HR 8084 — LIVE Beneficiaries Act Leveraging Integrity and Verification of Eligibility for Beneficiaries Act

changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italics, and existing law in which no 
change is proposed is shown in roman):

 SOCIAL SECURITY ACT

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TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

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 STATE PLANS FOR MEDICAL ASSISTANCE

 Sec. 1902. (a) 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 1903 are authorized by 
 this title; 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 a merit basis, 
 except that the Secretary shall exercise no authority 
 with respect to the selection, tenure of office, and 
 compensation of any individual employed in accordance 
 with such methods, including provision for utilization 
 of professional medical personnel in the administration 
 and, where administered locally, supervision of 
 administration of the plan, and, subject to section 
 1903(i), including a specification that the single 
 State agency described in paragraph (5) will ensure 
 necessary transportation for beneficiaries under the 
 State plan to and from providers and a description of 
 the methods that such agency will use to ensure such 
 transportation) as are found by the Secretary to be 
 necessary for the proper and efficient operation of the 
 plan, (B) for the training and effective use of paid 
 subprofessional staff, with particular emphasis on the 
 full-time or part-time employment of recipients and 
 other persons of low income, as community service 
 aides, in the administration of the plan and for the 
 use of nonpaid or partially paid volunteers in a social 
 service volunteer program in providing services to 
 applicants and recipients and in assisting any advisory 
 committees established by the State agency, (C) that 
 each State or local officer, employee, or independent 
 contractor who is responsible for the expenditure of 
 substantial amounts of funds under the State plan, each 
 individual who formerly was such an officer, employee, 
 or contractor, and each partner of such an officer, 
 employee, or contractor shall be prohibited from 
 committing any act, in relation to any activity under 
 the plan, the commission of which, in connection with 
 any activity concerning the United States Government, 
 by an officer or employee of the United States 
 Government, an individual who was such an officer or 
 employee, or a partner of such an officer or employee 
 is prohibited by section 207 or 208 of title 18, United 
 States Code, and (D) that each State or local officer, 
 employee, or independent contractor who is responsible 
 for selecting, awarding, or otherwise obtaining items 
 and services under the State plan shall be subject to 
 safeguards against conflicts of interest that are at 
 least as stringent as the safeguards that apply under 
 section 27 of the Office of Federal Procurement Policy 
 Act (41 U.S.C. 423) to persons described in subsection 
 (a)(2) of such section of that Act;
 (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 title I or XVI (insofar as it 
 relates to the aged) if the State is eligible to 
 participate in the State plan program established under 
 title XVI, or by the agency or agencies administering 
 the supplemental security income program established 
 under title XVI or the State plan approved under part A 
 of title IV if the State is not eligible to participate 
 in the State plan program established under title XVI;
 (6) provide that the State agency will make such 
 reports, in such form and containing such information, 
 as the Secretary may from time to time require, and 
 comply with such provisions as the Secretary may from 
 time to time find necessary to assure the correctness 
 and verification of such reports;
 (7) provide--
 (A) safeguards which restrict the use or 
 disclosure of information concerning applicants 
 and recipients to purposes directly connected 
 with--
 (i) the administration of the plan; 
 and
 (ii) the exchange of information 
 necessary to certify or verify the 
 certification of eligibility of 
 children for free or reduced price 
 breakfasts under the Child Nutrition 
 Act of 1966 and free or reduced price 
 lunches under the Richard B. Russell 
 National School Lunch Act, in 
 accordance with section 9(b) of that 
 Act, using data standards and formats 
 established by the State agency; and
 (B) that, notwithstanding the Express Lane 
 option under subsection (e)(13), the State may 
 enter into an agreement with the State agency 
 administering the school lunch program 
 established under the Richard B. Russell 
 National School Lunch Act under which the State 
 shall establish procedures to ensure that--
 (i) a child receiving medical 
 assistance under the State plan under 
 this title whose family income does not 
 exceed 133 percent of the poverty line 
 (as defined in section 673(2) of the 
 Community Services Block Grant Act, 
 including any revision required by such 
 section), as determined without regard 
 to any expense, block, or other income 
 disregard, applicable to a family of 
 the size involved, may be certified as 
 eligible for free lunches under the 
 Richard B. Russell National School 
 Lunch Act and free breakfasts under the 
 Child Nutrition Act of 1966 without 
 further application; and
 (ii) the State agencies responsible 
 for administering the State plan under 
 this title, and for carrying out the 
 school lunch program established under 
 the Richard B. Russell National School 
 Lunch Act (42 U.S.C. 1751 et seq.) or 
 the school breakfast program 
 established by section 4 of the Child 
 Nutrition Act of 1966 (42 U.S.C. 1773), 
 cooperate in carrying out paragraphs 
 (3)(F) and (15) of section 9(b) of that 
 Act;
 (8) provide that all individuals wishing to make 
 application for medical assistance under the plan shall 
 have opportunity to do so, and that such assistance 
 shall be furnished with reasonable promptness to all 
 eligible individuals;
 (9) provide--
 (A) that the State health agency, or other 
 appropriate State medical agency (whichever is 
 utilized by the Secretary for the purpose 
 specified in the first sentence of section 
 1864(a)), shall be responsible for establishing 
 and maintaining health standards for private or 
 public institutions in which recipients of 
 medical assistance under the plan may receive 
 care or services,
 (B) for the establishment or designation of a 
 State authority or authorities which shall be 
 responsible for establishing and maintaining 
 standards, other than those relating to health, 
 for such institutions,
 (C) that any laboratory services paid for 
 under such plan must be provided by a 
 laboratory which meets the applicable 
 requirements of section 1861(e)(9) or 
 paragraphs (16) and (17) of section 1861(s), 
 or, in the case of a laboratory which is in a 
 rural health clinic, of section 1861(aa)(2)(G), 
 and
 (D) that the State maintain a consumer-
 oriented website providing useful information 
 to consumers regarding all skilled nursing 
 facilities and all nursing facilities in the 
 State, including for each facility, Form 2567 
 State inspection reports (or a successor form), 
 complaint investigation reports, the facility's 
 plan of correction, and such other information 
 that the State or the Secretary considers 
 useful in assisting the public to assess the 
 quality of long term care options and the 
 quality of care provided by individual 
 facilities;
 (10) provide--
 (A) for making medical assistance available, 
 including at least the care and services listed 
 in paragraphs (1) through (5), (13)(B), (17), 
 (21), (28), (29), and (30) of section 1905(a), 
 to--
 (i) all individuals--
 (I) who are receiving aid or 
 assistance under any plan of 
 the State approved under title 
 I, X, XIV, or XVI, or part A or 
 part E of title IV (including 
 individuals eligible under this 
 title by reason of section 
 402(a)(37), 406(h), or 473(b), 
 or considered by the State to 
 be receiving such aid as 
 authorized under section 
 482(e)(6)),
 (II)(aa) with respect to whom 
 supplemental security income 
 benefits are being paid under 
 title XVI (or were being paid 
 as of the date of the enactment 
 of section 211(a) of the 
 Personal Responsibility and 
 Work Opportunity Reconciliation 
 Act of 1996 (P.L. 104-193) and 
 would continue to be paid but 
 for the enactment of that 
 section), (bb) who are 
 qualified severely impaired 
 individuals (as defined in 
 section 1905(q)), or (cc) who 
 are under 21 years of age and 
 with respect to whom 
 supplemental security income 
 benefits would be paid under 
 title XVI if subparagraphs (A) 
 and (B) of section 1611(c)(7) 
 were applied without regard to 
 the phrase ``the first day of 
 the month following'',
 (III) who are qualified 
 pregnant women or children as 
 defined in section 1905(n),
 (IV) who are described in 
 subparagraph (A) or (B) of 
 subsection (l)(1) and whose 
 family income does not exceed 
 the minimum income level the 
 State is required to establish 
 under subsection (l)(2)(A) for 
 such a family;
 (V) who are qualified family 
 members as defined in section 
 1905(m)(1),
 (VI) who are described in 
 subparagraph (C) of subsection 
 (l)(1) and whose family income 
 does not exceed the income 
 level the State is required to 
 establish under subsection 
 (l)(2)(B) for such a family,
 (VII) who are described in 
 subparagraph (D) of subsection 
 (l)(1) and whose family income 
 does not exceed the income 
 level the State is required to 
 establish under subsection 
 (l)(2)(C) for such a family;
 (VIII) beginning January 1, 
 2014, who are under 65 years of 
 age, not pregnant, not entitled 
 to, or enrolled for, benefits 
 under part A of title XVIII, or 
 enrolled for benefits under 
 part B of title XVIII, and are 
 not described in a previous 
 subclause of this clause, and 
 whose income (as determined 
 under subsection (e)(14)) does 
 not exceed 133 percent of the 
 poverty line (as defined in 
 section 2110(c)(5)) applicable 
 to a family of the size 
 involved, subject to subsection 
 (k); or
 (IX) who--
 (aa) are under 26 
 years of age;
 (bb) are not 
 described in and are 
 not enrolled under any 
 of subclauses (I) 
 through (VII) of this 
 clause or are described 
 in any of such 
 subclauses but have 
 income that exceeds the 
 level of income 
 applicable under the 
 State plan for 
 eligibility to enroll 
 for medical assistance 
 under such subclause;
 (cc) were in foster 
 care under the 
 responsibility of a 
 State on the date of 
 attaining 18 years of 
 age or such higher age 
 as the State has 
 elected under section 
 475(8)(B)(iii); and
 (dd) were enrolled in 
 a State plan under this 
 title or under a waiver 
 of such a plan while in 
 such foster care;
 (ii) at the option of the State, to 
 any group or groups of individuals 
 described in section 1905(a) (or, in 
 the case of individuals described in 
 section 1905(a)(i), to any reasonable 
 categories of such individuals) who are 
 not individuals described in clause (i) 
 of this subparagraph but--
 (I) who meet the income and 
 resources requirements of the 
 appropriate State plan 
 described in clause (i) or the 
 supplemental security income 
 program (as the case may be),
 (II) who would meet the 
 income and resources 
 requirements of the appropriate 
 State plan described in clause 
 (i) if their work-related child 
 care costs were paid from their 
 earnings rather than by a State 
 agency as a service 
 expenditure,
 (III) who would be eligible 
 to receive aid under the 
 appropriate State plan 
 described in clause (i) if 
 coverage under such plan was as 
 broad as allowed under Federal 
 law,
 (IV) with respect to whom 
 there is being paid, or who are 
 eligible, or would be eligible 
 if they were not in a medical 
 institution, to have paid with 
 respect to them, aid or 
 assistance under the 
 appropriate State plan 
 described in clause (i), 
 supplemental security income 
 benefits under title XVI, or a 
 State supplementary payment;
 (V) who are in a medical 
 institution for a period of not 
 less than 30 consecutive days 
 (with eligibility by reason of 
 this subclause beginning on the 
 first day of such period), who 
 meet the resource requirements 
 of the appropriate State plan 
 described in clause (i) or the 
 supplemental security income 
 program, and whose income does 
 not exceed a separate income 
 standard established by the 
 State which is consistent with 
 the limit established under 
 section 1903(f)(4)(C),
 (VI) who would be eligible 
 under the State plan under this 
 title 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 1915 they would require 
 the level of care provided in a 
 hospital, nursing facility or 
 intermediate care facility for 
 the mentally retarded the cost 
 of which could be reimbursed 
 under the State plan, and who 
 will receive home or community-
 based services pursuant to a 
 waiver granted by the Secretary 
 under subsection (c), (d), or 
 (e) of section 1915,
 (VII) who would be eligible 
 under the State plan under this 
 title 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 1905(o);
 (VIII) who is a child 
 described in section 
 1905(a)(i)--
 (aa) for whom there 
 is in effect an 
 adoption assistance 
 agreement (other than 
 an agreement under part 
 E of title IV) between 
 the State and an 
 adoptive parent or 
 parents,
 (bb) who the State 
 agency responsible for 
 adoption assistance has 
 determined cannot be 
 placed with adoptive 
 parents without medical 
 assistance because such 
 child has special needs 
 for medical or 
 rehabilitative care, 
 and
 (cc) who was eligible 
 for medical assistance 
 under the State plan 
 prior to the adoption 
 assistance agreement 
 being entered into, or 
 who would have been 
 eligible for medical 
 assistance at such time 
 if the eligibility 
 standards and 
 methodologies of the 
 State's foster care 
 program under part E of 
 title IV were applied 
 rather than the 
 eligibility standards 
 and methodologies of 
 the State's aid to 
 families with dependent 
 children program under 
 part A of title IV;
 (IX) who are described in 
 subsection (l)(1) and are not 
 described in clause (i)(IV), 
 clause (i)(VI), or clause 
 (i)(VII);
 (X) who are described in 
 subsection (m)(1);
 (XI) who receive only an 
 optional State supplementary 
 payment based on need and paid 
 on a regular basis, equal to 
 the difference between the 
 individual's countable income 
 and the income standard used to 
 determine eligibility for such 
 supplementary payment (with 
 countable income being the 
 income remaining after 
 deductions as established by 
 the State pursuant to standards 
 that may be more restrictive 
 than the standards for 
 supplementary security income 
 benefits under title XVI), 
 which are available to all 
 individuals in the State (but 
 which may be based on different 
 income standards by political 
 subdivision according to cost 
 of living differences), and 
 which are paid by a State that 
 does not have an agreement with 
 the Commissioner of Social 
 Security under section 1616 or 
 1634;
 (XII) who are described in 
 subsection (z)(1) (relating to 
 certain TB-infected 
 individuals);
 (XIII) who are in families 
 whose income is less than 250 
 percent of the income official 
 poverty line (as defined by the 
 Office of Management and 
 Budget, and revised annually in 
 accordance with section 673(2) 
 of the Omnibus Budget 
 Reconciliation Act of 1981) 
 applicable to a family of the 
 size involved, and who but for 
 earnings in excess of the limit 
 established under section 
 1905(q)(2)(B), would be 
 considered to be receiving 
 supplemental security income 
 (subject, notwithstanding 
 section 1916, to payment of 
 premiums or other cost-sharing 
 charges (set on a sliding scale 
 based on income) that the State 
 may determine);
 (XIV) who are optional 
 targeted low-income children 
 described in section 
 1905(u)(2)(B);
 (XV) who, but for earnings in 
 excess of the limit established 
 under section 1905(q)(2)(B), 
 would be considered to be 
 receiving supplemental security 
 income, who is at least 16, but 
 less than 65, years of age, and 
 whose assets, resources, and 
 earned or unearned income (or 
 both) do not exceed such 
 limitations (if any) as the 
 State may establish;
 (XVI) who are employed 
 individuals with a medically 
 improved disability described 
 in section 1905(v)(1) and whose 
 assets, resources, and earned 
 or unearned income (or both) do 
 not exceed such limitations (if 
 any) as the State may 
 establish, but only if the 
 State provides medical 
 assistance to individuals 
 described in subclause (XV);
 (XVII) who are independent 
 foster care adolescents (as 
 defined in section 1905(w)(1)), 
 or who are within any 
 reasonable categories of such 
 adolescents specified by the 
 State;
 (XVIII) who are described in 
 subsection (aa) (relating to 
 certain breast or cervical 
 cancer patients);
 (XIX) who are disabled 
 children described in 
 subsection (cc)(1);
 (XX) beginning January 1, 
 2014, who are under 65 years of 
 age and are not described in or 
 enrolled under a previous 
 subclause of this clause, and 
 whose income (as determined 
 under subsection (e)(14)) 
 exceeds 133 percent of the 
 poverty line (as defined in 
 section 2110(c)(5)) applicable 
 to a family of the size 
 involved but does not exceed 
 the highest income eligibility 
 level established under the 
 State plan or under a waiver of 
 the plan, subject to subsection 
 (hh);
 (XXI) who are described in 
 subsection (ii) (relating to 
 individuals who meet certain 
 income standards);
 (XXII) who are eligible for 
 home and community-based 
 services under needs-based 
 criteria established under 
 paragraph (1)(A) of section 
 1915(i), or who are eligible 
 for home and community-based 
 services under paragraph (6) of 
 such section, and who will 
 receive home and community-
 based services pursuant to a 
 State plan amendment under such 
 subsection; or
 (XXIII) during any portion of 
 the emergency period defined in 
 paragraph (1)(B) of section 
 1135(g) beginning on or after 
 the date of the enactment of 
 this subclause, who are 
 uninsured individuals (as 
 defined in subsection (ss));
 (B) that the medical assistance made 
 available to any individual described in 
 subparagraph (A)--
 (i) shall not be less in amount, 
 duration, or scope than the medical 
 assistance made available to any other 
 such individual, and
 (ii) shall not be less in amount, 
 duration, or scope than the medical 
 assistance made available to 
 individuals not described in 
 subparagraph (A);
 (C) that if medical assistance is included 
 for any group of individuals described in 
 section 1905(a) who are not described in 
 subparagraph (A) or (E), then--
 (i) the plan must include a 
 description of (I) the criteria for 
 determining eligibility of individuals 
 in the group for such medical 
 assistance, (II) the amount, duration, 
 and scope of medical assistance made 
 available to individuals in the group, 
 and (III) the single standard to be 
 employed in determining income and 
 resource eligibility for all such 
 groups, and the methodology to be 
 employed in determining such 
 eligibility, which shall be no more 
 restrictive than the methodology which 
 would be employed under the 
 supplemental security income program in 
 the case of groups consisting of aged, 
 blind, or disabled individuals in a 
 State in which such program is in 
 effect, and which shall be no more 
 restrictive than the methodology which 
 would be employed under the appropriate 
 State plan (described in subparagraph 
 (A)(i)) to which such group is most 
 closely categorically related in the 
 case of other groups;
 (ii) the plan must make available 
 medical assistance--
 (I) to individuals under the 
 age of 18 who (but for income 
 and resources) would be 
 eligible for medical assistance 
 as an individual described in 
 subparagraph (A)(i), and
 (II) to pregnant women, 
 during the course of their 
 pregnancy, who (but for income 
 and resources) would be 
 eligible for medical assistance 
 as an individual described in 
 subparagraph (A);
 (iii) such medical assistance must 
 include (I) with respect to children 
 under 18 and individuals entitled to 
 institutional services, ambulatory 
 services, and (II) with respect to 
 pregnant women, prenatal care and 
 delivery services; and
 (iv) if such medical assistance 
 includes services in institutions for 
 mental diseases or in an intermediate 
 care facility for the mentally retarded 
 (or both) for any such group, it also 
 must include for all groups covered at 
 least the care and services listed in 
 paragraphs (1) through (5), (13)(B), 
 and (17) of section 1905(a) or the care 
 and services listed in any 7 of the 
 paragraphs numbered (1) through (24) of 
 such section;
 (D) for the inclusion of home health services 
 for any individual who, under the State plan, 
 is entitled to nursing facility services;
 (E)(i) for making medical assistance 
 available for medicare cost-sharing (as defined 
 in section 1905(p)(3)) for qualified medicare 
 beneficiaries described in section 1905(p)(1);
 (ii) for making medical assistance available 
 for payment of medicare cost-sharing described 
 in section 1905(p)(3)(A)(i) for qualified 
 disabled and working individuals described in 
 section 1905(s);
 (iii) for making medical assistance available 
 for medicare cost sharing described in section 
 1905(p)(3)(A)(ii) subject to section 
 1905(p)(4), for individuals who would be 
 qualified medicare beneficiaries described in 
 section 1905(p)(1) (including such individuals 
 enrolled under section 1836(b)) but for the 
 fact that their income exceeds the income level 
 established by the State under section 
 1905(p)(2) but is less than 110 percent in 1993 
 and 1994, and 120 percent in 1995 and years 
 thereafter of the official poverty line 
 (referred to in such section) for a family of 
 the size involved; and
 (iv) subject to sections 1933 and 1905(p)(4), 
 for making medical assistance available for 
 medicare cost-sharing described in section 
 1905(p)(3)(A)(ii) for individuals who would be 
 qualified medicare beneficiaries described in 
 section 1905(p)(1) (including such individuals 
 enrolled under section 1836(b)) but for the 
 fact that their income exceeds the income level 
 established by the State under section 
 1905(p)(2) and is at least 120 percent, but 
 less than 135 percent, of the official poverty 
 line (referred to in such section) for a family 
 of the size involved and who are not otherwise 
 eligible for medical assistance under the State 
 plan;
 (F) at the option of a State, for making 
 medical assistance available for COBRA premiums 
 (as defined in subsection (u)(2)) for qualified 
 COBRA continuation beneficiaries described in 
 section 1902(u)(1); and
 (G) that, in applying eligibility criteria of 
 the supplemental security income program under 
 title XVI for purposes of determining 
 eligibility for medical assistance under the 
 State plan of an individual who is not 
 receiving supplemental security income, the 
 State will disregard the provisions of 
 subsections (c) and (e) of section 1613;
 except that (I) the making available of the services 
 described in paragraph (4), (14), or (16) of section 
 1905(a) 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 title XVIII to individuals eligible therefor (either 
 pursuant to an agreement entered into under section 
 1843 or by reason of the payment of premiums under such 
 title 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 title XVIII 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 individuals, (III) the making available of 
 medical assistance equal in amount, duration, and scope 
 to the medical assistance made available to 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 individuals 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 
 1916(a)(2) or (b)(2) 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 
 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 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 1905(o) to receive 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 title XVIII, 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 (l)(1)(A) 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), 
 medical assistance for services related to other 
 conditions which may complicate pregnancy, and medical 
 assistance for vaccines described in section 
 1905(a)(4)(E) and the administration of such vaccines 
 during the period described in such section, (VIII) the 
 medical assistance made available to a qualified 
 medicare beneficiary described in section 1905(p)(1) 
 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 1905(p)(3)), subject to the provisions of 
 subsection (n) and section 1916(b), (IX) the making 
 available of respiratory care services in accordance 
 with subsection (e)(9) 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 under subsection (e)(9)(A), 
 provided such services 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 1923(a)(1)(A), 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, (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 1906 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, (XII) 
 the medical assistance made available to an individual 
 described in subsection (u)(1) 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)), (XIII) the medical assistance made available 
 to an individual described in subsection (z)(1) who is 
 eligible for medical assistance only because of 
 subparagraph (A)(ii)(XII) shall be limited to medical 
 assistance for TB-related services (described in 
 subsection (z)(2)) and medical assistance for vaccines 
 described in section 1905(a)(4)(E) and the 
 administration of such vaccines during the period 
 described in such section, (XIV) the medical assistance 
 made available to an individual described in subsection 
 (aa) who is eligible for medical assistance only 
 because of subparagraph (A)(10)(ii)(XVIII) shall be 
 limited to medical assistance provided during the 
 period in which such an individual requires treatment 
 for breast or cervical cancer (XV) the medical 
 assistance made available to an individual described in 
 subparagraph (A)(i)(VIII) shall be limited to medical 
 assistance described in subsection (k)(1) and medical 
 assistance for vaccines described in section 
 1905(a)(4)(E) and the administration of such vaccines 
 during the period described in such section, (XVI) the 
 medical assistance made available to an individual 
 described in subsection (ii) shall be limited to family 
 planning services and supplies described in section 
 1905(a)(4)(C) including medical diagnosis and treatment 
 services that are provided pursuant to a family 
 planning service in a family planning setting and 
 medical assistance for vaccines described in section 
 1905(a)(4)(E) and the administration of such vaccines 
 during the period described in such section, (XVII) if 
 an individual is described in subclause (IX) of 
 subparagraph (A)(i) and is also described in subclause 
 (VIII) of that subparagraph, the medical assistance 
 shall be made available to the individual through 
 subclause (IX) instead of through subclause (VIII), and 
 (XVIII) the medical assistance made available to an 
 uninsured individual (as defined in subsection (ss)) 
 who is eligible for medical assistance only because of 
 subparagraph (A)(ii)(XXIII) shall be limited to medical 
 assistance for any in vitro diagnostic product 
 described in section 1905(a)(3)(B) that is administered 
 during any portion of the period at the end of the 
 emergency sentence described in such section beginning 
 on or after the date of the enactment of this subclause 
 (and the administration of such product), any service 
 described in section 1916(a)(2)(G) that is furnished 
 during any such portion, any vaccine described in 
 section 1905(a)(4)(E) (and the administration of such 
 vaccine) that is furnished during any such portion, and 
 testing and treatments for COVID-19, including 
 specialized equipment and therapies (including 
 preventive therapies), and, in the case of an 
 individual who is diagnosed with or presumed to have 
 COVID-19, during the period such individual has (or is 
 presumed to have) COVID-19, the treatment of a 
 condition that may seriously complicate the treatment 
 of COVID-19, if otherwise covered under the State plan 
 (or waiver of such plan), and (XIX) medical assistance 
 shall be made available during the period described in 
 section 1905(a)(4)(E) for vaccines described in such 
 section and the administration of such vaccines, for 
 any individual who is eligible for and receiving 
 medical assistance under the State plan or under a 
 waiver of such plan (other than an individual who is 
 eligible for medical assistance consisting only of 
 payment of premiums pursuant to subparagraph (E) or (F) 
 or section 1933), notwithstanding any provision of this 
 title or waiver under section 1115 impacting such 
 individual's eligibility for medical assistance under 
 such plan or waiver to coverage for a limited type of 
 benefits and services that would not otherwise include 
 coverage of a COVID-19 vaccine and its administration;
 (11)(A) provide for entering into cooperative 
 arrangements with the State agencies responsible for 
 administering or supervising the administration of 
 health services and vocational rehabilitation services 
 in the State looking toward maximum utilization of such 
 services in the provision of medical assistance under 
 the plan, (B) provide, to the extent prescribed by the 
 Secretary, for entering into agreements, with any 
 agency, institution, or organization receiving payments 
 under (or through an allotment under) title V, (i) 
 providing for utilizing such agency, institution, or 
 organization in furnishing care and services which are 
 available under such title or allotment and which are 
 included in the State plan approved under this section 
 (ii) making such provision as may be appropriate for 
 reimbursing such agency, institution, or organization 
 for the cost of any such care and services furnished 
 any individual for which payment would otherwise be 
 made to the State with respect to the individual under 
 section 1903, and (iii) providing for coordination of 
 information and education on pediatric vaccinations and 
 delivery of immunization services, and (C) provide for 
 coordination of the operations under this title, 
 including the provision of information and education on 
 pediatric vaccinations and the delivery of immunization 
 services, with the State's operations under the special 
 supplemental nutrition program for women, infants, and 
 children under section 17 of the Child Nutrition Act of 
 1966;
 (12) provide that, in determining whether an 
 individual is blind, there shall be an examination by a 
 physician skilled in the diseases of the eye or by an 
 optometrist, whichever the individual may select;
 (13) provide--
 (A) for a public process for determination of 
 rates of payment under the plan for hospital 
 services, nursing facility services, and 
 services of intermediate care facilities for 
 the mentally retarded under which--
 (i) proposed rates, the methodologies 
 underlying the establishment of such 
 rates, and justifications for the 
 proposed rates are published,
 (ii) providers, beneficiaries and 
 their representatives, and other 
 concerned State residents are given a 
 reasonable opportunity for review and 
 comment on the proposed rates, 
 methodologies, and justifications,
 (iii) final rates, the methodologies 
 underlying the establishment of such 
 rates, and justifications for such 
 final rates are published, and
 (iv) in the case of hospitals, such 
 rates take into account (in a manner 
 consistent with section 1923) the 
 situation of hospitals which serve a 
 disproportionate number of low-income 
 patients with special needs;
 (B) for payment for hospice care in amounts 
 no lower than the amounts, using the same 
 methodology, used under part A of title XVIII 
 and for payment of amounts under section 
 1905(o)(3); except that in the case of hospice 
 care which is furnished to an individual who is 
 a resident of a nursing facility or 
 intermediate care facility for the mentally 
 retarded, and who would be eligible under the 
 plan for nursing facility services or services 
 in an intermediate care facility for the 
 mentally retarded if he had not elected to 
 receive hospice care, there shall be paid an 
 additional amount, to take into account the 
 room and board furnished by the facility, equal 
 to at least 95 percent of the rate that would 
 have been paid by the State under the plan for 
 facility services in that facility for that 
 individual; and
 (C) payment for primary care services (as 
 defined in subsection (jj)) furnished in 2013 
 and 2014 by a physician with a primary 
 specialty designation of family medicine, 
 general internal medicine, or pediatric 
 medicine at a rate not less than 100 percent of 
 the payment rate that applies to such services 
 and physician under part B of title XVIII (or, 
 if greater, the payment rate that would be 
 applicable under such part if the conversion 
 factor under section 1848(d) for the year 
 involved were the conversion factor under such 
 section for 2009);
 (14) provide that enrollment fees, premiums, or 
 similar charges, and deductions, cost sharing, or 
 similar charges, may be imposed only as provided in 
 section 1916;
 (15) provide for payment for services described in 
 clause (B) or (C) of section 1905(a)(2) under the plan 
 in accordance with subsection (bb);
 (16) provide for inclusion, to the extent required by 
 regulations prescribed by the Secretary, of provisions 
 (conforming to such regulations) with respect to the 
 furnishing of medical assistance under the plan to 
 individuals who are residents of the State but are 
 absent therefrom;
 (17) except as provided in subsections (e)(14), 
 (e)(15), (l)(3), (m)(3), and (m)(4), include reasonable 
 standards (which shall be comparable for all groups and 
 may, in accordance with standards prescribed by the 
 Secretary, differ with respect to income levels, but 
 only in the case of applicants or recipients of 
 assistance under the plan who are not receiving aid or 
 assistance under any plan of the State approved under 
 title I, X, XIV, or XVI, or part A of title IV, and 
 with respect to whom supplemental security income 
 benefits are not being paid under title XVI, based on 
 the variations between shelter costs in urban areas and 
 in rural areas) for determining eligibility for and the 
 extent of medical assistance under the plan which (A) 
 are consistent with the objectives of this title, (B) 
 provide for taking into account only such income and 
 resources as are, as determined in accordance with 
 standards prescribed by the Secretary, available to the 
 applicant or recipient and (in the case of any 
 applicant or recipient who would, except for income and 
 resources, be eligible for aid or assistance in the 
 form of money payments under any plan of the State 
 approved under title I, X, XIV, or XVI, or part A of 
 title IV, or to have paid with respect to him 
 supplemental security income benefits under title XVI) 
 as would not be disregarded (or set aside for future 
 needs) in determining his eligibility for such aid, 
 assistance, or benefits, (C) provide for reasonable 
 evaluation of any such income or resources, and (D) do 
 not take into account the financial responsibility of 
 any individual for any applicant or recipient of 
 assistance under the plan unless such applicant or 
 recipient is such individual's spouse or such 
 individual's child who is under age 21 or (with respect 
 to States eligible to participate in the State program 
 established under title XVI), is blind or permanently 
 and totally disabled, or is blind or disabled as 
 defined in section 1614 (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 
 1903(f)(2)(B), or otherwise and regardless of whether 
 such costs are reimbursed under another public program 
 of the State or political subdivision thereof) incurred 
 for medical care or for any other type of remedial care 
 recognized under State law;
 (18) comply with the provisions of section 1917 with 
 respect to liens, adjustments and recoveries of medical 
 assistance correctly paid, transfers of assets, and 
 treatment of certain trusts;
 (19) provide such safeguards as may be necessary to 
 assure that eligibility for care and services under the 
 plan will be determined, and such care and services 
 will be provided, in a manner consistent with 
 simplicity of administration and the best interests of 
 the recipients;
 (20) if the State plan includes medical assistance in 
 behalf of individuals 65 years of age or older who are 
 patients in institutions for mental diseases--
 (A) provide for having in effect such 
 agreements or other arrangements with State 
 authorities concerned with mental diseases, 
 and, where appropriate, with such institutions, 
 as may be necessary for carrying out the State 
 plan, including arrangements for joint planning 
 and for development of alternate methods of 
 care, arrangements providing assurance of 
 immediate readmittance to institutions where 
 needed for individuals under alternate plans of 
 care, and arrangements providing for access to 
 patients and facilities, for furnishing 
 information, and for making reports;
 (B) provide for an individual plan for each 
 such patient to assure that the institutional 
 care provided to him is in his best interests, 
 including, to that end, assurances that there 
 will be initial and periodic review of his 
 medical and other needs, that he will be given 
 appropriate medical treatment within the 
 institution, and that there will be a periodic 
 determination of his need for continued 
 treatment in the institution; and
 (C) provide for the development of alternate 
 plans of care, making maximum utilization of 
 available resources, for recipients 65 years of 
 age or older who would otherwise need care in 
 such institutions, including appropriate 
 medical treatment and other aid or assistance; 
 for services referred to in section 
 3(a)(4)(A)(i) and (ii) or section 
 1603(a)(4)(A)(i) and (ii) which are appropriate 
 for such recipients and for such patients; and 
 for methods of administration necessary to 
 assure that the responsibilities of the State 
 agency under the State plan with respect to 
 such recipients and such patients will be 
 effectively carried out;
 (21) if the State plan includes medical assistance in 
 behalf of individuals 65 years of age or older who are 
 patients in public institutions for mental diseases, 
 show that the State is making satisfactory progress 
 toward developing and implementing a comprehensive 
 mental health program, including provision for 
 utilization of community mental health centers, nursing 
 facilities, and other alternatives to care in public 
 institutions for mental diseases;
 (22) include descriptions of (A) the kinds and 
 numbers of professional medical personnel and 
 supporting staff that will be used in the 
 administration of the plan and of the responsibilities 
 they will have, (B) the standards, for private or 
 public institutions in which recipients of medical 
 assistance under the plan may receive care or services, 
 that will be utilized by the State authority or 
 authorities responsible for establishing and 
 maintaining such standards, (C) the cooperative 
 arrangements with State health agencies and State 
 vocational rehabilitation agencies entered into with a 
 view to maximum utilization of and coordination of the 
 provision of medical assistance with the services 
 administered or supervised by such agencies, and (D) 
 other standards and methods that the State will use to 
 assure that medical or remedial care and services 
 provided to recipients of medical assistance are of 
 high quality;
 (23) provide that (A) any individual eligible for 
 medical assistance (including drugs) may obtain such 
 assistance from any institution, agency, community 
 pharmacy, or person, qualified to perform the service 
 or services required (including an organization which 
 provides such services, or arranges for their 
 availability, on a prepayment basis), who undertakes to 
 provide him such services, and (B) an enrollment of an 
 individual eligible for medical assistance in a primary 
 care case-management system (described in section 
 1915(b)(1)), a medicaid managed care organization, or a 
 similar entity shall not restrict the choice of the 
 qualified person from whom the individual may receive 
 services under section 1905(a)(4)(C), except as 
 provided in subsection (g) and in section 1915, except 
 that this paragraph shall not apply in the case of 
 Puerto Rico, the Virgin Islands, and Guam, and except 
 that nothing in this paragraph shall be construed as 
 requiring a State to provide medical assistance for 
 such services furnished by a person or entity convicted 
 of a felony under Federal or State law for an offense 
 which the State agency determines is inconsistent with 
 the best interests of beneficiaries under the State 
 plan or by a provider or supplier to which a moratorium 
 under subsection (kk)(4) is applied during the period 
 of such moratorium';
 (24) effective 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 Act, (B) to establish and maintain such fiscal 
 records as may be necessary for the proper and 
 efficient administration of this Act, and (C) to 
 provide information needed to determine payments due 
 under this Act on account of care and services 
 furnished to individuals;
 (25) provide--
 (A) that the State or local agency 
 administering such plan will take all 
 reasonable measures to ascertain the legal 
 liability of third parties (including health 
 insurers, self-insured plans, group health 
 plans (as defined in section 607(1) of the 
 Employee Retirement Income Security Act of 
 1974), service benefit plans, managed care 
 organizations, pharmacy benefit managers, or 
 other parties that are, by statute, contract, 
 or agreement, legally responsible for payment 
 of a claim for a health care item or service) 
 to pay for care and services available under 
 the plan, including--
 (i) the collection of sufficient 
 information (as specified by the 
 Secretary in regulations) to enable the 
 State to pursue claims against such 
 third parties, with such information 
 being collected at the time of any 
 determination or redetermination of 
 eligibility for medical assistance, and
 (ii) the submission to the Secretary 
 of a plan (subject to approval by the 
 Secretary) for pursuing claims against 
 such third parties, which plan shall be 
 integrated with, and be monitored as a 
 part of the Secretary's review of, the 
 State's mechanized claims processing 
 and information retrieval systems 
 required under section 1903(r);
 (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 1916), or (ii) in an amount which 
 exceeds the lesser of (I) the amount which may 
 be collected under section 1916, or (II) the 
 amount by which the amount payable for that 
 service under the plan (disregarding section 
 1916) exceeds the total of the amount of the 
 liabilities of third parties for that service;
 (D) that a person who furnishes services and 
 is participating under the plan may not refuse 
 to furnish services to an individual (who is 
 entitled to have payment made under the plan 
 for the services the person furnishes) because 
 of a third party's potential liability for 
 payment for the service;
 (E) that in the case of preventive pediatric 
 care (including early and periodic screening 
 and diagnosis services under section 
 1905(a)(4)(B)) covered under the State plan, 
 the State shall--
 (i) make payment for such service in 
 accordance with the usual payment 
 schedule under such plan for such 
 services without regard to the 
 liability of a third party for payment 
 for such services; and
 (i) make payment for such service in 
 accordance with the usual payment 
 schedule under such plan for such 
 services without regard to the 
 liability of a third party for payment 
 for such services, except that the 
 State may, if the State determines 
 doing so is cost-effective and will not 
 adversely affect access to care, only 
 make such payment if a third party so 
 liable has not made payment within 90 
 days after the date the provider of 
 such services has initially submitted a 
 claim to such third party for payment 
 for such services; and
 (ii) seek reimbursement from such 
 third party in accordance with 
 subparagraph (B);
 (F) that in the case of any services covered 
 under such plan which are provided to an 
 individual on whose behalf child support 
 enforcement is being carried out by the State 
 agency under part D of title IV of this Act, 
 the State shall--
 (i) make payment for such service in 
 accordance with the usual payment 
 schedule under such plan for such 
 services without regard to any third-
 party liability for payment for such 
 services, if such third-party liability 
 is derived (through insurance or 
 otherwise) from the parent whose 
 obligation to pay support is being 
 enforced by such agency, if payment has 
 not been made by such third party 
 within 30 days after such services are 
 furnished;
 (i) make payment for such service in 
 accordance with the usual payment 
 schedule under such plan for such 
 services without regard to any third-
 party liability for payment for such 
 services, if such third-party liability 
 is derived (through insurance or 
 otherwise) from the parent whose 
 obligation to pay support is being 
 enforced by such agency, if payment has 
 not been made by such third party 
 within 100 days after the date the 
 provider of such services has initially 
 submitted a claim to such third party 
 for payment for such services, except 
 that the State may make such payment 
 within 30 days after such date if the 
 State determines doing so is cost-
 effective and necessary to ensure 
 access to care.;
 (ii) seek reimbursement from such 
 third party in accordance with 
 subparagraph (B);
 (G) that the State prohibits any health 
 insurer (including a group health plan, as 
 defined in section 607(1) of the Employee 
 Retirement Income Security Act of 1974, a self-
 insured plan, a service benefit plan, a managed 
 care organization, a pharmacy benefit manager, 
 or other party that is, by statute, contract, 
 or agreement, legally responsible for payment 
 of a claim for a health care item or service), 
 in enrolling an individual or in making any 
 payments for benefits to the individual or on 
 the individual's behalf, from taking into 
 account that the individual is eligible for or 
 is provided medical assistance under a plan 
 under this title for such State, or any other 
 State;
 (H) that to the extent that payment has been 
 made under the State plan for medical 
 assistance in any case where a third party has 
 a legal liability to make payment for such 
 assistance, the State has in effect laws under 
 which, to the extent that payment has been made 
 under the State plan for medical assistance for 
 health care items or services furnished to an 
 individual, the State is considered to have 
 acquired the rights of such individual to 
 payment by any other party for such health care 
 items or services; and
 (I) that the State shall provide assurances 
 satisfactory to the Secretary that the State 
 has in effect laws requiring health insurers, 
 including self-insured plans, group health 
 plans (as defined in section 607(1) of the 
 Employee Retirement Income Security Act of 
 1974), service benefit plans, managed care 
 organizations, pharmacy benefit managers, or 
 other parties that are, by statute, contract, 
 or agreement, legally responsible for payment 
 of a claim for a health care item or service, 
 as a condition of doing business in the State, 
 to--
 (i) provide, with respect to 
 individuals who are eligible (and, at 
 State option, individuals who apply or 
 whose eligibility for medical 
 assistance is being evaluated in 
 accordance with section 1902(e)(13)(D)) 
 for, or are provided, medical 
 assistance under a State plan (or under 
 a waiver of the plan) under this title 
 and child health assistance under title 
 XXI, upon the request of the State, 
 information to determine during what 
 period the individual or their spouses 
 or their dependents may be (or may have 
 been) covered by a health insurer and 
 the nature of the coverage that is or 
 was provided by the health insurer 
 (including the name, address, and 
 identifying number of the plan) in a 
 manner prescribed by the Secretary;
 (ii)(I) accept the State's right of 
 recovery and the assignment to the 
 State of any right of an individual or 
 other entity to payment from the party 
 for an item or service for which 
 payment has been made under the State 
 plan (or under a waiver of such plan); 
 and
 (II) in the case of a responsible 
 third party (other than the original 
 medicare fee-for-service program under 
 parts A and B of title XVIII, a 
 Medicare Advantage plan offered by a 
 Medicare Advantage organization under 
 part C of such title, a reasonable cost 
 reimbursement plan under section 1876, 
 a health care prepayment plan under 
 section 1833, or a prescription drug 
 plan offered by a PDP sponsor under 
 part D of such title) that requires 
 prior authorization for an item or 
 service furnished to an individual 
 eligible to receive medical assistance 
 under this title, accept authorization 
 provided by the State that the item or 
 service is covered under the State plan 
 (or waiver of such plan) for such 
 individual, as if such authorization 
 were the prior authorization made by 
 the third party for such item or 
 service;
 (iii) not later than 60 days after 
 receiving any inquiry by the State 
 regarding a claim for payment for any 
 health care item or service that is 
 submitted not later than 3 years after 
 the date of the provision of such 
 health care item or service, respond to 
 such inquiry; and
 (iv) agree not to deny a claim 
 submitted by the State solely on the 
 basis of the date of submission of the 
 claim, the type or format of the claim 
 form, a failure to present proper 
 documentation at the point-of-sale that 
 is the basis of the claim, or in the 
 case of a responsible third party 
 (other than the original medicare fee-
 for-service program under parts A and B 
 of title XVIII, a Medicare Advantage 
 plan offered by a Medicare Advantage 
 organization under part C of such 
 title, a reasonable cost reimbursement 
 plan under section 1876, a health care 
 prepayment plan under section 1833, or 
 a prescription drug plan offered by a 
 PDP sponsor under part D of such title) 
 a failure to obtain a prior 
 authorization for the item or service 
 for which the claim is being submitted, 
 if--
 (I) the claim is submitted by 
 the State within the 3-year 
 period beginning on the date on 
 which the item or service was 
 furnished; and
 (II) any action by the State 
 to enforce its rights with 
 respect to such claim is 
 commenced within 6 years of the 
 State's submission of such 
 claim;
 (26) if the State plan includes medical assistance 
 for inpatient mental hospital services, provide, with 
 respect to each patient receiving such services, for a 
 regular program of medical review (including medical 
 evaluation) of his need for such services, and for a 
 written plan of care;
 (27) provide for agreements with every person or 
 institution providing services under the State plan 
 under which such person or institution agrees (A) to 
 keep such records as are necessary fully to disclose 
 the extent of the services provided to individuals 
 receiving assistance under the State plan, and (B) to 
 furnish the State agency or the Secretary with such 
 information, regarding any payments claimed by such 
 person or institution for providing services under the 
 State plan, as the State agency or the Secretary may 
 from time to time request;
 (28) provide--
 (A) that any nursing facility receiving 
 payments under such plan must satisfy all the 
 requirements of subsections (b) through (d) of 
 section 1919 as they apply to such facilities;
 (B) for including in ``nursing facility 
 services'' at least the items and services 
 specified (or deemed to be specified) by the 
 Secretary under section 1919(f)(7) 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 title; and
 (D) for compliance (by the date specified in 
 the respective sections) with the requirements 
 of--
 (i) section 1919(e);
 (ii) section 1919(g) (relating to 
 responsibility for survey and 
 certification of nursing facilities); 
 and
 (iii) sections 1919(h)(2)(B) and 
 1919(h)(2)(D) (relating to 
 establishment and application of 
 remedies);
 (29) include a State program which meets the 
 requirements set forth in section 1908, 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 1903(i)(4)) as may be necessary to safeguard 
 against unnecessary utilization of such care and 
 services and to assure that payments are consistent 
 with efficiency, economy, and quality of care and are 
 sufficient to enlist enough providers so that care and 
 services are available under the plan at least to the 
 extent that such care and services are available to the 
 general population in the geographic area; and
 (B) provide, under the program described in 
 subparagraph (A), that--
 (i) each admission to a hospital, 
 intermediate care facility for the mentally 
 retarded, or hospital for mental diseases is 
 reviewed or screened in accordance with 
 criteria established by medical and other 
 professional personnel who are not themselves 
 directly responsible for the care of the 
 patient involved, and who do not have a 
 significant financial interest in any such 
 institution and are not, except in the case of 
 a hospital, employed by the institution 
 providing the care involved, and
 (ii) the information developed from such 
 review or screening, along with the data 
 obtained from prior reviews of the necessity 
 for admission and continued stay of patients by 
 such professional personnel, shall be used as 
 the basis for establishing the size and 
 composition of the sample of admissions to be 
 subject to review and evaluation by such 
 personnel, and any such sample may be of any 
 size up to 100 percent of all admissions and 
 must be of sufficient size to serve the purpose 
 of (I) identifying the patterns of care being 
 provided and the changes occurring over time in 
 such patterns so that the need for modification 
 may be ascertained, and (II) subjecting 
 admissions to early or more extensive review 
 where information indicates that such 
 consideration is warranted to a hospital, 
 intermediate care facility for the mentally 
 retarded, or hospital for mental diseases;
 (31) with respect to services in an intermediate care 
 facility for the mentally retarded (where the State 
 plan includes medical assistance for such services) 
 provide, with respect to each patient receiving such 
 services, for a written plan of care, prior to 
 admission to or authorization of benefits in such 
 facility, in accordance with regulations of the 
 Secretary, and for a regular program of independent 
 professional review (including medical evaluation) 
 which shall periodically review his need for such 
 services;
 (32) provide that no payment under the plan for any 
 care or service provided to an individual shall be made 
 to anyone other than such individual or the person or 
 institution providing such care or service, under an 
 assignment or power of attorney or otherwise; except 
 that--
 (A) in the case of any care or service 
 provided by a physician, dentist, or other 
 individual practitioner, such payment may be 
 made (i) to the employer of such physician, 
 dentist, or other practitioner if such 
 physician, dentist, or practitioner is required 
 as a condition of his employment to turn over 
 his fee for such care or service to his 
 employer, or (ii) (where the care or service 
 was provided in a hospital, clinic, or other 
 facility) to the facility in which the care or 
 service was provided if there is a contractual 
 arrangement between such physician, dentist, or 
 practitioner and such facility under which such 
 facility submits the bill for such care or 
 service;
 (B) nothing in this paragraph shall be 
 construed (i) to prevent the making of such a 
 payment in accordance with an assignment from 
 the person or institution providing the care or 
 service involved if such assignment is made to 
 a governmental agency or entity or is 
 established by or pursuant to the order of a 
 court of competent jurisdiction, or (ii) to 
 preclude an agent of such person or institution 
 from receiving any such payment if (but only 
 if) such agent does so pursuant to an agency 
 agreement under which the compensation to be 
 paid to the agent for his services for or in 
 connection with the billing or collection of 
 payments due such person or institution under 
 the plan is unrelated (directly or indirectly) 
 to the amount of such payments or the billings 
 therefor, and is not dependent upon the actual 
 collection of any such payment;
 (C) in the case of services furnished (during 
 a period that does not exceed 14 continuous 
 days in the case of an informal reciprocal 
 arrangement or 90 continuous days (or such 
 longer period as the Secretary may provide) in 
 the case of an arrangement involving per diem 
 or other fee-for-time compensation) by, or 
 incident to the services of, one physician to 
 the patients of another physician who submits 
 the claim for such services, payment shall be 
 made to the physician submitting the claim (as 
 if the services were furnished by, or incident 
 to, the physician's services), but only if the 
 claim identifies (in a manner specified by the 
 Secretary) the physician who furnished the 
 services; and
 (D) in the case of payment for a childhood 
 vaccine administered before October 1, 1994, to 
 individuals entitled to medical assistance 
 under the State plan, the State plan may make 
 payment directly to the manufacturer of the 
 vaccine under a voluntary replacement program 
 agreed to by the State pursuant to which the 
 manufacturer (i) supplies doses of the vaccine 
 to providers administering the vaccine, (ii) 
 periodically replaces the supply of the 
 vaccine, and (iii) charges the State the 
 manufacturer's price to the Centers for Disease 
 Control and Prevention for the vaccine so 
 administered (which price includes a reasonable 
 amount to cover shipping and the handling of 
 returns);
 (33) provide--
 (A) that the State health agency, or other 
 appropriate State medical agency, shall be 
 responsible for establishing a plan, consistent 
 with regulations prescribed by the Secretary, 
 for the review by appropriate professional 
 health personnel of the appropriateness and 
 quality of care and services furnished to 
 recipients of medical assistance under the plan 
 in order to provide guidance with respect 
 thereto in the administration of the plan to 
 the State agency established or designated 
 pursuant to paragraph (5) and, where 
 applicable, to the State agency described in 
 the second sentence of this subsection; and
 (B) that, except as provided in section 
 1919(g), the State or local agency utilized by 
 the Secretary for the purpose specified in the 
 first sentence of section 1864(a), 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 title the 
 function of determining whether institutions 
 and agencies meet the requirements for 
 participation in the program under such plan, 
 except that, if the Secretary has cause to 
 question the adequacy of such determinations, 
 the Secretary is authorized to validate State 
 determinations and, on that basis, make 
 independent and binding determinations 
 concerning the extent to which individual 
 institutions and agencies meet the requirements 
 for participation;
 (34) provide that in the case of any individual who 
 has been determined to be eligible for medical 
 assistance under the plan, such assistance will be made 
 available to him for care and services included under 
 the plan and furnished in or after the third month 
 before the month in which he made application (or 
 application was made on his behalf in the case of a 
 deceased individual) for such assistance if such 
 individual was (or upon application would have been) 
 eligible for such assistance at the time such care and 
 services were furnished;
 (35) provide that any disclosing entity (as defined 
 in section 1124(a)(2)) receiving payments under such 
 plan complies with the requirements of section 1124;
 (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 title, and (B) the major additional 
 conditions which the Secretary finds necessary in the 
 interest of health and safety of individuals who are 
 furnished care or services by any such facility, 
 laboratory, clinic, agency, or organization;
 (37) provide for claims payment procedures which (A) 
 ensure that 90 per centum of claims for payment (for 
 which no further written information or substantiation 
 is required in order to make payment) made for services 
 covered under the plan and furnished by health care 
 practitioners through individual or group practices or 
 through shared health facilities are paid within 30 
 days of the date of receipt of such claims and that 99 
 per centum of such claims are paid within 90 days of 
 the date of receipt of such claims, and (B) provide for 
 procedures of prepayment and postpayment claims review, 
 including review of appropriate data with respect to 
 the recipient and provider of a service and the nature 
 of the service for which payment is claimed, to ensure 
 the proper and efficient payment of claims and 
 management of the program;
 (38) require that an entity (other than an individual 
 practitioner or a group of practitioners) that 
 furnishes, or arranges for the furnishing of, items or 
 services under the plan, shall supply (within such 
 period as may be specified in regulations by the 
 Secretary or by the single State agency which 
 administers or supervises the administration of the 
 plan) upon request specifically addressed to such 
 entity by the Secretary or such State agency, the 
 information described in section 1128(b)(9);
 (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 1128 or section 1128A, terminate 
 the participation of any individual or entity in such 
 program if (subject to such exceptions as are permitted 
 with respect to exclusion under sections 1128(c)(3)(B) 
 and 1128(d)(3)(B)) participation of such individual or 
 entity is terminated under title XVIII, any other State 
 plan under this title (or waiver of the plan), or any 
 State child health plan under title XXI (or waiver of 
 the plan) and such termination is included by the 
 Secretary in any database or similar system developed 
 pursuant to section 6401(b)(2) of the Patient 
 Protection and Affordable Care Act, and provide that no 
 payment may be made under the plan with respect to any 
 item or service furnished by such individual or entity 
 during such period;
 (40) require each health services facility or 
 organization which receives payments under the plan and 
 of a type for which a uniform reporting system has been 
 established under section 1121(a) to make reports to 
 the Secretary of information described in such section 
 in accordance with the uniform reporting system 
 (established under such section) for that type of 
 facility or organization;
 (41) provide, in accordance with subsection (kk)(8) 
 (as applicable), that whenever a provider of services 
 or any other person is terminated, suspended, or 
 otherwise sanctioned or prohibited from participating 
 under the State plan, the State agency shall promptly 
 notify the Secretary and, in the case of a physician 
 and notwithstanding paragraph (7), the State medical 
 licensing board of such action;
 (42) provide that--
 (A) the records of any entity participating 
 in the plan and providing services reimbursable 
 on a cost-related basis will be audited as the 
 Secretary determines to be necessary to insure 
 that proper payments are made under the plan; 
 and
 (B) not later than December 31, 2010, the 
 State shall--
 (i) establish a program under which 
 the State contracts (consistent with 
 State law and in the same manner as the 
 Secretary enters into contracts with 
 recovery audit contractors under 
 section 1893(h), subject to such 
 exceptions or requirements as the 
 Secretary may require for purposes of 
 this title or a particular State) with 
 1 or more recovery audit contractors 
 for the purpose of identifying 
 underpayments and overpayments and 
 recouping overpayments under the State 
 plan and under any waiver of the State 
 plan with respect to all services for 
 which payment is made to any entity 
 under such plan or waiver; and
 (ii) provide assurances satisfactory 
 to the Secretary that--
 (I) under such contracts, 
 payment shall be made to such a 
 contractor only from amounts 
 recovered;
 (II) from such amounts 
 recovered, payment--
 (aa) shall be made on 
 a contingent basis for 
 collecting 
 overpayments; and
 (bb) may be made in 
 such amounts as the 
 State may specify for 
 identifying 
 underpayments;
 (III) the State has an 
 adequate process for entities 
 to appeal any adverse 
 determination made by such 
 contractors; and
 (IV) such program is carried 
 out in accordance with such 
 requirements as the Secretary 
 shall specify, including--
 (aa) for purposes of 
 section 1903(a)(7), 
 that amounts expended 
 by the State to carry 
 out the program shall 
 be considered amounts 
 expended as necessary 
 for the proper and 
 efficient 
 administration of the 
 State plan or a waiver 
 of the plan;
 (bb) that section 
 1903(d) shall apply to 
 amounts recovered under 
 the program; and
 (cc) that the State 
 and any such 
 contractors under 
 contract with the State 
 shall coordinate such 
 recovery audit efforts 
 with other contractors 
 or entities performing 
 audits of entities 
 receiving payments 
 under the State plan or 
 waiver in the State, 
 including efforts with 
 Federal and State law 
 enforcement with 
 respect to the 
 Department of Justice, 
 including the Federal 
 Bureau of 
 Investigations, the 
 Inspector General of 
 the Department of 
 Health and Human 
 Services, and the State 
 medicaid fraud control 
 unit; and
 (43) provide for--
 (A) informing all persons in the State who 
 are under the age of 21 and who have been 
 determined to be eligible for medical 
 assistance including services described in 
 section 1905(a)(4)(B), of the availability of 
 early and periodic screening, diagnostic, and 
 treatment services as described in section 
 1905(r) and the need for age-appropriate 
 immunizations against vaccine-preventable 
 diseases,
 (B) providing or arranging for the provision 
 of such screening services in all cases where 
 they are requested,
 (C) arranging for (directly or through 
 referral to appropriate agencies, 
 organizations, or individuals) corrective 
 treatment the need for which is disclosed by 
 such child health screening services, and
 (D) reporting to the Secretary (in a uniform 
 form and manner established by the Secretary, 
 by age group and by basis of eligibility for 
 medical assistance, and by not later than April 
 1 after the end of each fiscal year, beginning 
 with fiscal year 1990) the following 
 information relating to early and periodic 
 screening, diagnostic, and treatment services 
 provided under the plan during each fiscal 
 year:
 (i) the number of children provided 
 child health screening services,
 (ii) the number of children referred 
 for corrective treatment (the need for 
 which is disclosed by such child health 
 screening services),
 (iii) the number of children 
 receiving dental services, and other 
 information relating to the provision 
 of dental services to such children 
 described in section 2108(e) and
 (iv) the State's results in attaining 
 the participation goals set for the 
 State under section 1905(r);
 (44) in each case for which payment for inpatient 
 hospital services, services in an intermediate care 
 facility for the mentally retarded, or inpatient mental 
 hospital services is made under the State plan--
 (A) a physician (or, in the case of skilled 
 nursing facility services or intermediate care 
 facility services, a physician, or a nurse 
 practitioner or clinical nurse specialist who 
 is not an employee of the facility but is 
 working in collaboration with a physician) 
 certifies at the time of admission, or, if 
 later, the time the individual applies for 
 medical assistance under the State plan (and a 
 physician, a physician assistant under the 
 supervision of a physician, or, in the case of 
 skilled nursing facility services or 
 intermediate care facility services, a 
 physician, or a nurse practitioner or clinical 
 nurse specialist who is not an employee of the 
 facility but is working in collaboration with a 
 physician, recertifies, where such services are 
 furnished over a period of time, in such cases, 
 at least as often as required under section 
 1903(g)(6) (or, in the case of services that 
 are services provided in an intermediate care 
 facility for the mentally retarded, every 
 year), and accompanied by such supporting 
 material, appropriate to the case involved, as 
 may be provided in regulations of the 
 Secretary), that such services are or were 
 required to be given on an inpatient basis 
 because the individual needs or needed such 
 services, and
 (B) such services were furnished under a plan 
 established and periodically reviewed and 
 evaluated by a physician, or, in the case of 
 skilled nursing facility services or 
 intermediate care facility services, a 
 physician, or a nurse practitioner or clinical 
 nurse specialist who is not an employee of the 
 facility but is working in collaboration with a 
 physician;
 (45) provide for mandatory assignment of rights of 
 payment for medical support and other medical care owed 
 to recipients, in accordance with section 1912;
 (46)(A) provide that information is requested and 
 exchanged for purposes of income and eligibility 
 verification in accordance with a State system which 
 meets the requirements of section 1137 of this Act; and
 (B) provide, with respect to an individual declaring 
 to be a citizen or national of the United States for 
 purposes of establishing eligibility under this title, 
 that the State shall satisfy the requirements of--
 (i) section 1903(x); or
 (ii) subsection (ee);
 (47) provide--
 (A) at the option of the State, for making 
 ambulatory prenatal care available to pregnant 
 women during a presumptive eligibility period 
 in accordance with section 1920 and provide for 
 making medical assistance for items and 
 services described in subsection (a) of section 
 1920A available to children during a 
 presumptive eligibility period in accordance 
 with such section and provide for making 
 medical assistance available to individuals 
 described in subsection (a) of section 1920B 
 during a presumptive eligibility period in 
 accordance with such section and provide for 
 making medical assistance available to 
 individuals described in subsection (a) of 
 section 1920C during a presumptive eligibility 
 period in accordance with such section; and
 (B) that any hospital that is a participating 
 provider under the State plan may elect to be a 
 qualified entity for purposes of determining, 
 on the basis of preliminary information, 
 whether any individual is eligible for medical 
 assistance under the State plan or under a 
 waiver of the plan for purposes of providing 
 the individual with medical assistance during a 
 presumptive eligibility period, in the same 
 manner, and subject to the same requirements, 
 as apply to the State options with respect to 
 populations described in section 1920, 1920A, 
 1920B, or 1920C (but without regard to whether 
 the State has elected to provide for a 
 presumptive eligibility period under any such 
 sections), subject to such guidance as the 
 Secretary shall establish;
 (48) provide a method of making cards evidencing 
 eligibility for medical assistance available to an 
 eligible individual who does not reside in a permanent 
 dwelling or does not have a fixed home or mailing 
 address;
 (49) provide that the State will provide information 
 and access to certain information respecting sanctions 
 taken against health care practitioners and providers 
 by State licensing authorities in accordance with 
 section 1921;
 (50) provide, in accordance with subsection (q), for 
 a monthly personal needs allowance for certain 
 institutionalized individuals and couples;
 (51) meet the requirements of section 1924 (relating 
 to protection of community spouses);
 (52) meet the requirements of section 1925 (relating 
 to extension of eligibility for medical assistance);
 (53) provide--
 (A) for notifying in a timely manner all 
 individuals in the State who are determined to 
 be eligible for medical assistance and who are 
 pregnant women, breastfeeding or postpartum 
 women (as defined in section 17 of the Child 
 Nutrition Act of 1966), or children below the 
 age of 5, of the availability of benefits 
 furnished by the special supplemental nutrition 
 program under such section, and
 (B) for referring any such individual to the 
 State agency responsible for administering such 
 program;
 (54) in the case of a State plan that provides 
 medical assistance for covered outpatient drugs (as 
 defined in section 1927(k)), comply with the applicable 
 requirements of section 1927;
 (55) provide for receipt and initial processing of 
 applications of individuals for medical assistance 
 under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), 
 (a)(10)(A)(i)(VII), (a)(10)(A)(ii)(IX), or 
 (a)(10)(A)(ii)(XXIII)--
 (A) at locations which are other than those 
 used for the receipt and processing of 
 applications for aid under part A of title IV 
 and which include facilities defined as 
 disproportionate share hospitals under section 
 1923(a)(1)(A) and Federally-qualified health 
 centers described in section 1905(1)(2)(B), and
 (B) using applications which are other than 
 those used for applications for aid under such 
 part;
 (56) provide, in accordance with subsection (s), for 
 adjusted payments for certain inpatient hospital 
 services;
 (57) provide that each hospital, nursing facility, 
 provider of home health care or personal care services, 
 hospice program, or medicaid managed care organization 
 (as defined in section 1903(m)(1)(A)) receiving funds 
 under the plan shall comply with the requirements of 
 subsection (w);
 (58) provide that the State, acting through a State 
 agency, association, or other private nonprofit entity, 
 develop a written description of the law of the State 
 (whether statutory or as recognized by the courts of 
 the State) concerning advance directives that would be 
 distributed by providers or organizations under the 
 requirements of subsection (w);
 (59) maintain a list (updated not less often than 
 monthly, and containing each physician's unique 
 identifier provided under the system established under 
 subsection (x)) of all physicians who are certified to 
 participate under the State plan;
 (60) provide that the State agency shall provide 
 assurances satisfactory to the Secretary that the State 
 has in effect the laws relating to medical child 
 support required under section 1908A;
 (61) provide that the State must demonstrate that it 
 operates a medicaid fraud and abuse control unit 
 described in section 1903(q) that effectively carries 
 out the functions and requirements described in such 
 section, as determined in accordance with standards 
 established by the Secretary, unless the State 
 demonstrates to the satisfaction of the Secretary that 
 the effective operation of such a unit in the State 
 would not be cost-effective because minimal fraud 
 exists in connection with the provision of covered 
 services to eligible individuals under the State plan, 
 and that beneficiaries under the plan will be protected 
 from abuse and neglect in connection with the provision 
 of medical assistance under the plan without the 
 existence of such a unit;
 (62) provide for a program for the distribution of 
 pediatric vaccines to program-registered providers for 
 the immunization of vaccine-eligible children in 
 accordance with section 1928;
 (63) provide for administration and determinations of 
 eligibility with respect to individuals who are (or 
 seek to be) eligible for medical assistance based on 
 the application of section 1931;
 (64) provide, not later than 1 year after the date of 
 the enactment of this paragraph, a mechanism to receive 
 reports from beneficiaries and others and compile data 
 concerning alleged instances of waste, fraud, and abuse 
 relating to the operation of this title;
 (65) provide that the State shall issue provider 
 numbers for all suppliers of medical assistance 
 consisting of durable medical equipment, as defined in 
 section 1861(n), and the State shall not issue or renew 
 such a supplier number for any such supplier unless--
 (A)(i) full and complete information as to 
 the identity of each person with an ownership 
 or control interest (as defined in section 
 1124(a)(3)) in the supplier or in any 
 subcontractor (as defined by the Secretary in 
 regulations) in which the supplier directly or 
 indirectly has a 5 percent or more ownership 
 interest; and
 (ii) to the extent determined to be feasible 
 under regulations of the Secretary, the name of 
 any disclosing entity (as defined in section 
 1124(a)(2)) with respect to which a person with 
 such an ownership or control interest in the 
 supplier is a person with such an ownership or 
 control interest in the disclosing entity; and
 (B) a surety bond in a form specified by the 
 Secretary under section 1834(a)(16)(B) and in 
 an amount that is not less than $50,000 or such 
 comparable surety bond as the Secretary may 
 permit under the second sentence of such 
 section;
 (66) provide for making eligibility determinations 
 under section 1935(a);
 (67) provide, with respect to services covered under 
 the State plan (but not under title XVIII) that are 
 furnished to a PACE program eligible individual 
 enrolled with a PACE provider by a provider 
 participating under the State plan that does not have a 
 contract or other agreement with the PACE provider that 
 establishes payment amounts for such services, that 
 such participating provider may not require the PACE 
 provider to pay the participating provider an amount 
 greater than the amount that would otherwise be payable 
 for the service to the participating provider under the 
 State plan for the State where the PACE provider is 
 located (in accordance with regulations issued by the 
 Secretary);
 (68) provide that any entity that receives or makes 
 annual payments under the State plan of at least 
 $5,000,000, as a condition of receiving such payments, 
 shall--
 (A) establish written policies for all 
 employees of the entity (including management), 
 and of any contractor or agent of the entity, 
 that provide detailed information about the 
 False Claims Act established under sections 
 3729 through 3733 of title 31, United States 
 Code, administrative remedies for false claims 
 and statements established under chapter 38 of 
 title 31, United States Code, any State laws 
 pertaining to civil or criminal penalties for 
 false claims and statements, and whistleblower 
 protections under such laws, with respect to 
 the role of such laws in preventing and 
 detecting fraud, waste, and abuse in Federal 
 health care programs (as defined in section 
 1128B(f));
 (B) include as part of such written policies, 
 detailed provisions regarding the entity's 
 policies and procedures for detecting and 
 preventing fraud, waste, and abuse; and
 (C) include in any employee handbook for the 
 entity, a specific discussion of the laws 
 described in subparagraph (A), the rights of 
 employees to be protected as whistleblowers, 
 and the entity's policies and procedures for 
 detecting and preventing fraud, waste, and 
 abuse;
 (69) provide that the State must comply with any 
 requirements determined by the Secretary to be 
 necessary for carrying out the Medicaid Integrity 
 Program established under section 1936;
 (70) at the option of the State and notwithstanding 
 paragraphs (1), (10)(B), and (23), provide for the 
 establishment of a non-emergency medical transportation 
 brokerage program in order to more cost-effectively 
 provide transportation for individuals eligible for 
 medical assistance under the State plan who need access 
 to medical care or services and have no other means of 
 transportation which--
 (A) may include a wheelchair van, taxi, 
 stretcher car, bus passes and tickets, secured 
 transportation, and such other transportation 
 as the Secretary determines appropriate; and
 (B) may be conducted under contract with a 
 broker who--
 (i) is selected through a competitive 
 bidding process based on the State's 
 evaluation of the broker's experience, 
 performance, references, resources, 
 qualifications, and costs;
 (ii) has oversight procedures to 
 monitor beneficiary access and 
 complaints and ensure that transport 
 personnel are licensed, qualified, 
 competent, and courteous;
 (iii) is subject to regular auditing 
 and oversight by the State in order to 
 ensure the quality of the 
 transportation services provided and 
 the adequacy of beneficiary access to 
 medical care and services; and
 (iv) complies with such requirements 
 related to prohibitions on referrals 
 and conflict of interest as the 
 Secretary shall establish (based on the 
 prohibitions on physician referrals 
 under section 1877 and such other 
 prohibitions and requirements as the 
 Secretary determines to be 
 appropriate);
 (71) provide that the State will implement an asset 
 verification program as required under section 1940;
 (72) provide that the State will not prevent a 
 Federally-qualified health center from entering into 
 contractual relationships with private practice dental 
 providers in the provision of Federally-qualified 
 health center services;
 (73) in the case of any State in which 1 or more 
 Indian Health Programs or Urban Indian Organizations 
 furnishes health care services, provide for a process 
 under which the State seeks advice on a regular, 
 ongoing basis from designees of such Indian Health 
 Programs and Urban Indian Organizations on matters 
 relating to the application of this title that are 
 likely to have a direct effect on such Indian Health 
 Programs and Urban Indian Organizations and that--
 (A) shall include solicitation of advice 
 prior to submission of any plan amendments, 
 waiver requests, and proposals for 
 demonstration projects likely to have a direct 
 effect on Indians, Indian Health Programs, or 
 Urban Indian Organizations; and
 (B) may include appointment of an advisory 
 committee and of a designee of such Indian 
 Health Programs and Urban Indian Organizations 
 to the medical care advisory committee advising 
 the State on its State plan under this title;
 (74) provide for maintenance of effort under the 
 State plan or under any waiver of the plan in 
 accordance with subsection (gg); and
 (75) provide that, beginning January 2015, and 
 annually thereafter, the State shall submit a report to 
 the Secretary that contains--
 (A) the total number of enrolled and newly 
 enrolled individuals in the State plan or under 
 a waiver of the plan for the fiscal year ending 
 on September 30 of the preceding calendar year, 
 disaggregated by population, including 
 children, parents, nonpregnant childless 
 adults, disabled individuals, elderly 
 individuals, and such other categories or sub-
 categories of individuals eligible for medical 
 assistance under the State plan or under a 
 waiver of the plan as the Secretary may 
 require;
 (B) a description, which may be specified by 
 population, of the outreach and enrollment 
 processes used by the State during such fiscal 
 year; and
 (C) any other data reporting determined 
 necessary by the Secretary to monitor 
 enrollment and retention of individuals 
 eligible for medical assistance under the State 
 plan or under a waiver of the plan;
 (76) provide that any data collected under the State 
 plan meets the requirements of section 3101 of the 
 Public Health Service Act;
 (77) provide that the State shall comply with 
 provider and supplier screening, oversight, and 
 reporting requirements in accordance with subsection 
 (kk);
 (78) provide that, not later than January 1, 2017, in 
 the case of a State that pursuant to its State plan or 
 waiver of the plan for medical assistance pays for 
 medical assistance on a fee-for-service basis, the 
 State shall require each provider furnishing items and 
 services to, or ordering, prescribing, referring, or 
 certifying eligibility for, services for individuals 
 eligible to receive medical assistance under such plan 
 to enroll with the State agency and provide to the 
 State agency the provider's identifying information, 
 including the name, specialty, date of birth, Social 
 Security number, national provider identifier (if 
 applicable), Federal taxpayer identification number, 
 and the State license or certification number of the 
 provider (if applicable);
 (79) provide that any agent, clearinghouse, or other 
 alternate payee (as defined by the Secretary) that 
 submits claims on behalf of a health care provider must 
 register with the State and the Secretary in a form and 
 manner specified by the Secretary;
 (80) provide that the State shall not provide any 
 payments for items or services provided under the State 
 plan or under a waiver to any financial institution or 
 entity located outside of the United States;
 (81) provide for implementation of the payment models 
 specified by the Secretary under section 1115A(c) for 
 implementation on a nationwide basis unless the State 
 demonstrates to the satisfaction of the Secretary that 
 implementation would not be administratively feasible 
 or appropriate to the health care delivery system of 
 the State;
 (82) provide that the State agency responsible for 
 administering the State plan under this title provides 
 assurances to the Secretary that the State agency is in 
 compliance with subparagraphs (A), (B), and (C) of 
 section 1128K(b)(2);
 (83) provide that, not later than January 1, 2017, in 
 the case of a State plan (or waiver of the plan) that 
 provides medical assistance on a fee-for-service basis 
 or through a primary care case-management system 
 described in section 1915(b)(1) (other than a primary 
 care case management entity (as defined by the 
 Secretary)), the State shall publish (and update on at 
 least an annual basis) on the public website of the 
 State agency administering the State plan, a directory 
 of the physicians described in subsection (mm) and, at 
 State option, other providers described in such 
 subsection that--
 (A) includes--
 (i) with respect to each such 
 physician or provider--
 (I) the name of the physician 
 or provider;
 (II) the specialty of the 
 physician or provider;
 (III) the address at which 
 the physician or provider 
 provides services; and
 (IV) the telephone number of 
 the physician or provider; and
 (ii) with respect to any such 
 physician or provider participating in 
 such a primary care case-management 
 system, information regarding--
 (I) whether the physician or 
 provider is accepting as new 
 patients individuals who 
 receive medical assistance 
 under this title; and
 (II) the physician's or 
 provider's cultural and 
 linguistic capabilities, 
 including the languages spoken 
 by the physician or provider or 
 by the skilled medical 
 interpreter providing 
 interpretation services at the 
 physician's or provider's 
 office; and
 (B) may include, at State option, with 
 respect to each such physician or provider--
 (i) the Internet website of such 
 physician or provider; or
 (ii) whether the physician or 
 provider is accepting as new patients 
 individuals who receive medical 
 assistance under this title;
 (84) provide that--
 (A) the State shall not terminate eligibility 
 for medical assistance under the State plan (or 
 waiver of such plan) for an individual who is 
 an eligible juvenile (as defined in subsection 
 (nn)(2)) because the juvenile is an inmate of a 
 public institution (as defined in subsection 
 (nn)(3)), but, subject to subparagraph (D), may 
 suspend coverage during the period the juvenile 
 is such an inmate;
 (B) in the case of an individual who is an 
 eligible juvenile described in paragraph (2)(A) 
 of subsection (nn), the State shall, prior to 
 the individual's release from such a public 
 institution, conduct a redetermination of 
 eligibility for such individual with respect to 
 such medical assistance (without requiring a 
 new application from the individual) and, if 
 the State determines pursuant to such 
 redetermination that the individual continues 
 to meet the eligibility requirements for such 
 medical assistance, the State shall restore 
 coverage for such medical assistance to such an 
 individual upon the individual's release from 
 such public institution;
 (C) in the case of an individual who is an 
 eligible juvenile described in paragraph (2)(B) 
 of subsection (nn), the State shall process any 
 application for medical assistance submitted 
 by, or on behalf of, such individual such that 
 the State makes a determination of eligibility 
 for such individual with respect to such 
 medical assistance upon release of such 
 individual from such public institution; and
 (D) in the case of an individual who is an 
 eligible juvenile described in subsection 
 (nn)(2) and is within 30 days of the date on 
 which such eligible juvenile is scheduled to be 
 released from a public institution following 
 adjudication, the State shall have in place a 
 plan, and in accordance with such plan, provide 
 for--
 (i) in the 30 days prior to the 
 release of such eligible juvenile from 
 such public institution (or not later 
 than one week, or as soon as 
 practicable, after release from the 
 public institution), and in 
 coordination with such institution, any 
 screening or diagnostic service which 
 meets reasonable standards of medical 
 and dental practice, as determined by 
 the State, or as indicated as medically 
 necessary, in accordance with 
 paragraphs (1)(A) and (5) of section 
 1905(r), including a behavioral health 
 screening or diagnostic service; and
 (ii) in the 30 days prior to the 
 release of such eligible juvenile from 
 such public institution, and for at 
 least 30 days following the release of 
 such eligible juvenile from such 
 institution, targeted case management 
 services, including referrals for such 
 eligible juvenile to the appropriate 
 care and services available in the 
 geographic region of the home or 
 residence of such eligible juvenile 
 (where feasible) under the State plan 
 (or waiver of such plan);
 (85) provide that the State is in compliance with the 
 drug review and utilization requirements under 
 subsection (oo)(1);
 (86) provide, at the option of the State, for making 
 medical assistance available on an inpatient or 
 outpatient basis at a residential pediatric recovery 
 center (as defined in subsection (pp)) to infants with 
 neonatal abstinence syndrome[; and];
 (87) provide for a mechanism, which may include 
 attestation, that ensures that, with respect to any 
 provider (including a transportation network company) 
 or individual driver of nonemergency transportation to 
 medically necessary services receiving payments under 
 such plan (but excluding any public transit authority), 
 at a minimum--
 (A) each such provider and individual driver 
 is not excluded from participation in any 
 Federal health care program (as defined in 
 section 1128B(f)) and is not listed on the 
 exclusion list of the Inspector General of the 
 Department of Health and Human Services;
 (B) each such individual driver has a valid 
 driver's license;
 (C) each such provider has in place a process 
 to address any violation of a State drug law; 
 and
 (D) each such provider has in place a process 
 to disclose to the State Medicaid program the 
 driving history, including any traffic 
 violations, of each such individual driver 
 employed by such provider, including any 
 traffic violations[.]; and
 (88) provide that the State shall comply with the 
 eligibility verification requirements under subsection 
 (uu), except that this paragraph shall apply only in 
 the case of the 50 States and the District of Columbia.
Notwithstanding paragraph (5), if on January 1, 1965, and on 
the date on which a State submits its plan for approval under 
this title, the State agency which administered or supervised 
the administration of the plan of such State approved under 
title X (or title XVI, 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 
title I (or title XVI, insofar as it relates to the aged), the 
State agency which administered or supervised the 
administration of such plan approved under title X (or title 
XVI, 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 title (except 
for purposes of paragraph (10)). The provisions of paragraphs 
(9)(A), (31), and (33) and of section 1903(i)(4) shall not 
apply to a religious nonmedical health care institution (as 
defined in section 1861(ss)(1)).
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 plan approved under title I, X, XIV, 
or XVI, or part A of title IV and who for such month was 
entitled to monthly insurance benefits under title II shall for 
purposes of this title 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 title II 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 may be waived by the Secretary if he finds that 
the State has exercised good faith in trying to meet such 
requirement. For purposes of this title, any child who meets 
the requirements of paragraph (1) or (2) of section 473(b) 
shall be deemed to be a dependent child as defined in section 
406 and shall be deemed to be a recipient of aid to families 
with dependent children under part A of title IV in the 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 1903(v).
 (b) 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) Notwithstanding subsection (b), the Secretary shall not 
approve any State plan for medical assistance if the State 
requires individuals described in subsection (l)(1) to apply 
for assistance under the State program funded under part A of 
title IV as a condition of applying for or receiving medical 
assistance under this title.
 (d) If a State contracts with an entity which meets the 
requirements of section 1152, as determined by the Secretary, 
or a utilization and quality control peer review organization 
having a contract with the Secretary under part B of title XI 
for the performance of medical or utilization review functions 
(including quality review functions described in subsection 
(a)(30)(C)) required under this title of a State plan with 
respect to specific services or providers (or services or 
providers in a geographic area of the State), such requirements 
shall be deemed to be met for those services or providers (or 
services or providers in that area) by delegation to such an 
entity or organization under the contract of the State's 
authority to conduct such review activities if the contract 
provides for the performance of activities not inconsistent 
with part B of title XI and provides for such assurances of 
satisfactory performance by such an entity or organization as 
the Secretary may prescribe.
 (e)(1) Beginning April 1, 1990, for provisions relating to 
the extension of eligibility for medical assistance for certain 
families who have received aid pursuant to a State plan 
approved under part A of title IV and have earned income, see 
section 1925.
 (2)(A) In the case of an individual who is enrolled with a 
medicaid managed care organization (as defined in section 
1903(m)(1)(A)), with a primary care case manager (as defined in 
section 1905(t)), or with an eligible organization with a 
contract under section 1876 and who would (but for this 
paragraph) lose eligibility for benefits under this title 
before the end of the minimum enrollment period (defined in 
subparagraph (B)), the State plan may provide, notwithstanding 
any other provision of this title, 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 1905(a)(4)(C), only with respect to such benefits 
provided to the individual as an enrollee of such organization 
or entity or by or through the case manager.
 (B) For purposes of subparagraph (A), the term ``minimum 
enrollment period'' means, with respect to an individual's 
enrollment with an organization or entity under a State plan, a 
period, established by the State, of not more than six months 
beginning on the date the individual's enrollment with the 
organization or entity becomes effective.
 (3) At the option of the State, any individual who--
 (A) is 18 years of age or younger and qualifies as a 
 disabled individual under section 1614(a);
 (B) with respect to whom there has been a 
 determination by the State that--
 (i) the individual requires a level of care 
 provided in a hospital, nursing facility, or 
 intermediate care facility for the mentally 
 retarded,
 (ii) it is appropriate to provide such care 
 for the individual outside such an institution, 
 and
 (iii) the estimated amount which would be 
 expended for medical assistance for the 
 individual for such care outside an institution 
 is not greater than the estimated amount which 
 would otherwise be expended for medical 
 assistance for the individual within an 
 appropriate institution; and
 (C) if the individual were in a medical institution, 
 would be eligible for medical assistance under the 
 State plan under this title,
 shall be deemed, for purposes of this title only, to be 
 an individual with respect to whom a supplemental 
 security income payment, or State supplemental payment, 
 respectively, is being paid under title XVI.
 (4) A child born to a woman eligible for and receiving 
medical assistance under a State plan on the date of the 
child's birth shall be deemed to have applied for medical 
assistance and to have been found eligible for such assistance 
under such plan on the date of such birth and to remain 
eligible for such assistance for a period of one year. During 
the period in which a child is deemed under the preceding 
sentence to be eligible for medical assistance, the medical 
assistance eligibility identification number of the mother 
shall also serve as the identification number of the child, and 
all claims shall be submitted and paid under such number 
(unless the State issues a separate identification number for 
the child before such period expires). Notwithstanding the 
preceding sentence, in the case of a child who is born in the 
United States to an alien mother for whom medical assistance 
for the delivery of the child is made available pursuant to 
section 1903(v), the State immediately shall issue a separate 
identification number for the child upon notification by the 
facility at which such delivery occurred of the child's birth.
 (5) A woman who, while pregnant, is eligible for, has applied 
for, and has received medical assistance under the State plan, 
shall continue to be eligible under the plan, as though she 
were pregnant, for all pregnancy-related and postpartum medical 
assistance under the plan, through the end of the month in 
which the 60-day period (beginning on the last day of her 
pregnancy) ends.
 (6) In the case of a pregnant woman described in subsection 
(a)(10) who, because of a change in income of the family of 
which she is a member, would not otherwise continue to be 
described in such subsection, the woman shall be deemed to 
continue to be an individual described in subsection 
(a)(10)(A)(i)(IV) and subsection (l)(1)(A) without regard to 
such change of income through the end of the month in which the 
60-day period (beginning on the last day of her pregnancy) 
ends. The preceding sentence shall not apply in the case of a 
woman who has been provided ambulatory prenatal care pursuant 
to section 1920 during a presumptive eligibility period and is 
then, in accordance with such section, determined to be 
ineligible for medical assistance under the State plan.
 (7) In the case of an infant or child described in 
subparagraph (B), (C), or (D) of subsection (l)(1) or paragraph 
(2) of section 1905(n)--
 (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 1905(p)(1)), 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 1903(a), such 
determination shall be considered to be valid for an individual 
for a period of 12 months, except that a State may provide for 
such determinations more frequently, but not more frequently 
than once every 6 months for an individual.
 (9)(A) At the option of the State, the plan may include as 
medical assistance respiratory care services for any individual 
who--
 (i) is medically dependent on a ventilator for life 
 support at least six hours per day;
 (ii) has been so dependent for at least 30 
 consecutive days (or the maximum number of days 
 authorized under the State plan, whichever is less) as 
 an inpatient;
 (iii) but for the availability of respiratory care 
 services, would require respiratory care as an 
 inpatient in a hospital, nursing facility, or 
 intermediate care facility for the mentally retarded 
 and would be eligible to have payment made for such 
 inpatient care under the State plan;
 (iv) has adequate social support services to be cared 
 for at home; and
 (v) wishes to be cared for at home.
 (B) The requirements of subparagraph (A)(ii) may be satisfied 
by a continuous stay in one or more hospitals, nursing 
facilities, or intermediate care facilities for the mentally 
retarded.
 (C) For purposes of this paragraph, respiratory care services 
means services provided on a part-time basis in the home of the 
individual by a respiratory therapist or other health care 
professional trained in respiratory therapy (as determined by 
the State), payment for which is not otherwise included within 
other items and services furnished to such individual as 
medical assistance under the plan.
 (10)(A) The fact that an individual, child, or pregnant woman 
may be denied aid under part A of title IV pursuant to section 
402(a)(43) shall not be construed as denying (or permitting a 
State to deny) medical assistance under this title to such 
individual, child, or woman who is eligible for assistance 
under this title 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 title IV and such aid is terminated 
pursuant to section 402(a)(43), the State may not discontinue 
medical assistance under this title for the individual, child, 
or woman until the State has determined that the individual, 
child, or woman is not eligible for assistance under this title 
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 1906 and who would (but for 
this paragraph) lose eligibility for benefits under this title 
before the end of the minimum enrollment period (defined in 
subparagraph (B)), the State plan may provide, notwithstanding 
any other provision of this title, that the individual shall be 
deemed to continue to be eligible for such benefits until the 
end of such minimum period, but only with respect to such 
benefits provided to the individual as an enrollee of such 
plan.
 (B) For purposes of subparagraph (A), the term ``minimum 
enrollment period'' means, with respect to an individual's 
enrollment with a group health plan, a period established by 
the State, of not more than 6 months beginning on the date the 
individual's enrollment under the plan becomes effective.
 (12) 1 year of continuous eligibility for children.--
 The State plan (or waiver of such State plan) shall 
 provide that an individual who is under the age of 19 
 and who is determined to be eligible for benefits under 
 a State plan (or waiver of such plan) approved under 
 this title under subsection (a)(10)(A) shall remain 
 eligible for such benefits until the earlier of--
 (A) the end of the 12-month period beginning 
 on the date of such determination;
 (B) the time that such individual attains the 
 age of 19; or
 (C) the date that such individual ceases to 
 be a resident of such State.
 (13) Express Lane Option.--
 (A) In general.--
 (i) Option to use a finding from an express 
 lane agency.--At the option of the State, the 
 State plan may provide that in determining 
 eligibility under this title for a child (as 
 defined in subparagraph (G)), the State may 
 rely on a finding made within a reasonable 
 period (as determined by the State) from an 
 Express Lane agency (as defined in subparagraph 
 (F)) when it determines whether a child 
 satisfies one or more components of eligibility 
 for medical assistance under this title. The 
 State may rely on a finding from an Express 
 Lane agency notwithstanding sections 
 1902(a)(46)(B) and 1137(d) or any differences 
 in budget unit, disregard, deeming or other 
 methodology, if the following requirements are 
 met:
 (I) Prohibition on determining 
 children ineligible for coverage.--If a 
 finding from an Express Lane agency 
 would result in a determination that a 
 child does not satisfy an eligibility 
 requirement for medical assistance 
 under this title and for child health 
 assistance under title XXI, the State 
 shall determine eligibility for 
 assistance using its regular 
 procedures.
 (II) Notice requirement.--For any 
 child who is found eligible for medical 
 assistance under the State plan under 
 this title or child health assistance 
 under title XXI and who is subject to 
 premiums based on an Express Lane 
 agency's finding of such child's income 
 level, the State shall provide notice 
 that the child may qualify for lower 
 premium payments if evaluated by the 
 State using its regular policies and of 
 the procedures for requesting such an 
 evaluation.
 (III) Compliance with screen and 
 enroll requirement.--The State shall 
 satisfy the requirements under 
 subparagraphs (A) and (B) of section 
 2102(b)(3) (relating to screen and 
 enroll) before enrolling a child in 
 child health assistance under title 
 XXI. At its option, the State may 
 fulfill such requirements in accordance 
 with either option provided under 
 subparagraph (C) of this paragraph.
 (IV) Verification of citizenship or 
 nationality status.--The State shall 
 satisfy the requirements of section 
 1902(a)(46)(B) or 2105(c)(9), as 
 applicable for verifications of 
 citizenship or nationality status.
 (V) Coding.--The State meets the 
 requirements of subparagraph (E).
 (ii) Option to apply to renewals and 
 redeterminations.--The State may apply the 
 provisions of this paragraph when conducting 
 initial determinations of eligibility, 
 redeterminations of eligibility, or both, as 
 described in the State plan.
 (B) Rules of construction.--Nothing in this paragraph 
 shall be construed--
 (i) to limit or prohibit a State from taking 
 any actions otherwise permitted under this 
 title or title XXI in determining eligibility 
 for or enrolling children into medical 
 assistance under this title or child health 
 assistance under title XXI; or
 (ii) to modify the limitations in section 
 1902(a)(5) concerning the agencies that may 
 make a determination of eligibility for medical 
 assistance under this title.
 (C) Options for satisfying the screen and enroll 
 requirement.--
 (i) In general.--With respect to a child 
 whose eligibility for medical assistance under 
 this title or for child health assistance under 
 title XXI has been evaluated by a State agency 
 using an income finding from an Express Lane 
 agency, a State may carry out its duties under 
 subparagraphs (A) and (B) of section 2102(b)(3) 
 (relating to screen and enroll) in accordance 
 with either clause (ii) or clause (iii).
 (ii) Establishing a screening threshold.--
 (I) In general.--Under this clause, 
 the State establishes a screening 
 threshold set as a percentage of the 
 Federal poverty level that exceeds the 
 highest income threshold applicable 
 under this title to the child by a 
 minimum of 30 percentage points or, at 
 State option, a higher number of 
 percentage points that reflects the 
 value (as determined by the State and 
 described in the State plan) of any 
 differences between income 
 methodologies used by the program 
 administered by the Express Lane agency 
 and the methodologies used by the State 
 in determining eligibility for medical 
 assistance under this title.
 (II) Children with income not above 
 threshold.--If the income of a child 
 does not exceed the screening 
 threshold, the child is deemed to 
 satisfy the income eligibility criteria 
 for medical assistance under this title 
 regardless of whether such child would 
 otherwise satisfy such criteria.
 (III) Children with income above 
 threshold.--If the income of a child 
 exceeds the screening threshold, the 
 child shall be considered to have an 
 income above the Medicaid applicable 
 income level described in section 
 2110(b)(4) and to satisfy the 
 requirement under section 2110(b)(1)(C) 
 (relating to the requirement that CHIP 
 matching funds be used only for 
 children not eligible for Medicaid). If 
 such a child is enrolled in child 
 health assistance under title XXI, the 
 State shall provide the parent, 
 guardian, or custodial relative with 
 the following:
 (aa) Notice that the child 
 may be eligible to receive 
 medical assistance under the 
 State plan under this title if 
 evaluated for such assistance 
 under the State's regular 
 procedures and notice of the 
 process through which a parent, 
 guardian, or custodial relative 
 can request that the State 
 evaluate the child's 
 eligibility for medical 
 assistance under this title 
 using such regular procedures.
 (bb) A description of 
 differences between the medical 
 assistance provided under this 
 title and child health 
 assistance under title XXI, 
 including differences in cost-
 sharing requirements and 
 covered benefits.
 (iii) Temporary enrollment in chip pending 
 screen and enroll.--
 (I) In general.--Under this clause, a 
 State enrolls a child in child health 
 assistance under title XXI for a 
 temporary period if the child appears 
 eligible for such assistance based on 
 an income finding by an Express Lane 
 agency.
 (II) Determination of eligibility.--
 During such temporary enrollment 
 period, the State shall determine the 
 child's eligibility for child health 
 assistance under title XXI or for 
 medical assistance under this title in 
 accordance with this clause.
 (III) Prompt follow up.--In making 
 such a determination, the State shall 
 take prompt action to determine whether 
 the child should be enrolled in medical 
 assistance under this title or child 
 health assistance under title XXI 
 pursuant to subparagraphs (A) and (B) 
 of section 2102(b)(3) (relating to 
 screen and enroll).
 (IV) Requirement for simplified 
 determination.--In making such a 
 determination, the State shall use 
 procedures that, to the maximum 
 feasible extent, reduce the burden 
 imposed on the individual of such 
 determination. Such procedures may not 
 require the child's parent, guardian, 
 or custodial relative to provide or 
 verify information that already has 
 been provided to the State agency by an 
 Express Lane agency or another source 
 of information unless the State agency 
 has reason to believe the information 
 is erroneous.
 (V) Availability of chip matching 
 funds during temporary enrollment 
 period.--Medical assistance for items 
 and services that are provided to a 
 child enrolled in title XXI during a 
 temporary enrollment period under this 
 clause shall be treated as child health 
 assistance under such title.
 (D) Option for automatic enrollment.--
 (i) In general.--The State may initiate and 
 determine eligibility for medical assistance 
 under the State Medicaid plan or for child 
 health assistance under the State CHIP plan 
 without a program application from, or on 
 behalf of, the child based on data obtained 
 from sources other than the child (or the 
 child's family), but a child can only be 
 automatically enrolled in the State Medicaid 
 plan or the State CHIP plan if the child or the 
 family affirmatively consents to being enrolled 
 through affirmation in writing, by telephone, 
 orally, through electronic signature, or 
 through any other means specified by the 
 Secretary or by signature on an Express Lane 
 agency application, if the requirement of 
 clause (ii) is met.
 (ii) Information requirement.--The 
 requirement of this clause is that the State 
 informs the parent, guardian, or custodial 
 relative of the child of the services that will 
 be covered, appropriate methods for using such 
 services, premium or other cost sharing charges 
 (if any) that apply, medical support 
 obligations (under section 1912(a)) created by 
 enrollment (if applicable), and the actions the 
 parent, guardian, or relative must take to 
 maintain enrollment and renew coverage.
 (E) Coding; application to enrollment error rates.--
 (i) In general.--For purposes of subparagraph 
 (A)(iv), the requirement of this subparagraph 
 for a State is that the State agrees to--
 (I) assign such codes as the 
 Secretary shall require to the children 
 who are enrolled in the State Medicaid 
 plan or the State CHIP plan through 
 reliance on a finding made by an 
 Express Lane agency for the duration of 
 the State's election under this 
 paragraph;
 (II) annually provide the Secretary 
 with a statistically valid sample (that 
 is approved by Secretary) of the 
 children enrolled in such plans through 
 reliance on such a finding by 
 conducting a full Medicaid eligibility 
 review of the children identified for 
 such sample for purposes of determining 
 an eligibility error rate (as described 
 in clause (iv)) with respect to the 
 enrollment of such children (and shall 
 not include such children in any data 
 or samples used for purposes of 
 complying with a Medicaid Eligibility 
 Quality Control (MEQC) review or a 
 payment error rate measurement (PERM) 
 requirement);
 (III) submit the error rate 
 determined under subclause (II) to the 
 Secretary;
 (IV) if such error rate exceeds 3 
 percent for either of the first 2 
 fiscal years in which the State elects 
 to apply this paragraph, demonstrate to 
 the satisfaction of the Secretary the 
 specific corrective actions implemented 
 by the State to improve upon such error 
 rate; and
 (V) if such error rate exceeds 3 
 percent for any fiscal year in which 
 the State elects to apply this 
 paragraph, a reduction in the amount 
 otherwise payable to the State under 
 section 1903(a) for quarters for that 
 fiscal year, equal to the total amount 
 of erroneous excess payments determined 
 for the fiscal year only with respect 
 to the children included in the sample 
 for the fiscal year that are in excess 
 of a 3 percent error rate with respect 
 to such children.
 (ii) No punitive action based on error 
 rate.--The Secretary shall not apply the error 
 rate derived from the sample under clause (i) 
 to the entire population of children enrolled 
 in the State Medicaid plan or the State CHIP 
 plan through reliance on a finding made by an 
 Express Lane agency, or to the population of 
 children enrolled in such plans on the basis of 
 the State's regular procedures for determining 
 eligibility, or penalize the State on the basis 
 of such error rate in any manner other than the 
 reduction of payments provided for under clause 
 (i)(V).
 (iii) Rule of construction.--Nothing in this 
 paragraph shall be construed as relieving a 
 State that elects to apply this paragraph from 
 being subject to a penalty under section 
 1903(u), for payments made under the State 
 Medicaid plan with respect to ineligible 
 individuals and families that are determined to 
 exceed the error rate permitted under that 
 section (as determined without regard to the 
 error rate determined under clause (i)(II)).
 (iv) Error rate defined.--In this 
 subparagraph, the term ``error rate'' means the 
 rate of erroneous excess payments for medical 
 assistance (as defined in section 
 1903(u)(1)(D)) for the period involved, except 
 that such payments shall be limited to 
 individuals for which eligibility 
 determinations are made under this paragraph 
 and except that in applying this paragraph 
 under title XXI, there shall be substituted for 
 references to provisions of this title 
 corresponding provisions within title XXI.
 (F) Express lane agency.--
 (i) In general.--In this paragraph, the term 
 ``Express Lane agency'' means a public agency 
 that--
 (I) is determined by the State 
 Medicaid agency or the State CHIP 
 agency (as applicable) to be capable of 
 making the determinations of one or 
 more eligibility requirements described 
 in subparagraph (A)(i);
 (II) is identified in the State 
 Medicaid plan or the State CHIP plan; 
 and
 (III) notifies the child's family--
 (aa) of the information which 
 shall be disclosed in 
 accordance with this paragraph;
 (bb) that the information 
 disclosed will be used solely 
 for purposes of determining 
 eligibility for medical 
 assistance under the State 
 Medicaid plan or for child 
 health assistance under the 
 State CHIP plan; and
 (cc) that the family may 
 elect to not have the 
 information disclosed for such 
 purposes; and
 (IV) enters into, or is subject to, 
 an interagency agreement to limit the 
 disclosure and use of the information 
 disclosed.
 (ii) Inclusion of specific public agencies 
 and indian tribes and tribal organizations.--
 Such term includes the following:
 (I) A public agency that determines 
 eligibility for assistance under any of 
 the following:
 (aa) The temporary assistance 
 for needy families program 
 funded under part A of title 
 IV.
 (bb) A State program funded 
 under part D of title IV.
 (cc) The State Medicaid plan.
 (dd) The State CHIP plan.
 (ee) The Food and Nutrition 
 Act of 2008 (7 U.S.C. 2011 et 
 seq.).
 (ff) The Head Start Act (42 
 U.S.C. 9801 et seq.).
 (gg) The Richard B. Russell 
 National School Lunch Act (42 
 U.S.C. 1751 et seq.).
 (hh) The Child Nutrition Act 
 of 1966 (42 U.S.C. 1771 et 
 seq.).
 (ii) The Child Care and 
 Development Block Grant Act of 
 1990 (42 U.S.C. 9858 et seq.).
 (jj) The Stewart B. McKinney 
 Homeless Assistance Act (42 
 U.S.C. 11301 et seq.).
 (kk) The United States 
 Housing Act of 1937 (42 U.S.C. 
 1437 et seq.).
 (ll) The Native American 
 Housing Assistance and Self-
 Determination Act of 1996 (25 
 U.S.C. 4101 et seq.).
 (II) A State-specified governmental 
 agency that has fiscal liability or 
 legal responsibility for the accuracy 
 of the eligibility determination 
 findings relied on by the State.
 (III) A public agency that is subject 
 to an interagency agreement limiting 
 the disclosure and use of the 
 information disclosed for purposes of 
 determining eligibility under the State 
 Medicaid plan or the State CHIP plan.
 (IV) The Indian Health Service, an 
 Indian Tribe, Tribal Organization, or 
 Urban Indian Organization (as defined 
 in section 1139(c)).
 (iii) Exclusions.--Such term does not include 
 an agency that determines eligibility for a 
 program established under the Social Services 
 Block Grant established under title XX or a 
 private, for-profit organization.
 (iv) Rules of construction.--Nothing in this 
 paragraph shall be construed as--
 (I) exempting a State Medicaid agency 
 from complying with the requirements of 
 section 1902(a)(4) relating to merit-
 based personnel standards for employees 
 of the State Medicaid agency and 
 safeguards against conflicts of 
 interest); or
 (II) authorizing a State Medicaid 
 agency that elects to use Express Lane 
 agencies under this subparagraph to use 
 the Express Lane option to avoid 
 complying with such requirements for 
 purposes of making eligibility 
 determinations under the State Medicaid 
 plan.
 (v) Additional definitions.--In this 
 paragraph:
 (I) State.--The term ``State'' means 
 1 of the 50 States or the District of 
 Columbia.
 (II) State chip agency.--The term 
 ``State CHIP agency'' means the State 
 agency responsible for administering 
 the State CHIP plan.
 (III) State chip plan.--The term 
 ``State CHIP plan'' means the State 
 child health plan established under 
 title XXI and includes any waiver of 
 such plan.
 (IV) State medicaid agency.--The term 
 ``State Medicaid agency'' means the 
 State agency responsible for 
 administering the State Medicaid plan.
 (V) State medicaid plan.--The term 
 ``State Medicaid plan'' means the State 
 plan established under title XIX and 
 includes any waiver of such plan.
 (G) Child defined.--For purposes of this paragraph, 
 the term ``child'' means an individual under 19 years 
 of age, or, at the option of a State, such higher age, 
 not to exceed 21 years of age, as the State may elect.
 (H) State option to rely on state income tax data or 
 return.--At the option of the State, a finding from an 
 Express Lane agency may include gross income or 
 adjusted gross income shown by State income tax records 
 or returns.
 (I) Application.--This paragraph shall not apply with 
 respect to eligibility determinations made after 
 September 30, 2029.
 (14) Income determined using modified adjusted gross 
 income.--
 (A) In general.--Notwithstanding subsection 
 (r) or any other provision of this title, 
 except as provided in subparagraph (D), for 
 purposes of determining income eligibility for 
 medical assistance under the State plan or 
 under any waiver of such plan and for any other 
 purpose applicable under the plan or waiver for 
 which a determination of income is required, 
 including with respect to the imposition of 
 premiums and cost-sharing, a State shall use 
 the modified adjusted gross income of an 
 individual and, in the case of an individual in 
 a family greater than 1, the household income 
 of such family. A State shall establish income 
 eligibility thresholds for populations to be 
 eligible for medical assistance under the State 
 plan or a waiver of the plan using modified 
 adjusted gross income and household income that 
 are not less than the effective income 
 eligibility levels that applied under the State 
 plan or waiver on the date of enactment of the 
 Patient Protection and Affordable Care Act. For 
 purposes of complying with the maintenance of 
 effort requirements under subsection (gg) 
 during the transition to modified adjusted 
 gross income and household income, a State 
 shall, working with the Secretary, establish an 
 equivalent income test that ensures individuals 
 eligible for medical assistance under the State 
 plan or under a waiver of the plan on the date 
 of enactment of the Patient Protection and 
 Affordable Care Act, do not lose coverage under 
 the State plan or under a waiver of the plan. 
 The Secretary may waive such provisions of this 
 title and title XXI as are necessary to ensure 
 that States establish income and eligibility 
 determination systems that protect 
 beneficiaries.
 (B) No income or expense disregards.--Subject 
 to subparagraph (I), no type of expense, block, 
 or other income disregard shall be applied by a 
 State to determine income eligibility for 
 medical assistance under the State plan or 
 under any waiver of such plan or for any other 
 purpose applicable under the plan or waiver for 
 which a determination of income is required.
 (C) No assets test.--A State shall not apply 
 any assets or resources test for purposes of 
 determining eligibility for medical assistance 
 under the State plan or under a waiver of the 
 plan.
 (D) Exceptions.--
 (i) Individuals eligible because of 
 other aid or assistance, elderly 
 individuals, medically needy 
 individuals, and individuals eligible 
 for medicare cost-sharing.--
 Subparagraphs (A), (B), and (C) shall 
 not apply to the determination of 
 eligibility under the State plan or 
 under a waiver for medical assistance 
 for the following:
 (I) Individuals who are 
 eligible for medical assistance 
 under the State plan or under a 
 waiver of the plan on a basis 
 that does not require a 
 determination of income by the 
 State agency administering the 
 State plan or waiver, including 
 as a result of eligibility for, 
 or receipt of, other Federal or 
 State aid or assistance, 
 individuals who are eligible on 
 the basis of receiving (or 
 being treated as if receiving) 
 supplemental security income 
 benefits under title XVI, and 
 individuals who are eligible as 
 a result of being or being 
 deemed to be a child in foster 
 care under the responsibility 
 of the State.
 (II) Individuals who have 
 attained age 65.
 (III) Individuals who qualify 
 for medical assistance under 
 the State plan or under any 
 waiver of such plan on the 
 basis of being blind or 
 disabled (or being treated as 
 being blind or disabled) 
 without regard to whether the 
 individual is eligible for 
 supplemental security income 
 benefits under title XVI on the 
 basis of being blind or 
 disabled and including an 
 individual who is eligible for 
 medical assistance on the basis 
 of section 1902(e)(3).
 (IV) Individuals described in 
 subsection (a)(10)(C).
 (V) Individuals described in 
 any clause of subsection 
 (a)(10)(E).
 (ii) Express lane agency findings.--
 In the case of a State that elects the 
 Express Lane option under paragraph 
 (13), notwithstanding subparagraphs 
 (A), (B), and (C), the State may rely 
 on a finding made by an Express Lane 
 agency in accordance with that 
 paragraph relating to the income of an 
 individual for purposes of determining 
 the individual's eligibility for 
 medical assistance under the State plan 
 or under a waiver of the plan.
 (iii) Medicare prescription drug 
 subsidies determinations.--
 Subparagraphs (A), (B), and (C) shall 
 not apply to any determinations of 
 eligibility for premium and cost-
 sharing subsidies under and in 
 accordance with section 1860D-14 made 
 by the State pursuant to section 
 1935(a)(2).
 (iv) Long-term care.--Subparagraphs 
 (A), (B), and (C) shall not apply to 
 any determinations of eligibility of 
 individuals for purposes of medical 
 assistance for nursing facility 
 services, a level of care in any 
 institution equivalent to that of 
 nursing facility services, home or 
 community-based services furnished 
 under a waiver or State plan amendment 
 under section 1915 or a waiver under 
 section 1115, and services described in 
 section 1917(c)(1)(C)(ii).
 (v) Grandfather of current enrollees 
 until date of next regular 
 redetermination.--An individual who, on 
 January 1, 2014, is enrolled in the 
 State plan or under a waiver of the 
 plan and who would be determined 
 ineligible for medical assistance 
 solely because of the application of 
 the modified adjusted gross income or 
 household income standard described in 
 subparagraph (A), shall remain eligible 
 for medical assistance under the State 
 plan or waiver (and subject to the same 
 premiums and cost-sharing as applied to 
 the individual on that date) through 
 March 31, 2014, or the date on which 
 the individual's next regularly 
 scheduled redetermination of 
 eligibility is to occur, whichever is 
 later.
 (E) Transition planning and oversight.--Each 
 State shall submit to the Secretary for the 
 Secretary's approval the income eligibility 
 thresholds proposed to be established using 
 modified adjusted gross income and household 
 income, the methodologies and procedures to be 
 used to determine income eligibility using 
 modified adjusted gross income and household 
 income and, if applicable, a State plan 
 amendment establishing an optional eligibility 
 category under subsection (a)(10)(A)(ii)(XX). 
 To the extent practicable, the State shall use 
 the same methodologies and procedures for 
 purposes of making such determinations as the 
 State used on the date of enactment of the 
 Patient Protection and Affordable Care Act. The 
 Secretary shall ensure that the income 
 eligibility thresholds proposed to be 
 established using modified adjusted gross 
 income and household income, including under 
 the eligibility category established under 
 subsection (a)(10)(A)(ii)(XX), and the 
 methodologies and procedures proposed to be 
 used to determine income eligibility, will not 
 result in children who would have been eligible 
 for medical assistance under the State plan or 
 under a waiver of the plan on the date of 
 enactment of the Patient Protection and 
 Affordable Care Act no longer being eligible 
 for such assistance.
 (F) Limitation on secretarial authority.--The 
 Secretary shall not waive compliance with the 
 requirements of this paragraph except to the 
 extent necessary to permit a State to 
 coordinate eligibility requirements for dual 
 eligible individuals (as defined in section 
 1915(h)(2)(B)) under the State plan or under a 
 waiver of the plan and under title XVIII and 
 individuals who require the level of care 
 provided in a hospital, a nursing facility, or 
 an intermediate care facility for the mentally 
 retarded.
 (G) Definitions of modified adjusted gross 
 income and household income.--In this 
 paragraph, the terms ``modified adjusted gross 
 income'' and ``household income'' have the 
 meanings given such terms in section 36B(d)(2) 
 of the Internal Revenue Code of 1986.
 (H) Continued application of medicaid rules 
 regarding point-in-time income and sources of 
 income.--The requirement under this paragraph 
 for States to use modified adjusted gross 
 income and household income to determine income 
 eligibility for medical assistance under the 
 State plan or under any waiver of such plan and 
 for any other purpose applicable under the plan 
 or waiver for which a determination of income 
 is required shall not be construed as affecting 
 or limiting the application of--
 (i) the requirement under this title 
 and under the State plan or a waiver of 
 the plan to determine an individual's 
 income as of the point in time at which 
 an application for medical assistance 
 under the State plan or a waiver of the 
 plan is processed; or
 (ii) any rules established under this 
 title or under the State plan or a 
 waiver of the plan regarding sources of 
 countable income.
 (I) Treatment of portion of modified adjusted 
 gross income.--For purposes of determining the 
 income eligibility of an individual for medical 
 assistance whose eligibility is determined 
 based on the application of modified adjusted 
 gross income under subparagraph (A), the State 
 shall--
 (i) determine the dollar equivalent 
 of the difference between the upper 
 income limit on eligibility for such an 
 individual (expressed as a percentage 
 of the poverty line) and such upper 
 income limit increased by 5 percentage 
 points; and
 (ii) notwithstanding the requirement 
 in subparagraph (A) with respect to use 
 of modified adjusted gross income, 
 utilize as the applicable income of 
 such individual, in determining such 
 income eligibility, an amount equal to 
 the modified adjusted gross income 
 applicable to such individual reduced 
 by such dollar equivalent amount.
 (J) Exclusion of parent mentor compensation 
 from income determination.--Any nominal amount 
 received by an individual as compensation, 
 including a stipend, for participation as a 
 parent mentor (as defined in paragraph (5) of 
 section 2113(f)) in an activity or program 
 funded through a grant under such section shall 
 be disregarded for purposes of determining the 
 income eligibility of such individual for 
 medical assistance under the State plan or any 
 waiver of such plan.
 (K) Treatment of certain lottery winnings and 
 income received as a lump sum.--
 (i) In general.--In the case of an 
 individual who is the recipient of 
 qualified lottery winnings (pursuant to 
 lotteries occurring on or after January 
 1, 2018) or qualified lump sum income 
 (received on or after such date) and 
 whose eligibility for medical 
 assistance is determined based on the 
 application of modified adjusted gross 
 income under subparagraph (A), a State 
 shall, in determining such eligibility, 
 include such winnings or income (as 
 applicable) as income received--
 (I) in the month in which 
 such winnings or income (as 
 applicable) is received if the 
 amount of such winnings or 
 income is less than $80,000;
 (II) over a period of 2 
 months if the amount of such 
 winnings or income (as 
 applicable) is greater than or 
 equal to $80,000 but less than 
 $90,000;
 (III) over a period of 3 
 months if the amount of such 
 winnings or income (as 
 applicable) is greater than or 
 equal to $90,000 but less than 
 $100,000; and
 (IV) over a period of 3 
 months plus 1 additional month 
 for each increment of $10,000 
 of such winnings or income (as 
 applicable) received, not to 
 exceed a period of 120 months 
 (for winnings or income of 
 $1,260,000 or more), if the 
 amount of such winnings or 
 income is greater than or equal 
 to $100,000.
 (ii) Counting in equal 
 installments.--For purposes of 
 subclauses (II), (III), and (IV) of 
 clause (i), winnings or income to which 
 such subclause applies shall be counted 
 in equal monthly installments over the 
 period of months specified under such 
 subclause.
 (iii) Hardship exemption.--An 
 individual whose income, by application 
 of clause (i), exceeds the applicable 
 eligibility threshold established by 
 the State, shall continue to be 
 eligible for medical assistance to the 
 extent that the State determines, under 
 procedures established by the State (in 
 accordance with standards specified by 
 the Secretary), that the denial of 
 eligibility of the individual would 
 cause an undue medical or financial 
 hardship as determined on the basis of 
 criteria established by the Secretary.
 (iv) Notifications and assistance 
 required in case of loss of 
 eligibility.--A State shall, with 
 respect to an individual who loses 
 eligibility for medical assistance 
 under the State plan (or a waiver of 
 such plan) by reason of clause (i)--
 (I) before the date on which 
 the individual loses such 
 eligibility, inform the 
 individual--
 (aa) of the 
 individual's 
 opportunity to enroll 
 in a qualified health 
 plan offered through an 
 Exchange established 
 under title I of the 
 Patient Protection and 
 Affordable Care Act 
 during the special 
 enrollment period 
 specified in section 
 9801(f)(3) of the 
 Internal Revenue Code 
 of 1986 (relating to 
 loss of Medicaid or 
 CHIP coverage); and
 (bb) of the date on 
 which the individual 
 would no longer be 
 considered ineligible 
 by reason of clause (i) 
 to receive medical 
 assistance under the 
 State plan or under any 
 waiver of such plan and 
 be eligible to reapply 
 to receive such medical 
 assistance; and
 (II) provide technical 
 assistance to the individual 
 seeking to enroll in such a 
 qualified health plan.
 (v) Qualified lottery winnings 
 defined.--In this subparagraph, the 
 term ``qualified lottery winnings'' 
 means winnings from a sweepstakes, 
 lottery, or pool described in paragraph 
 (3) of section 4402 of the Internal 
 Revenue Code of 1986 or a lottery 
 operated by a multistate or 
 multijurisdictional lottery 
 association, including amounts awarded 
 as a lump sum payment.
 (vi) Qualified lump sum income 
 defined.--In this subparagraph, the 
 term ``qualified lump sum income'' 
 means income that is received as a lump 
 sum from monetary winnings from 
 gambling (as defined by the Secretary 
 and including gambling activities 
 described in section 1955(b)(4) of 
 title 18, United States Code).
 (15) Exclusion of compensation for participation in a 
 clinical trial for testing of treatments for a rare 
 disease or condition.--The first $2,000 received by an 
 individual (who has attained 19 years of age) as 
 compensation for participation in a clinical trial 
 meeting the requirements of section 1612(b)(26) shall 
 be disregarded for purposes of determining the income 
 eligibility of such individual for medical assistance 
 under the State plan or any waiver of such plan.
 (16) Extending certain coverage for pregnant and 
 postpartum women.--
 (A) In general.--At the option of the State, 
 the State plan (or waiver of such State plan) 
 may provide, that an individual who, while 
 pregnant, is eligible for and has received 
 medical assistance under the State plan 
 approved under this title (or a waiver of such 
 plan) (including during a period of retroactive 
 eligibility under subsection (a)(34)) shall, in 
 addition to remaining eligible under paragraph 
 (5) for all pregnancy-related and postpartum 
 medical assistance available under the State 
 plan (or waiver) through the last day of the 
 month in which the 60-day period (beginning on 
 the last day of her pregnancy) ends, remain 
 eligible under the State plan (or waiver) for 
 medical assistance for the period beginning on 
 the first day occurring after the end of such 
 60-day period and ending on the last day of the 
 month in which the 12-month period (beginning 
 on the last day of her pregnancy) ends.
 (B) Full benefits during pregnancy and 
 throughout the 12-month postpartum period.--The 
 medical assistance provided for a pregnant or 
 postpartum individual by a State making an 
 election under this paragraph, without regard 
 to the basis on which the individual is 
 eligible for medical assistance under the State 
 plan (or waiver), shall--
 (i) include all items and services 
 covered under the State plan (or 
 waiver) that are not less in amount, 
 duration, or scope, or are determined 
 by the Secretary to be substantially 
 equivalent, to the medical assistance 
 available for an individual described 
 in subsection (a)(10)(A)(i); and
 (ii) be provided for the individual 
 while pregnant and during the 12-month 
 period that begins on the last day of 
 the individual's pregnancy and ends on 
 the last day of the month in which such 
 12-month period ends.
 (C) Coverage under chip.--A State making an 
 election under this paragraph that covers under 
 title XXI child health assistance for targeted 
 low-income children who are pregnant or 
 targeted low-income pregnant women, as 
 applicable, shall also make the election under 
 section 2107(e)(1)(J) of such title.
 (f) Notwithstanding any other provision of this title, except 
as provided in subsection (e) and section 1619(b)(3) and 
section 1924, except with respect to qualified disabled and 
working individuals (described in section 1905(s)), and except 
with respect to qualified medicare beneficiaries, qualified 
severely impaired individuals, and individuals described in 
subsection (m)(1), no State not eligible to participate in the 
State plan program established under title XVI shall be 
required to provide medical assistance to any aged, blind, or 
disabled individual (within the meaning of title XVI) for any 
month unless such State would be (or would have been) required 
to provide medical assistance to such individual for such month 
had its plan for medical assistance approved under this title 
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 1903(f) 
(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 shall be considered an individual eligible for 
medical assistance under paragraph (10)(A) of that subsection 
if that individual is, or is eligible to be (1) an individual 
with respect to whom there is payable a State supplementary 
payment on the basis of which similarly situated individuals 
are eligible to receive medical assistance equal in amount, 
duration, and scope to that provided to individuals eligible 
under paragraph (10)(A), or (2) an eligible individual or 
eligible spouse, as defined in title XVI, with respect to whom 
supplemental security income benefits are payable; otherwise 
that individual shall be considered to be an individual 
eligible for medical assistance under paragraph (10)(C) of that 
subsection. In States which do not provide medical assistance 
to individuals pursuant to paragraph (10)(C) of that 
subsection, an individual who is eligible for medical 
assistance by reason of the requirements of this section 
concerning the deduction of incurred medical expenses from 
income shall be considered an individual eligible for medical 
assistance under paragraph (10)(A) of that subsection.
 (g) In addition to any other sanction available to a State, a 
State may provide for a reduction of any payment amount 
otherwise due with respect to a person who furnishes services 
under the plan in an amount equal to up to three times the 
amount of any payment sought to be collected by that person in 
violation of subsection (a)(25)(C).
 (h)(1) Nothing in this title (including subsections (a)(13) 
and (a)(30) of this section) shall be construed as authorizing 
the Secretary to limit the amount of payment that may be made 
under a plan under this title for home and community care, home 
and community-based services provided under subsection (c), 
(d), or (i) of section 1915 or under a waiver or demonstration 
project under section 1115, self-directed personal assistance 
services provided pursuant to a written plan of care under 
section 1915(j), and home and community-based attendant 
services and supports under section 1915(k).
 (2) Nothing in this title, title XVIII, or title XI shall be 
construed as prohibiting receipt of any care or services 
specified in paragraph (1) in an acute care hospital that are--
 (A) identified in an individual's person-centered 
 service plan (or comparable plan of care);
 (B) provided to meet needs of the individual that are 
 not met through the provision of hospital services;
 (C) not a substitute for services that the hospital 
 is obligated to provide through its conditions of 
 participation or under Federal or State law, or under 
 another applicable requirement; and
 (D) designed to ensure smooth transitions between 
 acute care settings and home and community-based 
 settings, and to preserve the individual's functional 
 abilities.
 (i)(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 title and further determines 
that the facility's deficiencies--
 (A) immediately jeopardize the health and safety of 
 its patients, the State shall provide for the 
 termination of the facility's certification for 
 participation under the plan and may provide, or
 (B) do not immediately jeopardize the health and 
 safety of its patients, the State may, in lieu of 
 providing for terminating the facility's certification 
 for participation under the plan, establish alternative 
 remedies if the State demonstrates to the Secretary's 
 satisfaction that the alternative remedies are 
 effective in deterring noncompliance and correcting 
 deficiencies, and may provide
that no payment will be made under the State plan 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 title, to correct its deficiencies, and, following this 
period, has been given reasonable notice and opportunity for a 
hearing.
 (3) The State's decision to deny payment may be made 
effective only after such notice to the public and to the 
facility as may be provided for by the State, and its 
effectiveness shall terminate (A) when the State finds that the 
facility is in substantial compliance (or is making good faith 
efforts to achieve substantial compliance) with the 
requirements for such a facility under this title, 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) Notwithstanding any other requirement of this title, the 
Secretary may waive or modify any requirement of this title 
with respect to the medical assistance program in American 
Samoa and the Northern Mariana Islands, other than a waiver of 
the Federal medical assistance percentage, the limitation in 
section 1108(f),, the requirement that payment may be made for 
medical assistance only with respect to amounts expended by 
American Samoa or the Northern Mariana Islands for care and 
services described in a numbered paragraph of section 1905(a), 
or the requirement under subsection (qq)(1) (relating to data 
reporting).
 (k)(1) The medical assistance provided to an individual 
described in subclause (VIII) of subsection (a)(10)(A)(i) shall 
consist of benchmark coverage described in section 1937(b)(1) 
or benchmark equivalent coverage described in section 
1937(b)(2). Such medical assistance shall be provided subject 
to the requirements of section 1937, without regard to whether 
a State otherwise has elected the option to provide medical 
assistance through coverage under that section, unless an 
individual described in subclause (VIII) of subsection 
(a)(10)(A)(i) is also an individual for whom, under 
subparagraph (B) of section 1937(a)(2), the State may not 
require enrollment in benchmark coverage described in 
subsection (b)(1) of section 1937 or benchmark equivalent 
coverage described in subsection (b)(2) of that section.
 (2) Beginning with the first day of any fiscal year quarter 
that begins on or after April 1, 2010, and before January 1, 
2014, a State may elect through a State plan amendment to 
provide medical assistance to individuals who would be 
described in subclause (VIII) of subsection (a)(10)(A)(i) if 
that subclause were effective before January 1, 2014. A State 
may elect to phase-in the extension of eligibility for medical 
assistance to such individuals based on income, so long as the 
State does not extend such eligibility to individuals described 
in such subclause with higher income before making individuals 
described in such subclause with lower income eligible for 
medical assistance.
 (3) If an individual described in subclause (VIII) of 
subsection (a)(10)(A)(i) is the parent of a child who is under 
19 years of age (or such higher age as the State may have 
elected) who is eligible for medical assistance under the State 
plan or under a waiver of such plan (under that subclause or 
under a State plan amendment under paragraph (2), the 
individual may not be enrolled under the State plan unless the 
individual's child is enrolled under the State plan or under a 
waiver of the plan or is enrolled in other health insurance 
coverage. For purposes of the preceding sentence, the term 
``parent'' includes an individual treated as a caretaker 
relative for purposes of carrying out section 1931.
 (l)(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 (or, at 
 the option of a State, after any earlier date), who 
 have attained 6 years of age but have not attained 19 
 years of age,
who are not described in any of subclauses (I) through (III) of 
subsection (a)(10)(A)(i) 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)(i) For purposes of paragraph (1) with respect to 
individuals described in subparagraph (A) or (B) of that 
paragraph, the State shall establish an income level which is a 
percentage (not less than the percentage provided under clause 
(ii) and not more than 185 percent) of the income official 
poverty line (as defined by the Office of Management and 
Budget, and revised annually in accordance with section 673(2) 
of the Omnibus Budget Reconciliation Act of 1981) applicable to 
a family of the size involved.
 (ii) The percentage provided under this clause, with respect 
to eligibility for medical assistance on or after--
 (I) 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).
 (iii) In the case of a State which, as of the date of the 
enactment of this clause, 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 the date of the enactment of this clause, or
 (II) if no such percentage is specified as of the 
 date of the enactment of this clause, the percentage 
 established under the State's authorizing legislation 
 or provided for under the State's appropriations;
but in no case shall this clause require the percentage 
provided under clause (ii)(I) to exceed 100 percent.
 (iv) In the case of a State which, as of the date of the 
enactment of this clause, 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 the date of the enactment of this clause, or
 (II) if no such percentage is specified as of the 
 date of the enactment of this clause, the percentage 
 established under the State's authorizing legislation 
 or provided for under the State's appropriations.
 (B) For purposes of paragraph (1) with respect to individuals 
described in subparagraph (C) of such paragraph, the State 
shall establish an income level which is equal to 133 percent 
of the income official poverty line described in subparagraph 
(A) applicable to a family of the size involved.
 (C) For purposes of paragraph (1) with respect to individuals 
described in subparagraph (D) of that paragraph, the State 
shall establish an income level which is equal to 100 percent 
(or, beginning January 1, 2014, 133 percent) of the income 
official poverty line described in subparagraph (A) applicable 
to a family of the size involved.
 (3) Notwithstanding subsection (a)(17), for individuals who 
are eligible for medical assistance because of subsection 
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or 
(a)(10)(A)(ii)(IX)--
 (A) application of a resource standard shall be at 
 the option of the State;
 (B) any resource standard or methodology that is 
 applied with respect to an individual described in 
 subparagraph (A) of paragraph (1) may not be more 
 restrictive than the resource standard or methodology 
 that is applied under title XVI;
 (C) any resource standard or methodology that is 
 applied with respect to an individual described in 
 subparagraph (B), (C), or (D) of paragraph (1) may not 
 be more restrictive than the corresponding methodology 
 that is applied under the State plan under part A of 
 title IV;
 (D) the income standard to be applied is the 
 appropriate income standard established under paragraph 
 (2); and
 (E) family income shall be determined in accordance 
 with the methodology employed under the State plan 
 under part A or E of title IV (except to the extent 
 such methodology is inconsistent with clause (D) of 
 subsection (a)(17)), and costs incurred for medical 
 care or for any other type of remedial care shall not 
 be taken into account.
Any different treatment provided under this paragraph for such 
individuals shall not, because of subsection (a)(17), require 
or permit such treatment for other individuals.
 (4)(A) In the case of any State which is providing medical 
assistance to its residents under a waiver granted under 
section 1115, the Secretary shall require the State to provide 
medical assistance for pregnant women and infants under age 1 
described in subsection (a)(10)(A)(i)(IV) and for children 
described in subsection (a)(10)(A)(i)(VI) or subsection 
(a)(10)(A)(i)(VII) in the same manner as the State would be 
required to provide such assistance for such individuals if the 
State had in effect a plan approved under this title.
 (B) In the case of a State which is not one of the 50 States 
or the District of Columbia, the State need not meet the 
requirement of subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), 
or (a)(10)(A)(i)(VII) and, for purposes of paragraph (2)(A), 
the State may substitute for the percentage provided under 
clause (ii) of such paragraph any percentage.
 (m)(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 1614(a)(3)),
 (B) whose income (as determined under section 1612 
 for purposes of the supplemental security income 
 program, except as provided in paragraph (2)(C)) does 
 not exceed an income level established by the State 
 consistent with paragraph (2)(A), and
 (C) whose resources (as determined under section 1613 
 for purposes of the supplemental security income 
 program) do not exceed (except as provided in paragraph 
 (2)(B)) the maximum amount of resources that an 
 individual may have and obtain benefits under that 
 program.
 (2)(A) The income level established under paragraph (1)(B) 
may not exceed a percentage (not more than 100 percent) of the 
official poverty line (as defined by the Office of Management 
and Budget, and revised annually in accordance with section 
673(2) of the Omnibus Budget Reconciliation Act of 1981) 
applicable to a family of the size involved.
 (B) In the case of a State that provides medical assistance 
to individuals not described in subsection (a)(10)(A) and at 
the State's option, the State may use under paragraph (1)(C) 
such resource level (which is higher than the level described 
in that paragraph) as may be applicable with respect to 
individuals described in paragraph (1)(A) who are not described 
in subsection (a)(10)(A).
 (C) The provisions of section 1905(p)(2)(D) shall apply to 
determinations of income under this subsection in the same 
manner as they apply to determinations of income under section 
1905(p).
 (3) Notwithstanding subsection (a)(17), for individuals 
described in paragraph (1) who are covered under the State plan 
by virtue of subsection (a)(10)(A)(ii)(X)--
 (A) the income standard to be applied is the income 
 standard described in paragraph (1)(B), and
 (B) except as provided in section 1612(b)(4)(B)(ii), 
 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), require 
or permit such treatment for other individuals.
 (4) Notwithstanding subsection (a)(17), for qualified 
medicare beneficiaries described in section 1905(p)(1)--
 (A) the income standard to be applied is the income 
 standard described in section 1905(p)(1)(B), and
 (B) except as provided in section 1612(b)(4)(B)(ii), 
 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), require 
or permit such treatment for other individuals.
 (n)(1) In the case of medical assistance furnished under this 
title 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 title XVIII with respect 
to the service or item exceeding the amount that is otherwise 
payable under the State plan for the item or service for 
eligible individuals who are not qualified medicare 
beneficiaries.
 (2) In carrying out paragraph (1), a State is not required to 
provide any payment for any expenses incurred relating to 
payment for deductibles, coinsurance, or copayments for 
medicare cost-sharing to the extent that payment under title 
XVIII for the service would exceed the payment amount that 
otherwise would be made under the State plan under this title 
for such service if provided to an eligible recipient other 
than a medicare beneficiary.
 (3) In the case in which a State's payment for medicare cost-
sharing for a qualified medicare beneficiary with respect to an 
item or service is reduced or eliminated through the 
application of paragraph (2)--
 (A) for purposes of applying any limitation under 
 title XVIII on the amount that the beneficiary may be 
 billed or charged for the service, the amount of 
 payment made under title XVIII plus the amount of 
 payment (if any) under the State plan shall be 
 considered to be payment in full for the service;
 (B) the beneficiary shall not have any legal 
 liability to make payment to a provider or to an 
 organization described in section 1903(m)(1)(A) for the 
 service; and
 (C) any lawful sanction that may be imposed upon a 
 provider or such an organization for excess charges 
 under this title or title XVIII shall apply to the 
 imposition of any charge imposed upon the individual in 
 such case.
This paragraph shall not be construed as preventing payment of 
any medicare cost-sharing by a medicare supplemental policy or 
an employer retiree health plan on behalf of an individual.
 (o) Notwithstanding any provision of subsection (a) to the 
contrary, a State plan under this title shall provide that any 
supplemental security income benefits paid by reason of 
subparagraph (E) or (G) of section 1611(e)(1) 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, skilled 
nursing facility, or intermediate care facility.
 (p)(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 title for any reason for which 
the Secretary could exclude the individual or entity from 
participation in a program under title XVIII under section 
1128, 1128A, or 1866(b)(2).
 (2) In order for a State to receive payments for medical 
assistance under section 1903(a), with respect to payments the 
State makes to a medicaid managed care organization (as defined 
in section 1903(m)) or to an entity furnishing services under a 
waiver approved under section 1915(b)(1), 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 1128(b)(8) 
 (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 1128(b)(8)(B), or
 (C) employs or contracts with any individual or 
 entity that is excluded from participation under this 
 title under section 1128 or 1128A 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)(1)(A) In order to meet the requirement of subsection 
(a)(50), the State plan must provide that, in the case of an 
institutionalized individual or couple described in 
subparagraph (B), in determining the amount of the individual's 
or couple's income to be applied monthly to payment for the 
cost of care in an institution, there shall be deducted from 
the monthly income (in addition to other allowances otherwise 
provided under the State plan) a monthly personal needs 
allowance--
 (i) which is reasonable in amount for clothing and 
 other personal needs of the individual (or couple) 
 while in an institution, and
 (ii) which is not less (and may be greater) than the 
 minimum monthly personal needs allowance described in 
 paragraph (2).
 (B) In this subsection, the term ``institutionalized 
individual or couple'' means an individual or married couple--
 (i) who is an inpatient (or who are inpatients) in a 
 medical institution or nursing facility for which 
 payments are made under this title throughout a month, 
 and
 (ii) who is or are determined to be eligible for 
 medical assistance under the State plan.
 (2) The minimum monthly personal needs allowance described in 
this paragraph is $30 for an institutionalized individual and 
$60 for an institutionalized couple (if both are aged, blind, 
or disabled, and their incomes are considered available to each 
other in determining eligibility).
 (r)(1)(A) For purposes of sections 1902(a)(17) and 
1924(d)(1)(D) and for purposes of a waiver under section 1915, 
with respect to the post-eligibility treatment of income of 
individuals who are institutionalized or receiving home or 
community-based services under such a waiver, the treatment 
described in subparagraph (B) shall apply, there shall be 
disregarded reparation payments made by the Federal Republic of 
Germany, and there shall be taken into account amounts for 
incurred expenses for medical or remedial care that are not 
subject to payment by a third party, including--
 (i) medicare and other health insurance premiums, 
 deductibles, or coinsurance, and
 (ii) necessary medical or remedial care recognized 
 under State law but not covered under the State plan 
 under this title, subject to reasonable limits the 
 State may establish on the amount of these expenses.
 (B)(i) In the case of a veteran who does not have a spouse or 
a child, if the veteran--
 (I) receives, after the veteran has been determined 
 to be eligible for medical assistance under the State 
 plan under this title, a veteran's pension in excess of 
 $90 per month, and
 (II) resides in a State veterans home with respect to 
 which the Secretary of Veterans Affairs makes per diem 
 payments for nursing home care pursuant to section 
 1741(a) of title 38, United States Code,
any such pension payment, including any payment made due to the 
need for aid and attendance, or for unreimbursed medical 
expenses, that is in excess of $90 per month shall be counted 
as income only for the purpose of applying such excess payment 
to the State veterans home's cost of providing nursing home 
care to the veteran.
 (ii) The provisions of clause (i) shall apply with respect to 
a surviving spouse of a veteran who does not have a child in 
the same manner as they apply to a veteran described in such 
clause.
 (2)(A) The methodology to be employed in determining income 
and resource eligibility for individuals under subsection 
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), 
(a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) 
or under section 1905(p) may be less restrictive, and shall be 
no more restrictive, than the methodology--
 (i) in the case of groups consisting of aged, blind, 
 or disabled individuals, under the supplemental 
 security income program under title XVI, or
 (ii) in the case of other groups, under the State 
 plan most closely categorically related.
 (B) For purposes of this subsection and subsection (a)(10), 
methodology is considered to be ``no more restrictive'' if, 
using the methodology, additional individuals may be eligible 
for medical assistance and no individuals who are otherwise 
eligible are made ineligible for such assistance.
 (s) In order to meet the requirements of subsection (a)(55), 
the State plan must provide that payments to hospitals under 
the plan for inpatient hospital services furnished to infants 
who have not attained the age of 1 year, and to children who 
have not attained the age of 6 years and who receive such 
services in a disproportionate share hospital described in 
section 1923(b)(1), shall--
 (1) if made on a prospective basis (whether per diem, 
 per case, or otherwise) provide for an outlier 
 adjustment in payment amounts for medically necessary 
 inpatient hospital services involving exceptionally 
 high costs or exceptionally long lengths of stay,
 (2) not be limited by the imposition of day limits 
 with respect to the delivery of such services to such 
 individuals, and
 (3) not be limited by the imposition of dollar limits 
 (other than such limits resulting from prospective 
 payments as adjusted pursuant to paragraph (1)) with 
 respect to the delivery of such services to any such 
 individual who has not attained their first birthday 
 (or in the case of such an individual who is an 
 inpatient on his first birthday until such individual 
 is discharged).
 (t) Nothing in this title (including sections 1903(a) and 
1905(a)) shall be construed as authorizing the Secretary to 
deny or limit payments to a State for expenditures, for medical 
assistance for items or services, attributable to taxes of 
general applicability imposed with respect to the provision of 
such items or services.
 (u)(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 1612 
 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 673(2) of the Omnibus Budget Reconciliation Act 
 of 1981) applicable to a family of the size involved,
 (C) whose resources (as determined under section 1613 
 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 title resulting from 
 such enrollment is likely to exceed the amount of 
 payments for COBRA premiums made.
 (2) For purposes of subsection (a)(10)(F) and this 
subsection, the term ``COBRA premiums'' means the applicable 
premium imposed with respect to COBRA continuation coverage.
 (3) In this subsection, the term ``COBRA continuation 
coverage'' means coverage under a group health plan provided by 
an employer with 75 or more employees provided pursuant to 
title XXII of the Public Health Service Act, section 4980B of 
the Internal Revenue Code of 1986, or title VI of the Employee 
Retirement Income Security Act of 1974.
 (4) Notwithstanding subsection (a)(17), for individuals 
described in paragraph (1) who are covered under the State plan 
by virtue of subsection (a)(10)(A)(ii)(XI)--
 (A) the income standard to be applied is the income 
 standard described in paragraph (1)(B), and
 (B) except as provided in section 1612(b)(4)(B)(ii), 
 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), require or permit such treatment for other 
individuals.
 (v) A State plan may provide for the making of determinations 
of disability or blindness for the purpose of determining 
eligibility for medical assistance under the State plan by the 
single State agency or its designee, and make medical 
assistance available to individuals whom it finds to be blind 
or disabled and who are determined otherwise eligible for such 
assistance during the period of time prior to which a final 
determination of disability or blindness is made by the Social 
Security Administration with respect to such an individual. In 
making such determinations, the State must apply the 
definitions of disability and blindness found in section 
1614(a) of the Social Security Act.
 (w)(1) For purposes of subsection (a)(57) and sections 
1903(m)(1)(A) and 1919(c)(2)(E), the requirement of this 
subsection is that a provider or organization (as the case may 
be) maintain written policies and procedures with respect to 
all adult individuals receiving medical care by or through the 
provider or organization--
 (A) to provide written information to each such 
 individual concerning--
 (i) an individual's rights under State law 
 (whether statutory or as recognized by the 
 courts of the State) to make decisions 
 concerning such medical care, including the 
 right to accept or refuse medical or surgical 
 treatment and the right to formulate advance 
 directives (as defined in paragraph (3)), and
 (ii) the provider's or organization's written 
 policies respecting the implementation of such 
 rights;
 (B) to document in the individual's medical record 
 whether or not the individual has executed an advance 
 directive;
 (C) not to condition the provision of care or 
 otherwise discriminate against an individual based on 
 whether or not the individual has executed an advance 
 directive;
 (D) to ensure compliance with requirements of State 
 law (whether statutory or as recognized by the courts 
 of the State) respecting advance directives; and
 (E) to provide (individually or with others) for 
 education for staff and the community on issues 
 concerning advance directives.
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,
 (B) in the case of a nursing facility, at the time of 
 the individual's admission as a resident,
 (C) in the case of a provider of home health care or 
 personal care services, in advance of the individual 
 coming under the care of the provider,
 (D) in the case of a hospice program, at the time of 
 initial receipt of hospice care by the individual from 
 the program, and
 (E) in the case of a medicaid managed care 
 organization, at the time of enrollment of the 
 individual with the organization.
 (3) Nothing in this section shall be construed to prohibit 
the application of a State law which allows for an objection on 
the basis of conscience for any health care provider or any 
agent of such provider which as a matter of conscience cannot 
implement an advance directive.
 (4) In this subsection, the term ``advance directive'' means 
a written instruction, such as a living will or durable power 
of attorney for health care, recognized under State law 
(whether statutory or as recognized by the courts of the State) 
and relating to the provision of such care when the individual 
is incapacitated.
 (5) For construction relating to this subsection, see section 
7 of the Assisted Suicide Funding Restriction Act of 1997 
(relating to clarification respecting assisted suicide, 
euthanasia, and mercy killing).
 (x) The Secretary shall establish a system, for 
implementation by not later than July 1, 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 title.
 (y)(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 
1905(h)) and further finds that the hospital's deficiencies--
 (A) immediately jeopardize the health and safety of 
 its patients, the State shall terminate the hospital's 
 participation under the State plan; or
 (B) do not immediately jeopardize the health and 
 safety of its patients, the State may terminate the 
 hospital's participation under the State plan, or 
 provide that no payment will be made under the State 
 plan with respect to any individual admitted to such 
 hospital after the effective date of the finding, or 
 both.
 (2) Except as provided in paragraph (3), if a psychiatric 
hospital described in paragraph (1)(B) has not complied with 
the requirements for a psychiatric hospital under this title--
 (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 section 1903(a) with respect to further services 
 provided in the hospital until the State finds that the 
 hospital is in compliance with the requirements of this 
 title.
 (3) The Secretary may continue payments, over a period of not 
longer than 6 months from the date the hospital is found to be 
out of compliance with such requirements, if--
 (A) the State finds that it is more appropriate to 
 take alternative action to assure compliance of the 
 hospital with the requirements than to terminate the 
 certification of the hospital,
 (B) the State has submitted a plan and timetable for 
 corrective action to the Secretary for approval and the 
 Secretary approves the plan of corrective action, and
 (C) the State agrees to repay to the Federal 
 Government payments received under this paragraph if 
 the corrective action is not taken in accordance with 
 the approved plan and timetable.
 (z)(1) Individuals described in this paragraph are 
individuals not described in subsection (a)(10)(A)(i)--
 (A) who are infected with tuberculosis;
 (B) whose income (as determined under the State plan 
 under this title with respect to disabled individuals) 
 does not exceed the maximum amount of income a disabled 
 individual described in subsection (a)(10)(A)(i) may 
 have and obtain medical assistance under the plan; and
 (C) whose resources (as determined under the State 
 plan under this title with respect to disabled 
 individuals) do not exceed the maximum amount of 
 resources a disabled individual described in subsection 
 (a)(10)(A)(i) may have and obtain medical assistance 
 under the plan.
 (2) For purposes of subsection (a)(10), the term ``TB-related 
services'' means each of the following services relating to 
treatment of infection with tuberculosis:
 (A) Prescribed drugs.
 (B) Physicians' services and services described in 
 section 1905(a)(2).
 (C) Laboratory and X-ray services (including services 
 to confirm the presence of infection).
 (D) Clinic services and Federally-qualified health 
 center services.
 (E) Case management services (as defined in section 
 1915(g)(2)).
 (F) Services (other than room and board) designed to 
 encourage completion of regimens of prescribed drugs by 
 outpatients, including services to observe directly the 
 intake of prescribed drugs.
 (aa) Individuals described in this subsection are individuals 
who--
 (1) are not described in subsection (a)(10)(A)(i);
 (2) have not attained age 65;
 (3) have been screened for breast and cervical cancer 
 under the Centers for Disease Control and Prevention 
 breast and cervical cancer early detection program 
 established under title XV of the Public Health Service 
 Act (42 U.S.C. 300k et seq.) in accordance with the 
 requirements of section 1504 of that Act (42 U.S.C. 
 300n) and need treatment for breast or cervical cancer; 
 and
 (4) are not otherwise covered under creditable 
 coverage, as defined in section 2701(c) of the Public 
 Health Service Act (42 U.S.C. 300gg(c)), but applied 
 without regard to paragraph (1)(F) of such section.
 (bb) Payment for Services Provided by Federally-Qualified 
Health Centers and Rural Health Clinics.--
 (1) In general.--Beginning with fiscal year 2001 with 
 respect to services furnished on or after January 1, 
 2001, and each succeeding fiscal year, the State plan 
 shall provide for payment for services described in 
 section 1905(a)(2)(C) furnished by a Federally-
 qualified health center and services described in 
 section 1905(a)(2)(B) furnished by a rural health 
 clinic in accordance with the provisions of this 
 subsection.
 (2) Fiscal year 2001.--Subject to paragraph (4), for 
 services furnished on and after January 1, 2001, during 
 fiscal year 2001, the State plan shall provide for 
 payment for such services in an amount (calculated on a 
 per visit basis) that is equal to 100 percent of the 
 average of the costs of the center or clinic of 
 furnishing such services during fiscal years 1999 and 
 2000 which are reasonable and related to the cost of 
 furnishing such services, or based on such other tests 
 of reasonableness as the Secretary prescribes in 
 regulations under section 1833(a)(3), or, in the case 
 of services to which such regulations do not apply, the 
 same methodology used under section 1833(a)(3), 
 adjusted to take into account any increase or decrease 
 in the scope of such services furnished by the center 
 or clinic during fiscal year 2001.
 (3) Fiscal year 2002 and succeeding fiscal years.--
 Subject to paragraph (4), for services furnished during 
 fiscal year 2002 or a succeeding fiscal year, the State 
 plan shall provide for payment for such services in an 
 amount (calculated on a per visit basis) that is equal 
 to the amount calculated for such services under this 
 subsection for the preceding fiscal year--
 (A) increased by the percentage increase in 
 the MEI (as defined in section 1842(i)(3)) 
 applicable to primary care services (as defined 
 in section 1842(i)(4)) for that fiscal year; 
 and
 (B) adjusted to take into account any 
 increase or decrease in the scope of such 
 services furnished by the center or clinic 
 during that fiscal year.
 (4) Establishment of initial year payment amount for 
 new centers or clinics.--In any case in which an entity 
 first qualifies as a Federally-qualified health center 
 or rural health clinic after fiscal year 2000, the 
 State plan shall provide for payment for services 
 described in section 1905(a)(2)(C) furnished by the 
 center or services described in section 1905(a)(2)(B) 
 furnished by the clinic in the first fiscal year in 
 which the center or clinic so qualifies in an amount 
 (calculated on a per visit basis) that is equal to 100 
 percent of the costs of furnishing such services during 
 such fiscal year based on the rates established under 
 this subsection for the fiscal year for other such 
 centers or clinics located in the same or adjacent area 
 with a similar case load or, in the absence of such a 
 center or clinic, in accordance with the regulations 
 and methodology referred to in paragraph (2) or based 
 on such other tests of reasonableness as the Secretary 
 may specify. For each fiscal year following the fiscal 
 year in which the entity first qualifies as a 
 Federally-qualified health center or rural health 
 clinic, the State plan shall provide for the payment 
 amount to be calculated in accordance with paragraph 
 (3).
 (5) Administration in the case of managed care.--
 (A) In general.--In the case of services 
 furnished by a Federally-qualified health 
 center or rural health clinic pursuant to a 
 contract between the center or clinic and a 
 managed care entity (as defined in section 
 1932(a)(1)(B)), the State plan shall provide 
 for payment to the center or clinic by the 
 State of a supplemental payment equal to the 
 amount (if any) by which the amount determined 
 under paragraphs (2), (3), and (4) of this 
 subsection exceeds the amount of the payments 
 provided under the contract.
 (B) Payment schedule.--The supplemental 
 payment required under subparagraph (A) shall 
 be made pursuant to a payment schedule agreed 
 to by the State and the Federally-qualified 
 health center or rural health clinic, but in no 
 case less frequently than every 4 months.
 (6) Alternative payment methodologies.--
 Notwithstanding any other provision of this section, 
 the State plan may provide for payment in any fiscal 
 year to a Federally-qualified health center for 
 services described in section 1905(a)(2)(C) or to a 
 rural health clinic for services described in section 
 1905(a)(2)(B) in an amount which is determined under an 
 alternative payment methodology that--
 (A) is agreed to by the State and the center 
 or clinic; and
 (B) results in payment to the center or 
 clinic of an amount which is at least equal to 
 the amount otherwise required to be paid to the 
 center or clinic under this section.
 (cc)(1) Individuals described in this paragraph are 
individuals--
 (A) who are children who have not attained 19 years 
 of age and are born--
 (i) on or after January 1, 2001 (or, at the 
 option of a State, on or after an earlier 
 date), in the case of the second, third, and 
 fourth quarters of fiscal year 2007;
 (ii) on or after October 1, 1995 (or, at the 
 option of a State, on or after an earlier 
 date), in the case of each quarter of fiscal 
 year 2008; and
 (iii) after October 1, 1989, in the case of 
 each quarter of fiscal year 2009 and each 
 quarter of any fiscal year thereafter;
 (B) who would be considered disabled under section 
 1614(a)(3)(C) (as determined under title XVI for 
 children but without regard to any income or asset 
 eligibility requirements that apply under such title 
 with respect to children); and
 (C) whose family income does not exceed such income 
 level as the State establishes and does not exceed--
 (i) 300 percent of the poverty line (as 
 defined in section 2110(c)(5)) applicable to a 
 family of the size involved; or
 (ii) such higher percent of such poverty line 
 as a State may establish, except that--
 (I) any medical assistance provided 
 to an individual whose family income 
 exceeds 300 percent of such poverty 
 line may only be provided with State 
 funds; and
 (II) no Federal financial 
 participation shall be provided under 
 section 1903(a) for any medical 
 assistance provided to such an 
 individual.
 (2)(A) If an employer of a parent of an individual described 
in paragraph (1) offers family coverage under a group health 
plan (as defined in section 2791(a) of the Public Health 
Service Act), the State shall--
 (i) notwithstanding section 1906, require such parent 
 to apply for, enroll in, and pay premiums for such 
 coverage as a condition of such parent's child being or 
 remaining eligible for medical assistance under 
 subsection (a)(10)(A)(ii)(XIX) if the parent is 
 determined eligible for such coverage and the employer 
 contributes at least 50 percent of the total cost of 
 annual premiums for such coverage; and
 (ii) if such coverage is obtained--
 (I) subject to paragraph (2) of section 
 1916(h), reduce the premium imposed by the 
 State under that section in an amount that 
 reasonably reflects the premium contribution 
 made by the parent for private coverage on 
 behalf of a child with a disability; and
 (II) treat such coverage as a third party 
 liability under subsection (a)(25).
 (B) In the case of a parent to which subparagraph (A) 
applies, a State, notwithstanding section 1906 but subject to 
paragraph (1)(C)(ii), may provide for payment of any portion of 
the annual premium for such family coverage that the parent is 
required to pay. Any payments made by the State u