# Appendix — Oklahoma Department of Human Services v. Trust Co. of Oklahoma

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## Record

- **Collection:** Supreme Court brief
- **Document type:** Appendix
- **Published:** January 1, 1992
- **Citation:** 506 U.S. 906

## Text

Supreme Court,

(2) FILE)
' . >|

91-19 46

In The
SUPREME COURT OF THE UNITED STATES

October Term, 1992

STATE OF OKLAHOMA ex rel.
DEPARTMENT OF HUMAN SERVICES

Petitioner,
Vv.

TRUST COMPANY OF OKLAHOMA, guardian
of the estate of Ellen Lee Barker,
a minor child,

Respondent.

APPENDIX TO

PETITION FOR WRIT OF CERTIORARI

Richard W. Freeman, Jr.

Howard J. Pallotta

Assistant General Counsel
Department of Human Services

P. O. Box 53025

Oklahoma City, OK 73152-3025
(405) 521-3630

Attorney for Petitioner State of
Oklahoma ex rel. Department of
Human Services

IS

APPENDIX I

42 U.S.C. §1396a

MEDICAL ASSISTANCE
PROGRAMS

‘

$1396a. State plans for medical assistance
(a) Contents

A State plan for medical assistance
must--

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

(2) provide for financial
participation by the State equal to
not less than 40 per centum of the
non-Federal share of the expenditures
under the plan with respect to which
payments under section 1396b of this
title are authorized by this subchap-
ter; and, effective July 1, 1969,
provide for financial participation by
the State equal to all of such non-
Federal share or provide for
distribution of funds from Federal or
State sources, for carrying out the
State plan, on an equalization or
other basis which will assure that the
lack of adequate funds from local
sources will not result in lowering
the amount, duration, scope, or
quality of care and services available
under the plan;

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

(4) -provide (A) such methods of
administration (including methods
relating to the establishment and
maintenance of personnel standards on
& merit basis, except that’ the
Secretary shall exercise no authority
with respect to the selection, tenure
of office, and compensation of any
individual employed in accordance with

APP. 1

such methods, and including provision
for utilization of professional
medical personnel in the administra-
tion and, where administered locally,
supervision of administration of the
plan) as are found by the Secretary to
be necessary for the proper and
efficient operation of the plan, (B)
for the training and effective use of
paid subprofessional’_ staff, with
particular emphasis on the full-time
or part-time employment of recipients
and other persons of low income, as
community service aides, in the
administration of the plan and for the
use of nonpaid or partially paid
volunteers in a social service
volunteer program in providing
services to applicants and recipients
and in assisting any advisory
committees established by the State
agency, and (C) that each State or
local officer or employee who is
responsible for the expenditure of
substantial amounts of funds under the
State plan, each individual who
formerly was such an officer or
employee, and each partner of such an
officer or employee shall be
prohibited from committing any act, in
relation to any activity under the
plan, the commission of which, in
connection with any activity concern-
ing the United States Government, by
an officer or employee of the United
States Government, an individual who
was such an officer or employee, or a
partner of such an officer or employee

: ,

APP. 1

is prohibited by section 207 or 208 of
Title 18;

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

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

APP. 1

(7) provide safeguards which
restrict the use or disclosure of
information concerning applicants and
recipients to purposes directly
connected with the administration of
the plan;

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

(9) provide--
(A) that the State health agency,
or other appropriate State
medical agency (whichever is
utilized by the Secretary for the
purpose specified in the first
sentence of section 1395aa(a) of
this title), shall be responsible
for establishing and maintaining
health standards for private or
public institutions in which
recipients of medical assistance
under the plan may receive care
or services,
(B) for the establishment or
designation of a State authority
or authorities which shall be
responsible for establishing and
maintaining standards, other than
those relating to health, for
such institutions, and

(C) that any laboratory services

paid for under such plan must be

provided by a laboratory which
meets the applicable requirements
of section 1395x(e)(9) of this

4

|

APP. 1

title or paragraphs (13) and (14)
of section 1395x(s) of this
title, or, in the case of a
laboratory which is in a rural
health Clinic, of section
1395x(aa)(2)(G) of this title;
(10) provide--

(A) for making medical assistance
available, including at least the
care and services listed in
paragraphs (1) through (5), (17)
and (21) of section 1396d(a) of
this title, to--

(1) all individuals-

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

(II) with respect to whom
supplemental security income
benefits are being paid under
subchapter XVI of this chapter or
who are qualified severely
impaired individuals (as defined
in section 1396d(q) of this
title),

(III) who are qualified pregnant
women or children as defined in
section 1396d(n) of this title,

3

APP. 1

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

(V) who are qualified family
members as defined in section
1396d(m)(1) of this title;

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

(11) at the option of the State,
to any group or groups of
individuals described in section
1396d(a) of this title (or, in
the case of individuals described
in section 1396d(a)(i) of this
title, to any reasonable
categories of such individuals)
who are not individuals described
in clause (i) of this
subparagraph but--

6

————————————

APP. 1

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

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

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

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

(V) who are in a- medical
institution for a period of not
less than 30 consecutive days
(with eligibility by reason of
this subclause beginning on the
first day of such period), who
meet the resource requirements of

7

APP. 1

the appropriate State plan
described in clause (i) or the
supplemental security income
program, and whose income does
not exceed a separate income
standard established by the State
which is consistent with the
limit established under section
1396b(f)(4)(C) of this title,
(VI) who would be eligible under
the State plan under this
subchapter if they were in a
medical institution, with respect
to whom there has been a
determination that but for the
provision of home or community-
based services described in
subsection (c), (d), or (e) of
section 1396n of this title they
would require the level of care
provided in a hospital, nursing
facility oor intermediate care
facility for the mentally
retarded the cost of which could
be reimbursed under the State
plan, and who will receive home
or community-based services
pursuant to a waiver granted by
the Secretary under subsection
(c), (d), or (e) of section 1396n
of this title,

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

APP. 1

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

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

(bb) who the State agency
responsible for adoption
assistance has determined cannot
be placed with adoptive parents

without medical assistance
because such child has special
needs for medical or

rehabilitative care, and

(cc) who was eligible for medical
assistance under the State plan
prior to the adoption assistance
agreement being entered into, or
who would have been eligible for
medical assistance at such time
if the eligibility standards and
methodologies of the State's
foster care program under part E
of subchapter IV of this chapter
were applied rather than the
eligibility standards and
methodologies of the State's aid
to families with dependent
children program under part A of
subchapter IV of this chapter;
(IX) who are described in
subsection (1)(1) of this section
and are not described in clause
(i)(IV), clause (i)(VI), or
clause (i)(VII);

APP. 1

(xX) who are described in
subsection (m) (1) of this
section; or

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

(B) that the medical assistance
made available to any individual
described in subparagraph (A)--
(1) shall not be less in amount,
duration, or scope than the
medical assistance made available
to any other such individual, and
(11) shall not be less in amount,
duration, or scope than the
medical assistance made available

10

<<

APP. 1

to individuals not described in
subparagraph (A);

(C) that if medical assistance is
included for any group of
individuals described in section
1396d(a) of this title who are
not described in subparagraph (A)
or (E), then--

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

ll

APP. 1

(11) the plan must make available
medical assistance--

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

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

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

(iv) if such medical assistance
includes services in institutions
for mental diseases or in an
intermediate care facility for
the mentally retarded (or both)
for any such group, it also must
include for all groups covered at
least the care and services
listed in paragraphs (1) through
(5) and (17) of section 1396d(a)
of this title or the care and
services listed in any 7 of the
paragraphs numbered (1) through
(21) of such section;

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

12

APP. 1

individual who, under the State
plan, is entitled to nursing
facility services; and

(E)(1) for making medical
assistance available for medicare
cost-sharing (as defined in
section 1396d(p) (3) of this
title) for qualified medicare
beneficiaries described in sec-
tion 1396d(p)(1) of this title;
(11) for making medical
assistance available for payment
of medicare cost-sharing
described in section
1396d(p)(3)(A)(i) of this title
for qualified disabled and
working individual]s described in
section 1396d(s) of this title;
and

(iii) for making medical
assistance available for medicare
cost sharing described in section
1396(p)(3)(A)(ii) of this title
subject to section 1396d(p)(4) of
this title, for individuals who
would be qualified medicare
beneficiaries described in
section 1396(p)(1) of this title
but for the fact that their
income exceeds the income level
established by the State under
section 1396({p)(2) of this title
but is less than 110 percent in
1993 and 1994, and 120 percent in
1995 and years thereafter of the
official poverty line (referred
to in such section) for a family
of the size involved; and

13

APP. 1

(F) at the option of a State, for
making medical assistance
available for COBRA premiums (as
defined in subsection (u)(2) of
this section) for qualified COBRA
continuation beneficiaries
described in section 1396a(u) (1)
of this title;
except that (I) the making available of the
services described in paragraph (4), (14),
or (16) of section 1396d(a) of this title to
individuals meeting the age requirements
prescribed therein shall not, by reason of
this paragraph (10), require the making
available of any such services, or the
making available of such services of the
same amount, duration, and scope, to
individuals of any other ages, (II) the
making available of supplementary medical
insurance benefits under Part B of
subchapter XVIII of this chapter’ to
individuals eligible therefor (either
pursuant to an agreement entered into under
section 1395v of this title or by reason of
the payment of premiums under such
subchapter by the State agency on behalf of
such individuals), or provision for meeting
part or all of the cost of deductibles, cost
sharing, or similar charges under part B of
subchapter XVIII of this chapter for
individuals eligible for benefits under such
part, shall not, by reason of this paragraph
(10), require the making available of any
such benefits, or the making available of
services of the same amount, duration, and
scope, to any other individual]s, (III) the
making available of medical assistance equal
in amount, duration, and scope to the
medical assistance made available _ to

14

ee

APP. 1

individuals described in clause (A) to any
Classification of individuals approved by
the Secretary with respect to whom there is
being paid, or who are eligible, or would be
eligible if they were not in a medical
institution, to have paid with respect to
them, a State supplementary payment shall
not, by reason of this paragraph (10),
require the making available of any such
assistance, or the making available of such
assistance of the same amount, duration, and
scope, to any other individuais not
described in clause (A), (IV) the imposition
of a deductible, cost sharing. or similar
charge for any item or service furnished to
an individual not eligible for the exemption
under section 13960(a)(2) or (b)(2) of this
title shall not require the imposition of a
deductible, cost sharing, or similar charge
for the same item or service furnished to an
individual who is eligible for. such
exemption. (V) the making available to
pregnant women covered under the plan of
services relating to pregnancy (including
prenatal, delivery, and postpartum services)
or to any other condition which may
complicate pregnancy shall not, by reeson of
this paragraph (10), require the making
available of such services, or the making
available of such services of the same
amount, duration, and scope, to any other
individuals, provided such services are made
available (in the same amount, duration, and
scope) to all pregnant women covered under
the State plan, (VI) with respect to the
making available of medical assistance for
hospice care to terminally ill individuals
who have made a voluntary election described
in section 1396d(0) of this title to receive

15

APP. 1

hospice care instead of medical assistance
for certain other services, such assistance
may not be made available in an amount,
duration, or scope less than that provided
under subchapter XVIII of this chapter, and
the making available of such assistance
shall not, by reason of this paragraph (10),
require the making available of medical
assistance for hospice care to other
individuals or the making available of
medical assistance for services waived by
such terminally ill individuals, (VII) the
medical assistance made available to an
individual described in subsection (1)(1) (A)
of this section who is eligible for medical
assistance only because of subparagraph
(A)(i)(IV) or (A)(ii)(IX) shall be limited
to medical assistance for services related
to pregnancy (including prenatal, delivery,
postpartum, and family planning services)
and to other conditions which may complicate
pregnancy, (VIII) the medical assistance
made available to a qualified medicare
beneficiary described in section 1396d(p) (1)
of this title who is only entitled to
medical assistance because the individual is
such a beneficiary shall be limited to
medical assistance for medicare cost-sharing
(described in section 1396d(p)(3) of this
title), subject to the provisions of
subsection (n) of this section and section
13960(b) of this title, (IX) the making
available of respiratory care services in
accordance with subsection (e)(9) of this
section shall not, by reason of this
paragraph (10), require the making available
of such services, or the making available of
such services of the same amount, duration,
and scope, to any individuals not included

16

APP. 1

under subsection (e)(9)(A) of this section,
provided such serves are made available (in
the same amount, duration, and scope) to all
individuals described in such subsection,
(X) if the plan provides for any fixed
durational limit on medical assistance for
inpatient hospital services (whether or not
such a limit varies by medical condition or
diagnosis), the plan must establish
exceptions to such a limit for medically
necessary inpatient hospital services
furnished with respect to individuals under
one year of age in a hospital defined under
the State plan, pursuant to section 1396r-
4(a)(1) (A) of this titie, as a
disproportionate share hospital and
subparagraph (B) (relating to comparability)
shall not be construed as requiring such an
exception for other individuals, services,
or hospitals and (XI) the making available
of medical assistance to cover the costs of
premiums, deductibles, coinsurance, and
other cost-sharing obligations for certain
individuals for private health coverage as
described in section 1396e of this title
shall not, by reason of paragraph (10),
require the making available of any such
benefits or the making available of services
of the same amount, duration, and scope of
such private coverage to any other
individuals, and (XI) the medical assistance
made available to an individual described in
subsection (u)(1) of this section who is
eligible for medical assistance only because
of subparagraph (F) shall be limited to
medical assistance for COBRA continuation
premiums (as defined in subsection (u)(2) of
this section);

17

APP. .1

(11)(A) provide for entering into
cooperative arrangements with the State
agencies responsible for administering or
supervising the administration of health
services and vocational rehabilitation
services in the State looking toward maximum
utilization of such services in the
provision of medical assistance under the
plan, (B) effective July 1, 1969, provide,
to the extent prescribed by the Secretary,
for entering into agreements, with any
agency, institution, or organization
receiving payments under (or through an
allotment under) subchapter V of this
chapter, (i) providing for utilizing such
agency, institution, or organization in
furnishing care and services which are
available under such subchapter or allotment
and which are included in the State Plan
approved under this section and (ii) making
such provision as may be appropriate for
reimbursing such agency, institution, or
organization for the cost of any such care
and services furnished any individual for
which payment would otherwise be made to the
State with respect to him under section
1396b of this title, and (C) provide for
coordination of the operations under this
subchapter with the State's operations under
the special supplemental food program for
women, infants, and children under section
1786 of this title;

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

(13) provide--

18

me

APP. 1

(A) for payment (except where the
State agency is subject to an order
under section 1396m of this title) of
the hospital services, nursing
- facility services, and services in an
intermediate care facility for the
mentally retarded provided under the
plan through the use of rates
(determined in accordance with methods
and standards developed by the State
which, in the case of wnursing
facilities, take into account’ the
costs (including the costs of services
required to attain or maintain the
highest practicable physical, mental,
and psychosocial well-being of each
resident eligible for benefits under
this subchapter) of complying with
subsections (b) (other than paragraph
(3)(F) thereof), (c), and (d) of
section 1396r of this title and
provide (in the case of a nursing
facility with a waiver under section
1396r(b)(4)(C)(ii) of this title) for
an appropriate reduction to take into
account the lower costs (if any) of
the facility for nursing care, and
which, in the case of hospitals, taxe
into account the situation of
hospitals which serve a dispro-
portionate number of low income
patients with special needs_ and
provide, in the case of hospital
patients receiving services at an
inappropriate level of care (under
conditions similar to those described
in section 1395x(v)(1)(G) of this
title), for lower reimbursement rates
reflecting the level of care actually

19

APP. 1

received (in a manner consistent with
section 1395x(v)(1)(G) of this title) )
which the State finds, and makes
assurances satisfactory to the
Secretary, are reasonable and adequate
to meet the costs which must be in-
curred by efficiently and economically
operated facilities in order’ to
provide care and services in
conformity with applicable State and
Federal laws, regulations, and quality
and safety standards and to assure
that individuals eligible for medical
assistance have reasonable access
(taking into account geographic
location and reasonable travel time)
to inpatient hospital services of
adequate quality; and such State makes
further assurances, satisfactory to
the Secretary, for the filing of
uniform cost reports by each hospital,
nursing facility, and intermediate
care facility for the mentaliy
retarded and periodic audits by the
State of such reports;

(B) that the State shall provide
assurances satisfactory to the
Secretary that the payment methodology
utilized by the State for payments to
hospitals can reasonably be expected
not to increase such payments, solely
as a result of a change of ownership,
in excess of the increase which would
result from the application of section
1395x(v)(1)(0) of this title;

(C) that the State shall provide
assurances satisfactory to the
Secretary that the valuation of
capital assets, for purposes of

20

APP. 1

determining payment rates for nursing
facilities and for intermediate care
facilities for the mentally retarded,
will not be increased (as measured
from the date of acquisition by the
seller to the date of the change of
ownership), solely as a result of a
change of ownership, by more than the
lesser of--

(i) one-half of the percentage
increase (as measured over the same
period of time, or, if necessary, as
extrapolated retrospectively by the
Secretary) in the Dodge Construction
Systems Costs for Nursing Homes,
applied in the aggregate with respect
to those facilities which have
undergone a change of ownership during
the fiscal year, or

(11) one-half of the percentage
increase (as measured over the same
period of time) in the Consumer Price
Index for All Urban Consumers (United
States city average);

(D) for pavment for hospice care in
amounts no lower than the amounts,
using the same methodology, used under
part A of subchapter XVIII of this
chapter and for payment of amounts
under section 1396d(0)(3) of this
title; except that in the case of
hospice care which is furnished to an
individual who is a resident of a
nursing facility or intermediate care
facility for the mentally retarded,
and who would be eligible under the
plan for nursing facility services or
services in an intermediate care
facility for the mentally retarded if

21

APP. 1

he had not elected to receive hospice
care, there shall be paid an
additional amount, to take into
account the room and board furnished
by the facility, equal to at least 95
percent of the rate that would have
been paid by the State under the plan
for facility services in that facility
for that individual; for payment

(E) for payment for services described
in clause (B) or (C) of section
1396d(a)(2) of this title under the
plan of 100 percent of costs which are
reasonable and related to the cost of
furnishing such services or based on
such other tests of reasonableness, as
the Secretary prescribes in
regulations under section 13951l(a)(3)
of this title, or, in the case of
services to which those regulations do
not apply, on the same methodology
used under section 13951l(a)(3) of this
title; and

(F) for payment for home and community
care (as defined in section 1396t(a)
of this title and provided under such
section) through rates which are
reasonable and adequate to meet the
costs of providing care, efficiently
and economically, in conformity with
applicable State and Federal laws,
regulations, and quality and safety

standards;

(14) provide that enrollment fees,
premiums, or similar charges, and
deductions, cost sharing, or similar

charges, may be imposed only as provided in
section 13960 of this title;

22

|

APP. 1

(15) Repealed. Pub.L. 100-360, Title
III, § 301(e)(2)(C), as added by Pub.L. 100-
485, Title VI, § 608(d)(14)(I)(iii), Oct.
13, 1988, 102 Stat. 2416.

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

(17) except as provided in subsections
(1)(3), (m)(3), and (m)(4) of this section,
include reasonable standards (which shall be
comparable for all groups and may, in
accordance with standards prescribed by the
Secretary, differ with respect to income
levels, but only in the case of applicants
or recipients of assistance under the plan
who are not receiving aid or assistance
under any plan of the State approved under
subchapter I, X, XIV, or XVI, or part A of
subchapter IV of this chapter, and with
respect to whom supplemental security income
benefits are not being paid under subchapter
XVI of this chapter, based on the variations
between shelter costs in urban areas and in
rural areas) for determining eligibility for
and the extent of medical assistance under
the plan which (A) are consistent with the
objectives of this subchapter, (B) provide
for taking into account only such income and
resources as are, as determined in
accordance with standards prescribed by the
Secretary, available to the applicant or
recipient and (in the case of any applicant
or recipient who would, except for income
and resources, be eligible for aid or
assistance in the form of money payments

23

APP. 1

under any plan of the State approved under
subchapter I, X, XIV, or XVI, or part A of
subchapter IV, or to have paid with respect
to him supplemental security income benefits
under subchapter XVI of this chapter) as
would not be disregarded (or set aside for
future needs) in determining his eligibility
for such aid, assistance, or benefits, (C)
provide for reasonable evaluation of any
such income or resources, and (D) do not
take into account the financial
responsibility of any individual for any
applicant or recipient of assistance under
the plan unless such applicant or recipient
is such individual's spouse or such
individual's child who is under age 21 or
(with respect to States eligible to
participate in the State program established
under subchapter XVI of this chapter), is
blind or permanently and totally disabled,
or is blind or disabled as defined in
section 1382c of this title (with respect to
States which are not eligible to participate
in such program) ; and provide for
flexibility in the application of such
standards with respect to income by taking
into account, except to the extent
prescribed by the Secretary, the costs
(whether in the form of insurance premiums,
payments made to the State under section
1396b(f)(2)(B) of this title, or other wise
and regardless of_whether such costs are
reimbursed under another public program of
the State or political subdivision thereof)
incurred for medical care or for any other
type of remedial care recognized under State
law;

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

24

eect

APP. 1

liens, adjustments and recoveries of medical
assistance correctly paid, and transfers of
assets;

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

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

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

(B) provide for an individual plan for

each such patient to assure that the

institutional care provided to him is
in his best interests, including, to
that end, assurances that there will
be initial and periodic review of his
medical and other needs, that he will
be given appropriate medical treatment
within the institution, and that there

25

APP. 1

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

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

(22) include descriptions of (A) the
kinds and numbers of professional medical
personnel and supporting staff that will be
used in the administration of the plan and
of the responsibilities they will have, (B)
the standards, for private or public

26

APP. 1

institutions in which recipients of medical
assistance under the plan may receive care
or services, that will be utilized by the
State authority or authorities responsible
for establishing and maintaining such
standards, (C) the cooperative arrangements
with State health agencies and State
vocational rehabilitation agencies entered
into with a view to maximum utilization of
and coordination of the provision of medical
assistance with the services administered or
supervised by such agencies, and (D) other
standards and methods that the State will
use to assure that medical or remedial care
and services provided to recipients of
medical assistance are of high quality;
(23) except as provided in subsection
(g) of this section and in section 1396n of
this title and except in the case of Puerto
Rico, the Virgin Islands, and Guam, provide
that (A) any individual eligible for medical
assistance (including drugs) may obtain such
assistance from any institution, agency,
community pharmacy, or person, qualified to
perform the service or services required
(including an organization which provides
such services, or arranges for their
availability, on a prepayment basis), who
undertakes to provide him such services, and
(B) an enrollment of an individual eligible
for medical assistance in a primary care
case-management system (described in section
1396n(b)(1) of this title), a health
maintenance organization, or a similar
entity shall not restrict the choice of the
qualified person from whom the individual
may receive services under section
1396d(a)(4)(C) of this title;

27

APP. 1

(24) effective July 1, 1969, provide
for consultative services by health agencies
and other appropriate agencies of the State
to hospitals, nursing facilities, home
health agencies, clinics, laboratories, and
such other institutions as the Secretary may
specify in order to assist them (A) to
qualify for payments under this chapter, (B)
to establish and maintain such fiscal
records as maybe necessary for the proper
and efficient administration of this
chapter, and (C) to provide information
needed to determine payments due under this
chapter on account of care and services
furnished to individuals;

(25) provide--
(A) that the State or local agency
administering such plan will take ali
reasonable measures to ascertain the
legal liability of third parties
(including health insurers) to pay for
care and services available under the
plan, including--
(1) the collection of sufficient
information (as specified by the
Secretary in regulations) to enable
the State to pursue claims against
such third parties, with such
information being collected at the
time of any determination or
redetermination of eligibility for
medical assistance, and

(11) the submission to the Secretary

of a plan (subject to approval by the

Secretary) for pursuing claims against

such third parties, which plan shall--

(I) be integrated with, and be

monitored as a part of the Secretary's

review of the State's mechanized

28

————

APP. 1

claims processing and information
retrieval system under section
1396b(r) of this title, and

(II) be subject to the provisions of
section 1396b(r)(4) of this title
relating to reductions in Federal
payments for failure to meet
conditions cf approval, but shall not
be subject to any other financial
penalty as a result of any other
monitoring, quality control, or
auditing requirements;

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

(C) that in the case of an individual
who is entitled to medical assistance
under the State plan with respect to a
service for which a third party is
liable for payment, the person
furnishing the service may not seek to
collect from the individual (or any
financially responsible relative or
representative of that individual)
payment of an amount for that service
(i) if the total of the amount of the
liabilities of third parties for that
service is at least equal to the
amount payable for that service under
the plan (disregarding section 13960
of this title), or (ii) in an amount

29

APP. 1

which exceeds the lesser of (I) the
amount which may be collected under
section 13960 of this title, or (II)
the amount by which the amount payable
for that service under the plan
(disregarding section 13960 of this
title), exceeds the total of the
amount of the liabilities of third
parties for that service;

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

(EZ) that in the case of prenatal or
preventive pediatric care (including
early and periodic screening and
diagnosis services under’ section
1396d(a)(4)(B) of this title) covered
under the State plan, the State shall-
(1) make payment for such service in
accordance with the usual payment
schedule under such plan for such
services without regard to the
liability of a third party for payment
for such services; and

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

(F) that in the case of any services
covered under such plan which are
provided to an individual on whose
behalf child support enforcement is
being carried out by the State agency

30

APP. 1

under part D of subchapter IV of this
chapter, the State shall--
(4) make payment for such service in
accordance with the usual payment
schedule under such plan for _ such
services without regard to any third
party liability for payment for such
services, if such third-party
liability is derived (through
insurance or otherwise) from the
parent whose obligation to pay support
is being enforced by such agency, if
payment has not been made by such
third party within 30 days after such
services are furnished; and

(144) seek reimbursement from _ such

third party in accordance with

subparagraph (B); and

(G) that the State plan shall meet the

requirements of section 1396e of this

title (relating to enrollment of
individuals under group health plans
in certain cases);

(26) if the State plan includes medical
assistance for inpatient mental hospital
services, provide--

(A) with respect to each patient
receiving such services, for a regular
program of medical review (including
medical evaluation) of his need for
such services, and for a written plan
of care;

(B) for periodic inspections to be

made in all mental institutions within

the State by one or more medical
review teams (composed of physicians
and other appropriate health and
social service personnel) of the care
being provided to each person

31

APP. 1

receiving medical assistance,
including (i) the adequacy of the
services available to meet his current
health needs and promote his maximum
physical well-being, (ii) the
necessity and desirability of his
continued placement in the
institution, and (iii) the feasibility
of meeting his health care needs
through alternative institutional or
noninstitutional services; and

(C) for full reports to the State

agency by each medical review team of

the findings of each inspection under
subparagraph (B), together with any
recommendations;

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

(28) provide--
(A) that any nursing facility
receiving payments under such plan
must satisfy all the requirements of
subsections (b) through (d) of section
1396r of this title as they apply to
such facilities;

(B) for including in "nursing facility

services" at least the items and

32

4 :

APP. 1

services specified (or deemed to be

specified) by the Secretary under

section 1396r(f)(7) of this title and

making available upon request a

description of the items and services

so included;

(C) for procedures to make available

to the public the data and methodology

used in establishing payment rates for
nursing facilities under this
subchapter; and

(D) for compliance (by the _ date

specified in the respective sections)

with the requirements of--

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

(44) section 1396r(g) of this title

(relating to responsibility for survey

and certification of nursing

facilities); and

(444) sections 1396r(h)(2)(B) and

1396r(h)(2)(D) of this title (relating

to establishment and application of
remedies) ;

(29) include a State program which
meets the requirements set forth in section
1396g of this title, for the licensing of
administrators of nursing homes;

(30)(A) provide such methods and
procedures relating to the utilization of
and the payment for, care and services
available under the plan (including but not
limited to utilization review plans as
provided for in section 1396b(i)(4) of this
title) as may be necessary to safeguard
against unnecessary utilization of such care
and services and to assure that payments are
consistent with efficiency, economy, and
quality of care and are sufficient to enlist
enough providers so that care and services

33

APP. 1

are available under the plan at least to the
extent that such care and services are
available to the general population in the
geographic area;
(B) provide, under the program
described in subparagraph (A), that--
(1) each admission to a hospital,
intermediate care facility for the
mentally retarded, or hospital for
mental diseases is reviewed oor
screened in accordance with criteria
established by medical and other
professional personnel who are not
themselves directly responsible for
the care of the patient involved, and
who do not have a significant
financial interest in any such
institution and are not. except in the
case of a hospital, employed by the
institution providing the care
involved, and
(11) the information developed from
such review or screening, along with
the data obtained from prior reviews
of the necessity for admission and
continued stay of patients by such
professional personnel, shall be used
as the basis for establishing the size
and composition of the sample of
admissions to be subject to review and
evaluation by such personnel, and any
such sample maybe of any size up to
100 percent of all admissions and must
be of sufficient size to serve the
purpose of (I) identifying the
patterns of care being provided and
the changes occurring over time in
such patterns so that the need for
modification may be ascertained, and

34

APP. 1

(II) subjecting admissions to early or
more extensive review where
information indicates that such
consideration is warranted to a
hospital, intermediate care facility
for the mentally retarded, or hospital
for mental diseases; and

(C) use a utilization and quality
control peer review organization (under part
B of subchapter XI of this chapter), an
entity which meets the requirements of
section 1320c-1 of this title, as determined
by the Secretary, or a private accreditation
body to conduct (on an annual basis) an
independent, external review of the quality
of services furnished under each contract
under section 1396b(m) of this title, with
the results of such review made available to
the State and, upon request, to the
Secretary, the Inspector General in the
Department of Health and Human Services, and
the Comptroller General;

(31) with respect to services in an
intermediate care facility for the mentally
retarded (where the State plan includes
medical assistance for such’ services)
provide--

(A) with respect to each patient

receiving such services, for a written

plan of care, prior to admission to or
authorization of benefits in such
facility, in accordance with
regulations of the Secretary, and for

a regular program of independent

professional review (including medical

evaluation) which shall periodically
review his need for such services;

(B) with respect to each intermediate

care facility for the mentally

35

APP. 1

retarded within’ the State, for
periodic onsite inspections of the
care being provided to each person
receiving medical assistance, by one
or more independent professional
review teams (composed of a physician
or registered nurse and other
appropriate health and social service
personnel), including with respect to
each such person (i) the adequacy of
the services available to meet his
current health needs and promote his
maximum physical well-being, (ii) the
necessity and desirability of his
continued placement in the facility,
and (iii) the feasibility of meeting
his health care needs through
alternative institutional or
noninstitutional services; and
(C) for full reports to the State
agency by each independent
professional review team of the
findings of each inspection under
subparagraph (B), together with any
recommendations;

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

(A) in the case of any care or service

provided by a physician, dentist, or

other individual practitioner, such
payment may be made (i) to the
employer of such physician, dentist,
or other practitioner if such
physician, dentist, or practitioner is

36

APP. 1

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

(B) nothing in this paragraph shall be
construed (i) to prevent the making of
such a payment in accordance with an
assignment from the person or
institution providing the care or
service involved if such assignment is
made to a governmental agency or
entity or is established by or
pursuant to the order of a court of
competent jurisdiction, or (ii) to
preclude an agent of such person or
institution from receiving any such
payment if (but only if such agent
does so0 pursuant to an agency
agreement under which the compensation
to be paid to the agent for his
services for or in connection with the
billing or collection of payments due
such person or institution under the
plan is unrelated (directly or
indirectly) to the amount of such
payments or the billings therefor, and
is not cependent upon the actual
collection of any such payment; and
(C) in the case of services furnished
(during a period that does not exceed
14 continuous days in the case of an

37

APP. 1

informal reciprocal arrangement or 90
continuous days (or such longer period
as the Secretary may provide) in the
case of an arrangement involving per
diem or other fee-for-time
compensation) by, or incident to the
services of, one physician to the
patients of another physician who
submits the claim for such services,
payment shall be made to the physician
submitting the claim (as if the
services were furnished . by, or
incident to, the physician's
services), but only if the claim
identifies (in a manner specified by
the Secretary) the physician who
furnished the services.

- (33) provide-- .

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

(B) that, except as provided in
section i396r(g) of this title, the
State or local agency utilized by the

“38

- a SS La NB PA NET REN int Citi ter | 8 mens hae

APP. 1

Secretary for the purpose specified in
the first sentence of section
1395aa(a) of this title, or, if such
agency is not the State agency which
is responsible for licensing health
institutions, the State agency
responsible for such licensing, will
perform for the State agency
administering or supervising’ the
administration of the plan approved
under this subchapter the function of
determining whether institutions and
agencies meet the requirements for
participation in the program under
such plan, except that, if the
Secretary has cause to question the
adequacy of such determinations, the
Secretary is authorized to validate
State determinations and, on that
basis, make independent and binding
determinations concerning the extent
to which individual institutions and
agencies meet the requirements for
participation;

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

(35) provide that any disclosing entity
(as defined in section 1320a-3(a)(2) of this

39

APP. 1

title) receiving payments under such plan
complies with the requirements of section
1320a.3 of this title;

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

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

40

SLAP A. Binh

APP. 1

the recipient and provider of a service and
the nature of the service for which payment
is claimed, to ensure the proper and
efficient payment of claims and management
of the program;

(38) require that an entity (other than
an individual practitioner or a group of
practitioners) that furnishes, or arranges
for the furnishing of items or services
under the plan, shall supply (within such
period as may be specified in regulations by
the Secretary or by the single State agency
which administers or supervises the
administration of the plan) upon request
specifically addressed to such entity by the
Secretary or such State agency, the
information described in section 1320a-
7(b)(9) of this title;

(39) provide that the State agency
shall exclude any specified individual or
entity from participation in the program
under the State plan for the _ period
specified by the Secretary, when required by
him to do so pursuant to section 1320a-7 of
this title or section 1320a-7a of this
title, and provide that no payment may be
made under the plan with respect to any item
or service furnished by such individual or
entity during such period;

(40) require each health services
facility or organization which receives
payments under the plan and of a type for
which a uniform reporting system has been
established under section 1320a(a) of this
title to make reports to the Secretary of
information described in such section in
accordance with the uniform reporting system
(established under such section) for that
type of facility or organization;

41

APP. 1

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

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

(43) provide for--
(A) informing all persons in the State
who are under the age of 21 and who
have been determined to be eligible
for medical assistance including
services described in section
1396d(a)(4)(B) of this title, of the
availability of early and periodic
screening, diagnostic, and treatment
services as described in section
1396d(r) of this title,
(B) providing or arranging for the
provision of such screening services
in all cases where they are requested,
(C) arranging for (directly or through
referral to appropriate agencies,
organizations, or individuals)
corrective treatment the need for
which is disclosed by such child
health screening services, and

(D) reporting to the Secretary (in a

uniform form and manner established by

the Secretary, by age group and by

42

ee ee eee es

a OT ate Bade S ahha Neo BOS te see Bone

DIE ene ee

APP. 1

basis of eligibility for medical
assistance, and by not later than
April 1 after the end of each fiscal
year, beginning with fiscal year 1990)
the following information relating to
early and periodic screening,
diagnostic, and treatment services
provided under the plan during each
fiscal year,

(1) the number of children provided

child health screening services,

(44) the number of children referred

for corrective treatment (the need for

which is disclosed by such child
health screening services),

(111) the number of children receiving

dental services, and

(iv) the State's results in attaining

the participation goals set for the

State under section 1396d(r) of this

title;

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

(A) a physician (or, in the case of

skilled nursing facility services or

intermediate care facility services, a

physician, or a nurse practitioner or

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

working in collaboration with a

physician) certifies at the time of

admission, or, if later, the time the
individual applies for medical

assistance under the State plan (and a

physician, a physician assistant under

the supervision of a physician, or, in

43

APP. 1

the case of skilled nursing facility
services or intermediate care facility
services, a physician, or a nurse
practitioner- or clinical nurse
specialist who is not an employee of
the facility but is working in
collaboration with a physician,
recertified, where such services are
furnished over a period of time, in
such cases, at least as often as
required under section 1396b(g)(6) of
this title (or, in the case of
services that are services provided in
an intermediate care facility for the
mentally retarded, every year), and
accompanied by such supporting
material, appropriate to the case
involved, as may be provided in
regulations of the Secretary), that
such services are or were required to
be given on an inpatient basis because
the individual needs or needed such

services, and J

(B) such services were furnished under

a plan established and periodically

reviewed and evaluated by a physician,

or, in the case of skilled nursing
facility services or intermediate care

facility services, a physician, or a

nurse practitioner or clinical nurse

specialist who is not an employee of
the facility but is working in
collaboration with a physician;

(45) provide for mandatory assignment
of rights of payment for medical support and
other medical care owed to recipients, in
accordance with section 1396k of this title;

(46) provide that information is
requested and exchanged for purposes of

44

APP. 1

income and eligibility verification in
accordance with a State system which meets
the requirements of section 1320b-7 of this
title;

(47) at the option of the State,
provide for making ambulatory prenatal care
available to pregnant women during a pre-
sumptive eligibility period in accordance
with section 1396r-1 of this title;

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

(49) provide that the State will
provide information and access to certain
information respecting sanctions’ taken
against health care practitioners and
providers by State licensing authorities in
accordance with section 1396r-2 of this
title;

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

(51)(A) meet the requirements of.
section 1396r-5 of this title (relating to
protection of community spouses), and (B)
meet the requirement of section 1396p(c) of
this title (relating to transfer of assets);

(52) meet the requirements of section
1396r-6 of this title (relating to extension
of eligibility for medical assistance);

(53) provide--

(A) for notifying in a timely manner

all individuals in the State who are

determined to be eligible for medical
assistance and who are pregnant women,

45

APP. 1

breastfeeding or postpartum women (as

defined in section 1786 of this

title), or children below the age of

5, Of the availability of benefits

furnished by the special supplemental

food program under such section, and

(B) for referring any such individual

to the State agency responsible for

administering such program;

(54)(A) provide that, any formulary or
similar restriction (except as provided in
section 1396r-8(d) of this title) on the
coverage of covered outpatient drugs under
the plan shall permit the coverage of
covered outpatient drugs of any manufacturer
which has entered into and complies with an
agreement under section 1396r-8(a) of this
title, which are prescribed for-a medically
accepted indication (as defined in
subsection 13961-8(k)(6) of this title), and

(B) comply with the reporting

requirements of section 1396r-

8(b)(2)(A) of this’ title and the
requirements of subsections (d) and

(g) of section 1396r-8 of this title:

and

(55) provide for receipt and initial
processing of applications of individuals
for medical assistance under subsection
(a)(10)(A)(1i) (IV), (a) (10)(A)(i) (VI),
(a) (10) (A) (1) (VII), or (a) (10) (A) (ii) (IX) of
this section--

(A) at locations which are other than

those used for the receipt and

processing of applications for aid
under part A of subchapter IV of this
chapter and which include : facilities
defined as disproportionate share
hospitals under section 1396r-

46 -

ee tae a i Sl Malt le

na oo

APP, 1

4(a)(1)(A) of this title and

Federally-qualified health centers

described in section 1396d(1)(2)(B) of

this title, and

(B) using applications which are other

than those used for applicatjons for

aid under such part.

(55) . provide, in accordance with
subsection (s) of this section, for adjusted
payments for certain inpatient hospital
services.

(57) provide that each hospital,
nursing facility, provider of home health
care or personal care services, hospice
program, or health maintenance organization
(as defined in section 1396b(m)(1)(A) of
this title) receiving funds under the plan
shall comply with the requirements of
subsection (w) of this section;

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

(58) maintain a list (updated not less
often than monthly, and containing each
physician's unique identifier provided under
the system established under subsection (v)
of this section) of all physicians who are
certified to participate under the State
plan. -

Notwithstanding paragraph (5), if-on January
1, 1965, and on the date on which a State
submits its pjan for approval under this

47

APP. 1

subchapter, the State agency which
administered or supervised the
administration of the plan of such State
approved under subchapter X of this chapter
(or subchapter XVI of this chapter, insofar
as it relates to the blind) was different
from the State agency which administered or
supervised the administration of the State
plan approved under subchapter I of this
chapter (or subchapter XVI of this chapter,
insofar as it relates to the aged), the
State agency which administered or
supervised the administration of such plan
approved under subchapter X of this chapter
(or subchapter XVI of this chapter, insofar
as it relates to the blind) may be
designated to administer or supervise the
administration of the portion of the State
plan for medical assistance which relates to
blind individuals and a different State
agency may be established or designated to
administer or supervise the administration
of the rest of the State plan for medical
assistance; and in such case the part of the
plan which each such agency administers, or
the administration of which each such agency
supervises, shall be regarded as a separate
plan for purposes of this subchapter (except
for purposes of paragraph(10)). The
provisions of paragraphs(9)(A),(31), and
(33) and of section 1396b(i)(4) of this
title shall not apply to a Christian Science
sanatorium operated, or listed and
certified, by the First Church of Christ,
Scientist, Boston, Massachusetts.

For purposes of paragraph (10) any
individual who, for the month of August
1972, was eligible for or receiving aid or
assistance under a State pjan approved under

48

POE Ae wate OED eM BAN vO

ee ee ae oe

APP. 1

subchapter I, X, XIV, or XVI of this
chapter, or part A of subchapter IV of this
chapter and who for such month was entitled
to monthly insurance benefits under
subchapter II of this chapter shall for
purposes of this subchapter only be deemed
to be eligible for financial aid or
assistance for any month thereafter if such
individual would have been eligible for
financial aid or assistance for such month
had the increase in monthly insurance
benefits under subchapter II of this chapter
resulting from enactment of Public Law 92-
336 not been applicable to such individual.

The requirement of clause (A) of
paragraph (37) with respect to a State plan
maybe waived by the Secretary if he finds~
that the State has exercised good faith in
trying to meet such requirement. For
purposes of this subchapter, any child who
meets the requirements of paragraph(1) or(2)
of section 673(b) of this title shall be
deemed to be a dependent child as defined in
section 606 of this title and shall be
deemed to be a recipient of aid to families
with dependent children under part A of
subchapter IV of this chapter in tho State
where such child resides. Notwithstanding
paragraph (10)(B) or any other provision of
this subsection, a State plan shall provide
medical assistance with respect to an alien
who is not lawfully admitted for permanent
residence or otherwise permanently residing
in the United States under color of law only
in accordance with section 1396b(v) of this
title.

(b) Approval by Secretary

a6

a

APP. 1

The Secretary shall approve any plan
which fulfills the conditions specified in
subsection (a) of this section, except that
he shall not approve any plan which imposes,
as a condition of eligibility for medical
assistance under the plan--

(1) an age requirement of more
than 65 years; or
(2) any residence requirement
which excludes any individual who
resides in the State, regardless
of whether or not the residence
is maintained permanently or at a
fixed address; or
(3) any citizenship requirement
which excludes any citizen of the
United States.

(c) Lower payment levels or applying

for benefits as condition of
applying ' § for, or receiving, medical
assistance

Notwithstanding subsection (b) of this
section, the Secretary shall not approve any
State plan for medical assistance if--

(1) the State has in effect,
under its plan established under
part A of subchapter IV of this
chapter, payment levels that are
less than the payment levels in
effect under such plan on May l,
1988; or

(2) the State requires
individuals described in
subsection (1)(1) of this section
to apply for benefits under such
part as a condition of applying
for, or receiving, medical
assistance under this subchapter.

50

APP. 1

(da) Performance of medical or
utilization review functions.

If a State contracts with an entity
which meets the requirements for section
1320c-1 of this title, as determined by the
Secretary, for the performance of the
quality review functions described in
subsection (a)(30)(C) of this section, or a
utilization and quality control peer review
organization having a contract with the
Secretary under part B of subchapter XI of
this chapter for the performance of medical
or utilization review function (including
quality review functions described in
subsection (a)(30)(C) of this section)
required under this subchapter of a State
plan with respect to specific services or
providers (or services or providers in a
geographic area of the State), such
requirements shall be deemed to be met for
those services or providers (or services or
providers in that area) by delegation to an
entity or organization under the contract of
the State's authority to conduct such review
activities if the contract provides for the
performance of activities not inconsistent
with part B of subthapter XI of this chapter
and provides for such assurances of
satisfactory performance by an entity or
organization as the Secretary may prescribe.

(e) Continued eligibility of families
determined ineligible because of income and
resources or hours of work limitations of
plan; individuals enrolled with health
maintenance organizations; persons deemed
recipients of supplemental security income
or State supplemental payments; entitlement
for certain newborns; postpartum eligibility
for pregnant women

51

APP. 1

(1) (A) Notwithstanding any other
provision of this subchapter, effective
January 1, 1974, subject to subparagraph (B)
each State plan approved under this
subchapter must provide that each family
which was receiving aid pursuant to a plan
of the State approved under part A of
subchapter IV of this chapter in at least 3
of the 6 months immediately preceding the
month in which such family became ineligible
for such aid because of increased hours of,
or increased income from, employment, shall,
while a member of such family is employed,
remain eligible for assistance under the
plan approved under this subchapter (as
though the family was receiving aid under
the plan approved under part A of subchapter
Iv of this chapter) for 4 calendar months
beginning with the month in which such
family became ineligible for aid under the
plan approved under part A of subchapter IV
of this chapter because of income and
resources or hours of work limitations
contained in such plan.

(B) Subparagraph (A) shall net apply
with respect to families that cease to be
eligible for aid under part A of subchapter
Iv of this chapter during the period
beginning on April 1, 1990, and ending 6n
September 30, 1998. During such period, for
provisions relating to extension of
eligibility for medical assistance for
certain families who have received aid
pursuant to a State plan approved underpart
A of subchapter IV of this chapter and have
earned income, see section 1396r-6 of this
title.

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

52

i :

APP. 1

maintenance organization (as defined in
Title XIII of the Public Health Service Act
[42 U.S.C.A. § 300e et seq.]) or with an
entity described in paragraph (2)(B)(iii),
(2)(E), (2)(G), or (6) of section 1396b(m)
of this title under a contract described in
section 1396b(m)(2)(A) of this title or with
an eligible organization with a contract
under section 1395mm of this title and who
would (but for this paragraph) lose
eligibility for benefits under this
subchapter before the end of the minimum
enrollment period (defined in
subparagraph(B)), the State plan may
provide, notwithstanding any other provision
of this subchapter, that the individual
shall be deemed to continue to be eligible
for such benefits until the end of such
minimum period, but, except for benefits
furnished under section 1396d(a)(4)(C) of
this title, only with respect to such bene-
fits provided to the individual as an
enrolle of such organization or entity.

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

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

(A) is 18 years of age or younger and

qualifies as a disabled individual

under section 1382c(a) of this title;

(B) with respect to whom there has

been a determination by the State

that--

53

APP. 1

(1) the individual requires a level of
care provided in a hospital, nursing
facility, or intermediate care
facility for the mentally retarded,
(11) it is appropriate to provide such
care for the individual outside such
an institution, and
(111) the estimated amount which would
be expended for medical assistance for
the individual for such care outside
an institution is not greater than the
estimated amount which would otherwise
be expended for medical assistance for
the individual within an appropriate
institution; and

(C) if the individual were in a medical
institution, would be eligible for medical
assistance under the State plan under this
subchapter, shall be deemed, for purposes of
this subchapter only, to be an individual
with respect to whom a supplemental security
income payment, or State supplemental
payment, respectively,is being paid under
subchapter XVI of this chapter.

(4) A child born to a woman eligible
for and receiving medical assistance under
a State plan on the date of the child's
birth shall be deemed to have applied for
medical assistance and to have been found
eligible for such assistance under such plan
on the date of such birth and to remain
eligible for such assistance for a period of
one year so long as the child is a member of
the woman's household and the woman remains
(or would remain if pregnant) eligible for
such assistance. During the period in which
a child is deemed under the preceding
sentence to be eligible for medical
assistance, the medical assistance

54

—

APP. 1

eligibility identification number of the
mother shall also serve as the
identification number of the child, and all
Claims shall be submitted and paid under
such number (unless the State issues a
separate identification number for the child
before such period expires).

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

(6) In the case of a pregnant woman
described in subsection (a)(10) of this
section who, because of a change in income
of the family of which she is a member,
would not otherwise continue to be described
in such subsection, the woman shall be
deemed to continue to be an individual
described in subsection (a)(10)(A)(i)(IV) of
this section and subsection (1)(1)(A) of
this section without regard to such change
of income through the end of the month in
which the 60-day period (beginning on the
last day of her pregnancy) ends. The
preceding sentence shall not apply in the
case of a woman who has been provided
ambulatory prenatal care pursuant to section
1396r-l of this title during a presumptive
eligibility period and is_~ then, in
accordance with such section, determined to
be ineligible for medical assistance under
the State plan.

55

|

APP. 1

(7) In the case of an infant or child
described in subparagraph (B), (C), or (D)
of subsection (1)(1) of this section or
paragraph (2) of section 1396d(n) of this
title--

(A) who is receiving inpatient
services for which medical assistance
is provided on the date the infant or
child attains the maximum age with
respect to which coverage is provided
under the State plan for _ such
individuals, and
(B) who, but for attaining such age,
would remain eligible for medical
assistance under such subsection, the
infant or child shall continue to be
treated as an individual described in
such respective provision until the
end of the stay for which the
inpatient services are furnished.

(8) If an individual is determined to
be a qualified medicare beneficiary (as
defined in section 1396d(p)(1) of this
title), such determination shall apply to
services furnished after the end of the
month in which the determination first
occurs. For purposes of payment to a State
under section 1396b(a) of this title, such
determination shall be considered to be
valid for an individual for a period of 12
months, except that a State may provide for
such determinations more frequently, but not
more frequently than once every 6 months for
an individual.

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

56

APP. 1

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

(11) has been so dependent for at

least 30 consecutive days (or the

maximum number of days authorized
under the State plan, whichever is
less) as an inpatient;

(441) but for the availability of

respiratory care services, would

require respiratory care as an
inpatient in a hospital, nursing
facility, or intermediate care
facility for the mentally retarded and
would be eligible to have payment made
for such inpatient care under the

State plan;

(iv) has adequate social support

services to be cared for at home; and

(v) wishes to be cared for at home.

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

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

(10)(A) The fact that an individual,
child, or pregnant woman may be denied aid
under part A of subchapter IV of this
chapter pursuant to section 602(a)(43) of

57

|

APP. 1

this title shall not be construed as denying
(or permitting a State to deny) medical
assistance under this subchapter to such
individual, child, or woman who is eligible
for assistance under this subchapter on a
basis other than the receipt of aid under
such part.

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

(11)(A) In the case of an individual
who is enrolled with a group health plan
under section 1396e of this title and who
would (but for this paragraph) lose
eligibility for benefits under’ this
subchapter before the end of the minimum
enrollment period (defined in subparagraph
(B)),the State plan may provide,
notwithstanding any other provision of this
subchapter, that the individual shall be
deemed to continue to be eligible for such
benefits until the end of such minimum
period, but only with respect to such
benefits provided to the individual as an
enrolle of such plan.

(B) For purposes of subparagraph (A),

the term "minimum enrollment period"

means, with respect to an individual's

enrollment with a group health plan, a

period established by the State, of

58

aera)

APP. 1

not more than 6 months beginning on

the date the individual's enrollment

under the plan becomes effective.

(f) Effective date of State plan as
determinative of duty of State to provide
medical assistance to aged, blind, or
disabled individuals

Notwithstanding any other provision of
this subchapter, except as provided in
subsection (e) of this section and section
1382h(b)(3) of this title and section 1396r-
5 of this title, except with respect to
qualified disabled and working individuals
(described in section 1396d(s) of this
title), and except with respect to qualified
medicare beneficiaries, qualified severely
impaired individuals, and individuals
described in subsection (m)(1) of this
section, no State not eligible to
participate in the State plan program
established under subchapter XVI of this
chapter shall be required to provide medical
assistance to any aged, blind, or disabled
individual (within the meaning of subchapter
XVI of this chapter) for any month unless
such State would be (or would have been)
required to provide medical assistance to
such individual for such month had its plan
for medical assistance approved under this
subchapter and in effect on January 1, 1972,
been in effect in such month, except that
for this purpose any such individual shall
be deemed eligible for medical assistance
under such State plan if (in addition to
meeting such other requirements as are or
may be imposed under the State plan) the
income of any such individual as determined
in accordance with section 1396b(f) of this

59

APP. 1

title (after deducting any supplemental
security income payment and State
supplementary payment made with respect to
such individual, and incurred expenses for
medical care as recognized under State law
regardless of whether such expenses are
reimbursed under another public program of
the State or political subdivision thereof)
is not in excess of the standard for medical
assistance established under the State plan
as in effect on January 1, 1972. In States
which provide medical assistance to
individuals pursuant to paragraph (10)(C) of
subsection (a) of this section, an
individual who is eligible for medical
assistance by reason of the requirements of
this section concerning the deduction of
incurred medical expenses from income shali
be considered an individual eligible for
medical assistance under paragraph (10) (A)
of that subsection if that individual is, or
is eligible to be (1) an individual with
respect to whom there is payable a State
supplementary payment on the basis of which
similarly situated individuals are eligible
to receive medical assistance equal in
amount, duration, and scope to that provided
to individuals eligible under paragraph
(10)(A), or (2) an eligible individual or
eligible spouse, as defined in subchapter
XVI of this chapter, with respect to whom
supplemental security income benefits are
payable; otherwise that individual shall be
considered to be an individual eligible for
medical assistance under paragraph (10) (C)
of that subsection. In States which do not
provide medical assistance to individuals
pursuant to paragraph (10)(C) of that
subsection, an individual who is eligible

60

APP. 1

for medical assistance by reason of the
requirements of this section concerning the
deduction of incurred medical expenses from
income shall be considered an individual
eligible for medical assistance under
paragraph (10)(A) of that subsection.

(g) Reduction of aid or assistance to
providers of services attempting to collect
from beneficiary in violation of third-party
provisions

In addition to any other sanction
available to a State, a State may provide
for a reduction of any payment amount
otherwise due with respect to a person who
furnishes services under the plan in an
amount equal to up to three times the amount
of any payment sought to be collected by
that person in violation of subsection
(a)(25)(C) of this section.

(h) Payment adjustments with respect to
hospitals serving disproportionate number of
low-income patients with special needs and
for home and community care

Nothing in this subchapter (including
subsections (a)(13) and (a)(30) of this
section) shall be construed as authorizing
the Secretary to limit the amount of payment
adjustments that may be made under a plan
under this subchapter with respect to
hospitals that serve a disproportionate
number of low-income patients with special
needs or to limit the amount of payment that
may be made under a plan under this
subchapter for home and community care.

61

APP. 1

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

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

(A) immediately jeopardize the health and
safety of its patients, the State shail
provide for the termination of the facili-
ty's certification for participation under
the plan and may provide, or

(B) do not immediately jeopardize the health
and safety of its patients the State may, in
lieu of providing for terminating the
facility's certification for participation
under the plan, provide

that no payment will be made under the State
pian with respect to any individual admitted
to such facility after a date specified by
the State.

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

62

APP. 1

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

(j) Waiver or modification of subchapter
requirements with respect to medical
assistance program in American Samoa

Notwithstanding any other requirement
of this subchapter, the Secretary may waive
or modify any requirement of this subchapter
with respect to the medical assistayce
program in American Samoa and the Northern
Mariana Islands, other than a waiver of the
Federal medical assistance percentage, the
limitation in section 1308(c) of this title,
or the requirement that payment may be made
for medical assistance only with respect to
amounts expended by American Samoa or the

63

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APP. 1

Northern Mariana Islands for care and
services described in paragraphs (1) through
(22) of section 1396d(a) of this title.

(k) Treatment of potential payments from
medicaid qualifying trusts

(1) In the case of a medicaid qualifying
trust (described in paragraph (2)), the
amounts from the trust deemed available to
a grantor, for purposes of subsection
(a)(17) of this section, is the maximum
amount of payments that may be permitted
under the terms of the trust to be
distributed to the grantor, assuming the
full exercise of discretion by the trustee
or trustees for the distribution of the
maximum amount to the grantor. For purposes
of the previous sentence, the term "grantor"
means the individual referred to in
paragraph (2).
(2) For purposes of this subsection, a
“medicaid qualifying trust" is a trust, or
Similar legal device, established (other
than by will) by an individual (or an
individual's spouse) under which’ the
individual may be the beneficiary of all or
part of the payments from the trust and the
distribution of such payments is determined
by one or more trustees who are permitted to
exercise any discretion with respect to the
distribution to the individual.
(3) This subsection shall apply without
regard to--
(A) whether or not the medicaid
qualifying trust is irrevocable or is
established for purposes other than to
enable a grantor to qualify for

64

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APP. 1

medical assistance under this
subchapter; or
(B) whether or not the discretion
described in paragraph (2) is actually
exercised.
(4) The State may waive the application of
this subsection with respect to an
individual where the State determines that
such application would work an _ undue
hardship.

(1) Description of group

(1) Individuals described in this paragraph
are---
(A) women during pregnancy (and during
the 60-day period beginning on the
last day of the pregnancy),
(B) infants under one year of age,
(C) children who have attained one
year of age but have not attained 6
years of age, and
(D) children born after September 30,
1983, who have attained 6 years of age
but have not attained 19 years of age,
who are not described in any of
subclauses (I) through (III) of
subsection (a) (10) (A) (i) of this
section and whose family income does
not exceed the income level
established by the State under
paragraph (2) for a family size equal
to the size of the family, including
the woman, infant, or child. »
(2)(A)(1) For purposes of paragraph (1) with
respect to individuals described in
subparagraph (A) or (B) of that paragraph,
the State shall establish an income level
which is a percentage (not less than the

65

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APP. 1

percentage provided under clause (ii) and
not more than 185 percent) of the income
official poverty line (as defined by the
Office of Management and Budget, and revised
annually in accordance with section 9$02(2)
of this title) applicable to a family of the
size involved.

(11) The percentage provided under this
Clause, with respect to eligibility for
medical assistance on or after---

(I) July 1, 1989, is 75 percent, or,

if greater, the percentage provided

under clause (iii), and

(II) April 1, 1990, 133 percent, or,

if greater, the percentage provided

under clause (iv).

(111) In the case of a State which, as
of July 1, 1988, has elected to provide, and
provides, medical assistance to individuals
described in this subsection or has enacted
legislation authorizing, or appropriating
funds, to provide such assistance to such
individuals before July 1, 1989, the
percentage provided under clause (ii)(I)
shall not be less than--

(I) the percentage specified by the

State in an amendment to its State

plan (whether approved or not) as of

July 1, 1988, or

(II) if no such percentage is

specified as of July 1, 1988, the

percentage established under- the

State's authorizing legislation or

provided for under the State's

appropriations;
— in no case shall this clause require the
percentage provided under clause (ii)(I) to
exceed 100 percent.

66

APP. 1

(iv) In the case of a State which, as
of December 19, 1989, has established under
Clause (i), or has enacted legislation
authorizing, or appropriating funds, to
provide for, a percentage (of the income
official poverty line) that is greater than
133 percent, the percentage provided under
Clause (ii) for medical assistance on or
after April 1, 1990, shall not be less than-

(I) the percentage specified by the

State in an amendment to its State

plan (whether approved or not) as of

December 19, 1989, or

(II) if no such percentage is

specified as of December 19, 1989, the

percentage established under_- the

State's authorizing legislation or

provided for under the State's

appropriations.

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

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

(3) Notwithstanding subsection (a) (17)
of this section, for individuals who are
eligible for medical assistance because of
subsection (a) (10)(A)(i)(1IV),

67

APP. 1

(€)(10)(A)(i)(VI), (a)(10)(A)(L)(VII), or
(a)(10)(A)(ii)(IX) of this section.-

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

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

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

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

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

Any different treatment provided under this
paragraph for such individuals shall not,
because of subsection (a)(17) of this
section, require or permit such treatment
for other individuals.

(4)(A) In the case of any State which
is providing medical assistance to its

68

APP. 1

residents under a waiver granted under
section 1315 of this title, the Secretary
shall require the State to provide medical
assistance for pregnant women and infants
under age 1 described in subsection
(a)(10)(A)(i)(IV) of this section and for
children described in subsection
(a)(10)(A)(i) (VI) or subsection
(a)(10)(A)(i)(VII) of this section in the
same manner as the State would be required
to provide such assistance for such
individuals if the State had in effect a
plan approved under this subchapter.

(B) In the case of a State which is not
one of the 50 States or the District of
Columbia, the State need not meet the
requirement of subsection (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), or (a)(10)(A)(1) (VII) of
this section and, for purposes of paragraph
(2)(A), the State may substitute for the
percentage provided under clause (ii) of
such paragraph any percentage.

(m) Description of individuals

(1) Individuals described in this paragraph

are individuals--
(A) who are 65 years of age or older
or are disabled individuals (as
determined under section 1382c(a)(3)
of this title),
(B) whose income (as determined under
section 1382a of this title for
purposes of the supplemental security
income program, except as provided in
paragraph 2(C)) does not exceed an
income level established by the State
consistent with paragraph (2)(A), and

69

APP. 1

(C) whose resources (as determined
under section 1382b of this title for
purposes of the supplemental security
income program) do not exceed (except
as provided in paragraph (2)(B)) the
maximum amount of resources that an
individual may have and obtain
benefits under that program.

(2)(A) The income level established
under paragraph (1I)(B) may not exceed a
percentage (not more than 100 percent) of
the official poverty line (as defined by the
Office of Management and Budget, and revised
annually in accordance with section 9902(2)
of this title) applicable to a family of the
size involved.

(B) In the case of a State that

provides medical assistance to

individuals not described in
subsection (a)(10)(A) of this section
and at the State's option, the State
may use under paragraph (I)(C) such
resource level (which is higher than
the level described in that paragraph)
as may be applicable with respect to
individuals described in paragraph

(1)(A) who are not described in

subsection (a)(10)(A) of this section.

(C) The provisions of section

1396d(p)(2)(D) of this title shall

apply to determinations of income

- under this subsection in the same
manner as they apply to determinations
of income under section 1396d(p) of
this title.

(3) Notwithstanding subsection (a)(17)
of this section, for individuals described
in paragraph (1) who are covered under the

70

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APP. 1

plan by virtue of subsection

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

(A) the income standard to be applied
is the income standard described in
paragraph (I)(B). and

(B) except as provided in section
1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for
any other type of remedial care shall
not be taken into account in
determining income.

Any different treatment provided under
this paragraph for such individuals
shall not, because of subsection
(a)(17) of this section require or
permit such treatment for other
individuals.

(4) Notwithstanding subsection (a)(17)

of this section, for qualified medicare
beneficiaries described in section
1396d(p)(1) of this title---

(A) the income standard to be applied
is the income standard described in
section 1396d(p)(1)(B) of this title,
and

(B) except as provided in section
1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for
any other type of remedial care shall
not be taken into account in

determining income.
‘ Any different treatment provided under

this paragraph for such individuals
shall not, because of subsection
(a)(17) of this section, require or
permit such treatment for other
individuals.

71

APP. 1
(n) Payment amounts

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

(o) Certain benefits disregarded for
purposes of determining post-
eligibility contributions

Notwithstanding any provision of
subsection (a) of this section to the
contrary, a State plan under this subchapter
shall provide that any supplemental security
income benefits paid by reason of sub-
paragraph (E) or (G) of section 1382(e)(1)
of this title to an individual who--

(1) is eligible for medical assistance

under the plan, and

(2) is in a hospital, skilled nursing

facility, or intermediate care

facility at the time such benefits are
paid, will be disregarded for purposes
of determining the amount of any post-
eligibility contribution by the
individual to the cost of the care and
services provided by the hospital,

72

eee

APP. 1

skilled nursing facility, or
intermediate care facility.

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

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

(2) In order for a State to receive
payments for medical assistance under
section 1396b(a) of this title, with respect
to payments the State makes to a health
maintenance organization (as defined in
section 1396b(m) of this tit[e) or to an
entity furnishing services under a waiver
approved under section 1396n(b)(1) of this
title, the State must provide that it will
exclude from participation, as such an
organization or entity, any organization or
entity that--

(A) could be excluded under section

1320a.7(b)(8) of this title (relating

to owners and managing employees who
have been convicted of certain crimes
or received other sanctions),

(B) has, directly or indirectly, a

substantial contractual relationship

(as defined by the Secretary) with an

individual or entity that is described

in section 1320a-7(b)(8)(B) of this
title, or

73

APP. 1

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

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

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

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

74

APP. 1

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

(B) In this subsection, the term
"institutionalized individual or couple"
means an individual or married couple--

(1) who is an inpatient (or who are

inpatients) in a medical institution

or nursing facility for which payments
are made under this subchapter
throughout a month, and

(141) who is or are determined to be

eligible for medical assistance under

the State plan.

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

(r) Disregarding payments for certain
medical expenses by institutionalized
individuals
(1) For purposes of sections

1396a(a)(17) and 1396r-5(d)(1)(D) of this

title and for purposes of a waiver under
section 1396n of this title, with respect to
the post-eligibility treatment of income of
individuals who are institutionalized or
receiving home or community-based services
under such a waiver there shall be
disregarded reparation payments made by the

Federal Republic of Germany and, there shall

be taken into account amounts for incurred

expenses for medical or remedial care that

75

APP. 1

are not subject to payment by a third party,
including--

(1) medicare and other health

insurance premiums, deductibles, or

coinsurance, and

(11) necessary medical or remedial

care recognized under State law but

not covered under the State plan under

this subchapter, subject to reasonable

limits the State may establish on the

amount of these expenses.

(2)(A) The methodology to be employed

in determining income and resource

eligibility for individuals under

subsection (a)(10)(A)(i)(III),

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

(a)(10)(A)(1)(VIT), (a)(10)(A)(i1), |

(a)(10)(C)(i)(III), or (ff) of this |

section or under section 1396d(p) of

this title may be less restrictive,

and shall be no more restrictive, than

the methodology--

(1) in the case of groups consisting

of aged, blind, or disabled

individuals, under the supplemental

under subchapter XVI of this chapter,

or

(11) in the case of other groups,

under the State plan most closely

categorically related.

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

76

APP. 1

(8) Adjustment in payment for hospital
services furnished to low-income
children under age of 6 years

In order to meet the requirements of
subsection (a)(55) of this section, the
State plan must provide that payments to
hospitals under the plan for inpatient
hospital services furnished to infants who
have not attained the age of 1 year and to
children who have not attained the age of 6
years and who receive such services in a
disproportionate share hospital

described in section 1396r of this
title shall--

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

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

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

(t) Authority of Secretary; limitations

77

APP. 1

Except as provided in section 1396b(i)
of this title, nothing in this subchapter
(including sections 1396b(1) and 1396d(a) of
this title) shall be construed as
authorizing the Secretary to deny or limit
payments to a State for expenditures, for
medical assistance for items or services,
attributable to taxes (whether or not of
general applicability) imposed with respect
to the provision of such items or services.

(u) Qualified COBRA continuation
beneficiaries

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

(A) who are entitled to elect COBRA
continuation coverage (as defined in
Paragraph (3)).

(B) whose income (as determined under
section 1382a of this title for purposes of
the supplemental security income program)
does not exceed 100 percent of the official
poverty line (as defined by the Office of
Management and Budget, and revised annually
in accordance with section 9902(2) of this
title) applicable to a family of the size
involved,

(C) whose resources (as determined
under section 1382b of this title for
purposes of the supplemental security income
program) do not exceed twice the maximum
amount of resources that an individual may
have and obtain benefits under that program,
and

(D) with respect to whose enrollment
for COBRA continuation coverage the State
has determined that the savings in
expenditures under this subchapter resulting

78

‘ iia tala

APP. 1

from such enrollment is likely to exceed the
amount of payments for COBRA premiums made.

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

(3) In this subsection, the term "COBRA
continuation coverage" means coverage under
€& group health plan provided by an employer
with 75 or more employees provided pursuant
to title XXII of the Public Health Service
Act [42 U.S.C.A. §300bb-1 et seq. ] section
4980B of Title 26, or title VI of the
Empioyee Retirement Income Security Act of
1974 [29 U.S.C.A. §1161 et seq. ]

(4) Notwithstanding subsection (a) (17)
of this section, for individuals described
in paragraph (1) who are covered under the
State plan by virtue 0of subsection
(a)(10)(A)(ii)(XI) of this section--

(A) the income standard to be applied
is the income standard described in
paragraph (I)(B), and
(B) except as provided in section
1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for
any other type of remedial care shall
not be taken into account in
determining income.

Any different treatment provided under
this paragraph for such individuals
shall not, because of subsection
(a)(10)(B) or (a)(17) of this section,
require or permit such treatment for
other individuals.

79

APP. 1

(v) State agency determination of
disability and blindness and provision
of medical assistance prior to final
determination by Administration

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

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

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

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

80

Neel On. eA aetna oe ial M eh

PALM DE IAA OE me 0 LN BORO SM he 108 po? 6 IP tne

APP. 1

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

(11) the provider's or organization's
written policies respecting the
implementation of such rights:

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

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

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

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

Subparagraph (C) shall not be construed as
requiring the provision of care which
conflicts with an advance directive.

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

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

81

APP. 1

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

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

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

(EZ) in the case of a health maintenance
organization, at the time of enrollment of
the individual with the organization.

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

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

(x) Physician Identifier system;
establishment

The Secretary shall establish a system,
for implementation by not later than July l,
1991, which provides for a unique identifier
for each physician who furnishes services
for which payment may be made under a State
plan approved under this subchapter.

82

APP. 1

(y) Intermediate sanctions for psychiatric
hospitals

(1) In addition to any other authority
under State law, where a State determines
that a psychiatric hospital which is
certified for participation under its plan
no longer meets the requirements for a
psychiatric hospital (referred to in section
1396d(h) of this title) and further finds
that the hospital's deficiencies--

and safety of its patients, the State shall
terminate the hospital's participation under
the State plan; or

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

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

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

(B) within 6 months after the date the
hospital is found to be out of compliance
with such requirements, no Federal financial
participation shall be provided under

83

APP. 1

section 1396b(a) of this title with respect
to further services provided in the hospital
until the State finds that the hospital is
in compliance with the requirements of this
subchapter.

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

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

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

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

84

APPENDIX II

DEPARTMENT OF HUMAN SERVICES
MANUAL §1062.9-1063.211

MEDICAL SERVICES FOR PERSONS
UNDER 21 YEARS OF AGE

425 SORE RE é
TS

MEDICAL SERVICES FOR PERSONS UNDER 21 YEARS
OF AGE 1062.9-1063.211

1063 Eligibility.

1063.1 Determination of Eligibility.
Children who are categorically
needy and receiving a money
payment, children included in
AFDC Foster Care, and children
receiving a State Supplemental
Payment (B or D), are pre-
determined financially eligible
for the Crippled Children's
Program (CCP). Those children
determined categorically needy
under Title XIX and not receiving
a money payment are also
financially eligible for CCP.

For all other children, the
worker reviews Forms PS-1 and MS-
MA-CC-VR-MA-1 to verify financial
eligibility for CCP. Financial
eligibility is first determined
using Title XIX income’ and
resource standards. (see Section
1020). If the child is not Title
XIX eligible, then CCP income and
resource standards are applied.
If the child is determined
medically needy, using Title XIx
income and resource standards,
CCP income standards must then be
used to determine eligibility for
CCP services.

Documentation of income and
resources and any other
conditions which might effect the
eligibility of this child to
receive CCP services must be
included in the case record.

1-63.2
1063.21

1063.211

APP. 2
A determination of medical
eligibility for CCP must be made
for all children.

Conditions of Eligibility.

Financial Eligibility. A child
is considered financially
eligible for CCP i

[Text truncated at 120,000 characters. The full text is on the page linked above.]

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40386011_0765%3A2. Public record. Not legal advice.