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

“single source drug” applies in that section

The term “single source drug” means 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), which is produced or distributed under a new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application 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)).

“State agency” applies in that section

The term “State agency” means the agency designated under section 1396a(a)(5) of this title to administer or supervise the administration of the State plan for medical assistance. (10) Retail community pharmacy

“wholesaler” applies in that section

The term “wholesaler” means a drug wholesaler that is engaged in wholesale distribution of prescription drugs to retail community pharmacies, including (but not limited to) repackers, distributors, own-label distributors, private-label distributors, jobbers, brokers, warehouses (including distributor’s warehouses, chain drug warehouses, and wholesale drug warehouses) independent wholesale drug traders, and retail community pharmacies that conduct wholesale distributions.

“child” applies in that section

The term “child” means an individual 18 years of age or younger.;

“federally vaccine-eligible child” applies in that section

The term “federally vaccine-eligible child” means any of the following children: (i) A medicaid-eligible child. (ii) A child who is not insured. (iii) A child who (I) is administered a qualified pediatric vaccine by a federally-qualified health center (as defined in section 1396d( l )(2)(B) of this title) or a rural health clinic (as defined in section 1396d( l )(1) of this title), and (II) is not insured with respect to the vaccine. (iv) A child who is an Indian (as defined in subsection (h)(3)). (B) Definitions In subparagraph (A):;

“immunization” applies in that section

The term “immunization” means an immunization against a vaccine-preventable disease.;

“Indian” applies in that section

The terms “Indian”, “Indian tribe” and “tribal organization” have the meanings given such terms in section 4 of the Indian Health Care Improvement Act [ 25 U.S.C. 1603 ].;

“Indian tribe” applies in that section

The terms “Indian”, “Indian tribe” and “tribal organization” have the meanings given such terms in section 4 of the Indian Health Care Improvement Act [ 25 U.S.C. 1603 ].;

“insured” applies in that section

The term “insured” means, with respect to a child— (I) for purposes of subparagraph (A)(ii), that the child is enrolled under, and entitled to benefits under, a health insurance policy or plan, including a group health plan, a prepaid health plan, or an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1001 et seq.]; and (II) for purposes of subparagraph (A)(iii)(II) with respect to a pediatric vaccine, that the child is entitled to benefits under such a health insurance policy or plan, but such benefits are not available with respect to the cost of the pediatric vaccine. (3) State vaccine-eligible child

“manufacture” applies in that section

The term “manufacture” means to manufacture, import, process, or distribute a vaccine.;

“manufacturer” applies in that section

The term “manufacturer” means any corporation, organization, or institution, whether public or private (including Federal, State, and local departments, agencies, and instrumentalities), which manufactures, imports, processes, or distributes under its label any pediatric vaccine.

“medicaid-eligible” applies in that section

The term “medicaid-eligible” means, with respect to a child, a child who is entitled to medical assistance under a state 1 plan approved under this subchapter.;

“parent” applies in that section

The term “parent” includes, with respect to a child, an individual who qualifies as a legal guardian under State law.;

“pediatric vaccine” applies in that section

The term “pediatric vaccine” means a vaccine included on the list under subsection (e).;

“program-registered provider” applies in that section

the term “program-registered provider” means, with respect to a State, any health care provider that— (A) is licensed or otherwise authorized for administration of pediatric vaccines under the law of the State in which the administration occurs (subject to section 254f(e) of this title ), without regard to whether or not the provider participates in the plan under this subchapter; (B) submits to the State an executed provider agreement described in paragraph (2); and (C) has not been found, by the Secretary or the State, to have violated such agreement or other applicable requirements established by the Secretary or the State consistent with this section.

“qualified pediatric vaccine” applies in that section

The term “qualified pediatric vaccine” means a pediatric vaccine with respect to which a contract is in effect under subsection (d).;

“State vaccine-eligible child” applies in that section

The term “State vaccine-eligible child” means, with respect to a State and a qualified pediatric vaccine, a child who is within a class of children for which the State is purchasing the vaccine pursuant to subsection (d)(4)(B). (c) Program-registered providers (1) Defined In this section, except as otherwise provided,

“tribal organization” applies in that section

The terms “Indian”, “Indian tribe” and “tribal organization” have the meanings given such terms in section 4 of the Indian Health Care Improvement Act [ 25 U.S.C. 1603 ].;

“vaccine-eligible child” applies in that section

The term “vaccine-eligible child” means a child who is a federally vaccine-eligible child (as defined in paragraph (2)) or a State vaccine-eligible child (as defined in paragraph (3)). (2) Federally vaccine-eligible child (A) In general

“functionally disabled elderly individual” applies throughout its subchapter

the term “functionally disabled elderly individual” means an individual who— (A) is 65 years of age or older, (B) is determined to be a functionally disabled individual under subsection (c), and (C) subject to section 1396a(f) of this title (as applied consistent with section 1396a(r)(2) of this title ), is receiving supplemental security income benefits under subchapter XVI (or under a State plan approved under subchapter XVI) or, at the option of the State, is described in section 1396a(a)(10)(C) of this title .

“home and community care” applies throughout its subchapter

the term “home and community care” means one or more of the following services furnished to an individual who has been determined, after an assessment under subsection (c), to be a functionally disabled elderly individual, furnished in accordance with an individual community care plan (established and periodically reviewed and revised by a qualified community care case manager under subsection (d)): (1) Homemaker/home health aide services. (2) Chore services. (3) Personal care services. (4) Nursing care services provided by, or under the supervision of, a registered nurse. (5) Respite care. (6) Training for family members in managing the individual. (7) Adult day care.

“ICCP” applies in that section

the terms “individual community care plan” and “ICCP” mean, with respect to a functionally disabled elderly individual, a written plan which— (A) is established, and is periodically reviewed and revised, by a qualified case manager after a face-to-face interview with the individual or primary caregiver and based upon the most recent comprehensive functional assessment of such individual conducted under subsection (c)(2); (B) specifies, within any amount, duration, and scope limitations imposed on home and community care provided under the State plan, the home and community care to be provided to such individual under the plan, and indicates the individual’s preferences for the types and …

“individual community care plan” applies in that section

the terms “individual community care plan” and “ICCP” mean, with respect to a functionally disabled elderly individual, a written plan which— (A) is established, and is periodically reviewed and revised, by a qualified case manager after a face-to-face interview with the individual or primary caregiver and based upon the most recent comprehensive functional assessment of such individual conducted under subsection (c)(2); (B) specifies, within any amount, duration, and scope limitations imposed on home and community care provided under the State plan, the home and community care to be provided to such individual under the plan, and indicates the individual’s preferences for the types and …

“large community care setting” applies in that section

the term “large community care setting” means— (A) a nonresidential setting in which more than 8 individuals are served; or (B) a residential setting in which more than 8 unrelated adults reside and in which personal services are provided in conjunction with residing in the setting in which home and community care under this section is provided.

“qualified community care case manager” applies in that section

the term “qualified community care case manager” means a nonprofit or public agency or organization which— (A) has experience or has been trained in establishing, and in periodically reviewing and revising, individual community care plans and in the provision of case management services to the elderly; (B) is responsible for (i) assuring that home and community care covered under the State plan and specified in the ICCP is being provided, (ii) visiting each individual’s home or community setting where care is being provided not less often than once every 90 days, and (iii) informing the elderly individual or primary caregiver on how to contact the case manager if service providers fail to …

“small community care setting” applies in that section

the term “small community care setting” means— (A) a nonresidential setting that serves more than 2 and less than 8 individuals; or (B) a residential setting in which more than 2 and less than 8 unrelated adults reside and in which personal services (other than merely board) are provided in conjunction with residing in the setting.

“community supported living arrangements services” applies throughout its subchapter

the term “community supported living arrangements services” means one or more of the following services meeting the requirements of subsection (h) provided in a State eligible to provide services under this section (as defined in subsection (d)) to assist a developmentally disabled individual (as defined in subsection (b)) in activities of daily living necessary to permit such individual to live in the individual’s own home, apartment, family home, or rental unit furnished in a community supported living arrangement setting: (1) Personal assistance. (2) Training and habilitation services (necessary to assist the individual in achieving increased integration, independence and productivity).

“welfare reform effective date” applies in that section

the term “welfare reform effective date” means the effective date, with respect to a State, of title I of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (as specified in section 116 of such Act).

“covered Medicaid managed care services” applies in that section

The term “covered Medicaid managed care services” means, with respect to an individual enrolled with a managed care entity, items and services for which benefits are available with respect to the individual under the contract between the entity and the State involved. (E) Medicaid managed care program

“emergency medical condition” applies in that section

the term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in— (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.

“emergency services” applies in that section

the term “emergency services” means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that— (i) are furnished by a provider that is qualified to furnish such services under this subchapter, and (ii) are needed to evaluate or stabilize an emergency medical condition (as defined in subparagraph (C)). (C) “Emergency medical condition” defined In subparagraph (B)(ii),

“health care professional” applies in that section

the term “health care professional” means a physician (as defined in section 1395x(r) of this title ) or other health care professional if coverage for the professional’s services is provided under the contract referred to in subparagraph (A) for the services of the professional.

“Indian health care provider” applies in that section

The term “Indian health care provider” means an Indian Health Program or an Urban Indian Organization. (B) Indian Medicaid managed care entity

“Indian Medicaid managed care entity” applies in that section

The term “Indian Medicaid managed care entity” means a managed care entity that is controlled (within the meaning of the last sentence of section 1396b(m)(1)(C) of this title ) by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of 1 or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Service. (C) Non-Indian Medicaid managed care entity

“managed care entity” applies in that section

the term “managed care entity” means— (i) a medicaid managed care organization, as defined in section 1396b(m)(1)(A) of this title , that provides or arranges for services for enrollees under a contract pursuant to section 1396b(m) of this title ; and (ii) a primary care case manager, as defined in section 1396d(t)(2) of this title .

“Medicaid managed care program” applies in that section

The term “Medicaid managed care program” means a program under sections 1396b(m), 1396d(t), and 1396u–2 of this title and includes a managed care program operating under a waiver under section 1396n(b) or 1315 of this title or otherwise.

“network provider” applies in that section

the term “network provider” includes any provider, group of providers, or entity that has a network provider agreement with a managed care organization, a prepaid inpatient health plan (as defined by the Secretary), a prepaid ambulatory health plan (as defined by the Secretary), or a primary care case management entity (as defined by the Secretary) or a subcontractor of any such entity or plan, and receives payment under this subchapter directly or indirectly to order, refer, or render covered services as a result of the State’s contract with the entity or plan.

“non-Indian Medicaid managed care entity” applies in that section

The term “non-Indian Medicaid managed care entity” means a managed care entity that is not an Indian Medicaid managed care entity. (D) Covered Medicaid managed care services

“noncompliant behavior” applies in that section

the term “noncompliant behavior” includes repeated noncompliance with medical advice and repeated failure to appear for appointments. (iii) Timely review of proposed nonvoluntary disenrollment A proposed disenrollment, other than a voluntary disenrollment, shall be subject to timely review and final determination by the Secretary or by the State administering agency (as applicable), prior to the proposed disenrollment becoming effective.

“PACE demonstration waiver program” applies in that section

the term “PACE demonstration waiver program” means a demonstration program under either of the following sections (as in effect before the date of their repeal): (A) Section 603(c) of the Social Security Amendments of 1983 ( Public Law 98–21 ), as extended by section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985 ( Public Law 99–272 ). (B) Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 ( Public Law 99–509 ). (8) “State administering agency” defined For purposes of this section,

“PACE program” applies in that section

the term “PACE program” means a program of all-inclusive care for the elderly that meets the following requirements: (A) Operation The entity operating the program is a PACE provider (as defined in paragraph (3)). (B) Comprehensive benefits The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section.

“PACE program agreement” applies in that section

the term “PACE program agreement” means, with respect to a PACE provider, an agreement, consistent with this section, section 1395eee of this title (if applicable), and regulations promulgated to carry out such sections, among the PACE provider, the Secretary, and a State administering agency for the operation of a PACE program by the provider under such sections. (5) “PACE program eligible individual” defined For purposes of this section,

“PACE program eligible individual” applies in that section

the term “PACE program eligible individual” means, with respect to a PACE program, an individual who— (A) is 55 years of age or older; (B) subject to subsection (c)(4), is determined under subsection (c) to require the level of care required under the State medicaid plan for coverage of nursing facility services; (C) resides in the service area of the PACE program; and (D) meets such other eligibility conditions as may be imposed under the PACE program agreement for the program under subsection (e)(2)(A)(ii). (6) “PACE protocol” defined For purposes of this section,

“PACE protocol” applies in that section

the term “PACE protocol” means the Protocol for the Program of All-inclusive Care for the Elderly (PACE), as published by On Lok, Inc., as of April 14, 1995 , or any successor protocol that may be agreed upon between the Secretary and On Lok, Inc. (7) “PACE demonstration waiver program” defined For purposes of this section,

“PACE provider” applies in that section

the term “PACE provider” means an entity that— (i) subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986, and (ii) has entered into a PACE program agreement with respect to its operation of a PACE program.

“State administering agency” applies in that section

the term “State administering agency” means, with respect to the operation of a PACE program in a State, the agency of that State (which may be the single agency responsible for administration of the State plan under this subchapter in the State) responsible for administering PACE program agreements under this section and section 1395eee of this title in the State. (9) “Trial period” defined (A) In general For purposes of this section,

“trial period” applies in that section

the term “trial period” means, with respect to a PACE program operated by a PACE provider under a PACE program agreement, the first 3 contract years under such agreement with respect to such program. (B) Treatment of entities previously operating PACE demonstration waiver programs Each contract year (including a year occurring before the effective date of this section) during which an entity has operated a PACE demonstration waiver program shall be counted under subparagraph (A) as a contract year during which the entity operated a PACE program as a PACE provider under a PACE program agreement.

“full-benefit dual eligible individual” applies in that section

the term “full-benefit dual eligible individual” means for a State for a month an individual who— (i) has coverage for the month for covered part D drugs under a prescription drug plan under part D of subchapter XVIII, or under an MA–PD plan under part C of such subchapter; and (ii) is determined eligible by the State for medical assistance for full benefits under this subchapter for such month under section 1396a(a)(10)(A) or 1396a(a)(10)(C) of this title, by reason of section 1396a(f) of this title , or under any other category of eligibility for medical assistance for full benefits under this subchapter, as determined by the Secretary.

“full-benefit eligible individual” applies in that section

the term “full-benefit eligible individual” means for a State for a month an individual who is determined eligible by the State for medical assistance for all services defined in section 1396d(a) of this title which are covered under the State plan under this subchapter for such month under section 1396a(a)(10)(A) of this title or under any other category of eligibility for medical assistance for all such services under this subchapter, as determined by the Secretary.

“demonstration program Medicaid services” applies in that section

The term “demonstration program Medicaid services” means, with respect to an individual participating in a State demonstration program, services for which the individual would be provided medical assistance under this subchapter but for the application of the deductible described in paragraph (1)(A).;

“health opportunity account” applies in that section

the term “health opportunity account” means an account that meets the requirements of this subsection. (2) Contributions (A) In general No contribution may be made into a health opportunity account except— (i) contributions by the State under this subchapter; and (ii) contributions by other persons and entities, such as charitable organizations, as permitted under section 1396b(w) of this title . (B) State contribution A State shall specify the contribution amount that shall be deposited under subparagraph (A)(i) into a health opportunity account.

“maximum out-of-pocket cost sharing” applies in that section

the term “maximum out-of-pocket cost sharing” means, for an individual or family, the amount by which the annual deductible level applied under paragraph (1)(A) to the individual or family exceeds the balance in the health opportunity account for the individual or family. (8) Contributions by employers Nothing in this section shall be construed as preventing an employer from providing health benefits coverage consisting of the coverage described in paragraph (1)(A) to individuals who are provided alternative benefits under this section. (d) Health opportunity account (1) In general For purposes of this section,

“participating provider” applies in that section

The term “participating provider” means— (I) with respect to an individual described in subparagraph (A), a health care provider that has entered into a participation agreement with the State for the provision of services to individuals entitled to benefits under the State plan; or (II) with respect to an individual described in subparagraph (B) who is enrolled in a Medicaid managed care organization, a health care provider that has entered into an arrangement for the provision of services to enrollees of the organization under this subchapter.

“non-compliant State” applies in that section

the term “non-compliant State” means a State— (A) that is one of the 50 States, the District of Columbia, or Puerto Rico; (B) with respect to which the Secretary has not approved a State plan amendment submitted under subsection (a)(2); and (C) that is not operating, on an ongoing basis, an asset verification program in accordance with this section.

“controlled substance” applies in that section

The term “controlled substance” means a drug that is included in schedule II of section 812(c) of title 21 and, at the option of the State involved, a drug included in schedule III or IV of such section. (2) Covered individual

“covered individual” applies in that section

The term “covered individual” means, with respect to a State, an individual who is enrolled in the State plan (or under a waiver of such plan). Such term does not include an individual who— (A) is receiving— (i) hospice or palliative care; or (ii) treatment for cancer; (B) is a resident of a long-term care facility, of a facility described in section 1396d(d) of this title , or of another facility for which frequently abused drugs are dispensed for residents through a contract with a single pharmacy; or (C) the State elects to treat as exempted from such term. (3) Covered provider (A) In general

“covered provider” applies in that section

The term “covered provider” means, subject to subparagraph (B), with respect to a State, a health care provider who is participating under the State plan (or waiver of the State plan) and licensed, registered, or otherwise permitted by the State to prescribe a controlled substance (or the designee of such provider). (B) Exceptions (i) In general Beginning October 1, 2021 , for purposes of this section, such term does not include a health care provider included in any type of health care provider determined by the Secretary to be exempt from application of this section under clause (ii).

“chronic condition” applies in that section

The term “chronic condition” has the meaning given that term by the Secretary and shall include, but is not limited to, the following: (A) A mental health condition. (B) Substance use disorder. (C) Asthma. (D) Diabetes. (E) Heart disease. (F) Being overweight, as evidenced by having a Body Mass Index (BMI) over 25. (3) Health home

“designated provider” applies in that section

The term “designated provider” means a physician, clinical practice or clinical group practice, rural clinic, community health center, community mental health center, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined by the State and approved by the Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation evidencing that the physician, practice, or clinic— (A) has the systems and infrastructure in place to provide health home services; and (B) satisfies the qualification standards established by the Secretary under subsection (b).

“eligible individual with chronic conditions” applies in that section

the term “eligible individual with chronic conditions” means an individual who— (i) is eligible for medical assistance under the State plan or under a waiver of such plan; and (ii) has at least— (I) 2 chronic conditions; (II) 1 chronic condition and is at risk of having a second chronic condition; or (III) 1 serious and persistent mental health condition. (B) Rule of construction Nothing in this paragraph shall prevent the Secretary from establishing higher levels as to the number or severity of chronic or mental health conditions for purposes of determining eligibility for receipt of health home services under this section. (2) Chronic condition

“health home” applies in that section

The term “health home” means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services. (4) Health home services (A) In general

“health home services” applies in that section

The term “health home services” means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.

“health team” applies in that section

The term “health team” has the meaning given such term for purposes of section 256a–1 of this title .

“SUD-eligible individual” applies in that section

The term “SUD-eligible individual” means, with respect to a State, an individual who satisfies all of the following: (I) The individual is an eligible individual with chronic conditions. (II) The individual is an individual with a substance use disorder. (III) The individual has not previously received health home services under any other State plan amendment approved for the State under this section by the Secretary. (ii) SUD-focused State plan amendment

“SUD-focused State plan amendment” applies in that section

The term “SUD-focused State plan amendment” means a State plan amendment under this section that is designed to provide health home services primarily to SUD-eligible individuals. (d) Hospital referrals A State shall include in the State plan amendment a requirement for hospitals that are participating providers under the State plan or a waiver of such plan to establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers.

“team of health care professionals” applies in that section

The term “team of health care professionals” means a team of health professionals (as described in the State plan amendment) that may— (A) include physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State; and (B) be free standing, virtual, or based at a hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity deemed appropriate by the State and approved by the Secretary. (7) Health team

“child with medically complex conditions” applies in that section

the term “child with medically complex conditions” means an individual under 21 years of age who— (i) is eligible for medical assistance under the State plan (or under a waiver of such plan); and (ii) has at least— (I) one or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning (such as the ability to eat, drink, or breathe independently) and that also requires the use of medication, durable medical equipment, therapy, surgery, or other treatments; or (II) one life-limiting illness or rare pediatric disease (as defined in section 360ff(a)(3) of title 21 ).

“chronic condition” applies in that section

The term “chronic condition” means a serious, long-term physical, mental, or developmental disability or disease, including the following: (A) Cerebral palsy. (B) Cystic fibrosis. (C) HIV/AIDS. (D) Blood diseases, such as anemia or sickle cell disease. (E) Muscular dystrophy. (F) Spina bifida. (G) Epilepsy. (H) Severe autism spectrum disorder. (I) Serious emotional disturbance or serious mental health illness. (3) Health home

“designated provider” applies in that section

The term “designated provider” means a physician (including a pediatrician or a pediatric specialty or subspecialty provider), children’s hospital, clinical practice or clinical group practice, prepaid inpatient health plan or prepaid ambulatory health plan (as defined by the Secretary), rural clinic, community health center, community mental health center, home health agency, or any other entity or provider that is determined by the State and approved by the Secretary to be qualified to be a health home for children with medically complex conditions on the basis of documentation evidencing that the entity has the systems, expertise, and infrastructure in place to provide health home …

“health home” applies in that section

The term “health home” means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by a child with medically complex conditions (or the family of such child) to provide health home services. (4) Health home services (A) In general

“health home services” applies in that section

The term “health home services” means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.

“health team” applies in that section

The term “health team” has the meaning given such term for purposes of section 256a–1 of this title .

“team of health care professionals” applies in that section

The term “team of health care professionals” means a team of health care professionals (as described in the State plan amendment under this section) that may— (A) include— (i) physicians and other professionals, such as pediatricians or pediatric specialty or subspecialty providers, nurse care coordinators, dietitians, nutritionists, social workers, behavioral health professionals, physical therapists, occupational therapists, speech pathologists, nurses, individuals with experience in medical supportive technologies, or any professionals determined to be appropriate by the State and approved by the Secretary; (ii) an entity or individual who is designated to coordinate such a team; and …

“qualifying community-based mobile crisis intervention services” applies in that section

the term “qualifying community-based mobile crisis intervention services” means, with respect to a State, items and services for which medical assistance is available under the State plan under this subchapter or a waiver of such plan, that are— (1) furnished to an individual otherwise eligible for medical assistance under the State plan (or waiver of such plan) who is— (A) outside of a hospital or other facility setting; and (B) experiencing a mental health or substance use disorder crisis; (2) furnished by a multidisciplinary mobile crisis team— (A) that includes at least 1 behavioral health care professional who is capable of conducting an assessment of the individual, in accordance with …

“Secretary” applies in that section

The term “Secretary” means the Secretary of Health and Human Services. (2) State

“State” applies in that section

The term “State” means each of the 50 States, the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.

“applicable hospital” applies in that section

the term “applicable hospital” means any hospital located in a State that meets either of the following criteria: (A) The hospital provides labor and delivery services and more than 50 percent of the hospital’s births (in the most recent year for which such data is available) are financed by the Medicaid program or CHIP.

“new coverage period” applies in that section

the term “new coverage period” means the month immediately following the last month for which the premium has been paid. (4) Relation to medicaid requirements Nothing in this subsection shall be construed as affecting the rules relating to the use of enrollment fees, premiums, deductions, cost sharing, and similar charges in the case of targeted low-income children who are provided child health assistance in the form of coverage under a medicaid program under section 1397aa(a)(2) of this title .

“emergency shortfall State” applies in that section

the term “emergency shortfall State” means, with respect to a month beginning during the period beginning October 1, 2017 , and ending March 31, 2018 , a shortfall State for which the Secretary estimates, in accordance with subparagraph (A) (unless otherwise specified in this subclause) and on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under the State child health plan and under section 1397ee(g) of this title (calculated as if the reference under section 1397ee(g)(4)(A) of this title , as in effect on the day before January 22, 2018 , to “2017” were a reference to “2018” and insofar as the allotments are available …

“proportion” applies in that section

The term “proportion” means, with respect to the allotment of a subsection (b) State for a fiscal year, the amount of the allotment of such State under this subsection for the fiscal year divided by the total of the amount available under this subsection for all such allotments for the fiscal year. (ii) Subsection (b) State

“State” applies in that section

the term “State” means a State that receives an allotment for fiscal year 2007 under subsection (b). (i) Redistribution of unused fiscal year 2005 allotments to States with estimated funding shortfalls for fiscal year 2008 (1) In general Notwithstanding subsection (f) and subject to paragraphs (3) and (4), with respect to months beginning during fiscal year 2008, the Secretary shall provide for a redistribution under such subsection from the allotments for fiscal year 2005 under subsection (b) that are not expended by the end of fiscal year 2007, to a fiscal year 2008 shortfall State described in paragraph (2), such amount as the Secretary determines will eliminate the estimated shortfall …

“subsection (b) State” applies in that section

The term “subsection (b) State” means one of the 50 States or the District of Columbia. (c) Allotments to territories (1) In general Of the amount available for allotment under subsection (a) for a fiscal year, subject to subsections (d) and (m)(5), the Secretary shall allot 0.25 percent among each of the commonwealths and territories described in paragraph (3) in the same proportion as the percentage specified in paragraph (2) for such commonwealth or territory bears to the sum of such percentages for all such commonwealths or territories so described.

“health care provider” applies in that section

the term “health care provider” means a provider of services or supplier who is enrolled under this subchapter, subchapter XVIII, or subchapter XIX.

“premium assistance subsidy” applies in that section

the term “premium assistance subsidy” means, with respect to a targeted low-income child, the amount equal to the difference between the employee contribution required for enrollment only of the employee under qualified employer-sponsored coverage and the employee contribution required for enrollment of the employee and the child in such coverage, less any applicable premium cost-sharing applied under the State child health plan (subject to the limitations imposed under section 1397cc(e) of this title , including the requirement to count the total amount of the employee contribution required for enrollment of the employee and the child in such coverage toward the annual aggregate …

“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— (I) that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act; 3 (II) for which the employer contribution toward any premium for such coverage is at least 40 percent; and (III) 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).

“qualifying children” applies in that section

the term “qualifying children” means children who meet the eligibility criteria (including income, categorical eligibility, age, and immigration status criteria) in effect as of July 1, 2008 , for enrollment under subchapter XIX, taking into account criteria applied as of such date under subchapter XIX pursuant to a waiver under section 1315 of this title . (ii) Limitation A child described in clause (i) who is provided medical assistance during a presumptive eligibility period under section 1396r–1a of this title shall be considered to be a “qualifying child” only if the child is determined to be eligible for medical assistance under subchapter XIX.

“qualifying State” applies in that section

the term “qualifying State” means a State that, on and after April 15, 1997 , has an income eligibility standard that is at least 184 percent of the poverty line with respect to any 1 or more categories of children (other than infants) who are eligible for medical assistance under section 1396a(a)(10)(A) of this title or, in the case of a State that has a statewide waiver in effect under section 1315 of this title with respect to subchapter XIX that was first implemented on August 1, 1994 , or July 1, 1995 , has an income eligibility standard under such waiver for children that is at least 185 percent of the poverty line, or, in the case of a State that has a statewide waiver in effect …

“rural health facility” applies in that section

the term “rural health facility” means the following: (i) A subsection (d) hospital (as defined in paragraph (1)(B) of section 1395ww(d) of this title ) that— (I) is located in a rural area (as defined in paragraph (2)(D) of such section 6 ); (II) is treated as being located in a rural area pursuant to paragraph (8)(E) of such section 6 ; or (III) is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)). (ii) A critical access hospital (as defined in section 1395x(mm)(1) of this title ).

“State children’s health insurance expenditures” applies in that section

The term “State children’s health insurance expenditures” means the following: (i) The State share of expenditures under this subchapter. (ii) The State share of expenditures under subchapter XIX that are attributable to an enhanced FMAP under the fourth sentence of section 1396d(b) of this title . (iii) State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 1397cc(d) of this title .

“qualified empowerment zone” applies in that section

The term “qualified empowerment zone” means, with respect to a State, an area— (A) which has been designated (other than by the Secretary of the Interior) as an empowerment zone under part I of subchapter U of chapter 1 of the Internal Revenue Code of 1986; (B) with respect to which the designation is in effect; (C) the strategic plan for which is a qualified plan; and (D) part or all of which is in the State. (2) Qualified enterprise community

“qualified enterprise community” applies in that section

The term “qualified enterprise community” means, with respect to a State, an area— (A) which has been designated (other than by the Secretary of the Interior) as an enterprise community under part I of subchapter U of chapter 1 of the Internal Revenue Code of 1986; (B) with respect to which the designation is in effect; (C) the strategic plan for which is a qualified plan; and (D) part or all of which is in the State. (3) Strategic plan

“qualified plan” applies in that section

The term “qualified plan” means, with respect to an area, a plan that— (A) includes a detailed description of the activities proposed for the area that are to be funded with amounts provided under this section; (B) contains a commitment that the amounts provided under this section to any State for the area will not be used to supplant Federal or non-Federal funds for services and activities which promote the purposes of this section; (C) was developed in cooperation with the local government or governments with jurisdiction over the area; and (D) to the extent that any State will not use the amounts provided under this section for the area in the manner described in subsection (b), explains …

“rural area” applies in that section

The term “rural area” has the meaning given such term in section 1393(a)(2) of the Internal Revenue Code of 1986. (6) Urban area

“strategic plan” applies in that section

The term “strategic plan” means, with respect to an area, the plan contained in the application for designation of the area under part I of subchapter U of chapter 1 of the Internal Revenue Code of 1986. (4) Qualified plan

“urban area” applies in that section

The term “urban area” has the meaning given such term in section 1393(a)(3) of the Internal Revenue Code of 1986.

“eligible entity” applies in that section

The term “eligible entity” means a State, an Indian tribe or tribal organization, an institution of higher education, a local workforce development board established under section 3122 of title 29 , a sponsor of an apprenticeship program registered under the National Apprenticeship Act [ 29 U.S.C. 50 et seq.] or a community-based organization. (B) Eligible individual (i) In general

“eligible health and long-term care provider” applies in that section

The term “eligible health and long-term care provider” means a personal or home care agency (including personal or home care public authorities), a nursing home, a home health agency (as defined in section 1395x( o ) of this title), or any other health care provider the Secretary determines appropriate which— (i) is licensed or authorized to provide services in a participating State; and (ii) receives payment for services under subchapter XIX. (B) Personal care services

“eligible individual” applies in that section

The term “eligible individual” means a 1 individual receiving assistance under the State TANF program. (ii) Other low-income individuals Such term may include other low-income individuals described by the eligible entity in its application for a grant under this section. (C) Indian tribe; tribal organization

“Indian tribe” applies in that section

The terms “Indian tribe” and “tribal organization” have the meaning given such terms in section 5304 of title 25 . (D) Institution of higher education

“institution of higher education” applies in that section

The term “institution of higher education” has the meaning given that term in section 1001 of title 20 . (E) State

“personal care services” applies in that section

The term “personal care services” has the meaning given such term for purposes of subchapter XIX. (C) Personal or home care aide

“personal or home care aide” applies in that section

The term “personal or home care aide” means an individual who helps individuals who are elderly, disabled, ill, or mentally disabled (including an individual with Alzheimer’s disease or other dementia) to live in their own home or a residential care facility (such as a nursing home, assisted living facility, or any other facility the Secretary determines appropriate) by providing routine personal care services and other appropriate services to the individual. (D) State

“State” applies in that section

The term “State” means each of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, and American Samoa. (F) State TANF program

“State TANF program” applies in that section

The term “State TANF program” means the temporary assistance for needy families program funded under part A of subchapter IV. (G) Tribal College or University

“Tribal College or University” applies in that section

The term “Tribal College or University” has the meaning given that term in section 1059c(b)of title 20. (b) Demonstration project to develop training and certification programs for personal or home care aides (1) Authority to award grants Not later than 18 months after March 23, 2010 , the Secretary shall award grants to eligible entities that are States to conduct demonstration projects for purposes of developing core training competencies and certification programs for personal or home care aides.

“tribal organization” applies in that section

The terms “Indian tribe” and “tribal organization” have the meaning given such terms in section 5304 of title 25 . (D) Institution of higher education

“qualified CHIP look-alike program” applies in that section

the term “qualified CHIP look-alike program” means a State program— (A) under which children who are under the age of 19 and are not eligible to receive medical assistance under subchapter XIX or child health assistance under this subchapter may purchase coverage through the State that provides benefits that are at least identical to the benefits provided under the State child health plan under this subchapter (or a waiver of such plan); and (B) that is funded exclusively through non-Federal funds, including funds received by the State in the form of premiums for the purchase of such coverage.

“at-risk individual” applies in that section

The term “at-risk individual” means an individual who— (A) (i) as demonstrated in such manner as the Secretary determines appropriate, has been present for an aggregate total of 6 months in the geographic area subject to an emergency declaration specified under paragraph (2), during a period ending— (I) not less than 10 years prior to the date of such individual’s application under subparagraph (B); and (II) prior to the implementation of all the remedial and removal actions specified in the Record of Decision for Operating Unit 4 and the Record of Decision for Operating Unit 7; or (ii) meets such other criteria as the Secretary determines appropriate considering the type of environmental …

“contaminant” applies in that section

The terms “hazardous substance”, “pollutant”, and “contaminant” have the meanings given those terms in section 9601 of this title . (5) Superfund site

“emergency declaration” applies in that section

The term “emergency declaration” means a declaration of a public health emergency under section 9604(a) of this title . (3) Environmental health condition

“environmental health condition” applies in that section

The term “environmental health condition” means— (A) asbestosis, pleural thickening, or pleural plaques, as established by— (i) interpretation by a “B Reader” qualified physician of a plain chest x-ray or interpretation of a computed tomographic radiograph of the chest by a qualified physician, as determined by the Secretary; or (ii) such other diagnostic standards as the Secretary specifies; (B) mesothelioma, or malignancies of the lung, colon, rectum, larynx, stomach, esophagus, pharynx, or ovary, as established by— (i) pathologic examination of biopsy tissue; (ii) cytology from bronchioalveolar lavage; or (iii) such other diagnostic standards as the Secretary specifies; and (C) any other …

“hazardous substance” applies in that section

The terms “hazardous substance”, “pollutant”, and “contaminant” have the meanings given those terms in section 9601 of this title . (5) Superfund site

“pollutant” applies in that section

The terms “hazardous substance”, “pollutant”, and “contaminant” have the meanings given those terms in section 9601 of this title . (5) Superfund site

“Superfund site” applies in that section

The term “Superfund site” means a site included on the National Priorities List developed by the President in accordance with section 9605(a)(8)(B) of this title . (d) Health coverage unaffected Nothing in this section shall be construed to affect any coverage obligation of a governmental or private health plan or program relating to an at-risk individual. (e) Funding (1) In general Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary, to carry out the program under this section— (A) $23,000,000 for the period of fiscal years 2010 through 2014; and (B) $20,000,000 for each 5-fiscal year period thereafter.

“abuse” applies throughout its division

The term “abuse” means the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm. (2) Adult protective services

“adult protective services” applies throughout its division

The term “adult protective services” means such services provided to adults as the Secretary may specify and includes services such as— (A) receiving reports of adult abuse, neglect, or exploitation; (B) investigating the reports described in subparagraph (A); (C) case planning, monitoring, evaluation, and other case work and services; and (D) providing, arranging for, or facilitating the provision of medical, social service, economic, legal, housing, law enforcement, or other protective, emergency, or support services. (3) Caregiver

“caregiver” applies throughout its division

The term “caregiver” means an individual who has the responsibility for the care of an elder, either voluntarily, by contract, by receipt of payment for care, or as a result of the operation of law, and means a family member or other individual who provides (on behalf of such individual or of a public or private agency, organization, or institution) compensated or uncompensated care to an elder who needs supportive services in any setting. (4) Direct care

“direct care” applies throughout its division

The term “direct care” means care by an employee or contractor who provides assistance or long-term care services to a recipient. (5) Elder

“elder” applies throughout its division

The term “elder” means an individual age 60 or older. (6) Elder justice

“elder justice” applies throughout its division

The term “elder justice” means— (A) from a societal perspective, efforts to— (i) prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation; and (ii) protect elders with diminished capacity while maximizing their autonomy; and (B) from an individual perspective, the recognition of an elder’s rights, including the right to be free of abuse, neglect, and exploitation. (7) Eligible entity

“eligible entity” applies throughout its division

The term “eligible entity” means a State or local government agency, Indian tribe or tribal organization, or any other public or private entity that is engaged in and has expertise in issues relating to elder justice or in a field necessary to promote elder justice efforts. (8) Exploitation

“exploitation” applies throughout its division

The term “exploitation” means the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual, including a caregiver or fiduciary, that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets. (9) Fiduciary

“fiduciary” applies throughout its division

The term “fiduciary”— (A) means a person or entity with the legal responsibility— (i) to make decisions on behalf of and for the benefit of another person; and (ii) to act in good faith and with fairness; and (B) includes a trustee, a guardian, a conservator, an executor, an agent under a financial power of attorney or health care power of attorney, or a representative payee. (10) Grant

“grant” applies throughout its division

The term “grant” includes a contract, cooperative agreement, or other mechanism for providing financial assistance. (11) Guardianship

“guardianship” applies throughout its division

The term “guardianship” means— (A) the process by which a State court determines that an adult individual lacks capacity to make decisions about self-care or property, and appoints another individual or entity known as a guardian, as a conservator, or by a similar term, as a surrogate decisionmaker; (B) the manner in which the court-appointed surrogate decisionmaker carries out duties to the individual and the court; or (C) the manner in which the court exercises oversight of the surrogate decisionmaker. (12) Indian tribe (A) In general

“Indian tribe” applies throughout its division

The term “Indian tribe” has the meaning given such term in section 5304 of title 25 . (B) Inclusion of Pueblo and Rancheria

“law enforcement” applies throughout its division

The term “law enforcement” means the full range of potential responders to elder abuse, neglect, and exploitation including— (A) police, sheriffs, detectives, public safety officers, and corrections personnel; (B) prosecutors; (C) medical examiners; (D) investigators; and (E) coroners. (14) Long-term care (A) In general

“long-term care” applies throughout its division

The term “long-term care” means supportive and health services specified by the Secretary for individuals who need assistance because the individuals have a loss of capacity for self-care due to illness, disability, or vulnerability. (B) Loss of capacity for self-care For purposes of subparagraph (A),

“long-term care facility” applies throughout its division

The term “long-term care facility” means a residential care provider that arranges for, or directly provides, long-term care. (16) Neglect

“loss of capacity for self-care” applies throughout its division

the term “loss of capacity for self-care” means an inability to engage in 1 or more activities of daily living, including eating, dressing, bathing, management of one’s financial affairs, and other activities the Secretary determines appropriate. (15) Long-term care facility

“neglect” applies throughout its division

The term “neglect” means— (A) the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder; or (B) self-neglect. (17) Nursing facility (A) In general

“nursing facility” applies throughout its division

The term “nursing facility” has the meaning given such term under section 1396r(a) of this title . (B) Inclusion of skilled nursing facility

“self-neglect” applies throughout its division

The term “self-neglect” means an adult’s inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks including— (A) obtaining essential food, clothing, shelter, and medical care; (B) obtaining goods and services necessary to maintain physical health, mental health, or general safety; or (C) managing one’s own financial affairs. (19) Serious bodily injury (A) In general

“serious bodily injury” applies throughout its division

The term “serious bodily injury” means an injury— (i) involving extreme physical pain; (ii) involving substantial risk of death; (iii) involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or (iv) requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. (B) Criminal sexual abuse Serious bodily injury shall be considered to have occurred if the conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual abuse) or 2242 (relating to sexual abuse) of title 18 or any similar offense under State law.

“State legal assistance developer” applies throughout its division

The term “State legal assistance developer” means an individual described in section 3058j of this title . (22) State Long-Term Care Ombudsman

“State Long-Term Care Ombudsman” applies throughout its division

The term “State Long-Term Care Ombudsman” means the State Long-Term Care Ombudsman described in section 3058g(a)(2) of this title .

“child” applies throughout its subchapter

The term “child” means an individual under 19 years of age. (2) Creditable health coverage

“child health assistance” applies throughout its subchapter

the term “child health assistance” means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in section 1397ee(a)(1)(D)(i) of this title , payment for part or all of the cost of providing any of the following), as specified under the State plan: (1) Inpatient hospital services. (2) Outpatient hospital services. (3) Physician services. (4) Surgical services. (5) Clinic services (including health center services) and other ambulatory health care services.

“creditable health coverage” applies throughout its subchapter

The term “creditable health coverage” has the meaning given the term “creditable coverage” under section 2701(c) 2 of the Public Health Service Act ( 42 U.S.C. 300gg(c) ) and includes coverage that meets the requirements of section 1397cc of this title provided to a targeted low-income child under this subchapter or under a waiver approved under section 1397ee(c)(2)(B) of this title (relating to a direct service waiver). (3) Group health plan; health insurance coverage; etc.

“group health insurance coverage” applies throughout its subchapter

The terms “group health plan”, “group health insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 300gg–91 of this title . (4) Low-income child

“group health plan” applies throughout its subchapter

The terms “group health plan”, “group health insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 300gg–91 of this title . (4) Low-income child

“health insurance coverage” applies throughout its subchapter

The terms “group health plan”, “group health insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 300gg–91 of this title . (4) Low-income child

“low-income child” applies throughout its subchapter

The term “low-income child” means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. (5) Poverty line defined

“medicaid applicable income level” applies throughout its subchapter

The term “medicaid applicable income level” means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under subchapter XIX (including under a waiver authorized by the Secretary or under section 1396a(r)(2) of this title ), as of March 31, 1997 , for the child to be eligible for medical assistance under section 1396a( l )(2) or 1396d(n)(2) of this title (as selected by a State) for the age of such child.

“plan” applies throughout its subchapter

the terms “State child health plan” and “plan” mean a State child health plan approved under section 1397ff of this title . (8) Uncovered child

“poverty line” applies throughout its subchapter

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) Preexisting condition exclusion

“preexisting condition exclusion” applies throughout its subchapter

The term “preexisting condition exclusion” has the meaning given such term in section 2701(b)(1)(A) 2 of the Public Health Service Act ( 42 U.S.C. 300gg(b)(1)(A) ). (7) State child health plan; plan Unless the context otherwise requires,

“school-based health center” applies throughout its subchapter

The term “school-based health center” means a health clinic that— (i) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; (ii) is organized through school, community, and health provider relationships; (iii) is administered by a sponsoring facility; (iv) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and (v) satisfies such other requirements as a State may establish for the operation of such a clinic. (B) Sponsoring facility For purposes of subparagraph (A)(iii),

“sponsoring facility” applies throughout its subchapter

the term “sponsoring facility” includes any of the following: (i) A hospital. (ii) A public health department. (iii) A community health center. (iv) A nonprofit health care agency. (v) A local educational agency (as defined under section 7801 of title 20 . 1 (vi) A program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by an Indian tribe or a tribal organization.

“State child health plan” applies throughout its subchapter

the terms “State child health plan” and “plan” mean a State child health plan approved under section 1397ff of this title . (8) Uncovered child