42 U.S.C. § 1395v — Agreements with States

(a) Secretary’s duty; enrollment of eligible people

If a State^* asks before January 1, 1970, during 1981, or after 1988, the Secretary^* must enter into an agreement with that State. Under the agreement, all eligible people in one of the coverage groups described in subsection (b), as the agreement specifies, will be enrolled in the program established by this part.

This section does not define “eligible individual,” “coverage group,” or “agreement.”

(b) Groups that may be covered

An agreement with a State under subsection (a) may cover either of these groups:

(1) People receiving money payments under the State’s plan approved under subchapter I or subchapter XVI.

(2) People receiving money payments under all of the State’s plans approved under subchapters I, X, XIV, and XVI, and part A of subchapter IV.

Except as subsection (g) provides, a coverage group does not include a person^* who is entitled to monthly insurance benefits under subchapter II or who is entitled to an annuity under the Railroad Retirement Act of 1974 (45 U.S.C. 231 and following).

Starting January 1, 1974, and subject to section 1396a(f) of this title, the Secretary must continue an agreement with any State that is not eligible to participate in the State-plan program under subchapter XVI if that State asks. The Secretary may modify the agreement by regulation to account for the ending of any of that State’s plans approved under subchapters I, X, XIV, and XVI and for the creation of the supplemental security income program under subchapter XVI.

This section does not define “money payments,” “monthly insurance benefits,” “annuity,” “supplemental security income program,” or “medical assistance.”

(c) Eligible people

For this section, a person is treated as eligible only if the person is an eligible individual, as section 1395o of this title defines that term, on the date an agreement covering the person is made under subsection (a), or becomes such an eligible individual at any time after that date.

A person is treated as receiving the money payments described in subsection (b) if the person receives those payments for the month in which the agreement is made or for any later month.

(d) Monthly premiums and coverage periods

For a person enrolled under this section:

(1) The State’s monthly premium is determined under section 1395r of this title, without the increase under subsection (b) of that section.

(2) The coverage period starts on whichever of the following dates is latest:

(A) July 1, 1966.

(B) The first day of the third month after the month in which the State agreement is made.

(C) The first day of the first month in which the person is both an eligible individual and a member of a coverage group specified in the agreement under this section.

(D) Any date specified in the agreement.

(3) The coverage period based on the State agreement ends on the last day of whichever event occurs first:

(A) The State agency determines that the person has become ineligible both for the kind of money payments specified in the agreement and, if a modification under subsection (h) is in effect, for medical assistance. The coverage period ends on the last day of the month in which that determination is made.

(B) The person becomes entitled to monthly benefits under subchapter II or to an annuity or pension under the Railroad Retirement Act of 1974 (45 U.S.C. 231 and following). The coverage period ends on the last day of the month before the first month of that entitlement.

(e) Treating subsection (d)(3) terminations as enrollment under section 1395p

If a person’s coverage period based on the State agreement ends under subsection (d)(3), the person is treated, for this part, as having enrolled under section 1395p of this title during the initial general enrollment period provided by section 1395p(c) of this title. This treatment^* includes continuing the person’s coverage period under this part.

If such a person files notice during the last month of the State-agreement coverage period or during any of the next six months saying that the person no longer wants to participate in the insurance program established by this part, coverage under this part ends at the close of the month in which the notice is filed.

This section does not define “initial general enrollment period,” “notice,” or “insurance program.”

(f) State agency included as a “carrier”; provisions for deductions, coinsurance, and efficient operation

For an eligible person receiving money payments under a State plan approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, or eligible for medical assistance under the State plan approved under subchapter XIX, the agreement may say that the term “carrier,” as defined in section 1395u(f) of this title, also includes the State agency named in the agreement. That agency must administer, or supervise administration^* of, the State plan approved under subchapter I, XVI, or XIX.

The agreement must also include provisions that make the State’s and the carrier’s financial transactions easier with respect to deductions, coinsurance, and other matters. These provisions must promote economical and efficient operation for people receiving money payments under the State’s plans approved under subchapters I, X, XIV, and XVI, and part A of subchapter IV, and for people eligible for medical assistance under the State’s plan approved under subchapter XIX.

This section does not define “carrier,” “State agency,” “deductions,” “coinsurance,” “economy,” or “efficiency of operation.”

(g) Exclusions from coverage groups in subsection (b)

(1) If a State asks before January 1, 1970, during 1981, or after 1988, the Secretary must modify the State’s agreement under subsection (a) so that the second sentence of subsection (b) does not apply to that agreement.

(2) For a person who would be excluded from the applicable coverage group under that second sentence if this subsection did not apply:

(A) Subsections (c) and (d)(2) are applied as though they referred to the modification under this subsection instead of the agreement under subsection (a).

(B) Subsection (d)(3)(B) does not apply while a State modification under this subsection is in effect.

(h) Modifications involving the coverage groups in subsection (b)

(1) If a State asks before January 1, 1970, during 1981, or after 1988, the Secretary must modify the State’s agreement under subsection (a) to broaden the coverage group described in subsection (b) and specified in the agreement. The broadened group must include either or both of the following:

(A) People eligible for medical assistance under the State’s plan approved under subchapter XIX.

(B) Qualified Medicare beneficiaries, as section 1396d(p)(1) of this title defines that term.

(2) For this section, a person is treated as eligible for medical assistance under the State’s plan approved under subchapter XIX if, for the month in which the modification is made or for any later month, the person has been determined eligible for medical assistance under that plan.

For a person who would be excluded from the agreement if this subsection did not apply, subsections (c) and (d)(2) are applied as though they referred to the modification under this subsection instead of the agreement under subsection (a). Also, for subsection (d)(2)(C), except for qualified Medicare beneficiaries as defined in section 1396d(p)(1) of this title, “second month following the first month” is substituted for “first month.”

(3) In this subsection, “qualified Medicare beneficiary” also includes a person described in section 1396a(a)(10)(E)(iii) of this title.

(i) Enrollment of qualified Medicare beneficiaries

For rules about enrolling qualified Medicare beneficiaries under part A, see section 1395i–2(g) of this title.

This section does not define “qualified Medicare beneficiary.”