number of patients receiving that type of services in that quarter under the [State](/usc/42/619.md?p=5) plan in [facilities](/usc/42/1320a–3.md?p=c-5-B) or institutions for which a showing was required to be made under this subsection, and the numerator of which is equal to the number of such patients receiving such type of services in that quarter in those [facilities](/usc/42/1320a–3.md?p=c-5-B) or institutions for which a satisfactory and valid showing was not made for that calendar quarter.
  - (6)
    - (A) Recertifications required under [section 1396a(a)(44) of this title](/usc/42/1396a.md?p=a-44) shall be conducted at least every 60 days in the case of inpatient [hospital](/usc/42/300s–3.md?p=1) services.
    - (B) Such recertifications in the case of services in an [intermediate care facility for the mentally retarded](/usc/42/1396d.md?p=d) shall be conducted at least—
      - (i) 60 days after the date of the initial certification,
      - (ii) 180 days after the date of the initial certification,
      - (iii) 12 months after the date of the initial certification,
      - (iv) 18 months after the date of the initial certification,
      - (v) 24 months after the date of the initial certification, and
      - (vi) every 12 months thereafter.
    - (C) For purposes of determining compliance with the schedule established by this paragraph, a recertification shall be considered to have been done on a timely basis if it was performed not later than 10 days after the date the recertification was otherwise required and the [State](/usc/42/619.md?p=5) establishes good cause why the [physician](/usc/42/1301.md?p=a-7) or other [person](/usc/42/1301.md?p=a-3) making such recertification did not meet such schedule.
- (h) **Repealed. Pub. L. 100–203, title IV, § 4211(g)(1), Dec. 22, 1987, 101 Stat. 1330–205—**
- (i) **Payment for organ transplants; item or service furnished by excluded individual, entity, or physician; other restrictions—** Payment under the preceding provisions of this section shall not be made—
  - (1) for organ transplant procedures unless the [State](/usc/42/619.md?p=5) plan provides for written [standards](/usc/42/1320d.md?p=7) respecting the coverage of such procedures and unless such [standards](/usc/42/1320d.md?p=7) provide that—
    - (A) similarly situated individuals are treated alike; and
    - (B) any restriction, on the [facilities](/usc/42/1320a–3.md?p=c-5-B) or practitioners which may provide such procedures, is consistent with the accessibility of high quality care to individuals eligible for the procedures under the [State](/usc/42/619.md?p=5) plan; or
  - (2) with respect to any amount expended for an item or service (other than an emergency item or service, not [including](/usc/42/1301.md?p=b) items or services furnished in an emergency room of a [hospital](/usc/42/300s–3.md?p=1)) furnished—
    - (A) under the plan by any individual or entity during any period when the individual or entity is excluded from participation under subchapter V, XVIII, or XX or under this subchapter pursuant to section [1320a–7](/usc/42/1320a–7.md), [1320a–7a](/usc/42/1320a–7a.md), [1320c–5](/usc/42/1320c–5.md), or [1395u(j)(2)](/usc/42/1395u.md?p=j-2) of this title;
    - (B) at the medical direction or on the prescription of a [physician](/usc/42/1301.md?p=a-7), during the period when such [physician](/usc/42/1301.md?p=a-7) is excluded from participation under subchapter V, XVIII, or XX or under this subchapter pursuant to section [1320a–7](/usc/42/1320a–7.md), [1320a–7a](/usc/42/1320a–7a.md), [1320c–5](/usc/42/1320c–5.md), or [1395u(j)(2)](/usc/42/1395u.md?p=j-2) of this title and when the [person](/usc/42/1301.md?p=a-3) furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the [person](/usc/42/1301.md?p=a-3));
    - (C) by any individual or entity to whom the [State](/usc/42/619.md?p=5) has failed to suspend payments under the plan during any period when there is pending an investigation of a credible allegation of fraud against the individual or entity, as determined by the [State](/usc/42/619.md?p=5) in accordance with regulations promulgated by the [Secretary](/usc/42/1301.md?p=a-6) for purposes of [section 1395y(o)](/usc/42/1395y.md?p=o) of this title and this subparagraph, unless the [State](/usc/42/619.md?p=5) determines in accordance with such regulations there is good cause not to suspend such payments;
    - (D) beginning on July 1, 2018, under the plan by any provider of services or [person](/usc/42/1301.md?p=a-3) whose participation in the [State](/usc/42/619.md?p=5) plan is terminated (as described in [section 1396a(kk)(8) of this title](/usc/42/1396a.md?p=kk-8)) after the date that is 60 days after the date on which such termination is included in the database or other system under [section 1396a(ll)](/usc/42/1396a.md?p=ll) of this title; or
    - (E) with respect to any amount expended for such an item or service furnished during calendar quarters beginning on or after October 1, 2017, subject to [section 1396a(kk)(4)(A)(ii)(II) of this title](/usc/42/1396a.md?p=kk-4-A-ii-II), within a geographic area that is subject to a moratorium imposed under [section 1395cc(j)(7) of this title](/usc/42/1395cc.md?p=j-7) by a provider or supplier that meets the requirements specified in [subparagraph (C)(iii)](/usc/42/1395cc.md?p=j-7-C-iii) of such section, during the period of such moratorium; or
  - (3) with respect to any amount expended for inpatient [hospital](/usc/42/300s–3.md?p=1) services furnished under the plan (other than amounts attributable to the special situation of a [hospital](/usc/42/300s–3.md?p=1) which serves a disproportionate number of [low income](/usc/42/701.md?p=b-2) patients with special needs) to the extent that such amount exceeds the [hospital](/usc/42/300s–3.md?p=1)’s customary charges with respect to such services or (if such services are furnished under the plan by a public institution free of charge or at nominal charges to the public) exceeds an amount determined on the basis of those items (specified in regulations prescribed by the [Secretary](/usc/42/1301.md?p=a-6)) included in the determination of such payment which the [Secretary](/usc/42/1301.md?p=a-6) finds will provide fair compensation to such institution for such services; or
  - (4) with respect to any amount expended for care or services furnished under the plan by a [hospital](/usc/42/300s–3.md?p=1) unless such [hospital](/usc/42/300s–3.md?p=1) has in effect a utilization review plan which meets the requirements imposed by [section 1395x(k) of this title](/usc/42/1395x.md?p=k) for purposes of subchapter XVIII; and if such [hospital](/usc/42/300s–3.md?p=1) has in effect such a utilization review plan for purposes of subchapter XVIII, such plan shall serve as the plan required by this subsection (with the same [standards](/usc/42/1320d.md?p=7) and procedures and the same review committee or group) as a condition of payment under this subchapter; the [Secretary](/usc/42/1301.md?p=a-6) is authorized to waive the requirements of this paragraph if the [State agency](/usc/42/629a.md?p=a-3) demonstrates to his satisfaction that it has in operation utilization review procedures which are superior in their effectiveness to the procedures required under [section 1395x(k) of this title](/usc/42/1395x.md?p=k); or
  - (5) with respect to any amount expended for any [drug](/usc/42/11851.md?p=4) product for which payment may not be made under part B of subchapter XVIII because of [section 1395y(c) of this title](/usc/42/1395y.md?p=c); or
  - (6) with respect to any amount expended for inpatient [hospital](/usc/42/300s–3.md?p=1) tests (other than in emergency situations) not specifically ordered by the attending [physician](/usc/42/1301.md?p=a-7) or other responsible practitioner; or
  - (7) with respect to any amount expended for clinical diagnostic laboratory tests performed by a [physician](/usc/42/1301.md?p=a-7), independent laboratory, or [hospital](/usc/42/300s–3.md?p=1), to the extent such amount exceeds the amount that would be recognized under [section 1395l(h)](/usc/42/1395l.md?p=h) of this title for such tests performed for an individual enrolled under part B of subchapter XVIII; or
  - (8) with respect to any amount expended for [medical assistance](/usc/42/1396d.md?p=a) (A) for [nursing facility services](/usc/42/1396d.md?p=f) to reimburse (or otherwise compensate) a [nursing facility](/usc/42/1396d.md?p=c) for payment of a civil money penalty imposed under [section 1396r(h) of this title](/usc/42/1396r.md?p=h) or (B) for home and community care to reimburse (or otherwise compensate) a provider of such care for payment of a civil money penalty imposed under this subchapter or subchapter XI or for legal expenses in defense of an exclusion or civil money penalty under this subchapter or subchapter XI if there is no reasonable legal ground for the provider’s case; or
  - (9) with respect to any amount expended for non-emergency transportation authorized under [section 1396a(a)(4) of this title](/usc/42/1396a.md?p=a-4), unless the [State](/usc/42/619.md?p=5) plan provides for the methods and procedures required under [section 1396a(a)(30)(A) of this title](/usc/42/1396a.md?p=a-30-A); or
  - (10)
    - (A) with respect to covered outpatient [drugs](/usc/42/11851.md?p=4) unless there is a rebate agreement in effect under [section 1396r–8 of this title](/usc/42/1396r–8.md) with respect to such [drugs](/usc/42/11851.md?p=4) or unless [section 1396r–8(a)(3) of this title](/usc/42/1396r–8.md?p=a-3) applies,[^3]
    - (B) with respect to any amount expended for an innovator multiple source [drug](/usc/42/11851.md?p=4) (as defined in [section 1396r–8(k) of this title](/usc/42/1396r–8.md?p=k)) dispensed on or after July 1, 1991, if, under applicable [State](/usc/42/619.md?p=5) law, a less expensive multiple source [drug](/usc/42/11851.md?p=4) could have been dispensed, but only to the extent that such amount exceeds the upper payment limit for such multiple source [drug](/usc/42/11851.md?p=4);
    - (C) with respect to covered outpatient [drugs](/usc/42/11851.md?p=4) described in [section 1396r–8(a)(7) of this title](/usc/42/1396r–8.md?p=a-7), unless information respecting utilization data and coding on such [drugs](/usc/42/11851.md?p=4) that is required to be submitted under such section is submitted in accordance with such section;
    - (D) with respect to any amount expended for reimbursement to a pharmacy under this subchapter for the ingredient cost of a covered outpatient [drug](/usc/42/11851.md?p=4) for which the pharmacy has already received payment under this subchapter (other than with respect to a reasonable restocking fee for such [drug](/usc/42/11851.md?p=4)); and
    - (E) with respect to any amount expended for a covered outpatient [drug](/usc/42/11851.md?p=4) for which a suspension under [section 1396r–8(c)(4)(B)(ii)(II) of this title](/usc/42/1396r–8.md?p=c-4-B-ii-II) is in effect; or
  - (11) with respect to any amount expended for [physicians](/usc/42/1301.md?p=a-7)’ services furnished on or after the first day of the first quarter beginning more than 60 days after the date of establishment of the [physician](/usc/42/1301.md?p=a-7) identifier system under [section 1396a(x) of this title](/usc/42/1396a.md?p=x), unless the claim for the services [includes](/usc/42/1301.md?p=b) the unique [physician](/usc/42/1301.md?p=a-7) identifier provided under such system; or
  - (12) with respect to any amounts expended for—
    - (A) a vacuum erection system that is not medically necessary; or
    - (B) the insertion, repair, or removal and replacement of a penile prosthetic implant (unless such insertion, repair, or removal and replacement is medically necessary); or
  - (13) with respect to any amount expended to reimburse (or otherwise compensate) a [nursing facility](/usc/42/1396d.md?p=c) for payment of legal expenses associated with any action initiated by the [facility](/usc/42/1320a–3.md?p=c-5-B) that is dismissed on the basis that no reasonable legal ground existed for the institution of such action; or
  - (14) with respect to any amount expended on administrative costs to carry out the program under [section 1396s of this title](/usc/42/1396s.md); or
  - (15) with respect to any amount expended for a single-antigen vaccine and its [administration](/usc/42/1301.md?p=a-10) in any case in which the [administration](/usc/42/1301.md?p=a-10) of a combined-antigen vaccine was medically appropriate (as determined by the [Secretary](/usc/42/1301.md?p=a-6)); or
  - (16) with respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997 [[42 U.S.C. 14401](/usc/42/14401.md) et seq.]; or
  - (17) with respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under a [State](/usc/42/619.md?p=5) plan under this subchapter; or
  - (18) with respect to any amount expended for home health care services provided by an [agency](/usc/42/1397n–12.md?p=1) or organization unless the [agency](/usc/42/1397n–12.md?p=1) or organization provides the [State agency](/usc/42/629a.md?p=a-3) on a continuing basis a surety bond in a form specified by the [Secretary](/usc/42/1301.md?p=a-6) under [paragraph (7)](/usc/42/1395x.md?p=o-7) of section 1395x(o) of this title and in an amount that is not less than $50,000 or such comparable surety bond as the [Secretary](/usc/42/1301.md?p=a-6) may permit under the last sentence of such section; or
  - (19) with respect to any amount expended on administrative costs to initiate or pursue litigation described in [subsection (d)(3)(B)](#d-3-B);
  - (20) with respect to amounts expended for [medical assistance](/usc/42/1396d.md?p=a) provided to an individual described in subclause (XV) or (XVI) of [section 1396a(a)(10)(A)(ii) of this title](/usc/42/1396a.md?p=a-10-A-ii) for a [fiscal year](/usc/42/619.md?p=3) unless the [State](/usc/42/619.md?p=5) demonstrates to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that the level of [State](/usc/42/619.md?p=5) funds expended for such [fiscal year](/usc/42/619.md?p=3) for programs to enable working individuals with disabilities to work (other than for such [medical assistance](/usc/42/1396d.md?p=a)) is not less than the level expended for such programs during the most recent [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) ending before December 17, 1999;
  - (21) with respect to amounts expended for covered outpatient [drugs](/usc/42/11851.md?p=4) described in [section 1396r–8(d)(2)(C) of this title](/usc/42/1396r–8.md?p=d-2-C) (relating to [drugs](/usc/42/11851.md?p=4) when used for cosmetic purposes or hair growth), except where medically necessary, and [section 1396r–8(d)(2)(K) of this title](/usc/42/1396r–8.md) (relating to [drugs](/usc/42/11851.md?p=4) when used for [treatment](/usc/42/11851.md?p=11) of sexual or erectile dysfunction);
  - (22) with respect to amounts expended for [medical assistance](/usc/42/1396d.md?p=a) for an individual who declares under [section 1320b–7(d)(1)(A) of this title](/usc/42/1320b–7.md?p=d-1-A) to be a citizen or national of the [United States](/usc/42/1301.md?p=a-2) for purposes of establishing eligibility for benefits under this subchapter, unless the requirement of [section 1396a(a)(46)(B) of this title](/usc/42/1396a.md?p=a-46-B) is met;
  - (23) with respect to amounts expended for [medical assistance](/usc/42/1396d.md?p=a) for covered outpatient [drugs](/usc/42/11851.md?p=4) (as defined in [section 1396r–8(k)(2) of this title](/usc/42/1396r–8.md?p=k-2)) for which the prescription was executed in written (and non-electronic) form unless the prescription was executed on a tamper-resistant pad;
  - (24) if a [State](/usc/42/619.md?p=5) is required to implement an asset verification program under [section 1396w of this title](/usc/42/1396w.md) and fails to implement such program in accordance with such section, with respect to amounts expended by such [State](/usc/42/619.md?p=5) for [medical assistance](/usc/42/1396d.md?p=a) for individuals subject to asset verification under such section, unless—
    - (A) the [State](/usc/42/619.md?p=5) demonstrates to the [Secretary](/usc/42/1301.md?p=a-6)’s satisfaction that the [State](/usc/42/619.md?p=5) made a good faith effort to comply;
    - (B) not later than 60 days after the date of a finding that the [State](/usc/42/619.md?p=5) is in noncompliance, the [State](/usc/42/619.md?p=5) submits to the [Secretary](/usc/42/1301.md?p=a-6) (and the [Secretary](/usc/42/1301.md?p=a-6) approves) a corrective action plan to remedy such noncompliance; and
    - (C) not later than 12 months after the date of such submission (and approval), the [State](/usc/42/619.md?p=5) fulfills the terms of such corrective action plan;
  - (25) with respect to any amounts expended for [medical assistance](/usc/42/1396d.md?p=a) for individuals for whom the [State](/usc/42/619.md?p=5) does not report enrollee encounter data (as defined by the [Secretary](/usc/42/1301.md?p=a-6)) to the Medicaid Statistical Information System (MSIS) in a timely manner (as determined by the [Secretary](/usc/42/1301.md?p=a-6));
  - (26) with respect to any amounts expended for [medical assistance](/usc/42/1396d.md?p=a) for individuals described in subclause (VIII) of subsection (a)(10)(A)(i)[^6] other than [medical assistance](/usc/42/1396d.md?p=a) provided through benchmark coverage described in [section 1396u–7(b)(1) of this title](/usc/42/1396u–7.md?p=b-1) or benchmark equivalent coverage described in [section 1396u–7(b)(2) of this title](/usc/42/1396u–7.md?p=b-2); or
  - (27) with respect to any amounts expended by the [State](/usc/42/619.md?p=5) on the basis of a fee schedule for items described in [section 1395x(n) of this title](/usc/42/1395x.md?p=n) and furnished on or after January 1, 2018, as determined in the aggregate with respect to each class of such items as defined by the [Secretary](/usc/42/1301.md?p=a-6), in excess of the aggregate amount, if any, that would be paid for such items within such class on a fee-for-service basis under the program under part B of subchapter XVIII, [including](/usc/42/1301.md?p=b), as applicable, under a competitive acquisition program under [section 1395w–3 of this title](/usc/42/1395w–3.md) in an area of the [State](/usc/42/619.md?p=5).

  Nothing in [paragraph (1)](#i-1) shall be construed as permitting a [State](/usc/42/619.md?p=5) to provide services under its plan under this subchapter that are not reasonable in amount, duration, and scope to achieve their purpose. Paragraphs [(1)](#i-1), [(2)](#i-2), [(16)](#i-16), [(17)](#i-17), and [(18)](#i-18) shall apply with respect to items or services furnished and amounts expended by or through a managed care entity (as defined in [section 1396u–2(a)(1)(B) of this title](/usc/42/1396u–2.md?p=a-1-B)) in the same manner as such paragraphs apply to items or services furnished and amounts expended directly by the [State](/usc/42/619.md?p=5).

- (j) **Adjustment of amount—** Notwithstanding the preceding provisions of this section, the amount determined under [subsection (a)(1)](#a-1) for any [State](/usc/42/619.md?p=5) for any quarter shall be adjusted in accordance with [section 1396m of this title](/usc/42/1396m.md).
- (k) **Technical assistance to States—** The [Secretary](/usc/42/1301.md?p=a-6) is authorized to provide at the request of any [State](/usc/42/619.md?p=5) (and without cost to such [State](/usc/42/619.md?p=5)) such technical and actuarial assistance as may be necessary to assist such [State](/usc/42/619.md?p=5) to contract with any medicaid managed care organization which meets the requirements of [subsection (m)](#m) of this section for the purpose of providing [medical care](/usc/42/1301.md?p=a-7) and services to individuals who are entitled to [medical assistance](/usc/42/1396d.md?p=a) under this subchapter.
- (l) **Electronic visit verification system for personal care services and home health care services—**
  - (1) Subject to paragraphs [(3)](#l-3) and [(4)](#l-4), with respect to any amount expended for personal care services or home health care services requiring an in-home visit by a provider that are provided under a [State](/usc/42/619.md?p=5) plan under this subchapter (or under a waiver of the plan) and furnished in a calendar quarter beginning on or after January 1, 2020 (or, in the case of home health care services, on or after January 1, 2023), unless a [State](/usc/42/619.md?p=5) requires the use of an electronic visit verification system for such services furnished in such quarter under the plan or such waiver, the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) shall be reduced—
    - (A) in the case of personal care services—
      - (i) for calendar quarters in 2020, by .25 percentage points;
      - (ii) for calendar quarters in 2021, by .5 percentage points;
      - (iii) for calendar quarters in 2022, by .75 percentage points; and
      - (iv) for calendar quarters in 2023 and each year thereafter, by 1 percentage point; and
    - (B) in the case of home health care services—
      - (i) for calendar quarters in 2023 and 2024, by .25 percentage points;
      - (ii) for calendar quarters in 2025, by .5 percentage points;
      - (iii) for calendar quarters in 2026, by .75 percentage points; and
      - (iv) for calendar quarters in 2027 and each year thereafter, by 1 percentage point.
  - (2) Subject to paragraphs [(3)](#l-3) and [(4)](#l-4), in implementing the requirement for the use of an electronic visit verification system under [paragraph (1)](#l-1), a [State](/usc/42/619.md?p=5) shall—
    - (A) consult with [agencies](/usc/42/1397n–12.md?p=1) and entities that provide personal care services, home health care services, or both under the [State](/usc/42/619.md?p=5) plan (or under a waiver of the plan) to ensure that such system—
      - (i) is minimally burdensome;
      - (ii) takes into account existing best [practices](/usc/42/17061.md?p=19) and electronic visit verification systems in use in the [State](/usc/42/619.md?p=5); and
      - (iii) is conducted in accordance with the requirements of HIPAA privacy and security law (as defined in [section 300jj–19 of this title](/usc/42/300jj–19.md));
    - (B) take into account a stakeholder process that [includes](/usc/42/1301.md?p=b) input from beneficiaries, family [caregivers](/usc/42/1397j.md?p=3), individuals who furnish personal care services or home health care services, and other stakeholders, as determined by the [State](/usc/42/619.md?p=5) in accordance with guidance from the [Secretary](/usc/42/1301.md?p=a-6); and
    - (C) ensure that individuals who furnish personal care services, home health care services, or both under the [State](/usc/42/619.md?p=5) plan (or under a waiver of the plan) are provided the opportunity for training on the use of such system.
  - (3) Paragraphs [(1)](#l-1) and [(2)](#l-2) shall not apply in the case of a [State](/usc/42/619.md?p=5) that, as of December 13, 2016, requires the use of any system for the electronic verification of visits conducted as part of both personal care services and home health care services, so long as the [State](/usc/42/619.md?p=5) continues to require the use of such system with respect to the electronic verification of such visits.
  - (4)
    - (A) In the case of a [State](/usc/42/619.md?p=5) described in [subparagraph (B)](#l-4-B), the reduction under [paragraph (1)](#l-1) shall not apply—
      - (i) in the case of personal care services, for calendar quarters in 2020; and
      - (ii) in the case of home health care services, for calendar quarters in 2023.
    - (B) For purposes of [subparagraph (A)](#l-4-A), a [State](/usc/42/619.md?p=5) described in this subparagraph is a [State](/usc/42/619.md?p=5) that demonstrates to the [Secretary](/usc/42/1301.md?p=a-6) that the [State](/usc/42/619.md?p=5)—
      - (i) has made a good faith effort to comply with the requirements of paragraphs [(1)](#l-1) and [(2)](#l-2) ([including](/usc/42/1301.md?p=b) by taking steps to adopt the technology used for an electronic visit verification system); and
      - (ii) in implementing such a system, has encountered unavoidable system delays.
  - (5) In this subsection:
    - (A) The term “electronic visit verification system” means, with respect to personal care services or home health care services, a system under which visits conducted as part of such services are electronically verified with respect to—
      - (i) the type of service performed;
      - (ii) the individual receiving the service;
      - (iii) the date of the service;
      - (iv) the location of service delivery;
      - (v) the individual providing the service; and
      - (vi) the time the service begins and ends.
    - (B) The term “home health care services” means services described in [section 1396d(a)(7) of this title](/usc/42/1396d.md?p=a-7) provided under a [State](/usc/42/619.md?p=5) plan under this subchapter (or under a waiver of the plan).
    - (C) The term “personal care services” means personal care services provided under a [State](/usc/42/619.md?p=5) plan under this subchapter (or under a waiver of the plan), [including](/usc/42/1301.md?p=b) services provided under section [1396d(a)(24)](/usc/42/1396d.md?p=a-24), [1396n(c)](/usc/42/1396n.md?p=c), [1396n(i)](/usc/42/1396n.md?p=i), [1396n(j)](/usc/42/1396n.md?p=j), or [1396n(k)](/usc/42/1396n.md?p=k) of this title or under a wavier[^7] under [section 1315 of this title](/usc/42/1315.md).
  - (6)
    - (A) In the case in which a [State](/usc/42/619.md?p=5) requires personal care service and home health care service providers to utilize an electronic visit verification system operated by the [State](/usc/42/619.md?p=5) or a contractor on behalf of the [State](/usc/42/619.md?p=5), the [Secretary](/usc/42/1301.md?p=a-6) shall pay to the [State](/usc/42/619.md?p=5), for each quarter, an amount equal to 90 per centum of so much of the sums expended during such quarter as are attributable to the design, development, or installation of such system, and 75 per centum of so much of the sums for the operation and maintenance of such system.
    - (B) [Subparagraph (A)](#l-6-A) shall not apply in the case in which a [State](/usc/42/619.md?p=5) requires personal care service and home health care service providers to utilize an electronic visit verification system that is not operated by the [State](/usc/42/619.md?p=5) or a contractor on behalf of the [State](/usc/42/619.md?p=5).
- (m) **“Medicaid managed care organization” defined; duties and functions of Secretary; payments to States; reporting requirements; remedies—**
  - (1)
    - (A) The term “medicaid managed care organization” means a health maintenance organization, an eligible organization with a contract under [section 1395mm of this title](/usc/42/1395mm.md) or a [Medicare+Choice organization](/usc/42/1395w–28.md?p=a-1) with a contract under part C of subchapter XVIII, a provider sponsored organization, or any other public or private organization, which meets the requirement of [section 1396a(w) of this title](/usc/42/1396a.md?p=w) and—
      - (i) makes services it provides to individuals eligible for benefits under this subchapter accessible to such individuals, within the area served by the organization, to the same extent as such services are made accessible to individuals (eligible for [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan) not enrolled with the organization, and
      - (ii) has made adequate provision against the risk of insolvency, which provision is satisfactory to the [State](/usc/42/619.md?p=5), meets the requirements of [subparagraph (C)(i)](#m-1-C-i) (if applicable), and which assures that individuals eligible for benefits under this subchapter are in no case held liable for debts of the organization in case of the organization’s insolvency.

      An organization that is a qualified health maintenance organization (as defined in [section 300e–9(d)](/usc/42/300e–9.md?p=d)[^4] of this title) is deemed to meet the requirements of clauses [(i)](#m-1-A-i) and [(ii)](#m-1-A-ii).

    - (B) The duties and functions of the [Secretary](/usc/42/1301.md?p=a-6), insofar as they involve making determinations as to whether an organization is a medicaid managed care organization within the meaning of [subparagraph (A)](#m-1-A), shall be integrated with the [administration](/usc/42/1301.md?p=a-10) of [section 300e–11(a)](/usc/42/300e–11.md?p=a) and (b) of this title.
    - (C)
      - (i) Subject to [clause (ii)](#m-1-C-ii), a provision meets the requirements of this subparagraph for an organization if the organization meets solvency [standards](/usc/42/1320d.md?p=7) established by the [State](/usc/42/619.md?p=5) for private health maintenance organizations or is licensed or certified by the [State](/usc/42/619.md?p=5) as a risk-bearing entity.
      - (ii) [Clause (i)](#m-1-C-i) shall not apply to an organization if—
        - (I) the organization is not responsible for the provision (directly or through arrangements with providers of services) of inpatient [hospital](/usc/42/300s–3.md?p=1) services and [physicians](/usc/42/1301.md?p=a-7)’ services;
        - (II) the organization is a public entity;
        - (III) the solvency of the organization is guaranteed by the [State](/usc/42/619.md?p=5); or
        - (IV) the organization is (or is controlled by) one or more [Federally-qualified health centers](/usc/42/1396d.md?p=l-2-B) and meets solvency [standards](/usc/42/1320d.md?p=7) established by the [State](/usc/42/619.md?p=5) for such an organization.

        For purposes of [subclause (IV)](#m-1-C-ii-IV), the term “control” means the possession, whether direct or indirect, of the power to direct or cause the direction of the management and policies of the organization through membership, board representation, or an ownership interest equal to or greater than 50.1 percent.

  - (2)
    - (A) Except as provided in subparagraphs [(B)](#m-2-B), [(C)](#m-2-C), and [(G)](#m-2-G), no payment shall be made under this subchapter to a [State](/usc/42/619.md?p=5) with respect to expenditures incurred by it for payment (determined under a prepaid capitation basis or under any other risk basis) for services provided by any entity ([including](/usc/42/1301.md?p=b) a health insuring organization) which is responsible for the provision (directly or through arrangements with providers of services) of inpatient [hospital](/usc/42/300s–3.md?p=1) services and any other service described in paragraph (2), (3), (4), (5), or (7) of [section 1396d(a) of this title](/usc/42/1396d.md?p=a) or for the provision of any three or more of the services described in such paragraphs unless—
      - (i) the [Secretary](/usc/42/1301.md?p=a-6) has determined that the entity is a medicaid managed care organization as defined in [paragraph (1)](#m-1);
      - (ii) Repealed. Pub. L. 105–33, title IV, § 4703(a), Aug. 5, 1997, 111 Stat. 495.
      - (iii) such services are provided for the benefit of individuals eligible for benefits under this subchapter in accordance with a contract between the [State](/usc/42/619.md?p=5) and the entity under which prepaid payments to the entity are made on an actuarially sound basis and under which the [Secretary](/usc/42/1301.md?p=a-6) must provide prior approval for contracts providing for expenditures in excess of $1,000,000 for 1998 and, for a subsequent year, the amount established under this clause for the previous year increased by the percentage increase in the consumer price index for all urban consumers over the previous year;
      - (iv) such contract provides that the [Secretary](/usc/42/1301.md?p=a-6) and the [State](/usc/42/619.md?p=5) (or any [person](/usc/42/1301.md?p=a-3) or organization designated by either) shall have the right to audit and inspect any books and rec­ords of the entity (and of any subcontractor) that pertain (I) to the ability of the entity to bear the risk of potential financial losses, or (II) to services performed or determinations of amounts payable under the contract;
      - (v) such contract provides that in the entity’s enrollment, reenrollment, or disenrollment of individuals who are eligible for benefits under this subchapter and eligible to enroll, reenroll, or disenroll with the entity pursuant to the contract, the entity will not discriminate among such individuals on the basis of their health status or requirements for health care services;
      - (vi) such contract (I) permits individuals who have elected under the plan to enroll with the entity for provision of such benefits to terminate such enrollment in accordance with [section 1396u–2(a)(4) of this title](/usc/42/1396u–2.md?p=a-4), and (II) provides for notification in accordance with such section of each such individual, at the time of the individual’s enrollment, of such right to terminate such enrollment;
      - (vii) such contract provides that, in the case of medically necessary services which were provided (I) to an individual enrolled with the entity under the contract and entitled to benefits with respect to such services under the [State](/usc/42/619.md?p=5)’s plan and (II) other than through the organization because the services were immediately required due to an unforeseen illness, injury, or condition, either the entity or the [State](/usc/42/619.md?p=5) provides for reimbursement with respect to those services,[^3]
      - (viii) such contract provides for disclosure of information in accordance with [section 1320a–3 of this title](/usc/42/1320a–3.md) and paragraph (4) of this subsection;
      - (ix) such contract provides, in the case of an entity that has entered into a contract for the provision of services with a [Federally-qualified health center](/usc/42/1396d.md?p=l-2-B) or a [rural health clinic](/usc/42/1396d.md?p=l-1), that the entity shall provide payment that is not less than the level and amount of payment which the entity would make for the services if the services were furnished by a provider which is not a [Federally-qualified health center](/usc/42/1396d.md?p=l-2-B) or a [rural health clinic](/usc/42/1396d.md?p=l-1);
      - (x) any [physician](/usc/42/1301.md?p=a-7) incentive plan that it operates meets the requirements described in [section 1395mm(i)(8) of this title](/usc/42/1395mm.md?p=i-8);
      - (xi) such contract provides for maintenance of sufficient patient encounter data to identify the [physician](/usc/42/1301.md?p=a-7) who delivers services to patients and for the provision of such data to the [State](/usc/42/619.md?p=5) at a frequency and level of detail to be specified by the [Secretary](/usc/42/1301.md?p=a-6);
      - (xii) such contract, and the entity complies with the applicable requirements of [section 1396u–2 of this title](/usc/42/1396u–2.md); and
      - (xiii) such contract provides that (I) covered outpatient [drugs](/usc/42/11851.md?p=4) dispensed to individuals eligible for [medical assistance](/usc/42/1396d.md?p=a) who are enrolled with the entity shall be subject to the same rebate required by the agreement entered into under [section 1396r–8 of this title](/usc/42/1396r–8.md) as the [State](/usc/42/619.md?p=5) is subject to and that the [State](/usc/42/619.md?p=5) shall collect such rebates from manufacturers, (II) capitation rates paid to the entity shall be based on actual cost experience related to rebates and subject to the Federal regulations requiring actuarially sound rates, and (III) the entity shall report to the [State](/usc/42/619.md?p=5), on such timely and periodic basis as specified by the [Secretary](/usc/42/1301.md?p=a-6) in order to include in the information submitted by the [State](/usc/42/619.md?p=5) to a manufacturer and the [Secretary](/usc/42/1301.md?p=a-6) under [section 1396r–8(b)(2)(A) of this title](/usc/42/1396r–8.md?p=b-2-A), information on the total number of units of each dosage form and strength and package size by National Drug Code of each covered outpatient [drug](/usc/42/11851.md?p=4) dispensed to individuals eligible for [medical assistance](/usc/42/1396d.md?p=a) who are enrolled with the entity and for which the entity is responsible for coverage of such [drug](/usc/42/11851.md?p=4) under this subsection (other than covered outpatient [drugs](/usc/42/11851.md?p=4) that under subsection (j)(1) of [section 1396r–8 of this title](/usc/42/1396r–8.md) are not subject to the requirements of that section) and such other data as the [Secretary](/usc/42/1301.md?p=a-6) determines necessary to carry out this subsection.
    - (B) [Subparagraph (A)](#m-2-A)[^8] except with respect to [clause (ix)](#m-2-A-ix) of subparagraph (A), does not apply with respect to payments under this subchapter to a [State](/usc/42/619.md?p=5) with respect to expenditures incurred by it for payment for services provided by an entity which—
      - (i)
        - (I) received a [grant](/usc/42/1397j.md?p=10) of at least $100,000 in the [fiscal year](/usc/42/619.md?p=3) ending June 30, 1976, under section [254b(d)(1)(A)](/usc/42/254b.md?p=d-1-A) or [254c(d)(1)](/usc/42/254c.md?p=d-1) of this title,[^4] and for the period beginning July 1, 1976, and ending on the expiration of the period for which payments are to be made under this subchapter has been the recipient of a [grant](/usc/42/1397j.md?p=10) under either such section; and
        - (II) provides to its enrollees, on a prepaid capitation risk basis or on any other risk basis, all of the services and benefits described in paragraphs (1), (2), (3), (4)(C), and (5) of [section 1396d(a) of this title](/usc/42/1396d.md?p=a) and, to the extent required by [section 1396a(a)(10)(D) of this title](/usc/42/1396a.md?p=a-10-D) to be provided under a [State](/usc/42/619.md?p=5) plan for [medical assistance](/usc/42/1396d.md?p=a), the services and benefits described in paragraph (7) of [section 1396d(a) of this title](/usc/42/1396d.md?p=a); or
      - (ii) is a [nonprofit](/usc/42/300s–3.md?p=3) primary health care entity located in a rural area (as defined by the Appalachian Regional Commission)—
        - (I) which received in the [fiscal year](/usc/42/619.md?p=3) ending June 30, 1976, at least $100,000 (by [grant](/usc/42/1397j.md?p=10), subgrant, or subcontract) under the Appalachian Regional Development Act of 1965,[^4] and
        - (II) for the period beginning July 1, 1976, and ending on the expiration of the period for which payments are to be made under this subchapter either has been the recipient of a [grant](/usc/42/1397j.md?p=10), subgrant, or subcontract under such Act or has provided services under a contract (initially entered into during a year in which the entity was the recipient of such a [grant](/usc/42/1397j.md?p=10), subgrant, or subcontract) with a [State agency](/usc/42/629a.md?p=a-3) under this subchapter on a prepaid capitation risk basis or on any other risk basis; or
      - (iii) which has contracted with the single [State agency](/usc/42/629a.md?p=a-3) for the provision of services (but not [including](/usc/42/1301.md?p=b) inpatient [hospital](/usc/42/300s–3.md?p=1) services) to [persons](/usc/42/1301.md?p=a-3) eligible under this subchapter on a prepaid risk basis prior to 1970.
    - (C) to (E) Repealed. Pub. L. 105–33, title IV, § 4703(b)(1)(A), Aug. 5, 1997, 111 Stat. 495.
    - (F) Repealed. Pub. L. 105–33, title IV, § 4701(d)(2)(B), Aug. 5, 1997, 111 Stat. 494.
    - (G) In the case of an entity which is receiving (and has received during the previous two years) a [grant](/usc/42/1397j.md?p=10) of at least $100,000 under section [254b(d)(1)(A)](/usc/42/254b.md?p=d-1-A) or [254c(d)(1)](/usc/42/254c.md?p=d-1) of this title[^4] or is receiving (and has received during the previous two years) at least $100,000 (by [grant](/usc/42/1397j.md?p=10), subgrant, or subcontract) under the Appalachian Regional Development Act of 1965,[^4] [clause (i)](#m-2-A-i) of subparagraph (A) shall not apply.
    - (H) In the case of an individual who—
      - (i) in a month is eligible for benefits under this subchapter and enrolled with a medicaid managed care organization with a contract under this paragraph or with a [primary care case manager](/usc/42/1396d.md?p=t-2) with a contract described in [section 1396d(t)(3) of this title](/usc/42/1396d.md?p=t-3),
      - (ii) in the next month (or in the next 2 months) is not eligible for such benefits, but
      - (iii) in the succeeding month is again eligible for such benefits,

      the [State](/usc/42/619.md?p=5) plan, subject to [subparagraph (A)(vi)](#m-2-A-vi), may enroll the individual for that succeeding month with the organization described in [clause (i)](#m-2-H-i) if the organization continues to have a contract under this paragraph with the [State](/usc/42/619.md?p=5) or with the manager described in such clause if the manager continues to have a contract described in [section 1396d(t)(3) of this title](/usc/42/1396d.md?p=t-3) with the [State](/usc/42/619.md?p=5).

  - (3) No payment shall be made under this subchapter to a [State](/usc/42/619.md?p=5) with respect to expenditures incurred by the [State](/usc/42/619.md?p=5) for payment for services provided by a managed care entity (as defined under [section 1396u–2(a)(1) of this title](/usc/42/1396u–2.md?p=a-1)) under the [State](/usc/42/619.md?p=5) plan under this subchapter (or under a waiver of the plan) unless the [State](/usc/42/619.md?p=5)—
    - (A) beginning on July 1, 2018, has a contract with such entity that complies with the requirement specified in [section 1396u–2(d)(5) of this title](/usc/42/1396u–2.md?p=d-5); and
    - (B) beginning on January 1, 2018, complies with the requirement specified in [section 1396u–2(d)(6)(A) of this title](/usc/42/1396u–2.md?p=d-6-A).
  - (4)
    - (A) Each medicaid managed care organization which is not a qualified health maintenance organization (as defined in [section 300e–9(d)](/usc/42/300e–9.md?p=d)[^4] of this title) must report to the [State](/usc/42/619.md?p=5) and, upon request, to the [Secretary](/usc/42/1301.md?p=a-6), the Inspector General of the Department of Health and Human Services, and the Comptroller General a description of transactions between the organization and a party in interest (as defined in [section 300e–17(b) of this title](/usc/42/300e–17.md?p=b)), [including](/usc/42/1301.md?p=b) the following transactions:
      - (i) Any sale or exchange, or leasing of any property between the organization and such a party.
      - (ii) Any furnishing for consideration of goods, services ([including](/usc/42/1301.md?p=b) management services), or [facilities](/usc/42/1320a–3.md?p=c-5-B) between the organization and such a party, but not [including](/usc/42/1301.md?p=b) salaries paid to employees for services provided in the normal course of their employment.
      - (iii) Any lending of money or other extension of credit between the organization and such a party.

      The [State](/usc/42/619.md?p=5) or [Secretary](/usc/42/1301.md?p=a-6) may require that information reported respecting an organization which controls, or is controlled by, or is under common control with, another entity be in the form of a consolidated financial statement for the organization and such entity.

    - (B) Each organization shall make the information reported pursuant to [subparagraph (A)](#m-4-A) available to its enrollees upon reasonable request.
  - (5)
    - (A) If the [Secretary](/usc/42/1301.md?p=a-6) determines that an entity with a contract under this subsection—
      - (i) fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has substantial likelihood of adversely affecting) the individual;
      - (ii) imposes premiums on individuals enrolled under this subsection in excess of the premiums permitted under this subchapter;
      - (iii) acts to discriminate among individuals in [violation](/usc/42/2000e–16a.md?p=c) of the provision of [paragraph (2)(A)(v)](#m-2-A-v), [including](/usc/42/1301.md?p=b) expulsion or refusal to re-enroll an individual or engaging in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this subsection) by eligible individuals with the organization whose medical condition or history indicates a need for substantial future medical services;
      - (iv) misrepresents or falsifies information that is furnished—
        - (I) to the [Secretary](/usc/42/1301.md?p=a-6) or the [State](/usc/42/619.md?p=5) under this subsection, or
        - (II) to an individual or to any other entity under this subsection,[^3] or
      - (v) fails to comply with the requirements of [section 1395mm(i)(8) of this title](/usc/42/1395mm.md?p=i-8),

      the [Secretary](/usc/42/1301.md?p=a-6) may provide, in addition to any other remedies available under law, for any of the remedies described in [subparagraph (B)](#m-5-B).

    - (B) The remedies described in this subparagraph are—
      - (i) civil money penalties of not more than $25,000 for each determination under [subparagraph (A)](#m-5-A), or, with respect to a determination under clause [(iii)](#m-5-A-iii) or [(iv)(I)](#m-5-A-iv-I) of such subparagraph, of not more than $100,000 for each such determination, plus, with respect to a determination under [subparagraph (A)(ii)](#m-5-A-ii), double the excess amount charged in [violation](/usc/42/2000e–16a.md?p=c) of such subparagraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under [subparagraph (A)(iii)](#m-5-A-iii), $15,000 for each individual not enrolled as a result of a practice described in such subparagraph, or
      - (ii) denial of payment to the [State](/usc/42/619.md?p=5) for [medical assistance](/usc/42/1396d.md?p=a) furnished under the contract under this subsection for individuals enrolled after the date the [Secretary](/usc/42/1301.md?p=a-6) notifies the organization of a determination under [subparagraph (A)](#m-5-A) and until the [Secretary](/usc/42/1301.md?p=a-6) is satisfied that the basis for such determination has been corrected and is not likely to recur.

      The provisions of [section 1320a–7a of this title](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#b)) shall apply to a civil money penalty under [clause (i)](#m-5-B-i) in the same manner as such provisions apply to a penalty or proceeding under [section 1320a–7a(a) of this title](/usc/42/1320a–7a.md?p=a).

  - (6)
    - (A) For purposes of this subsection and [section 1396a(e)(2)(A) of this title](/usc/42/1396a.md?p=e-2-A), in the case of the [State](/usc/42/619.md?p=5) of New Jersey, the term “contract” shall be deemed to include an undertaking by the [State agency](/usc/42/629a.md?p=a-3), in the [State](/usc/42/619.md?p=5) plan under this subchapter, to operate a program meeting all requirements of this subsection.
    - (B) The undertaking described in [subparagraph (A)](#m-6-A) must provide—
      - (i) for the establishment of a separate entity responsible for the operation of a program meeting the requirements of this subsection, which entity may be a subdivision of the [State agency](/usc/42/629a.md?p=a-3) administering the [State](/usc/42/619.md?p=5) plan under this subchapter;
      - (ii) for separate accounting for the funds used to operate such program; and
      - (iii) for setting the capitation rates and any other payment rates for services provided in accordance with this subsection using a methodology satisfactory to the [Secretary](/usc/42/1301.md?p=a-6) designed to ensure that total Federal matching payments under this subchapter for such services will be lower than the matching payments that would be made for the same services, if provided under the [State](/usc/42/619.md?p=5) plan on a fee for service basis to an actuarially equivalent population.
    - (C) The undertaking described in [subparagraph (A)](#m-6-A) shall be subject to approval (and annual re-approval) by the [Secretary](/usc/42/1301.md?p=a-6) in the same manner as a contract under this subsection.
    - (D) The undertaking described in [subparagraph (A)](#m-6-A) shall not be eligible for a waiver under [section 1396n(b) of this title](/usc/42/1396n.md?p=b).
  - (7) Payment shall be made under this subchapter to a [State](/usc/42/619.md?p=5) for expenditures for capitation payments described in section 438.6(e) of title 42, Code of Federal Regulations (or any successor regulation).
  - (8)
    - (A) The [State agency](/usc/42/629a.md?p=a-3) administering the [State](/usc/42/619.md?p=5) plan under this subchapter may have reasonable access, as determined by the [State](/usc/42/619.md?p=5), to 1 or more prescription [drug](/usc/42/11851.md?p=4) monitoring program databases administered or accessed by the [State](/usc/42/619.md?p=5) to the extent the [State agency](/usc/42/629a.md?p=a-3) is permitted to access such databases under [State](/usc/42/619.md?p=5) law.
    - (B) Such [State agency](/usc/42/629a.md?p=a-3) may facilitate reasonable access, as determined by the [State](/usc/42/619.md?p=5), to 1 or more prescription [drug](/usc/42/11851.md?p=4) monitoring program databases administered or accessed by the [State](/usc/42/619.md?p=5), to same extent that the [State agency](/usc/42/629a.md?p=a-3) is permitted under [State](/usc/42/619.md?p=5) law to access such databases, for—
      - (i) any provider enrolled under the [State](/usc/42/619.md?p=5) plan to provide services to Medicaid beneficiaries; and
      - (ii) any managed care entity (as defined under [section 1396u–2(a)(1)(B) of this title](/usc/42/1396u–2.md?p=a-1-B)) that has a contract with the [State](/usc/42/619.md?p=5) under this subsection or under [section 1396d(t)(3) of this title](/usc/42/1396d.md?p=t-3).
    - (C) Such [State agency](/usc/42/629a.md?p=a-3) may share information in such databases, to the same extent that the [State agency](/usc/42/629a.md?p=a-3) is permitted under [State](/usc/42/619.md?p=5) law to share information in such databases, with—
      - (i) any provider enrolled under the [State](/usc/42/619.md?p=5) plan to provide services to Medicaid beneficiaries; and
      - (ii) any managed care entity (as defined under [section 1396u–2(a)(1)(B) of this title](/usc/42/1396u–2.md?p=a-1-B)) that has a contract with the [State](/usc/42/619.md?p=5) under this subsection or under [section 1396d(t)(3) of this title](/usc/42/1396d.md?p=t-3).
  - (9)
    - (A) With respect to expenditures described in [subparagraph (B)](#m-9-B) that are incurred by a [State](/usc/42/619.md?p=5) for any [fiscal year](/usc/42/619.md?p=3) after [fiscal year](/usc/42/619.md?p=3) 2020, in determining the pro rata share to which the [United States](/usc/42/1301.md?p=a-2) is equitably entitled under [subsection (d)(3)](#d-3), the [Secretary](/usc/42/1301.md?p=a-6) shall substitute the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) that applies for such [fiscal year](/usc/42/619.md?p=3) to the [State](/usc/42/619.md?p=5) under [section 1396d(b) of this title](/usc/42/1396d.md?p=b) (without regard to any adjustments to such percentage applicable under such section or any other provision of law) for the percentage that applies to such expenditures under [section 1396d(y) of this title](/usc/42/1396d.md?p=y).
    - (B) Expenditures described in this subparagraph, with respect to a [fiscal year](/usc/42/619.md?p=3) to which [subparagraph (A)](#m-9-A) applies, are expenditures incurred by a [State](/usc/42/619.md?p=5) for payment for [medical assistance](/usc/42/1396d.md?p=a) provided to individuals described in subclause (VIII) of [section 1396a(a)(10)(A)(i) of this title](/usc/42/1396a.md?p=a-10-A-i) by a managed care entity, or other specified entity (as defined in [subparagraph (D)(iii)](#m-9-D-iii)), that are treated as remittances because the [State](/usc/42/619.md?p=5)—
      - (i) has satisfied the requirement of section 438.8 of title 42, Code of Federal Regulations (or any successor regulation), by electing—
        - (I) in the case of a [State](/usc/42/619.md?p=5) described in [subparagraph (C)](#m-9-C), to apply a minimum medical loss ratio (as defined in [subparagraph (D)(ii)](#m-9-D-ii)) that is at least 85 percent but not greater than the minimum medical loss ratio (as so defined) that such [State](/usc/42/619.md?p=5) applied as of May 31, 2018; or
        - (II) in the case of a [State](/usc/42/619.md?p=5) not described in [subparagraph (C)](#m-9-C), to apply a minimum medical loss ratio that is equal to 85 percent; and
      - (ii) recovered all or a portion of the expenditures as a result of the entity’s failure to meet such ratio.
    - (C) For purposes of [subparagraph (B)](#m-9-B), a [State](/usc/42/619.md?p=5) described in this subparagraph is a [State](/usc/42/619.md?p=5) that as of May 31, 2018, applied a minimum medical loss ratio (as calculated under subsection (d) of section 438.8 of title 42, Code of Federal Regulations (as in effect on June 1, 2018)) for payment for services provided by entities described in such subparagraph under the [State](/usc/42/619.md?p=5) plan under this subchapter (or a waiver of the plan) that is equal to or greater than 85 percent.
    - (D) For purposes of this paragraph:
      - (i) The term “managed care entity” means a medicaid managed care organization described in [section 1396u–2(a)(1)(B)(i) of this title](/usc/42/1396u–2.md?p=a-1-B-i).
      - (ii) The term “minimum medical loss ratio” means, with respect to a [State](/usc/42/619.md?p=5), a minimum medical loss ratio (as calculated under subsection (d) of section 438.8 of title 42, Code of Federal Regulations (as in effect on June 1, 2018)) for payment for services provided by entities described in [subparagraph (B)](#m-9-B) under the [State](/usc/42/619.md?p=5) plan under this subchapter (or a waiver of the plan).
      - (iii) The term “other specified entity” means—
        - (I) a prepaid inpatient [health plan](/usc/42/1320d.md?p=5), as defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation); and
        - (II) a prepaid ambulatory [health plan](/usc/42/1320d.md?p=5), as defined in such section (or any successor regulation).
- (n) **Repealed. Pub. L. 100–93, § 8(h)(1), Aug. 18, 1987, 101 Stat. 694—**
- (o) **Restrictions on authorized payments to States—** Notwithstanding the preceding provisions of this section, no payment shall be made to a [State](/usc/42/619.md?p=5) under the preceding provisions of this section for expenditures for [medical assistance](/usc/42/1396d.md?p=a) provided for an individual under its [State](/usc/42/619.md?p=5) plan approved under this subchapter to the extent that a private insurer (as defined by the [Secretary](/usc/42/1301.md?p=a-6) by regulation and [including](/usc/42/1301.md?p=b) a [group health plan](/usc/42/1397jj.md?p=c-3) (as defined in [section 1167(1) of title 29](/usc/29/1167.md?p=1)), a service benefit plan, and a health maintenance organization) would have been obligated to provide such assistance but for a provision of its insurance contract which has the effect of limiting or excluding such obligation because the individual is eligible for or is provided [medical assistance](/usc/42/1396d.md?p=a) under the plan.
- (p) **Assignment of rights of payment; incentive payments for enforcement and collection—**
  - (1) When a political subdivision of a [State](/usc/42/619.md?p=5) makes, for the [State](/usc/42/619.md?p=5) of which it is a political subdivision, or one [State](/usc/42/619.md?p=5) makes, for another [State](/usc/42/619.md?p=5), the enforcement and collection of rights of support or payment assigned under [section 1396k of this title](/usc/42/1396k.md), pursuant to a cooperative arrangement under such section (either within or outside of such [State](/usc/42/619.md?p=5)), there shall be paid to such political subdivision or such other [State](/usc/42/619.md?p=5) from amounts which would otherwise represent the Federal share of payments for [medical assistance](/usc/42/1396d.md?p=a) provided to the eligible individuals on whose behalf such enforcement and collection was made, an amount equal to 15 percent of any amount collected which is attributable to such rights of support or payment.
  - (2) Where more than one jurisdiction is involved in such enforcement or collection, the amount of the incentive payment determined under [paragraph (1)](#p-1) shall be allocated among the jurisdictions in a manner to be prescribed by the [Secretary](/usc/42/1301.md?p=a-6).
- (q) **“State medicaid fraud control unit” defined—** For the purposes of this section, the term “[State](/usc/42/619.md?p=5) medicaid fraud control unit” means a single identifiable entity of the [State](/usc/42/619.md?p=5) government which the [Secretary](/usc/42/1301.md?p=a-6) certifies (and annually recertifies) as meeting the following requirements:
  - (1) The entity (A) is a unit of the office of the [State](/usc/42/619.md?p=5) Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal [violations](/usc/42/2000e–16a.md?p=c), (B) is in a [State](/usc/42/619.md?p=5) the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the [Secretary](/usc/42/1301.md?p=a-6), that (i) assure its referral of suspected criminal [violations](/usc/42/2000e–16a.md?p=c) relating to the program under this subchapter to the appropriate authority or authorities in the [State](/usc/42/619.md?p=5) for prosecution and (ii) assure its assistance of, and coordination with, such authority or authorities in such prosecutions, or (C) has a formal working relationship with the office of the [State](/usc/42/619.md?p=5) Attorney General and has formal procedures ([including](/usc/42/1301.md?p=b) procedures for its referral of suspected criminal [violations](/usc/42/2000e–16a.md?p=c) to such office) which are approved by the [Secretary](/usc/42/1301.md?p=a-6) and which provide effective coordination of activities between the entity and such office with respect to the detection, investigation, and prosecution of suspected criminal [violations](/usc/42/2000e–16a.md?p=c) relating to the program under this subchapter.
  - (2) The entity is separate and distinct from the single [State agency](/usc/42/629a.md?p=a-3) that administers or supervises the [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan under this subchapter.
  - (3) The entity’s function is conducting a statewide program for the investigation and prosecution of [violations](/usc/42/2000e–16a.md?p=c) of all applicable [State](/usc/42/619.md?p=5) laws regarding any and all aspects of fraud in connection with (A) any aspect of the provision of [medical assistance](/usc/42/1396d.md?p=a) and the activities of providers of such assistance under the [State](/usc/42/619.md?p=5) plan under this subchapter; and (B) upon the approval of the Inspector General of the relevant Federal [agency](/usc/42/1397n–12.md?p=1), any aspect of the provision of health care services and activities of providers of such services under any Federal health care program (as defined in [section 1320a–7b(f)(1) of this title](/usc/42/1320a–7b.md?p=f-1)), if the suspected fraud or [violation](/usc/42/2000e–16a.md?p=c) of law in such case or investigation is primarily related to the [State](/usc/42/619.md?p=5) plan under this subchapter.
  - (4)
    - (A) The entity has—
      - (i) procedures for reviewing complaints of [abuse](/usc/42/1397j.md?p=1) or [neglect](/usc/42/1397j.md?p=16) of patients in health care [facilities](/usc/42/1320a–3.md?p=c-5-B) which receive payments under the [State](/usc/42/619.md?p=5) plan under this subchapter;
      - (ii) at the option of the entity, procedures for reviewing complaints of [abuse](/usc/42/1397j.md?p=1) or [neglect](/usc/42/1397j.md?p=16) of patients residing in board and care [facilities](/usc/42/1320a–3.md?p=c-5-B) and of patients (who are receiving [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan under this subchapter (or waiver of such plan)) in a noninstitutional or other setting; and
      - (iii) procedures for acting upon such complaints under the criminal laws of the [State](/usc/42/619.md?p=5) or for referring such complaints to other [State agencies](/usc/42/629a.md?p=a-3) for action.
    - (B) For purposes of this paragraph, the term “board and care [facility](/usc/42/1320a–3.md?p=c-5-B)” means a residential setting which receives payment (regardless of whether such payment is made under the [State](/usc/42/619.md?p=5) plan under this subchapter) from or on behalf of two or more unrelated [adults](/usc/42/619.md?p=1) who reside in such [facility](/usc/42/1320a–3.md?p=c-5-B), and for whom one or both of the following is provided:
      - (i) Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse, or licensed nursing assistant.
      - (ii) A substantial amount of personal care services that assist residents with the activities of daily living, [including](/usc/42/1301.md?p=b) personal hygiene, dressing, bathing, eating, toileting, ambulation, transfer, positioning, self-medication, body care, travel to medical services, essential shopping, meal preparation, laundry, and housework.
  - (5) The entity provides for the collection, or referral for collection to a single [State agency](/usc/42/629a.md?p=a-3), of overpayments that are made under the [State](/usc/42/619.md?p=5) plan or under any Federal health care program (as so defined) to health care [facilities](/usc/42/1320a–3.md?p=c-5-B) and that are discovered by the entity in carrying out its activities. All funds collected in accordance with this paragraph shall be credited exclusively to, and available for expenditure under, the Federal health care program ([including](/usc/42/1301.md?p=b) the [State](/usc/42/619.md?p=5) plan under this subchapter) that was subject to the activity that was the basis for the collection.
  - (6) The entity employs such auditors, attorneys, investigators, and other necessary personnel and is organized in such a manner as is necessary to promote the effective and efficient conduct of the entity’s activities.
  - (7) The entity submits to the [Secretary](/usc/42/1301.md?p=a-6) an application and annual reports containing such information as the [Secretary](/usc/42/1301.md?p=a-6) determines, by regulation, to be necessary to determine whether the entity meets the other requirements of this subsection.
- (r) **Mechanized claims processing and information retrieval systems; operational, etc., requirements—**
  - (1) In order to receive payments under [subsection (a)](#a) for use of automated data systems in [administration](/usc/42/1301.md?p=a-10) of the [State](/usc/42/619.md?p=5) plan under this subchapter, a [State](/usc/42/619.md?p=5) must, in addition to meeting the requirements of [paragraph (3)](#r-3), have in operation mechanized claims processing and information retrieval systems that meet the requirements of this subsection and that the [Secretary](/usc/42/1301.md?p=a-6) has found—
    - (A) are adequate to provide efficient, economical, and effective [administration](/usc/42/1301.md?p=a-10) of such [State](/usc/42/619.md?p=5) plan;
    - (B) are compatible with the claims processing and information retrieval systems used in the [administration](/usc/42/1301.md?p=a-10) of subchapter XVIII, and for this purpose—
      - (i) have a uniform identification coding system for providers, other payees, and beneficiaries under this subchapter or subchapter XVIII;
      - (ii) provide liaison between [States](/usc/42/619.md?p=5) and carriers and intermediaries with agreements under subchapter XVIII to facilitate timely exchange of appropriate data;
      - (iii) provide for exchange of data between the [States](/usc/42/619.md?p=5) and the [Secretary](/usc/42/1301.md?p=a-6) with respect to [persons](/usc/42/1301.md?p=a-3) sanctioned under this subchapter or subchapter XVIII; and
      - (iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the [Secretary](/usc/42/1301.md?p=a-6) (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the [Secretary](/usc/42/1301.md?p=a-6) identifies in accordance with [paragraph (4)](#r-4);
    - (C) are capable of providing accurate and timely data;
    - (D) are complying with the applicable provisions of part C of subchapter XI;
    - (E) are designed to receive provider claims in [standard](/usc/42/1320d.md?p=7) formats to the extent specified by the [Secretary](/usc/42/1301.md?p=a-6); and
    - (F) effective for claims filed on or after January 1, 1999, provide for electronic transmission of claims data in the format specified by the [Secretary](/usc/42/1301.md?p=a-6) and consistent with the Medicaid Statistical Information System (MSIS) ([including](/usc/42/1301.md?p=b) detailed individual enrollee encounter data and other information that the [Secretary](/usc/42/1301.md?p=a-6) may find necessary and [including](/usc/42/1301.md?p=b), for data submitted to the [Secretary](/usc/42/1301.md?p=a-6) on or after January 1, 2010, data elements from the automated data system that the [Secretary](/usc/42/1301.md?p=a-6) determines to be necessary for program integrity, program oversight, and [administration](/usc/42/1301.md?p=a-10), at such frequency as the [Secretary](/usc/42/1301.md?p=a-6) shall determine).
  - (2) In order to meet the requirements of this paragraph, mechanized claims processing and information retrieval systems must meet the following requirements:
    - (A) The systems must be capable of developing provider, [physician](/usc/42/1301.md?p=a-7), and patient profiles which are sufficient to provide specific information as to the use of covered types of services and items, [including](/usc/42/1301.md?p=b) prescribed [drugs](/usc/42/11851.md?p=4).
    - (B) The [State](/usc/42/619.md?p=5) must provide that information on probable fraud or [abuse](/usc/42/1397j.md?p=1) which is obtained from, or developed by, the systems, is made available to the [State](/usc/42/619.md?p=5)’s medicaid fraud control unit (if any) certified under [subsection (q)](#q) of this section.
    - (C) The systems must meet all performance [standards](/usc/42/1320d.md?p=7) and other requirements for initial approval developed by the [Secretary](/usc/42/1301.md?p=a-6).
  - (3)
    - (A) In order to meet the requirements of this paragraph, a [State](/usc/42/619.md?p=5) must have in operation an eligibility determination system which provides for data matching through—
      - (i) the Public Assistance Reporting Information System (PARIS) facilitated by the [Secretary](/usc/42/1301.md?p=a-6) (or any successor system), [including](/usc/42/1301.md?p=b) matching with [medical assistance](/usc/42/1396d.md?p=a) programs operated by other [States](/usc/42/619.md?p=5); and
      - (ii) beginning October 1, 2029, the system established by the [Secretary](/usc/42/1301.md?p=a-6) under [section 1396a(uu) of this title](/usc/42/1396a.md?p=uu).
    - (B) Beginning October 1, 2029, the [Secretary](/usc/42/1301.md?p=a-6) may determine that a [State](/usc/42/619.md?p=5) is not required to have in operation an eligibility determination system which provides for data matching (for purposes of address verification under [section 1396a(vv) of this title](/usc/42/1396a.md?p=vv)) through the system described in [subparagraph (A)(i)](#r-3-A-i) to meet the requirements of this paragraph.
  - (4) For purposes of [paragraph (1)(B)(iv)](#r-1-B-iv), the [Secretary](/usc/42/1301.md?p=a-6) shall do the following:
    - (A) Not later than September 1, 2010:
      - (i) Identify those methodologies of the National Correct Coding Initiative administered by the [Secretary](/usc/42/1301.md?p=a-6) (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) which are compatible to claims filed under this subchapter.
      - (ii) Identify those methodologies of such Initiative (or such other national correct coding methodologies) that should be incorporated into claims filed under this subchapter with respect to items or services for which [States](/usc/42/619.md?p=5) provide [medical assistance](/usc/42/1396d.md?p=a) under this subchapter and no national correct coding methodologies have been established under such Initiative with respect to subchapter XVIII.
      - (iii) Notify [States](/usc/42/619.md?p=5) of—
        - (I) the methodologies identified under subparagraphs [(A)](#r-4-A) and [(B)](#r-4-B) (and of any other national correct coding methodologies identified under [subparagraph (B)](#r-4-B)); and
        - (II) how [States](/usc/42/619.md?p=5) are to incorporate such methodologies into claims filed under this subchapter.
    - (B) Not later than March 1, 2011, submit a report to Congress that [includes](/usc/42/1301.md?p=b) the notice to [States](/usc/42/619.md?p=5) under [clause (iii)](#r-4-A-iii) of subparagraph (A) and an analysis supporting the identification of the methodologies made under clauses [(i)](#r-4-A-i) and [(ii)](#r-4-A-ii) of subparagraph (A).
- (s) **Limitations on certain physician referrals—** Notwithstanding the preceding provisions of this section, no payment shall be made to a [State](/usc/42/619.md?p=5) under this section for expenditures for [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan consisting of a designated health service (as defined in subsection (h)(6) of [section 1395nn of this title](/usc/42/1395nn.md)) furnished to an individual on the basis of a referral that would result in the denial of payment for the service under subchapter XVIII if such subchapter provided for coverage of such service to the same extent and under the same terms and conditions as under the [State](/usc/42/619.md?p=5) plan, and subsections [(f)](/usc/42/1395nn.md?p=f) and [(g)(5)](/usc/42/1395nn.md?p=g-5) of such section shall apply to a provider of such a designated health service for which payment may be made under this subchapter in the same manner as such subsections apply to a provider of such a service for which payment may be made under such subchapter.
- (t) **Payments to encourage adoption and use of certified EHR technology—**
  - (1) For purposes of [subsection (a)(3)(F)](#a-3-F), the payments described in this paragraph to encourage the adoption and use of certified EHR technology are payments made by the [State](/usc/42/619.md?p=5) in accordance with this subsection—
    - (A) to Medicaid providers described in [paragraph (2)(A)](#t-2-A) not in excess of 85 percent of net average allowable costs (as defined in [paragraph (3)(E)](#t-3-E)) for certified EHR technology (and support services [including](/usc/42/1301.md?p=b) maintenance and training that is for, or is necessary for the adoption and operation of, such technology) with respect to such providers; and
    - (B) to Medicaid providers described in [paragraph (2)(B)](#t-2-B) not in excess of the maximum amount permitted under [paragraph (5)](#t-5) for the provider involved.
  - (2) In this subsection and [subsection (a)(3)(F)](#a-3-F), the term “Medicaid provider” means—
    - (A) an eligible professional (as defined in [paragraph (3)(B)](#t-3-B))—
      - (i) who is not [hospital](/usc/42/300s–3.md?p=1)-based and has at least 30 percent of the professional’s patient volume (as estimated in accordance with a methodology established by the [Secretary](/usc/42/1301.md?p=a-6)) attributable to individuals who are receiving [medical assistance](/usc/42/1396d.md?p=a) under this subchapter;
      - (ii) who is not described in [clause (i)](#t-2-A-i), who is a pediatrician, who is not [hospital](/usc/42/300s–3.md?p=1)-based, and who has at least 20 percent of the professional’s patient volume (as estimated in accordance with a methodology established by the [Secretary](/usc/42/1301.md?p=a-6)) attributable to individuals who are receiving [medical assistance](/usc/42/1396d.md?p=a) under this subchapter; and
      - (iii) who [practices](/usc/42/17061.md?p=19) predominantly in a Federally qualified health center or [rural health clinic](/usc/42/1396d.md?p=l-1) and has at least 30 percent of the professional’s patient volume (as estimated in accordance with a methodology established by the [Secretary](/usc/42/1301.md?p=a-6)) attributable to needy individuals (as defined in [paragraph (3)(F)](#t-3-F)); and
    - (B)
      - (i) a children’s [hospital](/usc/42/300s–3.md?p=1), or
      - (ii) an acute-care [hospital](/usc/42/300s–3.md?p=1) that is not described in [clause (i)](#t-2-B-i) and that has at least 10 percent of the [hospital](/usc/42/300s–3.md?p=1)’s patient volume (as estimated in accordance with a methodology established by the [Secretary](/usc/42/1301.md?p=a-6)) attributable to individuals who are receiving [medical assistance](/usc/42/1396d.md?p=a) under this subchapter.

    An eligible professional shall not qualify as a Medicaid provider under this subsection unless any right to payment under sections [1395w–4(o)](/usc/42/1395w–4.md?p=o) and [1395w–23(l)](/usc/42/1395w–23.md?p=l) of this title with respect to the eligible professional has been waived in a manner specified by the [Secretary](/usc/42/1301.md?p=a-6). For purposes of calculating patient volume under [subparagraph (A)(iii)](#t-2-A-iii), insofar as it is related to uncompensated care, the [Secretary](/usc/42/1301.md?p=a-6) may require the adjustment of such uncompensated care data so that it would be an appropriate proxy for charity care, [including](/usc/42/1301.md?p=b) a downward adjustment to eliminate bad debt data from uncompensated care. In applying subparagraphs [(A)](#t-2-A) and [(B)(ii)](#t-2-B-ii), the methodology established by the [Secretary](/usc/42/1301.md?p=a-6) for patient volume shall include individuals enrolled in a Medicaid managed care plan (under [subsection (m)](#m) or [section 1396u–2 of this title](/usc/42/1396u–2.md)).

  - (3) In this subsection and [subsection (a)(3)(F)](#a-3-F):
    - (A) The term “certified EHR technology” means a qualified electronic health record (as defined in[^9] [300jj(13)](/usc/42/300jj.md?p=13) of this title) that is certified pursuant to [section 300jj–11(c)(5) of this title](/usc/42/300jj–11.md?p=c-5) as meeting [standards](/usc/42/1320d.md?p=7) adopted under [section 300jj–14 of this title](/usc/42/300jj–14.md) that are applicable to the type of record involved (as determined by the [Secretary](/usc/42/1301.md?p=a-6), such as an ambulatory electronic health record for office-based [physicians](/usc/42/1301.md?p=a-7) or an inpatient [hospital](/usc/42/300s–3.md?p=1) electronic health record for [hospitals](/usc/42/300s–3.md?p=1)).
    - (B) The term “eligible professional” means a—
      - (i) [physician](/usc/42/1301.md?p=a-7);
      - (ii) dentist;
      - (iii) certified nurse mid-wife;
      - (iv) nurse practitioner; and
      - (v) [physician](/usc/42/1301.md?p=a-7) assistant insofar as the assistant is practicing in a [rural health clinic](/usc/42/1396d.md?p=l-1) that is led by a [physician](/usc/42/1301.md?p=a-7) assistant or is practicing in a Federally qualified health center that is so led.
    - (C) The term “average allowable costs” means, with respect to certified EHR technology of Medicaid providers described in [paragraph (2)(A)](#t-2-A) for—
      - (i) the first year of payment with respect to such a provider, the average costs for the purchase and initial implementation or upgrade of such technology (and support services [including](/usc/42/1301.md?p=b) training that is for, or is necessary for the adoption and initial operation of, such technology) for such providers, as determined by the [Secretary](/usc/42/1301.md?p=a-6) based upon studies conducted under [paragraph (4)(C)](#t-4-C); and
      - (ii) a subsequent year of payment with respect to such a provider, the average costs not described in [clause (i)](#t-3-C-i) relating to the operation, maintenance, and use of such technology for such providers, as determined by the [Secretary](/usc/42/1301.md?p=a-6) based upon studies conducted under [paragraph (4)(C)](#t-4-C).
    - (D) The term “[hospital](/usc/42/300s–3.md?p=1)-based” means, with respect to an eligible professional, a professional (such as a pathologist, anesthesiologist, or emergency [physician](/usc/42/1301.md?p=a-7)) who furnishes substantially all of the individual’s professional services in a [hospital](/usc/42/300s–3.md?p=1) inpatient or emergency room setting and through the use of the [facilities](/usc/42/1320a–3.md?p=c-5-B) and equipment, [including](/usc/42/1301.md?p=b) qualified electronic health records, of the [hospital](/usc/42/300s–3.md?p=1). The determination of whether an eligible professional is a [hospital](/usc/42/300s–3.md?p=1)-based eligible professional shall be made on the basis of the site of service (as defined by the [Secretary](/usc/42/1301.md?p=a-6)) and without regard to any employment or billing arrangement between the eligible professional and any other provider.
    - (E) The term “net average allowable costs” means, with respect to a Medicaid provider described in [paragraph (2)(A)](#t-2-A), average allowable costs reduced by the average payment the [Secretary](/usc/42/1301.md?p=a-6) estimates will be made to such Medicaid providers (determined on a percentage or other basis for such classes or types of providers as the [Secretary](/usc/42/1301.md?p=a-6) may specify) from other sources (other than under this subsection, or by the Federal government or a [State](/usc/42/619.md?p=5) or local government) that is directly attributable to payment for certified EHR technology or support services described in [subparagraph (C)](#t-3-C).
    - (F) The term “needy individual” means, with respect to a Medicaid provider, an individual—
      - (i) who is receiving assistance under this subchapter;
      - (ii) who is receiving assistance under subchapter XXI;
      - (iii) who is furnished uncompensated care by the provider; or
      - (iv) for whom charges are reduced by the provider on a sliding scale basis based on an individual’s ability to pay.
  - (4)
    - (A) With respect to a Medicaid provider described in [paragraph (2)(A)](#t-2-A), subject to [subparagraph (B)](#t-4-B), in no case shall—
      - (i) the net average allowable costs under this subsection for the first year of payment (which may not be later than 2016), which is intended to cover the costs described in [paragraph (3)(C)(i)](#t-3-C-i), exceed $25,000 (or such lesser amount as the [Secretary](/usc/42/1301.md?p=a-6) determines based on studies conducted under [subparagraph (C)](#t-4-C));
      - (ii) the net average allowable costs under this subsection for a subsequent year of payment, which is intended to cover costs described in [paragraph (3)(C)(ii)](#t-3-C-ii), exceed $10,000; and
      - (iii) payments be made for costs described in [clause (ii)](#t-4-A-ii) after 2021 or over a period of longer than 5 years.
    - (B) In the case of Medicaid[^10] provider described in [paragraph (2)(A)(ii)](#t-2-A-ii), the dollar amounts specified in [subparagraph (A)](#t-4-A) shall be ⅔ of the dollar amounts otherwise specified.
    - (C) For the purposes of determining average allowable costs under this subsection, the [Secretary](/usc/42/1301.md?p=a-6) shall study the average costs to Medicaid providers described in [paragraph (2)(A)](#t-2-A) of purchase and initial implementation and upgrade of certified EHR technology described in [paragraph (3)(C)(i)](#t-3-C-i) and the average costs to such providers of operations, maintenance, and use of such technology described in [paragraph (3)(C)(ii)](#t-3-C-ii). In determining such costs for such providers, the [Secretary](/usc/42/1301.md?p=a-6) may utilize studies of such amounts submitted by [States](/usc/42/619.md?p=5).
  - (5)
    - (A) In no case shall the payments described in [paragraph (1)(B)](#t-1-B) with respect to a Medicaid provider described in [paragraph (2)(B)](#t-2-B) exceed—
      - (i) in the aggregate the product of—
        - (I) the overall [hospital](/usc/42/300s–3.md?p=1) EHR amount for the provider computed under [subparagraph (B)](#t-5-B); and
        - (II) the Medicaid share for such provider computed under [subparagraph (C)](#t-5-C);
      - (ii) in any year 50 percent of the product described in [clause (i)](#t-5-A-i); and
      - (iii) in any 2-year period 90 percent of such product.
    - (B) For purposes of this paragraph, the overall [hospital](/usc/42/300s–3.md?p=1) EHR amount, with respect to a Medicaid provider, is the sum of the applicable amounts specified in [section 1395ww(n)(2)(A) of this title](/usc/42/1395ww.md?p=n-2-A) for such provider for the first 4 payment years (as estimated by the [Secretary](/usc/42/1301.md?p=a-6)) determined as if the Medicare share specified in [clause (ii)](/usc/42/1395ww.md?p=n-2-A-ii) of such section were 1. The [Secretary](/usc/42/1301.md?p=a-6) shall establish, in consultation with the [State](/usc/42/619.md?p=5), the overall [hospital](/usc/42/300s–3.md?p=1) EHR amount for each such Medicaid provider eligible for payments under [paragraph (1)(B)](#t-1-B). For purposes of this subparagraph in computing the amounts under [section 1395ww(n)(2)(C) of this title](/usc/42/1395ww.md?p=n-2-C) for payment years after the first payment year, the [Secretary](/usc/42/1301.md?p=a-6) shall assume that in subsequent payment years discharges increase at the average annual rate of growth of the most recent 3 years for which discharge data are available per year.
    - (C) The Medicaid share computed under this subparagraph, for a Medicaid provider for a period specified by the [Secretary](/usc/42/1301.md?p=a-6), shall be calculated in the same manner as the Medicare share under [section 1395ww(n)(2)(D) of this title](/usc/42/1395ww.md?p=n-2-D) for such a [hospital](/usc/42/300s–3.md?p=1) and period, except that there shall be substituted for the numerator under [clause (i)](/usc/42/1395ww.md?p=n-2-D-i) of such section the amount that is equal to the number of inpatient-bed-days (as established by the [Secretary](/usc/42/1301.md?p=a-6)) which are attributable to individuals who are receiving [medical assistance](/usc/42/1396d.md?p=a) under this subchapter and who are not described in [section 1395ww(n)(2)(D)(i) of this title](/usc/42/1395ww.md?p=n-2-D-i). In computing inpatient-bed-days under the previous sentence, the [Secretary](/usc/42/1301.md?p=a-6) shall take into account inpatient-bed-days attributable to inpatient-bed-days that are paid for individuals enrolled in a Medicaid managed care plan (under [subsection (m)](#m) or [section 1396u–2 of this title](/usc/42/1396u–2.md)).
    - (D) In no case may the payments described in [paragraph (1)(B)](#t-1-B) with respect to a Medicaid provider described in [paragraph (2)(B)](#t-2-B) be paid—
      - (i) for any year beginning after 2016 unless the provider has been provided payment under [paragraph (1)(B)](#t-1-B) for the previous year; and
      - (ii) over a period of more than 6 years of payment.
  - (6) Payments described in [paragraph (1)](#t-1) are not in accordance with this subsection unless the following requirements are met:
    - (A)
      - (i) The [State](/usc/42/619.md?p=5) provides assurances satisfactory to the [Secretary](/usc/42/1301.md?p=a-6) that amounts received under [subsection (a)(3)(F)](#a-3-F) with respect to payments to a Medicaid provider are paid, subject to [clause (ii)](#t-6-A-ii), directly to such provider (or to an employer or [facility](/usc/42/1320a–3.md?p=c-5-B) to which such provider has assigned payments) without any deduction or rebate.
      - (ii) Amounts described in [clause (i)](#t-6-A-i) may also be paid to an entity promoting the adoption of certified EHR technology, as designated by the [State](/usc/42/619.md?p=5), if participation in such a payment arrangement is voluntary for the eligible professional involved and if such entity does not retain more than 5 percent of such payments for costs not related to certified EHR technology (and support services [including](/usc/42/1301.md?p=b) maintenance and training) that is for, or is necessary for the operation of, such technology.
    - (B) A Medicaid provider described in [paragraph (2)(A)](#t-2-A) is responsible for payment of the remaining 15 percent of the net average allowable cost and shall be determined to have met such responsibility to the extent that the payment to the Medicaid provider is not in excess of 85 percent of the net average allowable cost.
    - (C)
      - (i) Subject to [clause (ii)](#t-6-C-ii), with respect to payments to a Medicaid provider—
        - (I) for the first year of payment to the Medicaid provider under this subsection, the Medicaid provider demonstrates that it is engaged in efforts to adopt, implement, or upgrade certified EHR technology; and
        - (II) for a year of payment, other than the first year of payment to the Medicaid provider under this subsection, the Medicaid provider demonstrates meaningful use of certified EHR technology through a means that is approved by the [State](/usc/42/619.md?p=5) and acceptable to the [Secretary](/usc/42/1301.md?p=a-6), and that may be based upon the methodologies applied under section [1395w–4(o)](/usc/42/1395w–4.md?p=o) or [1395ww(n)](/usc/42/1395ww.md?p=n) of this title.
      - (ii) In the case of a Medicaid provider who has completed adopting, implementing, or upgrading such technology prior to the first year of payment to the Medicaid provider under this subsection, [clause (i)(I)](#t-6-C-i-I) shall not apply and [clause (i)(II)](#t-6-C-i-II) shall apply to each year of payment to the Medicaid provider under this subsection, [including](/usc/42/1301.md?p=b) the first year of payment.
    - (D) To the extent specified by the [Secretary](/usc/42/1301.md?p=a-6), the certified EHR technology is compatible with [State](/usc/42/619.md?p=5) or Federal administrative management systems.

    For purposes of [subparagraph (B)](#t-6-B), a Medicaid provider described in [paragraph (2)(A)](#t-2-A) may accept payments for the costs described in such subparagraph from a [State](/usc/42/619.md?p=5) or local government. For purposes of [subparagraph (C)](#t-6-C), in establishing the means described in such subparagraph, which may include clinical quality reporting to the [State](/usc/42/619.md?p=5), the [State](/usc/42/619.md?p=5) shall ensure that populations with unique needs, such as children, are appropriately addressed.

  - (7) With respect to Medicaid providers described in [paragraph (2)(A)](#t-2-A), the [Secretary](/usc/42/1301.md?p=a-6) shall ensure coordination of payment with respect to such providers under sections [1395w–4(o)](/usc/42/1395w–4.md?p=o) and [1395w–23(l)](/usc/42/1395w–23.md?p=l) of this title and under this subsection to assure no duplication of funding. Such coordination shall include, to the extent practicable, a data matching process between [State](/usc/42/619.md?p=5) Medicaid [agencies](/usc/42/1397n–12.md?p=1) and the Centers for Medicare & Medicaid Services using national provider identifiers. For such purposes, the [Secretary](/usc/42/1301.md?p=a-6) may require the submission of such data relating to payments to such Medicaid providers as the [Secretary](/usc/42/1301.md?p=a-6) may specify.
  - (8) In carrying out [paragraph (6)(C)](#t-6-C), the [State](/usc/42/619.md?p=5) and [Secretary](/usc/42/1301.md?p=a-6) shall seek, to the maximum extent practicable, to avoid duplicative requirements from Federal and [State](/usc/42/619.md?p=5) governments to demonstrate meaningful use of certified EHR technology under this subchapter and subchapter XVIII. In doing so, the [Secretary](/usc/42/1301.md?p=a-6) may deem satisfaction of requirements for such meaningful use for a payment year under subchapter XVIII to be sufficient to qualify as meaningful use under this subsection. The [Secretary](/usc/42/1301.md?p=a-6) may also specify the reporting periods under this subsection in order to carry out this paragraph.
  - (9) In order to be provided Federal financial participation under [subsection (a)(3)(F)(ii)](#a-3-F-ii), a [State](/usc/42/619.md?p=5) must demonstrate to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6), that the [State](/usc/42/619.md?p=5)—
    - (A) is using the funds provided for the purposes of administering payments under this subsection, [including](/usc/42/1301.md?p=b) tracking of meaningful use by Medicaid providers;
    - (B) is conducting adequate oversight of the program under this subsection, [including](/usc/42/1301.md?p=b) routine tracking of meaningful use attestations and reporting mechanisms; and
    - (C) is pursuing initiatives to encourage the adoption of certified EHR technology to promote health care quality and the exchange of health care information under this subchapter, subject to applicable laws and regulations governing such exchange.
  - (10) The [Secretary](/usc/42/1301.md?p=a-6) shall periodically submit reports to the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate on status, progress, and oversight of payments described in [paragraph (1)](#t-1), [including](/usc/42/1301.md?p=b) steps taken to carry out [paragraph (7)](#t-7). Such reports shall also describe the extent of adoption of certified EHR technology among Medicaid providers resulting from the provisions of this subsection and any improvements in health outcomes, clinical quality, or efficiency resulting from such adoption.
- (u) **Limitation of Federal financial participation in erroneous medical assistance expenditures—**
  - (1)
    - (A) Notwithstanding [subsection (a)(1)](#a-1), if the ratio of a [State](/usc/42/619.md?p=5)’s erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a) (as defined in [subparagraph (D)](#u-1-D)) to its total expenditures for [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan approved under this subchapter exceeds 0.03, for the period consisting of the third and fourth quarters of [fiscal year](/usc/42/619.md?p=3) 1983, or for any full [fiscal year](/usc/42/619.md?p=3) thereafter, then the [Secretary](/usc/42/1301.md?p=a-6) shall make no payment for such period or [fiscal year](/usc/42/619.md?p=3) with respect to so much of such erroneous excess payments as exceeds such allowable error rate of 0.03.
    - (B) The [Secretary](/usc/42/1301.md?p=a-6) may waive, in certain limited cases, all or part of the reduction required under [subparagraph (A)](#u-1-A) with respect to any [State](/usc/42/619.md?p=5) if such [State](/usc/42/619.md?p=5) is unable to reach the allowable error rate for a period or [fiscal year](/usc/42/619.md?p=3) despite a good faith effort by such [State](/usc/42/619.md?p=5).
    - (C) In estimating the amount to be paid to a [State](/usc/42/619.md?p=5) under [subsection (d)](#d), the [Secretary](/usc/42/1301.md?p=a-6) shall take into consideration the limitation on Federal financial participation imposed by [subparagraph (A)](#u-1-A) and shall reduce the estimate he makes under [subsection (d)(1)](#d-1), for purposes of payment to the [State](/usc/42/619.md?p=5) under [subsection (d)(3)](#d-3), in light of any expected erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a) (estimated in accordance with such criteria, [including](/usc/42/1301.md?p=b) sampling procedures, as he may prescribe and subject to subsequent adjustment, if necessary, under [subsection (d)(2)](#d-2)).
    - (D)
      - (i) For purposes of this subsection, the term “erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a)” means the total of—
        - (I) payments under the [State](/usc/42/619.md?p=5) plan with respect to ineligible individuals and families, and
        - (II) overpayments on behalf of eligible individuals and families by reason of error in determining the amount of expenditures for [medical care](/usc/42/1301.md?p=a-7) required of an individual or family as a condition of eligibility.
      - (ii) In determining the amount of erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a) to an ineligible individual or family under [clause (i)(I)](#u-1-D-i-I), if such ineligibility is the result of an error in determining the amount of the resources of such individual or family, the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment with respect to such individual or family, or (II) the difference between the actual amount of such resources and the allowable resource level established under the [State](/usc/42/619.md?p=5) plan.
      - (iii) In determining the amount of erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a) to an individual or family under [clause (i)(II)](#u-1-D-i-II), the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment on behalf of the individual or family, or (II) the difference between the actual amount incurred for [medical care](/usc/42/1301.md?p=a-7) by the individual or family and the amount which should have been incurred in order to establish eligibility for [medical assistance](/usc/42/1396d.md?p=a).
      - (iv) In determining the amount of erroneous excess payments, there shall not be included any error resulting from a failure of an individual to cooperate or give correct information with respect to third-party liability as required under section [1396k(a)(1)(C)](/usc/42/1396k.md?p=a-1-C) or [602(a)(26)(C)](/usc/42/602.md)[^4] of this title or with respect to payments made in [violation](/usc/42/2000e–16a.md?p=c) of [section 1396e of this title](/usc/42/1396e.md).
      - (v) In determining the amount of erroneous excess payments, there shall not be included any erroneous payments made for ambulatory prenatal care provided during a presumptive eligibility period (as defined in [section 1396r–1(b)(1) of this title](/usc/42/1396r–1.md?p=b-1)), for items and services described in subsection (a) of [section 1396r–1a of this title](/usc/42/1396r–1a.md) provided to a [child](/usc/42/1382c.md?p=c) during a presumptive eligibility period under such section, for [medical assistance](/usc/42/1396d.md?p=a) provided to an individual described in subsection (a) of [section 1396r–1b of this title](/usc/42/1396r–1b.md) during a presumptive eligibility period under such section, or[^11] for [medical assistance](/usc/42/1396d.md?p=a) provided to an individual described in subsection (a) of [section 1396r–1c of this title](/usc/42/1396r–1c.md) during a presumptive eligibility period under such section, or for [medical assistance](/usc/42/1396d.md?p=a) provided to an individual during a presumptive eligibility period resulting from a determination of presumptive eligibility made by a [hospital](/usc/42/300s–3.md?p=1) that elects under [section 1396a(a)(47)(B) of this title](/usc/42/1396a.md?p=a-47-B) to be a qualified entity for such purpose.
    - (E) For purposes of [subparagraph (D)](#u-1-D), there shall be excluded, in determining both erroneous excess payments for [medical assistance](/usc/42/1396d.md?p=a) and total expenditures for [medical assistance](/usc/42/1396d.md?p=a)—
      - (i) payments with respect to any individual whose eligibility therefor was determined exclusively by the [Secretary](/usc/42/1301.md?p=a-6) under an agreement pursuant to [section 1383c of this title](/usc/42/1383c.md) and such other classes of individuals as the [Secretary](/usc/42/1301.md?p=a-6) may by regulation prescribe whose eligibility was determined in part under such an agreement; and
      - (ii) payments made as the result of a technical error.
  - (2) The [State agency](/usc/42/629a.md?p=a-3) administering the plan approved under this subchapter shall, at such times and in such form as the [Secretary](/usc/42/1301.md?p=a-6) may specify, provide information on the rates of erroneous excess payments made (or expected, with respect to future periods specified by the [Secretary](/usc/42/1301.md?p=a-6)) in connection with its [administration](/usc/42/1301.md?p=a-10) of such plan, together with any other data he requests that are reasonably necessary for him to carry out the provisions of this subsection.
  - (3)
    - (A) If a [State](/usc/42/619.md?p=5) fails to cooperate with the [Secretary](/usc/42/1301.md?p=a-6) in providing information necessary to carry out this subsection, the [Secretary](/usc/42/1301.md?p=a-6), directly or through contractual or such other arrangements as he may find appropriate, shall establish the error rates for that [State](/usc/42/619.md?p=5) on the basis of the best data reasonably available to him and in accordance with such techniques for sampling and estimating as he finds appropriate.
    - (B) In any case in which it is necessary for the [Secretary](/usc/42/1301.md?p=a-6) to exercise his authority under [subparagraph (A)](#u-3-A) to determine a [State](/usc/42/619.md?p=5)’s error rates for a [fiscal year](/usc/42/619.md?p=3), the amount that would otherwise be payable to such [State](/usc/42/619.md?p=5) under this subchapter for quarters in such year shall be reduced by the costs incurred by the [Secretary](/usc/42/1301.md?p=a-6) in making (directly or otherwise) such determination.
  - (4) This subsection shall not apply with respect to Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, or American Samoa.
- (v) **Medical assistance to aliens not lawfully admitted for permanent residence—**
  - (1) Notwithstanding the preceding provisions of this section, except as provided in paragraphs [(2)](#v-2), [(4)](#v-4), and [(5)](#v-5), no payment may be made to a [State](/usc/42/619.md?p=5) under this section for [medical assistance](/usc/42/1396d.md?p=a) furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the [United States](/usc/42/1301.md?p=a-2) under color of law.
  - (2) Payment shall be made under this section for care and services that are furnished to an alien described in [paragraph (1)](#v-1) only if—
    - (A) such care and services are necessary for the [treatment](/usc/42/11851.md?p=11) of an emergency medical condition of the alien,
    - (B) such alien otherwise meets the eligibility requirements for [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan approved under this subchapter (other than the requirement of the receipt of aid or assistance under subchapter IV, supplemental security income benefits under subchapter XVI, or a [State supplementary payment](/usc/42/1396d.md?p=j)), and
    - (C) such care and services are not related to an organ transplant procedure.
  - (3) For purposes of this subsection, the term “emergency medical condition” means a medical condition ([including](/usc/42/1301.md?p=b) emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity ([including](/usc/42/1301.md?p=b) severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—
    - (A) placing the patient’s health in serious jeopardy,
    - (B) serious impairment to bodily functions, or
    - (C) serious dysfunction of any bodily organ or part.
  - (4)
    - (A) A [State](/usc/42/619.md?p=5) may elect (in a plan amendment under this subchapter) to provide [medical assistance](/usc/42/1396d.md?p=a) under this subchapter, notwithstanding sections [1611(a)](/usc/8/1611.md?p=a), [1612(b)](/usc/8/1612.md?p=b), [1613](/usc/8/1613.md), and [1631](/usc/8/1631.md) of title 8, to children and pregnant women who are lawfully residing in the [United States](/usc/42/1301.md?p=a-2) ([including](/usc/42/1301.md?p=b) battered individuals described in [section 1641(c) of title 8](/usc/8/1641.md?p=c)) and who are otherwise eligible for such assistance, within either or both of the following eligibility categories:
      - (i) **Pregnant women—** Women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy).
      - (ii) **Children—** Individuals under 21 years of age, [including](/usc/42/1301.md?p=b) optional targeted low-income children described in [section 1396d(u)(2)(B) of this title](/usc/42/1396d.md?p=u-2-B).
    - (B) In the case of a [State](/usc/42/619.md?p=5) that has elected to provide [medical assistance](/usc/42/1396d.md?p=a) to a category of aliens under [subparagraph (A)](#v-4-A), no debt shall accrue under an affidavit of support against any sponsor of such an alien on the basis of provision of assistance to such category and the cost of such assistance shall not be considered as an unreimbursed cost.
    - (C) As part of the [State](/usc/42/619.md?p=5)’s ongoing eligibility redetermination requirements and procedures for an individual provided [medical assistance](/usc/42/1396d.md?p=a) as a result of an election by the [State](/usc/42/619.md?p=5) under [subparagraph (A)](#v-4-A), a [State](/usc/42/619.md?p=5) shall verify that the individual continues to lawfully reside in the [United States](/usc/42/1301.md?p=a-2) using the documentation presented to the [State](/usc/42/619.md?p=5) by the individual on initial enrollment. If the [State](/usc/42/619.md?p=5) cannot successfully verify that the individual is lawfully residing in the [United States](/usc/42/1301.md?p=a-2) in this manner, it shall require that the individual provide the [State](/usc/42/619.md?p=5) with further documentation or other evidence to verify that the individual is lawfully residing in the [United States](/usc/42/1301.md?p=a-2).
  - (5) Notwithstanding the preceding paragraphs of this subsection, beginning on October 1, 2026, except as provided in paragraphs [(2)](#v-2) and [(4)](#v-4), in no event shall payment be made to a [State](/usc/42/619.md?p=5) under this section for [medical assistance](/usc/42/1396d.md?p=a) furnished to an individual unless such individual is—
    - (A) a resident of 1 of the 50 [States](/usc/42/619.md?p=5), the District of Columbia, or a [territory](/usc/42/701.md?p=c-5-C) of the [United States](/usc/42/1301.md?p=a-2); and
    - (B) either—
      - (i) a citizen or national of the [United States](/usc/42/1301.md?p=a-2);
      - (ii) an alien lawfully admitted for permanent residence as an immigrant as defined by sections [1101(a)(15)](/usc/8/1101.md?p=a-15) and [1101(a)(20)](/usc/8/1101.md?p=a-20) of title 8, excluding, among others, alien visitors, tourists, diplomats, and students who enter the [United States](/usc/42/1301.md?p=a-2) temporarily with no intention of abandoning their residence in a foreign country;
      - (iii) an alien who has been granted the status of Cuban and Haitian entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980 (Public Law 96–422); or
      - (iv) an individual who lawfully resides in the [United States](/usc/42/1301.md?p=a-2) in accordance with a [Compact](/usc/42/2021b.md?p=4) of Free Association referred to in [section 1612(b)(2)(G) of title 8](/usc/8/1612.md?p=b-2-G).
- (w) **Prohibition on use of voluntary contributions, and limitation on use of provider-specific taxes to obtain Federal financial participation under medicaid—**
  - (1)
    - (A) Notwithstanding the previous provisions of this section, for purposes of determining the amount to be paid to a [State](/usc/42/619.md?p=5) (as defined in [paragraph (7)(D)](#w-7-D)) under [subsection (a)(1)](#a-1) for quarters in any [fiscal year](/usc/42/619.md?p=3), the total amount expended during such [fiscal year](/usc/42/619.md?p=3) as [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan (as determined without regard to this subsection) shall be reduced by the sum of any revenues received by the [State](/usc/42/619.md?p=5) (or by a unit of local government in the [State](/usc/42/619.md?p=5)) during the [fiscal year](/usc/42/619.md?p=3)—
      - (i) from provider-related donations (as defined in [paragraph (2)(A)](#w-2-A)), other than—
        - (I) bona fide provider-related donations (as defined in [paragraph (2)(B)](#w-2-B)), and
        - (II) donations described in [paragraph (2)(C)](#w-2-C);
      - (ii) from health care related taxes (as defined in [paragraph (3)(A)](#w-3-A)), other than broad-based health care related taxes (as defined in [paragraph (3)(B)](#w-3-B));
      - (iii) from a broad-based health care related tax, if there is in effect a hold harmless provision (described in [paragraph (4)](#w-4)) with respect to the tax; or
      - (iv) only with respect to [State](/usc/42/619.md?p=5) [fiscal years](/usc/42/619.md?p=3) (or portions thereof) occurring on or after January 1, 1992, and before October 1, 1995, from broad-based health care related taxes to the extent the amount of such taxes collected exceeds the limit established under [paragraph (5)](#w-5).
    - (B) Notwithstanding the previous provisions of this section, for purposes of determining the amount to be paid to a [State](/usc/42/619.md?p=5) under [subsection (a)(7)](#a-7) for all quarters in a Federal [fiscal year](/usc/42/619.md?p=3) (beginning with [fiscal year](/usc/42/619.md?p=3) 1993), the total amount expended during the [fiscal year](/usc/42/619.md?p=3) for administrative expenditures under the [State](/usc/42/619.md?p=5) plan (as determined without regard to this subsection) shall be reduced by the sum of any revenues received by the [State](/usc/42/619.md?p=5) (or by a unit of local government in the [State](/usc/42/619.md?p=5)) during such quarters from donations described in [paragraph (2)(C)](#w-2-C), to the extent the amount of such donations exceeds 10 percent of the amounts expended under the [State](/usc/42/619.md?p=5) plan under this subchapter during the [fiscal year](/usc/42/619.md?p=3) for purposes described in paragraphs [(2)](#a-2), [(3)](#a-3), [(4)](#a-4), [(6)](#a-6), and [(7)](#a-7) of subsection (a).
    - (C)
      - (i) Except as otherwise provided in [clause (ii)](#w-1-C-ii), [subparagraph (A)(i)](#w-1-A-i) shall apply to donations received on or after January 1, 1992.
      - (ii) Subject to the limits described in [clause (iii)](#w-1-C-iii) and [subparagraph (E)](#w-1-E), [subparagraph (A)(i)](#w-1-A-i) shall not apply to donations received before the effective date specified in [subparagraph (F)](#w-1-F) if such donations are received under programs in effect or as described in [State](/usc/42/619.md?p=5) plan amendments or related documents submitted to the [Secretary](/usc/42/1301.md?p=a-6) by September 30, 1991, and applicable to [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992, as demonstrated by [State](/usc/42/619.md?p=5) plan amendments, written agreements, [State](/usc/42/619.md?p=5) budget documentation, or other documentary evidence in existence on that date.
      - (iii) In applying [clause (ii)](#w-1-C-ii) in the case of donations received in [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1993, the maximum amount of such donations to which such clause may be applied may not exceed the total amount of such donations received in the corresponding period in [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992 (or not later than 5 days after the last day of the corresponding period).
    - (D)
      - (i) Except as otherwise provided in [clause (ii)](#w-1-D-ii), subparagraphs [(A)(ii)](#w-1-A-ii) and [(A)(iii)](#w-1-A-iii) shall apply to taxes received on or after January 1, 1992.
      - (ii) Subparagraphs [(A)(ii)](#w-1-A-ii) and [(A)(iii)](#w-1-A-iii) shall not apply to impermissible taxes (as defined in [clause (iii)](#w-1-D-iii)) received before the effective date specified in [subparagraph (F)](#w-1-F) to the extent the taxes ([including](/usc/42/1301.md?p=b) the tax rate or base) were in effect, or the legislation or regulations imposing such taxes were enacted or adopted, as of November 22, 1991.
      - (iii) In this subparagraph and [subparagraph (E)](#w-1-E), the term “impermissible tax” means a health care related tax for which a reduction may be made under clause [(ii)](#w-1-A-ii) or [(iii)](#w-1-A-iii) of subparagraph (A).
    - (E)
      - (i) In no case may the total amount of donations and taxes permitted under the exception provided in subparagraphs [(C)(ii)](#w-1-C-ii) and [(D)(ii)](#w-1-D-ii) for the portion of [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992 occurring during calendar year 1992 exceed the limit under [paragraph (5)](#w-5) minus the total amount of broad-based health care related taxes received in the portion of that [fiscal year](/usc/42/619.md?p=3).
      - (ii) In no case may the total amount of donations and taxes permitted under the exception provided in subparagraphs [(C)(ii)](#w-1-C-ii) and [(D)(ii)](#w-1-D-ii) for [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1993 exceed the limit under [paragraph (5)](#w-5) minus the total amount of broad-based health care related taxes received in that [fiscal year](/usc/42/619.md?p=3).
    - (F) In this paragraph in the case of a [State](/usc/42/619.md?p=5)—
      - (i) except as provided in [clause (iii)](#w-1-F-iii), with a [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) beginning on or before July 1, the effective date is October 1, 1992,
      - (ii) except as provided in [clause (iii)](#w-1-F-iii), with a [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) that begins after July 1, the effective date is January 1, 1993, or
      - (iii) with a [State](/usc/42/619.md?p=5) legislature which is not scheduled to have a regular legislative session in 1992, with a [State](/usc/42/619.md?p=5) legislature which is not scheduled to have a regular legislative session in 1993, or with a provider-specific tax enacted on November 4, 1991, the effective date is July 1, 1993.
  - (2)
    - (A) In this subsection (except as provided in [paragraph (6)](#w-6)), the term “provider-related donation” means any donation or other voluntary payment (whether in cash or in kind) made (directly or indirectly) to a [State](/usc/42/619.md?p=5) or unit of local government by—
      - (i) a [health care provider](/usc/42/1320d.md?p=3) (as defined in [paragraph (7)(B)](#w-7-B)),
      - (ii) an entity related to a [health care provider](/usc/42/1320d.md?p=3) (as defined in [paragraph (7)(C)](#w-7-C)), or
      - (iii) an entity providing goods or services under the [State](/usc/42/619.md?p=5) plan for which payment is made to the [State](/usc/42/619.md?p=5) under paragraph [(2)](#a-2), [(3)](#a-3), [(4)](#a-4), [(6)](#a-6), or [(7)](#a-7) of subsection (a).
    - (B) For purposes of [paragraph (1)(A)(i)(I)](#w-1-A-i-I), the term “bona fide provider-related donation” means a provider-related donation that has no direct or indirect relationship (as determined by the [Secretary](/usc/42/1301.md?p=a-6)) to payments made under this subchapter to that provider, to providers furnishing the same class of items and services as that provider, or to any related entity, as established by the [State](/usc/42/619.md?p=5) to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6). The [Secretary](/usc/42/1301.md?p=a-6) may by regulation specify types of provider-related donations described in the previous sentence that will be considered to be bona fide provider-related donations.
    - (C) For purposes of [paragraph (1)(A)(i)(II)](#w-1-A-i-II), donations described in this subparagraph are funds expended by a [hospital](/usc/42/300s–3.md?p=1), clinic, or similar entity for the direct cost ([including](/usc/42/1301.md?p=b) costs of training and of preparing and distributing outreach materials) of [State](/usc/42/619.md?p=5) or local [agency](/usc/42/1397n–12.md?p=1) personnel who are stationed at the [hospital](/usc/42/300s–3.md?p=1), clinic, or entity to determine the eligibility of individuals for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter and to provide outreach services to eligible or potentially eligible individuals.
  - (3)
    - (A) In this subsection (except as provided in [paragraph (6)](#w-6)), the term “health care related tax” means a tax (as defined in [paragraph (7)(F)](#w-7-F)) that—
      - (i) is related to health care items or services, or to the provision of, the authority to provide, or payment for, such items or services, or
      - (ii) is not limited to such items or services but provides for [treatment](/usc/42/11851.md?p=11) of individuals or entities that are providing or paying for such items or services that is different from the [treatment](/usc/42/11851.md?p=11) provided to other individuals or entities.

      In applying [clause (i)](#w-3-A-i), a tax is considered to relate to health care items or services if at least 85 percent of the burden of such tax falls on [health care providers](/usc/42/1320d.md?p=3).

    - (B) In this subsection, the term “broad-based health care related tax” means a health care related tax which is imposed with respect to a class of health care items or services (as described in [paragraph (7)(A)](#w-7-A)) or with respect to providers of such items or services and which, except as provided in subparagraphs [(D)](#w-3-D), [(E)](#w-3-E), and [(F)](#w-3-F)—
      - (i) is imposed at least with respect to all items or services in the class furnished by all non-Federal, nonpublic providers in the [State](/usc/42/619.md?p=5) (or, in the case of a tax imposed by a unit of local government, the area over which the unit has jurisdiction) or is imposed with respect to all non-Federal, nonpublic providers in the class; and
      - (ii) is imposed uniformly (in accordance with [subparagraph (C)](#w-3-C)).
    - (C)
      - (i) Subject to [clause (ii)](#w-3-C-ii), for purposes of [subparagraph (B)(ii)](#w-3-B-ii), a tax is considered to be imposed uniformly if—
        - (I) in the case of a tax consisting of a licensing fee or similar tax on a class of health care items or services (or providers of such items or services), the amount of the tax imposed is the same for every provider providing items or services within the class;
        - (II) in the case of a tax consisting of a licensing fee or similar tax imposed on a class of health care items or services (or providers of such services) on the basis of the number of beds (licensed or otherwise) of the provider, the amount of the tax is the same for each bed of each provider of such items or services in the class;
        - (III) in the case of a tax based on revenues or receipts with respect to a class of items or services (or providers of items or services) the tax is imposed at a uniform rate for all items and services (or providers of such items or services) in the class on all the gross revenues or receipts, or net operating revenues, relating to the provision of all such items or services (or all such providers) in the [State](/usc/42/619.md?p=5) (or, in the case of a tax imposed by a unit of local government within the [State](/usc/42/619.md?p=5), in the area over which the unit has jurisdiction); or
        - (IV) in the case of any other tax, the [State](/usc/42/619.md?p=5) establishes to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that the tax is imposed uniformly.
      - (ii) Subject to subparagraphs [(D)](#w-3-D) and [(E)](#w-3-E), a tax imposed with respect to a class of health care items and services is not considered to be imposed uniformly if the tax provides for any credits, exclusions, or deductions which have as their purpose or effect the return to providers of all or a portion of the tax paid in a manner that is inconsistent with subclauses [(I)](#w-3-E-ii-I) and [(II)](#w-3-E-ii-II) of subparagraph (E)(ii) or provides for a hold harmless provision described in [paragraph (4)](#w-4).
    - (D) A tax imposed with respect to a class of health care items and services is considered to be imposed uniformly—
      - (i) notwithstanding that the tax is not imposed with respect to items or services (or the providers thereof) for which payment is made under a [State](/usc/42/619.md?p=5) plan under this subchapter or subchapter XVIII, or
      - (ii) in the case of a tax described in [subparagraph (C)(i)(III)](#w-3-C-i-III), notwithstanding that the tax provides for exclusion (in whole or in part) of revenues or receipts from a [State](/usc/42/619.md?p=5) plan under this subchapter or subchapter XVIII.
    - (E)
      - (i) A [State](/usc/42/619.md?p=5) may submit an application to the [Secretary](/usc/42/1301.md?p=a-6) requesting that the [Secretary](/usc/42/1301.md?p=a-6) treat a tax as a broad-based health care related tax, notwithstanding that the tax does not apply to all health care items or services in class (or all providers of such items and services), provides for a credit, deduction, or exclusion, is not applied uniformly, or otherwise does not meet the requirements of subparagraph [(B)](#w-3-B) or [(C)](#w-3-C). Permissible waivers may include exemptions for rural or sole-community providers.
      - (ii) The [Secretary](/usc/42/1301.md?p=a-6) shall approve such an application if the [State](/usc/42/619.md?p=5) establishes to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6) that—
        - (I) the net impact of the tax and associated expenditures under this subchapter as proposed by the [State](/usc/42/619.md?p=5) is generally redistributive in nature, and
        - (II) the amount of the tax is not directly correlated to payments under this subchapter for items or services with respect to which the tax is imposed.
      - (iii) For purposes of [clause (ii)(I)](#w-3-E-ii-I), a tax is not considered to be generally redistributive if any of the following conditions apply:
        - (I) Within a permissible class, the tax rate imposed on any taxpayer or tax rate group (as defined in [paragraph (7)(J)](#w-7-J)) explicitly defined by its relatively lower volume or percentage of Medicaid taxable units (as defined in [paragraph (7)(H)](#w-7-H)) is lower than the tax rate imposed on any other taxpayer or tax rate group explicitly defined by its relatively higher volume or percentage of Medicaid taxable units.
        - (II) Within a permissible class, the tax rate imposed on any taxpayer or tax rate group (as so defined) based upon its Medicaid taxable units (as so defined) is higher than the tax rate imposed on any taxpayer or tax rate group based upon its non-Medicaid taxable unit (as defined in [paragraph (7)(I)](#w-7-I)).
        - (III) The tax excludes or imposes a lower tax rate on a taxpayer or tax rate group (as so defined) based on or defined by any description that results in the same effect as described in subclause [(I)](#w-3-E-iii-I) or [(II)](#w-3-E-iii-II) for a taxpayer or tax rate group. Characteristics that may indicate such type of exclusion include the use of terminology to establish a tax rate group—
          - (aa) based on payments or expenditures made under the program under this subchapter without mentioning the term “Medicaid” (or any similar term) to accomplish the same effect as described in subclause [(I)](#w-3-E-iii-I) or [(II)](#w-3-E-iii-II); or
          - (bb) that closely approximates a taxpayer or tax rate group under the program under this subchapter, to the same effect as described in subclause [(I)](#w-3-E-iii-I) or [(II)](#w-3-E-iii-II).

        The [Secretary](/usc/42/1301.md?p=a-6) shall by regulation specify types of credits, exclusions, and deductions that will be considered to meet the requirements of this subparagraph.

    - (F) In no case shall a tax not qualify as a broad-based health care related tax under this paragraph because it does not apply to a [hospital](/usc/42/300s–3.md?p=1) that is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under [section 501(a)](/usc/42/501.md) of such Code and that does not accept payment under the [State](/usc/42/619.md?p=5) plan under this subchapter or under subchapter XVIII.
  - (4) For purposes of [paragraph (1)(A)(iii)](#w-1-A-iii), there is in effect a hold harmless provision with respect to a broad-based health care related tax imposed with respect to a class of items or services if the [Secretary](/usc/42/1301.md?p=a-6) determines that any of the following applies:
    - (A) The [State](/usc/42/619.md?p=5) or other unit of government imposing the tax provides (directly or indirectly) for a payment (other than under this subchapter) to taxpayers and the amount of such payment is positively correlated either to the amount of such tax or to the difference between the amount of the tax and the amount of payment under the [State](/usc/42/619.md?p=5) plan.
    - (B) All or any portion of the payment made under this subchapter to the taxpayer varies based only upon the amount of the total tax paid.
    - (C)
      - (i) The [State](/usc/42/619.md?p=5) or other unit of government imposing the tax provides (directly or indirectly) for any payment, offset, or waiver that guarantees to hold taxpayers harmless for any portion of the costs of the tax.
      - (ii) For purposes of [clause (i)](#w-4-C-i), a determination of the existence of an indirect guarantee shall be made under paragraph (3)(i) of section 433.68(f) of title 42, Code of Federal Regulations, as in effect on November 1, 2006, except that for portions of [fiscal years](/usc/42/619.md?p=3) beginning on or after January 1, 2008, and before October 1, 2011, “5.5 percent” shall be substituted for “6 percent” each place it appears, and for [fiscal years](/usc/42/619.md?p=3) beginning on or after October 1, 2026, the applicable percent determined under [subparagraph (D)](#w-4-D) shall be substituted for “6 percent” each place it appears.
    - (D)
      - (i) For purposes of [subparagraph (C)(ii)](#w-4-C-ii), the applicable percent determined under this subparagraph is—
        - (I) in the case of a non-expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) and a class of health care items or services described in section 433.56(a) of title 42, Code of Federal Regulations (as in effect on May 1, 2025)—
          - (aa) if, on July 4, 2025, the non-expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) has enacted a tax and imposes such tax on such class and the [Secretary](/usc/42/1301.md?p=a-6) determines that the tax is within the hold harmless threshold as of that date, the applicable percent of net patient revenue attributable to such class that has been so determined; and
          - (bb) if, on July 4, 2025, the non-expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) has not enacted or does not impose a tax with respect to such class, 0 percent; and
        - (II) in the case of an expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) and a class of health care items or services described in section 433.56(a) of title 42, Code of Federal Regulations (as in effect on May 1, 2025), subject to [clause (iv)](#w-4-D-iv)—
          - (aa) if, on July 4, 2025, the expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) has enacted a tax and imposes such tax on such class and the [Secretary](/usc/42/1301.md?p=a-6) determines that the tax is within the hold harmless threshold as of that date, the lower of—
            - (AA) the applicable percent of net patient revenue attributable to such class that has been so determined; and
            - (BB) the applicable percent specified in [clause (ii)](#w-4-D-ii) for the [fiscal year](/usc/42/619.md?p=3); and
          - (bb) if, on July 4, 2025, the expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) has not enacted or does not impose a tax with respect to such class, 0 percent.
      - (ii) For purposes of [clause (i)(II)(aa)(BB)](#w-4-D-i-II-aa-BB), the applicable percent is—
        - (I) for [fiscal year](/usc/42/619.md?p=3) 2028, 5.5 percent;
        - (II) for [fiscal year](/usc/42/619.md?p=3) 2029, 5 percent;
        - (III) for [fiscal year](/usc/42/619.md?p=3) 2030, 4.5 percent;
        - (IV) for [fiscal year](/usc/42/619.md?p=3) 2031, 4 percent; and
        - (V) for [fiscal year](/usc/42/619.md?p=3) 2032 and each subsequent [fiscal year](/usc/42/619.md?p=3), 3.5 percent.
      - (iii) For purposes of [clause (i)](#w-4-D-i):
        - (I) **Expansion State—** The term “expansion [State](/usc/42/619.md?p=5)” means a [State](/usc/42/619.md?p=5) that, beginning on January 1, 2014, or on any date thereafter, elects to provide [medical assistance](/usc/42/1396d.md?p=a) to all individuals described in [section 1396a(a)(10)(A)(i)(VIII) of this title](/usc/42/1396a.md?p=a-10-A-i-VIII) under the [State](/usc/42/619.md?p=5) plan under this subchapter or under a waiver of such plan.
        - (II) **Non-expansion State—** The term “non-expansion [State](/usc/42/619.md?p=5)” means a [State](/usc/42/619.md?p=5) that is not an expansion [State](/usc/42/619.md?p=5).
      - (iv) In the case of a tax of an expansion [State](/usc/42/619.md?p=5) or unit of local government in such [State](/usc/42/619.md?p=5) in effect on July 4, 2025, that applies to a class of health care items or services that is described in paragraph (3) or (4) of section 433.56(a) of title 42, Code of Federal Regulations (as in effect on May 1, 2025), and for which, on such date, is within the hold harmless threshold (as determined by the [Secretary](/usc/42/1301.md?p=a-6)), the applicable percent of net patient revenue attributable to such class that has been so determined shall apply for a [fiscal year](/usc/42/619.md?p=3) instead of the applicable percent specified in [clause (ii)](#w-4-D-ii) for the [fiscal year](/usc/42/619.md?p=3).

    The provisions of this paragraph shall not prevent use of the tax to reimburse [health care providers](/usc/42/1320d.md?p=3) in a class for expenditures under this subchapter nor preclude [States](/usc/42/619.md?p=5) from relying on such reimbursement to justify or explain the tax in the legislative process.

  - (5)
    - (A) For purposes of this subsection, the limit under this subparagraph with respect to a [State](/usc/42/619.md?p=5) is an amount equal to 25 percent (or, if greater, the [State](/usc/42/619.md?p=5) base percentage, as defined in [subparagraph (B)](#w-5-B)) of the non-Federal share of the total amount expended under the [State](/usc/42/619.md?p=5) plan during a [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) (or portion thereof), as it would be determined pursuant to [paragraph (1)(A)](#w-1-A) without regard to [paragraph (1)(A)(iv)](#w-1-A-iv).
    - (B)
      - (i) In [subparagraph (A)](#w-5-A), the term “[State](/usc/42/619.md?p=5) base percentage” means, with respect to a [State](/usc/42/619.md?p=5), an amount (expressed as a percentage) equal to—
        - (I) the total of the amount of health care related taxes (whether or not broad-based) and the amount of provider-related donations (whether or not bona fide) projected to be collected (in accordance with [clause (ii)](#w-5-B-ii)) during [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992, divided by
        - (II) the non-Federal share of the total amount estimated to be expended under the [State](/usc/42/619.md?p=5) plan during such [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3).
      - (ii) For purposes of [clause (i)(I)](#w-5-B-i-I), in the case of a tax that is not in effect throughout [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992 or the rate (or base) of which is increased during such [fiscal year](/usc/42/619.md?p=3), the [Secretary](/usc/42/1301.md?p=a-6) shall [project](/usc/42/13641.md?p=2) the amount to be collected during such [fiscal year](/usc/42/619.md?p=3) as if the tax (or increase) were in effect during the entire [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3).
    - (C)
      - (i) The total amount of health care related taxes under [subparagraph (B)(i)(I)](#w-5-B-i-I) shall be determined by the [Secretary](/usc/42/1301.md?p=a-6) based on only those taxes ([including](/usc/42/1301.md?p=b) the tax rate or base) which were in effect, or for which legislation or regulations imposing such taxes were enacted or adopted, as of November 22, 1991.
      - (ii) The amount of provider-related donations under [subparagraph (B)(i)(I)](#w-5-B-i-I) shall be determined by the [Secretary](/usc/42/1301.md?p=a-6) based on programs in effect on September 30, 1991, and applicable to [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) 1992, as demonstrated by [State](/usc/42/619.md?p=5) plan amendments, written agreements, [State](/usc/42/619.md?p=5) budget documentation, or other documentary evidence in existence on that date.
      - (iii) The amount of expenditures described in [subparagraph (B)(i)(II)](#w-5-B-i-II) shall be determined by the [Secretary](/usc/42/1301.md?p=a-6) based on the best data available as of December 12, 1991.
  - (6)
    - (A) Notwithstanding the provisions of this subsection, the [Secretary](/usc/42/1301.md?p=a-6) may not restrict [States](/usc/42/619.md?p=5)’ use of funds where such funds are derived from [State](/usc/42/619.md?p=5) or local taxes (or funds appropriated to [State](/usc/42/619.md?p=5) university teaching [hospitals](/usc/42/300s–3.md?p=1)) transferred from or certified by units of government within a [State](/usc/42/619.md?p=5) as the non-Federal share of expenditures under this subchapter, regardless of whether the unit of government is also a [health care provider](/usc/42/1320d.md?p=3), except as provided in [section 1396a(a)(2) of this title](/usc/42/1396a.md?p=a-2), unless the transferred funds are derived by the unit of government from donations or taxes that would not otherwise be recognized as the non-Federal share under this section.
    - (B) For purposes of this subsection, funds the use of which the [Secretary](/usc/42/1301.md?p=a-6) may not restrict under [subparagraph (A)](#w-6-A) shall not be considered to be a provider-related donation or a health care related tax.
  - (7) For purposes of this subsection:
    - (A) Each of the following shall be considered a separate class of health care items and services:
      - (i) Inpatient [hospital](/usc/42/300s–3.md?p=1) services.
      - (ii) Outpatient [hospital](/usc/42/300s–3.md?p=1) services.
      - (iii) [Nursing facility services](/usc/42/1396d.md?p=f) (other than services of intermediate care [facilities](/usc/42/1320a–3.md?p=c-5-B) for the mentally retarded).
      - (iv) Services of intermediate care [facilities](/usc/42/1320a–3.md?p=c-5-B) for the mentally retarded.
      - (v) [Physicians](/usc/42/1301.md?p=a-7)’ services.
      - (vi) Home health care services.
      - (vii) Outpatient prescription [drugs](/usc/42/11851.md?p=4).
      - (viii) Services of managed care organizations ([including](/usc/42/1301.md?p=b) health maintenance organizations, preferred provider organizations, and such other similar organizations as the [Secretary](/usc/42/1301.md?p=a-6) may specify by regulation).
      - (ix) Such other classification of health care items and services consistent with this subparagraph as the [Secretary](/usc/42/1301.md?p=a-6) may establish by regulation.
    - (B) The term “[health care provider](/usc/42/1320d.md?p=3)” means an individual or [person](/usc/42/1301.md?p=a-3) that receives payments for the provision of health care items or services.
    - (C) An entity is considered to be “related” to a [health care provider](/usc/42/1320d.md?p=3) if the entity—
      - (i) is an organization, association, [corporation](/usc/42/1301.md?p=a-4) or partnership formed by or on behalf of [health care providers](/usc/42/1320d.md?p=3);
      - (ii) is a [person with an ownership or control interest](/usc/42/1320a–3.md?p=a-3) (as defined in [section 1320a–3(a)(3) of this title](/usc/42/1320a–3.md?p=a-3)) in the provider;
      - (iii) is the employee, spouse, parent, [child](/usc/42/1382c.md?p=c), or sibling of the provider (or of a [person](/usc/42/1301.md?p=a-3) described in [clause (ii)](#w-7-C-ii)); or
      - (iv) has a similar, close relationship (as defined in regulations) to the provider.
    - (D) The term “[State](/usc/42/619.md?p=5)” means only the 50 [States](/usc/42/619.md?p=5) and the District of Columbia but does not include any [State](/usc/42/619.md?p=5) whose entire program under this subchapter is operated under a waiver granted under [section 1315 of this title](/usc/42/1315.md).
    - (E) The “[State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3)” means, with respect to a specified year, a [State](/usc/42/619.md?p=5) [fiscal year](/usc/42/619.md?p=3) ending in that specified year.
    - (F) The term “tax” [includes](/usc/42/1301.md?p=b) any licensing fee, assessment, or other mandatory payment, but does not include payment of a criminal or civil fine or penalty (other than a fine or penalty imposed in lieu of or instead of a fee, assessment, or other mandatory payment).
    - (G) The term “unit of local government” means, with respect to a [State](/usc/42/619.md?p=5), a city, county, special purpose district, or other governmental unit in the [State](/usc/42/619.md?p=5).
    - (H) The term “Medicaid taxable unit” means a unit that is being taxed within a health care related tax that is applicable to the program under this subchapter. Such term [includes](/usc/42/1301.md?p=b) a unit that is used as the basis for—
      - (i) payment under the program under this subchapter (such as Medicaid bed days);
      - (ii) Medicaid revenue;
      - (iii) costs associated with the program under this subchapter (such as Medicaid charges, claims, or expenditures); and
      - (iv) other units associated with the program under this subchapter, as determined by the [Secretary](/usc/42/1301.md?p=a-6).
    - (I) The term “non-Medicaid taxable unit” means a unit that is being taxed within a health care related tax that is not applicable to the program under this subchapter. Such term [includes](/usc/42/1301.md?p=b) a unit that is used as the basis for—
      - (i) payment by non-Medicaid payers (such as non-Medicaid bed days);
      - (ii) non-Medicaid revenue;
      - (iii) costs that are not associated with the program under this subchapter (such as non-Medicaid charges, non-Medicaid claims, or non-Medicaid expenditures); and
      - (iv) other units not associated with the program under this subchapter, as determined by the [Secretary](/usc/42/1301.md?p=a-6).
    - (J) The term “tax rate group” means a group of entities contained within a permissible class of a health care related tax that are taxed at the same rate.
- (x) **Satisfactory documentary evidence of citizenship or nationality by individual declaring to be citizen or national of United States—**
  - (1) For purposes of [section 1396a(a)(46)(B)(i) of this title](/usc/42/1396a.md?p=a-46-B-i), the requirement of this subsection is, with respect to an individual declaring to be a citizen or national of the [United States](/usc/42/1301.md?p=a-2), that, subject to [paragraph (2)](#x-2), there is presented satisfactory documentary evidence of citizenship or nationality (as defined in [paragraph (3)](#x-3)) of the individual.
  - (2) The requirement of [paragraph (1)](#x-1) shall not apply to an individual declaring to be a citizen or national of the [United States](/usc/42/1301.md?p=a-2) who is eligible for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter—
    - (A) and is entitled to or enrolled for benefits under any part of subchapter XVIII;
    - (B) and is receiving—
      - (i) disability insurance benefits under [section 423 of this title](/usc/42/423.md) or monthly insurance benefits under [section 402 of this title](/usc/42/402.md) based on such individual’s disability (as defined in [section 423(d) of this title](/usc/42/423.md?p=d)); or
      - (ii) supplemental security income benefits under subchapter XVI;
    - (C) and with respect to whom—
      - (i) [child](/usc/42/1382c.md?p=c) welfare services are made available under part B of subchapter IV on the basis of being a [child](/usc/42/1382c.md?p=c) in foster care; or
      - (ii) adoption or foster care assistance is made available under part E of subchapter IV;
    - (D) pursuant to the application of [section 1396a(e)(4) of this title](/usc/42/1396a.md?p=e-4) (and, in the case of an individual who is eligible for [medical assistance](/usc/42/1396d.md?p=a) on such basis, the individual shall be deemed to have provided satisfactory documentary evidence of citizenship or nationality and shall not be required to provide further documentary evidence on any date that occurs during or after the period in which the individual is eligible for [medical assistance](/usc/42/1396d.md?p=a) on such basis); or
    - (E) on such basis as the [Secretary](/usc/42/1301.md?p=a-6) may specify under which satisfactory documentary evidence of citizenship or nationality has been previously presented.
  - (3)
    - (A) For purposes of this subsection, the term “satisfactory documentary evidence of citizenship or nationality” means—
      - (i) any document described in [subparagraph (B)](#x-3-B); or
      - (ii) a document described in [subparagraph (C)](#x-3-C) and a document described in [subparagraph (D)](#x-3-D).
    - (B) The following are documents described in this subparagraph:
      - (i) A [United States](/usc/42/1301.md?p=a-2) passport.
      - (ii) Form N–550 or N–570 (Certificate of Naturalization).
      - (iii) Form N–560 or N–561 (Certificate of [United States](/usc/42/1301.md?p=a-2) Citizenship).
      - (iv) A valid [State](/usc/42/619.md?p=5)-issued driver’s license or other identity document described in [section 1324a(b)(1)(D) of title 8](/usc/8/1324a.md?p=b-1-D), but only if the [State](/usc/42/619.md?p=5) issuing the license or such document requires proof of [United States](/usc/42/1301.md?p=a-2) citizenship before issuance of such license or document or obtains a [social](/usc/42/1397j.md?p=20) security number from the applicant and verifies before certification that such number is valid and assigned to the applicant who is a citizen.
      - (v)
        - (I) Except as provided in [subclause (II)](#x-3-B-v-II), a document issued by a federally recognized [Indian tribe](/usc/42/619.md?p=4-A) evidencing membership or enrollment in, or affiliation with, such tribe (such as a tribal enrollment card or certificate of degree of [Indian](/usc/42/619.md?p=4-A) blood).
        - (II) With respect to those federally recognized [Indian tribes](/usc/42/619.md?p=4-A) located within [States](/usc/42/619.md?p=5) having an international border whose membership [includes](/usc/42/1301.md?p=b) individuals who are not citizens of the [United States](/usc/42/1301.md?p=a-2), the [Secretary](/usc/42/1301.md?p=a-6) shall, after consulting with such tribes, issue regulations authorizing the presentation of such other forms of documentation ([including](/usc/42/1301.md?p=b) tribal documentation, if appropriate) that the [Secretary](/usc/42/1301.md?p=a-6) determines to be satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this subsection.
      - (vi) Such other document as the [Secretary](/usc/42/1301.md?p=a-6) may specify, by regulation, that provides proof of [United States](/usc/42/1301.md?p=a-2) citizenship or nationality and that provides a reliable means of documentation of personal identity.
    - (C) The following are documents described in this subparagraph:
      - (i) A certificate of birth in the [United States](/usc/42/1301.md?p=a-2).
      - (ii) Form FS–545 or Form DS–1350 (Certification of Birth Abroad).
      - (iii) Form I–197 ([United States](/usc/42/1301.md?p=a-2) Citizen Identification Card).
      - (iv) Form FS–240 (Report of Birth Abroad of a Citizen of the [United States](/usc/42/1301.md?p=a-2)).
      - (v) Such other document (not described in [subparagraph (B)(iv)](#x-3-B-iv)) as the [Secretary](/usc/42/1301.md?p=a-6) may specify that provides proof of [United States](/usc/42/1301.md?p=a-2) citizenship or nationality.
    - (D) The following are documents described in this subparagraph:
      - (i) Any identity document described in [section 1324a(b)(1)(D) of title 8](/usc/8/1324a.md?p=b-1-D).
      - (ii) Any other documentation of personal identity of such other type as the [Secretary](/usc/42/1301.md?p=a-6) finds, by regulation, provides a reliable means of identification.
    - (E) A reference in this paragraph to a form [includes](/usc/42/1301.md?p=b) a reference to any successor form.
  - (4) In the case of an individual declaring to be a citizen or national of the [United States](/usc/42/1301.md?p=a-2) with respect to whom a [State](/usc/42/619.md?p=5) requires the presentation of satisfactory documentary evidence of citizenship or nationality under [section 1396a(a)(46)(B)(i) of this title](/usc/42/1396a.md?p=a-46-B-i), the individual shall be provided at least the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under this subsection as is provided under clauses (i) and (ii) of [section 1320b–7(d)(4)(A) of this title](/usc/42/1320b–7.md?p=d-4-A) to an individual for the submittal to the [State](/usc/42/619.md?p=5) of evidence indicating a satisfactory immigration status.
  - (5) Nothing in subparagraph (A) or (B) of [section 1396a(a)(46) of this title](/usc/42/1396a.md?p=a-46), the preceding paragraphs of this subsection, or the Deficit Reduction Act of 2005, [including](/usc/42/1301.md?p=b) section 6036 of such Act, shall be construed as changing the requirement of [section 1396a(e)(4) of this title](/usc/42/1396a.md?p=e-4) that a [child](/usc/42/1382c.md?p=c) born in the [United States](/usc/42/1301.md?p=a-2) to an alien mother for whom [medical assistance](/usc/42/1396d.md?p=a) for the delivery of such [child](/usc/42/1382c.md?p=c) is available as [treatment](/usc/42/11851.md?p=11) of an emergency medical condition pursuant to [subsection (v)](#v) shall be deemed eligible for [medical assistance](/usc/42/1396d.md?p=a) during the first year of such [child](/usc/42/1382c.md?p=c)’s life.
- (y) **Payments for establishment of alternate non-emergency services providers—**
  - (1) **Payments—** In addition to the payments otherwise provided under [subsection (a)](#a), subject to [paragraph (2)](#y-2), the [Secretary](/usc/42/1301.md?p=a-6) shall provide for payments to [States](/usc/42/619.md?p=5) under such subsection for the establishment of alternate non-emergency service providers (as defined in [section 1396o–1(e)(5)(B)](/usc/42/1396o–1.md)[^12] of this title), or networks of such providers.
  - (2) **Limitation—** The total amount of payments under this subsection shall not exceed $50,000,000 during the 4-year period beginning with 2006. This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the [Secretary](/usc/42/1301.md?p=a-6) to provide for the payment of amounts provided under this subsection.
  - (3) **Preference—** In providing for payments to [States](/usc/42/619.md?p=5) under this subsection, the [Secretary](/usc/42/1301.md?p=a-6) shall provide preference to [States](/usc/42/619.md?p=5) that establish, or provide for, alternate non-emergency services providers or networks of such providers that—
    - (A) serve rural or underserved areas where beneficiaries under this subchapter may not have regular access to providers of [primary care](/usc/42/1396d.md?p=t-4) services; or
    - (B) are in partnership with local community [hospitals](/usc/42/300s–3.md?p=1).
  - (4) **Form and manner of payment—** Payment to a [State](/usc/42/619.md?p=5) under this subsection shall be made only upon the filing of such application in such form and in such manner as the [Secretary](/usc/42/1301.md?p=a-6) shall specify. Payment to a [State](/usc/42/619.md?p=5) under this subsection shall be made in the same manner as other payments under [subsection (a)](#a).
- (z) **Medicaid transformation payments—**
  - (1) **In general—** In addition to the payments provided under [subsection (a)](#a), subject to [paragraph (4)](#z-4), the [Secretary](/usc/42/1301.md?p=a-6) shall provide for payments to [States](/usc/42/619.md?p=5) for the adoption of innovative methods to improve the effectiveness and efficiency in providing [medical assistance](/usc/42/1396d.md?p=a) under this subchapter.
  - (2) **Permissible uses of funds—** The following are examples of innovative methods for which funds provided under this subsection may be used:
    - (A) Methods for reducing patient error rates through the implementation and use of electronic health records, electronic clinical decision support tools, or e-prescribing programs.
    - (B) Methods for improving rates of collection from estates of amounts owed under this subchapter.
    - (C) Methods for reducing waste, fraud, and [abuse](/usc/42/1397j.md?p=1) under the program under this subchapter, such as reducing improper payment rates as measured by annual payment error rate measurement (PERM) [project](/usc/42/13641.md?p=2) rates.
    - (D) Implementation of a medication risk management program as part of a [drug](/usc/42/11851.md?p=4) use review program under [section 1396r–8(g) of this title](/usc/42/1396r–8.md?p=g).
    - (E) Methods in reducing, in clinically appropriate ways, expenditures under this subchapter for covered outpatient [drugs](/usc/42/11851.md?p=4), particularly in the categories of greatest [drug](/usc/42/11851.md?p=4) utilization, by increasing the utilization of generic [drugs](/usc/42/11851.md?p=4) through the use of education programs and other incentives to promote greater use of generic [drugs](/usc/42/11851.md?p=4).
    - (F) Methods for improving access to primary and specialty [physician](/usc/42/1301.md?p=a-7) care for the uninsured using integrated university-based [hospital](/usc/42/300s–3.md?p=1) and clinic systems.
  - (3) **Application; terms and conditions—**
    - (A) **In general—** No payments shall be made to a [State](/usc/42/619.md?p=5) under this subsection unless the [State](/usc/42/619.md?p=5) applies to the [Secretary](/usc/42/1301.md?p=a-6) for such payments in a form, manner, and time specified by the [Secretary](/usc/42/1301.md?p=a-6).
    - (B) **Terms and conditions—** Such payments are made under such terms and conditions consistent with this subsection as the [Secretary](/usc/42/1301.md?p=a-6) prescribes.
    - (C) **Annual report—** Payment to a [State](/usc/42/619.md?p=5) under this subsection is conditioned on the [State](/usc/42/619.md?p=5) submitting to the [Secretary](/usc/42/1301.md?p=a-6) an annual report on the programs supported by such payment. Such report shall include information on—
      - (i) the specific uses of such payment;
      - (ii) an assessment of quality improvements and clinical outcomes under such programs; and
      - (iii) estimates of cost savings resulting from such programs.
  - (4) **Funding—**
    - (A) **Limitation on funds—** The total amount of payments under this subsection shall be equal to, and shall not exceed—
      - (i) $75,000,000 for [fiscal year](/usc/42/619.md?p=3) 2007; and
      - (ii) $75,000,000 for [fiscal year](/usc/42/619.md?p=3) 2008.

      This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the [Secretary](/usc/42/1301.md?p=a-6) to provide for the payment of amounts provided under this subsection.

    - (B) **Allocation of funds—** The [Secretary](/usc/42/1301.md?p=a-6) shall specify a method for allocating the funds made available under this subsection among [States](/usc/42/619.md?p=5). Such method shall provide preference for [States](/usc/42/619.md?p=5) that design programs that target health providers that treat significant numbers of Medicaid beneficiaries. Such method shall provide that not less than 25 percent of such funds shall be allocated among [States](/usc/42/619.md?p=5) the population of which (as determined according to data collected by the [United States](/usc/42/1301.md?p=a-2) Census Bureau) as of July 1, 2004, was more than 105 percent of the population of the respective [State](/usc/42/619.md?p=5) (as so determined) as of April 1, 2000.
    - (C) **Form and manner of payment—** Payment to a [State](/usc/42/619.md?p=5) under this subsection shall be made in the same manner as other payments under [subsection (a)](#a). There is no requirement for [State](/usc/42/619.md?p=5) matching funds to receive payments under this subsection.
  - (5) **Medication risk management program—**
    - (A) **In general—** For purposes of this subsection, the term “medication risk management program” means a program for targeted beneficiaries that ensures that covered outpatient [drugs](/usc/42/11851.md?p=4) are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events.
    - (B) **Elements—** Such program may include the following elements:
      - (i) The use of established principles and [standards](/usc/42/1320d.md?p=7) for [drug](/usc/42/11851.md?p=4) utilization review and best [practices](/usc/42/17061.md?p=19) to analyze prescription [drug](/usc/42/11851.md?p=4) claims of targeted beneficiaries and identify outlier [physicians](/usc/42/1301.md?p=a-7).
      - (ii) On an ongoing basis provide outlier [physicians](/usc/42/1301.md?p=a-7)—
        - (I) a comprehensive pharmacy claims history for each targeted beneficiary under their care;
        - (II) information regarding the frequency and cost of relapses and [hospitalizations](/usc/42/1301.md?p=a-7) of targeted beneficiaries under the [physician](/usc/42/1301.md?p=a-7)’s care; and
        - (III) applicable best practice guidelines and empirical references.
      - (iii) Monitor outlier [physician](/usc/42/1301.md?p=a-7)’s prescribing, such as failure to refill, dosage strengths, and provide incentives and information to encourage the adoption of best clinical [practices](/usc/42/17061.md?p=19).
    - (C) **Targeted beneficiaries—** For purposes of this paragraph, the term “targeted beneficiaries” means Medicaid eligible beneficiaries who are identified as having high prescription [drug](/usc/42/11851.md?p=4) costs and medical costs, such as individuals with behavioral disorders or multiple chronic diseases who are taking multiple medications.
- (aa) **Demonstration project to increase substance use provider capacity—**
  - (1) **In general—** Not later than the date that is 180 days after October 24, 2018, the [Secretary](/usc/42/1301.md?p=a-6) shall, in consultation, as appropriate, with the [Director](/usc/42/11851.md?p=5) of the [Agency](/usc/42/1397n–12.md?p=1) for Healthcare Research and Quality and the Assistant [Secretary](/usc/42/1301.md?p=a-6) for Mental Health and Substance Use, conduct a 54-month demonstration [project](/usc/42/13641.md?p=2) for the purpose described in [paragraph (2)](#aa-2) under which the [Secretary](/usc/42/1301.md?p=a-6) shall—
    - (A) for the first 18-month period of such [project](/usc/42/13641.md?p=2), award planning [grants](/usc/42/1397j.md?p=10) described in [paragraph (3)](#aa-3); and
    - (B) for the remaining 36-month period of such [project](/usc/42/13641.md?p=2), provide to each [State](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4) payments in accordance with [paragraph (5)](#aa-5).
  - (2) **Purpose—** The purpose described in this paragraph is for each [State](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4) to increase the [treatment](/usc/42/11851.md?p=11) capacity of providers participating under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) to provide substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under such plan (or waiver) through the following activities:
    - (A) For the purpose described in [paragraph (3)(C)(i)](#aa-3-C-i), activities that support an ongoing assessment of the behavioral health [treatment](/usc/42/11851.md?p=11) needs of the [State](/usc/42/619.md?p=5), taking into account the matters described in subclauses [(I)](#aa-3-C-i-I) through [(IV)](#aa-3-C-i-IV) of such paragraph.
    - (B) Activities that, taking into account the results of the assessment described in [subparagraph (A)](#aa-2-A), support the recruitment, training, and provision of technical assistance for providers participating under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) that offer substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services.
    - (C) Improved reimbursement for and expansion of, through the provision of education, training, and technical assistance, the number or [treatment](/usc/42/11851.md?p=11) capacity of providers participating under the [State](/usc/42/619.md?p=5) plan (or waiver) that—
      - (i) are authorized to dispense [drugs](/usc/42/11851.md?p=4) approved by the Food and [Drug](/usc/42/11851.md?p=4) [Administration](/usc/42/1301.md?p=a-10) for individuals with a substance use disorder who need withdrawal management or maintenance [treatment](/usc/42/11851.md?p=11) for such disorder; and
      - (ii) are qualified under applicable [State](/usc/42/619.md?p=5) law to provide substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services.
    - (D) Improved reimbursement for and expansion of, through the provision of education, training, and technical assistance, the number or [treatment](/usc/42/11851.md?p=11) capacity of providers participating under the [State](/usc/42/619.md?p=5) plan (or waiver) that have the qualifications to address the [treatment](/usc/42/11851.md?p=11) or recovery needs of—
      - (i) individuals enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) who have neonatal abstinence syndrome, in accordance with guidelines issued by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists relating to maternal care and infant care with respect to neonatal abstinence syndrome;
      - (ii) pregnant women, postpartum women, and infants, particularly the concurrent [treatment](/usc/42/11851.md?p=11), as appropriate, and comprehensive case management of pregnant women, postpartum women and infants, enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan);
      - (iii) adolescents and young [adults](/usc/42/619.md?p=1) between the ages of 12 and 21 enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan); or
      - (iv) American [Indian](/usc/42/619.md?p=4-A) and Alaska Native individuals enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan).
  - (3) **Planning grants—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall, with respect to the first 18-month period of the demonstration [project](/usc/42/13641.md?p=2) conducted under [paragraph (1)](#aa-1), award planning [grants](/usc/42/1397j.md?p=10) to at least 10 [States](/usc/42/619.md?p=5) selected in accordance with [subparagraph (B)](#aa-3-B) for purposes of preparing an application described in [paragraph (4)(C)](#aa-4-C) and carrying out the activities described in [subparagraph (C)](#aa-3-C).
    - (B) **Selection—** In selecting [States](/usc/42/619.md?p=5) for purposes of this paragraph, the [Secretary](/usc/42/1301.md?p=a-6) shall—
      - (i) select [States](/usc/42/619.md?p=5) that have a [State](/usc/42/619.md?p=5) plan (or waiver of the [State](/usc/42/619.md?p=5) plan) approved under this subchapter;
      - (ii) select [States](/usc/42/619.md?p=5) in a manner that ensures geographic diversity; and
      - (iii) give preference to [States](/usc/42/619.md?p=5) with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita [drug](/usc/42/11851.md?p=4) overdoses, or any other measure that the [Secretary](/usc/42/1301.md?p=a-6) deems appropriate.
    - (C) **Activities described—** Activities described in this subparagraph are, with respect to a [State](/usc/42/619.md?p=5), each of the following:
      - (i) Activities that support the development of an initial assessment of the behavioral health [treatment](/usc/42/11851.md?p=11) needs of the [State](/usc/42/619.md?p=5) to determine the extent to which providers are needed ([including](/usc/42/1301.md?p=b) the types of such providers and geographic area of need) to improve the network of providers that treat substance use disorders under the [State](/usc/42/619.md?p=5) plan (or waiver), [including](/usc/42/1301.md?p=b) the following:
        - (I) An estimate of the number of individuals enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) who have a substance use disorder.
        - (II) Information on the capacity of providers to provide substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services to individuals enrolled under the [State](/usc/42/619.md?p=5) plan (or waiver), [including](/usc/42/1301.md?p=b) information on providers who provide such services and their participation under the [State](/usc/42/619.md?p=5) plan (or waiver).
        - (III) Information on the gap in substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under the [State](/usc/42/619.md?p=5) plan (or waiver) based on the information described in subclauses [(I)](#aa-3-C-i-I) and [(II)](#aa-3-C-i-II).
        - (IV) Projections regarding the extent to which the [State](/usc/42/619.md?p=5) participating under the demonstration [project](/usc/42/13641.md?p=2) would increase the number of providers offering substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under the [State](/usc/42/619.md?p=5) plan (or waiver) during the period of the demonstration [project](/usc/42/13641.md?p=2).
      - (ii) Activities that, taking into account the results of the assessment described in [clause (i)](#aa-3-C-i), support the development of [State](/usc/42/619.md?p=5) infrastructure to, with respect to the provision of substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan), recruit prospective providers and provide training and technical assistance to such providers.
    - (D) **Funding—** For purposes of [subparagraph (A)](#aa-3-A), there is appropriated, out of any funds in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended.
  - (4) **Post-planning states—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall, with respect to the remaining 36-month period of the demonstration [project](/usc/42/13641.md?p=2) conducted under [paragraph (1)](#aa-1), select not more than 5 [States](/usc/42/619.md?p=5) in accordance with [subparagraph (B)](#aa-4-B) for purposes of carrying out the activities described in [paragraph (2)](#aa-2) and receiving payments in accordance with [paragraph (5)](#aa-5).
    - (B) **Selection—** In selecting [States](/usc/42/619.md?p=5) for purposes of this paragraph, the [Secretary](/usc/42/1301.md?p=a-6) shall—
      - (i) select [States](/usc/42/619.md?p=5) that received a planning [grant](/usc/42/1397j.md?p=10) under [paragraph (3)](#aa-3);
      - (ii) select [States](/usc/42/619.md?p=5) that submit to the [Secretary](/usc/42/1301.md?p=a-6) an application in accordance with the requirements in [subparagraph (C)](#aa-4-C), taking into consideration the quality of each such application;
      - (iii) select [States](/usc/42/619.md?p=5) in a manner that ensures geographic diversity; and
      - (iv) give preference to [States](/usc/42/619.md?p=5) with a prevalence of substance use disorders (in particular opioid use disorders) that is comparable to or higher than the national average prevalence, as measured by aggregate per capita [drug](/usc/42/11851.md?p=4) overdoses, or any other measure that the [Secretary](/usc/42/1301.md?p=a-6) deems appropriate.
    - (C) **Applications—**
      - (i) **In general—** A [State](/usc/42/619.md?p=5) seeking to be selected for purposes of this paragraph shall submit to the [Secretary](/usc/42/1301.md?p=a-6), at such time and in such form and manner as the [Secretary](/usc/42/1301.md?p=a-6) requires, an application that [includes](/usc/42/1301.md?p=b) such information, provisions, and assurances, as the [Secretary](/usc/42/1301.md?p=a-6) may require, in addition to the following:
        - (I) A proposed process for carrying out the ongoing assessment described in [paragraph (2)(A)](#aa-2-A), taking into account the results of the initial assessment described in [paragraph (3)(C)(i)](#aa-3-C-i).
        - (II) A review of reimbursement methodologies and other policies related to substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under the [State](/usc/42/619.md?p=5) plan (or waiver) that may create barriers to increasing the number of providers delivering such services.
        - (III) The development of a plan, taking into account activities carried out under [paragraph (3)(C)(ii)](#aa-3-C-ii), that will result in long-term and sustainable provider networks under the [State](/usc/42/619.md?p=5) plan (or waiver) that will offer a continuum of care for substance use disorders. Such plan shall include the following:
          - (aa) Specific activities to increase the number of providers ([including](/usc/42/1301.md?p=b) providers that specialize in providing substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services, [hospitals](/usc/42/300s–3.md?p=1), health care systems, Federally qualified health centers, and, as applicable, [certified community behavioral health clinics](/usc/42/1396d.md?p=jj-2)) that offer substance use disorder [treatment](/usc/42/11851.md?p=11), recovery, or support services, [including](/usc/42/1301.md?p=b) short-term detoxification services, outpatient substance use disorder services, and evidence-based peer recovery services.
          - (bb) Strategies that will incentivize providers described in subparagraphs [(C)](#aa-2-C) and [(D)](#aa-2-D) of paragraph (2) to obtain the necessary training, education, and support to deliver substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services in the [State](/usc/42/619.md?p=5).
          - (cc) Milestones and timeliness for implementing activities set forth in the plan.
          - (dd) Specific measurable targets for increasing the substance use disorder [treatment](/usc/42/11851.md?p=11) and recovery provider network under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan).
        - (IV) A proposed process for reporting the information required under [paragraph (6)(A)](#aa-6-A), [including](/usc/42/1301.md?p=b) information to assess the effectiveness of the efforts of the [State](/usc/42/619.md?p=5) to expand the capacity of providers to deliver substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services during the period of the demonstration [project](/usc/42/13641.md?p=2) under this subsection.
        - (V) The expected financial impact of the demonstration [project](/usc/42/13641.md?p=2) under this subsection on the [State](/usc/42/619.md?p=5).
        - (VI) A description of all funding sources available to the [State](/usc/42/619.md?p=5) to provide substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services in the [State](/usc/42/619.md?p=5).
        - (VII) A preliminary plan for how the [State](/usc/42/619.md?p=5) will sustain any increase in the capacity of providers to deliver substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services resulting from the demonstration [project](/usc/42/13641.md?p=2) under this subsection after the termination of such demonstration [project](/usc/42/13641.md?p=2).
        - (VIII) A description of how the [State](/usc/42/619.md?p=5) will coordinate the goals of the demonstration [project](/usc/42/13641.md?p=2) with any waiver granted (or submitted by the [State](/usc/42/619.md?p=5) and pending) pursuant to [section 1315 of this title](/usc/42/1315.md) for the delivery of substance use services under the [State](/usc/42/619.md?p=5) plan, as applicable.
      - (ii) **Consultation—** In completing an application under [clause (i)](#aa-4-C-i), a [State](/usc/42/619.md?p=5) shall consult with relevant stakeholders, [including](/usc/42/1301.md?p=b) Medicaid managed care plans, [health care providers](/usc/42/1320d.md?p=3), and Medicaid beneficiary advocates, and include in such application a description of such consultation.
  - (5) **Payment—**
    - (A) **In general—** For each quarter occurring during the period for which the demonstration [project](/usc/42/13641.md?p=2) is conducted (after the first 18 months of such period), the [Secretary](/usc/42/1301.md?p=a-6) shall pay under this subsection, subject to [subparagraph (C)](#aa-5-C), to each [State](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4) an amount equal to 80 percent of so much of the qualified sums expended during such quarter.
    - (B) **Qualified sums defined—** For purposes of [subparagraph (A)](#aa-5-A), the term “qualified sums” means, with respect to a [State](/usc/42/619.md?p=5) and a quarter, the amount equal to the amount (if any) by which the sums expended by the [State](/usc/42/619.md?p=5) during such quarter attributable to substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services furnished by providers participating under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) exceeds 1/4 of such sums expended by the [State](/usc/42/619.md?p=5) during [fiscal year](/usc/42/619.md?p=3) 2018 attributable to substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services.
    - (C) **Non-duplication of payment—** In the case that payment is made under [subparagraph (A)](#aa-5-A) with respect to expenditures for substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services furnished by providers participating under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan), payment may not also be made under [subsection (a)](#a) with respect to expenditures for the same services so furnished.
  - (6) **Reports—**
    - (A) **State reports—** A [State](/usc/42/619.md?p=5) receiving payments under [paragraph (5)](#aa-5) shall, for the period of the demonstration [project](/usc/42/13641.md?p=2) under this subsection, submit to the [Secretary](/usc/42/1301.md?p=a-6) a quarterly report, with respect to expenditures for substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services for which payment is made to the [State](/usc/42/619.md?p=5) under this subsection, on the following:
      - (i) The specific activities with respect to which payment under this subsection was provided.
      - (ii) The number of providers that delivered substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services in the [State](/usc/42/619.md?p=5) under the demonstration [project](/usc/42/13641.md?p=2) compared to the estimated number of providers that would have otherwise delivered such services in the absence of such demonstration [project](/usc/42/13641.md?p=2).
      - (iii) The number of individuals enrolled under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) who received substance use disorder [treatment](/usc/42/11851.md?p=11) or recovery services under the demonstration [project](/usc/42/13641.md?p=2) compared to the estimated number of such individuals who would have otherwise received such services in the absence of such demonstration [project](/usc/42/13641.md?p=2).
      - (iv) Other matters as determined by the [Secretary](/usc/42/1301.md?p=a-6).
    - (B) **CMS reports—**
      - (i) **Initial report—** Not later than October 1, 2020, the [Administrator](/usc/42/4005.md?p=1) of the Centers for Medicare & Medicaid Services shall, in consultation with the [Director](/usc/42/11851.md?p=5) of the [Agency](/usc/42/1397n–12.md?p=1) for Healthcare Research and Quality and the Assistant [Secretary](/usc/42/1301.md?p=a-6) for Mental Health and Substance Use, submit to Congress an initial report on—
        - (I) the [States](/usc/42/619.md?p=5) awarded planning [grants](/usc/42/1397j.md?p=10) under [paragraph (3)](#aa-3);
        - (II) the criteria used in such selection; and
        - (III) the activities carried out by such [States](/usc/42/619.md?p=5) under such planning [grants](/usc/42/1397j.md?p=10).
      - (ii) **Interim report—** Not later than October 1, 2022, the [Administrator](/usc/42/4005.md?p=1) of the Centers for Medicare & Medicaid Services shall, in consultation with the [Director](/usc/42/11851.md?p=5) of the [Agency](/usc/42/1397n–12.md?p=1) for Healthcare Research and Quality and the Assistant [Secretary](/usc/42/1301.md?p=a-6) for Mental Health and Substance Use, submit to Congress an interim report—
        - (I) on activities carried out under the demonstration [project](/usc/42/13641.md?p=2) under this subsection;
        - (II) on the extent to which [States](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4) have achieved the stated goals submitted in their applications under [subparagraph (C)](#aa-6-C) of such paragraph;
        - (III) with a description of the strengths and limitations of such demonstration [project](/usc/42/13641.md?p=2); and
        - (IV) with a plan for the sustainability of such [project](/usc/42/13641.md?p=2).
      - (iii) **Final report—** Not later than October 1, 2024, the [Administrator](/usc/42/4005.md?p=1) of the Centers for Medicare & Medicaid Services shall, in consultation with the [Director](/usc/42/11851.md?p=5) of the [Agency](/usc/42/1397n–12.md?p=1) for Healthcare Research and Quality and the Assistant [Secretary](/usc/42/1301.md?p=a-6) for Mental Health and Substance Use, submit to Congress a final report—
        - (I) providing updates on the matters reported in the interim report under [clause (ii)](#aa-6-B-ii);
        - (II) [including](/usc/42/1301.md?p=b) a description of any changes made with respect to the demonstration [project](/usc/42/13641.md?p=2) under this subsection after the submission of such interim report; and
        - (III) evaluating such demonstration [project](/usc/42/13641.md?p=2).
    - (C) **AHRQ report—** Not later than 3 years after October 24, 2018, the [Director](/usc/42/11851.md?p=5) of the [Agency](/usc/42/1397n–12.md?p=1) for Healthcare Research and Quality, in consultation with the [Administrator](/usc/42/4005.md?p=1) of the Centers for Medicare & Medicaid Services, shall submit to Congress a summary on the experiences of [States](/usc/42/619.md?p=5) awarded planning [grants](/usc/42/1397j.md?p=10) under [paragraph (3)](#aa-3) and [States](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4).
  - (7) **Data sharing and best practices—** During the period of the demonstration [project](/usc/42/13641.md?p=2) under this subsection, the [Secretary](/usc/42/1301.md?p=a-6) shall, in collaboration with [States](/usc/42/619.md?p=5) selected under [paragraph (4)](#aa-4), facilitate data sharing and the development of best [practices](/usc/42/17061.md?p=19) between such [States](/usc/42/619.md?p=5) and [States](/usc/42/619.md?p=5) that were not so selected.
  - (8) **CMS funding—** There is appropriated, out of any funds in the Treasury not otherwise appropriated, $5,000,000 to the Centers for Medicare & Medicaid Services for purposes of implementing this subsection. Such amount shall remain available until expended.
- (bb) **Supplemental payment reporting requirements—**
  - (1) **Collection and availability of supplemental payment data—**
    - (A) **In general—** Not later than October 1, 2021, the [Secretary](/usc/42/1301.md?p=a-6) shall establish a system for each [State](/usc/42/619.md?p=5) to submit reports, as determined appropriate by the [Secretary](/usc/42/1301.md?p=a-6), on supplemental payments data, as a requirement for a [State](/usc/42/619.md?p=5) plan or [State](/usc/42/619.md?p=5) plan amendment that would provide for a supplemental payment.
    - (B) **Requirements—** Each report submitted by a [State](/usc/42/619.md?p=5) in accordance with the requirement established under [subparagraph (A)](#bb-1-A) shall include the following:
      - (i) An explanation of how supplemental payments made under the [State](/usc/42/619.md?p=5) plan or a [State](/usc/42/619.md?p=5) plan amendment will result in payments that are consistent with [section 1396a(a)(30)(A) of this title](/usc/42/1396a.md?p=a-30-A), [including](/usc/42/1301.md?p=b) [standards](/usc/42/1320d.md?p=7) with respect to efficiency, economy, quality of care, and access, along with the stated purpose and intended effects of the supplemental payment.
      - (ii) The criteria used to determine which providers are eligible to receive the supplemental payment.
      - (iii) A comprehensive description of the methodology used to calculate the amount of, and distribute, the supplemental payment to each eligible provider, [including](/usc/42/1301.md?p=b)—
        - (I) data on the amount of the supplemental payment made to each eligible provider, if known, or, if the total amount is distributed using a formula based on data from 1 or more [fiscal years](/usc/42/619.md?p=3), data on the total amount of the supplemental payments for the [fiscal year](/usc/42/619.md?p=3) or years available to all providers eligible to receive a supplemental payment;
        - (II) if applicable, the specific criteria with respect to Medicaid service, utilization, or cost data to be used as the basis for calculations regarding the amount or distribution of the supplemental payment; and
        - (III) the timing of the supplemental payment made to each eligible provider.
      - (iv) An assurance that the total Medicaid payments made to an inpatient [hospital](/usc/42/300s–3.md?p=1) provider, [including](/usc/42/1301.md?p=b) the supplemental payment, will not exceed upper payment limits.
      - (v) If not already submitted, an upper payment limit demonstration under section 447.272 of title 42, Code of Federal Regulations (as such section is in effect as of December 27, 2020).
    - (C) **Public availability—** The [Secretary](/usc/42/1301.md?p=a-6) shall make all reports and related data submitted under this paragraph publicly available on the website of the Centers for Medicare & Medicaid Services on a timely basis.
  - (2) **Supplemental payment defined—**
    - (A) **In general—** Subject to [subparagraph (B)](#bb-2-B), in this subsection, the term “supplemental payment” means a payment to a provider that is in addition to any base payment made to the provider under the [State](/usc/42/619.md?p=5) plan under this subchapter or under demonstration authority.
    - (B) **DSH payments excluded—** Such term does not include a disproportionate share [hospital](/usc/42/300s–3.md?p=1) payment made under [section 1396r–4 of this title](/usc/42/1396r–4.md).

## Footnotes

[^1]: So in original. Probably should be “a quality improvement organization”.
[^2]: So in original. There is no subpar. (G).
[^3]: So in original. The comma probably should be a semicolon.
[^4]: See References in Text note below.
[^5]: So in original. The word “or” probably should precede “1396d(p)(1)”.
[^6]: Probably means subclause (VIII) of subsection (a)(10)(A)(i) of section 1396a of this title.
[^7]: So in original. Probably should be “waiver”.
[^8]: So in original. Probably should be followed by a comma.
[^9]: So in original. The word “section” probably should appear.
[^10]: So in original. Probably should be preceded by “a”.
[^11]: So in original. The word “or” probably should not appear.
[^12]: So in original. Probably should be section “1396o–1(e)(4)(B)”.

## Source credit

(Aug. 14, 1935, ch. 531, title XIX, § 1903, as added Pub. L. 89–97, title I, § 121(a), July 30, 1965, 79 Stat. 349; amended Pub. L. 90–248, title II, §§ 220(a), 222(c), (d), 225(a), 229(c), 241(f)(5), Jan. 2, 1968, 81 Stat. 898, 901, 902, 904, 917; Pub. L. 90–364, title III, § 303(a)(1), June 28, 1968, 82 Stat. 274; Pub. L. 91–56, § 2(a), Aug. 9, 1969, 83 Stat. 99; Pub. L. 92–603, title II, §§ 207(a), 221(c)(6), 224(c), 225, 226(e), 229(c), 230, 233(c), 235(a), 237(a)(1), 249B, 278(b)(1), (5), (7), (16), 290, 295, 299E(a), Oct. 30, 1972, 86 Stat. 1379, 1389, 1395, 1396, 1404, 1410, 1411, 1414, 1415, 1428, 1453, 1454, 1457, 1459, 1462; Pub. L. 93–66, title II, § 234(a), July 9, 1973, 87 Stat. 160; Pub. L. 93–233, §§ 13(a)(11), (12), 18(r)–(v), (x)(5), (6), (y)(1), Dec. 31, 1973, 87 Stat. 963, 971–973; Pub. L. 94–182, title I, §§ 110(a), 111(b), Dec. 31, 1975, 89 Stat. 1054; Pub. L. 94–460, title II, § 202(a), Oct. 8, 1976, 90 Stat. 1957; Pub. L. 94–552, § 1, Oct. 18, 1976, 90 Stat. 2540; Pub. L. 95–83, title I, § 105(a)(1), (2), Aug. 1, 1977, 91 Stat. 384; Pub. L. 95–142, §§ 3(c)(2), 8(c), 10(a), 11(a), 17(a)–(c), 20(a), Oct. 25, 1977, 91 Stat. 1179, 1195, 1196, 1201, 1205; Pub. L. 95–559, § 14(c), Nov. 1, 1978, 92 Stat. 2141; Pub. L. 95–626, title I, § 102(b)(3), Nov. 10, 1978, 92 Stat. 3551; Pub. L. 96–79, title I, § 128, Oct. 4, 1979, 93 Stat. 629; Pub. L. 96–398, title IX, § 901, Oct. 7, 1980, 94 Stat. 1609; Pub. L. 96–499, title IX, §§ 905(b), (c), 961(a), 963, 964, Dec. 5, 1980, 94 Stat. 2618, 2650, 2651; Pub. L. 97–35, title XXI, §§ 2101(a)(2), 2103(b)(1), 2106(b)(3), 2113(n), 2161, 2163, 2164(a), 2174(b), 2178(a), 2183(a), Aug. 13, 1981, 95 Stat. 786, 788, 792, 795, 803–806, 809, 813, 816; Pub. L. 97–248, title I, §§ 133(a), 137(a)(1), (2), (b)(11)–(16), (27), (g), 146(b), Sept. 3, 1982, 96 Stat. 373, 376, 378, 379, 381, 394; Pub. L. 97–448, title III, § 309(b)(16), Jan. 12, 1983, 96 Stat. 2409; Pub. L. 98–369, div. B, title III, §§ 2303(g)(2), 2363(a)(2), (4), (b), 2364, 2373(b)(11)–(14), July 18, 1984, 98 Stat. 1066, 1106, 1107, 1111, 1112; Pub. L. 98–617, § 3(a)(6), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99–272, title IX, §§ 9503(b), (f), 9507(a), 9512(a), 9517(a), (c)(1), 9518(a), Apr. 7, 1986, 100 Stat. 206, 207, 210, 212, 215, 216; Pub. L. 99–509, title IX, §§ 9401(e)(2), 9403(g)(2), 9406(a), 9407(c), 9431(b)(2), 9434(a)(1), (2), (b), Oct. 21, 1986, 100 Stat. 2052, 2055, 2057, 2060, 2066, 2068, 2069; Pub. L. 99–514, title XVIII, § 1895(c)(2), Oct. 22, 1986, 100 Stat. 2935; Pub. L. 99–603, title I, § 121(b)(2), Nov. 6, 1986, 100 Stat. 3390; Pub. L. 100–93, § 8(g), (h)(1), Aug. 18, 1987, 101 Stat. 694; Pub. L. 100–203, title IV, §§ 4112(b), 4113(a)(1), (b)(3), (d)(1), 4118(d)(1), (e)(11), (h)(1), (p)(5), 4211(d)(1), (g), (i), 4212(c)(1), (2), (d)(1), (e)(2), 4213(b)(2), Dec. 22, 1987, 101 Stat. 1330–149, 1330–150, 1330–152, 1330–155, 1330–159, 1330–204, 1330–205, 1330–207, 1330–212, 1330–213, 1330–219, as amended Pub. L. 100–360, title IV, § 411(a)(3)(A), (B)(iii), (k)(6)(B)(x), (7)(A), (D), (10)(D), (G)(ii), July 1, 1988, 102 Stat. 768, 794, 796; Pub. L. 100–360, title II, § 202(h)(2), title III, §§ 301(f), 302(c)(3), (e)(4), title IV, § 411(k)(12)(A), (13)(A), July 1, 1988, 102 Stat. 718, 750, 752, 753, 797, 798; Pub. L. 100–485, title VI, § 608(d)(26)(K)(ii), (f)(4), Oct. 13, 1988, 102 Stat. 2422, 2424; Pub. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 101–239, title VI, §§ 6401(b), 6411(d)(2), 6901(b)(5)(A), Dec. 19, 1989, 103 Stat. 2259, 2271, 2299; Pub. L. 101–508, title IV, §§ 4401(a)(1), (b)(1), 4402(b), (d)(3), 4601(a)(3)(A), 4701(b)(2), 4704(b)(1), (2), 4711(c)(2), 4723(a), 4731(a), (b)(2), 4732(a), (b)(2), (c), (d), 4751(b)(1), 4752(a)(2), (b)(1), (e), 4801(a)(8), (e)(16)(A), Nov. 5, 1990, 104 Stat. 1388–143, 1388–159, 1388–163, 1388–164, 1388–166, 1388–170, 1388–172, 1388–187, 1388–194 to 1388–196, 1388–205 to 1388–207, 1388–212, 1388–218; Pub. L. 102–119, § 26(i)(1), Oct. 7, 1991, 105 Stat. 607; Pub. L. 102–234, §§ 2(a), (b)(2), 3(b)(2)(B), 4(a), Dec. 12, 1991, 105 Stat. 1793, 1799, 1803, 1804; Pub. L. 103–66, title XIII, §§ 13602(b), 13604(a), 13622(a)(2), 13624(a), 13631(c), (h)(1), Aug. 10, 1993, 107 Stat. 619, 621, 632, 636, 643, 645; Pub. L. 104–193, title I, § 114(d)(2), Aug. 22, 1996, 110 Stat. 2180; Pub. L. 104–248, § 1(b)(1), Oct. 9, 1996, 110 Stat. 3148; Pub. L. 105–12, § 9(b)(1), Apr. 30, 1997, 111 Stat. 26; Pub. L. 105–33, title IV, §§ 4701(b)(1), (2)(A)(v)–(viii), (B), (C), (c), (d)(2), 4702(b)(1), 4703(a), (b)(1), 4705(b), 4706, 4707(b), 4708(a), (d), 4712(b)(2), (c)(2), 4722(a), (b), 4724(a), (b)(1), 4742(a), 4753(a), 4802(b)(2), 4912(b)(2), Aug. 5, 1997, 111 Stat. 492, 493, 495, 500, 501, 505, 506, 509, 514–516, 523, 525, 549, 573; Pub. L. 105–100, title I, § 162(4), Nov. 19, 1997, 111 Stat. 2189; Pub. L. 106–31, title III, § 3031(a), (b), May 21, 1999, 113 Stat. 103, 104; Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, §§ 604(a)(2)(B), (b)(2), 608(e)–(k), (aa)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–395, 1501A–397, 1501A–398; Pub. L. 106–170, title II, § 201(a)(4), (b), title IV, § 407(a)–(c), Dec. 17, 1999, 113 Stat. 1893, 1913; Pub. L. 106–354, § 2(b)(2)(B), Oct. 24, 2000, 114 Stat. 1383; Pub. L. 106–554, § 1(a)(6) [title VII, §§ 702(c)(1), 710(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–574, 2763A–578; Pub. L. 108–357, title VII, § 712(b), Oct. 22, 2004, 118 Stat. 1559; Pub. L. 108–446, title III, § 305(j)(1), Dec. 3, 2004, 118 Stat. 2806; Pub. L. 109–91, title I, § 104(b), Oct. 20, 2005, 119 Stat. 2092; Pub. L. 109–171, title VI, §§ 6002(b), 6033(a), 6036(a), 6043(b), 6051(a), 6062(c)(1), 6081, Feb. 8, 2006, 120 Stat. 59, 74, 80, 88, 92, 98, 111; Pub. L. 109–432, div. B, title IV, §§ 403, 405(c)(1)(A), Dec. 20, 2006, 120 Stat. 2994, 2998; Pub. L. 110–28, title VII, § 7002(b)(1), May 25, 2007, 121 Stat. 187; Pub. L. 110–252, title VII, § 7001(d)(3), June 30, 2008, 122 Stat. 2394; Pub. L. 110–379, § 3(a), Oct. 8, 2008, 122 Stat. 4075; Pub. L. 111–3, title II, §§ 201(b)(2)(A), 211(a)(1)(B), (3), (b)(1)–(3)(A), (4), 214(a), title IV, § 401(b), Feb. 4, 2009, 123 Stat. 39, 52–54, 56, 82; Pub. L. 111–5, div. B, title IV, § 4201(a), Feb. 17, 2009, 123 Stat. 489; Pub. L. 111–148, title II, §§ 2001(a)(2)(B), (5)(D), (e)(2)(B), 2004(c)(1), 2102(a)(8), 2202(b), 2303(a)(4)(B), (b)(2)(B), 2402(d)(2)(A), 2501(c)(1), title VI, §§ 6402(c), (h)(2), 6504(a), (b)(1), 6506(a)(1), 6507, Mar. 23, 2010, 124 Stat. 272, 275, 279, 283, 288, 291, 294, 296, 303, 308, 757, 760, 776–778; Pub. L. 111–157, § 5(a)(2), Apr. 15, 2010, 124 Stat. 1117; Pub. L. 111–309, title II, § 205(e), Dec. 15, 2010, 124 Stat. 3290; Pub. L. 114–113, div. O, title V, § 503(a)(1), Dec. 18, 2015, 129 Stat. 3020; Pub. L. 114–255, div. A, title V, §§ 5002, 5005(a)(4), 5008(a), div. B, title XII, § 12006(a), div. C, title XVII, § 17004(b)(1)(A), Dec. 13, 2016, 130 Stat. 1188, 1192, 1197, 1275, 1332; Pub. L. 115–222, § 1(a), July 30, 2018, 132 Stat. 1560; Pub. L. 115–271, title I, §§ 1003, 1013, 1016(a), title IV, § 4001, Oct. 24, 2018, 132 Stat. 3903, 3920, 3922, 3958; Pub. L. 116–16, §§ 6(a)(2)(A), 8(a), Apr. 18, 2019, 133 Stat. 861, 864; Pub. L. 116–260, div. CC, title II, §§ 202, 207, 209(a)(3), Dec. 27, 2020, 134 Stat. 2977, 2984, 2986; Pub. L. 117–215, title I, § 103(b)(5), Dec. 2, 2022, 136 Stat. 2263; Pub. L. 117–328, div. FF, title I, § 1262(b)(8), Dec. 29, 2022, 136 Stat. 5682; Pub. L. 118–42, div. G, title I, § 211, Mar. 9, 2024, 138 Stat. 414; Pub. L. 119–21, title VII, §§ 71103(a)(2)(A), 71106(a), 71109(a), 71115(a), 71117(a), July 4, 2025, 139 Stat. 292, 295, 297, 301, 304.)

## Notes

### Amendment of Subsection (u)(1)

Pub. L. 119–21, title VII, § 71106, July 4, 2025, 139 Stat. 295, provided that, applicable beginning with respect to fiscal year 2030, subsection (u)(1) of this section is amended—

(1) in subparagraph (A)—

(A) by inserting “for audits conducted by the Secretary, or, at the option of the Secretary, audits conducted by the State” after “exceeds 0.03”; and

(B) by inserting “, to the extent practicable” before the period at the end;

(2) in subparagraph (B)—

(A) by striking “The Secretary” and inserting “(i) Subject to clause (ii), the Secretary”; and

(B) by adding at the end the following new clause:

“(ii) The amount waived under clause (i) for a fiscal year may not exceed an amount equal to the erroneous excess payments for medical assistance described in subparagraph (D)(i)(II) made for such fiscal year that exceed the allowable error rate of 0.03.”;

(3) in subparagraph (C), by striking “he” in each place it appears and inserting “the Secretary” in each such place; and

(4) in subparagraph (D)(i)—

(A) in subclause (I), by striking “and” at the end;

(B) in subclause (II), by striking the period at the end and inserting “, or payments where insufficient information is available to confirm eligibility, and”; and

(C) by adding at the end the following new subclause:

“(III) payments (other than payments described in subclause (I)) for items and services furnished to an individual who is not eligible for medical assistance under the State plan (or a waiver of such plan) with respect to such items and services, or payments where insufficient information is available to confirm eligibility.”

See 2025 Amendment notes below.

### Editorial Notes

### References in Text

Subsection (w)(3)(A), referred to in subsec. (b)(5), was in the original “section 1902(w)(3)(A)”, and was translated as reading “section 1903(w)(3)(A)”, meaning section 1903(w)(3)(A) of the Social Security Act, to reflect the probable intent of Congress, because section 1902(w)(3), which is classified to section 1396a(w)(3) of this title, does not contain a subpar. (A), and subsec. (w)(3)(A) of this section relates to health care related taxes.

The Individuals with Disabilities Education Act, referred to in subsec. (c), is title VI of Pub. L. 91–230, Apr. 13, 1970, 84 Stat. 175. Parts B and C of the Act are classified generally to subchapters II (§ 1411 et seq.) and III (§ 1431 et seq.), respectively, of chapter 33 of Title 20, Education. For complete classification of this Act to the Code, see section 1400 of Title 20 and Tables.

The Internal Revenue Code of 1986, referred to in subsecs. (d)(3)(B)(i) and (w)(3)(F), is classified generally to Title 26, Internal Revenue Code.

Section 300e–9(d) of this title, referred to in subsecs. (g)(1) and (m)(1)(A), (4)(A), was redesignated section 300e–9(c) of this title by Pub. L. 100–517, § 7(b), Oct. 24, 1988, 102 Stat. 2580.

The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (i)(16), is Pub. L. 105–12, Apr. 30, 1997, 111 Stat. 23, which is classified principally to chapter 138 (§ 14401 et seq.) of this title. For complete classification of this Act to the Code, see Short Title note set out under section 14401 of this title and Tables.

Sections 254b and 254c of this title, referred to in subsec. (m)(2)(B)(i)(I), (G), were in the original references to sections 329 and 330 of the Public Health Service Act, act July 1, 1944, which were omitted in the general amendment of subpart I (§ 254b et seq.) of part D of subchapter II of chapter 6A of this title by Pub. L. 104–299, § 2, Oct. 11, 1996, 110 Stat. 3626. Sections 2 and 3(a) of Pub. L. 104–299 enacted new sections 330 and 330A of act July 1, 1944, which are classified, respectively, to sections 254b and 254c of this title.

The Appalachian Regional Development Act of 1965, referred to in subsec. (m)(2)(B)(ii), (G), is Pub. L. 89–4, Mar. 9, 1965, 79 Stat. 5, which was set out in the Appendix to former Title 40, Public Buildings, Property, and Works, and was repealed and reenacted as subtitle IV (§ 14101 et seq.) of Title 40, Public Buildings, Property, and Works, by Pub. L. 107–217, §§ 1, 6(b), Aug. 21, 2002, 116 Stat. 1062, 1304.

Section 602 of this title, referred to in subsec. (u)(1)(D)(iv), was repealed and a new section 602 enacted by Pub. L. 104–193, title I, § 103(a)(1), Aug. 22, 1996, 110 Stat. 2112, and, as so enacted, no longer contains a subsec. (a)(26)(C).

Section 501(e) of the Refugee Education Assistance Act of 1980, referred to in subsec. (v)(5)(B)(iii), is section 501(e) of Pub. L. 96–422, which is set out in a note under section 1522 of Title 8, Aliens and Nationality.

The Deficit Reduction Act of 2005, referred to in subsec. (x)(5), is Pub. L. 109–171, Feb. 8, 2006, 120 Stat. 4. Section 6036 of the Act amended this section and enacted provisions set out as notes under this section. For complete classification of this Act to the Code, see Short Title of 2006 Amendment note set out under section 1305 of this title and Tables.

### Amendments

2025—Subsec. (r)(3). Pub. L. 119–21, § 71103(a)(2)(A), designated existing provisions as subpar. (A), substituted “through—” for “through”, inserted cl. (i) designation before “the Public”, and added cl. (ii) of subpar. (A) and subpar. (B).

Subsec. (u)(1)(A). Pub. L. 119–21, § 71106(a)(1), inserted “for audits conducted by the Secretary, or, at the option of the Secretary, audits conducted by the State” after “exceeds 0.03” and “, to the extent practicable” before period at end.

Subsec. (u)(1)(B). Pub. L. 119–21, § 71106(a)(2), designated existing provisions as cl. (i), substituted “Subject to clause (ii), the Secretary” for “The Secretary”, and added cl. (ii).

Subsec. (u)(1)(C). Pub. L. 119–21, § 71106(a)(3), substituted “the Secretary makes” for “he makes” and “the Secretary may” for “he may”.

Subsec. (u)(1)(D)(i)(II). Pub. L. 119–21, § 71106(a)(4)(B), substituted “, or payments where insufficient information is available to confirm eligibility, and” for period at end.

Subsec. (u)(1)(D)(i)(III). Pub. L. 119–21, § 71106(a)(4)(A), (C), added subcl. (III).

Subsec. (v)(1). Pub. L. 119–21, § 71109(a)(1), substituted “, (4), and (5)” for “and (4)”.

Subsec. (v)(5). Pub. L. 119–21, § 71109(a)(2), added par. (5).

Subsec. (w)(3)(E)(iii). Pub. L. 119–21, § 71117(a)(1), added cl. (iii).

Subsec. (w)(4)(C)(ii). Pub. L. 119–21, § 71115(a)(1), inserted “, and for fiscal years beginning on or after October 1, 2026, the applicable percent determined under subparagraph (D) shall be substituted for ‘6 percent’ each place it appears” after “each place it appears”.

Subsec. (w)(4)(D). Pub. L. 119–21, § 71115(a)(2), added subpar. (D).

Subsec. (w)(7)(H) to (J). Pub. L. 119–21, § 71117(a)(2), added subpars. (H) to (J).

2024—Subsec. (m)(9)(A). Pub. L. 118–42 struck out “(and before fiscal year 2024)” after “fiscal year 2020”.

2022—Subsec. (aa)(2)(C)(ii). Pub. L. 117–328, § 1262(b)(8), redesignated cl. (iii) as (ii) and struck out former cl. (ii) which read as follows: “have in effect a registration or waiver under section 823(h) of title 21 for purposes of dispensing narcotic drugs to individuals for maintenance treatment or detoxification treatment and are in compliance with any regulation promulgated by the Assistant Secretary for Mental Health and Substance Use for purposes of carrying out the requirements of such section 823(h); and”.

Pub. L. 117–215 substituted “823(h)” for “823(g)” in two places.

Subsec. (aa)(2)(C)(iii). Pub. L. 117–328, § 1262(b)(8)(C), redesignated cl. (iii) as (ii).

2020—Subsec. (a)(6). Pub. L. 116–260, § 207(b), which directed amendment of concluding provisions by striking out “(as found necessary by the Secretary for the elimination of fraud in the provision and administration of medical assistance provided under the State plan (or waiver of such plan))”, was executed by striking out “(as found necessary by the Secretary for the elimination of fraud in the provision and administration of medical assistance provided under the State plan)” after “such quarter”, to reflect the probable intent of Congress.

Subsec. (i)(9). Pub. L. 116–260, § 209(a)(3), added par. (9).

Subsec. (q)(4)(A)(ii). Pub. L. 116–260, § 207(a), inserted “and of patients (who are receiving medical assistance under the State plan under this subchapter (or waiver of such plan)) in a noninstitutional or other setting” after “patients residing in board and care facilities”.

Subsec. (bb). Pub. L. 116–260, § 202, added subsec. (bb).

2019—Subsec. (i)(10)(C) to (E). Pub. L. 116–16, § 6(a)(2)(A), added subpar. (E) and realigned margins.

Subsec. (i)(12). Pub. L. 116–16, § 8(a), added par. (12).

2018—Subsec. (l)(1). Pub. L. 115–222, § 1(a)(1)(A), substituted “January 1, 2020” for “January 1, 2019” in introductory provisions.

Subsec. (l)(1)(A)(i). Pub. L. 115–222, § 1(a)(1)(B), struck out “2019 and” before “2020”.

Subsec. (l)(4)(A)(i). Pub. L. 115–222, § 1(a)(2), substituted “calendar quarters in 2020” for “calendar quarters in 2019”.

Subsec. (m)(7). Pub. L. 115–271, § 1013, added par. (7).

Subsec. (m)(8). Pub. L. 115–271, § 1016(a), added par. (8).

Subsec. (m)(9). Pub. L. 115–271, § 4001, added par. (9).

Subsec. (aa). Pub. L. 115–271, § 1003, added subsec. (aa).

2016—Subsec. (i)(2)(A). Pub. L. 114–255, § 5005(a)(4)(A)(i), substituted semicolon for comma at end.

Subsec. (i)(2)(D). Pub. L. 114–255, § 5005(a)(4)(A)(ii), (iii), added subpar. (D).

Subsec. (i)(2)(E). Pub. L. 114–255, § 17004(b)(1)(A), added subpar. (E).

Subsec. (i)(21). Pub. L. 114–255, § 5008(a), inserted “section 1396r–8(d)(2)(C) of this title (relating to drugs when used for cosmetic purposes or hair growth), except where medically necessary, and” after “drugs described in”.

Subsec. (i)(27). Pub. L. 114–255, § 5002, substituted “January 1, 2018” for “January 1, 2019”.

Subsec. (l). Pub. L. 114–255, § 12006(a), added subsec. (l).

Subsec. (m)(3). Pub. L. 114–255, § 5005(a)(4)(B), added par. (3).

2015—Subsec. (i)(27). Pub. L. 114–113 added par. (27).

2010—Subsec. (a)(3)(E). Pub. L. 111–148, § 2102(a)(8)(A), amended Pub. L. 111–3, § 211(a)(1)(B). See 2009 Amendment note below.

Subsec. (a)(3)(H). Pub. L. 111–148, § 2102(a)(8)(B), amended Pub. L. 111–3, § 211(a)(1)(B). See 2009 Amendment note below.

Subsec. (d)(2)(C). Pub. L. 111–148, § 6506(a)(1)(A), substituted “1 year” for “60 days” in first sentence and “1-year period” for “60 days” in second sentence.

Subsec. (d)(2)(D). Pub. L. 111–148, § 6506(a)(1)(B), designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (f)(4). Pub. L. 111–148, § 2402(d)(2)(A), inserted “1396a(a)(10)(A)(ii)(XXII),” after “1396a(a)(10)(A)(ii)(XXI),”.

Pub. L. 111–148, § 2303(a)(4)(B), inserted “1396a(a)(10)(A)(ii)(XXI),” after “1396a(a)(10)(A)(ii)(XX),”.

Pub. L. 111–148, § 2004(c)(1), inserted “1396a(a)(10)(A)(i)(IX),” after “1396a(a)(10)(A)(i)(VIII),”.

Pub. L. 111–148, § 2001(e)(2)(B), inserted “1396a(a)(10)(A)(ii)(XX),” after “1396a(a)(10)(A)(ii)(XIX),”.

Pub. L. 111–148, § 2001(a)(5)(D), inserted “1396a(a)(10)(A)(i)(VIII),” after “1396a(a)(10)(A)(i)(VII),”.

Subsec. (i)(2)(C). Pub. L. 111–148, § 6402(h)(2), added subpar. (C).

Subsec. (i)(25). Pub. L. 111–148, § 6402(c), added par. (25).

Subsec. (i)(26). Pub. L. 111–148, § 2001(a)(2)(B), added par. (26).

Subsec. (m)(2)(A)(xi). Pub. L. 111–148, § 6504(b)(1), inserted “and for the provision of such data to the State at a frequency and level of detail to be specified by the Secretary” after “patients”.

Subsec. (m)(2)(A)(xiii). Pub. L. 111–148, § 2501(c)(1), added cl. (xiii).

Subsec. (r)(1)(B)(iv). Pub. L. 111–148, § 6507(1), added cl. (iv).

Subsec. (r)(1)(F). Pub. L. 111–148, § 6504(a), inserted “and including, for data submitted to the Secretary on or after January 1, 2010, data elements from the automated data system that the Secretary determines to be necessary for program integrity, program oversight, and administration, at such frequency as the Secretary shall determine” after “necessary”.

Subsec. (r)(4). Pub. L. 111–148, § 6507(2), added par. (4).

Subsec. (t)(3)(D). Pub. L. 111–157 substituted “inpatient or emergency room setting” for “setting (whether inpatient or outpatient)”.

Subsec. (t)(3)(E). Pub. L. 111–309, § 205(e)(1), substituted “reduced by the average payment the Secretary estimates will be made to such Medicaid providers (determined on a percentage or other basis for such classes or types of providers as the Secretary may specify) from other sources (other than under this subsection, or by the Federal government or a State or local government)” for “reduced by any payment that is made to such Medicaid provider from any other source (other than under this subsection or by a State or local government)”.

Subsec. (t)(6)(B). Pub. L. 111–309, § 205(e)(2), inserted “and shall be determined to have met such responsibility to the extent that the payment to the Medicaid provider is not in excess of 85 percent of the net average allowable cost” before period at end.

Subsec. (u)(1)(D)(v). Pub. L. 111–148, § 2303(b)(2)(B), inserted “or for medical assistance provided to an individual described in subsection (a) of section 1396r–1c of this title during a presumptive eligibility period under such section,” after “section 1396r–1b of this title during a presumptive eligibility period under such section,”.

Pub. L. 111–148, § 2202(b), substituted “section, for medical” for “section, or for medical” and inserted before period at end “, or for medical assistance provided to an individual during a presumptive eligibility period resulting from a determination of presumptive eligibility made by a hospital that elects under section 1396a(a)(47)(B) of this title to be a qualified entity for such purpose”.

2009—Subsec. (a)(2)(E). Pub. L. 111–3, § 201(b)(2)(A), added subpar. (E).

Subsec. (a)(3)(A)(iii). Pub. L. 111–3, § 401(b), added cl. (iii).

Subsec. (a)(3)(D). Pub. L. 111–5, § 4201(a)(1)(A), struck out “and” at end.

Subsec. (a)(3)(E)(ii). Pub. L. 111–5, § 4201(a)(1)(B), substituted “and” for “plus” at end.

Pub. L. 111–3, § 211(a)(1)(B)(i), which directed substitution of “and” for “plus” at end and could not be executed, was struck out by Pub. L. 111–148, § 2102(a)(8)(A).

Subsec. (a)(3)(F). Pub. L. 111–5, § 4201(a)(1)(C), added subpar. (F).

Subsec. (a)(3)(H). Pub. L. 111–3, § 211(a)(1)(B), as amended by Pub. L. 111–148, § 2102(a)(8)(B), added subpar. (H).

Subsec. (i)(22). Pub. L. 111–3, § 211(a)(3)(A), substituted “section 1396a(a)(46)(B) of this title” for “subsection (x)”.

Subsec. (t). Pub. L. 111–5, § 4201(a)(2), added subsec. (t).

Subsec. (v)(1). Pub. L. 111–3, § 214(a)(1), substituted “paragraphs (2) and (4)” for “paragraph (2)”.

Subsec. (v)(4). Pub. L. 111–3, § 214(a)(2), added par. (4).

Subsec. (x)(1). Pub. L. 111–3, § 211(a)(3)(B), substituted “section 1396a(a)(46)(B)(i) of this title” for “subsection (i)(22)”.

Subsec. (x)(2)(B), (C). Pub. L. 111–3, § 211(b)(4), realigned margins.

Subsec. (x)(2)(D), (E). Pub. L. 111–3, § 211(b)(3)(A)(i), added subpar. (D) and redesignated former subpar. (D) as (E).

Subsec. (x)(3)(B)(v), (vi). Pub. L. 111–3, § 211(b)(1), added cl. (v) and redesignated former cl. (v) as (vi).

Subsec. (x)(4), (5). Pub. L. 111–3, § 211(b)(2), (3)(A)(ii), added pars. (4) and (5).

2008—Subsec. (i)(24). Pub. L. 110–252 added par. (24).

Subsec. (r)(1). Pub. L. 110–379, § 3(a)(1), inserted “, in addition to meeting the requirements of paragraph (3),” after “a State must” in introductory provisions.

Subsec. (r)(3). Pub. L. 110–379, § 3(a)(2), added par. (3).

2007—Subsec. (i)(23). Pub. L. 110–28 added par. (23).

2006—Subsec. (f)(4). Pub. L. 109–171, § 6062(c)(1), inserted “1396a(a)(10)(A)(ii)(XIX),” after “1396a(a)(10)(A)(ii)(XVIII),” in introductory provisions.

Subsec. (i)(10)(C). Pub. L. 109–171, § 6002(b), added subpar. (C).

Subsec. (i)(10)(D). Pub. L. 109–171, § 6033(a), added subpar. (D).

Subsec. (i)(22). Pub. L. 109–171, § 6036(a)(1), added par. (22).

Subsec. (w)(4)(C). Pub. L. 109–432, § 403, designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (w)(7)(A)(viii). Pub. L. 109–171, § 6051(a), amended cl. (viii) generally. Prior to amendment, cl. (viii) read as follows: “Services of a medicaid managed care organization with a contract under subsection (m) of this section.”

Subsec. (x). Pub. L. 109–171, § 6036(a)(2), added subsec. (x).

Subsec. (x)(1). Pub. L. 109–432, § 405(c)(1)(A)(i), substituted “(i)(22)” for “(i)(23)”.

Subsec. (x)(2). Pub. L. 109–432, § 405(c)(1)(A)(ii)(I), substituted “individual declaring to be a citizen or national of the United States” for “alien” in introductory provisions.

Subsec. (x)(2)(B). Pub. L. 109–432, § 405(c)(1)(A)(ii)(II), added subpar. (B) and struck out former subpar. (B) which read as follows: “on the basis of receiving supplemental security income benefits under subchapter XVI; or”.

Subsec. (x)(2)(C). Pub. L. 109–432, § 405(c)(1)(A)(ii)(V), added subpar. (C). Former subpar. (C) redesignated (D).

Pub. L. 109–432, § 405(c)(1)(A)(ii)(III), struck out “other” before “basis” and substituted “has” for “had”.

Subsec. (x)(2)(D). Pub. L. 109–432, § 405(c)(1)(A)(ii)(IV), redesignated subpar. (C) as (D).

Subsec. (x)(3)(C)(iii). Pub. L. 109–432, § 405(c)(1)(A)(iii), substituted “I–197” for “I–97”.

Subsec. (y). Pub. L. 109–171, § 6043(b), added subsec. (y).

Subsec. (z). Pub. L. 109–171, § 6081, added subsec. (z).

2005—Subsec. (i)(21). Pub. L. 109–91 added par. (21).

2004—Subsec. (a)(3)(D). Pub. L. 108–357, § 712(b)(1), substituted “and” for “plus”.

Subsec. (a)(3)(E). Pub. L. 108–357, § 712(b)(2), added subpar. (E).

Subsec. (c). Pub. L. 108–446 substituted “part C” for “part H”.

2000—Subsec. (f)(4). Pub. L. 106–554, § 1(a)(6) [title VII, § 710(a)], inserted “1396a(a)(10)(A)(ii)(XVII), 1396a(a)(10)(A)(ii)(XVIII),” after “1396a(a)(10)(A)(ii)(XVI),”.

Subsec. (m)(2)(A)(ix). Pub. L. 106–554, § 1(a)(6) [title VII, § 702(c)(1)], repealed Pub. L. 105–33, § 4712(c)(2). See 1997 Amendment note below.

Subsec. (u)(1)(D)(v). Pub. L. 106–354 substituted “, for items” for “or for items” and inserted before period at end “, or for medical assistance provided to an individual described in subsection (a) of section 1396r–1b of this title during a presumptive eligibility period under such section”.

1999—Subsec. (a)(3)(C)(i). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(a)(2)(B)], struck out “or quality review” after “medical and utilization review”.

Subsec. (b)(4). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(e)], inserted “of” after “for the use” in introductory provisions.

Subsec. (d)(3). Pub. L. 106–31, § 3031(a), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (d)(3)(B). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(f)], realigned margins.

Subsec. (f)(2). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(g)], struck out second period at end.

Subsec. (f)(4). Pub. L. 106–170, § 201(b), inserted “1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI),” before “1396d(p)(1)” in introductory provisions.

Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(aa)(2)], substituted “1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or 1396d(p)(1) of this title” for “1396d(p)(1), or 1396d(u) of this title” in introductory provisions.

Subsec. (i)(14). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(h)], inserted “or” after semicolon.

Subsec. (i)(19). Pub. L. 106–31, § 3031(b), added par. (19).

Subsec. (i)(20). Pub. L. 106–170, § 201(a)(4), added par. (20).

Subsec. (m)(2)(A)(vi). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(i)(1)], struck out semicolon after “section 1396u–2(a)(4) of this title”.

Subsec. (m)(2)(A)(xi), (xii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(i)(2)], redesignated cl. (xi), relating to section 1396u–2, as (xii).

Subsec. (m)(6)(B)(ii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(b)(2)(A)], inserted “and” at end.

Subsec. (m)(6)(B)(iii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(b)(2)(B)], substituted a period for “; and” at end.

Subsec. (m)(6)(B)(iv). Pub. L. 106–113, § 1000(a)(6) [title VI, § 604(b)(2)(C)], struck out cl. (iv) which read as follows: “that the State agency will contract, for purposes of meeting the requirement under section 1396a(a)(30)(C) of this title, with an organization or entity that under section 1320c–3 of this title reviews services provided by an eligible organization pursuant to a contract under section 1395mm of this title for the purpose of determining whether the quality of services meets professionally recognized standards of health care.”

Subsec. (o). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(j)], struck out second closing parenthesis after “section 1167(1) of title 29”.

Subsec. (q)(3). Pub. L. 106–170, § 407(a), inserted “(A)” after “in connection with” and added subpar. (B).

Subsec. (q)(4). Pub. L. 106–170, § 407(c), amended par. (4) generally. Prior to amendment, par. (4) read as follows: “The entity has procedures for reviewing complaints of the abuse and neglect of patients of health care facilities which receive payments under the State plan under this subchapter, and, where appropriate, for acting upon such complaints under the criminal laws of the State or for referring them to other State agencies for action.”

Subsec. (q)(5). Pub. L. 106–170, § 407(b), inserted “or under any Federal health care program (as so defined)” before “to health care facilities” and inserted at end “All funds collected in accordance with this paragraph shall be credited exclusively to, and available for expenditure under, the Federal health care program (including the State plan under this subchapter) that was subject to the activity that was the basis for the collection.”

Subsec. (w)(1)(B). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(k)(1)], substituted “purposes” for “puroses”.

Subsec. (w)(3)(B). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(k)(2)], inserted a comma after “(D)” in introductory provisions.

Subsec. (w)(7)(A)(viii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(k)(3)], realigned margins.

1997—Subsec. (a)(3)(C). Pub. L. 105–33, § 4705(b), designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (b)(4). Pub. L. 105–33, § 4707(b), added par. (4).

Subsec. (b)(5). Pub. L. 105–33, § 4722(b), added par. (5).

Subsec. (f)(4). Pub. L. 105–100 substituted “1396d(p)(1), or 1396d(u) of this title” for “or 1396d(p)(1) of this title” in introductory provisions.

Subsec. (f)(4)(C). Pub. L. 105–33, § 4802(b)(2), inserted “or who is a PACE program eligible individual enrolled in a PACE program under section 1396u–4 of this title,” after “section 1396a(a)(10)(A) of this title,”.

Subsec. (i). Pub. L. 105–33, § 4708(d), inserted at end of closing provisions “Paragraphs (1), (2), (16), (17), and (18) shall apply with respect to items or services furnished and amounts expended by or through a managed care entity (as defined in section 1396u–2(a)(1)(B) of this title) in the same manner as such paragraphs apply to items or services furnished and amounts expended directly by the State.”

Subsec. (i)(2). Pub. L. 105–33, § 4724(a)(1), substituted “; or” for the period at end.

Subsec. (i)(10)(B), (11). Pub. L. 105–33, § 4724(a)(2), inserted “or” at end.

Subsec. (i)(12). Pub. L. 105–33, § 4742(a), struck out par. (12) which related to restrictions on payments, on or after Jan. 1, 1992, for physicians’ services to children under 21 years of age and to pregnant women.

Subsec. (i)(13). Pub. L. 105–33, § 4724(a)(2), inserted “or” at end.

Subsec. (i)(16). Pub. L. 105–12 added par. (16).

Subsec. (i)(17). Pub. L. 105–33, § 4724(a)(1), (3), added par. (17).

Subsec. (i)(18). Pub. L. 105–33, § 4724(b)(1), added par. (18).

Subsec. (k). Pub. L. 105–33, § 4701(b)(2)(A)(v), substituted “medicaid managed care organization” for “health maintenance organization”.

Subsec. (m)(1)(A). Pub. L. 105–33, § 4701(b)(1), in introductory provisions, substituted “The term ‘medicaid managed care organization’ means a health maintenance organization, an eligible organization with a contract under section 1395mm of this title or a Medicare+Choice organization with a contract under part C of subchapter XVIII, a provider sponsored organization, or any other public or private organization, which meets the requirement of section 1396a(w) of this title and—” for “The term ‘health maintenance organization’ means a public or private organization, organized under the laws of any State, which meets the requirement of section 1396a(w) of this title is a qualified health maintenance organization (as defined in section 300e–9(d) of this title) or which meets the requirement of section 1396a(a) of this title and—” and inserted as closing provisions “An organization that is a qualified health maintenance organization (as defined in section 300e–9(d) of this title) is deemed to meet the requirements of clauses (i) and (ii).”

Subsec. (m)(1)(A)(ii). Pub. L. 105–33, § 4706(1), inserted “, meets the requirements of subparagraph (C)(i) (if applicable),” after “provision is satisfactory to the State”.

Subsec. (m)(1)(B). Pub. L. 105–33, § 4701(b)(2)(A)(vi), substituted “medicaid managed care organization” for “health maintenance organization”.

Subsec. (m)(1)(C). Pub. L. 105–33, § 4706(2), added subpar. (C).

Subsec. (m)(2)(A)(i). Pub. L. 105–33, § 4701(b)(2)(A)(vii), substituted “medicaid managed care organization” for “health maintenance organization”.

Subsec. (m)(2)(A)(ii). Pub. L. 105–33, § 4703(a), struck out cl. (ii) which read as follows: “less than 75 percent of the membership of the entity which is enrolled on a prepaid basis consists of individuals who (I) are insured for benefits under part B of subchapter XVIII of this chapter or for benefits under both parts A and B of such subchapter, or (II) are eligible to receive benefits under this subchapter;”.

Subsec. (m)(2)(A)(iii). Pub. L. 105–33, § 4708(a), substituted “$1,000,000 for 1998 and, for a subsequent year, the amount established udner this clause for the previous year increased by the percentage increase in the consumer price index for all urban consumers over the previous year” for “$100,000”.

Subsec. (m)(2)(A)(vi). Pub. L. 105–33, § 4701(d)(2)(A), struck out “except as provided under subparagraph (F),” after “such contract (I)”, substituted “in accordance with section 1396u–2(a)(4) of this title;” for “without cause as of the beginning of the first calendar month following a full calendar month after the request is made for such termination”, and inserted “in accordance with such section” after “provides for notification”.

Subsec. (m)(2)(A)(ix). Pub. L. 105–33, § 4712(c)(2), which directed the repeal of subsec. (m)(2)(A)(ix), was repealed by Pub. L. 106–554, § 1(a)(6) [title VII, § 702(c)(1)]. See 2000 Amendment note above and Effective Date of 1997 Amendment note below.

Pub. L. 105–33, § 4712(b)(2), amended cl. (ix) generally. Prior to amendment, cl. (ix) read as follows: “such contract provides, in the case of an entity that has entered into a contract for the provision of services of such center with a federally qualified health center, that (I) rates of prepayment from the State are adjusted to reflect fully the rates of payment specified in section 1396a(a)(13)(E) of this title, and (II) at the election of such center payments made by the entity to such a center for services described in 1396d(a)(2)(C) of this title are made at the rates of payment specified in section 1396a(a)(13)(E) of this title;”.

Subsec. (m)(2)(A)(xi). Pub. L. 105–33, § 4701(c), added cl. (xi) relating to section 1396u–2.

Subsec. (m)(2)(C) to (E). Pub. L. 105–33, § 4703(b)(1)(A), struck out subpars. (C) to (E) which read as follows:

“(C) Subparagraph (A)(ii) shall not apply with respect to payments under this subchapter to a State with respect to expenditures incurred by it for payment for services by an entity during the three-year period beginning on October 8, 1976, or beginning on the date the entity qualifies as a health maintenance organization (as determined by the Secretary), whichever occurs later, but only if the entity demonstrates to the satisfaction of the Secretary by the submission of plans for each year of such three-year period that it is making continuous efforts and progress toward achieving compliance with subparagraph (A)(ii).

“(D) In the case of a health maintenance organization that is a public entity, the Secretary may modify or waive the requirement described in subparagraph (A)(ii) but only if the Secretary determines that the organization has taken and is taking reasonable efforts to enroll individuals who are not entitled to benefits under the State plan approved under this subchapter or under subchapter XVIII of this chapter.

“(E) In the case of a health maintenance organization that—

“(i) is a nonprofit organization with at least 25,000 members,

“(ii) is and has been a qualified health maintenance organization (as defined in section 300e–9(d) of this title) for a period of at least four years,

“(iii) provides basic health services through members of the staff of the organization,

“(iv) is located in an area designated as medically underserved under section 300e–1(7) of this title, and

“(v) previously received a waiver of the requirement described in subparagraph (A)(ii) under section 1315 of this title,

the Secretary may modify or waive the requirement described in subparagraph (A)(ii) but only if the Secretary determines that special circumstances warrant such modification or waiver and that the organization has taken and is taking reasonable efforts to enroll individuals who are not entitled to benefits under the State plan approved under this subchapter or under subchapter XVIII of this chapter.”

Subsec. (m)(2)(F). Pub. L. 105–33, § 4701(d)(2)(B), struck out subpar. (F) which read as follows: “In the case of—

“(i) a contract with an entity described in subparagraph (E) or (G), with a qualified health maintenance organization (as defined in section 300e–9(d) of this title) which meets the requirement of subparagraph (A)(ii), or or with an eligible organization with a contract under section 1395mm of this title which meets the requirement of subparagraph (A)(ii), or

“(ii) a program pursuant to an undertaking described in paragraph (6) in which at least 25 percent of the membership enrolled on a prepaid basis are individuals who (I) are not insured for benefits under part B of subchapter XVIII of this chapter or eligible for benefits under this subchapter, and (II) (in the case of such individuals whose prepayments are made in whole or in part by any government entity) had the opportunity at the time of enrollment in the program to elect other coverage of health care costs that would have been paid in whole or in part by any governmental entity,

a State plan may restrict the period in which requests for termination of enrollment without cause under subparagraph (A)(vi)(I) are permitted to the first month of each period of enrollment, each such period of enrollment not to exceed six months in duration, but only if the State provides notification, at least twice per year, to individuals enrolled with such entity or organization of the right to terminate such enrollment and the restriction on the exercise of this right. Such restriction shall not apply to requests for termination of enrollment for cause.”

Subsec. (m)(2)(G). Pub. L. 105–33, § 4703(b)(1)(B), substituted “clause (i)” for “clauses (i) and (ii)”.

Subsec. (m)(2)(H). Pub. L. 105–33, § 4702(b)(1)(B), in concluding provisions, inserted before period at end “or with the manager described in such clause if the manager continues to have a contract described in section 1396d(t)(3) of this title with the State”.

Pub. L. 105–33, § 4701(b)(2)(B), struck out “health maintenance” before “organization described” in concluding provisions.

Subsec. (m)(2)(H)(i). Pub. L. 105–33, § 4702(b)(1)(A), inserted “or with a primary care case manager with a contract described in section 1396d(t)(3) of this title” before comma at end.

Pub. L. 105–33, § 4701(b)(2)(A)(vii), substituted “medicaid managed care organization” for “health maintenance organization”.

Subsec. (m)(4)(A). Pub. L. 105–33, § 4701(b)(2)(A)(viii), substituted “Each medicaid managed care organization” for “Each health maintenance organization”.

Subsec. (r)(1). Pub. L. 105–33, § 4753(a)(1), added par. (1) and struck out former par. (1) which read as follows:

“(1)(A) In order to receive payments under paragraphs (2)(A) and (7) of subsection (a) of this section without being subject to per centum reductions set forth in subparagraph (C) of this paragraph, a State must provide that mechanized claims processing and information retrieval systems of the type described in subsection (a)(3)(B) of this section and detailed in an advance planning document approved by the Secretary are operational on or before the deadline established under subparagraph (B).

“(B) The deadline for operation of such systems for a State is September 30, 1985.

“(C) If a State fails to meet the deadline established under subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) of subsection (a) of this section with respect to that State shall each be reduced by 5 percentage points for the first two quarters beginning on or after such deadline, and shall be further reduced by an additional 5 percentage points after each period consisting of two quarters during which the Secretary determines the State fails to meet the requirements of subparagraph (A); except that—

“(i) neither such per centum may be reduced by more than 25 percentage points by reason of this paragraph; and

“(ii) no reduction shall be made under this paragraph for any quarter following the quarter during which such State meets the requirements of subparagraph (A).”

Subsec. (r)(2). Pub. L. 105–33, § 4753(a)(1), (2)(B), (D), inserted introductory provisions, redesignated par. (5)(A)(i) to (iii) as par. (2)(A) to (C), and struck out former par. (2) which read as follows:

“(2)(A) In order to receive payments under paragraphs (2)(A) and (7) of subsection (a) of this section without being subject to the per centum reductions set forth in subparagraph (C) of this paragraph, a State must have its mechanized claims processing and information retrieval systems, of the type required to be operational under paragraph (1), initially approved by the Secretary in accordance with paragraph (5)(A) on or before the deadline established under subparagraph (B).

“(B) The deadline for approval of such systems for a State is the last day of the fourth quarter that begins after the date on which the Secretary determines that such systems became operational as required under paragraph (1).

“(C) If a State fails to meet the deadline established under subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) of subsection (a) of this section with respect to that State shall each be reduced by 5 percentage points for the first two quarters beginning after such deadline, and shall be further reduced by an additional 5 percentage points at the end of each period consisting of two quarters during which the State fails to meet the requirements of subparagraph (A); except that—

“(i) neither such per centum may be reduced by more than 25 percentage points by reason of this paragraph, and

“(ii) no reduction shall be made under this paragraph for any quarter following the quarter during which such State’s systems are approved by the Secretary as provided in subparagraph (A).

“(D) Any State’s systems which are approved by the Secretary for purposes of subsection (a)(3)(B) of this section on or before October 7, 1980, shall be deemed to be initially approved for purposes of this subsection.”

Subsec. (r)(3), (4). Pub. L. 105–33, § 4753(a)(1), struck out pars. (3) and (4) which related to Federal matching funds and Secretary’s periodic review of approved retrieval systems.

Subsec. (r)(5). Pub. L. 105–33, § 4753(a)(2), struck out introductory provisions relating to requirements for Secretary’s initial approval of mechanized claims processing and information retrieval systems and struck out “under paragraph (6)” before period at end of subpar. (A)(iii), redesignated subpar. (A)(i) to (iii) as par. (2)(A) to (C), and struck out subpar. (B) which related to requirements for Secretary’s reapproval of mechanized claims processing and information retrieval systems.

Subsec. (r)(6) to (8). Pub. L. 105–33, § 4753(a)(3), struck out pars. (6) to (8) which related to Secretary’s development of performance standards for approval of State mechanized processing claims and information retrieval systems, waiver of certain requirements for initial operation, and applicability of per centum reductions in certain situations.

Subsec. (u)(1)(D)(v). Pub. L. 105–33, § 4912(b)(2), inserted before period at end “or for items and services described in subsection (a) of section 1396r–1a of this title provided to a child during a presumptive eligibility period under such section”.

Subsec. (w)(3)(B). Pub. L. 105–33, § 4722(a)(1), substituted “(E), and (F)” for “and (E)” in introductory provisions.

Subsec. (w)(3)(F). Pub. L. 105–33, § 4722(a)(2), added subpar. (F).

Subsec. (w)(7)(A)(viii). Pub. L. 105–33, § 4701(b)(2)(C), amended cl. (viii) generally. Prior to amendment, cl. (viii) read as follows: “Services of health maintenance organizations (and other organizations with contracts under subsection (m) of this section).”

1996—Subsec. (i)(9). Pub. L. 104–193 struck out par. (9) which read as follows: “with respect to any amount of medical assistance for pregnant women and children described in section 1396a(a)(10)(A)(ii)(IX) of this title, if the State has in effect, under its plan established under part A of subchapter IV of this chapter, payment levels that are less than the payment levels in effect under such plan on July 1, 1987;”.

Subsec. (i)(12)(A)(i). Pub. L. 104–248, § 1(b)(1)(A), inserted “or is certified in family practice or pediatrics by the medical specialty board recognized by the American Osteopathic Association” before comma at end.

Subsec. (i)(12)(A)(vi). Pub. L. 104–248, § 1(b)(1)(C)(i), (iii), (iv), added cl. (vi) and redesignated former cl. (vi) as (vii).

Pub. L. 104–248, § 1(b)(1)(C)(ii), inserted “(or certified by the State in accordance with policies of the Secretary)” after “Secretary”.

Subsec. (i)(12)(A)(vii). Pub. L. 104–248, § 1(b)(1)(C)(iii), redesignated cl. (vi) as (vii).

Subsec. (i)(12)(B)(i). Pub. L. 104–248, § 1(b)(1)(B), inserted “or is certified in family practice or obstetrics by the medical specialty board recognized by the American Osteopathic Association” before comma at end.

Subsec. (i)(12)(B)(vi). Pub. L. 104–248, § 1(b)(1)(C)(i), (iii), (iv), added cl. (vi) and redesignated former cl. (vi) as (vii).

Pub. L. 104–248, § 1(b)(1)(C)(ii), inserted “(or certified by the State in accordance with policies of the Secretary)” after “Secretary”.

Subsec. (i)(12)(B)(vii). Pub. L. 104–248, § 1(b)(1)(C)(iii), redesignated cl. (vi) as (vii).

1993—Subsec. (i)(10). Pub. L. 103–66, § 13631(c)(1), which directed the amendment of par. (10) by striking all that follows “1396r–8(g) of this title” and inserting a semicolon, could not be executed because “1396r–8(g) of this title” did not appear subsequent to the general amendment of par. (10) by Pub. L. 103–66, § 13602(b). See below.

Pub. L. 103–66, § 13602(b), amended par. (10) generally. Prior to amendment, par. (10) read as follows: “with respect to covered outpatient drugs of a manufacturer dispensed in any State unless, (A) except as provided in section 1396r–8(a)(3) of this title, the manufacturer complies with the rebate requirements of section 1396r–8(a) of this title with respect to the drugs so dispensed in all States, and (B) effective January 1, 1993, the State provides for drug use review in accordance with section 1396r–8(g) of this title; or”.

Subsec. (i)(11). Pub. L. 103–66, § 13631(c)(2), redesignated par. (12) as (11), transferred such par. to appear after par. (10), and substituted semicolon for period at end. Former par. (11) redesignated (13).

Subsec. (i)(12). Pub. L. 103–66, § 13631(c)(3), redesignated par. (14) as (12), transferred such par. to appear after par. (11), as redesignated by Pub. L. 103–66, § 13631(c)(2), and substituted semicolon for period at end. Former par. (12) redesignated (11).

Subsec. (i)(13). Pub. L. 103–66, § 13631(c)(4), redesignated par. (11) as (13), transferred such par. to appear after par. (12), as redesignated by Pub. L. 103–66, § 13631(c)(3), and directed substitution of “; or” for period at end.

Subsec. (i)(14). Pub. L. 103–66, § 13631(c)(5), added par. (14).

Subsec. (i)(15). Pub. L. 103–66, § 13631(h)(1), added par. (15).

Subsec. (o). Pub. L. 103–66, § 13622(a)(2), substituted “regulation and including a group health plan (as defined in section 1167(1) of title 29)), a service benefit plan, and a health maintenance organization)” for “regulation)”.

Subsec. (s). Pub. L. 103–66, § 13624(a), added subsec. (s).

Subsec. (v)(2)(C). Pub. L. 103–66, § 13604(a), added subpar. (C).

1991—Subsec. (a)(1). Pub. L. 102–234, § 3(b)(2)(B), inserted “and section 1396r–4(f) of this title” after “of this section”.

Subsec. (c). Pub. L. 102–119 substituted “child with a disability” for “handicapped child”, “Individuals with Disabilities Education Act” for “Education of the Handicapped Act”, and “an infant or toddler with a disability” for “a handicapped infant or toddler”.

Subsec. (d)(6). Pub. L. 102–234, § 4(a), added par. (6).

Subsec. (i)(10). Pub. L. 102–234, § 2(b)(2), struck out par. (10) added by Pub. L. 101–508, § 4701(b)(2)(B), which read as follows: “with respect to any amount expended for medical assistance for care or services furnished by a hospital, nursing facility, or intermediate care facility for the mentally retarded to reimburse the hospital or facility for the costs attributable to taxes imposed by the State soley [sic] with respect to hospitals or facilities.”

Subsec. (w). Pub. L. 102–234, § 2(a), added subsec. (w).

1990—Subsec. (a)(1). Pub. L. 101–508, § 4402(d)(3), struck out before semicolon “(including expenditures for medicare cost-sharing and including expenditures for premiums under part B of subchapter XVIII of this chapter, for individuals who are eligible for medical assistance under the plan and (A) are receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, or with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter, or (B) with respect to whom there is being paid a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in section 1396a(a)(10)(A) of this title, and, except in the case of individuals sixty-five years of age or older and disabled individuals entitled to hospital insurance benefits under subchapter XVIII of this chapter who are not enrolled under part B of subchapter XVIII of this chapter, other insurance premiums for medical or any other type of remedial care or the cost thereof)”.

Subsec. (a)(2)(B). Pub. L. 101–508, § 4801(a)(8), substituted “October 1, 1990” for “July 1, 1990”.

Subsec. (a)(3)(C), (D). Pub. L. 101–508, § 4401(b)(1), substituted “and” for “plus” at end of subpar. (C) and added subpar. (D).

Subsec. (f)(2). Pub. L. 101–508, § 4723(a), inserted “(A)” after “(2)” and added cl. (B).

Subsec. (f)(4). Pub. L. 101–508, § 4601(a)(3)(A), substituted “1396a(a)(10)(A)(i)(III), 1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V), 1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII)” for “1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(VI)”.

Subsec. (i)(8). Pub. L. 101–508, § 4711(c)(2), inserted “(A)” after “medical assistance” and added cl. (B).

Subsec. (i)(10). Pub. L. 101–508, § 4701(b)(2), added par. (10) relating to any amount expended for medical assistance for care or services.

Pub. L. 101–508, § 4401(a)(1), added par. (10) relating to covered outpatient drugs.

Subsec. (i)(11). Pub. L. 101–508, § 4801(e)(16)(A), added par. (11).

Subsec. (i)(12). Pub. L. 101–508, § 4752(a)(2), added par. (12).

Subsec. (i)(14). Pub. L. 101–508, § 4752(e), added par. (14).

Subsec. (m)(1)(A). Pub. L. 101–508, § 4751(b)(1), inserted “meets the requirement of section 1396a(w) of this title” after “State, which” and “meets the requirement of section 1396a(a) of this title and” after “or which”.

Subsec. (m)(2)(A)(i). Pub. L. 101–508, § 4732(d)(1), struck out “(or the State as authorized by paragraph (3))” after “the Secretary”.

Subsec. (m)(2)(A)(ix). Pub. L. 101–508, § 4704(b)(1), added cl. (ix).

Subsec. (m)(2)(A)(x). Pub. L. 101–508, § 4731(a), added cl. (x).

Subsec. (m)(2)(A)(xi). Pub. L. 101–508, § 4752(b)(1), added cl. (xi).

Subsec. (m)(2)(B). Pub. L. 101–508, § 4704(b)(2), inserted “except with respect to clause (ix) of subparagraph (A),” after “Subparagraph (A)”.

Subsec. (m)(2)(D). Pub. L. 101–508, § 4732(a), struck out “(i) special circumstances warrant such modification or waiver, and (ii)” after “the Secretary determines that”.

Subsec. (m)(2)(F)(i). Pub. L. 101–508, § 4732(b)(2), substituted “(G),” for “(G) or” and inserted at end “or with an eligible organization with a contract under section 1395mm of this title which meets the requirement of subparagraph (A)(ii), or”.

Subsec. (m)(2)(H). Pub. L. 101–508, § 4732(c), added subpar. (H).

Subsec. (m)(3). Pub. L. 101–508, § 4732(d)(2), struck out par. (3) which read as follows: “A State may, in the case of an entity which has submitted an application to the Secretary for determination that it is a health maintenance organization within the meaning of paragraph (1) and for which no such determination has been made within 90 days of the submission of the application, make a provisional determination for the purposes of this subchapter that such entity is such a health maintenance organization. Such provisional determination shall remain in force until such time as the Secretary makes a determination regarding the entity’s qualification under paragraph (1).”

Subsec. (m)(5)(A)(v). Pub. L. 101–508, § 4731(b)(2), added cl. (v).

Subsec. (u)(1)(D)(iv). Pub. L. 101–508, § 4402(b), which directed amendment of subpar. (C)(iv) by inserting before period at end “or with respect to payments made in violation of section 1396e of this title”, was executed to subpar. (D)(iv) to reflect the probable intent of Congress because subpar. (C) does not have a cl. (iv).

1989—Subsec. (a)(2)(B). Pub. L. 101–239, § 6901(b)(5)(A), inserted “(including the costs for nurse aides to complete such competency evaluation programs)” after “1396r(e)(1) of this title” and “(or, for calendar quarters beginning on or after July 1, 1988, and before July 1, 1990, the lesser of 90 percent or the Federal medical assistance percentage plus 25 percentage points)” after “50 percent”.

Subsec. (f)(4). Pub. L. 101–239, § 6401(b), inserted “1396a(a)(10)(A)(i)(VI),” after “1396a(a)(10)(A) (i)(IV),”.

Subsec. (i)(2). Pub. L. 101–239, § 6411(d)(2), inserted “, not including items or services furnished in an emergency room of a hospital” after “emergency item or service”.

Subsec. (i)(5). Pub. L. 101–234 repealed Pub. L. 100–360, § 202(h)(2), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

1988—Subsec. (a)(1). Pub. L. 100–360, § 301(f), amended Pub. L. 99–509, § 9403(g)(2), see 1986 Amendment note below.

Subsec. (c). Pub. L. 100–360, § 411(k)(13)(A), added subsec. (c).

Subsec. (f)(2). Pub. L. 100–360, § 411(k)(10)(G)(ii), amended Pub. L. 100–203, § 4118(h)(1), see 1987 Amendment note below.

Subsec. (f)(4). Pub. L. 100–360, § 302(e)(4), inserted “1396a(a)(10)(A)(i)(IV),” before “1396a(a)(10)(A)(ii)(IX)” in introductory provisions.

Subsec. (i)(2)(A). Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), added Pub. L. 100–203, § 4118(e)(11)(A), see 1987 Amendment note below.

Subsec. (i)(2)(B). Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), added Pub. L. 100–203, § 4118(e)(11)(B), see 1987 Amendment note below.

Subsec. (i)(3). Pub. L. 100–360, § 411(k)(6)(B)(x), added Pub. L. 100–203, § 4112(b), see 1987 Amendment note below.

Subsec. (i)(5). Pub. L. 100–360, § 202(h)(2), substituted “section 1395y(c)(1)” for “section 1395y(c)”.

Subsec. (i)(9). Pub. L. 100–360, § 302(c)(3), added par. (9).

Subsec. (m)(2)(B)(i)(II). Pub. L. 100–485, § 608(f)(4), substituted “1396a(a)(10)(D) of this title” for “1396a(a)(13)(A)(ii) of this title”.

Subsec. (m)(2)(F). Pub. L. 100–360, § 411(k)(7)(D), repealed Pub. L. 100–203, § 4113(d)(1), see 1987 Amendment note below.

Pub. L. 100–360, § 411(a)(3)(A), (B)(iii), (k)(7)(A), amended Pub. L. 100–203, § 4113(a)(1)(B), see 1987 Amendment note below.

Subsec. (m)(5). Pub. L. 100–360, § 411(k)(12)(A), amended par. (5) generally. Prior to amendment, par. (5) read as follows:

“(A) Any entity with a contract under this subsection that fails substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under such contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals, is subject to a civil money penalty of not more than $10,000 for each such failure.

“(B) The provisions of section 1320a–7a of this title (other than subsection (a)) shall apply to a civil money penalty under subparagraph (A) in the same manner as they apply to a civil money penalty under that section.”

1987—Subsec. (a)(1). Pub. L. 100–203, § 4211(g)(2), substituted “and (j)” for “, (h), and (j)”.

Subsec. (a)(2)(A) to (C). Pub. L. 100–203, § 4211(d)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).

Subsec. (a)(2)(D). Pub. L. 100–203, § 4212(c)(1), added subpar. (D).

Subsec. (a)(3)(C). Pub. L. 100–203, § 4113(b)(3), inserted “or by an entity which meets the requirements of section 1320c–1 of this title, as determined by the Secretary,” after “organization”.

Subsec. (a)(7). Pub. L. 100–203, § 4212(e)(2), inserted “subject to section 1396r(g)(3)(B) of this title,” after “(7)”.

Subsec. (f)(2). Pub. L. 100–203, § 4118(h)(1), as amended by Pub. L. 100–360, § 411(k)(10)(G)(ii), substituted “(whether in the form of insurance premiums or otherwise and regardless of whether such costs are reimbursed under another public program of the State or political subdivision thereof)” for “(whether in the form of insurance premiums or otherwise)”.

Subsec. (f)(4). Pub. L. 100–203, § 4118(p)(5), inserted “, 1396a(a)(10)(A)(ii)(X), or 1396d(p)(1)” after “1396a(a)(10)(A)(ii)(IX)”.

Subsec. (g)(1). Pub. L. 100–203, § 4212(d)(1)(A), substituted “or services in an intermediate care facility for the mentally retarded” for first reference to “or intermediate care facility services”, struck out “, skilled nursing facility services for 30 days,” after first reference to “60 days”, substituted “or services in an intermediate care facility for the mentally retarded” for “, skilled nursing facility services, or intermediate care facility services”, and substituted “and intermediate care facilities for the mentally retarded” for “, skilled nursing facilities, and intermediate care facilities”.

Subsec. (g)(4)(B). Pub. L. 100–203, § 4212(d)(1)(B), substituted “and intermediate care facilities for the mentally retarded” for “, skilled nursing facilities, and intermediate care facilities”.

Subsec. (g)(6)(B) to (D). Pub. L. 100–203, § 4212(d)(1)(C), redesignated subpar. (C) as (B) and substituted “services in an intermediate care facility for the mentally retarded” for “intermediate care facility services”, redesignated subpar. (D) as (C), and struck out former subpar. (B) which read as follows: “Such recertifications in the case of skilled nursing facility services shall be conducted at least—

“(i) 30 days after the date of the initial certification,

“(ii) 60 days after the date of the initial certification,

“(iii) 90 days after the date of the initial certification, and

“(iv) every 60 days thereafter.”

Subsec. (g)(7). Pub. L. 100–203, § 4212(d)(1)(D), struck out par. (7) which read as follows: “It is the duty and responsibility of the Secretary to assure that standards which govern the provision of care in skilled nursing facilities and intermediate care facilities under plans approved under this subchapter, and the enforcement of such standards, are adequate to protect the health and safety of residents and to promote the effective and efficient use of public moneys.”

Subsec. (h). Pub. L. 100–203, § 4211(g)(1), struck out subsec. (h) which related to reduction by Secretary of amount otherwise considered as expenditures under State plan where reasonable cost differential between statewide average cost of skilled nursing facility services and statewide average cost of intermediate care facility services does not exist for any calendar quarter beginning after June 30, 1973.

Subsec. (i). Pub. L. 100–203, § 4118(d)(1)(B), inserted sentence at end that nothing in par. (1) be construed as permitting a State to provide services under its plan under this subchapter that are not reasonable in amount, duration, and scope to achieve their purpose.

Subsec. (i)(1). Pub. L. 100–203, § 4118(d)(1)(A), substituted “; or” for period at end.

Subsec. (i)(2). Pub. L. 100–93, § 8(g), amended par. (2) generally. Prior to amendment, par. (2) read as follows: “with respect to any amount paid for services furnished under the plan after December 31, 1972, by a provider or other person during any period of time, if payment may not be made under subchapter XVIII of this chapter with respect to services furnished by such provider or person during such period of time solely by reason of a determination by the Secretary under section 1395y(d)(1) of this title or under clause (D), (E), or (F) of section 1395cc(b)(2) of this title, or by reason of noncompliance with a request made by the Secretary under clause (C)(ii) of such section 1395cc(b)(2) or under section 1396a(a)(38) of this title; or”.

Subsec. (i)(2)(A). Pub. L. 100–203, § 4118(e)(11)(A), as added by Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), substituted “under subchapter V, XVIII, or XX or under this subchapter pursuant to section 1320a–7, 1320a–7a, 1320c–5, or 1395u(j)(2) of this title” for “in the State plan under this subchapter pursuant to section 1320a–7 of this title or section 1320a–7a of this title”.

Subsec. (i)(2)(B). Pub. L. 100–203, § 4118(e)(11)(B), as added by Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(ii), substituted “from participation under subchapter V, XVIII, or XX or under this subchapter pursuant to section 1320a–7, 1320a–7a, 1320c–5, or 1395u(j)(2) of this title” for “pursuant to section 1320a–7 of this title or section 1320a–7a of this title from participation in the program under this subchapter”.

Subsec. (i)(3). Pub. L. 100–203, § 4112(b), as added by Pub. L. 100–360, § 411(k)(6)(B)(x), inserted “(other than amounts attributable to the special situation of a hospital which serves a disproportionate number of low income patients with special needs)” before “to the extent”.

Subsec. (i)(4). Pub. L. 100–203, § 4211(i), struck out “or skilled nursing facility” after “hospital” in three places.

Subsec. (i)(8). Pub. L. 100–203, § 4213(b)(2), added par. (8).

Subsec. (m)(2)(F). Pub. L. 100–203, § 4113(d)(1), which directed the substitution of “subparagraphs (E) or (G)” for “subparagraph (G)”, was repealed by Pub. L. 100–360, § 411(k)(7)(D).

Pub. L. 100–203, § 4113(a)(1)(B), as amended by Pub. L. 100–360, § 411(a)(3)(A), (B)(iii), (k)(7)(A), substituted “(F) In the case of—” and cls. (i) and (ii) for “(F) In the case of a contract with an entity described in subparagraph (G) or with a qualified health maintenance organization (as defined in section 300e–9(d) of this title) which meets the requirement of subparagraph (A)(ii),”.

Subsec. (m)(6). Pub. L. 100–203, § 4113(a)(1)(A), added par. (6).

Subsec. (n). Pub. L. 100–93, § 8(h)(1), struck out subsec. (n) which related to State agency action upon disclosure or failure to disclose required information by institution, organization, etc.

Subsec. (r). Pub. L. 100–203, § 4212(c)(2), substituted “paragraphs (2)(A)” for “paragraphs (2)” in pars. (1)(A), (C) and (2)(A), (C).

1986—Subsec. (a)(1). Pub. L. 99–509, § 9403(g)(2), as amended by Pub. L. 100–360, § 301(f), inserted “including expenditures for medicare cost-sharing and” before “including expenditures”.

Subsec. (a)(3)(C). Pub. L. 99–509, § 9431(b)(2), inserted “or quality review” after “medical and utilization review”.

Subsec. (a)(4). Pub. L. 99–603 added par. (4).

Subsec. (d)(2). Pub. L. 99–272, § 9512(a), designated first sentence as subpar. (A), designated second sentence as subpar. (B), properly indented and aligned below subpar. (A), and added subpars. (C) and (D).

Subsec. (f)(4). Pub. L. 99–509, § 9401(e)(2), inserted “for any individual described in section 1396a(a)(10)(A)(ii)(IX) of this title or” after “as medical assistance”.

Subsec. (i)(1). Pub. L. 99–272, § 9507(a), added par. (1).

Subsec. (m)(2)(A). Pub. L. 99–272, § 9517(a)(1), substituted “subparagraphs (B), (C), and (G)” for “subparagraphs (B) and (C)” in introductory text.

Pub. L. 99–272, § 9517(c)(1), inserted “(including a health insuring organization)” after “any entity” and “(directly or through arrangements with providers of services)” after “responsible for the provision” in introductory text.

Subsec. (m)(2)(A)(iii). Pub. L. 99–509, § 9434(a)(2), inserted before the semicolon “and under which the Secretary must provide prior approval for contracts providing for expenditures in excess of $100,000”.

Subsec. (m)(2)(A)(viii). Pub. L. 99–509, § 9434(a)(1)(A), added cl. (viii).

Subsec. (m)(2)(F). Pub. L. 99–514, § 1895(c)(2), substituted “In the case” for “in the case”.

Pub. L. 99–272, § 9517(a)(2), struck out designation “(i)” at beginning of subpar. (F), substituted “in the case of a contract with an entity described in subparagraph (G) or with a qualified health maintenance organization (as defined in section 300e–9(d) of this title) which meets the requirement of subparagraph (A)(ii)” for “In the case of a contract with a health maintenance organization described in clause (ii)”, substituted “such entity or organization” for “such organization”, and struck out cl. (ii) which defined a health maintenance organization.

Subsec. (m)(2)(G). Pub. L. 99–272, § 9517(a)(3), added subpar. (G).

Subsec. (m)(4). Pub. L. 99–509, § 9434(a)(1)(B), added par. (4).

Subsec. (m)(5). Pub. L. 99–509, § 9434(b), added par. (5).

Subsec. (r)(1)(B). Pub. L. 99–272, § 9518(a), substituted “September 30, 1985” for “the earlier of (i) September 30, 1982, or (ii) the last day of the sixth month following the date specified for operation of such systems in the State’s most recently approved advance planning document submitted before October 7, 1980”.

Subsec. (r)(4)(A). Pub. L. 99–272, § 9503(b)(2), substituted “once every three years” for “once each fiscal year” and inserted at end “Reviews may, at the Secretary’s discretion, constitute reviews of the entire system or of only those standards, systems requirements, and other conditions which have demonstrated weakness in previous reviews.”

Subsec. (r)(6)(J). Pub. L. 99–272, § 9503(b)(1), amended subpar. (J) generally. Prior to amendment, subsec. (J) read as follows: “report on or before October 1, 1981, to the Congress on the extent to which States have developed and operated effective mechanized claims processing and information retrieval systems.”

Subsec. (u)(1)(D)(iv). Pub. L. 99–272, § 9503(f), added cl. (iv).

Subsec. (u)(1)(D)(v). Pub. L. 99–509, § 9407(c), added cl. (v).

Subsec. (v). Pub. L. 99–509, § 9406(a), added subsec. (v).

1984—Subsec. (g)(1). Pub. L. 98–369, § 2363(a)(2)(A), (B), in provision preceding subpar. (A), substituted “inpatient hospital services or intermediate care facility services for 60 days, skilled nursing facility services for 30 days, or inpatient mental hospital services for” for “care as an inpatient in a hospital (including an institution for tuberculosis), skilled nursing facility or intermediate care facility on 60 days, or in a hospital for mental diseases on”, and struck out “which for purposes of this section means the four calendar quarters ending with June 30,” before “the Federal medical assistance percentage”, and struck out “in the same fiscal year” before “shall be decreased by a per centum thereof”.

Pub. L. 98–369, § 2363(a)(2)(C), substituted “, skilled nursing facility services, or intermediate care facility services furnished beyond 60 days (or inpatient mental hospital services furnished beyond 90 days), such State has an effective program of medical review of the care of patients in mental hospitals, skilled nursing facilities, and intermediate care facilities pursuant to paragraphs (26) and (31) of section 1396a(a) of this title whereby the professional management of each case is reviewed and evaluated at least annually by independent professional review teams” for “(including tuberculosis hospitals), skilled nursing facility services, or intermediate care facility services furnished beyond 60 days (or inpatient mental hospital services furnished beyond 90 days), there is in operation in the State an effective program of control over utilization of such services; such a showing must include evidence that—” and former subpars. (A) through (D) requirement for evidence concerning an effective program of utilization of certain medical services.

Subsec. (g)(4)(B). Pub. L. 98–369, § 2373(b)(11), substituted “paragraphs (26)” for “paragraph (26)” and “diligence” for “deligence”.

Subsec. (g)(6). Pub. L. 98–369, § 2363(a)(4), in amending par. (6) generally, substituted provisions relating to recertifications for provisions relating to reports to Congress concerning Secretary’s determination and review of showing respecting any decrease of Federal medical assistance percentage of amounts paid for services.

Subsec. (g)(7). Pub. L. 98–369, § 2363(b), as amended by Pub. L. 98–617, § 3(a)(6), added par. (7).

Subsec. (i)(7). Pub. L. 98–369, § 2303(g)(2), added par. (7).

Subsec. (m)(2)(A)(vi). Pub. L. 98–369, § 2364(1), inserted “except as provided under subparagraph (F),” after “(I)”.

Subsec. (m)(2)(B)(i)(I). Pub. L. 98–369, § 2373(b)(12)(A), (C), struck out “(II)” before “for the period” and substituted “period” for “peroid”.

Subsec. (m)(2)(B)(i)(II). Pub. L. 98–369, § 2373(b)(12)(B), substituted “of section 1396d(a) of this title” for “of such section”.

Subsec. (m)(2)(C). Pub. L. 98–369, § 2373(b)(13), realigned margin of subpar. (C).

Subsec. (m)(2)(E), (F). Pub. L. 98–369, § 2364(2), added subpars. (E) and (F).

Subsec. (s)(3)(B). Pub. L. 98–369, § 2373(b)(14), substituted “non-Federal” for “nonfederal”.

1983—Subsec. (t)(3). Pub. L. 97–448 substituted “purposes” for “purpose” and “the lower of the Federal medical assistance percentage for the State in effect for fiscal year 1981, or the Federal medical assistance percentage for the State in effect for fiscal year 1982” for “the Federal medical assistance percentage for States in effect for fiscal year 1981, disregarding any change in such percentage after fiscal year 1981”.

1982—Subsec. (a)(3)(C). Pub. L. 97–248, § 146(b), substituted “utilization and quality control peer review organization” for “Professional Standards Review Organization”.

Subsec. (f)(3). Pub. L. 97–248, § 137(g), struck out “(without regard to section 608 of this title)” after “consisting of one person if such plan”.

Subsec. (g)(1). Pub. L. 97–248, § 137(b)(11), inserted “or which is a qualified health maintenance organization (as defined in section 300e–9(d) of this title)”.

Subsec. (g)(1)(A). Pub. L. 97–248, § 137(b)(12), substituted “provided in an institution for the mentally retarded” for “described in section 1396d(d) of this title”.

Subsec. (k). Pub. L. 97–248, § 137(b)(13), substituted “subsection (m) of this section” for “section 1395mm of this title”.

Subsec. (m)(2)(A). Pub. L. 97–248, § 137(b)(14), substituted “or” for “and” before “(II)” in cl. (iv), and substituted “unforeseen” for “unforseen” in cl. (vii)(II).

Subsec. (s). Pub. L. 97–248, § 137(a)(2), amended directory language of Pub. L. 97–35, § 2161(c)(1), to correct an error, and did not involve any change in text. See 1981 Amendment note below.

Subsec. (s)(1)(A). Pub. L. 97–248, § 137(b)(15)(A), (B), in provisions following cl. (iii), substituted “fiscal year 1982” for “fiscal year 1981”, and “subsections (a)(6) and (t) of this section, without regard to payments for claims relating to expenditures made for medical assistance for services received through a facility of the Indian Health Service,” for “subsection (t) of this section”.

Subsec. (s)(1)(C). Pub. L. 97–248, § 137(b)(15)(C), inserted “a program in operation under”, before “a plan approved”.

Subsec. (s)(3)(D). Pub. L. 97–248, § 137(b)(15)(D), substituted “must determine that” for “determines that”, “most recent year (which shall consist of a 12-month period determined by the Secretary for this purpose)” for “most recent calendar year”, and “2- or 3-year period” for “2 or 3 calendar year period”, and struck out “calendar” wherever appearing.

Subsec. (s)(4)(B). Pub. L. 97–248, § 137(b)(15)(E), inserted “and paragraph (3)(D)”.

Subsec. (s)(5)(A)(i). Pub. L. 97–248, § 137(b)(15)(F), inserted “(including amounts saved, to the extent such amounts can be documented to the satisfaction of the Secretary, by reason of the suspension or termination of a provider or other person for fraud or abuse, but only during the period of such suspension or termination or, if shorter, the 1-year period beginning on the date of such termination or suspension)” after “recovered or diverted”.

Subsec. (s)(5)(B). Pub. L. 97–248, § 137(b)(27), inserted “or quarters” after “carried forward to the following quarter”.

Subsec. (t). Pub. L. 97–248, § 137(a)(1), (2), amended directory language of Pub. L. 97–35, § 2161(b), (c)(2), to correct an error, and did not involve any change in text. See 1981 Amendment note below.

Subsec. (t)(1)(A). Pub. L. 97–248, § 137(b)(16)(A), substituted “payments under subsection (a)(6) of this section, interest paid under subsection (d)(5) of this section, and payments for claims relating to expenditures made for medical assistance for services received through a facility of the Indian Health Service” for “interest paid under subsection (d)(5) of this section”.

Subsec. (t)(1)(B). Pub. L. 97–248, § 137(b)(16)(B), (D), substituted “Consumer Price Index for all urban consumers (U.S. city average) published by the Bureau of Labor Statistics” for “consumer price index for all urban consumers (published by the Bureau of Labor Statistics)” and “for the 12-month period ending on September 30, 1983” for “between September 1982 and September 1983”.

Subsec. (t)(1)(C). Pub. L. 97–248, § 137(b)(16)(C), (D), substituted “Consumer Price Index for all urban consumers (U.S. city average) published by the Bureau of Labor Statistics” for “consumer price index for all urban consumers (published by the Bureau of Labor Statistics)” and “for the 24-month period ending on September 30, 1984” for “between September 1982 and September 1984”.

Subsec. (t)(2)(A). Pub. L. 97–248, § 137(b)(16)(A), substituted “payments under subsection (a)(6) of this section, interest paid under subsection (d)(5) of this section, and payments for claims relating to expenditures made for medical assistance for services received through a facility of the Indian Health Service” for “interest paid under subsection (d)(5) of this section”.

Subsec. (t)(3). Pub. L. 97–248, § 137(b)(16)(E), substituted “for fiscal years 1982, 1983, and 1984” for “for fiscal year 1984” wherever appearing, “years 1983, 1984, and 1985, respectively” for “year 1985”, “in effect for fiscal year 1981” for “in effect for fiscal year 1983”, and “after fiscal year 1981” for “between fiscal year 1983 and fiscal year 1984”.

Subsec. (u). Pub. L. 97–248, § 133(a), added subsec. (u).

1981—Subsec. (a)(3)(B). Pub. L. 97–35, § 2113(n), substituted “and” for “plus” at the end of subpar. (B) and added subpar. (C).

Subsec. (d)(5). Pub. L. 97–35, § 2163, substituted “determination at a rate” for “determination (but not to exceed a period of twelve months with respect to disallowances made prior to October 1, 1981, or six months with respect to disallowances made thereafter) at a rate”.

Subsec. (e). Pub. L. 97–35, § 2101(a)(2), added subsec. (e).

Subsec. (g)(1)(A). Pub. L. 97–35, § 2183(a), inserted “and the physician, or a physician assistant or nurse practitioner under the supervision of a physician” and “or, in the case of services that are intermediate care facility services described in section 1396d(d) of this title, every year” in parenthetical text.

Subsec. (i)(1). Pub. L. 97–35, § 2174(b), struck out par. (1) which provided that payments shall not be made with respect to any amount paid for items or services furnished under the plan after Dec. 31, 1972, to the extent that such amount exceeds the charge which would be determined to be reasonable for such items or services under fourth and fifth sentences of section 1395u(b)(3) of this title.

Subsec. (i)(5). Pub. L. 97–35, § 2103(b)(1), added par. (5).

Subsec. (i)(6). Pub. L. 97–35, § 2164(a), added par. (6).

Subsec. (m)(1)(A). Pub. L. 97–35, § 2178(a)(1), redefined “Health Maintenance Organization” substantially, and substituted reference to public and private organizations making services to individuals eligible for benefits under this subchapter and which makes adequate provision against the risk of insolvency for reference to a legal entity which provides health services to individuals enrolled in such organization and providing services and benefits to individuals eligible for benefits under specified provisions of this subchapter.

Subsec. (m)(2)(A). Pub. L. 97–35, § 2178(a)(2), in cl. (ii), substituted “75 percent of the membership of the entity which is enrolled on a prepaid basis” for “one-half of the membership of the entity”, and added cls. (iii) to (vii).

Subsec. (m)(2)(D). Pub. L. 97–35, § 2178(a)(3), added subpar. (D).

Subsec. (n). Pub. L. 97–35, § 2106(b)(3), struck out “of this section” after “section 1395cc of this title” thereby perfecting the amendment made by Pub. L. 96–499, § 905(c)(2).

Subsec. (s). Pub. L. 97–35, § 2161(c)(1), as amended by Pub. L. 97–248, § 137(a)(2), repealed subsec. (s) which provided for reduction in medicaid payments to States, limitations on reductions, States included, and percentage reductions reduced under certain circumstances. See Effective Date of 1981 Amendment note below.

Pub. L. 97–35, § 2161(a), added subsec. (s).

Subsec. (t). Pub. L. 97–35, § 2161(c)(2), as amended by Pub. L. 97–248, § 137(a)(2), repealed subsec. (t) which provided for offset for meeting Federal medicaid expenditure targets, and computation for meeting expenditure targets. See Effective Date of 1981 Amendment note below.

Pub. L. 97–35, § 2161(b), as amended by Pub. L. 97–248, § 137(a)(1), added subsec. (t).

1980—Subsec. (a)(1). Pub. L. 96–499, § 905(b), inserted reference to subsection (j) of this section.

Subsec. (a)(6). Pub. L. 96–499, § 963, substituted “such a quarter within the twelve-quarter period beginning with the first quarter in which a payment is made to the State pursuant to this paragraph, and (B) 75 per centum of the sums expended during each succeeding calendar quarter” for “each quarter beginning on or after October 1, 1977, and ending before October 1, 1980”.

Subsec. (d)(5). Pub. L. 96–499, § 961(a), added par. (5).

Subsec. (g)(3)(B). Pub. L. 96–499, § 964, substituted “January 1, 1978” for “October 1, 1977” and “any calendar quarter ending on or before December 31, 1978” for “the calendar quarter ending on December 31, 1977”.

Subsec. (j). Pub. L. 96–499, § 905(c)(1), substituted provisions relating to the adjustment of amounts determined under subsec. (a)(1) of this section in accordance with section 1396m of this title for provisions relating to orders for suspension of payment.

Subsec. (n). Pub. L. 96–499, § 905(c)(2), struck out “or is subject to a suspension of payment order issued under subsection (j)” after “section 1395cc of this title”.

Subsec. (r). Pub. L. 96–398 added subsec. (r).

1979—Subsec. (m)(2)(C). Pub. L. 96–79 substituted “the date the entity qualifies as a health maintenance organization (as determined by the Secretary)” for “the date the entity enters into a contract with the State under this subchapter for the provision of health services on a prepaid risk basis”.

1978—Subsec. (m)(1)(B). Pub. L. 95–559 struck out “shall be administered through the Assistant Secretary for Health and in the Office of the Assistant Secretary for Health, and the administration of such duties and functions” after “subparagraph (A),”.

Subsec. (m)(2)(B)(i)(I). Pub. L. 95–626 substituted “section 254b(d)(1)(A)” for “section 247d(d)(1)(A)”.

1977—Subsec. (a)(3)(B). Pub. L. 95–142, § 10(a), inserted provisions relating to notice to individuals in a sample group and provisions exempting notice respecting confidential services from notice requirements.

Subsec. (a)(6), (7). Pub. L. 95–142, § 17(a), added par. (6) and redesignated former par. (6) as (7).

Subsec. (b)(3). Pub. L. 95–142, § 17(b), added par. (3).

Subsec. (g). Pub. L. 95–142, § 20(a), in par. (1) substituted “Subject to paragraph (3), with respect to” for “With respect to” and “by a per centum thereof (determined under paragraph (5))” for “by 33⅓ per centum thereof”, in par. (2) inserted “timely” before “sample onsite surveys”, and added pars. (3) to (6).

Subsec. (i)(2). Pub. L. 95–142, § 3(c)(2), inserted provisions relating to noncompliance under sections 1395cc(b)(2) and 1396a(a)(38) of this title.

Subsec. (m)(2)(A). Pub. L. 95–83, § 105(a)(1), in revising text, incorporated former cl. (i) (I) and (II) provisions in introductory text relating to responsibility for providing inpatient hospital services and other described services, substituting “capitation basis” for “capitation risk basis” and inserting “unless”; redesignated as cl. (i) former cl. (ii), substituting “has determined that the entity is a health maintenance organization” for “has not determined to be a health maintenance organization”; and redesignated as cl. (ii) former cl. (iii), substituting “less than one-half of the membership of the entity consists of individuals who (I) are insured for benefits under part B of subchapter XVIII of this chapter or for benefits under both parts A and B of such subchapter, or (II) are eligible to receive benefits under this subchapter” for “more than one-half of the membership of which consists of individuals who are insured under parts A and B of subchapter XVIII of this chapter or recipients of benefits under this subchapter.”

Subsec. (m)(2)(C). Pub. L. 95–83, § 105(a)(2), substituted reference to subpar. “(A)(ii)” for “(A)(iii)” wherever appearing.

Subsec. (n). Pub. L. 95–142, § 8(c), added subsec. (n).

Subsecs. (o), (p). Pub. L. 95–142, § 11(a), added subsecs. (o) and (p).

Subsec. (q). Pub. L. 95–142, § 17(c), added subsec. (q).

1976—Subsec. (l). Pub. L. 94–552 repealed subsec. (l) which provided for reduction of amount of payments to States found not to be in compliance with section 1396a(g) of this title.

Subsec. (m). Pub. L. 94–460 added subsec. (m).

1975—Subsec. (g)(1)(C). Pub. L. 94–182, § 110(a), inserted provisions specifying the method by which the size and composition of the sample of admissions subject to review is to be established.

Subsec. (l). Pub. L. 94–182, § 111(b), added subsec. (l).

1973—Subsec. (a). Pub. L. 93–233, § 18(x)(5), struck out reference to section 1317 of this title in introductory parenthetical phrase.

Subsec. (a)(1). Pub. L. 93–233, §§ 13(a)(11), 18(r)(1), substituted “individuals who are eligible for medical assistance under the plan and (A) are receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or part A of subchapter IV of this chapter, or with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter, or (B) with respect to whom there is being paid a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in section 1396a(a)(10)(A) of this title” for “individuals who are recipients of money payments under a State plan approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV of this chapter” and inserted “and disabled individuals entitled to hospital insurance benefits under subchapter XVIII of this chapter,” after “individuals sixty-five years of age or older”.

Subsec. (a)(4). Pub. L. 93–233, § 18(s), substituted “sums expended with respect to costs incurred” for “sums expended”.

Subsec. (a)(5). Pub. L. 93–233, § 18(t), struck out “(as found necessary by the Secretary for the proper and efficient administration of the plan)” after “such quarter”.

Subsec. (b). Pub. L. 93–233, §§ 18(r)(2), (u), (x)(6), inserted in par. (2) after “individuals sixty-five years of age or older” text reading “and disabled individuals entitled to hospital insurance benefits under subchapter XVIII” and end text reading “, other than amounts expended under provisions of the plan of such State required by section 1396a(a)(34) of this title,” and redesignated pars. (2) and (3) as (1) and (2), respectively.

Subsec. (c). Pub. L. 93–233, § 18(y)(1)(A), struck out subsec. (c) which provided for Federal medical assistance percentage and Federal share of State medical expenses during fiscal year ending June 30, 1965.

Subsec. (d)(1). Pub. L. 93–233, § 18(y)(1)(B), struck out reference to subsec. (c) of this section.

Subsec. (f)(4). Pub. L. 93–233, § 13(a)(12), in subpar. (A), made payment limitations inapplicable to individual with respect to whom supplemental security income benefits are being paid under subchapter XVI of this chapter; in subpar. (B), made payment limitations inapplicable to individual with respect to whom such benefits are not being paid, and in cls. (i) and (ii) inserted “to have such benefits paid with respect to him”, and added subpar. (C).

Subsec. (g)(1)(C). Pub. L. 93–233, § 18(v), substituted “directly responsible for the care of the patient or financially interested in any such institution or, except in the case of hospitals, employed by the institution” for “directly responsible for the care of the patient and who are not employed by or financially interested in any such institution”.

Subsec. (j). Pub. L. 93–66 struck out provisions respecting skilled nursing facility services and intermediate care facility services.

1972—Subsec. (a)(1). Pub. L. 92–603, § 207(a)(2), inserted reference to subsecs. (g) and (h) and of this section.

Subsec. (a)(3). Pub. L. 92–603, § 235(a), added par. (3). Former par. (3) redesignated (4).

Subsec. (a)(4). Pub. L. 92–603, § 249B, temporarily added par. (4) which provided for payments to States of 100 per centum of sums expended for costs incurred during a quarter attributable to compensation or training of personnel responsible for inspecting public or private institutions providing long-term care to recipients of medical assistance to determine compliance with health or safety standards. Former par. 4 redesignated (5). See Effective Date of 1972 Amendment note below.

Pub. L. 92–603, § 235(a), redesignated former par. (3) as (4).

Subsec. (a)(5). Pub. L. 92–603, § 299E(a), added par. (5). Former par. (5) redesignated (6).

Pub. L. 92–603, § 249B, redesignated former par. (4) as (5).

Subsec. (a)(6). Pub. L. 92–603, § 299E, redesignated former par. (5) as (6).

Subsec. (b)(1). Pub. L. 92–603, § 295, struck out par. (1) which related to amount of quarterly expenditures exceeding average of total expenditures for each quarter of fiscal year ending June 30, 1965.

Subsec. (b)(3). Pub. L. 92–603, § 221(c)(6), added par. (3).

Subsec. (e). Pub. L. 92–603, § 230, repealed subsec. (e) which related to furnishing for comprehensive care and services by July 1, 1977.

Subsec. (g). Pub. L. 92–603, §§ 207(a)(1), 278(b)(1), added subsec. (g) and substituted “skilled nursing facility” for “skilled nursing home” and “skilled nursing facilities” for “skilled nursing homes” wherever appearing.

Subsec. (h). Pub. L. 92–603, §§ 207(a)(1), 278(b)(1)(5), added subsec. (h) and substituted “skilled nursing facility” for “skilled nursing home” wherever appearing.

Subsec. (i). Pub. L. 92–603, §§ 224(c), 229(c), 233(c), 237(a)(1), 278(b)(7), added subsec. (i) and substituted “skilled nursing facility” for “skilled nursing home” wherever appearing.

Subsec. (j). Pub. L. 92–603, § 290, added subsec. (j) relating to orders for suspension of payment.

Pub. L. 92–603, §§ 225, 278(b)(16), added subsec. (j) relating to skilled nursing facilities services, and substituted “skilled nursing facility” for “skilled nursing home” wherever appearing.

Subsec. (k). Pub. L. 92–603, § 226(e), added subsec. (k).

1969—Subsec. (e). Pub. L. 91–56 extended from July 1, 1975, to July 1, 1977, the date by which comprehensive care and services for eligible individuals must be made available for a State to be eligible for payments.

1968—Subsec. (a)(1). Pub. L. 90–248, § 222(d), substituted “and, except in the case of individuals sixty-five years of age or older who are not enrolled under part B of subchapter XVIII of this chapter, other insurance premiums” for “and other insurance premiums”.

Pub. L. 90–248, § 241(f)(5), struck out “IV,” after “I,” and inserted “or part A of subchapter IV of this chapter,” after “XVI of this chapter,”.

Subsec. (a)(2). Pub. L. 90–248, § 225(a), substituted “of the State agency or any other public agency” for “of the State agency (or of the local agency administering the State plan in the political subdivision)”.

Subsec. (b). Pub. L. 90–248, § 222(c), designated existing provisions as par. (1) and added par. (2).

Subsec. (b)(2). Pub. L. 90–364 substituted “1969” for “1967”.

Subsec. (d)(2). Pub. L. 90–248, § 229(c), provided for treatment of expenditures for which payments were made to the State under subsec. (a) as an overpayment to the extent that the State or local agency administering the plan has been reimbursed for such expenditures by a third party pursuant to the provisions of its plan in compliance with section 1396a(a)(25) of this title.

Subsec. (f). Pub. L. 90–248, § 220(a), added subsec. (f).

### Statutory Notes and Related Subsidiaries

### Change of Name

References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Pub. L. 108–173, set out as a note under section 1395w–21 of this title.

### Effective Date of 2025 Amendment

Pub. L. 119–21, title VII, § 71106(b), July 4, 2025, 139 Stat. 295, provided that: “The amendments made by subsection (a) [amending this section] shall apply beginning with respect to fiscal year 2030.”

Pub. L. 119–21, title VII, § 71117(c), July 4, 2025, 139 Stat. 305, provided that: “The amendments made by this section [amending this section] shall take effect upon the date of enactment of this Act [July 4, 2025], subject to any applicable transition period determined appropriate by the Secretary of Health and Human Services, not to exceed 3 fiscal years.”

### Effective Date of 2020 Amendment

Amendment by section 209(a)(3) of Pub. L. 116–260 effective Dec. 27, 2020, and applicable to transportation furnished on or after such date, see section 209(a)(4) of Pub. L. 116–260, set out as a note under section 1396a of this title.

### Effective Date of 2019 Amendment

Amendment by section 6(a)(2)(A) of Pub. L. 116–16 effective on Apr. 18, 2019, and applicable to covered outpatient drugs supplied by manufacturers under agreements under section 1396r–8 of this title on or after that date, see section 6(e) of Pub. L. 116–16, set out as a note under section 1320a–7 of this title.

Pub. L. 116–16, § 8(b), Apr. 18, 2019, 133 Stat. 864, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to items and services furnished on or after January 1, 2020.”

### Effective Date of 2018 Amendment

Pub. L. 115–271, title I, § 1016(c), Oct. 24, 2018, 132 Stat. 3923, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on the date of enactment of this Act [Oct. 24, 2018].”

### Effective Date of 2016 Amendment

Pub. L. 114–255, div. A, title V, § 5008(b), Dec. 13, 2016, 130 Stat. 1197, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to calendar quarters beginning on or after the date of the enactment of this Act [Dec. 13, 2016].”

### Effective Date of 2010 Amendment

Pub. L. 111–309, title II, § 205(e), Dec. 15, 2010, 124 Stat. 3290, provided that the amendment made by section 205(e) is effective as if included in the enactment of section 4201(a)(2) of the American Recovery and Reinvestment Act of 2009 (Pub. L. 111–5).

Amendment by Pub. L. 111–157 effective as if included in the enactment of the HITECH Act (Pub. L. 111–5, div. A, title XIII, div. B, title IV), see section 5(b) of Pub. L. 111–157, set out as a note under section 1395w–4 of this title.

Amendment by section 2004(c)(1) of Pub. L. 111–148 effective Jan. 1, 2014, see section 2004(d) of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

Pub. L. 111–148, title II, § 2102(a), Mar. 23, 2010, 124 Stat. 288, provided that the amendment made by section 2102(a)(8) of Pub. L. 111–148 is effective as if included in the enactment of the Children’s Health Insurance Program Reauthorization Act of 2009 (Pub. L. 111–3).

Amendment by section 2202(b) of Pub. L. 111–148 effective Jan. 1, 2014, and applicable to services furnished on or after that date, see section 2202(c) of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

Amendment by section 2303(a)(4)(B), (b)(2)(B) of Pub. L. 111–148 effective Mar. 23, 2010, and applicable to items and services furnished on or after such date, see section 2303(d) of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

Amendment by section 2402(d)(2)(A) of Pub. L. 111–148 effective on the first day of the first fiscal year quarter that begins after Mar. 23, 2010, see section 2402(g) of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

Pub. L. 111–148, title VI, § 6504(b)(2), Mar. 23, 2010, 124 Stat. 777, provided that: “The amendment made by paragraph (1) [amending this section] shall apply with respect to contract years beginning on or after January 1, 2010.”

Pub. L. 111–148, title VI, § 6506(a)(2), Mar. 23, 2010, 124 Stat. 777, provided that: “The amendments made by this subsection [amending this section] take effect on the date of enactment of this Act [Mar. 23, 2010] and apply to overpayments discovered on or after that date.”

Amendment by sections 6504(a) and 6507 of Pub. L. 111–148 effective Jan. 1, 2011, without regard to whether final regulations to carry out such amendments and subtitle F (§§ 6501–6508) of title VI of Pub. L. 111–148 have been promulgated by that date, see section 6508 of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

### Effective Date of 2009 Amendment

Amendment by sections 201(b)(2)(A), 214(a), and 401(b) of Pub. L. 111–3 effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of Pub. L. 111–3, set out as an Effective Date note under section 1396 of this title.

Amendment by section 211 of Pub. L. 111–3 effective Jan. 1, 2010, except that amendment by section 211(b)(1)–(3)(A) of Pub. L. 111–3 effective as if included in the enactment of section 6036 of Pub. L. 109–171 and amendment by section 211(b)(4) of Pub. L. 111–3 effective as if included in the enactment of section 405 of Pub. L. 109–432, with restoration of eligibility and special transition rule for Indians, see section 211(d) of Pub. L. 111–3, set out as a note under section 1396a of this title.

### Effective Date of 2008 Amendment

Pub. L. 110–379, § 3(b), Oct. 8, 2008, 122 Stat. 4075, provided that: In general.—Except as provided in paragraph (2), the amendments made by subsection (a) [amending this section] take effect on October 1, 2009. Extension of effective date for state law amendment.—In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by subsection (a), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act [Oct. 8, 2008]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session is considered to be a separate regular session of the State legislature.”

### Effective Date of 2007 Amendment

Pub. L. 110–28, title VII, § 7002(b)(2), May 25, 2007, 121 Stat. 188, as amended by Pub. L. 110–90, § 5, Sept. 29, 2007, 121 Stat. 985, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to prescriptions executed after March 31, 2008.”

[Pub. L. 110–90, § 5, Sept. 29, 2007, 121 Stat. 985, provided in part that the amendment by section 5 of Pub. L. 110–90 to section 7002(b)(2) of Pub. L. 110–28, set out above, is effective as if included in the enactment of section 7002(b) of Pub. L. 110–28.]

### Effective Date of 2006 Amendment

Pub. L. 109–432, div. B, title IV, § 405(c)(1)(A), Dec. 20, 2006, 120 Stat. 2998, provided that the amendment made by section 405(c)(1)(A) is effective as if included in the amendment made by section 6036(a)(2) of the Deficit Reduction Act of 2005 [Pub. L. 109–171].

Pub. L. 109–171, title VI, § 6033(b), Feb. 8, 2006, 120 Stat. 74, provided that: “The amendments made by subsection (a) [amending this section] take effect on the first day of the first fiscal year quarter that begins after the date of enactment of this Act [Feb. 8, 2006].”

Pub. L. 109–171, title VI, § 6036(b), Feb. 8, 2006, 120 Stat. 81, as amended by Pub. L. 109–432, div. B, title IV, § 405(c)(2)(A)(v)(I), Dec. 20, 2006, 120 Stat. 3000, provided that: “The amendments made by subsection (a) [amending this section] shall apply to determinations of initial eligibility for medical assistance made on or after July 1, 2006, and to redeterminations of eligibility made on or after such date in the case of individuals for whom the requirement of section 1903(x) of the Social Security Act [42 U.S.C. 1396b(x)], as added by such amendments, was not previously met.”

Pub. L. 109–171, title VI, § 6043(c), Feb. 8, 2006, 120 Stat. 88, provided that: “The amendments made by this section [amending this section and section 1396o–1 of this title] shall apply to non-emergency services furnished on or after January 1, 2007.”

Pub. L. 109–171, title VI, § 6051(b), Feb. 8, 2006, 120 Stat. 92, provided that: In general.—Subject to paragraph (2), the amendment made by subsection (a) [amending this section] shall be effective as of the date of the enactment of this Act [Feb. 8, 2006].Delay in effective date.— In general.—Subject to subparagraph (B), in the case of a State specified in subparagraph (B), the amendment made by subsection (a) shall be effective as of October 1, 2009. Specified states.—For purposes of subparagraph (A), the States specified in this subparagraph are States that have enacted a law providing for a tax on the services of a Medicaid managed care organization with a contract under section 1903(m) of the Social Security Act [42 U.S.C. 1396b(m)] as of December 8, 2005.”

Amendment by section 6062(c)(1) of Pub. L. 109–171 applicable to medical assistance for items and services furnished on or after Jan. 1, 2007, see section 6062(d) of Pub. L. 109–171, set out as a note under section 1396a of this title.

### Effective Date of 2005 Amendment

Pub. L. 109–91, title I, § 104(d), Oct. 20, 2005, 119 Stat. 2093, provided that: “The amendments made by this section [amending this section and sections 1396r–8 and 1396u–5 of this title] shall apply to drugs dispensed on or after January 1, 2006.”

### Effective Date of 2004 Amendment

Pub. L. 108–357, title VII, § 712(d), Oct. 22, 2004, 118 Stat. 1561, provided that: “The amendments made by subsections (a) and (b) [amending this section and section 1396d of this title] take effect on the date of enactment of this Act [Oct. 22, 2004] and apply to medical assistance and services provided under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) on or after that date.”

### Effective Date of 2000 Amendments

Amendment by section 702(c)(1) of Pub. L. 106–554 effective Jan. 1, 2001, and applicable to services furnished on or after such date, see section 1(a)(6) [title VII, § 702(e)] of Pub. L. 106–554, set out as a note under section 1396a of this title.

Pub. L. 106–554, § 1(a)(6) [title VII, § 710(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A–578, provided that: The amendment made by subsection (a)(1) [amending this section] shall be effective as if included in the enactment of section 121 of the Foster Care Independence Act of 1999 (Public Law 106–169 [amending sections 1396a and 1396d of this title and enacting provisions set out as notes under section 1396a of this title]). The amendment made by subsection (a)(2) [amending this section] shall be effective as if included in the enactment of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106–354).”

Amendment by Pub. L. 106–354 applicable to medical assistance for items and services furnished on or after Oct. 1, 2000, without regard to whether final regulations to carry out such amendments have been promulgated by such date, see section 2(d) of Pub. L. 106–354, set out as a note under section 1396a of this title.

### Effective Date of 1999 Amendment

Amendment by section 201(a)(4), (b) of Pub. L. 106–170 applicable to medical assistance for items and services furnished on or after Oct. 1, 2000, see section 201(d) of Pub. L. 106–170, set out as a note under section 1396a of this title.

Pub. L. 106–170, title IV, § 407(d), Dec. 17, 1999, 113 Stat. 1914, provided that: “The amendments made by this section [amending this section] take effect on the date of the enactment of this Act [Dec. 17, 1999].”

Amendment by section 1000(a)(6) [title VI, § 604(a)(2)(B), (b)(2)] of Pub. L. 106–113 applicable as of such date as the Secretary of Health and Human Services certifies to Congress that the Secretary is fully implementing section 1396u–2(c)(2) of this title, see section 1000(a)(6) [title VI, § 604(c)(2)] of Pub. L. 106–113, set out as a note under section 1396a of this title.

Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 608(aa)], Nov. 29, 1999, 113 Stat. 1536, 1501A–398, provided that the amendment made by section 1000(a)(6) [title VI, § 608(aa)(2)] is effective as if included in the enactment of BBA [the Balanced Budget Act of 1997, Pub. L. 105–33].

Amendment by section 1000(a)(6) [title VI, § 608(e)–(k)] of Pub. L. 106–113 effective Nov. 29, 1999, see section 1000(a)(6) [title VI, § 608(bb)] of Pub. L. 106–113, set out as a note under section 1396a of this title.

Pub. L. 106–31, title III, § 3031(c), May 21, 1999, 113 Stat. 104, provided that: “This section [amending this section] and the amendments made by this section shall apply to amounts paid to a State prior to, on, or after the date of the enactment of this Act [May 21, 1999].”

### Effective Date of 1997 Amendment

Pub. L. 105–100, title I, § 162, Nov. 19, 1997, 111 Stat. 2188, provided that the amendment made by that section is effective as if included in the enactment of subtitle J (§§ 4901–4923) of title IV of the Balanced Budget Act of 1997, Pub. L. 105–33.

Pub. L. 105–33, title IV, § 4710, Aug. 5, 1997, 111 Stat. 506, provided that: General Effective Date.—Except as otherwise provided in this chapter [chapter 1 (§§ 4701–4710) of subtitle H of title IV of Pub. L. 105–33, enacting section 1396u–2 of this title, amending this section and sections 1320a–3, 1320a–7b, 1396a, 1396d, 1396o, 1396r–6, 1396r–8, 1396u–2, and 1396v of this title, and enacting provisions set out as a note under section 1396u–2 of this title] and section 4759 [enacting provisions set out as a note under section 1396a of this title], the amendments made by this chapter shall take effect on the date of the enactment of this Act [Aug. 5, 1997] and shall apply to contracts entered into or renewed on or after October 1, 1997. Specific Effective Dates.—Subject to subsection (c) and section 4759— PCCM option.—The amendments made by section 4702 [amending this section and sections 1396a and 1396d of this title] shall apply to primary care case management services furnished on or after October 1, 1997. 75:25 rule.—The amendments made by section 4703 [amending this section and section 1396r–6 of this title] apply to contracts under section 1903(m) of the Social Security Act (42 U.S.C. 1396b(m)) on and after June 20, 1997. Quality standards.—Section 1932(c)(1) of the Social Security Act [42 U.S.C. 1396u–2(c)(1)], as added by section 4705(a), shall take effect on January 1, 1999.Solvency standards.— In general.—The amendments made by section 4706 [amending this section] shall apply to contracts entered into or renewed on or after October 1, 1998. Transition rule.—In the case of an organization that as of the date of the enactment of this Act [Aug. 5, 1997] has entered into a contract under section 1903(m) of the Social Security Act [42 U.S.C. 1396b(m)] with a State for the provision of medical assistance under title XIX of such Act [42 U.S.C. 1396 et seq.] under which the organization assumes full financial risk and is receiving capitation payments, the amendment made by section 4706 shall not apply to such organization until 3 years after the date of the enactment of this Act. Sanctions for noncompliance.—Section 1932(e) of the Social Security Act [42 U.S.C. 1396u–2(e)], as added by section 4707(a), shall apply to contracts entered into or renewed on or after April 1, 1998. Limitation on ffp for enrollment brokers.—The amendment made by section 4707(b) [amending this section] shall apply to amounts expended on or after October 1, 1997. 6-month guaranteed eligibility.—The amendments made by section 4709 [amending section 1396a of this title] shall take effect on October 1, 1997. Nonapplication to Waivers.—Nothing in this chapter (or the amendments made by this chapter) shall be construed as affecting the terms and conditions of any waiver, or the authority of the Secretary of Health and Human Services with respect to any such waiver, under section 1115 or 1915 of the Social Security Act (42 U.S.C. 1315, 1396n).”

Amendment by section 4712(b)(2) of Pub. L. 105–33 applicable to services furnished on or after Oct. 1, 1997, see section 4712(b)(3) of Pub. L. 105–33, set out as a note under section 1396a of this title.

Pub. L. 105–33, title IV, § 4712(c), Aug. 5, 1997, 111 Stat. 509, as amended by Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 603(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–394, which provided that the amendment made by section 4712(c) was effective for services furnished on or after Oct. 1, 2004, was repealed by Pub. L. 106–554, § 1(a)(6) [title VII, § 702(c)(1), (e)], Dec. 21, 2000, 114 Stat. 2763, 2763A–574, effective Jan. 1, 2001, and applicable to services furnished on or after such date.

Pub. L. 105–33, title IV, § 4722(d), Aug. 5, 1997, 111 Stat. 515, provided that: “The amendments made by subsection (a) [amending this section] shall apply to taxes imposed before, on, or after the date of the enactment of this Act [Aug. 5, 1997] and the amendment made by subsection (b) [amending this section] shall apply to taxes imposed on or after such date.”

Pub. L. 105–33, title IV, § 4724(b)(2), Aug. 5, 1997, 111 Stat. 516, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to home health care services furnished on or after January 1, 1998.”

Pub. L. 105–33, title IV, § 4742(b), Aug. 5, 1997, 111 Stat. 523, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after the date of the enactment of this Act [Aug. 5, 1997].”

Amendment by section 4753(a) of Pub. L. 105–33 effective Jan. 1, 1998, except as otherwise specifically provided, see section 4753(c) of Pub. L. 105–33, set out as a note under section 1396a of this title.

Amendment by section 4912(b)(2) of Pub. L. 105–33 effective Aug. 5, 1997, see section 4912(c) of Pub. L. 105–33, set out as a note under section 1396a of this title.

Amendment by Pub. L. 105–12 effective Apr. 30, 1997, and applicable to Federal payments made pursuant to obligations incurred after Apr. 30, 1997, for items and services provided on or after such date, subject to also being applicable with respect to contracts entered into, renewed, or extended after Apr. 30, 1997, as well as contracts entered into before Apr. 30, 1997, to the extent permitted under such contracts, see section 11 of Pub. L. 105–12, set out as an Effective Date note under section 14401 of this title.

### Effective Date of 1996 Amendment

Pub. L. 104–248, § 1(b)(2), Oct. 9, 1996, 110 Stat. 3149, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to physicians’ services furnished on or after January 1, 1992.”

Amendment by Pub. L. 104–193 effective July 1, 1997, with transition rules relating to State options to accelerate such date, rules relating to claims, actions, and proceedings commenced before such date, rules relating to closing out of accounts for terminated or substantially modified programs and continuance in office of Assistant Secretary for Family Support, and provisions relating to termination of entitlement under AFDC program, see section 116 of Pub. L. 104–193, as amended, set out as an Effective Date note under section 601 of this title.

### Effective Date of 1993 Amendment

Amendment by section 13602(b) of Pub. L. 103–66 effective as if included in enactment of the Omnibus Budget Reconciliation Act of 1990, Pub. L. 101–508, see section 13602(d)(1) of Pub. L. 103–66, set out as a note under section 1396r–8 of this title.

Pub. L. 103–66, title XIII, § 13604(b), Aug. 10, 1993, 107 Stat. 621, provided that: Subject to paragraph (2), the amendments made by subsection (a) [amending this section] shall apply as if included in the enactment of OBRA–1986 [Pub. L. 99–509]. The Secretary of Health and Human Services shall not disallow expenditures made for the care and services described in section 1903(v)(2)(C) of the Social Security Act [42 U.S.C. 1396b(v)(2)(C)], as added by subsection (a), furnished before the date of the enactment of this Act [Aug. 10, 1993].”

Amendment by section 13622(a)(2) of Pub. L. 103–66 applicable to items and services furnished on or after Oct. 1, 1993, see section 13622(d)(3) of Pub. L. 103–66, set out as a note under section 1396a of this title.

Pub. L. 103–66, title XIII, § 13624(b), Aug. 10, 1993, 107 Stat. 636, provided that: “The amendment made by subsection (a) [amending this section] shall apply to referrals made on or after December 31, 1994.”

Pub. L. 103–66, title XIII, § 13631(h)(2), Aug. 10, 1993, 107 Stat. 645, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to amounts expended for vaccines administered on or after October 1, 1993.”

Amendment by section 13631(c) of Pub. L. 103–66 applicable to payments under State plans approved under this subchapter for calendar quarters beginning on or after Oct. 1, 1994, see section 13631(i) of Pub. L. 103–66, set out as a note under section 1396a of this title.

### Effective Date of 1991 Amendment

Amendments by section 2(a), (b)(2) of Pub. L. 102–234 effective Jan. 1, 1992, without regard to whether or not regulations have been promulgated to carry out such amendments by such date, see section 2(c)(1) of Pub. L. 102–234, set out as a note under section 1396a of this title.

Amendment by section 3(b)(2)(B) of Pub. L. 102–234 effective Jan. 1, 1992, see section 3(e)(1) of Pub. L. 102–234, set out as a note under section 1396a of this title.

Pub. L. 102–234, § 4(b), Dec. 12, 1991, 105 Stat. 1804, provided that: “The amendment made by subsection (a) [amending this section] shall apply to fiscal years ending after the date of the enactment of this Act [Dec. 12, 1991].”

### Effective Date of 1990 Amendments

Amendment by section 4402(b), (d)(3) of Pub. L. 101–508 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after Jan. 1, 1991, without regard to whether or not final regulations to carry out the amendments by section 4402 of Pub. L. 101–508 have been promulgated by such date, see section 4402(e) of Pub. L. 101–508, set out as a note under section 1396a of this title.

Amendment by section 4601(a)(3)(A) of Pub. L. 101–508 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after July 1, 1991, without regard to whether or not final regulations to carry out the amendments by section 4601 of Pub. L. 101–508 have been promulgated by such date, see section 4601(b) of Pub. L. 101–508, set out as a note under section 1396a of this title.

Pub. L. 101–508, title IV, § 4701(c), Nov. 5, 1990, 104 Stat. 1388–171, provided that: “The amendment made by subsection (b) [amending this section and section 1396a of this title] shall take effect on January 1, 1991.”

Amendment by section 4704(b)(1), (2) of Pub. L. 101–508 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1989, Pub. L. 101–239, see section 4704(f) of Pub. L. 101–508, set out as a note under section 1396a of this title.

Amendment by section 4711(c)(2) of Pub. L. 101–508 applicable to civil money penalties imposed after Nov. 5, 1990, see section 4711(e)(2)(B) of Pub. L. 101–508, set out as a note under section 1396a of this title.

Pub. L. 101–508, title IV, § 4731(c), Nov. 5, 1990, 104 Stat. 1388–195, provided that: “The amendments made by subsections (a) and (b)(2) [amending this section] shall apply with respect to contract years beginning on or after January 1, 1992, and the amendments made by subsection (b)(1) [amending section 1320a–7a of this title] shall take effect on the date of the enactment of this Act [Nov. 5, 1990].”

Amendment by section 4751(b)(1) of Pub. L. 101–508 applicable with respect to services furnished on or after first day of first month beginning more than 1 year after Nov. 5, 1990, see section 4751(c) of Pub. L. 101–508, set out as a note under section 1396a of this title.

Pub. L. 101–508, title IV, § 4752(b)(2), Nov. 5, 1990, 104 Stat. 1388–206, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to contract years beginning after the date of the establishment of the system described in section 1902(x) of the Social Security Act [42 U.S.C. 1396a(x)].”

Pub. L. 101–508, title IV, § 4801(a)(9), Nov. 5, 1990, 104 Stat. 1388–212, provided that: “Except as provided in paragraph (6), the amendments made by this subsection [amending this section and section 1396r of this title] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203].”

Pub. L. 101–508, title IV, § 4801(e)(16)(B), Nov. 5, 1990, 104 Stat. 1388–218, provided that: “The amendments made by subparagraph (A) [amending this section] shall apply with respect to actions initiated on or after the date of the enactment of this Act [Nov. 5, 1990].”

### Effective Date of 1989 Amendment

Amendment by section 6401(b) of Pub. L. 101–239 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after Apr. 1, 1990, with respect to eligibility for medical assistance on or after such date, without regard to whether or not final regulations to carry out the amendments by section 6401 of Pub. L. 101–239 have been promulgated by such date, see section 6401(c) of Pub. L. 101–239, set out as a note under section 1396a of this title.

Amendment by section 6901(b)(5)(A) of Pub. L. 101–239 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, see section 6901(b)(6) of Pub. L. 101–239, set out as a note under section 1395i–3 of this title.

Amendment by Pub. L. 101–234 effective Jan. 1, 1990, see section 201(c) of Pub. L. 101–234, set out as a note under section 1320a–7a of this title.

### Effective Date of 1988 Amendment

Amendment by section 608(d)(26)(K)(ii) of Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g)(1) of Pub. L. 100–485, set out as a note under section 704 of this title.

Amendment by section 608(f)(4) of Pub. L. 100–485 effective Oct. 13, 1988, see section 608(g)(2) of Pub. L. 100–485, set out as a note under section 704 of this title.

Amendment by section 202(h)(2) of Pub. L. 100–360 applicable to items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. L. 100–360, set out as a note under section 1395u of this title.

Pub. L. 100–360, title III, § 301(f), July 1, 1988, 102 Stat. 750, provided that the amendment made by that section is effective as though included in the enactment of the Omnibus Budget Reconciliation Act of 1986, Pub. L. 99–509.

Amendment by section 302(c)(3) of Pub. L. 100–360 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after July 1, 1989, with respect to eligibility for medical assistance on or after that date, without regard to whether or not final regulations to carry out such amendment have been promulgated by such date, see section 302(f) of Pub. L. 100–360, set out as a note under section 1396a of this title.

Except as specifically provided in section 411 of Pub. L. 100–360, amendment by section 411(a)(3)(A), (B)(iii), (k)(6)(B)(x), (7)(A), (D), (10)(D), (G)(ii) of Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Pub. L. 100–360, title IV, § 411(k)(12)(B), July 1, 1988, 102 Stat. 798, provided that: “The amendment made by subparagraph (A) [amending this section] shall apply to actions occurring on or after the date of the enactment of this Act [July 1, 1988].”

Pub. L. 100–360, title IV, § 411(k)(13)(B), July 1, 1988, 102 Stat. 798, provided that: “The amendment made by subparagraph (A) [amending this section] shall take effect on the date of the enactment of this Act [July 1, 1988].”

### Effective Date of 1987 Amendment

Pub. L. 100–203, title IV, § 4118(d)(2), Dec. 22, 1987, 101 Stat. 1330–155, provided that: “The amendments made by paragraph (1) [amending this section] shall be effective as if included in the enactment of section 9507 of the Consolidated Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99–272].”

Amendment by section 4118(h)(1) of Pub. L. 100–203 applicable to costs incurred after Dec. 22, 1987, see section 4118(h)(3) of Pub. L. 100–203, as amended, set out as a note under section 1396a of this title.

Amendments by sections 4211(d)(1), (g), (i), 4212(c)(1), (2), (d)(1), (e)(2) of Pub. L. 100–203 applicable to nursing facility services furnished on or after Oct. 1, 1990, without regard to whether regulations implementing such amendments are promulgated by such date, except as otherwise specifically provided in section 1396r of this title, with transitional rule, see section 4214(a), (b)(2) of Pub. L. 100–203, as amended, set out as an Effective Date note under section 1396r of this title.

Amendment by section 4212(d)(1) of Pub. L. 100–203 not applicable until such date as of which the State has specified the resident assessment instrument under section 1396r(e)(5) of this title, and the State has begun conducting surveys under section 1396r(g)(2) of this title, see section 4212(d)(4) of Pub. L. 100–203, set out as a note under section 1396a of this title.

Amendment by section 4213(b)(2) of Pub. L. 100–203 applicable to payments under this subchapter for calendar quarters beginning on or after Dec. 22, 1987, without regard to whether regulations implementing such amendment are promulgated by such date, except as otherwise specifically provided in section 1396r of this title, see section 4214(b)(1) of Pub. L. 100–203, as amended, set out as an Effective Date note under section 1396r of this title.

Amendment by Pub. L. 100–93 effective at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable to administrative proceedings commenced before end of such period, see section 15(a) of Pub. L. 100–93, set out as a note under section 1320a–7 of this title.

### Effective Date of 1986 Amendment

Amendment by Pub. L. 99–603 effective Oct. 1, 1987, see section 121(c)(2) of Pub. L. 99–603, set out as a note under section 502 of this title.

Amendment by Pub. L. 99–514 effective, except as otherwise provided, as if included in enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. 99–272, see section 1895(e) of Pub. L. 99–514, set out as a note under section 162 of Title 26, Internal Revenue Code.

Amendment by section 9401(e)(2) of Pub. L. 99–509 applicable to medical assistance furnished in calendar quarters beginning on or after Apr. 1, 1987, without regard to whether of not final regulations to carry out such amendment have been promulgated by such date, see section 9401(f) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Amendment by section 9403(g)(2) of Pub. l. 99–509 applicable to payments under this subchapter for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date, see section 9403(h) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Amendment by section 9406(a) of Pub. L. 99–509 applicable, except as otherwise provided, to medical assistance furnished to aliens on or after Jan. 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date, see section 9406(c) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Amendment by section 9407(c) of Pub. L. 99–509 applicable to ambulatory prenatal care furnished in calendar quarters beginning on or after Apr. 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date, see section 9407(d) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Amendment by section 9431(b)(2) of Pub. L. 99–509 applicable to payments under this subchapter for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date, see section 9431(c) of Pub. L. 99–509, set out as a note under section 1396a of this title.

Pub. L. 99–509, title IX, § 9434(a)(3), Oct. 21, 1986, 100 Stat. 2069, provided that: The amendments made by paragraph (1) [amending this section] shall take effect 6 months after the date of the enactment of this Act [Oct. 21, 1986]. The amendment made by paragraph (2) [amending this section] shall take effect on the date of the enactment of this Act and shall apply to contracts entered into, renewed, or extended after the end of the 30-day period beginning on the date of the enactment of this Act.”

Amendment by section 9503(b), (f) of Pub. L. 99–272 applicable to calendar quarters beginning on or after Apr. 7, 1986, except as otherwise provided, see section 9503(g)(1), (2) of Pub. L. 99–272, set out as a note under section 1396a of this title.

Pub. L. 99–272, title IX, § 9507(b), Apr. 7, 1986, 100 Stat. 210, provided that: “The amendments made by subsection (a) [amending this section] shall apply to medical assistance furnished on or after January 1, 1987.”

Pub. L. 99–272, title IX, § 9512(b), Apr. 7, 1986, 100 Stat. 213, provided that: “The amendments made by this section [amending this section] shall apply to overpayments identified for quarters beginning on or after October 1, 1985.”

Pub. L. 99–272, title IX, § 9517(c)(2), (3), Apr. 7, 1986, 100 Stat. 216, as amended by Pub. L. 99–509, title IX, § 9435(e), Oct. 21, 1986, 100 Stat. 2070; Pub. L. 99–514, title XVIII, § 1895(c)(4), Oct. 22, 1986, 100 Stat. 2935; Pub. L. 101–508, title IV, § 4734, Nov. 5, 1990, 104 Stat. 1388–196; Pub. L. 104–240, § 1(a), Oct. 8, 1996, 110 Stat. 3140; Pub. L. 106–554, § 1(a)(6) [title VII, § 704(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–575; Pub. L. 110–275, title II, § 205(a), July 15, 2008, 122 Stat. 2593, provided that: Except as provided in subparagraph (B) and in paragraph (3), the amendments made by paragraph (1) [amending this section] shall apply to expenditures incurred for health insuring organizations which first become operational on or after January 1, 1986. For purposes of this paragraph, a health insuring organization is not considered to be operational until the date on which it first enrolls patients. In the case of a health insuring organization— which first becomes operational on or after January 1, 1986, but for which the Secretary of Health and Human Services has waived, under section 1915(b) of the Social Security Act [42 U.S.C. 1396n(b)] and before such date, certain requirements of section 1902 of such Act [42 U.S.C. 1396a],clauses (ii) and (vi) of section 1903(m)(2)(A) of such Act [42 U.S.C. 1396b(m)(2)(A)(ii), (vi)] shall not apply during the period for which such waiver is effective. In the case of the Hartford Health Network, Inc., clauses (ii) and (vi) of section 1903(m)(2)(A) of the Social Security Act shall not apply during the period for which a waiver by the Secretary of Health and Human Services, under section 1915(b) of such Act, of certain requirements of section 1902 of such Act is in effect (pursuant to a request for a waiver under section 1915(b) of such Act submitted before January 1, 1986). Nothing in section 1903(m)(1)(A) of the Social Security Act shall be construed as requiring a health-insuring organization to be organized under the health maintenance organization laws of a State. Subject to subparagraph (C), in the case of up to 3 health insuring organizations which are described in subparagraph (B), in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Ventura County, and in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Merced County, which first become operational on or after January 1, 1986, and which are designated by the Governor, and approved by the Legislature, of California, the amendments made by paragraph (1) shall not apply. A health insuring organization described in this subparagraph is one that— is operated directly by a public entity established by a county government in the State of California under a State enabling statute; enrolls all medicaid beneficiaries residing in the county or counties in which it operates; meets the requirements for health maintenance organizations under the Knox-Keene Act (Cal. Health and Safety Code, section 1340 et seq.) and the Waxman-Duffy Act (Cal. Welfare and Institutions Code, section 14450 et seq.); assures a reasonable choice of providers, which includes providers that have historically served medicaid beneficiaries and which does not impose any restriction which substantially impairs access to covered services of adequate quality where medically necessary; provides for a payment adjustment for a disproportionate share hospital (as defined under State law consistent with section 1923 of the Social Security Act [42 U.S.C. 1396r–4]) in a manner consistent with the requirements of such section; and provides for payment, in the case of childrens’ hospital services provided to medicaid beneficiaries who are under 21 years of age, who are children with special health care needs under title V of the Social Security Act [42 U.S.C. 701 et seq.], and who are receiving care coordination services under such title, at rates determined by the California Medical Assistance Commission. Subparagraph (A) shall not apply with respect to any period for which the Secretary of Health and Human Services determines that the number of medicaid beneficiaries enrolled with health insuring organizations described in subparagraph (B) exceeds 16 percent of the number of such beneficiaries in the State of California. In this paragraph, the term ‘medicaid beneficiary’ means an individual who is entitled to medical assistance under the State plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], other than a qualified medicare beneficiary who is only entitled to such assistance because of section 1902(a)(10)(E) of such title [42 U.S.C. 1396a(a)(10)(E)].”

[Pub. L. 110–275, title II, § 205(b), July 15, 2008, 122 Stat. 2594, provided that: “The amendments made by subsection (a) [amending section 9517(c)(3)(A), (C) of Pub. L. 99–272, set out above] shall take effect on the date of the enactment of this Act [July 15, 2008].” ]

[Pub. L. 106–554, § 1(a)(6) [title VII, § 704(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A–575, provided that: “The amendment made by subsection (a) [amending section 9517(c)(3)(C) of Pub. L. 99–272, set out above] takes effect on the date of the enactment of this Act [Dec. 21, 2000].” ]

[Pub. L. 104–240, § 1(b), Oct. 8, 1996, 110 Stat. 3140, provided that: “The amendment made by subsection (a) [amending section 9517(c)(3)(B)(ii) of Pub. L. 99–272, set out above] shall apply to quarters beginning on or after October 1, 1996.” ]

Pub. L. 99–272, title IX, § 9518(b), Apr. 7, 1986, 100 Stat. 216, provided that: “The amendment made by subsection (a) [amending this section] shall apply to payment under section 1903(a) of the Social Security Act [42 U.S.C. 1396b(a)] for calendar quarters beginning on or after October 1, 1982.”

### Effective Date of 1984 Amendment

Amendment by Pub. L. 98–617 effective as if originally included in the Deficit Reduction Act of 1984, Pub. L. 98–369, see section 3(c) of Pub. L. 98–617, set out as a note under section 1395f of this title.

Amendment by section 2303(g)(2) of Pub. L. 98–369 applicable to payments for calendar quarters beginning on or after Oct. 1, 1984, but not applicable to clinical diagnostic laboratory tests furnished to inpatients of a provider operating under a waiver granted pursuant to section 602(k) of Pub. L. 98–21, set out as a note under section 1395y of this title, see section 2303(j)(2) and (3) of Pub. L. 98–369, set out as a note under section 1395l of this title.

Pub. L. 98–369, div. B, title III, § 2363(c), July 18, 1984, 98 Stat. 1107, provided that: “The amendments made by subsection (a) [amending this section and section 1396a of this title] apply to calendar quarters beginning on or after the date of the enactment of this Act [July 18, 1984], except that, in the case of individuals admitted to skilled nursing facilities before such date, the amendments made by such subsection shall not require recertifications sooner or more frequently than were required under the law in effect before such date.”

### Effective Date of 1983 Amendment

Amendment by Pub. L. 97–448 effective as if originally included as a part of this section as this section was amended by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) of Pub. L. 97–448, set out as a note under section 426–1 of this title.

### Effective Date of 1982 Amendment

Pub. L. 97–248, title I, § 133(b), Sept. 3, 1982, 96 Stat. 374, provided that: “The amendment made by subsection (a) [amending this section] shall become effective on the date of the enactment of this Act [Sept. 3, 1982].”

Amendment by section 137(a)(1), (2) of Pub. L. 97–248 effective as if originally included in the provision of the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97–35, to which such amendment relates, see section 137(d)(1) of Pub. L. 97–248, set out as a note under section 1396a of this title.

Amendment by section 137(b)(11)–(16), (27) of Pub. L. 97–248 effective as if originally included as part of this section as this section was amended by the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97–35, see section 137(d)(2) of Pub. L. 97–248, set out as a note under section 1396a of this title.

Pub. L. 97–248, title I, § 137(g), Sept. 3, 1982, 96 Stat. 381, provided that the amendment made by that section is effective Oct. 1, 1982.

Amendment by section 146(b) of Pub. L. 97–248 effective with respect to contracts entered into or renewed on or after Sept. 3, 1982, see section 149 of Pub. L. 97–248, set out as an Effective Date note under section 1320c of this title.

### Effective Date of 1981 Amendment

Amendment by section 2101(a)(2) of Pub. L. 97–35 applicable only to services furnished by a hospital during any accounting year beginning on or after Oct. 1, 1981, see section 2101(c) of Pub. L. 97–35, set out as an Effective Date note under section 1395uu of this title.

Pub. L. 97–35, title XXI, § 2103(b)(2), Aug. 13, 1981, 95 Stat. 788, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to amounts expended on or after October 1, 1981.”

Amendment by section 2113(n) of Pub. L. 97–35 applicable to agreements with Professional Standards Review Organizations entered into on or after Oct. 1, 1981, see section 2113(o) of Pub. L. 97–35, set out as a note under section 1396a of this title.

Pub. L. 97–35, title XXI, § 2161(c)(1), Aug. 13, 1981, 95 Stat. 805, as amended by Pub. L. 97–248, title I, § 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the amendment made by such section 2161(c)(1) is effective for calendar quarters beginning on or after Oct. 1, 1984.

Pub. L. 97–35, title XXI, § 2161(c)(2), Aug. 13, 1981, 95 Stat. 805, as amended by Pub. L. 97–248, title I, § 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the amendment made by such section 2161(c)(2) is effective after payments for the first quarter of fiscal year 1985.

Pub. L. 97–35, title XXI, § 2164(b), Aug. 13, 1981, 95 Stat. 806, provided that: “The amendments made by subsection (a) [amending this section] shall apply to tests occurring on or after October 1, 1981.”

Amendment by section 2174(b) of Pub. L. 97–35 applicable to services furnished on or after Oct. 1, 1981, see section 2174(c) of Pub. L. 97–35, set out as a note under section 1396a of this title.

Amendment by section 2178(a) of Pub. L. 97–35 applicable with respect to services furnished, under a State plan approved under this subchapter, on or before Oct. 1, 1981, except that such amendments not applicable with respect to services furnished by a health maintenance organization under a contract with a State entered into under this subchapter before Oct. 1, 1981, unless the organization requests that such amendments apply and the Secretary and the State agency agree to such request, see section 2178(c) of Pub. L. 97–35, set out as a note under section 1396a of this title.

Pub. L. 97–35, title XXI, § 2183(b), Aug. 13, 1981, 95 Stat. 816, provided that: “The amendments made by subsection (a) [amending this section] shall apply to payments made to States for calendar quarters beginning on or after October 1, 1981.”

### Effective Date of 1980 Amendment

Pub. L. 96–499, title IX, § 961(b), Dec. 5, 1980, 94 Stat. 2650, provided that: “The amendment made by subsection (a) [amending this section] shall be effective with respect to expenditures for services furnished on or after October 1, 1980.”

### Effective Date of 1977 Amendment

Amendment by section 3(c)(2) of Pub. L. 95–142 effective Jan. 1, 1978, see section 3(e) of Pub. L. 95–142, set out as an Effective Date note under section 1320a–3 of this title.

Amendment by section 8(c) of Pub. L. 95–142 effective with respect to contracts, agreements, etc., made on and after the first day of the fourth month beginning after Oct. 25, 1977, see section 8(e) of Pub. L. 95–142, set out as an Effective Date note under section 1320a–5 of this title.

Pub. L. 95–142, § 10(b), Oct. 25, 1977, 91 Stat. 1196, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to calendar quarters beginning after the date of the enactment of this Act [Oct. 25, 1977].”

Pub. L. 95–142, § 11(c), Oct. 25, 1977, 91 Stat. 1197, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to medical assistance provided, under a State plan approved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], on and after January 1, 1978.”

Pub. L. 95–142, § 17(e)(1), Oct. 25, 1977, 91 Stat. 1202, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to calendar quarters beginning after September 30, 1977.”

Pub. L. 95–142, § 20(c), Oct. 25, 1977, 91 Stat. 1207, as amended by Pub. L. 95–292, § 8(e), June 13, 1978, 92 Stat. 316, provided that: Except as provided in paragraph (2), the amendments made by this section [amending this section and section 1396a of this title] shall be effective on October 1, 1977, and the Secretary of Health, Education, and Welfare shall promptly adjust payments made to States under section 1903 of the Social Security Act [42 U.S.C. 1396b] to reflect the changes made by such amendments. The amount of any reduction in the Federal medical assistance percentage of a State, otherwise required to be imposed under section 1903(g)(1) of the Social Security Act [42 U.S.C. 1396b(g)(1)] because of an unsatisfactory or invalid showing made by the State with respect to a calendar quarter beginning on or after January 1, 1977, shall be determined under such section as amended by this section. Subparagraph (B) of paragraph (4) of section 1903(g) of such Act [42 U.S.C. 1396b(g)(4)(B)], as added by this section, shall apply to any showing made by a State under such section with respect to a calendar quarter beginning on or after January 1, 1977.”

Pub. L. 95–83, title I, § 105(a)(3), Aug. 1, 1977, 91 Stat. 384, provided that: “The amendments made by paragraphs (1) and (2) [amending this section] shall apply with respect to payments under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] to States for services provided— after October 8, 1976, under contracts under such title [42 U.S.C. 1396 et seq.] entered into or renegotiated after such date, or after the expiration of the one-year period beginning on such date,whichever occurs first.”

### Effective Date of 1976 Amendment

Amendment by Pub. L. 94–552 effective Jan. 1, 1976, see section 2 of Pub. L. 94–552, set out as a note under section 1396a of this title.

Pub. L. 94–460, title II, § 202(b), Oct. 8, 1976, 90 Stat. 1959, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to payments under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] to States for services provided— after the date of enactment of subsection (a) [Oct. 8, 1976] under contracts under such title entered into or renegotiated after such date, or after the expiration of the 1-year period beginning on such date of enactment,whichever occurs first.”

### Effective Date of 1975 Amendment

Pub. L. 94–182, title I, § 110(b), Dec. 31, 1975, 89 Stat. 1054, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on the first day of the first calendar month which begins not less than 90 days after the date of enactment of this Act [Dec. 31, 1975].”

Amendment by section 111(b) of Pub. L. 94–182 effective January 1, 1976, except as otherwise provided therein, see section 111(c) of Pub. L. 94–182, set out as a note under section 1396a of this title.

### Effective Date of 1973 Amendment

Amendment by section 13(a)(11), (12) of Pub. L. 93–233 effective with respect to payments under this section for calendar quarters commencing after Dec. 31, 1973, see section 13(d) of Pub. L. 93–233, set out as a note under section 1396a of this title.

Amendment by section 18(u) of Pub. L. 93–233 effective July 1, 1973, see section 18(z–3)(4) of Pub. L. 93–233, set out as a note under section 1396a of this title.

Pub. L. 93–66, title II, § 234(b), July 9, 1973, 87 Stat. 160, provided that: “The amendment made by subsection (a) [amending this section] shall be applicable in the case of expenditures for skilled nursing services and for intermediate care facility services furnished in calendar quarters which begin after December 31, 1972.”

### Effective Date of 1972 Amendment

Pub. L. 92–603, title II, § 207(b), Oct. 30, 1972, 86 Stat. 1380, provided that: “The amendments made by subsection (a) [amending this section] shall, except as otherwise provided therein, be effective July 1, 1973.”

Amendment by section 226(e) of Pub. L. 92–603 effective with respect to services provided on or after July 1, 1973, see section 226(f) of Pub. L. 92–603, set out as an Effective Date note under section 1395mm of this title.

Amendment by section 233(c) of Pub. L. 92–603 applicable with respect to services furnished by hospitals in accounting periods beginning after Dec. 31, 1972, see section 233(f) of Pub. L. 92–603, set out as a note under section 1395f of this title. See, also, section 16 of Pub. L. 93–233, set out as an Effective Date note under section 1395f of this title.

Pub. L. 92–603, title II, § 235(b), Oct. 30, 1972, 86 Stat. 1414, provided that: “The amendments made by subsection (a) [amending this section] shall apply with respect to expenditures under State plans approved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], made after June 30, 1971.”

Pub. L. 92–603, title II, § 237(d)(1), Oct. 30, 1972, 86 Stat. 1416, provided that: “The amendments made by subsections (a)(1) and (b) [amending this section and section 706 of this title] shall apply with respect to services furnished in calendar quarters beginning after June 30, 1973.”

Pub. L. 92–603, title II, § 249B, Oct. 30, 1972, 86 Stat. 1428, as amended by Pub. L. 93–368, § 8, Aug. 7, 1974, 88 Stat. 422; Pub. L. 95–83, title III, § 309(b), Aug. 1, 1977, 91 Stat. 396, provided that the amendment made by that section is effective for period beginning Oct. 1, 1972, and ending Sept. 30, 1980.

### Effective Date of 1968 Amendment

Pub. L. 90–248, title II, § 220(b), Jan. 2, 1968, 81 Stat. 899, provided that: In the case of any State whose plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] is approved by the Secretary of Health, Education, and Welfare under section 1902 [42 U.S.C. 1396a] after July 25, 1967, the amendment made by subsection (a) [amending this section] shall apply with respect to calendar quarters beginning after the date of enactment of this Act [Jan. 2, 1968]. In the case of any State whose plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] was approved by the Secretary of Health, Education, and Welfare under section 1902 of the Social Security Act [42 U.S.C. 1396a] prior to July 26, 1967, amendments made by subsection (a) [amending this section] shall apply with respect to calendar quarters beginning after June 30, 1968, except that— with respect to the third and fourth calendar quarters of 1968, such subsection shall be applied by substituting in subsection (f) of section 1903 of the Social Security Act [42 U.S.C. 1396b(f)] 150 percent for 133½ percent each time such latter figure appears in such subsection (f), and with respect to all calendar quarters during 1969, such subsection shall be applied by substituting in subsection (f) of section 1903 of such Act [42 U.S.C. 1396b(f)] 140 percent for 133½ percent each time such latter figure appears in such subsection (f).”

Pub. L. 90–248, title II, § 222(d), Jan. 2, 1968, 81 Stat. 901, as amended by Pub. L. 90–364, title III, § 303(a)(2), June 29, 1968, 82 Stat. 274, provided that the amendment made by such section 222(d) is effective with respect to calendar quarters beginning after December 31, 1969.

Pub. L. 90–248, title II, § 225(b), Jan. 2, 1968, 81 Stat. 902, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to expenditures made after December 31, 1967.”

Pub. L. 90–364, title III, § 303(b), June 29, 1968, 82 Stat. 274, provided that: “The amendments made by subsection (a) [amending this section] shall be effective with respect to calendar quarters beginning after December 31, 1967.”

### Regulations

Pub. L. 111–148, title VI, § 6506(b), Mar. 23, 2010, 124 Stat. 777, provided that: “The Secretary [of Health and Human Services] shall promulgate regulations that require States to correct Federally identified claims overpayments, of an ongoing or recurring nature, with new Medicaid Management Information System (MMIS) edits, audits, or other appropriate corrective action.”

Pub. L. 102–234, § 5, Dec. 12, 1991, 105 Stat. 1804, provided that: In General.—Subject to subsection (b), the Secretary of Health and Human Services shall issue such regulations (on an interim final or other basis) as may be necessary to implement this Act [see Short Title of 1991 Amendment note set out under section 1305 of this title] and the amendments made by this Act. Regulations Changing Treatment of Intergovernmental Transfers.—The Secretary may not issue any interim final regulation that changes the treatment (specified in section 433.45(a) of title 42, Code of Federal Regulations) of public funds as a source of State share of financial participation under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], except as may be necessary to permit the Secretary to deny Federal financial participation for public funds described in section 1903(w)(6)(A) of such Act [42 U.S.C. 1396b(w)(6)(A)] (as added by section 2(a) of this Act) that are derived from donations or taxes that would not otherwise be recognized as the non-Federal share under section 1903(w) of such Act. Consultation With States.—The Secretary shall consult with the States before issuing any regulations under this Act.”

Secretary of Health and Human Services to promulgate final regulations necessary to carry out subsec. (r)(6)(j) of this section within 6 months after Apr. 7, 1986, see section 9503(c) of Pub. L. 99–272, set out as a note under section 1396a of this title.

### References to Provisions of Part A of Subchapter IV Considered References to Such Provisions as in Effect July 16, 1996

For provisions that certain references to provisions of part A (§ 601 et seq.) of subchapter IV of this chapter be considered references to such provisions of part A as in effect July 16, 1996, see section 1396u–1(a) of this title.

### Implementation of Subsections (i)(22) and (x) Requirements

Pub. L. 109–171, title VI, § 6036(c), Feb. 8, 2006, 120 Stat. 81, as amended by Pub. L. 109–432, div. B, title IV, § 405(c)(2)(A)(v)(II), Dec. 20, 2006, 120 Stat. 3000, provided that: “As soon as practicable after the date of enactment of this Act [Feb. 8, 2006], the Secretary of Health and Human Services shall establish an outreach program that is designed to educate individuals who are likely to be affected by the requirements of subsections (i)(22) and (x) of section 1903 of the Social Security Act [42 U.S.C. 1396b(i)(22), (x)] (as added by subsection (a)) about such requirements and how they may be satisfied.”

### Construction of 2016 Amendment

Nothing in amendment by section 5005 of Pub. L. 114–255 to be construed as changing or limiting the appeal rights of providers or the process for appeals of States under the Social Security Act, see section 5005(d) of Pub. L. 114–255, set out as a note under section 1396a of this title.

Pub. L. 114–255, div. B, title XII, § 12006(c), Dec. 13, 2016, 130 Stat. 1277, provided that: No employer-employee relationship established.—Nothing in the amendment made by this section [amending this section] may be construed as establishing an employer-employee relationship between the agency or entity that provides for personal care services or home health care services and the individuals who, under a contract with such an agency or entity, furnish such services for purposes of part 552 of title 29, Code of Federal Regulations (or any successor regulations). No particular or uniform electronic visit verification system required.—Nothing in the amendment made by this section shall be construed to require the use of a particular or uniform electronic visit verification system (as defined in subsection (l)(5) of section 1903 of the Social Security Act (42 U.S.C. 1396b), as inserted by subsection (a)) by all agencies or entities that provide personal care services or home health care under a State plan under title XIX of the Social Security Act (or under a waiver of the plan) (42 U.S.C. 1396 et seq.). No limits on provision of care.—Nothing in the amendment made by this section may be construed to limit, with respect to personal care services or home health care services provided under a State plan under title XIX of the Social Security Act (or under a waiver of the plan) (42 U.S.C. 1396 et seq.), provider selection, constrain beneficiaries’ selection of a caregiver, or impede the manner in which care is delivered. No prohibition on state quality measures requirements.—Nothing in the amendment made by this section shall be construed as prohibiting a State, in implementing an electronic visit verification system (as defined in subsection (l)(5) of section 1903 of the Social Security Act (42 U.S.C. 1396b), as inserted by subsection (a)), from establishing requirements related to quality measures for such system.”

### Construction of 2015 Amendment

Pub. L. 114–113, div. O, title V, § 503(a)(2), Dec. 18, 2015, 129 Stat. 3021, provided that: “Nothing in the amendments made by paragraph (1) [amending this section] shall be construed to prohibit a State Medicaid program from providing medical assistance for durable medical equipment for which payment is denied or not available under the Medicare program under title XVIII of such Act [act Aug. 14, 1935, ch. 531, 42 U.S.C. 1395 et seq.].”

### Non-Application to Territories

Pub. L. 119–21, title VII, § 71115(b), July 4, 2025, 139 Stat. 302, provided that: “The amendments made by this section [amending this section] shall only apply with respect to a State that is 1 of the 50 States or the District of Columbia.”

Pub. L. 119–21, title VII, § 71117(b), July 4, 2025, 139 Stat. 305, provided that: “The amendments made by this section [amending this section] shall only apply with respect to a State that is 1 of the 50 States or the District of Columbia.”

### Prohibiting Conflicts of Interest

Pub. L. 119–21, title VII, § 71119(c), July 4, 2025, 139 Stat. 314, provided that: “A State shall not use a Medicaid managed care entity or other specified entity (as such terms are defined in section 1903(m)(9)(D) [42 U.S.C. 1396b(m)(9)(D)]), or other contractor to determine beneficiary compliance under such section unless the contractor has no direct or indirect financial relationship with any Medicaid managed care entity or other specified entity that is responsible for providing or arranging for coverage of medical assistance for individuals enrolled with the entity pursuant to a contract with such State.”

### Security and Privacy

Pub. L. 115–271, title I, § 1016(b), Oct. 24, 2018, 132 Stat. 3923, provided that: “All applicable State and Federal security and privacy protections and laws shall apply to any State agency, individual, or entity accessing 1 or more prescription drug monitoring program databases or obtaining information in such databases in accordance with section 1903(m)(8) of the Social Security Act [42 U.S.C. 1396b(m)(8)] (as added by subsection (a)).”

### Collection and Dissemination of Best Practices

Pub. L. 114–255, div. B, title XII, § 12006(b), Dec. 13, 2016, 130 Stat. 1277, provided that: “Not later than January 1, 2018, the Secretary of Health and Human Services shall, with respect to electronic visit verification systems (as defined in subsection (l)(5) of section 1903 of the Social Security Act (42 U.S.C. 1396b), as inserted by subsection (a)), collect and disseminate best practices to State Medicaid Directors with respect to— training individuals who furnish personal care services, home health care services, or both under the State plan under title XIX of such Act [42 U.S.C. 1396 et seq.] (or under a waiver of the plan) on such systems and the operation of such systems and the prevention of fraud with respect to the provision of personal care services or home health care services (as defined in such subsection (l)(5)); and the provision of notice and educational materials to family caregivers and beneficiaries with respect to the use of such electronic visit verification systems and other means to prevent such fraud.”

### Clarification Regarding Non-Regulation of Transfers

Pub. L. 111–3, title VI, § 615, Feb. 4, 2009, 123 Stat. 102, provided that: In General.—Nothing in section 1903(w) of the Social Security Act (42 U.S.C. 1396b(w)) shall be construed by the Secretary of Health and Human Services as prohibiting a State’s use of funds as the non-Federal share of expenditures under title XIX of such Act [42 U.S.C. 1396 et seq.] where such funds are transferred from or certified by a publicly-owned regional medical center located in another State and described in subsection (b), so long as the Secretary determines that such use of funds is proper and in the interest of the program under title XIX. Center Described.—A center described in this subsection is a publicly-owned regional medical center that— provides level 1 trauma and burn care services; provides level 3 neonatal care services; is obligated to serve all patients, regardless of ability to pay; is located within a Standard Metropolitan Statistical Area (SMSA) that includes at least 3 States; provides services as a tertiary care provider for patients residing within a 125-mile radius; and meets the criteria for a disproportionate share hospital under section 1923 of such Act (42 U.S.C. 1396r–4) in at least one State other than the State in which the center is located.”

Pub. L. 108–173, title X, § 1001(e), Dec. 8, 2003, 117 Stat. 2431, provided that: In general.—Nothing in section 1903(w) of the Social Security Act (42 U.S.C. 1396b(w)) shall be construed by the Secretary [of Health and Human Services] as prohibiting a State’s use of funds as the non-Federal share of expenditures under title XIX of such Act [42 U.S.C. 1396 et seq.] where such funds are transferred from or certified by a publicly-owned regional medical center located in another State and described in paragraph (2), so long as the Secretary determines that such use of funds is proper and in the interest of the program under title XIX. Center described.—A center described in this paragraph is a publicly-owned regional medical center that— provides level 1 trauma and burn care services; provides level 3 neonatal care services; is obligated to serve all patients, regardless of State of origin; is located within a Standard Metropolitan Statistical Area (SMSA) that includes at least 3 States, including the States described in paragraph (1); serves as a tertiary care provider for patients residing within a 125 mile radius; and meets the criteria for a disproportionate share hospital under section 1923 of such Act [42 U.S.C. 1396r–4] in at least one State other than the one in which the center is located. Effective period.—This subsection shall apply through December 31, 2005.”

### Treatment of Donation or Tax Proceeds Prior to Effective Date of Subsection (w)

Pub. L. 102–234, § 2(c)(2), Dec. 12, 1991, 105 Stat. 1799, provided that: “Except as specifically provided in section 1903(w) of the Social Security Act [42 U.S.C. 1396b(w)] and notwithstanding any other provision of such Act [42 U.S.C. 301 et seq.], the Secretary of Health and Human Services shall not, with respect to expenditures prior to the effective date specified in section 1903(w)(1)(F) of such Act, disallow any claim submitted by a State for, or otherwise withhold Federal financial participation with respect to, amounts expended for medical assistance under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] by reason of the fact that the source of the funds used to constitute the non-Federal share of such expenditures is a tax imposed on, or a donation received from, a health care provider, or on the ground that the amount of any donation or tax proceeds must be credited against the amount of the expenditure.”

### Temporary Increase in Federal Match for Administrative Costs

Pub. L. 101–508, title IV, § 4401(b)(2), Nov. 5, 1990, 104 Stat. 1388–159, provided that: “The per centum to be applied under section 1903(a)(7) of the Social Security Act [42 U.S.C. 1396b(a)(7)] for amounts expended during calendar quarters in fiscal year 1991 which are attributable to administrative activities necessary to carry out section 1927 (other than subsection (g)) of such Act [42 U.S.C. 1396r–8] shall be 75 percent, rather than 50 percent; after fiscal year 1991, the match shall revert back to 50 percent.”

### Report on Errors in Eligibility Determinations; Error Rate Transition Rules

Pub. L. 101–508, title IV, § 4607, Nov. 5, 1990, 104 Stat. 1388–170, directed Secretary of Health and Human Services to report to Congress, by not later than July 1, 1991, on error rates by States in determining eligibility of individuals described in subparagraph (A) or (B) of section 1396a(l)(1) of this title for medical assistance under plans approved under this subchapter, and directed that there should not be taken into account, for purposes of subsec. (u) of this section, payments and expenditures for medical assistance attributable to medical assistance for individuals described in such subparagraph (A) or (B), and made on or after July 1, 1989, and before the first calendar quarter that begins more than 12 months after the date of submission of the Secretary’s report.

### Medically Needy Income Levels for Certain 1-Member Families

Pub. L. 101–508, title IV, § 4718, Nov. 5, 1990, 104 Stat. 1388–193, provided that: In General.—For purposes of section 1903(f)(1)(B) [probably means section 1903(f)(1)(B) of the Social Security Act, 42 U.S.C. 1396b(f)(1)(B)], for payments made before, on, or after the date of the enactment of this Act [Nov. 5, 1990], a State described in subparagraph (B) may use, in determining the ‘highest amount which would ordinarily be paid to a family of the same size’ (under the State’s plan approved under part A of title IV of such Act [probably means 42 U.S.C. 601 et seq.]) in the case of a family consisting only of one individual and without regard to whether or not such plan provides for aid to families consisting only of one individual, an amount reasonably related to the highest money payment which would ordinarily be made under such a plan to a family of two without income or resources. States Covered.—Subsection (a) shall only apply to a State the State plan of which (under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]) as of June 1, 1989, provided for the policy described in such paragraph. For purposes of the previous sentence, a State plan includes all the matter included in a State plan under section 2373(c)(5) of the Deficit Reduction Act of 1984 [Pub. L. 98–369, set out as a note under section 1396a of this title] (as amended by section 9 of the Medicare and Medicaid Patient and Program Protection Act of 1987 [Pub. L. 100–93]).”

### Day Habilitation and Related Services

Pub. L. 101–239, title VI, § 6411(g), Dec. 19, 1989, 103 Stat. 2272, provided that: Prohibition of disallowance pending issuance of regulations.—Except as specifically permitted under paragraph (3), the Secretary of Health and Human Services may not— withhold, suspend, disallow, or deny Federal financial participation under section 1903(a) of the Social Security Act [42 U.S.C. 1396b(a)] for day habilitation and related services under paragraph (9) or (13) of section 1905(a) of such Act [42 U.S.C. 1396d(a)(9), (13)] on behalf of persons with mental retardation or with related conditions pursuant to a provision of its State plan as approved on or before June 30, 1989, or withdraw Federal approval of any such State plan provision. Requirements for regulation.—A final regulation described in this paragraph is a regulation, promulgated after a notice of proposed rule-making and a period of at least 60 days for public comment, that— specifies the types of day habilitation and related services that a State may cover under paragraph (9) or (13) of section 1905(a) of the Social Security Act on behalf of persons with mental retardation or with related conditions, and any requirements respecting such coverage. Prospective application of regulation.—If the Secretary promulgates a final regulation described in paragraph (2) and the Secretary determines that a State plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] does not comply with such regulation, the Secretary shall notify the State of the determination and its basis, and such determination shall not apply to day habilitation and related services furnished before the first day of the first calendar quarter beginning after the date of the notice to the State.”

### Nurse Aide Training and Evaluation Programs; Allocation of Costs Before October 1, 1990

Pub. L. 101–239, title VI, § 6901(b)(5)(B), Dec. 19, 1989, 103 Stat. 2299, provided that: “In making payments under section 1903(a)(2)(B) of the Social Security Act [42 U.S.C. 1396b(a)(2)(B)] for amounts expended for nurse aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1) of such Act [42 U.S.C. 1396r(e)(1)], in the case of activities conducted before October 1, 1990, the Secretary of Health and Human Services shall not take into account, or allocate amounts on the basis of, the proportion of residents of nursing facilities that is entitled to benefits under title XVIII or XIX of such Act [42 U.S.C. 1395 et seq., 1396 et seq.].”

### Clarification of Federal Matching Rate for Survey and Certification Activities

Pub. L. 101–239, title VI, § 6901(d)(2), Dec. 19, 1989, 103 Stat. 2300, provided that: “During the period before October 1, 1990, the Federal percentage matching payment rate under section 1903(a) of the Social Security Act [42 U.S.C. 1396b(a)] for so much of the sums expended under a State plan under title XIX of such Act [42 U.S.C. 1396 et seq.] as are attributable to compensation or training of personnel responsible for inspecting public or private skilled nursing or intermediate care facilities to individuals receiving medical assistance to determine compliance with health or safety standards shall be 75 percent.”

### Quality Control Transition Provisions

Pub. L. 100–485, title VI, § 608(h), Oct. 13, 1988, 102 Stat. 2424, provided that: “There shall not be taken into account, for purposes of section 1903(u) of the Social Security Act [42 U.S.C. 1396b(u)], payments and expenditures for medical assistance which are made on or after January 1, 1989, and before July 1, 1989, and which are attributable to medicare-cost [sic] sharing for qualified medicare beneficiaries (as defined in section 1905(p) of such Act [42 U.S.C. 1396d(p)]).”

### Delay Quality Control Sanctions for Medicaid

Pub. L. 100–203, title IV, § 4117, Dec. 22, 1987, 101 Stat. 1330–154, provided that: “The Secretary of Health and Human Services shall not, prior to July 1, 1988, implement any reductions in payments to States pursuant to section 1903(u) of the Social Security Act [42 U.S.C. 1396b(u)] (or any provision of law described in subsection (c) of section 133 of the Tax Equity and Fiscal Responsibility Act of 1982 [section 133(c) of Pub. L. 97–248, set out below]).”

### Temporary Technical Error Definition

Pub. L. 100–203, title IV, § 4118(n), Dec. 22, 1987, 101 Stat. 1330–157, provided that: “For purposes of section 1903(u)(1)(E)(ii) of the Social Security Act [42 U.S.C. 1396b(u)(1)(E)(ii)], effective for the period beginning on the date of enactment of this Act [Dec. 22, 1987] and ending December 31, 1988, a ‘technical error’ is an error in eligibility condition (such as assignment of social security numbers and assignment of rights to third-party benefits as a condition of eligibility) that, if corrected, would not result in a difference in the amount of medical assistance paid.”

### Enhanced Funding for Nurse Aide Training

Pub. L. 100–203, title IV, § 4211(d)(2), Dec. 22, 1987, 101 Stat. 1330–204, as amended by Pub. L. 100–360, title IV, § 411(l)(3)(F), July 1, 1988, 102 Stat. 803, provided that: “For the 8 calendar quarters (beginning with the calendar quarter that begins on July 1, 1988), with respect to payment under section 1903(a)(2)(B) of the Social Security Act [42 U.S.C. 1396b(a)(2)(B)] to a State for additional amounts expended by the State under its plan approved under title XIX of such Act [42 U.S.C. 1396 et seq.] for nursing aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1) of such title [42 U.S.C. 1396r(e)(1)], any reference to ‘50 percent’ is deemed a reference to the sum of the Federal medical assistance percentage (determined under section 1905(b) of such Act [42 U.S.C. 1396d(b)]) plus 25 percentage points, but not to exceed 90 percent.”

### Expenses Incurred for Review of Care Provided to Residents of Nursing Facilities

Pub. L. 100–203, title IV, § 4212(c)(3), Dec. 22, 1987, 101 Stat. 1330–212, provided that: “For purposes of section 1903(a) of the Social Security Act [42 U.S.C. 1396b(a)], proper expenses incurred by a State for medical review by independent professionals of the care provided to residents of nursing facilities who are entitled to medical assistance under title XIX of such Act [42 U.S.C. 1396 et seq.] shall be reimbursable as expenses necessary for the proper and efficient administration of the State plan under that title.”

### Quality Control Studies and Penalty Moratorium

Pub. L. 99–272, title XII, § 12301, Apr. 7, 1986, 100 Stat. 291, as amended by Pub. L. 99–514, title XVII, § 1710, Oct. 22, 1986, 100 Stat. 2783; Pub. L. 100–485, title VI, § 609(b), Oct. 13, 1988, 102 Stat. 2425, provided that: Studies.— The Secretary of Health and Human Services (hereafter referred to in this section as the ‘Secretary’) shall conduct a study of quality control systems for the Aid to Families with Dependent Children Program under title IV–A of the Social Security Act [42 U.S.C. 601 et seq.] and for the Medicaid Program under title XIX of such Act [42 U.S.C. 1396 et seq.]. The study shall examine how best to operate such systems in order to obtain information which will allow program managers to improve the quality of administration, and provide reasonable data on the basis of which Federal funding may be withheld for States with excessive levels of erroneous payments. The Secretary shall also contract with the National Academy of Sciences to conduct a concurrent independent study for the purpose described in paragraph (1). For purposes of such study, the Secretary shall provide to the National Academy of Sciences any relevant data available to the Secretary at the onset of the study and on an ongoing basis. The Secretary and the National Academy of Sciences shall report the results of their respective studies to the Congress within one year after the date the Secretary and the National Academy of Sciences enter into the contract required under paragraph (2). Moratorium on Penalties.— During the 24-month period beginning with the first calendar quarter which begins after the date of the enactment of this Act [Apr. 7, 1986] (hereafter in this section referred to as the ‘moratorium period’), the Secretary shall not impose any reductions in payments to States pursuant to section 403(i) of the Social Security Act [42 U.S.C. 603(i)] (or prior regulations), or pursuant to any comparable provision of law relating to the programs under title IV–A of such Act [42 U.S.C. 601 et seq.] in Puerto Rico, Guam, the Virgin Islands, American Samoa, or the Northern Mariana Islands. During the moratorium period, the Secretary and the States shall continue to operate the quality control systems in effect under title IV–A of the Social Security Act, and to calculate the error rates under the provisions referred to in paragraph (1). Restructured Quality Control Systems.— Not later than 6 months after the date on which the results of both studies required under subsection (a)(3) have been reported, the Secretary shall publish regulations which shall— restructure the quality control systems under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] to the extent the Secretary determines to be appropriate, taking into account the studies conducted under subsection (a); and establish, taking into account the studies conducted under subsection (a), criteria for adjusting the reductions which shall be made for quarters prior to the implementation of the restructured quality control systems so as to eliminate reductions for those quarters which would not be required if the restructured quality control systems had been in effect during those quarters. Beginning with the first calendar quarter after the moratorium period, the Secretary shall implement the revised quality control systems under title XIX, and shall reduce payments to States— for quarters after the moratorium period in accordance with the restructured quality control systems; and for quarters in and before the moratorium period, as provided under the regulations described in paragraph (1)(B). Effective Date.—This section shall become effective on the date of the enactment of this Act [Apr. 7, 1986].”

### Effectiveness of Laws Limiting Federal Financial Participation With Respect to Erroneous Payments Made by States Under a State Plan Approved Under This Subchapter

Pub. L. 97–248, title I, § 133(c), Sept. 3, 1982, 96 Stat. 374, provided that: “No provision of law limiting Federal financial participation with respect to erroneous payments made by States under a State plan approved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] (including any provision contained in, or incorporated by reference into, any appropriation Act or resolution making continuing appropriations), other than the limitations contained in section 1903 of such Act [42 U.S.C. 1396b], shall be effective with respect to payments to States under such section 1903 for quarters beginning on or after October 1, 1982, unless such provision of law is enacted after the date of the date of the enactment of this Act [Sept. 3, 1982] and expressly provides that such limitation is in addition to or in lieu of the limitations contained in section 1903 of the Social Security Act.”

### Medicaid Payments for Indian Health Service Facilities To Be Paid Entirely by Federal Funds; Exclusion of Payments to States in Computation of Target Amount of Federal Medicaid Expenditures

Pub. L. 97–92, §§ 102, 118, Dec. 15, 1981, 95 Stat. 1193, 1197, as amended by Pub. L. 97–161, Mar. 31, 1982, 96 Stat. 22, provided, for the period Dec. 15, 1981, to not later than Sept. 30, 1982, that: “Notwithstanding section 1903(s) of the Social Security Act [42 U.S.C. 1396b(s)], all medicaid payments to the States for Indian health service facilities as defined by section 1911 of the Social Security Act [42 U.S.C. 1396j] shall be paid entirely by Federal funds, and notwithstanding section 1903(t) of the Social Security Act [42 U.S.C. 1396b(t)], all medicaid payments to the States for Indian health service facilities shall not be included in the computation of the target amount of Federal medicaid expenditures.”

### Promulgation of Regulations for Implementation of Amendments by Section 17 of Pub. L. 95–142

Pub. L. 95–142, § 17(e)(2), Oct. 25, 1977, 91 Stat. 1202, required Secretary of Health, Education, and Welfare to establish regulations, not later than 90 days after Oct. 25, 1977, to carry out amendments made by section 17 (amending sections 1395b–1 and 1396b of this title). See section 1302 of this title.

### Deferral of Implementation of Decreases in Matching Funds

Pub. L. 95–59, § 6, June 30, 1977, 91 Stat. 255, provided that: “Notwithstanding the provisions of subsection (g) of section 1903 of the Social Security Act [42 U.S.C. 1396b(g)], the amount payable to any State for the calendar quarters during the period commencing April 1, 1977, and ending September 30, 1977, on account of expenditures made under a State plan approved under title XIX of such Act [42 U.S.C. 1396 et seq.], shall not be decreased by reason of the application of the provisions of such subsection with respect to any period for which such State plan was in operation prior to April 1, 1977.”

### Comprehensive Care and Services for Eligible Individuals by July 1, 1977; Requirement Inapplicable for Any Period Prior to July 1, 1971; Regulations; Advice to States

Pub. L. 91–56, § 2(b), Aug. 9, 1969, 83 Stat. 99, which provided that subsection (e) of this section was inapplicable to the period prior to July 1, 1971, and which authorized the Secretary to issue regulations, was repealed by Pub. L. 92–603, title II, § 230, Oct. 30, 1972, 86 Stat. 1410.

### Exemption of Puerto Rico, the Virgin Islands, and Guam From Limitations on Federal Payments for Medical Assistance

Pub. L. 90–248, title II, § 248(d), Jan. 2, 1968, 81 Stat. 919, provided that: “The amendment made by section 220(a) of this Act [amending this section] shall not apply in the case of Puerto Rico, the Virgin Islands, or Guam.”

### Nonduplication of Payments to States; Limitation on Institutional Care

Pub. L. 89–97, title I, § 121(b), July 30, 1965, 79 Stat. 352, as amended by Pub. L. 92–603, title II, § 249D, Oct. 30, 1972, 86 Stat. 1429, provided that: “No payment may be made to any State under title I, IV, X, XIV, or XVI of the Social Security Act [42 U.S.C. 301 et seq., 601 et seq., 1201 et seq., 1351 et seq., 1381 et seq.] with respect to aid or assistance in the form of medical or any other type of remedial care for any period for which such State receives payments under title XIX of such Act [42 U.S.C. 1396 et seq.], or for any period after December 31, 1969. After the date of enactment of the Social Security Amendments of 1972 [Oct. 30, 1972], Federal matching shall not be available for any portion of any payment by any State under title I, X, XIV, or XVI, or part A of title IV, of the Social Security Act [42 U.S.C. 301 et seq., 1201 et seq., 1351 et seq., 1381 et seq., 601 et seq.] for or on account of any medical or any other type of remedial care provided by an institution to any individual as an inpatient thereof, in the case of any State which has a plan approved under title XIX of such Act [42 U.S.C. 1396 et seq.], if such care is (or could be) provided under a State plan approved under title XIX of such Act by an institution certified under such title XIX.”