42 U.S.C. § 1396r–6 — Extension of eligibility for medical assistance

(a) Initial 6-month extension

(1) Requirement

(A) In general. Regardless of other rules in this subchapter, and subject to subparagraph (B) and paragraph (5), every State^* plan approved under this subchapter must provide the following. A family qualifies if it received aid under a State plan approved under part A of subchapter IV for at least 3 of the 6 months immediately before the month when the family becomes ineligible for that aid. The family must become ineligible because of the caretaker relative’s hours of work or employment income, or because of section 602(a)(8)(B)(ii)(II) of this title, which provides a time-limited earned-income disregard. "Caretaker relative" is defined in subsection (e). This section does not define "dependent child" or "medical assistance^*.

Subject to paragraph (3), the family stays eligible for assistance under the State plan approved under this subchapter during the next 6 months. The family does not have to apply again for benefits under the plan.

(B) State option to waive requirement for 3 months before receipt of medical assistance. A State may choose to apply subparagraph (A) also to a family that received the aid for fewer than 3 months, or that applied for and was eligible for the aid for fewer than 3 months, during the 6 immediately preceding months.

(2) Notice of benefits. When a State sends a family that meets paragraph (1) a notice ending its aid under part A of subchapter IV, the State—

(A) must tell the family about its right to extended medical assistance under this subsection. The notice must describe the reporting requirement in subsection (b)(2)(B)(i) and the circumstances in paragraph (3) that can end the extension; and

(B) must include a card or other proof that the family is entitled to assistance under this subchapter for the period provided by this subsection.

(3) Termination of extension

(A) No dependent child. Subject to subparagraphs (B) and (C), a family’s assistance extension during the 6-month period in paragraph (1) ends at the close of the first month in that period when the family no longer includes a child. This applies whether or not the child is, or would be if needy, a "dependent child" under part A of subchapter IV. This section does not define that term.

(B) Notice before termination. Assistance may not end under subparagraph (A) until the State has given the family notice of the reason for ending it.

(C) Continuation in certain cases until redetermination. A child who would lose medical assistance because of subparagraph (A) may still qualify under the State plan because the child is described in clause (i) of section 1396d(a), or in clause (i)(IV), (i)(VI), (i)(VII), or (ii)(IX) of section 1396a(a)(10)(A). In that situation, the State may not stop the child’s assistance under subparagraph (A) until the State determines that the child is not eligible under the plan. The section does not define the quoted eligibility categories.

(4) Scope of coverage

(A) In general. Subject to subparagraph (B), during the 6-month extension, the amount, length, and range of medical assistance available to the family must be the same as if the family were still receiving aid under the plan approved under part A of subchapter IV.

(B) State Medicaid "wrap-around" option. A State may choose to pay the family’s premiums, deductibles, coinsurance, and similar costs for health insurance or other health coverage offered by an employer of the caretaker relative or by an employer of the absent parent^* of a dependent child. This section does not define "wrap-around," "deductible," "coinsurance," or "similar costs.

For coverage offered by the caretaker relative’s employer—

(i) the State may require the caretaker relative to apply for that employer coverage as a condition of extending coverage for the caretaker and the caretaker’s family, but only if both of these conditions are met:

(I) the caretaker relative does not have to make financial contributions for the coverage. Contributions include payroll deductions, deductibles, coinsurance, similar costs, or any other required payment; and

(II) the State directly or indirectly pays any premium, deductible, coinsurance, or similar expense that the employee otherwise would have to pay; and

(ii) the State must treat coverage under the employer plan as a third-party liability under section 1396a(a)(25) of this title. This section does not define "third-party liability.

For purposes of section 1396b(a), State payments for premiums, deductibles, coinsurance, and similar expenses under this subparagraph count as payments for medical assistance.

(5) Option of 12-month initial eligibility period. A State may choose to treat every reference in this subsection to a 6-month period or 6 months as a reference to a 12-month period or 12 months. If the State makes that choice, subsection (b) does not apply.

(b) Additional 6-month extension

(1) Requirement. Regardless of other rules in this subchapter, and subject to subsection (a)(5), every State plan approved under this subchapter must provide the following. A family that received assistance during the entire 6-month period under subsection (a), and that meets the requirement in paragraph (2)(B)(i), must be offered, during the last month of that period, the choice to extend coverage under this subsection for the next 6 months. The choice is subject to paragraph (3).

(2) Notice and reporting requirements

(A) Notices

(i) Notice during initial extension period of option and requirements. During the 3rd and 6th month of any extended assistance provided to a family under subsection (a), the State must notify the family about its option for additional extended assistance under this subsection.

The 3rd-month notice must state the reporting requirement in subparagraph (B)(i). The 6th-month notice must state the reporting requirement in subparagraph (B)(ii). Each notice must also include—

(I) the applicable reporting requirement just described;

(II) a statement saying whether the family must pay any premiums for the additional extended assistance; and

(III) a description of other out-of-pocket expenses, benefits, reporting and payment procedures, and any limits on coverage under alternative coverage options offered under paragraph (4)(D). These limits include pre-existing-condition limits and waiting periods. This section does not define the quoted terms.

The 6th-month notice must state the premium amount, if any, that the particular family must pay for each of the first 3 months of additional extended assistance under this subsection.

(ii) Notice during additional extension period of reporting requirements and premiums. During the 3rd month of additional extended assistance under this subsection, the State must notify the family of the reporting requirement in subparagraph (B)(ii). The State must also state the amount of any premium required for the next 3 months of that extended assistance.

(B) Reporting requirements

(i) During initial extension period. As a condition of receiving additional extended assistance under this subsection, the State must require a family receiving assistance under subsection (a) to report to the State by the 21st day of the 4th month of the subsection (a) extension. The family must report its gross monthly earnings and its costs for child care that is necessary for the caretaker relative’s employment in each of the first 3 months of that extension.

A State may allow the additional extended assistance even when the family did not report under this clause on time if the family proves, to the State’s satisfaction, good cause for the late report. This section does not define "good cause."

(ii) During additional extension period. A State must require a family receiving assistance under this subsection to report to the State by the 21st day of both the 1st month and the 4th month of the additional extension. For each report, the family must give its gross monthly earnings and its costs for child care necessary for the caretaker relative’s employment during each of the 3 preceding months.

(iii) Clarification on frequency of reporting. A State may not require a family receiving assistance under this subsection or subsection (a) to report more often than required by clause (i) or (ii).

(3) Termination of extension

(A) In general. Subject to subparagraphs (B) and (C), a family’s assistance extension during the 6-month period in paragraph (1) ends during that period as follows:

(i) No dependent child. The extension ends at the close of the first month in which the family no longer includes a child. This applies whether or not the child is, or would be if needy, a "dependent child" under part A of subchapter IV. This section does not define that term.

(ii) Failure to pay any premium. If the family does not pay a premium required for a month under paragraph (5) by the 21st day of the following month, the extension ends at the close of that following month. It does not end for this reason if the family proves, to the State’s satisfaction, good cause for not paying on time.

(iii) Quarterly income reporting and test. The extension ends at the close of the 1st or 4th month of the 6-month period if any of the following applies:

(I) The family does not report to the State by the 21st day of that month the information required by paragraph (2)(B)(ii), unless the family proves, to the State’s satisfaction, good cause for the late report.

(II) The caretaker relative had no earnings in one or more of the preceding 3 months. This does not apply if the lack of earnings resulted from an involuntary loss of employment, illness, or another good cause established to the State’s satisfaction.

(III) The State determines that the family’s average gross monthly earnings during the immediately preceding 3 months, after subtracting the costs of child care necessary for the caretaker relative’s employment, are more than 185 percent of the official poverty line for a family of the relevant size. The Office of Management and Budget defines the "official poverty line," and it is revised each year under section 9902(2) of this title.

The information described in subclause (I) is subject to the limits on using and disclosing information under section 602(a)(9) of this title.

Instead of ending the extension under subclause (I), a State may choose to suspend it until the month after the month when the family reports the information required by paragraph (2)(B)(ii). The State may do this only if the extension has not otherwise ended under subclause (II) or (III) of clause (iii).

Each time the State receives a family’s report under paragraph (2)(B)(ii), the State must make the determination required by clause (iii)(III) for that family.

(B) Notice before termination. Assistance may not end under subparagraph (A) until the State gives the family notice of the reason. If the reason is subparagraph (A)(iii)(II), concerning no continued earnings, the notice must explain how the family may reestablish eligibility for medical assistance under the State plan. The termination may not take effect earlier than 10 days after the notice is mailed.

(C) Continuation in certain cases until redetermination

(i) Dependent children. A child who would lose medical assistance because of subparagraph (A)(i) may still qualify under the State plan because the child is described in clause (i) of section 1396d(a), or in clause (i)(IV), (i)(VI), (i)(VII), or (ii)(IX) of section 1396a(a)(10)(A). The State may not stop the child’s assistance under that subparagraph until the State determines that the child is not eligible under the plan. This section does not define the quoted eligibility categories.

(ii) Medically needy. An individual who would lose medical assistance because of clause (ii) or (iii) of subparagraph (A) may still qualify under the State plan because the individual is in a category for which the plan provides medical assistance under section 1396a(a)(10)(C), concerning "medically needy individuals." This section does not define that quoted term. The State may not stop the individual’s assistance under that subparagraph until the State determines that the individual is not eligible under the plan.

(4) Coverage

(A) In general. During the extension under this subsection—

(i) the State plan must offer each family medical assistance that, subject to subparagraphs (B) and (C), has the same amount, length, and range as the family would receive if it were still receiving aid under the plan approved under part A of subchapter IV; and

(ii) the State plan may offer the alternative coverage described in subparagraph (D).

(B) Elimination of most non-acute care benefits. At the State’s option, and despite any other rule in this subchapter, the State may choose not to provide medical assistance under this subsection for any or all of the items and services described in paragraphs (4)(A), (6), (7), (8), (11), (13), (14), (15), (16), (18), (20), and (21) of section 1396d(a). This section does not list or define those items and services.

(C) State Medicaid "wrap-around" option. At the State’s option, the State may use the option in subsection (a)(4)(B), concerning "wrap-around" coverage, for families that choose medical assistance under this subsection. The option must be used in the same way it is used for families receiving extended medical-assistance eligibility under subsection (a). This section does not define "wrap-around."

(D) Alternative assistance. At the State’s option, the State may offer families a choice of health-care coverage under one or more of the following instead of the medical assistance otherwise available under this subsection:

(i) Enrollment in family option of employer plan. Enrollment of the caretaker relative and dependent children in a family option under the group health plan^* offered to the caretaker relative.

(ii) Enrollment in family option of State employee plan. Enrollment of the caretaker relative and dependent children in a family option within the group health-plan options offered by the State to State employees.

(iii) Enrollment in State uninsured plan. Enrollment of the caretaker relative and dependent children in a basic State health plan^* offered to people in the State, or in areas of the State, who otherwise cannot obtain health-insurance coverage.

(iv) Enrollment in Medicaid managed-care organization. Enrollment of the caretaker relative and dependent children in a Medicaid managed-care organization, as defined in section 1396b(m)(1)(A). This section does not define "managed-care organization."

If a State offers an enrollment option under this subparagraph, the State must pay the premiums and other enrollment costs imposed on the family. The State may also pay deductibles and coinsurance imposed on the family.

For purposes of section 1396b(a)(1), the State’s premium payments for these family enrollments, excluding premiums that an employer otherwise must pay and subtracting premiums collected from the families under paragraph (5), count as payments for medical assistance. The State’s payments of deductibles and coinsurance also count as payments for medical assistance.

(E) Prohibition on cost-sharing^* for maternity and preventive pediatric care

(i) In general. If a State offers families any alternative option under subparagraph (D), the State must make sure that the care described in clause (ii) is available to the families at no charge under every such option. The State must do this by paying the deductibles, coinsurance, and other cost-sharing for that care; by providing the care under the State plan with no cost-sharing; or by using a combination of those methods. This section does not define "cost-sharing."

(ii) Care described. The care covered by this clause consists of—

(I) services related to pregnancy, including prenatal, delivery, and postpartum services; and

(II) outpatient preventive pediatric care, including outpatient early and periodic screening, diagnosis, and treatment^* services under section 1396d(a)(4)(B), for each child who meets the age and birth-date requirements for being a qualified child under section 1396d(n)(2). This section does not define the quoted eligibility terms.

(5) Premium

(A) Permitted. Despite any other rule in this subchapter, including section 1396o, a State may charge a family a premium for additional extended coverage under this subsection for a premium-payment period defined in subparagraph (D)(i). The State may do so only if the family’s average gross monthly earnings during the premium-base period, after subtracting the average monthly cost of child care necessary for the caretaker relative’s employment, are more than 100 percent of the official poverty line for a family of the relevant size. The Office of Management and Budget defines the "official poverty line," and it is revised annually under section 9902(2).

(B) Level may vary by option offered. For the same family, the premium may have a different amount for each option the State offers under paragraph (4)(D).

(C) Limit on premium. For either of the premium-payment periods described in subparagraph (D)(i), the premium charged to a family for any month may never exceed 3 percent of the family’s average gross monthly earnings during the premium-base period, after subtracting the average monthly cost of child care necessary for the caretaker relative’s employment.

(D) Definitions. In this paragraph—

(i) "Premium-payment period" means a 3-month period that begins with the 1st or 4th month of the 6-month additional extension under this subsection; and

(ii) "Premium-base period" means, for a particular premium-payment period, the 3 consecutive months whose last month is 4 months before that premium-payment period begins.

(c) Applicability in States and territories

(1) States operating under demonstration projects. If a State provides medical assistance to its residents under a waiver granted under section 1315(a), the Secretary^* must require the State to meet this section’s requirements in the same way the State would have to meet them if it had a plan approved under this subchapter. This section does not define "waiver" or "demonstration project^*.

(2) Inapplicability in commonwealths and territories. This section applies only to the 50 States and the District of Columbia. It does not apply to commonwealths or territories.

(d) General disqualification for fraud

(1) Ineligibility for aid. This section does not apply to an individual who is a member of a family that received aid under part A of subchapter IV if the State finds that, at any time during the last 6 months when the family received that aid before the individual would otherwise receive extended eligibility under this section, the individual was ineligible for that aid because of fraud. This section does not define "fraud."

(2) General disqualifications. For additional rules about fraud and program abuse, see sections 1320a–7, 1320a–7a, and 1320a–7b. This section does not define "program abuse."

(e) "Caretaker relative" defined. In this section, "caretaker relative" has the meaning that the term has in part A of subchapter IV. This section does not give that meaning itself.

(f) Collection and reporting of participation information

(1) Collection of information from States. Each State must collect and submit to the Secretary, and make publicly available, information in the format the Secretary specifies. The information must cover average monthly enrollment and average monthly participation rates for adults and children under this section. It must also cover the number and percentage of children who become ineligible for medical assistance under this section but whose assistance continues under another eligibility category, or who enroll under the State’s child health plan under subchapter XXI. This section does not define "participation rate," "eligibility category," or "child health plan.

The State must submit this information at the same time and as often as it submits other enrollment information under this subchapter to the Secretary.

(2) Annual reports to Congress. Using the information submitted under paragraph (1), the Secretary must send Congress an annual report about the enrollment and participation rates described in that paragraph.