[House Report 118-605]
[From the U.S. Government Publishing Office]


118th Congress }                                             { Report
                        HOUSE OF REPRESENTATIVES
  2d Session   }                                             { 118-605

======================================================================



 
                    MEDICAID PROGRAM IMPROVEMENT ACT

                                _______
                                

 July 23, 2024.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

     Mrs. Rodgers of Washington, from the Committee on Energy and  
                   Commerce, submitted the following

                              R E P O R T

                        [To accompany H.R. 8111]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 8111) to amend title XIX of the Social Security 
Act to ensure the reliability of address information provided 
under the Medicaid program, having considered the same, reports 
favorably thereon with an amendment and recommends that the 
bill as amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Committee Action.................................................     3
Committee Votes..................................................     3
Oversight Findings and Recommendations...........................     5
New Budget Authority, Entitlement Authority, and Tax Expenditures     5
Congressional Budget Office Estimate.............................     5
Federal Mandates Statement.......................................     5
Statement of General Performance Goals and Objectives............     5
Duplication of Federal Programs..................................     5
Related Committee and Subcommittee Hearings......................     5
Committee Cost Estimate..........................................     5
Earmark, Limited Tax Benefits, and Limited Tariff Benefits.......     6
Advisory Committee Statement.....................................     6
Applicability to Legislative Branch..............................     6
Section-by-Section Analysis of the Legislation...................     6
Changes in Existing Law Made by the Bill, as Reported............     6

    The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Medicaid Program Improvement Act''. 





  
  
  
  

SEC. 2. ENSURING THE RELIABILITY OF ADDRESS INFORMATION PROVIDED UNDER THE 
          MEDICAID PROGRAM.

  (a) In General.--Section 1902(a) of the Social Security Act (42 
U.S.C. 1396a(a)) is amended--
          (1) in paragraph (86), by striking ``and'' at the end;
          (2) in paragraph (87), by striking the period at the end and 
        inserting ``; and''; and
          (3) by inserting after paragraph (87) the following new 
        paragraph:
          ``(88) beginning January 1, 2026, provide for a process to 
        regularly obtain address information for individuals enrolled 
        under such plan (or a waiver of such plan) from reliable data 
        sources (as described in section 435.919(f)(1)(iii) of title 
        42, Code of Federal Regulations (or a successor regulation)) 
        and act on any changes to such an address based on such 
        information in accordance with such section (or successor 
        regulation), except that this paragraph shall only apply in the 
        case of the 50 States and the District of Columbia.''.
  (b) Application to CHIP.--Section 2107(e)(1) of the Social Security 
Act (42 U.S.C. 1397gg(e)(1)) is amended--
          (1) by redesignating subparagraphs (H) through (U) as 
        subparagraphs (I) through (V), respectively; and
          (2) by inserting after subparagraph (G) the following new 
        subparagraph:
                  ``(H) Section 1902(a)(88) (relating to regularly 
                obtaining address information for enrollees).''.
  (c) Ensuring Transmission of Address Information From Managed Care 
Organizations.--Section 1932 of the Social Security Act (42 U.S.C. 
1396u-2) is amended by adding at the end the following new subsection:
  ``(j) Transmission of Address Information.--Beginning January 1, 
2026, each contract under a State plan with a managed care entity under 
section 1903(m) shall provide that the entity transmits to the State 
any address information for an individual enrolled with the entity that 
is provided to such entity directly from, or verified by such entity 
directly with, such individual.''.

                          Purpose and Summary

    H.R. 8111 would require States to regularly obtain 
beneficiary address information from reliable sources, 
including (where applicable) Medicaid managed care plans, to 
promote the State's ability to contact the beneficiary, and to 
confirm a Medicaid beneficiary's residence is within the state.

                  Background and Need for Legislation

    The Department of Health and Human Services (HHS) Office of 
the Inspector General (OIG) has found that nearly every State 
inadvertently paid Medicaid managed care per member per month 
payments on behalf of beneficiaries who were enrolled in two 
State programs at the same time, creating waste.\1\
---------------------------------------------------------------------------
    \1\U.S. Department of Health and Human Services Office of Inspector 
General, ``Nearly All States Made Capitation Payments for Beneficiaries 
Who Were Concurrently Enrolled in a Medicaid Managed Care Program in 
Two States'', A-05-20-00025, 2022, https://oig.hhs.gov/reports-and-
publications/all-reports-and-publications/nearly-all-states-made-
capitation-payments-for-beneficiaries-who-were-concurrently-enrolled-
in-a-medicaid-managed-care-program-in-two-
states/.
---------------------------------------------------------------------------
    H.R. 8111 would require States to establish processes to 
regularly obtain address information from reliable data 
sources, including by requiring state Medicaid agencies to 
collect address information provided by beneficiaries to 
managed care entities (where applicable). Receiving such 
information helps to promote program integrity by ensuring that 
payments are not made for beneficiaries who do not live in the 
State, and allowing beneficiaries who remain in the state but 
have moved to another in-state address to be more readily 
contacted.\2\
---------------------------------------------------------------------------
    \2\U.S. Government Publishing Office, ``Rules and Regulations'', 
Federal Register, Volume 89, Number 64, April 2, 2024, https://
www.govinfo.gov/content/pkg/FR-2024-04-02/pdf/2024-06566.pdf.
---------------------------------------------------------------------------

                            Committee Action

    On April 30, 2024, the Subcommittee on Health held a 
hearing on H.R. 8111. The title of the hearing was 
``Legislative Proposals to Increase Medicaid Access and Improve 
Program Integrity.'' The Subcommittee received testimony from:
           Daniel Tsai, Deputy Administrator and 
        Director for the Center for Medicaid and CHIP Services, 
        Centers for Medicare & Medicaid Services.
    On May 16, 2024, the Subcommittee on Health met in open 
markup session and forwarded H.R. 8111 to the full Committee by 
a recorded vote of 22 yeas and 0 nays.
    On June 12, 2024, the full Committee on Energy and Commerce 
met in open markup session and ordered H.R. 8111, as amended, 
favorably reported to the House by a recorded vote of 46 yeas 
and 0 nays.

                            Committee Votes

    Clause 3(b) of rule XIII requires the Committee to list the 
record votes on the motion to report legislation and amendments 
thereto. The following reflects the record votes taken during 
the Committee consideration:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

                 Oversight Findings and Recommendations

    Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of 
rule XIII, the Committee held a hearing and made findings that 
are reflected in this report.

      New Budget Authority, Entitlement Authority, and Tax  
                         Expenditures 

    Pursuant to clause 3(c)(2) of rule XIII, the Committee 
finds that H.R. 8111 would result in no new or increased budget 
authority, entitlement authority, or tax expenditures or 
revenues.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII, at the time this 
report was filed, the cost estimate prepared by the Director of 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974 was not available.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

         Statement of General Performance Goals and Objectives

    Pursuant to clause 3(c)(4) of rule XIII, the general 
performance goal or objective of this legislation is to require 
States to have processes to regularly verify residency data for 
Medicaid beneficiaries.

                    Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 8111 is known to be duplicative of another Federal 
program, including any program that was included in a report to 
Congress pursuant to section 21 of Public Law 111-139 or the 
most recent Catalog of Federal Domestic Assistance.

              Related Committee and Subcommittee Hearings

    Pursuant to clause 3(c)(6) of rule XIII, the following 
hearing was used to develop or consider H.R. 8111:
           On April 30, 2024, the Subcommittee on 
        Health held a hearing on H.R. 8111. The title of the 
        hearing was ``Legislative Proposals to Increase 
        Medicaid Access and Improve Program Integrity.'' The 
        Subcommittee received testimony from:
                   Daniel Tsai, Deputy 
                Administrator and Director for the Center for 
                Medicaid and CHIP Services, Centers for 
                Medicare & Medicaid Services.

                        Committee Cost Estimate

    Pursuant to clause 3(d)(1) of rule XIII, the Committee 
adopts as its own the cost estimate prepared by the Director of 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974. At the time this report was 
filed, the estimate was not available.

      Earmark, Limited Tax Benefits, and Limited Tariff Benefits 

    P ursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 8111 contains no earmarks, limited 
tax benefits, or limited tariff benefits.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 provides that the Act may be cited as the 
``Medicaid Program Improvement Act''.

Section 2. Ensuring the reliability of address information provided 
        under the Medicaid program

    Section 2 requires States to have processes to regularly 
verify residency data for Medicaid beneficiaries.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, 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

           *       *       *       *       *       *       *

           TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE  
                                PROGRAMS 

           *       *       *       *       *       *       *

                   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) beginning January 1, 2026, provide for a process 
        to regularly obtain address information for individuals 
        enrolled under such plan (or a waiver of such plan) 
        from reliable data sources (as described in section 
        435.919(f)(1)(iii) of title 42, Code of Federal 
        Regulations (or a successor regulation)) and act on any 
        changes to such an address based on such information in 
        accordance with such section (or successor regulation), 
        except that this paragraph shall only apply 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 under this 
subparagraph shall be considered, for purposes of section 
1903(a), to be payments for medical assistance.
  (dd) Electronic Transmission of Information.--If the State 
agency determining eligibility for medical assistance under 
this title or child health assistance under title XXI verifies 
an element of eligibility based on information from an Express 
Lane Agency (as defined in subsection (e)(13)(F)), or from 
another public agency, then the applicant's signature under 
penalty of perjury shall not be required as to such element. 
Any signature requirement for an application for medical 
assistance may be satisfied through an electronic signature, as 
defined in section 1710(1) of the Government Paperwork 
Elimination Act (44 U.S.C. 3504 note). The requirements of 
subparagraphs (A) and (B) of section 1137(d)(2) may be met 
through evidence in digital or electronic form.
  (ee)(1) For purposes of subsection (a)(46)(B)(ii), the 
requirements of this subsection with respect to an individual 
declaring to be a citizen or national of the United States for 
purposes of establishing eligibility under this title, are, in 
lieu of requiring the individual to present satisfactory 
documentary evidence of citizenship or nationality under 
section 1903(x) (if the individual is not described in 
paragraph (2) of that section), as follows:
          (A) The State submits the name and social security 
        number of the individual to the Commissioner of Social 
        Security as part of the program established under 
        paragraph (2).
          (B) If the State receives notice from the 
        Commissioner of Social Security that the name or social 
        security number, or the declaration of citizenship or 
        nationality, of the individual is inconsistent with 
        information in the records maintained by the 
        Commissioner--
                  (i) the State makes a reasonable effort to 
                identify and address the causes of such 
                inconsistency, including through typographical 
                or other clerical errors, by contacting the 
                individual to confirm the accuracy of the name 
                or social security number submitted or 
                declaration of citizenship or nationality and 
                by taking such additional actions as the 
                Secretary, through regulation or other 
                guidance, or the State may identify, and 
                continues to provide the individual with 
                medical assistance while making such effort; 
                and
                  (ii) in the case such inconsistency is not 
                resolved under clause (i), the State--
                          (I) notifies the individual of such 
                        fact;
                          (II) provides the individual with a 
                        period of 90 days from the date on 
                        which the notice required under 
                        subclause (I) is received by the 
                        individual to either present 
                        satisfactory documentary evidence of 
                        citizenship or nationality (as defined 
                        in section 1903(x)(3)) or resolve the 
                        inconsistency with the Commissioner of 
                        Social Security (and continues to 
                        provide the individual with medical 
                        assistance during such 90-day period); 
                        and
                          (III) disenrolls the individual from 
                        the State plan under this title within 
                        30 days after the end of such 90-day 
                        period if no such documentary evidence 
                        is presented or if such inconsistency 
                        is not resolved.
  (2)(A) Each State electing to satisfy the requirements of 
this subsection for purposes of section 1902(a)(46)(B) shall 
establish a program under which the State submits at least 
monthly to the Commissioner of Social Security for comparison 
of the name and social security number, of each individual 
newly enrolled in the State plan under this title that month 
who is not described in section 1903(x)(2) and who declares to 
be a United States citizen or national, with information in 
records maintained by the Commissioner.
  (B) In establishing the State program under this paragraph, 
the State may enter into an agreement with the Commissioner of 
Social Security--
          (i) to provide, through an on-line system or 
        otherwise, for the electronic submission of, and 
        response to, the information submitted under 
        subparagraph (A) for an individual enrolled in the 
        State plan under this title who declares to be citizen 
        or national on at least a monthly basis; or
          (ii) to provide for a determination of the 
        consistency of the information submitted with the 
        information maintained in the records of the 
        Commissioner through such other method as agreed to by 
        the State and the Commissioner and approved by the 
        Secretary, provided that such method is no more 
        burdensome for individuals to comply with than any 
        burdens that may apply under a method described in 
        clause (i).
  (C) The program established under this paragraph shall 
provide that, in the case of any individual who is required to 
submit a social security number to the State under subparagraph 
(A) and who is unable to provide the State with such number, 
shall be provided with at least the reasonable opportunity to 
present satisfactory documentary evidence of citizenship or 
nationality (as defined in section 1903(x)(3)) as is provided 
under clauses (i) and (ii) of section 1137(d)(4)(A) to an 
individual for the submittal to the State of evidence 
indicating a satisfactory immigration status.
  (3)(A) The State agency implementing the plan approved under 
this title shall, at such times and in such form as the 
Secretary may specify, provide information on the percentage 
each month that the inconsistent submissions bears to the total 
submissions made for comparison for such month. For purposes of 
this subparagraph, a name, social security number, or 
declaration of citizenship or nationality of an individual 
shall be treated as inconsistent and included in the 
determination of such percentage only if--
          (i) the information submitted by the individual is 
        not consistent with information in records maintained 
        by the Commissioner of Social Security;
          (ii) the inconsistency is not resolved by the State;
          (iii) the individual was provided with a reasonable 
        period of time to resolve the inconsistency with the 
        Commissioner of Social Security or provide satisfactory 
        documentation of citizenship status and did not 
        successfully resolve such inconsistency; and
          (iv) payment has been made for an item or service 
        furnished to the individual under this title.
  (B) If, for any fiscal year, the average monthly percentage 
determined under subparagraph (A) is greater than 3 percent--
          (i) the State shall develop and adopt a corrective 
        plan to review its procedures for verifying the 
        identities of individuals seeking to enroll in the 
        State plan under this title and to identify and 
        implement changes in such procedures to improve their 
        accuracy; and
          (ii) pay to the Secretary an amount equal to the 
        amount which bears the same ratio to the total payments 
        under the State plan for the fiscal year for providing 
        medical assistance to individuals who provided 
        inconsistent information as the number of individuals 
        with inconsistent information in excess of 3 percent of 
        such total submitted bears to the total number of 
        individuals with inconsistent information.
  (C) The Secretary may waive, in certain limited cases, all or 
part of the payment under subparagraph (B)(ii) if the State is 
unable to reach the allowable error rate despite a good faith 
effort by such State.
  (D) Subparagraphs (A) and (B) shall not apply to a State for 
a fiscal year if there is an agreement described in paragraph 
(2)(B) in effect as of the close of the fiscal year that 
provides for the submission on a real-time basis of the 
information described in such paragraph.
  (4) Nothing in this subsection shall affect the rights of any 
individual under this title to appeal any disenrollment from a 
State plan.
  (ff) Notwithstanding any other requirement of this title or 
any other provision of Federal or State law, a State shall 
disregard the following property from resources for purposes of 
determining the eligibility of an individual who is an Indian 
for medical assistance under this title:
          (1) Property, including real property and 
        improvements, that is held in trust, subject to Federal 
        restrictions, or otherwise under the supervision of the 
        Secretary of the Interior, located on a reservation, 
        including any federally recognized Indian Tribe's 
        reservation, pueblo, or colony, including former 
        reservations in Oklahoma, Alaska Native regions 
        established by the Alaska Native Claims Settlement Act, 
        and Indian allotments on or near a reservation as 
        designated and approved by the Bureau of Indian Affairs 
        of the Department of the Interior.
          (2) For any federally recognized Tribe not described 
        in paragraph (1), property located within the most 
        recent boundaries of a prior Federal reservation.
          (3) Ownership interests in rents, leases, royalties, 
        or usage rights related to natural resources (including 
        extraction of natural resources or harvesting of 
        timber, other plants and plant products, animals, fish, 
        and shellfish) resulting from the exercise of federally 
        protected rights.
          (4) Ownership interests in or usage rights to items 
        not covered by paragraphs (1) through (3) that have 
        unique religious, spiritual, traditional, or cultural 
        significance or rights that support subsistence or a 
        traditional lifestyle according to applicable tribal 
        law or custom.
  (gg) Maintenance of Effort.--
          (1) General requirement to maintain eligibility 
        standards until state exchange is fully operational.--
        Subject to the succeeding paragraphs of this 
        subsection, during the period that begins on the date 
        of enactment of the Patient Protection and Affordable 
        Care Act and ends on the date on which the Secretary 
        determines that an Exchange established by the State 
        under section 1311 of the Patient Protection and 
        Affordable Care Act is fully operational, as a 
        condition for receiving any Federal payments under 
        section 1903(a) for calendar quarters occurring during 
        such period, a State shall not have in effect 
        eligibility standards, methodologies, or procedures 
        under the State plan under this title or under any 
        waiver of such plan that is in effect during that 
        period, that are more restrictive than the eligibility 
        standards, methodologies, or procedures, respectively, 
        under the plan or waiver that are in effect on the date 
        of enactment of the Patient Protection and Affordable 
        Care Act.
          (2) Continuation of eligibility standards for 
        children through september 30, 2029.--The requirement 
        under paragraph (1) shall continue to apply to a State 
        through September 30, 2029, (but during the period that 
        begins on October 1, 2019, and ends on September 30, 
        2029, only with respect to children in families whose 
        income does not exceed 300 percent of the poverty line 
        (as defined in section 2110(c)(5)) applicable to a 
        family of the size involved) with respect to the 
        eligibility standards, methodologies, and procedures 
        under the State plan under this title or under any 
        waiver of such plan that are applicable to determining 
        the eligibility for medical assistance of any child who 
        is under 19 years of age (or such higher age as the 
        State may have elected).
          (3) Nonapplication.--During the period that begins on 
        January 1, 2011, and ends on December 31, 2013, the 
        requirement under paragraph (1) shall not apply to a 
        State with respect to nonpregnant, nondisabled adults 
        who are eligible for medical assistance under the State 
        plan or under a waiver of the plan at the option of the 
        State and whose income exceeds 133 percent of the 
        poverty line (as defined in section 2110(c)(5)) 
        applicable to a family of the size involved if, on or 
        after December 31, 2010, the State certifies to the 
        Secretary that, with respect to the State fiscal year 
        during which the certification is made, the State has a 
        budget deficit, or with respect to the succeeding State 
        fiscal year, the State is projected to have a budget 
        deficit. Upon submission of such a certification to the 
        Secretary, the requirement under paragraph (1) shall 
        not apply to the State with respect to any remaining 
        portion of the period described in the preceding 
        sentence.
          (4) Determination of compliance.--
                  (A) States shall apply modified adjusted 
                gross income.--A State's determination of 
                income in accordance with subsection (e)(14) 
                shall not be considered to be eligibility 
                standards, methodologies, or procedures that 
                are more restrictive than the standards, 
                methodologies, or procedures in effect under 
                the State plan or under a waiver of the plan on 
                the date of enactment of the Patient Protection 
                and Affordable Care Act for purposes of 
                determining compliance with the requirements of 
                paragraph (1), (2), or (3).
                  (B) States may expand eligibility or move 
                waivered populations into coverage under the 
                state plan.--With respect to any period 
                applicable under paragraph (1), (2), or (3), a 
                State that applies eligibility standards, 
                methodologies, or procedures under the State 
                plan under this title or under any waiver of 
                the plan that are less restrictive than the 
                eligibility standards, methodologies, or 
                procedures, applied under the State plan or 
                under a waiver of the plan on the date of 
                enactment of the Patient Protection and 
                Affordable Care Act, or that makes individuals 
                who, on such date of enactment, are eligible 
                for medical assistance under a waiver of the 
                State plan, after such date of enactment 
                eligible for medical assistance through a State 
                plan amendment with an income eligibility level 
                that is not less than the income eligibility 
                level that applied under the waiver, or as a 
                result of the application of subclause (VIII) 
                of section 1902(a)(10)(A)(i), shall not be 
                considered to have in effect eligibility 
                standards, methodologies, or procedures that 
                are more restrictive than the standards, 
                methodologies, or procedures in effect under 
                the State plan or under a waiver of the plan on 
                the date of enactment of the Patient Protection 
                and Affordable Care Act for purposes of 
                determining compliance with the requirements of 
                paragraph (1), (2), or (3).
  (hh)(1) A State may elect to phase-in the extension of 
eligibility for medical assistance to individuals described in 
subclause (XX) of subsection (a)(10)(A)(ii) based on the 
categorical group (including nonpregnant childless adults) or 
income, so long as the State does not extend such eligibility 
to individuals described in such subclause with higher income 
before making individuals described in such subclause with 
lower income eligible for medical assistance.
  (2) If an individual described in subclause (XX) of 
subsection (a)(10)(A)(ii) is the parent of a child who is under 
19 years of age (or such higher age as the State may have 
elected) who is eligible for medical assistance under the State 
plan or under a waiver of such plan, the individual may not be 
enrolled under the State plan unless the individual's child is 
enrolled under the State plan or under a waiver of the plan or 
is enrolled in other health insurance coverage. For purposes of 
the preceding sentence, the term ``parent'' includes an 
individual treated as a caretaker relative for purposes of 
carrying out section 1931.
  (ii)(1) Individuals described in this subsection are 
individuals--
                  (A) whose income does not exceed an income 
                eligibility level established by the State that 
                does not exceed the highest income eligibility 
                level established under the State plan under 
                this title (or under its State child health 
                plan under title XXI) for pregnant women; and
                  (B) who are not pregnant.
          (2) At the option of a State, individuals described 
        in this subsection may include individuals who, had 
        individuals applied on or before January 1, 2007, would 
        have been made eligible pursuant to the standards and 
        processes imposed by that State for benefits described 
        in clause (XVI) of the matter following subparagraph 
        (G) of section subsection (a)(10) pursuant to a waiver 
        granted under section 1115.
          (3) At the option of a State, for purposes of 
        subsection (a)(17)(B), in determining eligibility for 
        services under this subsection, the State may consider 
        only the income of the applicant or recipient.
  (jj) Primary Care Services Defined.--For purposes of 
subsection (a)(13)(C), the term ``primary care services'' 
means--
          (1) evaluation and management services that are 
        procedure codes (for services covered under title 
        XVIII) for services in the category designated 
        Evaluation and Management in the Healthcare Common 
        Procedure Coding System (established by the Secretary 
        under section 1848(c)(5) as of December 31, 2009, and 
        as subsequently modified); and
          (2) services related to immunization administration 
        for vaccines and toxoids for which CPT codes 90465, 
        90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as 
        subsequently modified) apply under such System.
  (kk) Provider and Supplier Screening, Oversight, and 
Reporting Requirements.--For purposes of subsection (a)(77), 
the requirements of this subsection are the following:
          (1) Screening.--The State complies with the process 
        for screening providers and suppliers under this title, 
        as established by the Secretary under section 
        1866(j)(2).
          (2) Provisional period of enhanced oversight for new 
        providers and suppliers.--The State complies with 
        procedures to provide for a provisional period of 
        enhanced oversight for new providers and suppliers 
        under this title, as established by the Secretary under 
        section 1866(j)(3).
          (3) Disclosure requirements.--The State requires 
        providers and suppliers under the State plan or under a 
        waiver of the plan to comply with the disclosure 
        requirements established by the Secretary under section 
        1866(j)(5).
          (4) Temporary moratorium on enrollment of new 
        providers or suppliers.--
                  (A) Temporary moratorium imposed by the 
                secretary.--
                          (i) In general.--Subject to clause 
                        (ii), the State complies with any 
                        temporary moratorium on the enrollment 
                        of new providers or suppliers imposed 
                        by the Secretary under section 
                        1866(j)(7).
                          (ii) Exceptions.--
                                  (I) Compliance with 
                                moratorium.--A State shall not 
                                be required to comply with a 
                                temporary moratorium described 
                                in clause (i) if the State 
                                determines that the imposition 
                                of such temporary moratorium 
                                would adversely impact 
                                beneficiaries' access to 
                                medical assistance.
                                  (II) FFP available.--
                                Notwithstanding section 
                                1903(i)(2)(E), payment may be 
                                made to a State under this 
                                title with respect to amounts 
                                expended for items and services 
                                described in such section if 
                                the Secretary, in consultation 
                                with the State agency 
                                administering the State plan 
                                under this title (or a waiver 
                                of the plan), determines that 
                                denying payment to the State 
                                pursuant to such section would 
                                adversely impact beneficiaries' 
                                access to medical assistance. 
                          (iii) Limitation on charges to 
                        beneficiaries.--With respect to any 
                        amount expended for items or services 
                        furnished during calendar quarters 
                        beginning on or after October 1, 2017, 
                        the State prohibits, during the period 
                        of a temporary moratorium described in 
                        clause (i), a provider meeting the 
                        requirements specified in subparagraph 
                        (C)(iii) of section 1866(j)(7) from 
                        charging an individual or other person 
                        eligible to receive medical assistance 
                        under the State plan under this title 
                        (or a waiver of the plan) for an item 
                        or service described in section 
                        1903(i)(2)(E) furnished to such an 
                        individual.
                  (B) Moratorium on enrollment of providers and 
                suppliers.--At the option of the State, the 
                State imposes, for purposes of entering into 
                participation agreements with providers or 
                suppliers under the State plan or under a 
                waiver of the plan, periods of enrollment 
                moratoria, or numerical caps or other limits, 
                for providers or suppliers identified by the 
                Secretary as being at high-risk for fraud, 
                waste, or abuse as necessary to combat fraud, 
                waste, or abuse, but only if the State 
                determines that the imposition of any such 
                period, cap, or other limits would not 
                adversely impact beneficiaries' access to 
                medical assistance.
          (5) Compliance programs.--The State requires 
        providers and suppliers under the State plan or under a 
        waiver of the plan to establish, in accordance with the 
        requirements of section 1866(j)(7), a compliance 
        program that contains the core elements established 
        under subparagraph (B) of that section 1866(j)(7) for 
        providers or suppliers within a particular industry or 
        category.
          (6) Reporting of adverse provider actions.--The State 
        complies with the national system for reporting 
        criminal and civil convictions, sanctions, negative 
        licensure actions, and other adverse provider actions 
        to the Secretary, through the Administrator of the 
        Centers for Medicare & Medicaid Services, in accordance 
        with regulations of the Secretary.
          (7) Enrollment and npi of ordering or referring 
        providers.--The State requires--
                  (A) all ordering or referring physicians or 
                other professionals to be enrolled under the 
                State plan or under a waiver of the plan as a 
                participating provider; and
                  (B) the national provider identifier of any 
                ordering or referring physician or other 
                professional to be specified on any claim for 
                payment that is based on an order or referral 
                of the physician or other professional.
          (8) Provider terminations.--
                  (A) In general.--Beginning on July 1, 2018, 
                in the case of a notification under subsection 
                (a)(41) with respect to a termination for a 
                reason specified in section 455.101 of title 
                42, Code of Federal Regulations (as in effect 
                on November 1, 2015) or for any other reason 
                specified by the Secretary, of the 
                participation of a provider of services or any 
                other person under the State plan (or under a 
                waiver of the plan), the State, not later than 
                30 days after the effective date of such 
                termination, submits to the Secretary with 
                respect to any such provider or person, as 
                appropriate--
                          (i) the name of such provider or 
                        person;
                          (ii) the provider type of such 
                        provider or person;
                          (iii) the specialty of such 
                        provider's or person's practice;
                          (iv) the date of birth, Social 
                        Security number, national provider 
                        identifier (if applicable), Federal 
                        taxpayer identification number, and the 
                        State license or certification number 
                        of such provider or person (if 
                        applicable);
                          (v) the reason for the termination;
                          (vi) a copy of the notice of 
                        termination sent to the provider or 
                        person;
                          (vii) the date on which such 
                        termination is effective, as specified 
                        in the notice; and
                          (viii) any other information required 
                        by the Secretary.
                  (B) Effective date defined.--For purposes of 
                this paragraph, the term ``effective date'' 
                means, with respect to a termination described 
                in subparagraph (A), the later of--
                          (i) the date on which such 
                        termination is effective, as specified 
                        in the notice of such termination; or
                          (ii) the date on which all appeal 
                        rights applicable to such termination 
                        have been exhausted or the timeline for 
                        any such appeal has expired.
          (9) Other state oversight.--Nothing in this 
        subsection shall be interpreted to preclude or limit 
        the ability of a State to engage in provider and 
        supplier screening or enhanced provider and supplier 
        oversight activities beyond those required by the 
        Secretary.
  (ll) Termination Notification Database.--In the case of a 
provider of services or any other person whose participation 
under this title or title XXI is terminated (as described in 
subsection (kk)(8)), the Secretary shall, not later than 30 
days after the date on which the Secretary is notified of such 
termination under subsection (a)(41) (as applicable), review 
such termination and, if the Secretary determines appropriate, 
include such termination in any database or similar system 
developed pursuant to section 6401(b)(2) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 1395cc note; 
Public Law 111-148).
  (mm) Directory Physician or Provider Described.--A physician 
or provider described in this subsection is--
          (1) in the case of a physician or provider of a 
        provider type for which the State agency, as a 
        condition on receiving payment for items and services 
        furnished by the physician or provider to individuals 
        eligible to receive medical assistance under the State 
        plan, requires the enrollment of the physician or 
        provider with the State agency, a physician or a 
        provider that--
                  (A) is enrolled with the agency as of the 
                date on which the directory is published or 
                updated (as applicable) under subsection 
                (a)(83); and
                  (B) received payment under the State plan in 
                the 12-month period preceding such date; and
          (2) in the case of a physician or provider of a 
        provider type for which the State agency does not 
        require such enrollment, a physician or provider that 
        received payment under the State plan (or a waiver of 
        the plan) in the 12-month period preceding the date on 
        which the directory is published or updated (as 
        applicable) under subsection (a)(83).
  (nn) Juvenile; Eligible Juvenile; Public Institution.--For 
purposes of subsection (a)(84) and this subsection:
          (1) Juvenile.--The term ``juvenile'' means an 
        individual who is--
                  (A) under 21 years of age; or
                  (B) described in subsection 
                (a)(10)(A)(i)(IX).
          (2) Eligible juvenile.--The term ``eligible 
        juvenile'' means a juvenile who is an inmate of a 
        public institution and who--
                  (A) was determined eligible for medical 
                assistance under the State plan (or waiver of 
                such plan) immediately before becoming an 
                inmate of such a public institution; or
                  (B) is determined eligible for such medical 
                assistance while an inmate of a public 
                institution.
          (3) Inmate of a public institution.--The term 
        ``inmate of a public institution'' has the meaning 
        given such term for purposes of applying the 
        subdivision (A) following the last numbered paragraph 
        of section 1905(a), taking into account the exception 
        in such subdivision for a patient of a medical 
        institution.
  (oo) Drug Review and Utilization Requirements.--
          (1) In general.--For purposes of subsection (a)(85), 
        the drug review and utilization requirements under this 
        subsection are, subject to paragraph (3) and beginning 
        October 1, 2019, the following:
                  (A) Claims review limitations.--
                          (i) In general.--The State has in 
                        place--
                                  (I) safety edits (as 
                                specified by the State) for 
                                subsequent fills for opioids 
                                and a claims review automated 
                                process (as designed and 
                                implemented by the State) that 
                                indicates when an individual 
                                enrolled under the State plan 
                                (or under a waiver of the State 
                                plan) is prescribed a 
                                subsequent fill of opioids in 
                                excess of any limitation that 
                                may be identified by the State;
                                  (II) safety edits (as 
                                specified by the State) on the 
                                maximum daily morphine 
                                equivalent that can be 
                                prescribed to an individual 
                                enrolled under the State plan 
                                (or under a waiver of the State 
                                plan) for treatment of chronic 
                                pain and a claims review 
                                automated process (as designed 
                                and implemented by the State) 
                                that indicates when an 
                                individual enrolled under the 
                                plan (or waiver) is prescribed 
                                the morphine equivalent for 
                                such treatment in excess of any 
                                limitation that may be 
                                identified by the State; and
                                  (III) a claims review 
                                automated process (as designed 
                                and implemented by the State) 
                                that monitors when an 
                                individual enrolled under the 
                                State plan (or under a waiver 
                                of the State plan) is 
                                concurrently prescribed opioids 
                                and--
                                          (aa) benzodiazepines; 
                                        or
                                          (bb) antipsychotics.
                          (ii) Managed care entities.--The 
                        State requires each managed care entity 
                        (as defined in section 1932(a)(1)(B)) 
                        with respect to which the State has a 
                        contract under section 1903(m) or under 
                        section 1905(t)(3) to have in place, 
                        subject to paragraph (3), with respect 
                        to individuals who are eligible for 
                        medical assistance under the State plan 
                        (or under a waiver of the State plan) 
                        and who are enrolled with the entity, 
                        the limitations described in subclauses 
                        (I) and (II) of clause (i) and a claims 
                        review automated process described in 
                        subclause (III) of such clause.
                          (iii) Rules of construction.--Nothing 
                        in this subparagraph may be construed 
                        as prohibiting a State or managed care 
                        entity from designing and implementing 
                        a claims review automated process under 
                        this subparagraph that provides for 
                        prospective or retrospective reviews of 
                        claims. Nothing in this subparagraph 
                        shall be understood as prohibiting the 
                        exercise of clinical judgment from a 
                        provider enrolled as a participating 
                        provider in a State plan (or waiver of 
                        the State plan) or contracting with a 
                        managed care entity regarding the best 
                        items and services for an individual 
                        enrolled under such State plan (or 
                        waiver).
                  (B) Program to monitor antipsychotic 
                medications by children.--The State has in 
                place a program (as designed and implemented by 
                the State) to monitor and manage the 
                appropriate use of antipsychotic medications by 
                children enrolled under the State plan (or 
                under a waiver of the State plan) and submits 
                annually to the Secretary such information as 
                the Secretary may require on activities carried 
                out under such program for individuals not more 
                than the age of 18 years generally and children 
                in foster care specifically.
                  (C) Fraud and abuse identification.--The 
                State has in place a process (as designed and 
                implemented by the State) that identifies 
                potential fraud or abuse of controlled 
                substances by individuals enrolled under the 
                State plan (or under a waiver of the State 
                plan), health care providers prescribing drugs 
                to individuals so enrolled, and pharmacies 
                dispensing drugs to individuals so enrolled.
                  (D) Reports.--The State shall include in the 
                annual report submitted to the Secretary under 
                section 1927(g)(3)(D) information on the 
                limitations, requirement, program, and 
                processes applied by the State under 
                subparagraphs (A) through (C) in accordance 
                with such manner and time as specified by the 
                Secretary.
                  (E) Clarification.--Nothing shall prevent a 
                State from satisfying the requirement--
                          (i) described in subparagraph (A) by 
                        having safety edits or a claims review 
                        automated process described in such 
                        subparagraph that was in place before 
                        October 1, 2019;
                          (ii) described in subparagraph (B) by 
                        having a program described in such 
                        subparagraph that was in place before 
                        such date; or
                          (iii) described in subparagraph (C) 
                        by having a process described in such 
                        subparagraph that was in place before 
                        such date.
          (2) Annual report by secretary.--For each fiscal year 
        beginning with fiscal year 2020, the Secretary shall 
        submit to Congress a report on the most recent 
        information submitted by States under paragraph (1)(D).
          (3) Exceptions.--
                  (A) Certain individuals exempted.--The drug 
                review and utilization requirements under this 
                subsection shall not apply with respect to an 
                individual who--
                          (i) is receiving--
                                  (I) hospice or palliative 
                                care; or
                                  (II) treatment for cancer;
                          (ii) is a resident of a long-term 
                        care facility, of a facility described 
                        in section 1905(d), or of another 
                        facility for which frequently abused 
                        drugs are dispensed for residents 
                        through a contract with a single 
                        pharmacy; or
                          (iii) the State elects to treat as 
                        exempted from such requirements.
                  (B)  Exception relating to ensuring access.--
                In order to ensure reasonable access to health 
                care, the Secretary shall waive the drug review 
                and utilization requirements under this 
                subsection, with respect to a State, in the 
                case of natural disasters and similar 
                situations, and in the case of the provision of 
                emergency services (as defined for purposes of 
                section 1860D-4(c)(5)(D)(ii)(II)).
  (pp) Residential Pediatric Recovery Center Defined.--
          (1) In general.--For purposes of section 1902(a)(86), 
        the term ``residential pediatric recovery center'' 
        means a center or facility that furnishes items and 
        services for which medical assistance is available 
        under the State plan to infants with the diagnosis of 
        neonatal abstinence syndrome without any other 
        significant medical risk factors.
          (2) Counseling and services.--A residential pediatric 
        recovery center may offer counseling and other services 
        to mothers (and other appropriate family members and 
        caretakers) of infants receiving treatment at such 
        centers if such services are otherwise covered under 
        the State plan under this title or under a waiver of 
        such plan. Such other services may include the 
        following:
                  (A) Counseling or referrals for services.
                  (B) Activities to encourage caregiver-infant 
                bonding.
                  (C) Training on caring for such infants.
  (qq) Application of Certain Data Reporting and Program 
Integrity Requirements to Northern Mariana Islands, American 
Samoa, and Guam.--
          (1) In general.--Not later than October 1, 2021, the 
        Northern Mariana Islands, American Samoa, and Guam 
        shall--
                  (A) demonstrate progress in implementing 
                methods, satisfactory to the Secretary, for the 
                collection and reporting of reliable data to 
                the Transformed Medicaid Statistical 
                Information System (T-MSIS) (or a successor 
                system); and
                  (B) demonstrate progress in establishing a 
                State medicaid fraud control unit described in 
                section 1903(q).
          (2) Determination of progress.--For purposes of 
        paragraph (1), the Secretary shall deem that a 
        territory described in such paragraph has demonstrated 
        satisfactory progress in implementing methods for the 
        collection and reporting of reliable data or 
        establishing a State medicaid fraud control unit if the 
        territory has made a good faith effort to implement 
        such methods or establish such a unit, given the 
        circumstances of the territory.
  (rr) Program Integrity Requirements for Puerto Rico.--
          (1) System for tracking federal medicaid funding 
        provided to puerto rico.--
                  (A) In general.--Puerto Rico shall establish 
                and maintain a system, which may include the 
                use of a quarterly Form CMS-64, for tracking 
                any amounts paid by the Federal Government to 
                Puerto Rico with respect to the State plan of 
                Puerto Rico (or a waiver of such plan). Under 
                such system, Puerto Rico shall ensure that 
                information is available, with respect to each 
                quarter in a fiscal year (beginning with the 
                first quarter beginning on or after the date 
                that is 1 year after the date of the enactment 
                of this subsection), on the following:
                          (i) In the case of a quarter other 
                        than the first quarter of such fiscal 
                        year--
                                  (I) the total amount expended 
                                by Puerto Rico during any 
                                previous quarter of such fiscal 
                                year under the State plan of 
                                Puerto Rico (or a waiver of 
                                such plan); and
                                  (II) a description of how 
                                such amount was so expended.
                          (ii) The total amount that Puerto 
                        Rico expects to expend during the 
                        quarter under the State plan of Puerto 
                        Rico (or a waiver of such plan), and a 
                        description of how Puerto Rico expects 
                        to expend such amount.
                  (B) Report to cms.--For each quarter with 
                respect to which Puerto Rico is required under 
                subparagraph (A) to ensure that information 
                described in such subparagraph is available, 
                Puerto Rico shall submit to the Administrator 
                of the Centers for Medicare & Medicaid Services 
                a report on such information for such quarter, 
                which may include the submission of a quarterly 
                Form CMS-37.
          (2) Submission of documentation on contracts upon 
        request.--Puerto Rico shall, upon request, submit to 
        the Administrator of the Centers for Medicare & 
        Medicaid Services all documentation requested with 
        respect to contracts awarded under the State plan of 
        Puerto Rico (or a waiver of such plan).
          (3) Reporting on medicaid and chip scorecard 
        measures.--Beginning 12 months after the date of 
        enactment of this subsection, Puerto Rico shall begin 
        to report to the Administrator of the Centers for 
        Medicare & Medicaid Services on selected measures 
        included in the Medicaid and CHIP Scorecard developed 
        by the Centers for Medicare & Medicaid Services.
  (ss) Uninsured Individual Defined.--For purposes of this 
section, the term ``uninsured individual'' means, 
notwithstanding any other provision of this title, any 
individual who is--
          (1) not described in subsection (a)(10)(A)(i) 
        (excluding subclause (VIII) of such subsection if the 
        individual is a resident of a State which does not 
        furnish medical assistance to individuals described in 
        such subclause); and
          (2) not enrolled in a Federal health care program (as 
        defined in section 1128B(f)), a group health plan, 
        group or individual health insurance coverage offered 
        by a health insurance issuer (as such terms are defined 
        in section 2791 of the Public Health Service Act), or a 
        health plan offered under chapter 89 of title 5, United 
        States Code, except that individuals who are eligible 
        for medical assistance under subsection 
        (a)(10)(A)(ii)(XII), subsection (a)(10)(A)(ii)(XVIII), 
        subsection (a)(10)(A)(ii)(XXI), or subsection 
        (a)(10)(C) (but only to the extent such an individual 
        is considered to not have minimum essential coverage 
        under section 5000A(f)(1) of the Internal Revenue Code 
        of 1986), or who are described in subsection (l)(1)(A) 
        and are eligible for medical assistance only because of 
        subsection (a)(10)(A)(i)(IV) or (a)(10)(A)(ii)(IX) and 
        whose eligibility for such assistance is limited by the 
        State under clause (VII) in the matter following 
        subsection (a)(10)(G), shall not be treated as enrolled 
        in a Federal health care program for purposes of this 
        paragraph.
  (tt) Requirements Relating to Transition From Families First 
Coronavirus Response Act FMAP Increase Requirements; 
Enforcement and Corrective Action.--
          (1) Reporting requirements.--For each month occurring 
        during the period that begins on April 1, 2023, and 
        ends on June 30, 2024, each State shall submit to the 
        Secretary, on a timely basis, a report, that the 
        Secretary shall make publicly available, on the 
        activities of the State relating to eligibility 
        redeterminations conducted during such period, and 
        which include, with respect to the month for which the 
        report is submitted, the following information:
                  (A) The number of eligibility renewals 
                initiated, beneficiaries renewed on a total and 
                ex parte basis, and individuals whose coverage 
                for medical assistance, child health 
                assistance, or pregnancy-related assistance was 
                terminated.
                  (B) The number of individuals whose coverage 
                for medical assistance, child health 
                assistance, or pregnancy-related assistance was 
                so terminated for procedural reasons.
                  (C) Where applicable, the number of 
                individuals who were enrolled in a State child 
                health plan or waiver in the form described in 
                paragraph (1) of section 2101(a).
                  (D) Unless the Administrator of the Centers 
                for Medicare & Medicaid Services reports such 
                information on behalf of the State:
                          (i) In a State with a Federal or 
                        State American Health Benefit Exchange 
                        established under title I of the 
                        Patient Protection and Affordable Care 
                        Act in which the systems used to 
                        determine eligibility for assistance 
                        under this title or title XXI are not 
                        integrated with the systems used to 
                        determine eligibility for coverage 
                        under a qualified health plan with 
                        advance payment under section 1412(a) 
                        of the Patient Protection and 
                        Affordable Care Act of any premium tax 
                        credit allowed under section 36B of the 
                        Internal Revenue Code of 1986--
                                  (I) the number of individuals 
                                whose accounts were received 
                                via secure electronic transfer 
                                by the Federal or State 
                                American Health Benefit 
                                Exchange, or a basic health 
                                program established under 
                                section 1331 of the Patient 
                                Protection and Affordable Care 
                                Act;
                                  (II) the number of 
                                individuals identified in 
                                subclause (I) who were 
                                determined eligible for a 
                                qualified health plan, as 
                                defined in section 1301(a)(1) 
                                of the Patient Protection and 
                                Affordable Care Act, or (if 
                                applicable) the basic health 
                                program established under 
                                section 1331 of such Act; and
                                  (III) the number of 
                                individuals identified in 
                                subclause (II) who made a 
                                qualified health plan selection 
                                or were enrolled in a basic 
                                health program plan (if 
                                applicable).
                          (ii) In a State with a State American 
                        Health Benefit Exchange established 
                        under title I of the Patient Protection 
                        and Affordable Care Act in which the 
                        systems used to determine eligibility 
                        for assistance under this title or 
                        title XXI are integrated with the 
                        systems used to determine eligibility 
                        for coverage under a qualified health 
                        plan with advance payment under section 
                        1412(a) of the Patient Protection and 
                        Affordable Care Act of any premium tax 
                        credit allowed under section 36B of the 
                        Internal Revenue Code of 1986--
                                  (I) the number of individuals 
                                who were determined eligible 
                                for a qualified health plan, as 
                                defined in section 1301(a)(1) 
                                of the Patient Protection and 
                                Affordable Care Act, or (if 
                                applicable) the basic health 
                                program established under 
                                section 1331 of such Act; and
                                  (II) the number of 
                                individuals identified in 
                                subclause (I) who made a 
                                qualified health plan selection 
                                or were enrolled in a basic 
                                health program plan (if 
                                applicable).
                  (E) The total call center volume, average 
                wait times, and average abandonment rate (as 
                determined by the Secretary) for each call 
                center of the State agency responsible for 
                administering the State plan under this title 
                (or a waiver of such plan) during such month.
                  (F) Such other information related to 
                eligibility redeterminations and renewals 
                during the period described in paragraph (1), 
                as identified by the Secretary.
          (2) Enforcement and corrective action.--
                  (A) In general.--For each fiscal quarter that 
                occurs during the period that begins on July 1, 
                2023, and ends on June 30, 2024, if a State 
                does not satisfy the requirements of paragraph 
                (1), the Federal medical assistance percentage 
                determined for the State for the quarter under 
                section 1905(b) shall be reduced by the number 
                of percentage points (not to exceed 1 
                percentage point) equal to the product of 0.25 
                percentage points and the number of fiscal 
                quarters during such period for which the State 
                has failed to satisfy such requirements.
                  (B) Corrective action plan; additional 
                authority.--
                          (i) In general.--The Secretary may 
                        assess a State's compliance with all 
                        Federal requirements applicable to 
                        eligibility redeterminations and the 
                        reporting requirements described in 
                        paragraph (1), and, if the Secretary 
                        determines that a State did not comply 
                        with any such requirements during the 
                        period that begins on April 1, 2023, 
                        and ends on June 30, 2024, the 
                        Secretary may require the State to 
                        submit and implement a corrective 
                        action plan in accordance with clause 
                        (ii).
                          (ii) Corrective action plan.--A State 
                        that receives a written notice from the 
                        Secretary that the Secretary has 
                        determined that the State is not in 
                        compliance with a requirement described 
                        in clause (i) shall--
                                  (I) not later than 14 days 
                                after receiving such notice, 
                                submit a corrective action plan 
                                to the Secretary;
                                  (II) not later than 21 days 
                                after the date on which such 
                                corrective action plan is 
                                submitted to the Secretary, 
                                receive approval for the plan 
                                from the Secretary; and
                                  (III) begin implementation of 
                                such corrective action plan not 
                                later than 14 days after such 
                                approval.
                          (iii) Effect of failure to submit or 
                        implement a corrective action plan.--If 
                        a State fails to submit or implement an 
                        approved corrective action plan in 
                        accordance with clause (ii), the 
                        Secretary may, in addition to any 
                        reduction applied under subparagraph 
                        (A) to the Federal medical assistance 
                        percentage determined for the State and 
                        any other remedy available to the 
                        Secretary for the purpose of carrying 
                        out this title, require the State to 
                        suspend making all or some terminations 
                        of eligibility for medical assistance 
                        from the State plan under this title 
                        (including any waiver of such plan) 
                        that are for procedural reasons until 
                        the State takes appropriate corrective 
                        action, as determined by the Secretary, 
                        and may impose a civil money penalty of 
                        not more than $100,000 for each day a 
                        State is not in compliance.

           *       *       *       *       *       *       *

                  provisions relating to managed care

  Sec. 1932. (a) State Option To Use Managed Care.--
          (1) Use of medicaid managed care organizations and 
        primary care case managers.--
                  (A) In general.--Subject to the succeeding 
                provisions of this section, and notwithstanding 
                paragraph (1), (10)(B), or (23)(A) of section 
                1902(a), a State--
                          (i) may require an individual who is 
                        eligible for medical assistance under 
                        the State plan under this title to 
                        enroll with a managed care entity as a 
                        condition of receiving such assistance 
                        (and, with respect to assistance 
                        furnished by or under arrangements with 
                        such entity, to receive such assistance 
                        through the entity), if--
                                  (I) the entity and the 
                                contract with the State meet 
                                the applicable requirements of 
                                this section and section 
                                1903(m) or section 1905(t), and
                                  (II) the requirements 
                                described in the succeeding 
                                paragraphs of this subsection 
                                are met; and
                          (ii) may restrict the number of 
                        provider agreements with managed care 
                        entities under the State plan if such 
                        restriction does not substantially 
                        impair access to services.
                  (B) Definition of managed care entity.--In 
                this section, the term ``managed care entity'' 
                means--
                          (i) a medicaid managed care 
                        organization, as defined in section 
                        1903(m)(1)(A), that provides or 
                        arranges for services for enrollees 
                        under a contract pursuant to section 
                        1903(m); and
                          (ii) a primary care case manager, as 
                        defined in section 1905(t)(2).
          (2) Special rules.--
                  (A) Exemption of certain children with 
                special needs.--A State may not require under 
                paragraph (1) the enrollment in a managed care 
                entity of an individual under 19 years of age 
                who--
                          (i) is eligible for supplemental 
                        security income under title XVI;
                          (ii) is described in section 
                        501(a)(1)(D);
                          (iii) is described in section 
                        1902(e)(3);
                          (iv) is receiving foster care or 
                        adoption assistance under part E of 
                        title IV; or
                          (v) is in foster care or otherwise in 
                        an out-of-home placement.
                  (B) Exemption of medicare beneficiaries.--A 
                State may not require under paragraph (1) the 
                enrollment in a managed care entity of an 
                individual who is a qualified medicare 
                beneficiary (as defined in section 1905(p)(1)) 
                or an individual otherwise eligible for 
                benefits under title XVIII.
                  (C) Indian enrollment.--A State may not 
                require under paragraph (1) the enrollment in a 
                managed care entity of an individual who is an 
                Indian (as defined in section 4(c) of the 
                Indian Health Care Improvement Act of 1976 (25 
                U.S.C. 1603(c)) unless the entity is one of the 
                following (and only if such entity is 
                participating under the plan):
                          (i) The Indian Health Service.
                          (ii) An Indian health program 
                        operated by an Indian tribe or tribal 
                        organization pursuant to a contract, 
                        grant, cooperative agreement, or 
                        compact with the Indian Health Service 
                        pursuant to the Indian Self-
                        Determination Act (25 U.S.C. 450 et 
                        seq.).
                          (iii) An urban Indian health program 
                        operated by an urban Indian 
                        organization pursuant to a grant or 
                        contract with the Indian Health Service 
                        pursuant to title V of the Indian 
                        Health Care Improvement Act (25 U.S.C. 
                        1601 et seq.).
          (3) Choice of coverage.--
                  (A) In general.--A State must permit an 
                individual to choose a managed care entity from 
                not less than two such entities that meet the 
                applicable requirements of this section, and of 
                section 1903(m) or section 1905(t).
                  (B) State option.--At the option of the 
                State, a State shall be considered to meet the 
                requirements of subparagraph (A) in the case of 
                an individual residing in a rural area, if the 
                State requires the individual to enroll with a 
                managed care entity if such entity--
                          (i) permits the individual to receive 
                        such assistance through not less than 
                        two physicians or case managers (to the 
                        extent that at least two physicians or 
                        case managers are available to provide 
                        such assistance in the area), and
                          (ii) permits the individual to obtain 
                        such assistance from any other provider 
                        in appropriate circumstances (as 
                        established by the State under 
                        regulations of the Secretary).
                  (C) Treatment of certain county-operated 
                health insuring organizations.--A State shall 
                be considered to meet the requirement of 
                subparagraph (A) if--
                          (i) the managed care entity in which 
                        the individual is enrolled is a health-
                        insuring organization which--
                                  (I) first became operational 
                                prior to January 1, 1986, or
                                  (II) is described in section 
                                9517(c)(3) of the Omnibus 
                                Budget Reconciliation Act of 
                                1985 (as added by section 
                                4734(2) of the Omnibus Budget 
                                Reconciliation Act of 1990), 
                                and
                          (ii) the individual is given a choice 
                        between at least two providers within 
                        such entity.
          (4) Process for enrollment and termination and change 
        of enrollment.--As conditions under paragraph (1)(A)--
                  (A) In general.--The State, enrollment broker 
                (if any), and managed care entity shall permit 
                an individual eligible for medical assistance 
                under the State plan under this title who is 
                enrolled with the entity under this title to 
                terminate (or change) such enrollment--
                          (i) for cause at any time (consistent 
                        with section 1903(m)(2)(A)(vi)), and
                          (ii) without cause--
                                  (I) during the 90-day period 
                                beginning on the date the 
                                individual receives notice of 
                                such enrollment, and
                                  (II) at least every 12 months 
                                thereafter.
                  (B) Notice of termination rights.--The State 
                shall provide for notice to each such 
                individual of the opportunity to terminate (or 
                change) enrollment under such conditions. Such 
                notice shall be provided at least 60 days 
                before each annual enrollment opportunity 
                described in subparagraph (A)(ii)(II).
                  (C) Enrollment priorities.--In carrying out 
                paragraph (1)(A), the State shall establish a 
                method for establishing enrollment priorities 
                in the case of a managed care entity that does 
                not have sufficient capacity to enroll all such 
                individuals seeking enrollment under which 
                individuals already enrolled with the entity 
                are given priority in continuing enrollment 
                with the entity.
                  (D) Default enrollment process.--In carrying 
                out paragraph (1)(A), the State shall establish 
                a default enrollment process--
                          (i) under which any such individual 
                        who does not enroll with a managed care 
                        entity during the enrollment period 
                        specified by the State shall be 
                        enrolled by the State with such an 
                        entity which has not been found to be 
                        out of substantial compliance with the 
                        applicable requirements of this section 
                        and of section 1903(m) or section 
                        1905(t); and
                          (ii) that takes into consideration--
                                  (I) maintaining existing 
                                provider-individual 
                                relationships or relationships 
                                with providers that have 
                                traditionally served 
                                beneficiaries under this title; 
                                and
                                  (II) if maintaining such 
                                provider relationships is not 
                                possible, the equitable 
                                distribution of such 
                                individuals among qualified 
                                managed care entities available 
                                to enroll such individuals, 
                                consistent with the enrollment 
                                capacities of the entities.
          (5) Provision of information.--
                  (A) Information in easily understood form.--
                Each State, enrollment broker, or managed care 
                entity shall provide all enrollment notices and 
                informational and instructional materials 
                relating to such an entity under this title in 
                a manner and form which may be easily 
                understood by enrollees and potential enrollees 
                of the entity who are eligible for medical 
                assistance under the State plan under this 
                title.
                  (B) Information to enrollees and potential 
                enrollees.--Each managed care entity that is a 
                medicaid managed care organization shall, upon 
                request, make available to enrollees and 
                potential enrollees in the organization's 
                service area information concerning the 
                following:
                          (i) Providers.--The identity, 
                        locations, qualifications, and 
                        availability of health care providers 
                        that participate with the organization.
                          (ii) Enrollee rights and 
                        responsibilities.--The rights and 
                        responsibilities of enrollees.
                          (iii) Grievance and appeal 
                        procedures.--The procedures available 
                        to an enrollee and a health care 
                        provider to challenge or appeal the 
                        failure of the organization to cover a 
                        service.
                          (iv) Information on covered items and 
                        services.--All items and services that 
                        are available to enrollees under the 
                        contract between the State and the 
                        organization that are covered either 
                        directly or through a method of 
                        referral and prior authorization. Each 
                        managed care entity that is a primary 
                        care case manager shall, upon request, 
                        make available to enrollees and 
                        potential enrollees in the 
                        organization's service area the 
                        information described in clause (iii).
                  (C) Comparative information.--A State that 
                requires individuals to enroll with managed 
                care entities under paragraph (1)(A) shall 
                annually (and upon request) provide, directly 
                or through the managed care entity, to such 
                individuals a list identifying the managed care 
                entities that are (or will be) available and 
                information (presented in a comparative, chart-
                like form) relating to the following for each 
                such entity offered:
                          (i) Benefits and cost-sharing.--The 
                        benefits covered and cost-sharing 
                        imposed by the entity.
                          (ii) Service area.--The service area 
                        of the entity.
                          (iii) Quality and performance.--To 
                        the extent available, quality and 
                        performance indicators for the benefits 
                        under the entity.
                  (D) Information on benefits not covered under 
                managed care arrangement.--A State, directly or 
                through managed care entities, shall, on or 
                before an individual enrolls with such an 
                entity under this title, inform the enrollee in 
                a written and prominent manner of any benefits 
                to which the enrollee may be entitled to under 
                this title but which are not made available to 
                the enrollee through the entity. Such 
                information shall include information on where 
                and how such enrollees may access benefits not 
                made available to the enrollee through the 
                entity.
  (b) Beneficiary Protections.--
          (1) Specification of benefits.--Each contract with a 
        managed care entity under section 1903(m) or under 
        section 1905(t)(3) shall specify the benefits the 
        provision (or arrangement) for which the entity is 
        responsible.
          (2) Assuring coverage to emergency services.--
                  (A) In general.--Each contract with a 
                medicaid managed care organization under 
                section 1903(m) and each contract with a 
                primary care case manager under section 
                1905(t)(3) shall require the organization or 
                manager--
                          (i) to provide coverage for emergency 
                        services (as defined in subparagraph 
                        (B)) without regard to prior 
                        authorization or the emergency care 
                        provider's contractual relationship 
                        with the organization or manager, and
                          (ii) to comply with guidelines 
                        established under section 1852(d)(2) 
                        (respecting coordination of post-
                        stabilization care) in the same manner 
                        as such guidelines apply to 
                        Medicare+Choice plans offered under 
                        part C of title XVIII.
                The requirement under clause (ii) shall first 
                apply 30 days after the date of promulgation of 
                the guidelines referred to in such clause.
                  (B) Emergency services defined.--In 
                subparagraph (A)(i), the term ``emergency 
                services'' means, with respect to an individual 
                enrolled with an organization, covered 
                inpatient and outpatient services that--
                          (i) are furnished by a provider that 
                        is qualified to furnish such services 
                        under this title, and
                          (ii) are needed to evaluate or 
                        stabilize an emergency medical 
                        condition (as defined in subparagraph 
                        (C)).
                  (C) Emergency medical condition defined.--In 
                subparagraph (B)(ii), the term ``emergency 
                medical condition'' means a medical condition 
                manifesting itself by acute symptoms of 
                sufficient severity (including severe pain) 
                such that a prudent layperson, who possesses an 
                average knowledge of health and medicine, could 
                reasonably expect the absence of immediate 
                medical attention to result in--
                          (i) placing the health of the 
                        individual (or, with respect to a 
                        pregnant woman, the health of the woman 
                        or her unborn child) in serious 
                        jeopardy,
                          (ii) serious impairment to bodily 
                        functions, or
                          (iii) serious dysfunction of any 
                        bodily organ or part.
                  (D) Emergency services furnished by non-
                contract providers.--Any provider of emergency 
                services that does not have in effect a 
                contract with a Medicaid managed care entity 
                that establishes payment amounts for services 
                furnished to a beneficiary enrolled in the 
                entity's Medicaid managed care plan must accept 
                as payment in full no more than the amounts 
                (less any payments for indirect costs of 
                medical education and direct costs of graduate 
                medical education) that it could collect if the 
                beneficiary received medical assistance under 
                this title other than through enrollment in 
                such an entity. In a State where rates paid to 
                hospitals under the State plan are negotiated 
                by contract and not publicly released, the 
                payment amount applicable under this 
                subparagraph shall be the average contract rate 
                that would apply under the State plan for 
                general acute care hospitals or the average 
                contract rate that would apply under such plan 
                for tertiary hospitals.
          (3) Protection of enrollee-provider communications.--
                  (A) In general.--Subject to subparagraphs (B) 
                and (C), under a contract under section 1903(m) 
                a medicaid managed care organization (in 
                relation to an individual enrolled under the 
                contract) shall not prohibit or otherwise 
                restrict a covered health care professional (as 
                defined in subparagraph (D)) from advising such 
                an individual who is a patient of the 
                professional about the health status of the 
                individual or medical care or treatment for the 
                individual's condition or disease, regardless 
                of whether benefits for such care or treatment 
                are provided under the contract, if the 
                professional is acting within the lawful scope 
                of practice.
                  (B) Construction.--Subparagraph (A) shall not 
                be construed as requiring a medicaid managed 
                care organization to provide, reimburse for, or 
                provide coverage of, a counseling or referral 
                service if the organization--
                          (i) objects to the provision of such 
                        service on moral or religious grounds; 
                        and
                          (ii) in the manner and through the 
                        written instrumentalities such 
                        organization deems appropriate, makes 
                        available information on its policies 
                        regarding such service to prospective 
                        enrollees before or during enrollment 
                        and to enrollees within 90 days after 
                        the date that the organization adopts a 
                        change in policy regarding such a 
                        counseling or referral service.
                Nothing in this subparagraph shall be construed 
                to affect disclosure requirements under State 
                law or under the Employee Retirement Income 
                Security Act of 1974.
                  (C) Health care professional defined.--For 
                purposes of this paragraph, the term ``health 
                care professional'' means a physician (as 
                defined in section 1861(r)) or other health 
                care professional if coverage for the 
                professional's services is provided under the 
                contract referred to in subparagraph (A) for 
                the services of the professional. Such term 
                includes a podiatrist, optometrist, 
                chiropractor, psychologist, dentist, physician 
                assistant, physical or occupational therapist 
                and therapy assistant, speech-language 
                pathologist, audiologist, registered or 
                licensed practical nurse (including nurse 
                practitioner, clinical nurse specialist, 
                certified registered nurse anesthetist, and 
                certified nurse-midwife), licensed certified 
                social worker, registered respiratory 
                therapist, and certified respiratory therapy 
                technician.
          (4) Grievance procedures.--Each medicaid managed care 
        organization shall establish an internal grievance 
        procedure under which an enrollee who is eligible for 
        medical assistance under the State plan under this 
        title, or a provider on behalf of such an enrollee, may 
        challenge the denial of coverage of or payment for such 
        assistance.
          (5) Demonstration of adequate capacity and 
        services.--Each medicaid managed care organization 
        shall provide the State and the Secretary with adequate 
        assurances (in a time and manner determined by the 
        Secretary) that the organization, with respect to a 
        service area, has the capacity to serve the expected 
        enrollment in such service area, including assurances 
        that the organization--
                  (A) offers an appropriate range of services 
                and access to preventive and primary care 
                services for the population expected to be 
                enrolled in such service area, and
                  (B) maintains a sufficient number, mix, and 
                geographic distribution of providers of 
                services.
          (6) Protecting enrollees against liability for 
        payment.--Each medicaid managed care organization shall 
        provide that an individual eligible for medical 
        assistance under the State plan under this title who is 
        enrolled with the organization may not be held liable--
                  (A) for the debts of the organization, in the 
                event of the organization's insolvency,
                  (B) for services provided to the individual--
                          (i) in the event of the organization 
                        failing to receive payment from the 
                        State for such services; or
                          (ii) in the event of a health care 
                        provider with a contractual, referral, 
                        or other arrangement with the 
                        organization failing to receive payment 
                        from the State or the organization for 
                        such services, or
                  (C) for payments to a provider that furnishes 
                covered services under a contractual, referral, 
                or other arrangement with the organization in 
                excess of the amount that would be owed by the 
                individual if the organization had directly 
                provided the services.
          (7) Antidiscrimination.--A medicaid managed care 
        organization shall not discriminate with respect to 
        participation, reimbursement, or indemnification as to 
        any provider who is acting within the scope of the 
        provider's license or certification under applicable 
        State law, solely on the basis of such license or 
        certification. This paragraph shall not be construed to 
        prohibit an organization from including providers only 
        to the extent necessary to meet the needs of the 
        organization's enrollees or from establishing any 
        measure designed to maintain quality and control costs 
        consistent with the responsibilities of the 
        organization.
          (8) Compliance with certain maternity and mental 
        health requirements.--Each medicaid managed care 
        organization shall comply with the requirements of 
        subpart 2 of part A of title XXVII of the Public Health 
        Service Act insofar as such requirements apply and are 
        effective with respect to a health insurance issuer 
        that offers group health insurance coverage. In 
        applying the previous sentence with respect to 
        requirements under paragraph (8) of section 2726(a) of 
        the Public Health Service Act, a Medicaid managed care 
        organization (or a prepaid inpatient health plan (as 
        defined by the Secretary) or prepaid ambulatory health 
        plan (as defined by the Secretary) that offers services 
        to enrollees of a Medicaid managed care organization) 
        shall be treated as in compliance with such 
        requirements if the Medicaid managed care organization 
        (or prepaid inpatient health plan or prepaid ambulatory 
        health plan) is in compliance with subpart K of part 
        438 of title 42, Code of Federal Regulations, and 
        section 438.3(n) of such title, or any successor 
        regulation.
  (c) Quality Assurance Standards.--
          (1) Quality assessment and improvement strategy.--
                  (A) In general.--If a State provides for 
                contracts with medicaid managed care 
                organizations under section 1903(m), the State 
                shall develop and implement a quality 
                assessment and improvement strategy consistent 
                with this paragraph. Such strategy shall 
                include the following:
                          (i) Access standards.--Standards for 
                        access to care so that covered services 
                        are available within reasonable 
                        timeframes and in a manner that ensures 
                        continuity of care and adequate primary 
                        care and specialized services capacity.
                          (ii) Other measures.--Examination of 
                        other aspects of care and service 
                        directly related to the improvement of 
                        quality of care (including grievance 
                        procedures and marketing and 
                        information standards).
                          (iii) Monitoring procedures.--
                        Procedures for monitoring and 
                        evaluating the quality and 
                        appropriateness of care and services to 
                        enrollees that reflect the full 
                        spectrum of populations enrolled under 
                        the contract and that includes 
                        requirements for provision of quality 
                        assurance data to the State using the 
                        data and information set that the 
                        Secretary has specified for use under 
                        part C of title XVIII or such 
                        alternative data as the Secretary 
                        approves, in consultation with the 
                        State.
                          (iv) Periodic review.--Regular, 
                        periodic examinations of the scope and 
                        content of the strategy.
                  (B) Standards.--The strategy developed under 
                subparagraph (A) shall be consistent with 
                standards that the Secretary first establishes 
                within 1 year after the date of the enactment 
                of this section. Such standards shall not 
                preempt any State standards that are more 
                stringent than such standards. Guidelines 
                relating to quality assurance that are applied 
                under section 1915(b)(1) shall apply under this 
                subsection until the effective date of 
                standards for quality assurance established 
                under this subparagraph.
                  (C) Monitoring.--The Secretary shall monitor 
                the development and implementation of 
                strategies under subparagraph (A).
                  (D) Consultation.--The Secretary shall 
                conduct activities under subparagraphs (B) and 
                (C) in consultation with the States.
          (2) External independent review of managed care 
        activities.--
                  (A) Review of contracts.--
                          (i) In general.--Each contract under 
                        section 1903(m) with a medicaid managed 
                        care organization shall provide for an 
                        annual (as appropriate) external 
                        independent review conducted by a 
                        qualified independent entity of the 
                        quality outcomes and timeliness of, and 
                        access to, the items and services for 
                        which the organization is responsible 
                        under the contract. The requirement for 
                        such a review shall not apply until 
                        after the date that the Secretary 
                        establishes the identification method 
                        described in clause (ii).
                          (ii) Qualifications of reviewer.--The 
                        Secretary, in consultation with the 
                        States, shall establish a method for 
                        the identification of entities that are 
                        qualified to conduct reviews under 
                        clause (i).
                          (iii) Use of protocols.--The 
                        Secretary, in coordination with the 
                        National Governors' Association, shall 
                        contract with an independent quality 
                        review organization (such as the 
                        National Committee for Quality 
                        Assurance) to develop the protocols to 
                        be used in external independent reviews 
                        conducted under this paragraph on and 
                        after January 1, 1999.
                          (iv) Availability of results.--The 
                        results of each external independent 
                        review conducted under this 
                        subparagraph shall be available to 
                        participating health care providers, 
                        enrollees, and potential enrollees of 
                        the organization, except that the 
                        results may not be made available in a 
                        manner that discloses the identity of 
                        any individual patient.
                  (B) Nonduplication of accreditation.--A State 
                may provide that, in the case of a medicaid 
                managed care organization that is accredited by 
                a private independent entity (such as those 
                described in section 1852(e)(4)) or that has an 
                external review conducted under section 
                1852(e)(3), the external review activities 
                conducted under subparagraph (A) with respect 
                to the organization shall not be duplicative of 
                review activities conducted as part of the 
                accreditation process or the external review 
                conducted under such section.
                  (C) Deemed compliance for medicare managed 
                care organizations.--At the option of a State, 
                the requirements of subparagraph (A) shall not 
                apply with respect to a medicaid managed care 
                organization if the organization is an eligible 
                organization with a contract in effect under 
                section 1876 or a Medicare+Choice organization 
                with a contract in effect under part C of title 
                XVIII and the organization has had a contract 
                in effect under section 1903(m) at least during 
                the previous 2-year period.
  (d) Protections Against Fraud and Abuse.--
          (1) Prohibiting affiliations with individuals 
        debarred by Federal agencies.--
                  (A) In general.--A managed care entity may 
                not knowingly--
                          (i) have a person described in 
                        subparagraph (C) as a director, 
                        officer, partner, or person with 
                        beneficial ownership of more than 5 
                        percent of the entity's equity, or
                          (ii) have an employment, consulting, 
                        or other agreement with a person 
                        described in such subparagraph for the 
                        provision of items and services that 
                        are significant and material to the 
                        entity's obligations under its contract 
                        with the State.
                  (B) Effect of noncompliance.--If a State 
                finds that a managed care entity is not in 
                compliance with clause (i) or (ii) of 
                subparagraph (A), the State--
                          (i) shall notify the Secretary of 
                        such noncompliance;
                          (ii) may continue an existing 
                        agreement with the entity unless the 
                        Secretary (in consultation with the 
                        Inspector General of the Department of 
                        Health and Human Services) directs 
                        otherwise; and
                          (iii) may not renew or otherwise 
                        extend the duration of an existing 
                        agreement with the entity unless the 
                        Secretary (in consultation with the 
                        Inspector General of the Department of 
                        Health and Human Services) provides to 
                        the State and to Congress a written 
                        statement describing compelling reasons 
                        that exist for renewing or extending 
                        the agreement.
                  (C) Persons described.--A person is described 
                in this subparagraph if such person--
                          (i) is debarred, suspended, or 
                        otherwise excluded from participating 
                        in procurement activities under the 
                        Federal Acquisition Regulation or from 
                        participating in nonprocurement 
                        activities under regulations issued 
                        pursuant to Executive Order No. 12549 
                        or under guidelines implementing such 
                        order; or
                          (ii) is an affiliate (as defined in 
                        such Regulation) of a person described 
                        in clause (i).
          (2) Restrictions on marketing.--
                  (A) Distribution of materials.--
                          (i) In general.--A managed care 
                        entity, with respect to activities 
                        under this title, may not distribute 
                        directly or through any agent or 
                        independent contractor marketing 
                        materials within any State--
                                  (I) without the prior 
                                approval of the State, and
                                  (II) that contain false or 
                                materially misleading 
                                information.
                        The requirement of subclause (I) shall 
                        not apply with respect to a State until 
                        such date as the Secretary specifies in 
                        consultation with such State.
                          (ii) Consultation in review of market 
                        materials.--In the process of reviewing 
                        and approving such materials, the State 
                        shall provide for consultation with a 
                        medical care advisory committee.
                  (B) Service market.--A managed care entity 
                shall distribute marketing materials to the 
                entire service area of such entity covered 
                under the contract under section 1903(m) or 
                section 1905(t)(3).
                  (C) Prohibition of tie-ins.--A managed care 
                entity, or any agency of such entity, may not 
                seek to influence an individual's enrollment 
                with the entity in conjunction with the sale of 
                any other insurance.
                  (D) Prohibiting marketing fraud.--Each 
                managed care entity shall comply with such 
                procedures and conditions as the Secretary 
                prescribes in order to ensure that, before an 
                individual is enrolled with the entity, the 
                individual is provided accurate oral and 
                written information sufficient to make an 
                informed decision whether or not to enroll.
                  (E) Prohibition of ``cold-call'' marketing.--
                Each managed care entity shall not, directly or 
                indirectly, conduct door-to-door, telephonic, 
                or other ``cold-call'' marketing of enrollment 
                under this title.
          (3) State conflict-of-interest safeguards in medicaid 
        risk contracting.--A medicaid managed care organization 
        may not enter into a contract with any State under 
        section 1903(m) unless the State has in effect 
        conflict-of-interest safeguards with respect to 
        officers and employees of the State with 
        responsibilities relating to contracts with such 
        organizations or to the default enrollment process 
        described in subsection (a)(4)(C)(ii) that are at least 
        as effective as the Federal safeguards provided under 
        section 27 of the Office of Federal Procurement Policy 
        Act (41 U.S.C. 423), against conflicts of interest that 
        apply with respect to Federal procurement officials 
        with comparable responsibilities with respect to such 
        contracts.
          (4) Use of unique physician identifier for 
        participating physicians.--Each medicaid managed care 
        organization shall require each physician providing 
        services to enrollees eligible for medical assistance 
        under the State plan under this title to have a unique 
        identifier in accordance with the system established 
        under section 1173(b).
          (5) Contract requirement for managed care entities.--
        With respect to any contract with a managed care entity 
        under section 1903(m) or 1905(t)(3) (as applicable), no 
        later than July 1, 2018, such contract shall include a 
        provision that providers of services or persons 
        terminated (as described in section 1902(kk)(8)) from 
        participation under this title, title XVIII, or title 
        XXI shall be terminated from participating under this 
        title as a provider in any network of such entity that 
        serves individuals eligible to receive medical 
        assistance under this title.
          (6) Enrollment of participating providers.--
                  (A) In general.--Beginning not later than 
                January 1, 2018, a State shall require that, in 
                order to participate as a provider in the 
                network of a managed care entity that provides 
                services to, or orders, prescribes, refers, or 
                certifies eligibility for services for, 
                individuals who are eligible for medical 
                assistance under the State plan under this 
                title (or under a waiver of the plan) and who 
                are enrolled with the entity, the provider is 
                enrolled consistent with section 1902(kk) with 
                the State agency administering the State plan 
                under this title. Such enrollment shall include 
                providing to the State agency the provider's 
                identifying information, including the name, 
                specialty, date of birth, Social Security 
                number, national provider identifier, Federal 
                taxpayer identification number, and the State 
                license or certification number of the 
                provider.
                  (B) Rule of construction.--Nothing in 
                subparagraph (A) shall be construed as 
                requiring a provider described in such 
                subparagraph to provide services to individuals 
                who are not enrolled with a managed care entity 
                under this title.
  (e) Sanctions for Noncompliance.--
          (1) Use of intermediate sanctions by the state to 
        enforce requirements.--
                  (A) In general.--A State may not enter into 
                or renew a contract under section 1903(m) 
                unless the State has established intermediate 
                sanctions, which may include any of the types 
                described in paragraph (2), other than the 
                termination of a contract with a medicaid 
                managed care organization, which the State may 
                impose against a medicaid managed care 
                organization with such a contract, if the 
                organization--
                          (i) fails substantially to provide 
                        medically necessary items and services 
                        that are required (under law or under 
                        such organization's contract with the 
                        State) to be provided to an enrollee 
                        covered under the contract;
                          (ii) imposes premiums or charges on 
                        enrollees in excess of the premiums or 
                        charges permitted under this title;
                          (iii) acts to discriminate among 
                        enrollees on the basis of their health 
                        status or requirements for health care 
                        services, including expulsion or 
                        refusal to reenroll an individual, 
                        except as permitted by this title, or 
                        engaging in any practice that would 
                        reasonably be expected to have the 
                        effect of denying or discouraging 
                        enrollment with the organization by 
                        eligible individuals whose medical 
                        condition or history indicates a need 
                        for substantial future medical 
                        services;
                          (iv) misrepresents or falsifies 
                        information that is furnished--
                                  (I) to the Secretary or the 
                                State under this title; or
                                  (II) to an enrollee, 
                                potential enrollee, or a health 
                                care provider under such title; 
                                or
                          (v) fails to comply with the 
                        applicable requirements of section 
                        1903(m)(2)(A)(x).
                The State may also impose such intermediate 
                sanction against a managed care entity if the 
                State determines that the entity distributed 
                directly or through any agent or independent 
                contractor marketing materials in violation of 
                subsection (d)(2)(A)(i)(II).
                  (B) Rule of construction.--Clause (i) of 
                subparagraph (A) shall not apply to the 
                provision of abortion services, except that a 
                State may impose a sanction on any medicaid 
                managed care organization that has a contract 
                to provide abortion services if the 
                organization does not provide such services as 
                provided for under the contract.
          (2) Intermediate sanctions.--The sanctions described 
        in this paragraph are as follows:
                  (A) Civil money penalties as follows:
                          (i) Except as provided in clause 
                        (ii), (iii), or (iv), not more than 
                        $25,000 for each determination under 
                        paragraph (1)(A).
                          (ii) With respect to a determination 
                        under clause (iii) or (iv)(I) of 
                        paragraph (1)(A), not more than 
                        $100,000 for each such determination.
                          (iii) With respect to a determination 
                        under paragraph (1)(A)(ii), double the 
                        excess amount charged in violation of 
                        such subsection (and the excess amount 
                        charged shall be deducted from the 
                        penalty and returned to the individual 
                        concerned).
                          (iv) Subject to clause (ii), with 
                        respect to a determination under 
                        paragraph (1)(A)(iii), $15,000 for each 
                        individual not enrolled as a result of 
                        a practice described in such 
                        subsection.
                  (B) The appointment of temporary management--
                          (i) to oversee the operation of the 
                        medicaid managed care organization upon 
                        a finding by the State that there is 
                        continued egregious behavior by the 
                        organization or there is a substantial 
                        risk to the health of enrollees; or
                          (ii) to assure the health of the 
                        organization's enrollees, if there is a 
                        need for temporary management while--
                                  (I) there is an orderly 
                                termination or reorganization 
                                of the organization; or
                                  (II) improvements are made to 
                                remedy the violations found 
                                under paragraph (1),
                        except that temporary management under 
                        this subparagraph may not be terminated 
                        until the State has determined that the 
                        medicaid managed care organization has 
                        the capability to ensure that the 
                        violations shall not recur.
                  (C) Permitting individuals enrolled with the 
                managed care entity to terminate enrollment 
                without cause, and notifying such individuals 
                of such right to terminate enrollment.
                  (D) Suspension or default of all enrollment 
                of individuals under this title after the date 
                the Secretary or the State notifies the entity 
                of a determination of a violation of any 
                requirement of section 1903(m) or this section.
                  (E) Suspension of payment to the entity under 
                this title for individuals enrolled after the 
                date the Secretary or State notifies the entity 
                of such a determination and until the Secretary 
                or State is satisfied that the basis for such 
                determination has been corrected and is not 
                likely to recur.
          (3) Treatment of chronic substandard entities.--In 
        the case of a medicaid managed care organization which 
        has repeatedly failed to meet the requirements of 
        section 1903(m) and this section, the State shall 
        (regardless of what other sanctions are provided) 
        impose the sanctions described in subparagraphs (B) and 
        (C) of paragraph (2).
          (4) Authority to terminate contract.--
                  (A) In general.--In the case of a managed 
                care entity which has failed to meet the 
                requirements of this part or a contract under 
                section 1903(m) or 1905(t)(3), the State shall 
                have the authority to terminate such contract 
                with the entity and to enroll such entity's 
                enrollees with other managed care entities (or 
                to permit such enrollees to receive medical 
                assistance under the State plan under this 
                title other than through a managed care 
                entity).
                  (B) Availability of hearing prior to 
                termination of contract.--A State may not 
                terminate a contract with a managed care entity 
                under subparagraph (A) unless the entity is 
                provided with a hearing prior to the 
                termination.
                  (C) Notice and right to disenroll in cases of 
                termination hearing.--A State may--
                          (i) notify individuals enrolled with 
                        a managed care entity which is the 
                        subject of a hearing to terminate the 
                        entity's contract with the State of the 
                        hearing, and
                          (ii) in the case of such an entity, 
                        permit such enrollees to disenroll 
                        immediately with the entity without 
                        cause.
          (5) Other protections for managed care entities 
        against sanctions imposed by state.--Before imposing 
        any sanction against a managed care entity other than 
        termination of the entity's contract, the State shall 
        provide the entity with notice and such other due 
        process protections as the State may provide, except 
        that a State may not provide a managed care entity with 
        a pre-termination hearing before imposing the sanction 
        described in paragraph (2)(B).
  (f) Timeliness of Payment; Adequacy of Payment for Primary 
Care Services.--A contract under section 1903(m) with a 
medicaid managed care organization shall provide that the 
organization shall make payment to health care providers for 
items and services which are subject to the contract and that 
are furnished to individuals eligible for medical assistance 
under the State plan under this title who are enrolled with the 
organization on a timely basis consistent with the claims 
payment procedures described in section 1902(a)(37)(A), unless 
the health care provider and the organization agree to an 
alternate payment schedule and, in the case of primary care 
services described in section 1902(a)(13)(C), consistent with 
the minimum payment rates specified in such section (regardless 
of the manner in which such payments are made, including in the 
form of capitation or partial capitation).
  (g) Identification of Patients for Purposes of Making DSH 
Payments.--Each contract with a managed care entity under 
section 1903(m) or under section 1905(t)(3) shall require the 
entity either--
          (1) to report to the State information necessary to 
        determine the hospital services provided under the 
        contract (and the identity of hospitals providing such 
        services) for purposes of applying sections 
        1886(d)(5)(F) and 1923; or
          (2) to include a sponsorship code in the 
        identification card issued to individuals covered under 
        this title in order that a hospital may identify a 
        patient as being entitled to benefits under this title.
  (h) Special Rules With Respect to Indian Enrollees, Indian 
Health Care Providers, and Indian Managed Care Entities.--
          (1) Enrollee option to select an indian health care 
        provider as primary care provider.--In the case of a 
        non-Indian Medicaid managed care entity that--
                  (A) has an Indian enrolled with the entity; 
                and
                  (B) has an Indian health care provider that 
                is participating as a primary care provider 
                within the network of the entity,
        insofar as the Indian is otherwise eligible to receive 
        services from such Indian health care provider and the 
        Indian health care provider has the capacity to provide 
        primary care services to such Indian, the contract with 
        the entity under section 1903(m) or under section 
        1905(t)(3) shall require, as a condition of receiving 
        payment under such contract, that the Indian shall be 
        allowed to choose such Indian health care provider as 
        the Indian's primary care provider under the entity.
          (2) Assurance of payment to indian health care 
        providers for provision of covered services.--Each 
        contract with a managed care entity under section 
        1903(m) or under section 1905(t)(3) shall require any 
        such entity, as a condition of receiving payment under 
        such contract, to satisfy the following requirements:
                  (A) Demonstration of access to indian health 
                care providers and application of alternative 
                payment arrangements.--Subject to subparagraph 
                (C), to--
                          (i) demonstrate that the number of 
                        Indian health care providers that are 
                        participating providers with respect to 
                        such entity are sufficient to ensure 
                        timely access to covered Medicaid 
                        managed care services for those Indian 
                        enrollees who are eligible to receive 
                        services from such providers; and
                          (ii) agree to pay Indian health care 
                        providers, whether such providers are 
                        participating or nonparticipating 
                        providers with respect to the entity, 
                        for covered Medicaid managed care 
                        services provided to those Indian 
                        enrollees who are eligible to receive 
                        services from such providers at a rate 
                        equal to the rate negotiated between 
                        such entity and the provider involved 
                        or, if such a rate has not been 
                        negotiated, at a rate that is not less 
                        than the level and amount of payment 
                        which the entity would make for the 
                        services if the services were furnished 
                        by a participating provider which is 
                        not an Indian health care provider.
                The Secretary shall establish procedures for 
                applying the requirements of clause (i) in 
                States where there are no or few Indian health 
                providers.
                  (B) Prompt payment.--To agree to make prompt 
                payment (consistent with rule for prompt 
                payment of providers under section 1932(f)) to 
                Indian health care providers that are 
                participating providers with respect to such 
                entity or, in the case of an entity to which 
                subparagraph (A)(ii) or (C) applies, that the 
                entity is required to pay in accordance with 
                that subparagraph.
                  (C) Application of special payment 
                requirements for federally-qualified health 
                centers and for services provided by certain 
                indian health care providers.--
                          (i) Federally-qualified health 
                        centers.--
                                  (I) Managed care entity 
                                payment requirement.--To agree 
                                to pay any Indian health care 
                                provider that is a federally-
                                qualified health center under 
                                this title but not a 
                                participating provider with 
                                respect to the entity, for the 
                                provision of covered Medicaid 
                                managed care services by such 
                                provider to an Indian enrollee 
                                of the entity at a rate equal 
                                to the amount of payment that 
                                the entity would pay a 
                                federally-qualified health 
                                center that is a participating 
                                provider with respect to the 
                                entity but is not an Indian 
                                health care provider for such 
                                services.
                                  (II) Continued application of 
                                state requirement to make 
                                supplemental payment.--Nothing 
                                in subclause (I) or 
                                subparagraph (A) or (B) shall 
                                be construed as waiving the 
                                application of section 
                                1902(bb)(5) regarding the State 
                                plan requirement to make any 
                                supplemental payment due under 
                                such section to a federally-
                                qualified health center for 
                                services furnished by such 
                                center to an enrollee of a 
                                managed care entity (regardless 
                                of whether the federally-
                                qualified health center is or 
                                is not a participating provider 
                                with the entity).
                          (ii) Payment rate for services 
                        provided by certain indian health care 
                        providers.--If the amount paid by a 
                        managed care entity to an Indian health 
                        care provider that is not a federally-
                        qualified health center for services 
                        provided by the provider to an Indian 
                        enrollee with the managed care entity 
                        is less than the rate that applies to 
                        the provision of such services by the 
                        provider under the State plan, the plan 
                        shall provide for payment to the Indian 
                        health care provider, whether the 
                        provider is a participating or 
                        nonparticipating provider with respect 
                        to the entity, of the difference 
                        between such applicable rate and the 
                        amount paid by the managed care entity 
                        to the provider for such services.
                  (D) Construction.--Nothing in this paragraph 
                shall be construed as waiving the application 
                of section 1902(a)(30)(A) (relating to 
                application of standards to assure that 
                payments are consistent with efficiency, 
                economy, and quality of care).
          (3) Special rule for enrollment for indian managed 
        care entities.--Regarding the application of a Medicaid 
        managed care program to Indian Medicaid managed care 
        entities, an Indian Medicaid managed care entity may 
        restrict enrollment under such program to Indians in 
        the same manner as Indian Health Programs may restrict 
        the delivery of services to Indians.
          (4) Definitions.--For purposes of this subsection:
                  (A) Indian health care provider.--The term 
                ``Indian health care provider'' means an Indian 
                Health Program or an Urban Indian Organization.
                  (B) Indian medicaid managed care entity.--The 
                term ``Indian Medicaid managed care entity'' 
                means a managed care entity that is controlled 
                (within the meaning of the last sentence of 
                section 1903(m)(1)(C)) by the Indian Health 
                Service, a Tribe, Tribal Organization, or Urban 
                Indian Organization, or a consortium, which may 
                be composed of 1 or more Tribes, Tribal 
                Organizations, or Urban Indian Organizations, 
                and which also may include the Service.
                  (C) Non-indian medicaid managed care 
                entity.--The term ``non-Indian Medicaid managed 
                care entity'' means a managed care entity that 
                is not an Indian Medicaid managed care entity.
                  (D) Covered medicaid managed care services.--
                The term ``covered Medicaid managed care 
                services'' means, with respect to an individual 
                enrolled with a managed care entity, items and 
                services for which benefits are available with 
                respect to the individual under the contract 
                between the entity and the State involved.
                  (E) Medicaid managed care program.--The term 
                ``Medicaid managed care program'' means a 
                program under sections 1903(m), 1905(t), and 
                1932 and includes a managed care program 
                operating under a waiver under section 1915(b) 
                or 1115 or otherwise.
  (i) Drug Utilization Review Activities and Requirements.--
Beginning not later than October 1, 2019, each contract under a 
State plan with a managed care entity (other than a primary 
care case manager) under section 1903(m) shall provide that the 
entity is in compliance with the applicable provisions of 
section 438.3(s)(2) of title 42, Code of Federal Regulations, 
section 483.3(s)(4)) of such title, and section 483.3(s)(5) of 
such title, as such provisions were in effect on March 31, 
2018.
  (j) Transmission of Address Information.--Beginning January 
1, 2026, each contract under a State plan with a managed care 
entity under section 1903(m) shall provide that the entity 
transmits to the State any address information for an 
individual enrolled with the entity that is provided to such 
entity directly from, or verified by such entity directly with, 
such individual.

           *       *       *       *       *       *       *

             TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE  
                                PROGRAM 

           *       *       *       *       *       *       *


SEC. 2107. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN 
             ADMINISTRATION.

  (a) Strategic Objectives and Performance Goals.--
          (1) Description.--A State child health plan shall 
        include a description of--
                  (A) the strategic objectives,
                  (B) the performance goals, and
                  (C) the performance measures,
        the State has established for providing child health 
        assistance to targeted low-income children under the 
        plan and otherwise for maximizing health benefits 
        coverage for other low-income children and children 
        generally in the State.
          (2) Strategic objectives.--Such plan shall identify 
        specific strategic objectives relating to increasing 
        the extent of creditable health coverage among targeted 
        low-income children and other low-income children.
          (3) Performance goals.--Such plan shall specify one 
        or more performance goals for each such strategic 
        objective so identified.
          (4) Performance measures.--Such plan shall describe 
        how performance under the plan will be--
                  (A) measured through objective, independently 
                verifiable means, and
                  (B) compared against performance goals, in 
                order to determine the State's performance 
                under this title.
  (b) Records, Reports, Audits, and Evaluation.--
          (1) Data collection, records, and reports.--A State 
        child health plan shall include an assurance that the 
        State will collect the data, maintain the records, and 
        furnish the reports to the Secretary, at the times and 
        in the standardized format the Secretary may require in 
        order to enable the Secretary to monitor State program 
        administration and compliance and to evaluate and 
        compare the effectiveness of State plans under this 
        title.
          (2) State assessment and study.--A State child health 
        plan shall include a description of the State's plan 
        for the annual assessments and reports under section 
        2108(a) and the evaluation required by section 2108(b).
          (3) Audits.--A State child health plan shall include 
        an assurance that the State will afford the Secretary 
        access to any records or information relating to the 
        plan for the purposes of review or audit.
  (c) Program Development Process.--A State child health plan 
shall include a description of the process used to involve the 
public in the design and implementation of the plan and the 
method for ensuring ongoing public involvement.
  (d) Program Budget.--A State child health plan shall include 
a description of the budget for the plan. The description shall 
be updated periodically as necessary and shall include details 
on the planned use of funds and the sources of the non-Federal 
share of plan expenditures, including any requirements for 
cost-sharing by beneficiaries.
  (e) Application of Certain General Provisions.--The following 
sections of this Act shall apply to States under this title in 
the same manner as they apply to a State under title XIX:
          (1) Title xix provisions.--
                  (A) Section 1902(a)(4)(C) (relating to 
                conflict of interest standards).
                  (B) Section 1902(a)(25) (relating to third 
                party liability).
                  (C) Section 1902(a)(39) (relating to 
                termination of participation of certain 
                providers).
                  (D) Section 1902(a)(78) (relating to 
                enrollment of providers participating in State 
                plans providing medical assistance on a fee-
                for-service basis).
                  (E) Section 1902(a)(72) (relating to limiting 
                FQHC contracting for provision of dental 
                services).
                  (F) Section 1902(a)(73) (relating to 
                requiring certain States to seek advice from 
                designees of Indian Health Programs and Urban 
                Indian Organizations).
                  (G) Subsections (a)(77) and (kk) of section 
                1902 (relating to provider and supplier 
                screening, oversight, and reporting 
                requirements).
                  (H) Section 1902(a)(88) (relating to 
                regularly obtaining address information for 
                enrollees).
                  [(H)] (I) Section 1902(e)(13) (relating to 
                the State option to rely on findings from an 
                Express Lane agency to help evaluate a child's 
                eligibility for medical assistance).
                  [(I)] (J) Section 1902(e)(14) (relating to 
                income determined using modified adjusted gross 
                income and household income).
                  [(J)] (K) Paragraphs (5) and (16) of section 
                1902(e) (relating to the State option to 
                provide medical assistance consisting of full 
                benefits during pregnancy and throughout the 
                12-month postpartum period under title XIX), if 
                the State provides child health assistance for 
                targeted low-income children who are pregnant 
                or to targeted low-income pregnant women and 
                the State has elected to apply such paragraph 
                (16) with respect to pregnant women under title 
                XIX, the provision of assistance under the 
                State child health plan or waiver for targeted 
                low-income children or targeted low-income 
                pregnant women during pregnancy and the 12-
                month postpartum period shall be required and 
                not at the option of the State and shall 
                include coverage of all items or services 
                provided to a targeted low-income child or 
                targeted low-income pregnant woman (as 
                applicable) under the State child health plan 
                or waiver).
                  [(K)] (L) Section 1902(e)(12) (relating to 1 
                year of continuous eligibility for children), 
                except that a targeted low-income child 
                enrolled under the State child health plan or 
                waiver may be transferred to the Medicaid 
                program under title XIX for the remaining 
                duration of the 12-month continuous eligibility 
                period, if the child becomes eligible for full 
                benefits under title XIX during such period.
                  [(L)] (M) Section 1902(bb) (relating to 
                payment for services provided by Federally-
                qualified health centers and rural health 
                clinics).
                  [(M)] (N) Section 1902(ff) (relating to 
                disregard of certain property for purposes of 
                making eligibility determinations).
                  [(N)] (O) Paragraphs (2), (16), and (17) of 
                section 1903(i) (relating to limitations on 
                payment).
                  [(O)] (P) Section 1903(m)(3) (relating to 
                limitation on payment with respect to managed 
                care).
                  [(P)] (Q) Paragraph (4) of section 1903(v) 
                (relating to optional coverage of categories of 
                lawfully residing immigrant children or 
                pregnant women), but only if the State has 
                elected to apply such paragraph with respect to 
                such category of children or pregnant women 
                under title XIX.
                  [(Q)] (R) Section 1903(w) (relating to 
                limitations on provider taxes and donations).
                  [(R)] (S) Section 1920A (relating to 
                presumptive eligibility for children).
                  [(S)] (T) Subsections (a)(2)(C) (relating to 
                Indian enrollment), (d)(5) (relating to 
                contract requirement for managed care 
                entities), (d)(6) (relating to enrollment of 
                providers participating with a managed care 
                entity), and (h) (relating to special rules 
                with respect to Indian enrollees, Indian health 
                care providers, and Indian managed care 
                entities) of section 1932.
                  [(T)] (U) Section 1942 (relating to 
                authorization to receive data directly relevant 
                to eligibility determinations).
                  [(U)] (V) Section 1943(b) (relating to 
                coordination with State Exchanges and the State 
                Medicaid agency).
          (2) Title xi provisions.--
                  (A) Section 1115 (relating to waiver 
                authority).
                  (B) Section 1116 (relating to administrative 
                and judicial review), but only insofar as 
                consistent with this title.
                  (C) Section 1124 (relating to disclosure of 
                ownership and related information).
                  (D) Section 1126 (relating to disclosure of 
                information about certain convicted 
                individuals).
                  (E) Section 1128A (relating to civil monetary 
                penalties).
                  (F) Section 1128B(d) (relating to criminal 
                penalties for certain additional charges).
                  (G) Section 1132 (relating to periods within 
                which claims must be filed).
  (f) Limitation of Waiver Authority.--Notwithstanding 
subsection (e)(2)(A) and section 1115(a)(1):
          (1) The Secretary may not approve a waiver, 
        experimental, pilot, or demonstration project that 
        would allow funds made available under this title to be 
        used to provide child health assistance or other health 
        benefits coverage to a nonpregnant childless adult or a 
        parent (as defined in section 2111(c)(2)(A)), who is 
        not pregnant, of a targeted low-income child.
          (2) The Secretary may not approve, extend, renew, or 
        amend a waiver, experimental, pilot, or demonstration 
        project with respect to a State after the date of 
        enactment of the Children's Health Insurance Program 
        Reauthorization Act of 2009 that would waive or modify 
        the requirements of section 2111.
  (g) Use of Blended Risk Pools.--
          (1) In general.--Nothing in this title (or any other 
        provision of Federal law) shall be construed as 
        preventing a State from considering children enrolled 
        in a qualified CHIP look-alike program and children 
        enrolled in a State child health plan under this title 
        (or a waiver of such plan) as members of a single risk 
        pool.
          (2) Qualified chip look-alike program.--In this 
        subsection, the term ``qualified CHIP look-alike 
        program'' means a State program--
                  (A) under which children who are under the 
                age of 19 and are not eligible to receive 
                medical assistance under title XIX or child 
                health assistance under this title may purchase 
                coverage through the State that provides 
                benefits that are at least identical to the 
                benefits provided under the State child health 
                plan under this title (or a waiver of such 
                plan); and
                  (B) that is funded exclusively through non-
                Federal funds, including funds received by the 
                State in the form of premiums for the purchase 
                of such coverage.

           *       *       *       *       *       *       *


                                  [all]