r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE wiki — defined terms

“erroneous excess payments for medical assistance” applies in that section

the term “erroneous excess payments for medical assistance” means the total of— (I) payments under the State plan with respect to ineligible individuals and families, and (II) overpayments on behalf of eligible individuals and families by reason of error in determining the amount of expenditures for medical care required of an individual or family as a condition of eligibility.

“expansion State” applies in that section

The term “expansion State” means a State that, beginning on January 1, 2014 , or on any date thereafter, elects to provide medical assistance to all individuals described in section 1396a(a)(10)(A)(i)(VIII) of this title under the State plan under this subchapter or under a waiver of such plan. (II) Non-expansion State

“health care provider” applies in that section

The term “health care provider” means an individual or person that receives payments for the provision of health care items or services. (C) An entity is considered to be “related” to a health care provider if the entity— (i) is an organization, association, corporation or partnership formed by or on behalf of health care providers; (ii) is a person with an ownership or control interest (as defined in section 1320a–3(a)(3) of this title ) in the provider; (iii) is the employee, spouse, parent, child, or sibling of the provider (or of a person described in clause (ii)); or (iv) has a similar, close relationship (as defined in regulations) to the provider.;

“health care related tax” applies in that section

the term “health care related tax” means a tax (as defined in paragraph (7)(F)) that— (i) is related to health care items or services, or to the provision of, the authority to provide, or payment for, such items or services, or (ii) is not limited to such items or services but provides for treatment of individuals or entities that are providing or paying for such items or services that is different from the treatment provided to other individuals or entities. In applying clause (i), a tax is considered to relate to health care items or services if at least 85 percent of the burden of such tax falls on health care providers. (B) In this subsection,

“home health care services” applies in that section

The term “home health care services” means services described in section 1396d(a)(7) of this title provided under a State plan under this subchapter (or under a waiver of the plan).;

“hospital-based” applies in that section

The term “hospital-based” means, with respect to an eligible professional, a professional (such as a pathologist, anesthesiologist, or emergency physician) who furnishes substantially all of the individual’s professional services in a hospital inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.;

“impermissible tax” applies in that section

the term “impermissible tax” means a health care related tax for which a reduction may be made under clause (ii) or (iii) of subparagraph (A). (E) (i) In no case may the total amount of donations and taxes permitted under the exception provided in subparagraphs (C)(ii) and (D)(ii) for the portion of State fiscal year 1992 occurring during calendar year 1992 exceed the limit under paragraph (5) minus the total amount of broad-based health care related taxes received in the portion of that fiscal year.

“managed care entity” applies in that section

The term “managed care entity” means a medicaid managed care organization described in section 1396u–2(a)(1)(B)(i) of this title .;

“medicaid managed care organization” applies in that section

The term “medicaid managed care organization” means a health maintenance organization, an eligible organization with a contract under section 1395mm of this title or a Medicare+Choice organization with a contract under part C of subchapter XVIII, a provider sponsored organization, or any other public or private organization, which meets the requirement of section 1396a(w) of this title and— (i) makes services it provides to individuals eligible for benefits under this subchapter accessible to such individuals, within the area served by the organization, to the same extent as such services are made accessible to individuals (eligible for medical assistance under the State plan) not enrolled …

“Medicaid provider” applies in that section

the term “Medicaid provider” means— (A) an eligible professional (as defined in paragraph (3)(B))— (i) who is not hospital-based and has at least 30 percent of the professional’s patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to individuals who are receiving medical assistance under this subchapter; (ii) who is not described in clause (i), who is a pediatrician, who is not hospital-based, and who has at least 20 percent of the professional’s patient volume (as estimated in accordance with a methodology established by the Secretary) attributable to individuals who are receiving medical assistance under this subchapter; and (iii) who …

“Medicaid taxable unit” applies in that section

The term “Medicaid taxable unit” means a unit that is being taxed within a health care related tax that is applicable to the program under this subchapter. Such term includes a unit that is used as the basis for— (i) payment under the program under this subchapter (such as Medicaid bed days); (ii) Medicaid revenue; (iii) costs associated with the program under this subchapter (such as Medicaid charges, claims, or expenditures); and (iv) other units associated with the program under this subchapter, as determined by the Secretary.;

“medication risk management program” applies in that section

the term “medication risk management program” means a program for targeted beneficiaries that ensures that covered outpatient drugs are appropriately used to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events. (B) Elements Such program may include the following elements: (i) The use of established principles and standards for drug utilization review and best practices to analyze prescription drug claims of targeted beneficiaries and identify outlier physicians.

“minimum medical loss ratio” applies in that section

The term “minimum medical loss ratio” means, with respect to a State, a minimum medical loss ratio (as calculated under subsection (d) of section 438.8 of title 42, Code of Federal Regulations (as in effect on June 1, 2018 )) for payment for services provided by entities described in subparagraph (B) under the State plan under this subchapter (or a waiver of the plan).;

“needy individual” applies in that section

The term “needy individual” means, with respect to a Medicaid provider, an individual— (i) who is receiving assistance under this subchapter; (ii) who is receiving assistance under subchapter XXI; (iii) who is furnished uncompensated care by the provider; or (iv) for whom charges are reduced by the provider on a sliding scale basis based on an individual’s ability to pay.

“net average allowable costs” applies in that section

The term “net average allowable costs” means, with respect to a Medicaid provider described in paragraph (2)(A), average allowable costs reduced by the average payment the Secretary estimates will be made to such Medicaid providers (determined on a percentage or other basis for such classes or types of providers as the Secretary may specify) from other sources (other than under this subsection, or by the Federal government or a State or local government) that is directly attributable to payment for certified EHR technology or support services described in subparagraph (C).;

“non-expansion State” applies in that section

The term “non-expansion State” means a State that is not an expansion State. (iv) In the case of a tax of an expansion State or unit of local government in such State in effect on July 4, 2025 , that applies to a class of health care items or services that is described in paragraph (3) or (4) of section 433.56(a) of title 42, Code of Federal Regulations (as in effect on May 1, 2025 ), and for which, on such date, is within the hold harmless threshold (as determined by the Secretary), the applicable percent of net patient revenue attributable to such class that has been so determined shall apply for a fiscal year instead of the applicable percent specified in clause (ii) for the fiscal year.

“non-Medicaid taxable unit” applies in that section

The term “non-Medicaid taxable unit” means a unit that is being taxed within a health care related tax that is not applicable to the program under this subchapter. Such term includes a unit that is used as the basis for— (i) payment by non-Medicaid payers (such as non-Medicaid bed days); (ii) non-Medicaid revenue; (iii) costs that are not associated with the program under this subchapter (such as non-Medicaid charges, non-Medicaid claims, or non-Medicaid expenditures); and (iv) other units not associated with the program under this subchapter, as determined by the Secretary.;

“other specified entity” applies in that section

The term “other specified entity” means— (I) a prepaid inpatient health plan, as defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation); and (II) a prepaid ambulatory health plan, as defined in such section (or any successor regulation). (n) Repealed. Pub. L. 100–93, § 8(h)(1) , Aug. 18, 1987 , 101 Stat.

“personal care services” applies in that section

The term “personal care services” means personal care services provided under a State plan under this subchapter (or under a waiver of the plan), including services provided under section 1396d(a)(24), 1396n(c), 1396n(i), 1396n(j), or 1396n(k) of this title or under a wavier 7 under section 1315 of this title .

“provider-related donation” applies in that section

the term “provider-related donation” means any donation or other voluntary payment (whether in cash or in kind) made (directly or indirectly) to a State or unit of local government by— (i) a health care provider (as defined in paragraph (7)(B)), (ii) an entity related to a health care provider (as defined in paragraph (7)(C)), or (iii) an entity providing goods or services under the State plan for which payment is made to the State under paragraph (2), (3), (4), (6), or (7) of subsection (a). (B) For purposes of paragraph (1)(A)(i)(I),

“qualified sums” applies in that section

the term “qualified sums” means, with respect to a State and a quarter, the amount equal to the amount (if any) by which the sums expended by the State during such quarter attributable to substance use disorder treatment or recovery services furnished by providers participating under the State plan (or a waiver of such plan) exceeds 1/4 of such sums expended by the State during fiscal year 2018 attributable to substance use disorder treatment or recovery services.

“satisfactory documentary evidence of citizenship or nationality” applies in that section

the term “satisfactory documentary evidence of citizenship or nationality” means— (i) any document described in subparagraph (B); or (ii) a document described in subparagraph (C) and a document described in subparagraph (D). (B) The following are documents described in this subparagraph: (i) A United States passport. (ii) Form N–550 or N–570 (Certificate of Naturalization). (iii) Form N–560 or N–561 (Certificate of United States Citizenship).

“State” applies in that section

The term “State” means only the 50 States and the District of Columbia but does not include any State whose entire program under this subchapter is operated under a waiver granted under section 1315 of this title . (E) The “State fiscal year” means, with respect to a specified year, a State fiscal year ending in that specified year.;

“State base percentage” applies in that section

the term “State base percentage” means, with respect to a State, an amount (expressed as a percentage) equal to— (I) the total of the amount of health care related taxes (whether or not broad-based) and the amount of provider-related donations (whether or not bona fide) projected to be collected (in accordance with clause (ii)) during State fiscal year 1992, divided by (II) the non-Federal share of the total amount estimated to be expended under the State plan during such State fiscal year.

“State medicaid fraud control unit” applies in that section

the term “State medicaid fraud control unit” means a single identifiable entity of the State government which the Secretary certifies (and annually recertifies) as meeting the following requirements: (1) The entity (A) is a unit of the office of the State Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal violations, (B) is in a State the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the Secretary, that (i) assure its referral of suspected criminal violations relating to the program under this subchapter to …

“supplemental payment” applies in that section

the term “supplemental payment” means a payment to a provider that is in addition to any base payment made to the provider under the State plan under this subchapter or under demonstration authority. (B) DSH payments excluded Such term does not include a disproportionate share hospital payment made under section 1396r–4 of this title .

“targeted beneficiaries” applies in that section

the term “targeted beneficiaries” means Medicaid eligible beneficiaries who are identified as having high prescription drug costs and medical costs, such as individuals with behavioral disorders or multiple chronic diseases who are taking multiple medications.

“tax” applies in that section

The term “tax” includes any licensing fee, assessment, or other mandatory payment, but does not include payment of a criminal or civil fine or penalty (other than a fine or penalty imposed in lieu of or instead of a fee, assessment, or other mandatory payment).;

“tax rate group” applies in that section

The term “tax rate group” means a group of entities contained within a permissible class of a health care related tax that are taxed at the same rate. (x) Satisfactory documentary evidence of citizenship or nationality by individual declaring to be citizen or national of United States (1) For purposes of section 1396a(a)(46)(B)(i) of this title , the requirement of this subsection is, with respect to an individual declaring to be a citizen or national of the United States, that, subject to paragraph (2), there is presented satisfactory documentary evidence of citizenship or nationality (as defined in paragraph (3)) of the individual.

“unit of local government” applies in that section

The term “unit of local government” means, with respect to a State, a city, county, special purpose district, or other governmental unit in the State.;

“health care-acquired condition” applies in that section

the term “health care-acquired condition” means a medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of the Social Security Act ( 42 U.S.C. 1395ww(d)(4)(D)(iv) ). (c) Medicare provisions In carrying out this section, the Secretary shall apply to State plans (or waivers) under title XIX of the Social Security Act [ 42 U.S.C. 1396 et seq.] the regulations promulgated pursuant to section 1886(d)(4)(D) of such Act ( 42 U.S.C.

“birth attendant” applies throughout its subchapter

the term “birth attendant” means an individual who is recognized or registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law (or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a birth attendant. (m) Qualified family member (1) Subject to paragraph (2),

“certified community behavioral health clinic” applies in that section

The term “certified community behavioral health clinic” means an organization that— (A) has been certified by a State as meeting the criteria established by the Secretary pursuant to subsection (a) of section 223 of the Protecting Access to Medicare Act 1 as of January 1, 2024 , and any subsequent updates to such criteria, regardless of whether the State is carrying out a demonstration program under this subchapter under subsection (d) of such section; (B) is engaged in furnishing all of the services described in paragraph (1); and (C) agrees, as a condition of the certification described in subparagraph (A), to furnish to the State or Secretary any data required as part of ongoing …

“certified community behavioral health services” applies in that section

The term “certified community behavioral health services” means any of the following services when furnished to an individual as a patient of a certified community behavioral health clinic (as defined in paragraph (2)), in a manner reflecting person-centered care and which, if not available directly through a certified community behavioral health clinic, may be provided or referred through formal relationships with other providers: (A) Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization. (B) Screening, assessment, and diagnosis, including risk assessment.

“counseling and pharmacotherapy for cessation of tobacco use by pregnant women” applies throughout its subchapter

the term “counseling and pharmacotherapy for cessation of tobacco use by pregnant women” means diagnostic, therapy, and counseling services and pharmacotherapy (including the coverage of prescription and nonprescription tobacco cessation agents approved by the Food and Drug Administration) for cessation of tobacco use by pregnant women who use tobacco products or who are being treated for tobacco use that is furnished— (A) by or under the supervision of a physician; or (B) by any other health care professional who— (i) is legally authorized to furnish such services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished; and …

“disaster-recovery FMAP adjustment State” applies in that section

the term “disaster-recovery FMAP adjustment State” means a State that is one of the 50 States or the District of Columbia, for which, at any time during the preceding 7 fiscal years, the President has declared a major disaster under section 401 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act [ 42 U.S.C. 5170 ] and determined as a result of such disaster that every county or parish in the State warrant individual and public assistance or public assistance from the Federal Government under such Act [ 42 U.S.C.

“early and periodic screening, diagnostic, and treatment services” applies throughout its subchapter

The term “early and periodic screening, diagnostic, and treatment services” means the following items and services: (1) Screening services— (A) which are provided— (i) at intervals which meet reasonable standards of medical and dental practice, as determined by the State after consultation with recognized medical and dental organizations involved in child health care and, with respect to immunizations under subparagraph (B)(iii), in accordance with the schedule referred to in section 1396s(c)(2)(B)(i) of this title for pediatric vaccines, and (ii) at such other intervals, indicated as medically necessary, to determine the existence of certain physical or mental illnesses or conditions; and …

“employed individual with a medically improved disability” applies in that section

The term “employed individual with a medically improved disability” means an individual who— (A) is at least 16 years of age; (B) is employed (as defined in paragraph (2)); (C) ceases to be eligible for medical assistance under section 1396a(a)(10)(A)(ii)(XV) of this title because the individual, by reason of medical improvement, is determined at the time of a regularly scheduled continuing disability review to no longer be eligible for benefits under section 423(d) or 1382c(a)(3) of this title; and (D) continues to have a severe medically determinable impairment, as determined under regulations of the Secretary.

“Federally-qualified health center” applies throughout its subchapter

The term “Federally-qualified health center” means an entity which— (i) is receiving a grant under section 254b of this title , (ii) (I) is receiving funding from such a grant under a contract with the recipient of such a grant, and (II) meets the requirements to receive a grant under section 254b of this title , (iii) based on the recommendation of the Health Resources and Services Administration within the Public Health Service, is determined by the Secretary to meet the requirements for receiving such a grant, including requirements of the Secretary that an entity may not be owned, controlled, or operated by another entity, or (iv) was treated by the Secretary, for purposes of part B of …

“Federally-qualified health center services” applies throughout its subchapter

The term “Federally-qualified health center services” means services of the type described in subparagraphs (A) through (C) of section 1395x(aa)(1) of this title when furnished to an individual as an 3 patient of a Federally-qualified health center and, for this purpose, any reference to a rural health clinic or a physician described in section 1395x(aa)(2)(B) of this title is deemed a reference to a Federally-qualified health center or a physician at the center, respectively.;

“freestanding birth center” applies throughout its subchapter

The term “freestanding birth center” means a health facility— (i) that is not a hospital; (ii) where childbirth is planned to occur away from the pregnant woman’s residence; (iii) that is licensed or otherwise approved by the State to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the plan; and (iv) that complies with such other requirements relating to the health and safety of individuals furnished services by the facility as the State shall establish.

“freestanding birth center services” applies throughout its subchapter

The term “freestanding birth center services” means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)) at such center.;

“full benefits” applies in that section

The term “full benefits” means, with respect to an individual, medical assistance for all services covered under the State plan under this subchapter that is not less in amount, duration, or scope, or is determined by the Secretary to be substantially equivalent, to the medical assistance available for an individual described in section 1396a(a)(10)(A)(i) of this title .

“hospice care” applies throughout its subchapter

the term “hospice care” means the care described in section 1395x(dd)(1) of this title furnished by a hospice program (as defined in section 1395x(dd)(2) of this title ) to a terminally ill individual who has voluntarily elected (in accordance with paragraph (2)) to have payment made for hospice care instead of having payment made for certain benefits described in section 1395d(d)(2)(A) of this title and for which payment may otherwise be made under subchapter XVIII and intermediate care facility services under the plan.

“independent foster care adolescent” applies throughout its subchapter

the term “independent foster care adolescent” means an individual— (A) who is under 21 years of age; (B) who, on the individual’s 18th birthday, was in foster care under the responsibility of a State; and (C) whose assets, resources, and income do not exceed such levels (if any) as the State may establish consistent with paragraph (2). (2) The levels established by a State under paragraph (1)(C) may not be less than the corresponding levels applied by the State under section 1396u–1(b) of this title .

“inpatient psychiatric hospital services for individuals under age 21” applies throughout its subchapter

the term “inpatient psychiatric hospital services for individuals under age 21” includes only— (A) inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined in section 1395x(f) of this title or in another inpatient setting that the Secretary has specified in regulations; (B) inpatient services which, in the case of any individual (i) involve active treatment which meets such standards as may be prescribed in regulations by the Secretary, and (ii) a team, consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof, has determined are …

“institution for mental diseases” applies throughout its subchapter

The term “institution for mental diseases” means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. (j) State supplementary payment

“intermediate care facility for the mentally retarded” applies throughout its subchapter

The term “intermediate care facility for the mentally retarded” means an institution (or distinct part thereof) for the mentally retarded or persons with related conditions if— (1) the primary purpose of such institution (or distinct part thereof) is to provide health or rehabilitative services for mentally retarded individuals and the institution meets such standards as may be prescribed by the Secretary; (2) the mentally retarded individual with respect to whom a request for payment is made under a plan approved under this subchapter is receiving active treatment under such a program; and (3) in the case of a public institution, the State or political subdivision responsible for the …

“medical assistance” applies throughout its subchapter

The term “medical assistance” means payment of part or all of the cost of the following care and services or the care and services themselves, or both (if provided in or after the third month before the month in which the recipient makes application for assistance or, in the case of medicare cost-sharing with respect to a qualified medicare beneficiary described in subsection (p)(1), if provided after the month in which the individual becomes such a beneficiary) for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals (other than individuals with respect to whom there is being paid, or who are eligible, or would be eligible if they …

“medicare cost-sharing” applies throughout its subchapter

The term “medicare cost-sharing” means (subject to section 1396a(n)(2) of this title ) the following costs incurred with respect to a qualified medicare beneficiary, without regard to whether the costs incurred were for items and services for which medical assistance is otherwise available under the plan: (A) (i) premiums under section 1395i–2 or 1395i–2a of this title, and (ii) premiums under section 1395r of this title , 5 (B) Coinsurance under subchapter XVIII (including coinsurance described in section 1395e of this title ). (C) Deductibles established under subchapter XVIII (including those described in section 1395e of this title and section 1395 l (b) of this title).

“medication-assisted treatment” applies in that section

the term “medication-assisted treatment”— (A) means all drugs approved under section 355 of title 21 , including methadone, and all biological products licensed under section 262 of this title to treat opioid use disorders; and (B) includes, with respect to the provision of such drugs and biological products, counseling services and behavioral therapy.

“newly eligible” applies in that section

The term “newly eligible” means, with respect to an individual described in subclause (VIII) of section 1396a(a)(10)(A)(i) of this title , an individual who is not under 19 years of age (or such higher age as the State may have elected) and who, as of December 1, 2009 , is not eligible under the State plan or under a waiver of the plan for full benefits or for benchmark coverage described in subparagraph (A), (B), or (C) of section 1396u–7(b)(1) of this title or benchmark equivalent coverage described in section 1396u–7(b)(2) of this title that has an aggregate actuarial value that is at least actuarially equivalent to benchmark coverage described in subparagraph (A), (B), or (C) of section …

“nursing facility services” applies throughout its subchapter

the term “nursing facility services” means services which are or were required to be given an individual who needs or needed on a daily basis nursing care (provided directly by or requiring the supervision of nursing personnel) or other rehabilitation services which as a practical matter can only be provided in a nursing facility on an inpatient basis.

“optional targeted low-income child” applies in that section

the term “optional targeted low-income child” means a targeted low-income child as defined in section 1397jj(b)(1) of this title (determined without regard to that portion of subparagraph (C) of such section concerning eligibility for medical assistance under this subchapter) who would not qualify for medical assistance under the State plan under this subchapter as in effect on March 31, 1997 (but taking into account the expansion of age of eligibility effected through the operation of section 1396a( l )(1)(D) of this title). Such term excludes any child eligible for medical assistance only by reason of section 1396a(a)(10)(A)(ii)(XIX) of this title .

“primary care” applies in that section

the term “primary care” includes all health care services customarily provided in accordance with State licensure and certification laws and regulations, and all laboratory services customarily provided by or through, a general practitioner, family medicine physician, internal medicine physician, obstetrician/gynecologist, or pediatrician. (u) Conditions for State plans (1) The conditions described in this paragraph for a State plan are as follows: (A) The State is complying with the requirement of section 1397ee(d)(1) of this title .

“primary care case management contract” applies throughout its subchapter

The term “primary care case management contract” means a contract between a primary care case manager and a State under which the manager undertakes to locate, coordinate, and monitor covered primary care (and such other covered services as may be specified under the contract) to all individuals enrolled with the manager, and which— (A) provides for reasonable and adequate hours of operation, including 24-hour availability of information, referral, and treatment with respect to medical emergencies; (B) restricts enrollment to individuals residing sufficiently near a service delivery site of the manager to be able to reach that site within a reasonable time using available and affordable …

“primary care case management services” applies throughout its subchapter

The term “primary care case management services” means case-management related services (including locating, coordinating, and monitoring of health care services) provided by a primary care case manager under a primary care case management contract.;

“primary care case manager” applies throughout its subchapter

The term “primary care case manager” means any of the following that provides services of the type described in paragraph (1) under a contract referred to in such paragraph: (A) A physician, a physician group practice, or an entity employing or having other arrangements with physicians to provide such services. (B) At State option— (i) a nurse practitioner (as described in subsection (a)(21)); (ii) a certified nurse-midwife (as defined in section 1395x(gg) of this title ); or (iii) a physician assistant (as defined in section 1395x(aa)(5) of this title ).;

“qualified disabled and working individual” applies throughout its subchapter

The term “qualified disabled and working individual” means an individual— (1) who is entitled to enroll for hospital insurance benefits under part A of subchapter XVIII under section 1395i–2a of this title ; (2) whose income (as determined under section 1382a of this title for purposes of the supplemental security income program) does not exceed 200 percent of the official poverty line (as defined by the Office of Management and Budget and revised annually in accordance with section 9902(2) of this title ) applicable to a family of the size involved; (3) whose resources (as determined under section 1382b of this title for purposes of the supplemental security income program) do not exceed …

“qualified family member” applies throughout its subchapter

the term “qualified family member” means an individual (other than a qualified pregnant woman or child, as defined in subsection (n)) who is a member of a family that would be receiving aid under the State plan under part A of subchapter IV pursuant to section 607 1 of this title if the State had not exercised the option under section 607(b)(2)(B)(i) 1 of this title. (2) No individual shall be a qualified family member for any period after September 30, 1998 . (n) “Qualified pregnant woman or child” defined

“qualified medicare beneficiary” applies throughout its subchapter

The term “qualified medicare beneficiary” means an individual— (A) who is entitled to hospital insurance benefits under part A of subchapter XVIII (including an individual entitled to such benefits pursuant to an enrollment under section 1395i–2 of this title , but not including an individual entitled to such benefits only pursuant to an enrollment under section 1395i–2a of this title ) or who is enrolled under part B for the purpose of coverage of immunosuppressive drugs under section 1395 o (b) of this title, (B) whose income (as determined under section 1382a of this title for purposes of the supplemental security income program, except as provided in paragraph (2)(D)) does not exceed an …

“qualified pregnant woman or child” applies throughout its subchapter

The term “qualified pregnant woman or child” means— (1) a pregnant woman who— (A) would be eligible for aid to families with dependent children under part A of subchapter IV (or would be eligible for such aid if coverage under the State plan under part A of subchapter IV included aid to families with dependent children of unemployed parents pursuant to section 607 of this title ) if her child had been born and was living with her in the month such aid would be paid, and such pregnancy has been medically verified; (B) is a member of a family which would be eligible for aid under the State plan under part A of subchapter IV pursuant to section 607 of this title if the plan required the …

“qualified severely impaired individual” applies throughout its subchapter

The term “qualified severely impaired individual” means an individual under age 65— (1) who for the month preceding the first month to which this subsection applies to such individual— (A) received (i) a payment of supplemental security income benefits under section 1382(b) of this title on the basis of blindness or disability, (ii) a supplementary payment under section 1382e of this title or under section 212 of Public Law 93–66 on such basis, (iii) a payment of monthly benefits under section 1382h(a) of this title , or (iv) a supplementary payment under section 1382e(c)(3), and (B) was eligible for medical assistance under the State plan approved under this subchapter; and (2) with …

“qualifying clinical trial” applies in that section

the term “qualifying clinical trial” means a clinical trial (in any clinical phase of development) that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition and is described in any of the following clauses: (i) The study or investigation is approved, conducted, or supported (which may include funding through in-kind contributions) by one or more of the following: (I) The National Institutes of Health. (II) The Centers for Disease Control and Prevention. (III) The Agency for Healthcare Research and Quality. (IV) The Centers for Medicare & Medicaid Services.

“qualifying State” applies in that section

the term “qualifying State” means a State which— (A) has not expended amounts for all individuals described in section 1396a(a)(10)(A)(i)(VIII) of this title before March 11, 2021 ; and (B) begins to expend amounts for all such individuals prior to January 1, 2026 . (jj) Certified community behavioral health clinic services (1) In general

“regular FMAP” applies in that section

the term “regular FMAP” means, for each fiscal year for which this subsection applies to a State, the Federal medical assistance percentage that would otherwise apply to the State for the fiscal year, as determined under subsection (b) and without regard to this subsection, subsections (y) and (z), and section 10202 of the Patient Protection and Affordable Care Act.

“rural health clinic” applies throughout its subchapter

The terms “rural health clinic services” and “rural health clinic” have the meanings given such terms in section 1395x(aa) of this title , except that (A) clause (ii) of section 1395x(aa)(2) of this title shall not apply to such terms, and (B) the physician arrangement required under section 1395x(aa)(2)(B) of this title shall only apply with respect to rural health clinic services and, with respect to other ambulatory care services, the physician arrangement required shall be only such as may be required under the State plan for those services. (2);

“rural health clinic services” applies throughout its subchapter

The terms “rural health clinic services” and “rural health clinic” have the meanings given such terms in section 1395x(aa) of this title , except that (A) clause (ii) of section 1395x(aa)(2) of this title shall not apply to such terms, and (B) the physician arrangement required under section 1395x(aa)(2)(B) of this title shall only apply with respect to rural health clinic services and, with respect to other ambulatory care services, the physician arrangement required shall be only such as may be required under the State plan for those services. (2);

“State supplementary payment” applies throughout its subchapter

The term “State supplementary payment” means any cash payment made by a State on a regular basis to an individual who is receiving supplemental security income benefits under subchapter XVI or who would but for his income be eligible to receive such benefits, as assistance based on need in supplementation of such benefits (as determined by the Commissioner of Social Security), but only to the extent that such payments are made with respect to an individual with respect to whom supplemental security income benefits are payable under subchapter XVI, or would but for his income be payable under that subchapter.

“transition month” applies throughout its subchapter

the term “transition month” means each month in a year through the month following the month in which the annual revision of the official poverty line, referred to in subparagraph (A), is published.;

“cost-effective” applies in that section

The term “cost-effective” has the meaning given that term in section 1397ee(c)(3)(A) of this title .

“group health plan” applies in that section

The term “group health plan” has the meaning given such term in section 5000(b)(1) of the Internal Revenue Code of 1986, and includes the provision of continuation coverage by such a plan pursuant to title XXII of the Public Health Service Act [ 42 U.S.C. 300bb–1 et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI 1 of the Employee Retirement Income Security Act of 1974.;

“premium assistance subsidy” applies in that section

the term “premium assistance subsidy” means the amount of the employee contribution for enrollment in the qualified employer-sponsored coverage by the individual or by the individual’s family. Premium assistance subsidies under this section shall be considered, for purposes of section 1396b(a) of this title , to be a payment for medical assistance. (d) Voluntary participation (1) Employers Participation by an employer in a premium assistance subsidy offered by a State under this section shall be voluntary. An employer may notify a State that it elects to opt-out of being directly paid a premium assistance subsidy on behalf of an employee.

“qualified employer-sponsored coverage” applies in that section

the term “qualified employer-sponsored coverage” means a group health plan or health insurance coverage offered through an employer— (A) that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act; 2 (B) for which the employer contribution toward any premium for such coverage is at least 40 percent; and (C) that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).

“insurer” applies in that section

the term “insurer” includes a group health plan, as defined in section 1167(1) of title 29 , a health maintenance organization, and an entity offering a service benefit plan.

“activities of daily living” applies in that section

The term “activities of daily living” includes tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (B) Consumer controlled

“agency-provider model” applies in that section

The term “agency-provider model” means, with respect to the provision of home and community-based attendant services and supports for an individual, subject to paragraph (4), a method of providing consumer controlled services and supports under which entities contract for the provision of such services and supports. (ii) Other models

“approved self-directed services plan and budget” applies in that section

the term “approved self-directed services plan and budget” means, with respect to a participant, the establishment of a plan and budget for the provision of self-directed personal assistance services, consistent with the following requirements: (A) Self-direction The participant (or in the case of a participant who is a minor child, the participant’s parent or guardian, or in the case of an incapacitated adult, another individual recognized by State law to act on behalf of the participant) exercises choice and control over the budget, planning, and purchase of self-directed personal assistance services, including the amount, duration, scope, provider, and location of service provision.

“base year” applies in that section

the term “base year” means the most recent year (ending before December 22, 1987 ) for which actual final expenditures under this subchapter have been reported to, and accepted by, the Secretary. (II) For purposes of subparagraph (C), in the case of a State that does not report expenditures on the basis of the age categories described in such subparagraph for a year ending before December 22, 1987 ,

“case management services” applies in that section

The term “case management services” means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services. (ii) Such term includes the following: (I) Assessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services. Such assessment activities include the following: (aa) Taking client history. (bb) Identifying the needs of the individual, and completing related documentation.

“consumer controlled” applies in that section

The term “consumer controlled” means a method of selecting and providing services and supports that allow the individual, or where appropriate, the individual’s representative, maximum control of the home and community-based attendant services and supports, regardless of who acts as the employer of record. (C) Delivery models (i) Agency-provider model

“dual eligible individual” applies in that section

the term “dual eligible individual” means an individual who is entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and is eligible for medical assistance under the State plan under this subchapter or under a waiver of such plan.

“eligible individual” applies in that section

The term “eligible individual” means an individual who— (i) with respect to a State, is enrolled for medical assistance under the State plan or a waiver of such plan; (ii) is at least 21 years of age; (iii) has not attained 65 years of age; and (iv) has at least 1 substance use disorder. (B) Eligible institution for mental diseases

“eligible institution for mental diseases” applies in that section

The term “eligible institution for mental diseases” means an institution for mental diseases that— (i) follows reliable, evidence-based practices; and (ii) offers at least 2 forms of medication-assisted treatment for substance use disorders on site, including, in the case of medication-assisted treatment for opioid use disorder, at least 1 antagonist and 1 partial agonist. (C) Institution for mental diseases

“habilitation services” applies in that section

the term “habilitation services”— (A) means services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings; and (B) includes (except as provided in subparagraph (C)) prevocational, educational, and supported employment services; but (C) does not include— (i) special education and related services (as such terms are defined in section 1401 of title 20 ) which otherwise are available to the individual through a local educational agency; and (ii) vocational rehabilitation services which otherwise are available to the individual through a program funded under …

“health-related tasks” applies in that section

The term “health-related tasks” means specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under State law to be performed by an attendant. (E) Individual’s representative

“home and community-based services” applies in that section

The term “home and community-based services” includes services described in sections 1396d(a)(7) and 1396d(a)(8) of this title, services described in subsection (c)(4)(B), services described in paragraph (4), and personal care services. (ii) (I) Subject to subclause (II),

“individual’s representative” applies in that section

the term “individual’s representative” means, with respect to an individual, a parent, a family member, or a guardian of the individual, an advocate for the individual, or any other individual who is authorized to represent the individual. (3) Nonapplication A State may elect in the State plan amendment approved under this section to not comply with the requirements of section 1396a(a)(10)(B) of this title (relating to comparability) and section 1396a(a)(10)(C)(i)(III) of this title (relating to income and resource rules applicable in the community), but only for purposes of provided home and community-based services in accordance with such amendment.

“institution for mental diseases” applies in that section

The term “institution for mental diseases” has the meaning given that term in section 1396d(i) of this title .

“instrumental activities of daily living” applies in that section

The term “instrumental activities of daily living” includes (but is not limited to) meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.

“other models” applies in that section

The term “other models” means, subject to paragraph (4), methods, other than an agency-provider model, for the provision of consumer controlled services and supports. Such models may include the provision of vouchers, direct cash payments, or use of a fiscal agent to assist in obtaining services. (D) Health-related tasks

“self-directed” applies in that section

The term “self-directed” means, with respect to the home and community-based services offered under the State plan amendment, such services for the individual which are planned and purchased under the direction and control of such individual or the individual’s authorized representative, including the amount, duration, scope, provider, and location of such services, under the State plan consistent with the following requirements: (aa) Assessment There is an assessment of the needs, capabilities, and preferences of the individual with respect to such services.

“self-directed personal assistance services” applies in that section

the term “self-directed personal assistance services” means personal care and related services, or home and community-based services otherwise available under the plan under this subchapter or subsection (c), that are provided to an eligible participant under a self-directed personal assistance services program under this section, under which individuals, within an approved self-directed services plan and budget, purchase personal assistance and related services, and permits participants to hire, fire, supervise, and manage the individuals providing such services.

“specified individual” applies in that section

the term “specified individual” means an individual who has a family income (as determined in accordance with section 1396a(e)(14) of this title ) that exceeds the poverty line (as defined in section 1397jj(c)(5) of this title ) applicable to a family of the size involved and— (A) is enrolled under section 1396a(a)(10)(A)(i)(VIII) of this title ; or (B) is described in such subsection and otherwise enrolled under a waiver of the State plan that provides coverage that is equivalent to minimum essential coverage (as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and determined in accordance with standards prescribed by the Secretary in regulations) to all individuals …

“State” applies in that section

the term “State” means 1 of the 50 States or the District of Columbia.

“alternative non-emergency services provider” applies in that section

The term “alternative non-emergency services provider” means, with respect to non-emergency services for the diagnosis or treatment of a condition, a health care provider, such as a physician’s office, health care clinic, community health center, hospital outpatient department, or similar health care provider, that can provide clinically appropriate services for the diagnosis or treatment of a condition contemporaneously with the provision of the non-emergency services that would be provided in an emergency department of a hospital for the diagnosis or treatment of a condition, and that is participating in the program under this subchapter.

“cost sharing” applies in that section

The term “cost sharing” includes any deduction, copayment, or similar charge. (b) Limitations on exercise of authority (1) Individuals with family income between 100 and 150 percent of the poverty line In the case of an individual whose family income exceeds 100 percent, but does not exceed 150 percent, of the poverty line applicable to a family of the size involved— (A) no premium may be imposed under the plan; and (B) with respect to cost sharing— (i) the cost sharing imposed under subsection (a) with respect to any item or service may not exceed 10 percent of the cost of such item or service; and (ii) the total aggregate amount of cost sharing imposed under this section (including any …

“non-emergency services” applies in that section

The term “non-emergency services” means any care or services furnished in an emergency department of a hospital that do not constitute an appropriate medical screening examination or stabilizing examination and treatment required to be provided by the hospital under section 1395dd of this title . (B) Alternate non-emergency services provider

“poverty line” applies in that section

the term “poverty line” has the meaning given such term in section 9902(2) of this title , including any revision required by such section. (6) Construction Nothing in this section shall be construed— (A) as preventing a State from further limiting the premiums and cost sharing imposed under this section beyond the limitations provided under this section; (B) as affecting the authority of the Secretary through waiver to modify limitations on premiums and cost sharing under this section; or (C) as affecting any such waiver of requirements in effect under this subchapter before February 8, 2006 , with regard to the imposition of premiums and cost sharing.

“premium” applies in that section

The term “premium” includes any enrollment fee or similar charge. (B) Cost sharing

“assets” applies in that section

the term “assets” includes an annuity purchased by or on behalf of an annuitant who has applied for medical assistance with respect to nursing facility services or other long-term care services under this subchapter unless— (i) the annuity is— (I) an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue Code of 1986; or (II) purchased with proceeds from— (aa) an account or trust described in subsection (a), (c), or (p) of section 408 of such Code; (bb) a simplified employee pension (within the meaning of section 408(k) of such Code); or (cc) a Roth IRA described in section 408A of such Code; or (ii) the annuity— (I) is irrevocable and nonassignable; (II) is …

“income” applies in that section

The term “income” has the meaning given such term in section 1382a of this title .;

“institutionalized individual” applies in that section

The term “institutionalized individual” means an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1396a(a)(10)(A)(ii)(VI) of this title .;

“long-term care insurance policy” applies in that section

the term “long-term care insurance policy” includes a certificate issued under a group insurance contract. (iv) With respect to a State which had a State plan amendment approved as of May 14, 1993 , such a State satisfies this clause for purposes of clause (ii) if the Secretary determines that the State plan amendment provides for consumer protection standards which are no less stringent than the consumer protection standards which applied under such State plan amendment as of December 31, 2005 .

“model Act” applies in that section

the terms “model regulation” and “model Act” mean the long-term care insurance model regulation, and the long-term care insurance model Act, respectively, promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000); (ii) any provision of the model regulation or model Act listed under subparagraph (A) shall be treated as including any other provision of such regulation or Act necessary to implement the provision; and (iii) with respect to a long-term care insurance policy issued in a State, the policy shall be deemed to meet applicable requirements of the model regulation or the model Act if the State plan amendment under paragraph (1)(C)(iii) provides …

“model regulation” applies in that section

the terms “model regulation” and “model Act” mean the long-term care insurance model regulation, and the long-term care insurance model Act, respectively, promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000); (ii) any provision of the model regulation or model Act listed under subparagraph (A) shall be treated as including any other provision of such regulation or Act necessary to implement the provision; and (iii) with respect to a long-term care insurance policy issued in a State, the policy shall be deemed to meet applicable requirements of the model regulation or the model Act if the State plan amendment under paragraph (1)(C)(iii) provides …

“noninstitutionalized individual” applies in that section

The term “noninstitutionalized individual” means an individual receiving any of the services specified in subsection (c)(1)(C)(ii).;

“qualified State long-term care insurance partnership” applies in that section

the term “qualified State long-term care insurance partnership” means an approved State plan amendment under this subchapter that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a long-term care insurance policy if the following requirements are met: (I) The policy covers an insured who was a resident of such State when coverage first became effective under the policy.

“resources” applies in that section

the term “resources” has the meaning given such term in section 1382b of this title , without regard to the exclusion described in subsection (a)(1) thereof. (d) Treatment of trust amounts (1) For purposes of determining an individual’s eligibility for, or amount of, benefits under a State plan under this subchapter, subject to paragraph (4), the rules specified in paragraph (3) shall apply to a trust established by such individual.

“trust” applies in that section

The term “trust” includes any legal instrument or device that is similar to a trust but includes an annuity only to such extent and in such manner as the Secretary specifies. (e) Disclosure and treatment of annuities (1) In order to meet the requirements of this section for purposes of section 1396a(a)(18) of this title , a State shall require, as a condition for the provision of medical assistance for services described in subsection (c)(1)(C)(i) (relating to long-term care services) for an individual, the application of the individual for such assistance (including any recertification of eligibility for such assistance) shall disclose a description of any interest the individual or …

“certain medicaid-eligible individual” applies in that section

the term “certain medicaid-eligible individual” means an individual who is entitled to medical assistance for nursing facility services in the facility under this subchapter but with respect to whom such benefits are not being paid because, in determining the amount of the individual’s income to be applied monthly to payment for the costs of such services, the amount of such income exceeds the payment amounts established by the State for such services under this subchapter.

“licensed health professional” applies in that section

the term “licensed health professional” means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, or licensed or certified social worker.

“nurse aide” applies in that section

the term “nurse aide” means any individual providing nursing or nursing-related services to residents in a nursing facility, but does not include an individual— (i) who is a licensed health professional (as defined in subparagraph (G)) or a registered dietician, or (ii) who volunteers to provide such services without monetary compensation. Such term includes an individual who provides such services through an agency or under a contract with the facility. (G) Licensed health professional defined In this paragraph,

“nursing facility” applies throughout its subchapter

the term “nursing facility” means an institution (or a distinct part of an institution) which— (1) is primarily engaged in providing to residents— (A) skilled nursing care and related services for residents who require medical or nursing care, (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or (C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; (2) has in effect a transfer …

“specialized services” applies in that section

The term “specialized services” has the meaning given such term by the Secretary in regulations, but does not include, in the case of a resident of a nursing facility, services within the scope of services which the facility must provide or arrange for its residents under subsection (b)(4).

“presumptive eligibility period” applies in that section

the term “presumptive eligibility period” means, with respect to a pregnant woman, the period that— (A) begins with the date on which a qualified provider determines, on the basis of preliminary information, that the family income of the woman does not exceed the applicable income level of eligibility under the State plan, and (B) ends with (and includes) the earlier of— (i) the day on which a determination is made with respect to the eligibility of the woman for medical assistance under the State plan, or (ii) in the case of a woman who does not file an application by the last day of the month following the month during which the provider makes the determination referred to in subparagraph …

“qualified provider” applies in that section

the term “qualified provider” means any provider that— (A) is eligible for payments under a State plan approved under this subchapter, (B) provides services of the type described in subparagraph (A) or (B) of section 1396d(a)(2) of this title or in section 1396d(a)(9) of this title , (C) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A), and (D) (i) receives funds under— (I) section 254b or 254c of this title, (II) subchapter V of this chapter, or (III) title V of the Indian Health Care Improvement Act [ 25 U.S.C.

“child” applies in that section

The term “child” means an individual under 19 years of age.;

“presumptive eligibility period” applies in that section

The term “presumptive eligibility period” means, with respect to a child, the period that— (A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the family income of the child does not exceed the applicable income level of eligibility under the State plan, and (B) ends with (and includes) the earlier of— (i) the day on which a determination is made with respect to the eligibility of the child for medical assistance under the State plan, or (ii) in the case of a child on whose behalf an application is not filed by the last day of the month following the month during which the entity makes the determination referred to in subparagraph …

“qualified entity” applies in that section

the term “qualified entity” means any entity that— (i) (I) is eligible for payments under a State plan approved under this subchapter and provides items and services described in subsection (a), (II) is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act ( 42 U.S.C. 9831 et seq.), eligibility of a child to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 [ 42 U.S.C.

“presumptive eligibility period” applies in that section

The term “presumptive eligibility period” means, with respect to an individual described in subsection (a), the period that— (A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in section 1396a(aa) of this title ; and (B) ends with (and includes) the earlier of— (i) the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or (ii) in the case of such an individual who does not file an application by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last …

“qualified entity” applies in that section

the term “qualified entity” means any entity that— (i) is eligible for payments under a State plan approved under this subchapter; and (ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A). (B) Regulations The Secretary may issue regulations further limiting those entities that may become qualified entities in order to prevent fraud and abuse and for other reasons. (C) Rule of construction Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities, consistent with any limitations imposed under subparagraph (B).

“presumptive eligibility period” applies in that section

The term “presumptive eligibility period” means, with respect to an individual described in subsection (a), the period that— (A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in section 1396a(ii) of this title ; and (B) ends with (and includes) the earlier of— (i) the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or (ii) in the case of such an individual who does not file an application by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last …

“qualified entity” applies in that section

the term “qualified entity” means any entity that— (i) is eligible for payments under a State plan approved under this subchapter; and (ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A). (B) Rule of construction Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse.

“final adverse action” applies in that section

the term “final adverse action” includes— (i) civil judgments against a health care provider, supplier, or practitioner in State court related to the delivery of a health care item or service; (ii) State criminal convictions related to the delivery of a health care item or service; (iii) exclusion from participation in State health care programs (as defined in section 1320a–7(h) of this title ); (iv) any licensing or certification action described in subsection (a)(1)(A) taken against a supplier by a State licensing or certification agency; and (v) any other adjudicated actions or decisions that the Secretary shall establish by regulation.

“State law or fraud enforcement agency” applies in that section

The term “State law or fraud enforcement agency” includes— (A) a State law enforcement agency; and (B) a State medicaid fraud control unit (as defined in section 1396b(q) of this title ). (3) Final adverse action (A) In general Subject to subparagraph (B),

“State licensing or certification agency” applies in that section

The term “State licensing or certification agency” includes any authority of a State (or of a political subdivision thereof) responsible for the licensing of health care practitioners (or any peer review organization or private accreditation entity reviewing the services provided by health care practitioners) or entities. (2) State law or fraud enforcement agency

“inpatient day” applies in that section

the term “inpatient day” includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere. (3) For purposes of paragraph (1)(B),

“low-income utilization rate” applies in that section

the term “low-income utilization rate” means, for a hospital, the sum of— (A) the fraction (expressed as a percentage)— (i) the numerator of which is the sum (for a period) of (I) the total revenues paid the hospital for patient services under a State plan under this subchapter (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) and (II) the amount of the cash subsidies for patient services received directly from State and local governments, and (ii) the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and (B) a fraction (expressed …

“medicaid inpatient utilization rate” applies in that section

the term “medicaid inpatient utilization rate” means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital’s number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under a State plan approved under this subchapter in a period (regardless of whether such patients receive medical assistance on a fee-for-service basis or through a managed care entity), and the denominator of which is the total number of the hospital’s inpatient days in that period. In this paragraph,

“obstetrician” applies in that section

the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures. (3) No hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) or (e) of this section unless the hospital has a medicaid inpatient utilization rate (as defined in subsection (b)(2)) of not less than 1 percent.

“State” applies in that section

the term “State” means the 50 States and the District of Columbia. (v) Distribution of aggregate reductions The Secretary shall distribute the aggregate reductions under clause (ii) among States in accordance with subparagraph (B).

“community spouse” applies in that section

The term “community spouse” means the spouse of an institutionalized spouse.

“excess shelter allowance” applies in that section

the term “excess shelter allowance” means, for a community spouse, the amount by which the sum of— (A) the spouse’s expenses for rent or mortgage payment (including principal and interest), taxes and insurance and, in the case of a condominium or cooperative, required maintenance charge, for the community spouse’s principal residence, and (B) the standard utility allowance (used by the State under section 2014(e) of title 7 ) or, if the State does not use such an allowance, the spouse’s actual utility expenses, exceeds 30 percent of the amount described in paragraph (3)(A)(i), except that, in the case of a condominium or cooperative, for which a maintenance charge is included under …

“institutionalized spouse” applies in that section

The term “institutionalized spouse” means an individual who— (A) is in a medical institution or nursing facility or who (at the option of the State) is described in section 1396a(a)(10)(A)(ii)(VI) of this title , and (B) is married to a spouse who is not in a medical institution or nursing facility; but does not include any such individual who is not likely to meet the requirements of subparagraph (A) for at least 30 consecutive days.;

“caretaker relative” applies in that section

the term “caretaker relative” has the meaning of such term as used in part A of subchapter IV. (f) Collection and reporting of participation information (1) Collection of information from States Each State shall collect and submit to the Secretary (and make publicly available), in a format specified by the Secretary, information on average monthly enrollment and average monthly participation rates for adults and children under this section and of the number and percentage of children who become ineligible for medical assistance under this section whose medical assistance is continued under another eligibility category or who are enrolled under the State’s child health plan under subchapter …

“premium base period” applies in that section

The term “premium base period” means, with respect to a particular premium payment period, the period of 3 consecutive months the last of which is 4 months before the beginning of that premium payment period. (c) Applicability in States and territories (1) States operating under demonstration projects In the case of any State which is providing medical assistance to its residents under a waiver granted under section 1315(a) of this title , the Secretary shall require the State to meet the requirements of this section in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this subchapter.

“applicable quarter” applies in that section

the term “applicable quarter” means, with respect to a drug described in clause (iii), the fifth full calendar quarter after which the drug is marketed as a drug other than a single source drug or an innovator multiple source drug.

“average manufacturer price” applies in that section

the term “average manufacturer price” means, with respect to a covered outpatient drug of a manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United States by— (i) wholesalers for drugs distributed to retail community pharmacies; and (ii) retail community pharmacies that purchase drugs directly from the manufacturer.

“best price” applies in that section

The term “best price” means, with respect to a single source drug or innovator multiple source drug of a manufacturer (including the lowest price available to any entity for any such drug of a manufacturer that is sold under a new drug application approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act [ 21 U.S.C.

“covered entity” applies in that section

the term “covered entity” means an entity described in section 256b(a)(4) of this title . (C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within 12 months of November 4, 1992 , the following requirements shall apply: (i) Entities Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title when it is seeking reimbursement from the State plan for medical assistance described in section 1396d(a)(12) of this title with respect to a unit of any covered outpatient drug which is subject to an agreement under section 256b(a) of …

“covered outpatient drug” applies in that section

the term “covered outpatient drug” means— (A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title , a drug which may be dispensed only upon prescription (except as provided in paragraph (4)), and— (i) which is approved for safety and effectiveness as a prescription drug under section 505 [ 21 U.S.C. 355 ] or 507 4 of the Federal Food, Drug, and Cosmetic Act or which is approved under section 505(j) of such Act [ 21 U.S.C.

“innovator multiple source drug” applies in that section

The term “innovator multiple source drug” means a multiple source drug that is marketed under a new drug application approved by the Food and Drug Administration, unless the Secretary determines that a narrow exception applies (as described in section 447.502 of title 42, Code of Federal Regulations (or any successor regulation)). (iii) Noninnovator multiple source drug

“line extension” applies in that section

the term “line extension” means, with respect to a drug, a new formulation of the drug, such as an extended release formulation, but does not include an abuse-deterrent formulation of the drug (as determined by the Secretary), regardless of whether such abuse-deterrent formulation is an extended release formulation. (D) Maximum rebate amount In no case shall the sum of the amounts applied under paragraph (1)(A)(ii) and this paragraph with respect to each dosage form and strength of a single source drug or an innovator multiple source drug for a rebate period beginning after December 31, 2009 , and before January 1, 2024 , exceed 100 percent of the average manufacturer price of the drug.

“manufacturer” applies in that section

The term “manufacturer” means any entity which is engaged in— (A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis, or (B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law. (6) Medically accepted indication

“medically accepted indication” applies in that section

The term “medically accepted indication” means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act [ 21 U.S.C. 301 et seq.] or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i). (7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug (A) Defined (i) Multiple source drug

“multiple source drug” applies in that section

The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug, including a drug product approved for marketing as a non-prescription drug that is regarded as a covered outpatient drug under paragraph (4), for which there 2 at least 1 other drug product which— (I) is rated as therapeutically equivalent (under the Food and Drug Administration’s most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”), (II) except as provided in subparagraph (B), is pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and (III) is sold or marketed in the …

“noninnovator multiple source drug” applies in that section

The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator multiple source drug. (iv) Single source drug

“rebate period” applies in that section

The term “rebate period” means, with respect to an agreement under subsection (a), a calendar quarter or other period specified by the Secretary with respect to the payment of rebates under such agreement. (9) State agency

“retail community pharmacy” applies in that section

The term “retail community pharmacy” means an independent pharmacy, a chain pharmacy, a supermarket pharmacy, or a mass merchandiser pharmacy that is licensed as a pharmacy by the State and that dispenses medications to the general public at retail prices. Such term does not include a pharmacy that dispenses prescription medications to patients primarily through the mail, nursing home pharmacies, long-term care facility pharmacies, hospital pharmacies, clinics, charitable or not-for-profit pharmacies, government pharmacies, or pharmacy benefit managers. (11) Wholesaler