
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-354 Section 2(b)(2)(B)]
[Document affected by Public Law 106-554 Section 1(a)(6)]
[Document affected by Public Law 106-554 Section 1(a)(6)[710(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[704(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[704(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[710(b)]]
[CITE: 42USC1396b]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
    SUBCHAPTER XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
 
Sec. 1396b. Payment to States


(a) Computation of amount

    From the sums appropriated therefor, the Secretary (except as 
otherwise provided in this section) shall pay to each State which has a 
plan approved under this subchapter, for each quarter, beginning with 
the quarter commencing January 1, 1966--
        (1) an amount equal to the Federal medical assistance percentage 
    (as defined in section 1396d(b) of this title, subject to 
    subsections (g) and (j) of this section and section 1396r-4(f) of 
    this title) of the total amount expended during such quarter as 
    medical assistance under the State plan; plus
        (2)(A) an amount equal to 75 per centum of so much of the sums 
    expended during such quarter (as found necessary by the Secretary 
    for the proper and efficient administration of the State plan) as 
    are attributable to compensation or training of skilled professional 
    medical personnel, and staff directly supporting such personnel, of 
    the State agency or any other public agency; plus
        (B) notwithstanding paragraph (1) or subparagraph (A), with 
    respect to amounts expended for nursing aide training and competency 
    evaluation programs, and competency evaluation programs, described 
    in section 1396r(e)(1) of this title (including the costs for nurse 
    aides to complete such competency evaluation programs), regardless 
    of whether the programs are provided in or outside nursing 
    facilities or of the skill of the personnel involved in such 
    programs, an amount equal to 50 percent (or, for calendar quarters 
    beginning on or after July 1, 1988, and before October 1, 1990, the 
    lesser of 90 percent or the Federal medical assistance percentage 
    plus 25 percentage points) of so much of the sums expended during 
    such quarter (as found necessary by the Secretary for the proper and 
    efficient administration of the State plan) as are attributable to 
    such programs; plus
        (C) an amount equal to 75 percent of so much of the sums 
    expended during such quarter (as found necessary by the Secretary 
    for the proper and efficient administration of the State plan) as 
    are attributable to preadmission screening and resident review 
    activities conducted by the State under section 1396r(e)(7) of this 
    title; plus
        (D) for each calendar quarter during--
            (i) fiscal year 1991, an amount equal to 90 percent,
            (ii) fiscal year 1992, an amount equal to 85 percent,
            (iii) fiscal year 1993, an amount equal to 80 percent, and
            (iv) fiscal year 1994 and thereafter, an amount equal to 75 
        percent,

    of so much of the sums expended during such quarter (as found 
    necessary by the Secretary for the proper and efficient 
    administration of the State plan) as are attributable to State 
    activities under section 1396r(g) of this title; plus
        (3) an amount equal to--
            (A)(i) 90 per centum of so much of the sums expended during 
        such quarter as are attributable to the design, development, or 
        installation of such mechanized claims processing and 
        information retrieval systems as the Secretary determines are 
        likely to provide more efficient, economical, and effective 
        administration of the plan and to be compatible with the claims 
        processing and information retrieval systems utilized in the 
        administration of subchapter XVIII of this chapter, including 
        the State's share of the cost of installing such a system to be 
        used jointly in the administration of such State's plan and the 
        plan of any other State approved under this chapter, and
            (ii) 90 per centum of so much of the sums expended during 
        any such quarter in the fiscal year ending June 30, 1972, or the 
        fiscal year ending June 30, 1973, as are attributable to the 
        design, development, or installation of cost determination 
        systems for State-owned general hospitals (except that the total 
        amount paid to all States under this clause for either such 
        fiscal year shall not exceed $150,000), and
            (B) 75 per centum of so much of the sums expended during 
        such quarter as are attributable to the operation of systems 
        (whether such systems are operated directly by the State or by 
        another person under a contract with the State) of the type 
        described in subparagraph (A)(i) (whether or not designed, 
        developed, or installed with assistance under such subparagraph) 
        which are approved by the Secretary and which include provision 
        for prompt written notice to each individual who is furnished 
        services covered by the plan, or to each individual in a sample 
        group of individuals who are furnished such services, of the 
        specific services (other than confidential services) so covered, 
        the name of the person or persons furnishing the services, the 
        date or dates on which the services were furnished, and the 
        amount of the payment or payments made under the plan on account 
        of the services; and

            (C)(i) 75 per centum of the sums expended with respect to 
        costs incurred during such quarter (as found necessary by the 
        Secretary for the proper and efficient administration of the 
        State plan) as are attributable to the performance of medical 
        and utilization review by a utilization and quality control peer 
        review organization or by an entity which meets the requirements 
        of section 1320c-1 of this title, as determined by the 
        Secretary, under a contract entered into under section 1396a(d) 
        of this title; and
            (ii) 75 percent of the sums expended with respect to costs 
        incurred during such quarter (as found necessary by the 
        Secretary for the proper and efficient administration of the 
        State plan) as are attributable to the performance of 
        independent external reviews conducted under section 1396u-
        2(c)(2) of this title; and
            (D) 75 percent of so much of the sums expended by the State 
        plan during a quarter in 1991, 1992, or 1993, as the Secretary 
        determines is attributable to the statewide adoption of a drug 
        use review program which conforms to the requirements of section 
        1396r-8(g) of this title; plus

        (4) an amount equal to 100 percent of the sums expended during 
    the quarter which are attributable to the costs of the 
    implementation and operation of the immigration status verification 
    system described in section 1320b-7(d) of this title; plus
        (5) an amount equal to 90 per centum of the sums expended during 
    such quarter which are attributable to the offering, arranging, and 
    furnishing (directly or on a contract basis) of family planning 
    services and supplies;
        (6) subject to subsection (b)(3) of this section, an amount 
    equal to--
            (A) 90 per centum of the sums expended during such a quarter 
        within the twelve-quarter period beginning with the first 
        quarter in which a payment is made to the State pursuant to this 
        paragraph, and
            (B) 75 per centum of the sums expended during each 
        succeeding calendar quarter,

    with respect to costs incurred during such quarter (as found 
    necessary by the Secretary for the elimination of fraud in the 
    provision and administration of medical assistance provided under 
    the State plan) which are attributable to the establishment and 
    operation of (including the training of personnel employed by) a 
    State medicaid fraud control unit (described in subsection (q) of 
    this section); plus
        (7) subject to section 1396r(g)(3)(B) of this title, an amount 
    equal to 50 per centum of the remainder of the amounts expended 
    during such quarter as found necessary by the Secretary for the 
    proper and efficient administration of the State plan.

(b) Quarterly expenditures beginning after December 31, 1969

    (1) Notwithstanding the preceding provisions of this section, the 
amount determined under subsection (a)(1) of this section for any State 
for any quarter beginning after December 31, 1969, shall not take into 
account any amounts expended as medical assistance with respect to 
individuals aged 65 or over and disabled individuals entitled to 
hospital insurance benefits under subchapter XVIII of this chapter which 
would not have been so expended if the individuals involved had been 
enrolled in the insurance program established by part B of subchapter 
XVIII of this chapter, other than amounts expended under provisions of 
the plan of such State required by section 1396a(a)(34) of this title.
    (2) For limitation on Federal participation for capital expenditures 
which are out of conformity with a comprehensive plan of a State or 
areawide planning agency, see section 1320a-1 of this title.
    (3) The amount of funds which the Secretary is otherwise obligated 
to pay a State during a quarter under subsection (a)(6) of this section 
may not exceed the higher of--
        (A) $125,000, or
        (B) one-quarter of 1 per centum of the sums expended by the 
    Federal, State, and local governments during the previous quarter in 
    carrying out the State's plan under this subchapter.

    (4) Amounts expended by a State for the use of an enrollment broker 
in marketing medicaid managed care organizations and other managed care 
entities to eligible individuals under this subchapter shall be 
considered, for purposes of subsection (a)(7) of this section, to be 
necessary for the proper and efficient administration of the State plan 
but only if the following conditions are met with respect to the broker:
        (A) The broker is independent of any such entity and of any 
    health care providers (whether or not any such provider participates 
    in the State plan under this subchapter) that provide coverage of 
    services in the same State in which the broker is conducting 
    enrollment activities.
        (B) No person who is an owner, employee, consultant, or has a 
    contract with the broker either has any direct or indirect financial 
    interest with such an entity or health care provider or has been 
    excluded from participation in the program under this subchapter or 
    subchapter XVIII of this chapter or debarred by any Federal agency, 
    or subject to a civil money penalty under this chapter.

    (5) Notwithstanding the preceding provisions of this section, the 
amount determined under subsection (a)(1) of this section for any State 
shall be decreased in a quarter by the amount of any health care related 
taxes (described in subsection (w)(3)(A) of this section) \1\ that are 
imposed on a hospital described in subsection (w)(3)(F) of this section 
in that quarter.
---------------------------------------------------------------------------
    \1\ See References in Text note below.
---------------------------------------------------------------------------

(c) Treatment of educationally-related services

    Nothing in this subchapter shall be construed as prohibiting or 
restricting, or authorizing the Secretary to prohibit or restrict, 
payment under subsection (a) of this section for medical assistance for 
covered services furnished to a child with a disability because such 
services are included in the child's individualized education program 
established pursuant to part B of the Individuals with Disabilities 
Education Act [20 U.S.C. 1411 et seq.] or furnished to an infant or 
toddler with a disability because such services are included in the 
child's individualized family service plan adopted pursuant to part H 
\1\ of such Act.

(d) Estimates of State entitlement; installments; adjustments to reflect 
        overpayments or underpayments; time for recovery or adjustment; 
        uncollectable or discharged debts; obligated appropriations; 
        disputed claims

    (1) Prior to the beginning of each quarter, the Secretary shall 
estimate the amount to which a State will be entitled under subsections 
(a) and (b) of this section for such quarter, such estimates to be based 
on (A) a report filed by the State containing its estimate of the total 
sum to be expended in such quarter in accordance with the provisions of 
such subsections, and stating the amount appropriated or made available 
by the State and its political subdivisions for such expenditures in 
such quarter, and if such amount is less than the State's proportionate 
share of the total sum of such estimated expenditures, the source or 
sources from which the difference is expected to be derived, and (B) 
such other investigation as the Secretary may find necessary.
    (2)(A) The Secretary shall then pay to the State, in such 
installments as he may determine, the amount so estimated, reduced or 
increased to the extent of any overpayment or underpayment which the 
Secretary determines was made under this section to such State for any 
prior quarter and with respect to which adjustment has not already been 
made under this subsection.
    (B) Expenditures for which payments were made to the State under 
subsection (a) of this section shall be treated as an overpayment to the 
extent that the State or local agency administering such plan has been 
reimbursed for such expenditures by a third party pursuant to the 
provisions of its plan in compliance with section 1396a(a)(25) of this 
title.
    (C) For purposes of this subsection, when an overpayment is 
discovered, which was made by a State to a person or other entity, the 
State shall have a period of 60 days in which to recover or attempt to 
recover such overpayment before adjustment is made in the Federal 
payment to such State on account of such overpayment. Except as 
otherwise provided in subparagraph (D), the adjustment in the Federal 
payment shall be made at the end of the 60 days, whether or not recovery 
was made.
    (D) In any case where the State is unable to recover a debt which 
represents an overpayment (or any portion thereof) made to a person or 
other entity on account of such debt having been discharged in 
bankruptcy or otherwise being uncollectable, no adjustment shall be made 
in the Federal payment to such State on account of such overpayment (or 
portion thereof).
    (3)(A) The pro rata share to which the United States is equitably 
entitled, as determined by the Secretary, of the net amount recovered 
during any quarter by the State or any political subdivision thereof 
with respect to medical assistance furnished under the State plan shall 
be considered an overpayment to be adjusted under this subsection.
    (B)(i) Subparagraph (A) and paragraph (2)(B) shall not apply to any 
amount recovered or paid to a State as part of the comprehensive 
settlement of November 1998 between manufacturers of tobacco products, 
as defined in section 5702(d) of the Internal Revenue Code of 1986, and 
State Attorneys General, or as part of any individual State settlement 
or judgment reached in litigation initiated or pursued by a State 
against one or more such manufacturers.
    (ii) Except as provided in subsection (i)(19) of this section, a 
State may use amounts recovered or paid to the State as part of a 
comprehensive or individual settlement, or a judgment, described in 
clause (i) for any expenditures determined appropriate by the State.
    (4) Upon the making of any estimate by the Secretary under this 
subsection, any appropriations available for payments under this section 
shall be deemed obligated.
    (5) In any case in which the Secretary estimates that there has been 
an overpayment under this section to a State on the basis of a claim by 
such State that has been disallowed by the Secretary under section 
1316(d) of this title, and such State disputes such disallowance, the 
amount of the Federal payment in controversy shall, at the option of the 
State, be retained by such State or recovered by the Secretary pending a 
final determination with respect to such payment amount. If such final 
determination is to the effect that any amount was properly disallowed, 
and the State chose to retain payment of the amount in controversy, the 
Secretary shall offset, from any subsequent payments made to such State 
under this subchapter, an amount equal to the proper amount of the 
disallowance plus interest on such amount disallowed for the period 
beginning on the date such amount was disallowed and ending on the date 
of such final determination at a rate (determined by the Secretary) 
based on the average of the bond equivalent of the weekly 90-day 
treasury bill auction rates during such period.
    (6)(A) Each State (as defined in subsection (w)(7)(D) of this 
section) shall include, in the first report submitted under paragraph 
(1) after the end of each fiscal year, information related to--
        (i) provider-related donations made to the State or units of 
    local government during such fiscal year, and
        (ii) health care related taxes collected by the State or such 
    units during such fiscal year.

    (B) Each State shall include, in the first report submitted under 
paragraph (1) after the end of each fiscal year, information related to 
the total amount of payment adjustments made, and the amount of payment 
adjustments made to individual providers (by provider), under section 
1396r-4(c) of this title during such fiscal year.

(e) Transition costs of closures or conversions permitted

    A State plan approved under this subchapter may include, as a cost 
with respect to hospital services under the plan under this subchapter, 
periodic expenditures made to reflect transitional allowances 
established with respect to a hospital closure or conversion under 
section 1395uu of this title.

(f) Limitation on Federal participation in medical assistance

    (1)(A) Except as provided in paragraph (4), payment under the 
preceding provisions of this section shall not be made with respect to 
any amount expended as medical assistance in a calendar quarter, in any 
State, for any member of a family the annual income of which exceeds the 
applicable income limitation determined under this paragraph.
    (B)(i) Except as provided in clause (ii) of this subparagraph, the 
applicable income limitation with respect to any family is the amount 
determined, in accordance with standards prescribed by the Secretary, to 
be equivalent to 133\1/3\ percent of the highest amount which would 
ordinarily be paid to a family of the same size without any income or 
resources, in the form of money payments, under the plan of the State 
approved under part A of subchapter IV of this chapter.
    (ii) If the Secretary finds that the operation of a uniform maximum 
limits payments to families of more than one size, he may adjust the 
amount otherwise determined under clause (i) to take account of families 
of different sizes.
    (C) The total amount of any applicable income limitation determined 
under subparagraph (B) shall, if it is not a multiple of $100 or such 
other amount as the Secretary may prescribe, be rounded to the next 
higher multiple of $100 or such other amount, as the case may be.
    (2)(A) In computing a family's income for purposes of paragraph (1), 
there shall be excluded any costs (whether in the form of insurance 
premiums or otherwise and regardless of whether such costs are 
reimbursed under another public program of the State or political 
subdivision thereof) incurred by such family for medical care or for any 
other type of remedial care recognized under State law or, (B) 
notwithstanding section 1396o of this title at State option, an amount 
paid by such family, at the family's option, to the State, provided that 
the amount, when combined with costs incurred in prior months, is 
sufficient when excluded from the family's income to reduce such 
family's income below the applicable income limitation described in 
paragraph (1). The amount of State expenditures for which medical 
assistance is available under subsection (a)(1) of this section will be 
reduced by amounts paid to the State pursuant to this subparagraph.
    (3) For purposes of paragraph (1)(B), in the case of a family 
consisting of only one individual, the ``highest amount which would 
ordinarily be paid'' to such family under the State's plan approved 
under part A of subchapter IV of this chapter shall be the amount 
determined by the State agency (on the basis of reasonable relationship 
to the amounts payable under such plan to families consisting of two or 
more persons) to be the amount of the aid which would ordinarily be 
payable under such plan to a family (without any income or resources) 
consisting of one person if such plan provided for aid to such a family.
    (4) The limitations on payment imposed by the preceding provisions 
of this subsection shall not apply with respect to any amount expended 
by a State as medical assistance for any individual described in section 
1396a(a)(10)(A)(i)(III), 1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V), 
1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII), 
1396a(a)(10)(A)(ii)(IX), 1396a(a)(10)(A)(ii)(X), 
1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or \2\ 
1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI), 1396d(p)(1) of this 
title or for any individual--
---------------------------------------------------------------------------
    \2\ So in original. The word ``or'' probably should precede 
``1396(p)(1)''.
---------------------------------------------------------------------------
        (A) who is receiving aid or assistance under any plan of the 
    State approved under subchapter I, X, XIV or XVI, or part A of 
    subchapter IV, or with respect to whom supplemental security income 
    benefits are being paid under subchapter XVI of this chapter, or
        (B) who is not receiving such aid or assistance, and with 
    respect to whom such benefits are not being paid, but (i) is 
    eligible to receive such aid or assistance, or to have such benefits 
    paid with respect to him, or (ii) would be eligible to receive such 
    aid or assistance, or to have such benefits paid with respect to him 
    if he were not in a medical institution, or
        (C) with respect to whom there is being paid, or who is 
    eligible, or would be eligible if he were not in a medical 
    institution, to have paid with respect to him, a State supplementary 
    payment and is eligible for medical assistance equal in amount, 
    duration, and scope to the medical assistance made available to 
    individuals described in section 1396a(a)(10)(A) of this title, or 
    who is a PACE program eligible individual enrolled in a PACE program 
    under section 1396u-4 of this title, but only if the income of such 
    individual (as determined under section 1382a of this title, but 
    without regard to subsection (b) thereof) does not exceed 300 
    percent of the supplemental security income benefit rate established 
    by section 1382(b)(1) of this title,

at the time of the provision of the medical assistance giving rise to 
such expenditure.

(g) Decrease in Federal medical assistance percentage of amounts paid 
        for services furnished under State plan after June 30, 1973

    (1) Subject to paragraph (3), with respect to amounts paid for the 
following services furnished under the State plan after June 30, 1973 
(other than services furnished pursuant to a contract with a health 
maintenance organization as defined in section 1395mm of this title or 
which is a qualified health maintenance organization (as defined in 
section 300e-9(d) \3\ of this title)), the Federal medical assistance 
percentage shall be decreased as follows: After an individual has 
received inpatient hospital services or services in an intermediate care 
facility for the mentally retarded for 60 days or inpatient mental 
hospital services for 90 days (whether or not such days are 
consecutive), during any fiscal year, the Federal medical assistance 
percentage with respect to amounts paid for any such care furnished 
thereafter to such individual shall be decreased by a per centum thereof 
(determined under paragraph (5)) unless the State agency responsible for 
the administration of the plan makes a showing satisfactory to the 
Secretary that, with respect to each calendar quarter for which the 
State submits a request for payment at the full Federal medical 
assistance percentage for amounts paid for inpatient hospital services 
or services in an intermediate care facility for the mentally retarded 
furnished beyond 60 days (or inpatient mental hospital services 
furnished beyond 90 days), such State has an effective program of 
medical review of the care of patients in mental hospitals and 
intermediate care facilities for the mentally retarded pursuant to 
paragraphs (26) and (31) of section 1396a(a) of this title whereby the 
professional management of each case is reviewed and evaluated at least 
annually by independent professional review teams. In determining the 
number of days on which an individual has received services described in 
this subsection, there shall not be counted any days with respect to 
which such individual is entitled to have payments made (in whole or in 
part) on his behalf under section 1395d of this title.
---------------------------------------------------------------------------
    \3\ See References in Text note below.
---------------------------------------------------------------------------
    (2) The Secretary shall, as part of his validation procedures under 
this subsection, conduct timely sample onsite surveys of private and 
public institutions in which recipients of medical assistance may 
receive care and services under a State plan approved under this 
subchapter, and his findings with respect to such surveys (as well as 
the showings of the State agency required under this subsection) shall 
be made available for public inspection.
    (3)(A) No reduction in the Federal medical assistance percentage of 
a State otherwise required to be imposed under this subsection shall 
take effect--
        (i) if such reduction is due to the State's unsatisfactory or 
    invalid showing made with respect to a calendar quarter beginning 
    before January 1, 1977;
        (ii) before January 1, 1978;
        (iii) unless a notice of such reduction has been provided to the 
    State at least 30 days before the date such reduction takes effect; 
    or
        (iv) due to the State's unsatisfactory or invalid showing made 
    with respect to a calendar quarter beginning after September 30, 
    1977, unless notice of such reduction has been provided to the State 
    no later than the first day of the fourth calendar quarter following 
    the calendar quarter with respect to which such showing was made.

    (B) The Secretary shall waive application of any reduction in the 
Federal medical assistance percentage of a State otherwise required to 
be imposed under paragraph (1) because a showing by the State, made 
under such paragraph with respect to a calendar quarter ending after 
January 1, 1977, and before January 1, 1978, is determined to be either 
unsatisfactory under such paragraph or invalid under paragraph (2), if 
the Secretary determines that the State's showing made under paragraph 
(1) with respect to any calendar quarter ending on or before December 
31, 1978, is satisfactory under such paragraph and is valid under 
paragraph (2).
    (4)(A) The Secretary may not find the showing of a State, with 
respect to a calendar quarter under paragraph (1), to be satisfactory if 
the showing is submitted to the Secretary later than the 30th day after 
the last day of the calendar quarter, unless the State demonstrates to 
the satisfaction of the Secretary good cause for not meeting such 
deadline.
    (B) The Secretary shall find a showing of a State, with respect to a 
calendar quarter under paragraph (1), to be satisfactory under such 
paragraph with respect to the requirement that the State conduct annual 
onsite inspections in mental hospitals and intermediate care facilities 
for the mentally retarded under paragraphs (26) and (31) of section 
1396a(a) of this title, if the showing demonstrates that the State has 
conducted such an onsite inspection during the 12-month period ending on 
the last date of the calendar quarter--
        (i) in each of not less than 98 per centum of the number of such 
    hospitals and facilities requiring such inspection, and
        (ii) in every such hospital or facility which has 200 or more 
    beds,

and that, with respect to such hospitals and facilities not inspected 
within such period, the State has exercised good faith and due diligence 
in attempting to conduct such inspection, or if the State demonstrates 
to the satisfaction of the Secretary that it would have made such a 
showing but for failings of a technical nature only.
    (5) In the case of a State's unsatisfactory or invalid showing made 
with respect to a type of facility or institutional services in a 
calendar quarter, the per centum amount of the reduction of the State's 
Federal medical assistance percentage for that type of services under 
paragraph (1) is equal to 33\1/3\ per centum multiplied by a fraction, 
the denominator of which is equal to the total number of patients 
receiving that type of services in that quarter under the State plan in 
facilities or institutions for which a showing was required to be made 
under this subsection, and the numerator of which is equal to the number 
of such patients receiving such type of services in that quarter in 
those facilities or institutions for which a satisfactory and valid 
showing was not made for that calendar quarter.
    (6)(A) Recertifications required under section 1396a(a)(44) of this 
title shall be conducted at least every 60 days in the case of inpatient 
hospital services.
    (B) Such recertifications in the case of services in an intermediate 
care facility for the mentally retarded shall be conducted at least--
        (i) 60 days after the date of the initial certification,
        (ii) 180 days after the date of the initial certification,
        (iii) 12 months after the date of the initial certification,
        (iv) 18 months after the date of the initial certification,
        (v) 24 months after the date of the initial certification, and
        (vi) every 12 months thereafter.

    (C) For purposes of determining compliance with the schedule 
established by this paragraph, a recertification shall be considered to 
have been done on a timely basis if it was performed not later than 10 
days after the date the recertification was otherwise required and the 
State establishes good cause why the physician or other person making 
such recertification did not meet such schedule.

(h) Repealed. Pub. L. 100-203, title IV, Sec. 4211(g)(1), Dec. 22, 1987, 
        101 Stat. 1330-205

(i) Payment for organ transplants; item or service furnished by excluded 
        individual, entity, or physician; other restrictions

    Payment under the preceding provisions of this section shall not be 
made--
        (1) for organ transplant procedures unless the State plan 
    provides for written standards respecting the coverage of such 
    procedures and unless such standards provide that--
            (A) similarly situated individuals are treated alike; and
            (B) any restriction, on the facilities or practitioners 
        which may provide such procedures, is consistent with the 
        accessibility of high quality care to individuals eligible for 
        the procedures under the State plan; or

        (2) with respect to any amount expended for an item or service 
    (other than an emergency item or service, not including items or 
    services furnished in an emergency room of a hospital) furnished--
            (A) under the plan by any individual or entity during any 
        period when the individual or entity is excluded from 
        participation under subchapter V, XVIII, or XX of this chapter 
        or under this subchapter pursuant to section 1320a-7, 1320a-7a, 
        1320c-5, or 1395u(j)(2) of this title, or
            (B) at the medical direction or on the prescription of a 
        physician, during the period when such physician is excluded 
        from participation under subchapter V, XVIII, or XX of this 
        chapter or under this subchapter pursuant to section 1320a-7, 
        1320a-7a, 1320c-5, or 1395u(j)(2) of this title and when the 
        person furnishing such item or service knew or had reason to 
        know of the exclusion (after a reasonable time period after 
        reasonable notice has been furnished to the person); or

        (3) with respect to any amount expended for inpatient hospital 
    services furnished under the plan (other than amounts attributable 
    to the special situation of a hospital which serves a 
    disproportionate number of low income patients with special needs) 
    to the extent that such amount exceeds the hospital's customary 
    charges with respect to such services or (if such services are 
    furnished under the plan by a public institution free of charge or 
    at nominal charges to the public) exceeds an amount determined on 
    the basis of those items (specified in regulations prescribed by the 
    Secretary) included in the determination of such payment which the 
    Secretary finds will provide fair compensation to such institution 
    for such services; or
        (4) with respect to any amount expended for care or services 
    furnished under the plan by a hospital unless such hospital has in 
    effect a utilization review plan which meets the requirements 
    imposed by section 1395x(k) of this title for purposes of subchapter 
    XVIII of this chapter; and if such hospital has in effect such a 
    utilization review plan for purposes of subchapter XVIII of this 
    chapter, such plan shall serve as the plan required by this 
    subsection (with the same standards and procedures and the same 
    review committee or group) as a condition of payment under this 
    subchapter; the Secretary is authorized to waive the requirements of 
    this paragraph if the State agency demonstrates to his satisfaction 
    that it has in operation utilization review procedures which are 
    superior in their effectiveness to the procedures required under 
    section 1395x(k) of this title; or
        (5) with respect to any amount expended for any drug product for 
    which payment may not be made under part B of subchapter XVIII of 
    this chapter because of section 1395y(c) of this title; or
        (6) with respect to any amount expended for inpatient hospital 
    tests (other than in emergency situations) not specifically ordered 
    by the attending physician or other responsible practitioner; or
        (7) with respect to any amount expended for clinical diagnostic 
    laboratory tests performed by a physician, independent laboratory, 
    or hospital, to the extent such amount exceeds the amount that would 
    be recognized under section 1395l(h) of this title for such tests 
    performed for an individual enrolled under part B of subchapter 
    XVIII of this chapter; or
        (8) with respect to any amount expended for medical assistance 
    (A) for nursing facility services to reimburse (or otherwise 
    compensate) a nursing facility for payment of a civil money penalty 
    imposed under section 1396r(h) of this title or (B) for home and 
    community care to reimburse (or otherwise compensate) a provider of 
    such care for payment of a civil money penalty imposed under this 
    subchapter or subchapter XI of this chapter or for legal expenses in 
    defense of an exclusion or civil money penalty under this subchapter 
    or subchapter XI of this chapter if there is no reasonable legal 
    ground for the provider's case; or
        (9) Repealed. Pub. L. 104-193, title I, Sec. 114(d)(2), Aug. 22, 
    1996, 110 Stat. 2180.
        (10)(A) with respect to covered outpatient drugs unless there is 
    a rebate agreement in effect under section 1396r-8 of this title 
    with respect to such drugs or unless section 1396r-8(a)(3) of this 
    title applies, and
        (B) with respect to any amount expended for an innovator 
    multiple source drug (as defined in section 1396r-8(k) of this 
    title) dispensed on or after July 1, 1991, if, under applicable 
    State law, a less expensive multiple source drug could have been 
    dispensed, but only to the extent that such amount exceeds the upper 
    payment limit for such multiple source drug; or
        (11) with respect to any amount expended for physicians' 
    services furnished on or after the first day of the first quarter 
    beginning more than 60 days after the date of establishment of the 
    physician identifier system under section 1396a(x) of this title, 
    unless the claim for the services includes the unique physician 
    identifier provided under such system; or
        (12) Repealed. Pub. L. 105-33, title IV, Sec. 4742(a), Aug. 5, 
    1997, 111 Stat. 523.
        (13) with respect to any amount expended to reimburse (or 
    otherwise compensate) a nursing facility for payment of legal 
    expenses associated with any action initiated by the facility that 
    is dismissed on the basis that no reasonable legal ground existed 
    for the institution of such action; or
        (14) with respect to any amount expended on administrative costs 
    to carry out the program under section 1396s of this title; or
        (15) with respect to any amount expended for a single-antigen 
    vaccine and its administration in any case in which the 
    administration of a combined-antigen vaccine was medically 
    appropriate (as determined by the Secretary); or
        (16) with respect to any amount expended for which funds may not 
    be used under the Assisted Suicide Funding Restriction Act of 1997 
    [42 U.S.C. 14401 et seq.]; or
        (17) with respect to any amount expended for roads, bridges, 
    stadiums, or any other item or service not covered under a State 
    plan under this subchapter; or
        (18) with respect to any amount expended for home health care 
    services provided by an agency or organization unless the agency or 
    organization provides the State agency on a continuing basis a 
    surety bond in a form specified by the Secretary under paragraph (7) 
    of section 1395x(o) of this title and in an amount that is not less 
    than $50,000 or such comparable surety bond as the Secretary may 
    permit under the last sentence of such section; or
        (19) with respect to any amount expended on administrative costs 
    to initiate or pursue litigation described in subsection (d)(3)(B) 
    of this section; or
        (20) with respect to amounts expended for medical assistance 
    provided to an individual described in subclause (XV) or (XVI) of 
    section 1396a(a)(10)(A)(ii) of this title for a fiscal year unless 
    the State demonstrates to the satisfaction of the Secretary that the 
    level of State funds expended for such fiscal year for programs to 
    enable working individuals with disabilities to work (other than for 
    such medical assistance) is not less than the level expended for 
    such programs during the most recent State fiscal year ending before 
    December 17, 1999.

Nothing in paragraph (1) shall be construed as permitting a State to 
provide services under its plan under this subchapter that are not 
reasonable in amount, duration, and scope to achieve their purpose. 
Paragraphs (1), (2), (16), (17), and (18) shall apply with respect to 
items or services furnished and amounts expended by or through a managed 
care entity (as defined in section 1396u-2(a)(1)(B) of this title) in 
the same manner as such paragraphs apply to items or services furnished 
and amounts expended directly by the State.

(j) Adjustment of amount

    Notwithstanding the preceding provisions of this section, the amount 
determined under subsection (a)(1) of this section for any State for any 
quarter shall be adjusted in accordance with section 1396m of this 
title.

(k) Technical assistance to States

    The Secretary is authorized to provide at the request of any State 
(and without cost to such State) such technical and actuarial assistance 
as may be necessary to assist such State to contract with any medicaid 
managed care organization which meets the requirements of subsection (m) 
of this section for the purpose of providing medical care and services 
to individuals who are entitled to medical assistance under this 
subchapter.

(l) Repealed. Pub. L. 94-552, Sec. 1, Oct. 18, 1976, 90 Stat. 2540

(m) ``Medicaid managed care organization'' defined; duties and functions 
        of Secretary; payments to States; reporting requirements; 
        remedies

    (1)(A) 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 of this 
chapter, 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 with the 
    organization, and
        (ii) has made adequate provision against the risk of insolvency, 
    which provision is satisfactory to the State, meets the requirements 
    of subparagraph (C)(i) (if applicable), and which assures that 
    individuals eligible for benefits under this subchapter are in no 
    case held liable for debts of the organization in case of the 
    organization's insolvency.

An organization that is a qualified health maintenance organization (as 
defined in section 300e-9(d) \4\ of this title) is deemed to meet the 
requirements of clauses (i) and (ii).
---------------------------------------------------------------------------
    \4\ See References in Text note below.
---------------------------------------------------------------------------
    (B) The duties and functions of the Secretary, insofar as they 
involve making determinations as to whether an organization is a 
medicaid managed care organization within the meaning of subparagraph 
(A), shall be integrated with the administration of section 300e-11(a) 
and (b) of this title.
    (C)(i) Subject to clause (ii), a provision meets the requirements of 
this subparagraph for an organization if the organization meets solvency 
standards established by the State for private health maintenance 
organizations or is licensed or certified by the State as a risk-bearing 
entity.
    (ii) Clause (i) shall not apply to an organization if--
        (I) the organization is not responsible for the provision 
    (directly or through arrangements with providers of services) of 
    inpatient hospital services and physicians' services;
        (II) the organization is a public entity;
        (III) the solvency of the organization is guaranteed by the 
    State; or
        (IV) the organization is (or is controlled by) one or more 
    Federally-qualified \5\ health centers and meets solvency standards 
    established by the State for such an organization.
---------------------------------------------------------------------------
    \5\ So in original. Probably should not be capitalized.

For purposes of subclause (IV), the term ``control'' means the 
possession, whether direct or indirect, of the power to direct or cause 
the direction of the management and policies of the organization through 
membership, board representation, or an ownership interest equal to or 
greater than 50.1 percent.
    (2)(A) Except as provided in subparagraphs (B), (C), and (G), no 
payment shall be made under this subchapter to a State with respect to 
expenditures incurred by it for payment (determined under a prepaid 
capitation basis or under any other risk basis) for services provided by 
any entity (including a health insuring organization) which is 
responsible for the provision (directly or through arrangements with 
providers of services) of inpatient hospital services and any other 
service described in paragraph (2), (3), (4), (5), or (7) of section 
1396d(a) of this title or for the provision of any three or more of the 
services described in such paragraphs unless--
        (i) the Secretary has determined that the entity is a medicaid 
    managed care organization as defined in paragraph (1);
        (ii) Repealed. Pub. L. 105-33, title IV, Sec. 4703(a), Aug. 5, 
    1997, 111 Stat. 495.
        (iii) such services are provided for the benefit of individuals 
    eligible for benefits under this subchapter in accordance with a 
    contract between the State and the entity under which prepaid 
    payments to the entity are made on an actuarially sound basis and 
    under which the Secretary must provide prior approval for contracts 
    providing for expenditures in excess of $1,000,000 for 1998 and, for 
    a subsequent year, the amount established under this clause for the 
    previous year increased by the percentage increase in the consumer 
    price index for all urban consumers over the previous year;
        (iv) such contract provides that the Secretary and the State (or 
    any person or organization designated by either) shall have the 
    right to audit and inspect any books and records of the entity (and 
    of any subcontractor) that pertain (I) to the ability of the entity 
    to bear the risk of potential financial losses, or (II) to services 
    performed or determinations of amounts payable under the contract;
        (v) such contract provides that in the entity's enrollment, 
    reenrollment, or disenrollment of individuals who are eligible for 
    benefits under this subchapter and eligible to enroll, reenroll, or 
    disenroll with the entity pursuant to the contract, the entity will 
    not discriminate among such individuals on the basis of their health 
    status or requirements for health care services;
        (vi) such contract (I) permits individuals who have elected 
    under the plan to enroll with the entity for provision of such 
    benefits to terminate such enrollment in accordance with section 
    1396u-2(a)(4) of this title, and (II) provides for notification in 
    accordance with such section of each such individual, at the time of 
    the individual's enrollment, of such right to terminate such 
    enrollment;
        (vii) such contract provides that, in the case of medically 
    necessary services which were provided (I) to an individual enrolled 
    with the entity under the contract and entitled to benefits with 
    respect to such services under the State's plan and (II) other than 
    through the organization because the services were immediately 
    required due to an unforeseen illness, injury, or condition, either 
    the entity or the State provides for reimbursement with respect to 
    those services,\6\
---------------------------------------------------------------------------
    \6\ So in original. The comma probably should be a semicolon.
---------------------------------------------------------------------------
        (viii) such contract provides for disclosure of information in 
    accordance with section 1320a-3 of this title and paragraph (4) of 
    this subsection;
        (ix) such contract provides, in the case of an entity that has 
    entered into a contract for the provision of services with a 
    Federally-qualified \5\ health center or a rural health clinic, that 
    the entity shall provide payment that is not less than the level and 
    amount of payment which the entity would make for the services if 
    the services were furnished by a provider which is not a Federally-
    qualified health center or a rural health clinic;
        (x) any physician incentive plan that it operates meets the 
    requirements described in section 1395mm(i)(8) of this title;
        (xi) such contract provides for maintenance of sufficient 
    patient encounter data to identify the physician who delivers 
    services to patients; and
        (xii) such contract, and the entity complies with the applicable 
    requirements of section 1396u-2 of this title.

    (B) Subparagraph (A) \7\ except with respect to clause (ix) of 
subparagraph (A), does not apply with respect to payments under this 
subchapter to a State with respect to expenditures incurred by it for 
payment for services provided by an entity which--
---------------------------------------------------------------------------
    \7\ So in original. Probably should be followed by a comma.
---------------------------------------------------------------------------
        (i)(I) received a grant of at least $100,000 in the fiscal year 
    ending June 30, 1976, under section 254b(d)(1)(A) or 254c(d)(1) of 
    this title,\8\ and for the period beginning July 1, 1976, and ending 
    on the expiration of the period for which payments are to be made 
    under this subchapter has been the recipient of a grant under either 
    such section; and
---------------------------------------------------------------------------
    \8\ See References in Text note below.
---------------------------------------------------------------------------
        (II) provides to its enrollees, on a prepaid capitation risk 
    basis or on any other risk basis, all of the services and benefits 
    described in paragraphs (1), (2), (3), (4)(C), and (5) of section 
    1396d(a) of this title and, to the extent required by section 
    1396a(a)(10)(D) of this title to be provided under a State plan for 
    medical assistance, the services and benefits described in paragraph 
    (7) of section 1396d(a) of this title; or
        (ii) is a nonprofit primary health care entity located in a 
    rural area (as defined by the Appalachian Regional Commission)--
            (I) which received in the fiscal year ending June 30, 1976, 
        at least $100,000 (by grant, subgrant, or subcontract) under the 
        Appalachian Regional Development Act of 1965, and
            (II) for the period beginning July 1, 1976, and ending on 
        the expiration of the period for which payments are to be made 
        under this subchapter either has been the recipient of a grant, 
        subgrant, or subcontract under such Act or has provided services 
        under a contract (initially entered into during a year in which 
        the entity was the recipient of such a grant, subgrant, or 
        subcontract) with a State agency under this subchapter on a 
        prepaid capitation risk basis or on any other risk basis; or

        (iii) which has contracted with the single State agency for the 
    provision of services (but not including inpatient hospital 
    services) to persons eligible under this subchapter on a prepaid 
    risk basis prior to 1970.

    (C) to (E) Repealed. Pub. L. 105-33, title IV, Sec. 4703(b)(1)(A), 
Aug. 5, 1997, 111 Stat. 495.
    (F) Repealed. Pub. L. 105-33, title IV, Sec. 4701(d)(2)(B), Aug. 5, 
1997, 111 Stat. 494.
    (G) In the case of an entity which is receiving (and has received 
during the previous two years) a grant of at least $100,000 under 
section 254b(d)(1)(A) or 254c(d)(1) of this title \8\ or is receiving 
(and has received during the previous two years) at least $100,000 (by 
grant, subgrant, or subcontract) under the Appalachian Regional 
Development Act of 1965, clause (i) of subparagraph (A) shall not apply.
    (H) In the case of an individual who--
        (i) in a month is eligible for benefits under this subchapter 
    and enrolled with a medicaid managed care organization with a 
    contract under this paragraph or with a primary care case manager 
    with a contract described in section 1396d(t)(3) of this title,
        (ii) in the next month (or in the next 2 months) is not eligible 
    for such benefits, but
        (iii) in the succeeding month is again eligible for such 
    benefits,

the State plan, subject to subparagraph (A)(vi), may enroll the 
individual for that succeeding month with the organization described in 
clause (i) if the organization continues to have a contract under this 
paragraph with the State or with the manager described in such clause if 
the manager continues to have a contract described in section 
1396d(t)(3) of this title with the State.
    (3) Repealed. Pub. L. 101-508, title IV, Sec. 4732(d)(2), Nov. 5, 
1990, 104 Stat. 1388-196.
    (4)(A) Each medicaid managed care organization which is not a 
qualified health maintenance organization (as defined in section 300e-
9(d) \8\ of this title) must report to the State and, upon request, to 
the Secretary, the Inspector General of the Department of Health and 
Human Services, and the Comptroller General a description of 
transactions between the organization and a party in interest (as 
defined in section 300e-17(b) of this title), including the following 
transactions:
        (i) Any sale or exchange, or leasing of any property between the 
    organization and such a party.
        (ii) Any furnishing for consideration of goods, services 
    (including management services), or facilities between the 
    organization and such a party, but not including salaries paid to 
    employees for services provided in the normal course of their 
    employment.
        (iii) Any lending of money or other extension of credit between 
    the organization and such a party.

The State or Secretary may require that information reported respecting 
an organization which controls, or is controlled by, or is under common 
control with, another entity be in the form of a consolidated financial 
statement for the organization and such entity.
    (B) Each organization shall make the information reported pursuant 
to subparagraph (A) available to its enrollees upon reasonable request.
    (5)(A) If the Secretary determines that an entity with a contract 
under this subsection--
        (i) fails substantially to provide medically necessary items and 
    services that are required (under law or under the contract) to be 
    provided to an individual covered under the contract, if the failure 
    has adversely affected (or has substantial likelihood of adversely 
    affecting) the individual;
        (ii) imposes premiums on individuals enrolled under this 
    subsection in excess of the premiums permitted under this 
    subchapter;
        (iii) acts to discriminate among individuals in violation of the 
    provision of paragraph (2)(A)(v), including expulsion or refusal to 
    re-enroll an individual or engaging in any practice that would 
    reasonably be expected to have the effect of denying or discouraging 
    enrollment (except as permitted by this subsection) by eligible 
    individuals with the organization whose medical condition or history 
    indicates a need for substantial future medical services;
        (iv) misrepresents or falsifies information that is furnished--
            (I) to the Secretary or the State under this subsection, or
            (II) to an individual or to any other entity under this 
        subsection,\9\ or
---------------------------------------------------------------------------
    \9\ So in original. The comma probably should be a semicolon.

        (v) fails to comply with the requirements of section 
---------------------------------------------------------------------------
    1395mm(i)(8) of this title,

the Secretary may provide, in addition to any other remedies available 
under law, for any of the remedies described in subparagraph (B).
    (B) The remedies described in this subparagraph are--
        (i) civil money penalties of not more than $25,000 for each 
    determination under subparagraph (A), or, with respect to a 
    determination under clause (iii) or (iv)(I) of such subparagraph, of 
    not more than $100,000 for each such determination, plus, with 
    respect to a determination under subparagraph (A)(ii), double the 
    excess amount charged in violation of such subparagraph (and the 
    excess amount charged shall be deducted from the penalty and 
    returned to the individual concerned), and plus, with respect to a 
    determination under subparagraph (A)(iii), $15,000 for each 
    individual not enrolled as a result of a practice described in such 
    subparagraph, or
        (ii) denial of payment to the State for medical assistance 
    furnished under the contract under this subsection for individuals 
    enrolled after the date the Secretary notifies the organization of a 
    determination under subparagraph (A) and until the Secretary is 
    satisfied that the basis for such determination has been corrected 
    and is not likely to recur.

The provisions of section 1320a-7a of this title (other than subsections 
(a) and (b)) shall apply to a civil money penalty under clause (i) in 
the same manner as such provisions apply to a penalty or proceeding 
under section 1320a-7a(a) of this title.
    (6)(A) For purposes of this subsection and section 1396a(e)(2)(A) of 
this title, in the case of the State of New Jersey, the term 
``contract'' shall be deemed to include an undertaking by the State 
agency, in the State plan under this subchapter, to operate a program 
meeting all requirements of this subsection.
    (B) The undertaking described in subparagraph (A) must provide--
        (i) for the establishment of a separate entity responsible for 
    the operation of a program meeting the requirements of this 
    subsection, which entity may be a subdivision of the State agency 
    administering the State plan under this subchapter;
        (ii) for separate accounting for the funds used to operate such 
    program; and
        (iii) for setting the capitation rates and any other payment 
    rates for services provided in accordance with this subsection using 
    a methodology satisfactory to the Secretary designed to ensure that 
    total Federal matching payments under this subchapter for such 
    services will be lower than the matching payments that would be made 
    for the same services, if provided under the State plan on a fee for 
    service basis to an actuarially equivalent population.

    (C) The undertaking described in subparagraph (A) shall be subject 
to approval (and annual re-approval) by the Secretary in the same manner 
as a contract under this subsection.
    (D) The undertaking described in subparagraph (A) shall not be 
eligible for a waiver under section 1396n(b) of this title.

(n) Repealed. Pub. L. 100-93, Sec. 8(h)(1), Aug. 18, 1987, 101 Stat. 694

(o) Restrictions on authorized payments to States

    Notwithstanding the preceding provisions of this section, no payment 
shall be made to a State under the preceding provisions of this section 
for expenditures for medical assistance provided for an individual under 
its State plan approved under this subchapter to the extent that a 
private insurer (as defined by the Secretary by regulation and including 
a group health plan (as defined in section 1167(1) of title 29), a 
service benefit plan, and a health maintenance organization) would have 
been obligated to provide such assistance but for a provision of its 
insurance contract which has the effect of limiting or excluding such 
obligation because the individual is eligible for or is provided medical 
assistance under the plan.

(p) Assignment of rights of payment; incentive payments for enforcement 
        and collection

    (1) When a political subdivision of a State makes, for the State of 
which it is a political subdivision, or one State makes, for another 
State, the enforcement and collection of rights of support or payment 
assigned under section 1396k of this title, pursuant to a cooperative 
arrangement under such section (either within or outside of such State), 
there shall be paid to such political subdivision or such other State 
from amounts which would otherwise represent the Federal share of 
payments for medical assistance provided to the eligible individuals on 
whose behalf such enforcement and collection was made, an amount equal 
to 15 percent of any amount collected which is attributable to such 
rights of support or payment.
    (2) Where more than one jurisdiction is involved in such enforcement 
or collection, the amount of the incentive payment determined under 
paragraph (1) shall be allocated among the jurisdictions in a manner to 
be prescribed by the Secretary.

(q) ``State medicaid fraud control unit'' defined

    For the purposes of this 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 the appropriate authority or 
    authorities in the State for prosecution and (ii) assure its 
    assistance of, and coordination with, such authority or authorities 
    in such prosecutions, or (C) has a formal working relationship with 
    the office of the State Attorney General and has formal procedures 
    (including procedures for its referral of suspected criminal 
    violations to such office) which are approved by the Secretary and 
    which provide effective coordination of activities between the 
    entity and such office with respect to the detection, investigation, 
    and prosecution of suspected criminal violations relating to the 
    program under this subchapter.
        (2) The entity is separate and distinct from the single State 
    agency that administers or supervises the administration of the 
    State plan under this subchapter.
        (3) The entity's function is conducting a statewide program for 
    the investigation and prosecution of violations of all applicable 
    State laws regarding any and all aspects of fraud in connection with 
    (A) any aspect of the provision of medical assistance and the 
    activities of providers of such assistance under the State plan 
    under this subchapter; and (B) upon the approval of the Inspector 
    General of the relevant Federal agency, any aspect of the provision 
    of health care services and activities of providers of such services 
    under any Federal health care program (as defined in section 1320a-
    7b(f)(1) of this title), if the suspected fraud or violation of law 
    in such case or investigation is primarily related to the State plan 
    under this subchapter.
        (4)(A) The entity has--
            (i) procedures for reviewing complaints of abuse or neglect 
        of patients in health care facilities which receive payments 
        under the State plan under this subchapter;
            (ii) at the option of the entity, procedures for reviewing 
        complaints of abuse or neglect of patients residing in board and 
        care facilities; and
            (iii) procedures for acting upon such complaints under the 
        criminal laws of the State or for referring such complaints to 
        other State agencies for action.

        (B) For purposes of this paragraph, the term ``board and care 
    facility'' means a residential setting which receives payment 
    (regardless of whether such payment is made under the State plan 
    under this subchapter) from or on behalf of two or more unrelated 
    adults who reside in such facility, and for whom one or both of the 
    following is provided:
            (i) Nursing care services provided by, or under the 
        supervision of, a registered nurse, licensed practical nurse, or 
        licensed nursing assistant.
            (ii) A substantial amount of personal care services that 
        assist residents with the activities of daily living, including 
        personal hygiene, dressing, bathing, eating, toileting, 
        ambulation, transfer, positioning, self-medication, body care, 
        travel to medical services, essential shopping, meal 
        preparation, laundry, and housework.

        (5) The entity provides for the collection, or referral for 
    collection to a single State agency, of overpayments that are made 
    under the State plan or under any Federal health care program (as so 
    defined) to health care facilities and that are discovered by the 
    entity in carrying out its activities. All funds collected in 
    accordance with this paragraph shall be credited exclusively to, and 
    available for expenditure under, the Federal health care program 
    (including the State plan under this subchapter) that was subject to 
    the activity that was the basis for the collection.
        (6) The entity employs such auditors, attorneys, investigators, 
    and other necessary personnel and is organized in such a manner as 
    is necessary to promote the effective and efficient conduct of the 
    entity's activities.
        (7) The entity submits to the Secretary an application and 
    annual reports containing such information as the Secretary 
    determines, by regulation, to be necessary to determine whether the 
    entity meets the other requirements of this subsection.

(r) Mechanized claims processing and information retrieval systems; 
        operational, etc., requirements

    (1) In order to receive payments under subsection (a) of this 
section for use of automated data systems in administration of the State 
plan under this subchapter, a State must have in operation mechanized 
claims processing and information retrieval systems that meet the 
requirements of this subsection and that the Secretary has found--
        (A) are adequate to provide efficient, economical, and effective 
    administration of such State plan;
        (B) are compatible with the claims processing and information 
    retrieval systems used in the administration of subchapter XVIII of 
    this chapter, and for this purpose--
            (i) have a uniform identification coding system for 
        providers, other payees, and beneficiaries under this subchapter 
        or subchapter XVIII of this chapter;
            (ii) provide liaison between States and carriers and 
        intermediaries with agreements under subchapter XVIII of this 
        chapter to facilitate timely exchange of appropriate data; and
            (iii) provide for exchange of data between the States and 
        the Secretary with respect to persons sanctioned under this 
        subchapter or subchapter XVIII of this chapter;

        (C) are capable of providing accurate and timely data;
        (D) are complying with the applicable provisions of part C of 
    subchapter XI of this chapter;
        (E) are designed to receive provider claims in standard formats 
    to the extent specified by the Secretary; and
        (F) effective for claims filed on or after January 1, 1999, 
    provide for electronic transmission of claims data in the format 
    specified by the Secretary and consistent with the Medicaid 
    Statistical Information System (MSIS) (including detailed individual 
    enrollee encounter data and other information that the Secretary may 
    find necessary).

    (2) In order to meet the requirements of this paragraph, mechanized 
claims processing and information retrieval systems must meet the 
following requirements:
        (A) The systems must be capable of developing provider, 
    physician, and patient profiles which are sufficient to provide 
    specific information as to the use of covered types of services and 
    items, including prescribed drugs.
        (B) The State must provide that information on probable fraud or 
    abuse which is obtained from, or developed by, the systems, is made 
    available to the State's medicaid fraud control unit (if any) 
    certified under subsection (q) of this section.
        (C) The systems must meet all performance standards and other 
    requirements for initial approval developed by the Secretary.

(s) Limitations on certain physician referrals

    Notwithstanding the preceding provisions of this section, no payment 
shall be made to a State under this section for expenditures for medical 
assistance under the State plan consisting of a designated health 
service (as defined in subsection (h)(6) of section 1395nn of this 
title) furnished to an individual on the basis of a referral that would 
result in the denial of payment for the service under subchapter XVIII 
of this chapter if such subchapter provided for coverage of such service 
to the same extent and under the same terms and conditions as under the 
State plan, and subsections (f) and (g)(5) of such section shall apply 
to a provider of such a designated health service for which payment may 
be made under this subchapter in the same manner as such subsections 
apply to a provider of such a service for which payment may be made 
under such subchapter.

(t) Repealed. Pub. L. 97-35, title XXI, Sec. 2161(c)(2), Aug. 13, 1981, 
        95 Stat. 805, as amended by Pub. L. 97-248, title I, 
        Sec. 137(a)(2), Sept. 3, 1982, 96 Stat. 376

(u) Limitation of Federal financial participation in erroneous medical 
        assistance expenditures

    (1)(A) Notwithstanding subsection (a)(1) of this section, if the 
ratio of a State's erroneous excess payments for medical assistance (as 
defined in subparagraph (D)) to its total expenditures for medical 
assistance under the State plan approved under this subchapter exceeds 
0.03, for the period consisting of the third and fourth quarters of 
fiscal year 1983, or for any full fiscal year thereafter, then the 
Secretary shall make no payment for such period or fiscal year with 
respect to so much of such erroneous excess payments as exceeds such 
allowable error rate of 0.03.
    (B) The Secretary may waive, in certain limited cases, all or part 
of the reduction required under subparagraph (A) with respect to any 
State if such State is unable to reach the allowable error rate for a 
period or fiscal year despite a good faith effort by such State.
    (C) In estimating the amount to be paid to a State under subsection 
(d) of this section, the Secretary shall take into consideration the 
limitation on Federal financial participation imposed by subparagraph 
(A) and shall reduce the estimate he makes under subsection (d)(1) of 
this section, for purposes of payment to the State under subsection 
(d)(3) of this section, in light of any expected erroneous excess 
payments for medical assistance (estimated in accordance with such 
criteria, including sampling procedures, as he may prescribe and subject 
to subsequent adjustment, if necessary, under subsection (d)(2) of this 
section).
    (D)(i) For purposes of this subsection, 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.

    (ii) In determining the amount of erroneous excess payments for 
medical assistance to an ineligible individual or family under clause 
(i)(I), if such ineligibility is the result of an error in determining 
the amount of the resources of such individual or family, the amount of 
the erroneous excess payment shall be the smaller of (I) the amount of 
the payment with respect to such individual or family, or (II) the 
difference between the actual amount of such resources and the allowable 
resource level established under the State plan.
    (iii) In determining the amount of erroneous excess payments for 
medical assistance to an individual or family under clause (i)(II), the 
amount of the erroneous excess payment shall be the smaller of (I) the 
amount of the payment on behalf of the individual or family, or (II) the 
difference between the actual amount incurred for medical care by the 
individual or family and the amount which should have been incurred in 
order to establish eligibility for medical assistance.
    (iv) In determining the amount of erroneous excess payments, there 
shall not be included any error resulting from a failure of an 
individual to cooperate or give correct information with respect to 
third-party liability as required under section 1396k(a)(1)(C) or 
602(a)(26)(C) \10\ of this title or with respect to payments made in 
violation of section 1396e of this title.
---------------------------------------------------------------------------
    \10\ See References in Text note below.
---------------------------------------------------------------------------
    (v) In determining the amount of erroneous excess payments, there 
shall not be included any erroneous payments made for ambulatory 
prenatal care provided during a presumptive eligibility period (as 
defined in section 1396r-1(b)(1) of this title) or for items and 
services described in subsection (a) of section 1396r-1a of this title 
provided to a child during a presumptive eligibility period under such 
section.
    (E) For purposes of subparagraph (D), there shall be excluded, in 
determining both erroneous excess payments for medical assistance and 
total expenditures for medical assistance--
        (i) payments with respect to any individual whose eligibility 
    therefor was determined exclusively by the Secretary under an 
    agreement pursuant to section 1383c of this title and such other 
    classes of individuals as the Secretary may by regulation prescribe 
    whose eligibility was determined in part under such an agreement; 
    and
        (ii) payments made as the result of a technical error.

    (2) The State agency administering the plan approved under this 
subchapter shall, at such times and in such form as the Secretary may 
specify, provide information on the rates of erroneous excess payments 
made (or expected, with respect to future periods specified by the 
Secretary) in connection with its administration of such plan, together 
with any other data he requests that are reasonably necessary for him to 
carry out the provisions of this subsection.
    (3)(A) If a State fails to cooperate with the Secretary in providing 
information necessary to carry out this subsection, the Secretary, 
directly or through contractual or such other arrangements as he may 
find appropriate, shall establish the error rates for that State on the 
basis of the best data reasonably available to him and in accordance 
with such techniques for sampling and estimating as he finds 
appropriate.
    (B) In any case in which it is necessary for the Secretary to 
exercise his authority under subparagraph (A) to determine a State's 
error rates for a fiscal year, the amount that would otherwise be 
payable to such State under this subchapter for quarters in such year 
shall be reduced by the costs incurred by the Secretary in making 
(directly or otherwise) such determination.
    (4) This subsection shall not apply with respect to Puerto Rico, 
Guam, the Virgin Islands, the Northern Mariana Islands, or American 
Samoa.

(v) Medical assistance to aliens not lawfully admitted for permanent 
        residence

    (1) Notwithstanding the preceding provisions of this section, except 
as provided in paragraph (2), no payment may be made to a State under 
this section for medical assistance furnished to an alien who is not 
lawfully admitted for permanent residence or otherwise permanently 
residing in the United States under color of law.
    (2) Payment shall be made under this section for care and services 
that are furnished to an alien described in paragraph (1) only if--
        (A) such care and services are necessary for the treatment of an 
    emergency medical condition of the alien,
        (B) such alien otherwise meets the eligibility requirements for 
    medical assistance under the State plan approved under this 
    subchapter (other than the requirement of the receipt of aid or 
    assistance under subchapter IV of this chapter, supplemental 
    security income benefits under subchapter XVI of this chapter, or a 
    State supplementary payment), and
        (C) such care and services are not related to an organ 
    transplant procedure.

    (3) For purposes of this subsection, the term ``emergency medical 
condition'' means a medical condition (including emergency labor and 
delivery) manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that the absence of immediate medical 
attention could reasonably be expected to result in--
        (A) placing the patient's health in serious jeopardy,
        (B) serious impairment to bodily functions, or
        (C) serious dysfunction of any bodily organ or part.

(w) Prohibition on use of voluntary contributions, and limitation on use 
        of provider-specific taxes to obtain Federal financial 
        participation under medicaid

    (1)(A) Notwithstanding the previous provisions of this section, for 
purposes of determining the amount to be paid to a State (as defined in 
paragraph (7)(D)) under subsection (a)(1) of this section for quarters 
in any fiscal year, the total amount expended during such fiscal year as 
medical assistance under the State plan (as determined without regard to 
this subsection) shall be reduced by the sum of any revenues received by 
the State (or by a unit of local government in the State) during the 
fiscal year--
        (i) from provider-related donations (as defined in paragraph 
    (2)(A)), other than--
            (I) bona fide provider-related donations (as defined in 
        paragraph (2)(B)), and
            (II) donations described in paragraph (2)(C);

        (ii) from health care related taxes (as defined in paragraph 
    (3)(A)), other than broad-based health care related taxes (as 
    defined in paragraph (3)(B));
        (iii) from a broad-based health care related tax, if there is in 
    effect a hold harmless provision (described in paragraph (4)) with 
    respect to the tax; or
        (iv) only with respect to State fiscal years (or portions 
    thereof) occurring on or after January 1, 1992, and before October 
    1, 1995, from broad-based health care related taxes to the extent 
    the amount of such taxes collected exceeds the limit established 
    under paragraph (5).

    (B) Notwithstanding the previous provisions of this section, for 
purposes of determining the amount to be paid to a State under 
subsection (a)(7) of this section for all quarters in a Federal fiscal 
year (beginning with fiscal year 1993), the total amount expended during 
the fiscal year for administrative expenditures under the State plan (as 
determined without regard to this subsection) shall be reduced by the 
sum of any revenues received by the State (or by a unit of local 
government in the State) during such quarters from donations described 
in paragraph (2)(C), to the extent the amount of such donations exceeds 
10 percent of the amounts expended under the State plan under this 
subchapter during the fiscal year for purposes described in paragraphs 
(2), (3), (4), (6), and (7) of subsection (a) of this section.
    (C)(i) Except as otherwise provided in clause (ii), subparagraph 
(A)(i) shall apply to donations received on or after January 1, 1992.
    (ii) Subject to the limits described in clause (iii) and 
subparagraph (E), subparagraph (A)(i) shall not apply to donations 
received before the effective date specified in subparagraph (F) if such 
donations are received under programs in effect or as described in State 
plan amendments or related documents submitted to the Secretary by 
September 30, 1991, and applicable to State fiscal year 1992, as 
demonstrated by State plan amendments, written agreements, State budget 
documentation, or other documentary evidence in existence on that date.
    (iii) In applying clause (ii) in the case of donations received in 
State fiscal year 1993, the maximum amount of such donations to which 
such clause may be applied may not exceed the total amount of such 
donations received in the corresponding period in State fiscal year 1992 
(or not later than 5 days after the last day of the corresponding 
period).
    (D)(i) Except as otherwise provided in clause (ii), subparagraphs 
(A)(ii) and (A)(iii) shall apply to taxes received on or after January 
1, 1992.
    (ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to 
impermissible taxes (as defined in clause (iii)) received before the 
effective date specified in subparagraph (F) to the extent the taxes 
(including the tax rate or base) were in effect, or the legislation or 
regulations imposing such taxes were enacted or adopted, as of November 
22, 1991.
    (iii) In this subparagraph and subparagraph (E), 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.
    (ii) In no case may the total amount of donations and taxes 
permitted under the exception provided in subparagraphs (C)(ii) and 
(D)(ii) for State fiscal year 1993 exceed the limit under paragraph (5) 
minus the total amount of broad-based health care related taxes received 
in that fiscal year.
    (F) In this paragraph in the case of a State--
        (i) except as provided in clause (iii), with a State fiscal year 
    beginning on or before July 1, the effective date is October 1, 
    1992,
        (ii) except as provided in clause (iii), with a State fiscal 
    year that begins after July 1, the effective date is January 1, 
    1993, or
        (iii) with a State legislature which is not scheduled to have a 
    regular legislative session in 1992, with a State legislature which 
    is not scheduled to have a regular legislative session in 1993, or 
    with a provider-specific tax enacted on November 4, 1991, the 
    effective date is July 1, 1993.

    (2)(A) In this subsection (except as provided in paragraph (6)), 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) of this section.

    (B) For purposes of paragraph (1)(A)(i)(I), the term ``bona fide 
provider-related donation'' means a provider-related donation that has 
no direct or indirect relationship (as determined by the Secretary) to 
payments made under this subchapter to that provider, to providers 
furnishing the same class of items and services as that provider, or to 
any related entity, as established by the State to the satisfaction of 
the Secretary. The Secretary may by regulation specify types of 
provider-related donations described in the previous sentence that will 
be considered to be bona fide provider-related donations.
    (C) For purposes of paragraph (1)(A)(i)(II), donations described in 
this subparagraph are funds expended by a hospital, clinic, or similar 
entity for the direct cost (including costs of training and of preparing 
and distributing outreach materials) of State or local agency personnel 
who are stationed at the hospital, clinic, or entity to determine the 
eligibility of individuals for medical assistance under this subchapter 
and to provide outreach services to eligible or potentially eligible 
individuals.
    (3)(A) In this subsection (except as provided in paragraph (6)), 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, the term ``broad-based health care related 
tax'' means a health care related tax which is imposed with respect to a 
class of health care items or services (as described in paragraph 
(7)(A)) or with respect to providers of such items or services and 
which, except as provided in subparagraphs (D), (E), and (F)--
        (i) is imposed at least with respect to all items or services in 
    the class furnished by all non-Federal, nonpublic providers in the 
    State (or, in the case of a tax imposed by a unit of local 
    government, the area over which the unit has jurisdiction) or is 
    imposed with respect to all non-Federal, nonpublic providers in the 
    class; and
        (ii) is imposed uniformly (in accordance with subparagraph (C)).

    (C)(i) Subject to clause (ii), for purposes of subparagraph (B)(ii), 
a tax is considered to be imposed uniformly if--
        (I) in the case of a tax consisting of a licensing fee or 
    similar tax on a class of health care items or services (or 
    providers of such items or services), the amount of the tax imposed 
    is the same for every provider providing items or services within 
    the class;
        (II) in the case of a tax consisting of a licensing fee or 
    similar tax imposed on a class of health care items or services (or 
    providers of such services) on the basis of the number of beds 
    (licensed or otherwise) of the provider, the amount of the tax is 
    the same for each bed of each provider of such items or services in 
    the class;
        (III) in the case of a tax based on revenues or receipts with 
    respect to a class of items or services (or providers of items or 
    services) the tax is imposed at a uniform rate for all items and 
    services (or providers of such items or services) in the class on 
    all the gross revenues or receipts, or net operating revenues, 
    relating to the provision of all such items or services (or all such 
    providers) in the State (or, in the case of a tax imposed by a unit 
    of local government within the State, in the area over which the 
    unit has jurisdiction); or
        (IV) in the case of any other tax, the State establishes to the 
    satisfaction of the Secretary that the tax is imposed uniformly.

    (ii) Subject to subparagraphs (D) and (E), a tax imposed with 
respect to a class of health care items and services is not considered 
to be imposed uniformly if the tax provides for any credits, exclusions, 
or deductions which have as their purpose or effect the return to 
providers of all or a portion of the tax paid in a manner that is 
inconsistent with subclauses (I) and (II) of subparagraph (E)(ii) or 
provides for a hold harmless provision described in paragraph (4).
    (D) A tax imposed with respect to a class of health care items and 
services is considered to be imposed uniformly--
        (i) notwithstanding that the tax is not imposed with respect to 
    items or services (or the providers thereof) for which payment is 
    made under a State plan under this subchapter or subchapter XVIII of 
    this chapter, or
        (ii) in the case of a tax described in subparagraph (C)(i)(III), 
    notwithstanding that the tax provides for exclusion (in whole or in 
    part) of revenues or receipts from a State plan under this 
    subchapter or subchapter XVIII of this chapter.

    (E)(i) A State may submit an application to the Secretary requesting 
that the Secretary treat a tax as a broad-based health care related tax, 
notwithstanding that the tax does not apply to all health care items or 
services in class (or all providers of such items and services), 
provides for a credit, deduction, or exclusion, is not applied 
uniformly, or otherwise does not meet the requirements of subparagraph 
(B) or (C). Permissible waivers may include exemptions for rural or 
sole-community providers.
    (ii) The Secretary shall approve such an application if the State 
establishes to the satisfaction of the Secretary that--
        (I) the net impact of the tax and associated expenditures under 
    this subchapter as proposed by the State is generally redistributive 
    in nature, and
        (II) the amount of the tax is not directly correlated to 
    payments under this subchapter for items or services with respect to 
    which the tax is imposed.

The Secretary shall by regulation specify types of credits, exclusions, 
and deductions that will be considered to meet the requirements of this 
subparagraph.
    (F) In no case shall a tax not qualify as a broad-based health care 
related tax under this paragraph because it does not apply to a hospital 
that is described in section 501(c)(3) of the Internal Revenue Code of 
1986 and exempt from taxation under section 501(a) of such Code and that 
does not accept payment under the State plan under this subchapter or 
under subchapter XVIII of this chapter.
    (4) For purposes of paragraph (1)(A)(iii), there is in effect a hold 
harmless provision with respect to a broad-based health care related tax 
imposed with respect to a class of items or services if the Secretary 
determines that any of the following applies:
        (A) The State or other unit of government imposing the tax 
    provides (directly or indirectly) for a payment (other than under 
    this subchapter) to taxpayers and the amount of such payment is 
    positively correlated either to the amount of such tax or to the 
    difference between the amount of the tax and the amount of payment 
    under the State plan.
        (B) All or any portion of the payment made under this subchapter 
    to the taxpayer varies based only upon the amount of the total tax 
    paid.
        (C) The State or other unit of government imposing the tax 
    provides (directly or indirectly) for any payment, offset, or waiver 
    that guarantees to hold taxpayers harmless for any portion of the 
    costs of the tax.

The provisions of this paragraph shall not prevent use of the tax to 
reimburse health care providers in a class for expenditures under this 
subchapter nor preclude States from relying on such reimbursement to 
justify or explain the tax in the legislative process.
    (5)(A) For purposes of this subsection, the limit under this 
subparagraph with respect to a State is an amount equal to 25 percent 
(or, if greater, the State base percentage, as defined in subparagraph 
(B)) of the non-Federal share of the total amount expended under the 
State plan during a State fiscal year (or portion thereof), as it would 
be determined pursuant to paragraph (1)(A) without regard to paragraph 
(1)(A)(iv).
    (B)(i) In subparagraph (A), 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.

    (ii) For purposes of clause (i)(I), in the case of a tax that is not 
in effect throughout State fiscal year 1992 or the rate (or base) of 
which is increased during such fiscal year, the Secretary shall project 
the amount to be collected during such fiscal year as if the tax (or 
increase) were in effect during the entire State fiscal year.
    (C)(i) The total amount of health care related taxes under 
subparagraph (B)(i)(I) shall be determined by the Secretary based on 
only those taxes (including the tax rate or base) which were in effect, 
or for which legislation or regulations imposing such taxes were enacted 
or adopted, as of November 22, 1991.
    (ii) The amount of provider-related donations under subparagraph 
(B)(i)(I) shall be determined by the Secretary based on programs in 
effect on September 30, 1991, and applicable to State fiscal year 1992, 
as demonstrated by State plan amendments, written agreements, State 
budget documentation, or other documentary evidence in existence on that 
date.
    (iii) The amount of expenditures described in subparagraph 
(B)(i)(II) shall be determined by the Secretary based on the best data 
available as of December 12, 1991.
    (6)(A) Notwithstanding the provisions of this subsection, the 
Secretary may not restrict States' use of funds where such funds are 
derived from State or local taxes (or funds appropriated to State 
university teaching hospitals) transferred from or certified by units of 
government within a State as the non-Federal share of expenditures under 
this subchapter, regardless of whether the unit of government is also a 
health care provider, except as provided in section 1396a(a)(2) of this 
title, unless the transferred funds are derived by the unit of 
government from donations or taxes that would not otherwise be 
recognized as the non-Federal share under this section.
    (B) For purposes of this subsection, funds the use of which the 
Secretary may not restrict under subparagraph (A) shall not be 
considered to be a provider-related donation or a health care related 
tax.
    (7) For purposes of this subsection:
        (A) Each of the following shall be considered a separate class 
    of health care items and services:
            (i) Inpatient hospital services.
            (ii) Outpatient hospital services.
            (iii) Nursing facility services (other than services of 
        intermediate care facilities for the mentally retarded).
            (iv) Services of intermediate care facilities for the 
        mentally retarded.
            (v) Physicians' services.
            (vi) Home health care services.
            (vii) Outpatient prescription drugs.
            (viii) Services of a medicaid managed care organization with 
        a contract under subsection (m) of this section.
            (ix) Such other classification of health care items and 
        services consistent with this subparagraph as the Secretary may 
        establish by regulation.

        (B) 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.

        (D) 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.
        (F) 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).
        (G) 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.

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1903, as added Pub. L. 89-97, 
title I, Sec. 121(a), July 30, 1965, 79 Stat. 349; amended Pub. L. 90-
248, title II, Secs. 220(a), 222(c), (d), 225(a), 229(c), 241(f)(5), 
Jan. 2, 1968, 81 Stat. 898, 901, 902, 904, 917; Pub. L. 90-364, title 
III, Sec. 303(a)(1), June 28, 1968, 82 Stat. 274; Pub. L. 91-56, 
Sec. 2(a), Aug. 9, 1969, 83 Stat. 99; Pub. L. 92-603, title II, 
Secs. 207(a), 221(c)(6), 224(c), 225, 226(e), 229(c), 230, 233(c), 
235(a), 237(a)(1), 249B, 278(b)(1), (5), (7), (16), 290, 295, 299E(a), 
Oct. 30, 1972, 86 Stat. 1379, 1389, 1395, 1396, 1404, 1410, 1411, 1414, 
1415, 1428, 1453, 1454, 1457, 1459, 1462; Pub. L. 93-66, title II, 
Sec. 234(a), July 9, 1973, 87 Stat. 160; Pub. L. 93-233, 
Secs. 13(a)(11), (12), 18(r)-(v), (x)(5), (6), (y)(1), Dec. 31, 1973, 87 
Stat. 963, 971-973; Pub. L. 94-182, title I, Secs. 110(a), 111(b), Dec. 
31, 1975, 89 Stat. 1054; Pub. L. 94-460, title II, Sec. 202(a), Oct. 8, 
1976, 90 Stat. 1957; Pub. L. 94-552, Sec. 1, Oct. 18, 1976, 90 Stat. 
2540; Pub. L. 95-83, title I, Sec. 105(a)(1), (2), Aug. 1, 1977, 91 
Stat. 384; Pub. L. 95-142, Secs. 3(c)(2), 8(c), 10(a), 11(a), 17(a)-(c), 
20(a), Oct. 25, 1977, 91 Stat. 1179, 1195, 1196, 1201, 1205; Pub. L. 95-
559, Sec. 14(c), Nov. 1, 1978, 92 Stat. 2141; Pub. L. 95-626, title I, 
Sec. 102(b)(3), Nov. 10, 1978, 92 Stat. 3551; Pub. L. 96-79, title I, 
Sec. 128, Oct. 4, 1979, 93 Stat. 629; Pub. L. 96-398, title IX, 
Sec. 901, Oct. 7, 1980, 94 Stat. 1609; Pub. L. 96-499, title IX, 
Secs. 905(b), (c), 961(a), 963, 964, Dec. 5, 1980, 94 Stat. 2618, 2650, 
2651; Pub. L. 97-35, title XXI, Secs. 2101(a)(2), 2103(b)(1), 
2106(b)(3), 2113(n), 2161, 2163, 2164(a), 2174(b), 2178(a), 2183(a), 
Aug. 13, 1981, 95 Stat. 786, 788, 792, 795, 803-806, 809, 813, 816; Pub. 
L. 97-248, title I, Secs. 133(a), 137(a)(1), (2), (b)(11)-(16), (27), 
(g), 146(b), Sept. 3, 1982, 96 Stat. 373, 376, 378, 379, 381, 394; Pub. 
L. 97-448, title III, Sec. 309(b)(16), Jan. 12, 1983, 96 Stat. 2409; 
Pub. L. 98-369, div. B, title III, Secs. 2303(g)(2), 2363(a)(2), (4), 
(b), 2364, 2373(b)(11)-(14), July 18, 1984, 98 Stat. 1066, 1106, 1107, 
1111, 1112; Pub. L. 98-617, Sec. 3(a)(6), Nov. 8, 1984, 98 Stat. 3295; 
Pub. L. 99-272, title IX, Secs. 9503(b), (f), 9507(a), 9512(a), 9517(a), 
(c)(1), 9518(a), Apr. 7, 1986, 100 Stat. 206, 207, 210, 212, 215, 216; 
Pub. L. 99-509, title IX, Secs. 9401(e)(2), 9403(g)(2), 9406(a), 
9407(c), 9431(b)(2), 9434(a)(1), (2), (b), Oct. 21, 1986, 100 Stat. 
2052, 2055, 2057, 2060, 2066, 2068, 2069; Pub. L. 99-514, title XVIII, 
Sec. 1895(c)(2), Oct. 22, 1986, 100 Stat. 2935; Pub. L. 99-603, title I, 
Sec. 121(b)(2), Nov. 6, 1986, 100 Stat. 3390; Pub. L. 100-93, Sec. 8(g), 
(h)(1), Aug. 18, 1987, 101 Stat. 694; Pub. L. 100-203, title IV, 
Secs. 4112(b), 4113(a)(1), (b)(3), (d)(1), 4118(d)(1), (e)(11), (h)(1), 
(p)(5), 4211(d)(1), (g), (i), 4212(c)(1), (2), (d)(1), (e)(2), 
4213(b)(2), Dec. 22, 1987, 101 Stat. 1330-149, 1330-150, 1330-152, 1330-
155, 1330-159, 1330-204, 1330-205, 1330-207, 1330-212, 1330-213, 1330-
219, as amended Pub. L. 100-360, title IV, Sec. 411(a)(3)(A), (B)(iii), 
(k)(6)(B)(x), (7)(A), (D), (10)(D), (G)(ii), July 1, 1988, 102 Stat. 
768, 794, 796; Pub. L. 100-360, title II, Sec. 202(h)(2), title III, 
Secs. 301(f), 302(c)(3), (e)(4), title IV, Sec. 411(k)(12)(A), (13)(A), 
July 1, 1988, 102 Stat. 718, 750, 752, 753, 797, 798; Pub. L. 100-485, 
title VI, Sec. 608(d)(26)(K)(ii), (f)(4), Oct. 13, 1988, 102 Stat. 2422, 
2424; Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 
1981; Pub. L. 101-239, title VI, Secs. 6401(b), 6411(d)(2), 
6901(b)(5)(A), Dec. 19, 1989, 103 Stat. 2259, 2271, 2299; Pub. L. 101-
508, title IV, Secs. 4401(a)(1), (b)(1), 4402(b), (d)(3), 4601(a)(3)(A), 
4701(b)(2), 4704(b)(1), (2), 4711(c)(2), 4723(a), 4731(a), (b)(2), 
4732(a), (b)(2), (c), (d), 4751(b)(1), 4752(a)(2), (b)(1), (e), 
4801(a)(8), (e)(16)(A), Nov. 5, 1990, 104 Stat. 1388-143, 1388-159, 
1388-163, 1388-164, 1388-166, 1388-170, 1388-172, 1388-187, 1388-194 to 
1388-196, 1388-205 to 1388-207, 1388-212, 1388-218; Pub. L. 102-119, 
Sec. 26(i)(1), Oct. 7, 1991, 105 Stat. 607; Pub. L. 102-234, Secs. 2(a), 
(b)(2), 3(b)(2)(B), 4(a), Dec. 12, 1991, 105 Stat. 1793, 1799, 1803, 
1804; Pub. L. 103-66, title XIII, Secs. 13602(b), 13604(a), 13622(a)(2), 
13624(a), 13631(c), (h)(1), Aug. 10, 1993, 107 Stat. 619, 621, 632, 636, 
643, 645; Pub. L. 104-193, title I, Sec. 114(d)(2), Aug. 22, 1996, 110 
Stat. 2180; Pub. L. 104-248, Sec. 1(b)(1), Oct. 9, 1996, 110 Stat. 3148; 
Pub. L. 105-12, Sec. 9(b)(1), Apr. 30, 1997, 111 Stat. 26; Pub. L. 105-
33, title IV, Secs. 4701(b)(1), (2)(A)(v)-(viii), (B), (C), (c), (d)(2), 
4702(b)(1), 4703(a), (b)(1), 4705(b), 4706, 4707(b), 4708(a), (d), 
4712(b)(2), (c)(2), 4722(a), (b), 4724(a), (b)(1), 4742(a), 4753(a), 
4802(b)(2), 4912(b)(2), Aug. 5, 1997, 111 Stat. 492, 493, 495, 500, 501, 
505, 506, 509, 514-516, 523, 525, 549, 573; Pub. L. 105-100, title I, 
Sec. 162(4), Nov. 19, 1997, 111 Stat. 2189; Pub. L. 106-31, title III, 
Sec. 3031(a), (b), May 21, 1999, 113 Stat. 103, 104; Pub. L. 106-113, 
div. B, Sec. 1000(a)(6) [title VI, Secs. 604(a)(2)(B), (b)(2), 608(e)-
(k), (aa)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-395, 1501A-397, 
1501A-398; Pub. L. 106-170, title II, Sec. 201(a)(4), (b), title IV, 
Sec. 407(a)-(c), Dec. 17, 1999, 113 Stat. 1893, 1913.)

                   Repeal of Subsection (m)(2)(A)(ix)

        Pub. L. 105-33, title IV, Sec. 4712(c)(2), Aug. 5, 1997, 111 
    Stat. 509, provided that, effective for services furnished on or 
    after Oct. 1, 2004, subsection (m)(2)(A)(ix) of this section is 
    repealed.

                       References in Text

    Parts A and B of subchapter XVIII of this chapter, referred to in 
subsecs. (b) and (i), are classified to sections 1395c et seq. and 1395j 
et seq., respectively, of this title.
    Subsection (w)(3)(A) of this section, referred to in subsec. (b)(5), 
was in the original ``section 1902(w)(3)(A)'', and was translated as 
reading ``section 1903(w)(3)(A)'', meaning section 1903(w)(3)(A) of the 
Social Security Act, to reflect the probable intent of Congress, because 
section 1902(w)(3), which is classified to section 1396a(w)(3) of this 
title, does not contain a subpar. (A), and subsec. (w)(3)(A) of this 
section relates to health care related taxes.
    The Individuals with Disabilities Education Act, referred to in 
subsec. (c), is title VI of Pub. L. 91-230, Apr. 13, 1970, 84 Stat. 175, 
as amended. Part B of the Act is classified generally to subchapter II 
(Sec. 1411 et seq.) of chapter 33 of Title 20, Education. Part H of the 
Act was classified generally to subchapter VIII (Sec. 1471 et seq.) of 
chapter 33 of Title 20, prior to repeal by Pub. L. 105-17, title II, 
Sec. 203(b), June 4, 1997, 111 Stat. 157, effective July 1, 1998. For 
complete classification of this Act to the Code, see section 1400 of 
Title 20 and Tables.
    Part A of subchapter IV of this chapter, referred to in subsec. (f), 
is classified to section 601 et seq. of this title.
    Section 300e-9(d) of this title, referred to in subsecs. (g)(1) and 
(m)(1)(A), (4)(A), was redesignated section 300e-9(c) of this title by 
Pub. L. 100-517, Sec. 7(b), Oct. 24, 1988, 102 Stat. 2580.
    The Assisted Suicide Funding Restriction Act of 1997, referred to in 
subsec. (i)(16), is Pub. L. 105-12, Apr. 30, 1997, 111 Stat. 23, which 
is classified principally to chapter 138 (Sec. 14401 et seq.) of this 
title. For complete classification of this Act to the Code, see Short 
Title note set out under section 14401 of this title and Tables.
    Part C of subchapter XVIII of this chapter, referred to in subsec. 
(m)(1)(A), is classified to section 1395w-21 et seq. of this title.
    Sections 254b and 254c of this title, referred to in subsec. 
(m)(2)(B)(i)(I), (G), were in the original references to sections 329 
and 330 of the Public Health Service Act, act July 1, 1944, which were 
omitted in the general amendment of subpart I (Sec. 254b et seq.) of 
part D of subchapter II of chapter 6A of this title by Pub. L. 104-299, 
Sec. 2, Oct. 11, 1996, 110 Stat. 3626. Sections 2 and 3(a) of Pub. L. 
104-299 enacted new sections 330 and 330A of act July 1, 1944, which are 
classified, respectively, to sections 254b and 254c of this title.
    The Appalachian Regional Development Act of 1965, referred to in 
subsec. (m)(2)(B)(ii), (G), is Pub. L. 89-4, Mar. 9, 1965, 79 Stat. 5, 
as amended, which is set out in the Appendix to Title 40, Public 
Buildings, Property, and Works. For complete classification of this Act 
to the Code, see Tables.
    Part C of subchapter XI of this chapter, referred to in subsec. 
(r)(1)(D), is classified to section 1320d et seq. of this title.
    Section 602 of this title, referred to in subsec. (u)(1)(D)(iv), was 
repealed and a new section 602 enacted by Pub. L. 104-193, title I, 
Sec. 103(a)(1), Aug. 22, 1996, 110 Stat. 2112, and, as so enacted, no 
longer contains a subsec. (a)(26)(C).
    The Internal Revenue Code of 1986, referred to in subsecs. 
(d)(3)(B)(i) and (w)(3)(F), is classified generally to Title 26, 
Internal Revenue Code.


                               Amendments

    1999--Subsec. (a)(3)(C)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title 
VI, Sec. 604(a)(2)(B)], struck out ``or quality review'' after ``medical 
and utilization review''.
    Subsec. (b)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(e)], inserted ``of'' after ``for the use'' in introductory 
provisions.
    Subsec. (d)(3). Pub. L. 106-31, Sec. 3031(a), designated existing 
provisions as subpar. (A) and added subpar. (B).
    Subsec. (d)(3)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(f)], realigned margins.
    Subsec. (f)(2). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(g)], struck out second period at end.
    Subsec. (f)(4). Pub. L. 106-170, Sec. 201(b), inserted 
``1396a(a)(10)(A)(ii)(XV), 1396a(a)(10)(A)(ii)(XVI),'' before 
``1396d(p)(1)'' in introductory provisions.
    Pub. L. 106-113, Sec. 1000(a)(6) [title VI, Sec. 608(aa)(2)], 
substituted ``1396a(a)(10)(A)(ii)(XIII), 1396a(a)(10)(A)(ii)(XIV), or 
1396d(p)(1) of this title'' for ``1396d(p)(1), or 1396d(u) of this 
title'' in introductory provisions.
    Subsec. (i)(14). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(h)], inserted ``or'' after semicolon.
    Subsec. (i)(19). Pub. L. 106-31, Sec. 3031(b), added par. (19).
    Subsec. (i)(20). Pub. L. 106-170, Sec. 201(a)(4), added par. (20).
    Subsec. (m)(2)(A)(vi). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(i)(1)], struck out semicolon after ``section 1396u-2(a)(4) of 
this title''.
    Subsec. (m)(2)(A)(xi), (xii). Pub. L. 106-113, Sec. 1000(a)(6) 
[title VI, Sec. 608(i)(2)], redesignated cl. (xi), relating to section 
1396u-2, as (xii).
    Subsec. (m)(6)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 604(b)(2)(A)], inserted ``and'' at end.
    Subsec. (m)(6)(B)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 604(b)(2)(B)], substituted a period for ``; and'' at end.
    Subsec. (m)(6)(B)(iv). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 604(b)(2)(C)], struck out cl. (iv) which read as follows: ``that 
the State agency will contract, for purposes of meeting the requirement 
under section 1396a(a)(30)(C) of this title, with an organization or 
entity that under section 1320c-3 of this title reviews services 
provided by an eligible organization pursuant to a contract under 
section 1395mm of this title for the purpose of determining whether the 
quality of services meets professionally recognized standards of health 
care.''
    Subsec. (o). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(j)], struck out second closing parenthesis after ``section 
1167(1) of title 29''.
    Subsec. (q)(3). Pub. L. 106-170, Sec. 407(a), inserted ``(A)'' after 
``in connection with'' and added subpar. (B).
    Subsec. (q)(4). Pub. L. 106-170, Sec. 407(c), amended par. (4) 
generally. Prior to amendment, par. (4) read as follows: ``The entity 
has procedures for reviewing complaints of the abuse and neglect of 
patients of health care facilities which receive payments under the 
State plan under this subchapter, and, where appropriate, for acting 
upon such complaints under the criminal laws of the State or for 
referring them to other State agencies for action.''
    Subsec. (q)(5). Pub. L. 106-170, Sec. 407(b), inserted ``or under 
any Federal health care program (as so defined)'' before ``to health 
care facilities'' and inserted at end ``All funds collected in 
accordance with this paragraph shall be credited exclusively to, and 
available for expenditure under, the Federal health care program 
(including the State plan under this subchapter) that was subject to the 
activity that was the basis for the collection.''
    Subsec. (w)(1)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(k)(1)], substituted ``purposes'' for ``puroses''.
    Subsec. (w)(3)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(k)(2)], inserted a comma after ``(D)'' in introductory 
provisions.
    Subsec. (w)(7)(A)(viii). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(k)(3)], realigned margins.
    1997--Subsec. (a)(3)(C). Pub. L. 105-33, Sec. 4705(b), designated 
existing provisions as cl. (i) and added cl. (ii).
    Subsec. (b)(4). Pub. L. 105-33, Sec. 4707(b), added par. (4).
    Subsec. (b)(5). Pub. L. 105-33, Sec. 4722(b), added par. (5).
    Subsec. (f)(4). Pub. L. 105-100 substituted ``1396d(p)(1), or 
1396d(u) of this title'' for ``or 1396d(p)(1) of this title'' in 
introductory provisions.
    Subsec. (f)(4)(C). Pub. L. 105-33, Sec. 4802(b)(2), inserted ``or 
who is a PACE program eligible individual enrolled in a PACE program 
under section 1396u-4 of this title,'' after ``section 1396a(a)(10)(A) 
of this title,''.
    Subsec. (i). Pub. L. 105-33, Sec. 4708(d), inserted at end of 
closing provisions ``Paragraphs (1), (2), (16), (17), and (18) shall 
apply with respect to items or services furnished and amounts expended 
by or through a managed care entity (as defined in section 1396u-
2(a)(1)(B) of this title) in the same manner as such paragraphs apply to 
items or services furnished and amounts expended directly by the 
State.''
    Subsec. (i)(2). Pub. L. 105-33, Sec. 4724(a)(1), substituted ``; 
or'' for the period at end.
    Subsec. (i)(10)(B), (11). Pub. L. 105-33, Sec. 4724(a)(2), inserted 
``or'' at end.
    Subsec. (i)(12). Pub. L. 105-33, Sec. 4742(a), struck out par. (12) 
which related to restrictions on payments, on or after Jan. 1, 1992, for 
physicians' services to children under 21 years of age and to pregnant 
women.
    Subsec. (i)(13). Pub. L. 105-33, Sec. 4724(a)(2), inserted ``or'' at 
end.
    Subsec. (i)(16). Pub. L. 105-12 added par. (16).
    Subsec. (i)(17). Pub. L. 105-33, Sec. 4724(a)(1), (3), added par. 
(17).
    Subsec. (i)(18). Pub. L. 105-33, Sec. 4724(b)(1), added par. (18).
    Subsec. (k). Pub. L. 105-33, Sec. 4701(b)(2)(A)(v), substituted 
``medicaid managed care organization'' for ``health maintenance 
organization''.
    Subsec. (m)(1)(A). Pub. L. 105-33, Sec. 4701(b)(1), in introductory 
provisions, substituted ``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 of this 
chapter, a provider sponsored organization, or any other public or 
private organization, which meets the requirement of section 1396a(w) of 
this title and--'' for ``The term `health maintenance organization' 
means a public or private organization, organized under the laws of any 
State, which meets the requirement of section 1396a(w) of this title is 
a qualified health maintenance organization (as defined in section 300e-
9(d) of this title) or which meets the requirement of section 1396a(a) 
of this title and--'' and inserted as closing provisions ``An 
organization that is a qualified health maintenance organization (as 
defined in section 300e-9(d) of this title) is deemed to meet the 
requirements of clauses (i) and (ii).''
    Subsec. (m)(1)(A)(ii). Pub. L. 105-33, Sec. 4706(1), inserted ``, 
meets the requirements of subparagraph (C)(i) (if applicable),'' after 
``provision is satisfactory to the State''.
    Subsec. (m)(1)(B). Pub. L. 105-33, Sec. 4701(b)(2)(A)(vi), 
substituted ``medicaid managed care organization'' for ``health 
maintenance organization''.
    Subsec. (m)(1)(C). Pub. L. 105-33, Sec. 4706(2), added subpar. (C).
    Subsec. (m)(2)(A)(i). Pub. L. 105-33, Sec. 4701(b)(2)(A)(vii), 
substituted ``medicaid managed care organization'' for ``health 
maintenance organization''.
    Subsec. (m)(2)(A)(ii). Pub. L. 105-33, Sec. 4703(a), struck out cl. 
(ii) which read as follows: ``less than 75 percent of the membership of 
the entity which is enrolled on a prepaid basis consists of individuals 
who (I) are insured for benefits under part B of subchapter XVIII of 
this chapter or for benefits under both parts A and B of such 
subchapter, or (II) are eligible to receive benefits under this 
subchapter;''.
    Subsec. (m)(2)(A)(iii). Pub. L. 105-33, Sec. 4708(a), substituted 
``$1,000,000 for 1998 and, for a subsequent year, the amount established 
udner this clause for the previous year increased by the percentage 
increase in the consumer price index for all urban consumers over the 
previous year'' for ``$100,000''.
    Subsec. (m)(2)(A)(vi). Pub. L. 105-33, Sec. 4701(d)(2)(A), struck 
out ``except as provided under subparagraph (F),'' after ``such contract 
(I)'', substituted ``in accordance with section 1396u-2(a)(4) of this 
title;'' for ``without cause as of the beginning of the first calendar 
month following a full calendar month after the request is made for such 
termination'', and inserted ``in accordance with such section'' after 
``provides for notification''.
    Subsec. (m)(2)(A)(ix). Pub. L. 105-33, Sec. 4712(b)(2), amended cl. 
(ix) generally. Prior to amendment, cl. (ix) read as follows: ``such 
contract provides, in the case of an entity that has entered into a 
contract for the provision of services of such center with a federally 
qualified health center, that (I) rates of prepayment from the State are 
adjusted to reflect fully the rates of payment specified in section 
1396a(a)(13)(E) of this title, and (II) at the election of such center 
payments made by the entity to such a center for services described in 
1396d(a)(2)(C) of this title are made at the rates of payment specified 
in section 1396a(a)(13)(E) of this title;''.
    Subsec. (m)(2)(A)(xi). Pub. L. 105-33, Sec. 4701(c), added cl. (xi) 
relating to section 1396u-2.
    Subsec. (m)(2)(C) to (E). Pub. L. 105-33, Sec. 4703(b)(1)(A), struck 
out subpars. (C) to (E) which read as follows:
    ``(C) Subparagraph (A)(ii) shall not apply with respect to payments 
under this subchapter to a State with respect to expenditures incurred 
by it for payment for services by an entity during the three-year period 
beginning on October 8, 1976, or beginning on the date the entity 
qualifies as a health maintenance organization (as determined by the 
Secretary), whichever occurs later, but only if the entity demonstrates 
to the satisfaction of the Secretary by the submission of plans for each 
year of such three-year period that it is making continuous efforts and 
progress toward achieving compliance with subparagraph (A)(ii).
    ``(D) In the case of a health maintenance organization that is a 
public entity, the Secretary may modify or waive the requirement 
described in subparagraph (A)(ii) but only if the Secretary determines 
that the organization has taken and is taking reasonable efforts to 
enroll individuals who are not entitled to benefits under the State plan 
approved under this subchapter or under subchapter XVIII of this 
chapter.
    ``(E) In the case of a health maintenance organization that--
        ``(i) is a nonprofit organization with at least 25,000 members,
        ``(ii) is and has been a qualified health maintenance 
    organization (as defined in section 300e-9(d) of this title) for a 
    period of at least four years,
        ``(iii) provides basic health services through members of the 
    staff of the organization,
        ``(iv) is located in an area designated as medically underserved 
    under section 300e-1(7) of this title, and
        ``(v) previously received a waiver of the requirement described 
    in subparagraph (A)(ii) under section 1315 of this title,
the Secretary may modify or waive the requirement described in 
subparagraph (A)(ii) but only if the Secretary determines that special 
circumstances warrant such modification or waiver and that the 
organization has taken and is taking reasonable efforts to enroll 
individuals who are not entitled to benefits under the State plan 
approved under this subchapter or under subchapter XVIII of this 
chapter.''
    Subsec. (m)(2)(F). Pub. L. 105-33, Sec. 4701(d)(2)(B), struck out 
subpar. (F) which read as follows: ``In the case of--
        ``(i) a contract with an entity described in subparagraph (E) or 
    (G), with a qualified health maintenance organization (as defined in 
    section 300e-9(d) of this title) which meets the requirement of 
    subparagraph (A)(ii), or or with an eligible organization with a 
    contract under section 1395mm of this title which meets the 
    requirement of subparagraph (A)(ii), or
        ``(ii) a program pursuant to an undertaking described in 
    paragraph (6) in which at least 25 percent of the membership 
    enrolled on a prepaid basis are individuals who (I) are not insured 
    for benefits under part B of subchapter XVIII of this chapter or 
    eligible for benefits under this subchapter, and (II) (in the case 
    of such individuals whose prepayments are made in whole or in part 
    by any government entity) had the opportunity at the time of 
    enrollment in the program to elect other coverage of health care 
    costs that would have been paid in whole or in part by any 
    governmental entity,
a State plan may restrict the period in which requests for termination 
of enrollment without cause under subparagraph (A)(vi)(I) are permitted 
to the first month of each period of enrollment, each such period of 
enrollment not to exceed six months in duration, but only if the State 
provides notification, at least twice per year, to individuals enrolled 
with such entity or organization of the right to terminate such 
enrollment and the restriction on the exercise of this right. Such 
restriction shall not apply to requests for termination of enrollment 
for cause.''
    Subsec. (m)(2)(G). Pub. L. 105-33, Sec. 4703(b)(1)(B), substituted 
``clause (i)'' for ``clauses (i) and (ii)''.
    Subsec. (m)(2)(H). Pub. L. 105-33, Sec. 4702(b)(1)(B), in concluding 
provisions, inserted before period at end ``or with the manager 
described in such clause if the manager continues to have a contract 
described in section 1396d(t)(3) of this title with the State''.
    Pub. L. 105-33, Sec. 4701(b)(2)(B), struck out ``health 
maintenance'' before ``organization described'' in concluding 
provisions.
    Subsec. (m)(2)(H)(i). Pub. L. 105-33, Sec. 4702(b)(1)(A), inserted 
``or with a primary care case manager with a contract described in 
section 1396d(t)(3) of this title'' before comma at end.
    Pub. L. 105-33, Sec. 4701(b)(2)(A)(vii), substituted ``medicaid 
managed care organization'' for ``health maintenance organization''.
    Subsec. (m)(4)(A). Pub. L. 105-33, Sec. 4701(b)(2)(A)(viii), 
substituted ``Each medicaid managed care organization'' for ``Each 
health maintenance organization''.
    Subsec. (r)(1). Pub. L. 105-33, Sec. 4753(a)(1), added par. (1) and 
struck out former par. (1) which read as follows:
    ``(1)(A) In order to receive payments under paragraphs (2)(A) and 
(7) of subsection (a) of this section without being subject to per 
centum reductions set forth in subparagraph (C) of this paragraph, a 
State must provide that mechanized claims processing and information 
retrieval systems of the type described in subsection (a)(3)(B) of this 
section and detailed in an advance planning document approved by the 
Secretary are operational on or before the deadline established under 
subparagraph (B).
    ``(B) The deadline for operation of such systems for a State is 
September 30, 1985.
    ``(C) If a State fails to meet the deadline established under 
subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) 
of subsection (a) of this section with respect to that State shall each 
be reduced by 5 percentage points for the first two quarters beginning 
on or after such deadline, and shall be further reduced by an additional 
5 percentage points after each period consisting of two quarters during 
which the Secretary determines the State fails to meet the requirements 
of subparagraph (A); except that--
        ``(i) neither such per centum may be reduced by more than 25 
    percentage points by reason of this paragraph; and
        ``(ii) no reduction shall be made under this paragraph for any 
    quarter following the quarter during which such State meets the 
    requirements of subparagraph (A).''
    Subsec. (r)(2). Pub. L. 105-33, Sec. 4753(a)(1), (2)(B), (D), 
inserted introductory provisions, redesignated par. (5)(A)(i) to (iii) 
as par. (2)(A) to (C), and struck out former par. (2) which read as 
follows:
    ``(2)(A) In order to receive payments under paragraphs (2)(A) and 
(7) of subsection (a) of this section without being subject to the per 
centum reductions set forth in subparagraph (C) of this paragraph, a 
State must have its mechanized claims processing and information 
retrieval systems, of the type required to be operational under 
paragraph (1), initially approved by the Secretary in accordance with 
paragraph (5)(A) on or before the deadline established under 
subparagraph (B).
    ``(B) The deadline for approval of such systems for a State is the 
last day of the fourth quarter that begins after the date on which the 
Secretary determines that such systems became operational as required 
under paragraph (1).
    ``(C) If a State fails to meet the deadline established under 
subparagraph (B), the per centums specified in paragraphs (2)(A) and (7) 
of subsection (a) of this section with respect to that State shall each 
be reduced by 5 percentage points for the first two quarters beginning 
after such deadline, and shall be further reduced by an additional 5 
percentage points at the end of each period consisting of two quarters 
during which the State fails to meet the requirements of subparagraph 
(A); except that--
        ``(i) neither such per centum may be reduced by more than 25 
    percentage points by reason of this paragraph, and
        ``(ii) no reduction shall be made under this paragraph for any 
    quarter following the quarter during which such State's systems are 
    approved by the Secretary as provided in subparagraph (A).
    ``(D) Any State's systems which are approved by the Secretary for 
purposes of subsection (a)(3)(B) of this section on or before October 7, 
1980, shall be deemed to be initially approved for purposes of this 
subsection.''
    Subsec. (r)(3), (4). Pub. L. 105-33, Sec. 4753(a)(1), struck out 
pars. (3) and (4) which related to Federal matching funds and 
Secretary's periodic review of approved retrieval systems.
    Subsec. (r)(5). Pub. L. 105-33, Sec. 4753(a)(2), struck out 
introductory provisions relating to requirements for Secretary's initial 
approval of mechanized claims processing and information retrieval 
systems and struck out ``under paragraph (6)'' before period at end of 
subpar. (A)(iii), redesignated subpar. (A)(i) to (iii) as par. (2)(A) to 
(C), and struck out subpar. (B) which related to requirements for 
Secretary's reapproval of mechanized claims processing and information 
retrieval systems.
    Subsec. (r)(6) to (8). Pub. L. 105-33, Sec. 4753(a)(3), struck out 
pars. (6) to (8) which related to Secretary's development of performance 
standards for approval of State mechanized processing claims and 
information retrieval systems, waiver of certain requirements for 
initial operation, and applicability of per centum reductions in certain 
situations.
    Subsec. (u)(1)(D)(v). Pub. L. 105-33, Sec. 4912(b)(2), inserted 
before period at end ``or for items and services described in subsection 
(a) of section 1396r-1a of this title provided to a child during a 
presumptive eligibility period under such section''.
    Subsec. (w)(3)(B). Pub. L. 105-33, Sec. 4722(a)(1), substituted 
``(E), and (F)'' for ``and (E)'' in introductory provisions.
    Subsec. (w)(3)(F). Pub. L. 105-33, Sec. 4722(a)(2), added subpar. 
(F).
    Subsec. (w)(7)(A)(viii). Pub. L. 105-33, Sec. 4701(b)(2)(C), amended 
cl. (viii) generally. Prior to amendment, cl. (viii) read as follows: 
``Services of health maintenance organizations (and other organizations 
with contracts under subsection (m) of this section).''
    1996--Subsec. (i)(9). Pub. L. 104-193 struck out par. (9) which read 
as follows: ``with respect to any amount of medical assistance for 
pregnant women and children described in section 1396a(a)(10)(A)(ii)(IX) 
of this title, if the State has in effect, under its plan established 
under part A of subchapter IV of this chapter, payment levels that are 
less than the payment levels in effect under such plan on July 1, 
1987;''.
    Subsec. (i)(12)(A)(i). Pub. L. 104-248, Sec. 1(b)(1)(A), inserted 
``or is certified in family practice or pediatrics by the medical 
specialty board recognized by the American Osteopathic Association'' 
before comma at end.
    Subsec. (i)(12)(A)(vi). Pub. L. 104-248, Sec. 1(b)(1)(C)(i), (iii), 
(iv), added cl. (vi) and redesignated former cl. (vi) as (vii).
    Pub. L. 104-248, Sec. 1(b)(1)(C)(ii), inserted ``(or certified by 
the State in accordance with policies of the Secretary)'' after 
``Secretary''.
    Subsec. (i)(12)(A)(vii). Pub. L. 104-248, Sec. 1(b)(1)(C)(iii), 
redesignated cl. (vi) as (vii).
    Subsec. (i)(12)(B)(i). Pub. L. 104-248, Sec. 1(b)(1)(B), inserted 
``or is certified in family practice or obstetrics by the medical 
specialty board recognized by the American Osteopathic Association'' 
before comma at end.
    Subsec. (i)(12)(B)(vi). Pub. L. 104-248, Sec. 1(b)(1)(C)(i), (iii), 
(iv), added cl. (vi) and redesignated former cl. (vi) as (vii).
    Pub. L. 104-248, Sec. 1(b)(1)(C)(ii), inserted ``(or certified by 
the State in accordance with policies of the Secretary)'' after 
``Secretary''.
    Subsec. (i)(12)(B)(vii). Pub. L. 104-248, Sec. 1(b)(1)(C)(iii), 
redesignated cl. (vi) as (vii).
    1993--Subsec. (i)(10). Pub. L. 103-66, Sec. 13631(c)(1), which 
directed the amendment of par. (10) by striking all that follows 
``1396r-8(g) of this title'' and inserting a semicolon, could not be 
executed because ``1396r-8(g) of this title'' did not appear subsequent 
to the general amendment of par. (10) by Pub. L. 103-66, Sec. 13602(b). 
See below.
    Pub. L. 103-66, Sec. 13602(b), amended par. (10) generally. Prior to 
amendment, par. (10) read as follows: ``with respect to covered 
outpatient drugs of a manufacturer dispensed in any State unless, (A) 
except as provided in section 1396r-8(a)(3) of this title, the 
manufacturer complies with the rebate requirements of section 1396r-8(a) 
of this title with respect to the drugs so dispensed in all States, and 
(B) effective January 1, 1993, the State provides for drug use review in 
accordance with section 1396r-8(g) of this title; or''.
    Subsec. (i)(11). Pub. L. 103-66, Sec. 13631(c)(2), redesignated par. 
(12) as (11), transferred such par. to appear after par. (10), and 
substituted semicolon for period at end. Former par. (11) redesignated 
(13).
    Subsec. (i)(12). Pub. L. 103-66, Sec. 13631(c)(3), redesignated par. 
(14) as (12), transferred such par. to appear after par. (11), as 
redesignated by Pub. L. 103-66, Sec. 13631(c)(2), and substituted 
semicolon for period at end. Former par. (12) redesignated (11).
    Subsec. (i)(13). Pub. L. 103-66, Sec. 13631(c)(4), redesignated par. 
(11) as (13), transferred such par. to appear after par. (12), as 
redesignated by Pub. L. 103-66, Sec. 13631(c)(3), and directed 
substitution of ``; or'' for period at end.
    Subsec. (i)(14). Pub. L. 103-66, Sec. 13631(c)(5), added par. (14).
    Subsec. (i)(15). Pub. L. 103-66, Sec. 13631(h)(1), added par. (15).
    Subsec. (o). Pub. L. 103-66, Sec. 13622(a)(2), substituted 
``regulation and including a group health plan (as defined in section 
1167(1) of title 29)), a service benefit plan, and a health maintenance 
organization)'' for ``regulation)''.
    Subsec. (s). Pub. L. 103-66, Sec. 13624(a), added subsec. (s).
    Subsec. (v)(2)(C). Pub. L. 103-66, Sec. 13604(a), added subpar. (C).
    1991--Subsec. (a)(1). Pub. L. 102-234, Sec. 3(b)(2)(B), inserted 
``and section 1396r-4(f) of this title'' after ``of this section''.
    Subsec. (c). Pub. L. 102-119 substituted ``child with a disability'' 
for ``handicapped child'', ``Individuals with Disabilities Education 
Act'' for ``Education of the Handicapped Act'', and ``an infant or 
toddler with a disability'' for ``a handicapped infant or toddler''.
    Subsec. (d)(6). Pub. L. 102-234, Sec. 4(a), added par. (6).
    Subsec. (i)(10). Pub. L. 102-234, Sec. 2(b)(2), struck out par. (10) 
added by Pub. L. 101-508, Sec. 4701(b)(2)(B), which read as follows: 
``with respect to any amount expended for medical assistance for care or 
services furnished by a hospital, nursing facility, or intermediate care 
facility for the mentally retarded to reimburse the hospital or facility 
for the costs attributable to taxes imposed by the State soley [sic] 
with respect to hospitals or facilities.''
    Subsec. (w). Pub. L. 102-234, Sec. 2(a), added subsec. (w).
    1990--Subsec. (a)(1). Pub. L. 101-508, Sec. 4402(d)(3), struck out 
before semicolon ``(including expenditures for medicare cost-sharing and 
including expenditures for premiums under part B of subchapter XVIII of 
this chapter, for individuals who are eligible for medical assistance 
under the plan and (A) are receiving aid or assistance under any plan of 
the State approved under subchapter I, X, XIV, or XVI, or part A of 
subchapter IV, or with respect to whom supplemental security income 
benefits are being paid under subchapter XVI of this chapter, or (B) 
with respect to whom there is being paid a State supplementary payment 
and are eligible for medical assistance equal in amount, duration, and 
scope to the medical assistance made available to individuals described 
in section 1396a(a)(10)(A) of this title, and, except in the case of 
individuals sixty-five years of age or older and disabled individuals 
entitled to hospital insurance benefits under subchapter XVIII of this 
chapter who are not enrolled under part B of subchapter XVIII of this 
chapter, other insurance premiums for medical or any other type of 
remedial care or the cost thereof)''.
    Subsec. (a)(2)(B). Pub. L. 101-508, Sec. 4801(a)(8), substituted 
``October 1, 1990'' for ``July 1, 1990''.
    Subsec. (a)(3)(C), (D). Pub. L. 101-508, Sec. 4401(b)(1), 
substituted ``and'' for ``plus'' at end of subpar. (C) and added subpar. 
(D).
    Subsec. (f)(2). Pub. L. 101-508, Sec. 4723(a), inserted ``(A)'' 
after ``(2)'' and added cl. (B).
    Subsec. (f)(4). Pub. L. 101-508, Sec. 4601(a)(3)(A), substituted 
``1396a(a)(10)(A)(i)(III), 1396a(a)(10) (A)(i)(IV), 
1396a(a)(10)(A)(i)(V), 1396a(a)(10) (A)(i)(VI), 
1396a(a)(10)(A)(i)(VII)'' for ``1396a(a)(10) (A)(i)(IV), 
1396a(a)(10)(A)(i)(VI)''.
    Subsec. (i)(8). Pub. L. 101-508, Sec. 4711(c)(2), inserted ``(A)'' 
after ``medical assistance'' and added cl. (B).
    Subsec. (i)(10). Pub. L. 101-508, Sec. 4701(b)(2), added par. (10) 
relating to any amount expended for medical assistance for care or 
services.
    Pub. L. 101-508, Sec. 4401(a)(1), added par. (10) relating to 
covered outpatient drugs.
    Subsec. (i)(11). Pub. L. 101-508, Sec. 4801(e)(16)(A), added par. 
(11).
    Subsec. (i)(12). Pub. L. 101-508, Sec. 4752(a)(2), added par. (12).
    Subsec. (i)(14). Pub. L. 101-508, Sec. 4752(e), added par. (14).
    Subsec. (m)(1)(A). Pub. L. 101-508, Sec. 4751(b)(1), inserted 
``meets the requirement of section 1396a(w) of this title'' after 
``State, which'' and ``meets the requirement of section 1396a(a) of this 
title and'' after ``or which''.
    Subsec. (m)(2)(A)(i). Pub. L. 101-508, Sec. 4732(d)(1), struck out 
``(or the State as authorized by paragraph (3))'' after ``the 
Secretary''.
    Subsec. (m)(2)(A)(ix). Pub. L. 101-508, Sec. 4704(b)(1), added cl. 
(ix).
    Subsec. (m)(2)(A)(x). Pub. L. 101-508, Sec. 4731(a), added cl. (x).
    Subsec. (m)(2)(A)(xi). Pub. L. 101-508, Sec. 4752(b)(1), added cl. 
(xi).
    Subsec. (m)(2)(B). Pub. L. 101-508, Sec. 4704(b)(2), inserted 
``except with respect to clause (ix) of subparagraph (A),'' after 
``Subparagraph (A)''.
    Subsec. (m)(2)(D). Pub. L. 101-508, Sec. 4732(a), struck out ``(i) 
special circumstances warrant such modification or waiver, and (ii)'' 
after ``the Secretary determines that''.
    Subsec. (m)(2)(F)(i). Pub. L. 101-508, Sec. 4732(b)(2), substituted 
``(G),'' for ``(G) or'' and inserted at end ``or with an eligible 
organization with a contract under section 1395mm of this title which 
meets the requirement of subparagraph (A)(ii), or''.
    Subsec. (m)(2)(H). Pub. L. 101-508, Sec. 4732(c), added subpar. (H).
    Subsec. (m)(3). Pub. L. 101-508, Sec. 4732(d)(2), struck out par. 
(3) which read as follows: ``A State may, in the case of an entity which 
has submitted an application to the Secretary for determination that it 
is a health maintenance organization within the meaning of paragraph (1) 
and for which no such determination has been made within 90 days of the 
submission of the application, make a provisional determination for the 
purposes of this subchapter that such entity is such a health 
maintenance organization. Such provisional determination shall remain in 
force until such time as the Secretary makes a determination regarding 
the entity's qualification under paragraph (1).''
    Subsec. (m)(5)(A)(v). Pub. L. 101-508, Sec. 4731(b)(2), added cl. 
(v).
    Subsec. (u)(1)(D)(iv). Pub. L. 101-508, Sec. 4402(b), which directed 
amendment of subpar. (C)(iv) by inserting before period at end ``or with 
respect to payments made in violation of section 1396e of this title'', 
was executed to subpar. (D)(iv) to reflect the probable intent of 
Congress because subpar. (C) does not have a cl. (iv).
    1989--Subsec. (a)(2)(B). Pub. L. 101-239, Sec. 6901(b)(5)(A), 
inserted ``(including the costs for nurse aides to complete such 
competency evaluation programs)'' after ``1396r(e)(1) of this title'' 
and ``(or, for calendar quarters beginning on or after July 1, 1988, and 
before July 1, 1990, the lesser of 90 percent or the Federal medical 
assistance percentage plus 25 percentage points)'' after ``50 percent''.
    Subsec. (f)(4). Pub. L. 101-239, Sec. 6401(b), inserted 
``1396a(a)(10)(A)(i)(VI),'' after ``1396a(a)(10)(A) (i)(IV),''.
    Subsec. (i)(2). Pub. L. 101-239, Sec. 6411(d)(2), inserted ``, not 
including items or services furnished in an emergency room of a 
hospital'' after ``emergency item or service''.
    Subsec. (i)(5). Pub. L. 101-234 repealed Pub. L. 100-360, 
Sec. 202(h)(2), and provided that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, see 1988 Amendment note below.
    1988--Subsec. (a)(1). Pub. L. 100-360, Sec. 301(f), amended Pub. L. 
99-509, Sec. 9403(g)(2), see 1986 Amendment note below.
    Subsec. (c). Pub. L. 100-360, Sec. 411(k)(13)(A), added subsec. (c).
    Subsec. (f)(2). Pub. L. 100-360, Sec. 411(k)(10)(G)(ii), amended 
Pub. L. 100-203, Sec. 4118(h)(1), see 1987 Amendment note below.
    Subsec. (f)(4). Pub. L. 100-360, Sec. 302(e)(4), inserted 
``1396a(a)(10)(A)(i)(IV),'' before ``1396a(a)(10)(A)(ii)(IX)'' in 
introductory provisions.
    Subsec. (i)(2)(A). Pub. L. 100-360, Sec. 411(k)(10)(D), as amended 
by Pub. L. 100-485, Sec. 608(d)(26)(K)(ii), added Pub. L. 100-203, 
Sec. 4118(e)(11)(A), see 1987 Amendment note below.
    Subsec. (i)(2)(B). Pub. L. 100-360, Sec. 411(k)(10)(D), as amended 
by Pub. L. 100-485, Sec. 608(d)(26)(K)(ii), added Pub. L. 100-203, 
Sec. 4118(e)(11)(B), see 1987 Amendment note below.
    Subsec. (i)(3). Pub. L. 100-360, Sec. 411(k)(6)(B)(x), added Pub. L. 
100-203, Sec. 4112(b), see 1987 Amendment note below.
    Subsec. (i)(5). Pub. L. 100-360, Sec. 202(h)(2), substituted 
``section 1395y(c)(1)'' for ``section 1395y(c)''.
    Subsec. (i)(9). Pub. L. 100-360, Sec. 302(c)(3), added par. (9).
    Subsec. (m)(2)(B)(i)(II). Pub. L. 100-485, Sec. 608(f)(4), 
substituted ``1396a(a)(10)(D) of this title'' for ``1396a(a)(13)(A)(ii) 
of this title''.
    Subsec. (m)(2)(F). Pub. L. 100-360, Sec. 411(k)(7)(D), repealed Pub. 
L. 100-203, Sec. 4113(d)(1), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(iii), (k)(7)(A), amended 
Pub. L. 100-203, Sec. 4113(a)(1)(B), see 1987 Amendment note below.
    Subsec. (m)(5). Pub. L. 100-360, Sec. 411(k)(12)(A), amended par. 
(5) generally. Prior to amendment, par. (5) read as follows:
    ``(A) Any entity with a contract under this subsection that fails 
substantially to provide medically necessary items and services that are 
required (under law or such contract) to be provided to individuals 
covered under such contract, if the failure has adversely affected (or 
has a substantial likelihood of adversely affecting) these individuals, 
is subject to a civil money penalty of not more than $10,000 for each 
such failure.
    ``(B) The provisions of section 1320a-7a of this title (other than 
subsection (a)) shall apply to a civil money penalty under subparagraph 
(A) in the same manner as they apply to a civil money penalty under that 
section.''
    1987--Subsec. (a)(1). Pub. L. 100-203, Sec. 4211(g)(2), substituted 
``and (j)'' for ``, (h), and (j)''.
    Subsec. (a)(2)(A) to (C). Pub. L. 100-203, Sec. 4211(d)(1), 
designated existing provisions as subpar. (A) and added subpars. (B) and 
(C).
    Subsec. (a)(2)(D). Pub. L. 100-203, Sec. 4212(c)(1), added subpar. 
(D).
    Subsec. (a)(3)(C). Pub. L. 100-203, Sec. 4113(b)(3), inserted ``or 
by an entity which meets the requirements of section 1320c-1 of this 
title, as determined by the Secretary,'' after ``organization''.
    Subsec. (a)(7). Pub. L. 100-203, Sec. 4212(e)(2), inserted ``subject 
to section 1396r(g)(3)(B) of this title,'' after ``(7)''.
    Subsec. (f)(2). Pub. L. 100-203, Sec. 4118(h)(1), as amended by Pub. 
L. 100-360, Sec. 411(k)(10)(G)(ii), substituted ``(whether in the form 
of insurance premiums or otherwise and regardless of whether such costs 
are reimbursed under another public program of the State or political 
subdivision thereof)'' for ``(whether in the form of insurance premiums 
or otherwise)''.
    Subsec. (f)(4). Pub. L. 100-203, Sec. 4118(p)(5), inserted ``, 
1396a(a)(10)(A)(ii)(X), or 1396d(p)(1)'' after 
``1396a(a)(10)(A)(ii)(IX)''.
    Subsec. (g)(1). Pub. L. 100-203, Sec. 4212(d)(1)(A), substituted 
``or services in an intermediate care facility for the mentally 
retarded'' for first reference to ``or intermediate care facility 
services'', struck out ``, skilled nursing facility services for 30 
days,'' after first reference to ``60 days'', substituted ``or services 
in an intermediate care facility for the mentally retarded'' for ``, 
skilled nursing facility services, or intermediate care facility 
services'', and substituted ``and intermediate care facilities for the 
mentally retarded'' for ``, skilled nursing facilities, and intermediate 
care facilities''.
    Subsec. (g)(4)(B). Pub. L. 100-203, Sec. 4212(d)(1)(B), substituted 
``and intermediate care facilities for the mentally retarded'' for ``, 
skilled nursing facilities, and intermediate care facilities''.
    Subsec. (g)(6)(B) to (D). Pub. L. 100-203, Sec. 4212(d)(1)(C), 
redesignated subpar. (C) as (B) and substituted ``services in an 
intermediate care facility for the mentally retarded'' for 
``intermediate care facility services'', redesignated subpar. (D) as 
(C), and struck out former subpar. (B) which read as follows: ``Such 
recertifications in the case of skilled nursing facility services shall 
be conducted at least--
        ``(i) 30 days after the date of the initial certification,
        ``(ii) 60 days after the date of the initial certification,
        ``(iii) 90 days after the date of the initial certification, and
        ``(iv) every 60 days thereafter.''
    Subsec. (g)(7). Pub. L. 100-203, Sec. 4212(d)(1)(D), struck out par. 
(7) which read as follows: ``It is the duty and responsibility of the 
Secretary to assure that standards which govern the provision of care in 
skilled nursing facilities and intermediate care facilities under plans 
approved under this subchapter, and the enforcement of such standards, 
are adequate to protect the health and safety of residents and to 
promote the effective and efficient use of public moneys.''
    Subsec. (h). Pub. L. 100-203, Sec. 4211(g)(1), struck out subsec. 
(h) which related to reduction by Secretary of amount otherwise 
considered as expenditures under State plan where reasonable cost 
differential between statewide average cost of skilled nursing facility 
services and statewide average cost of intermediate care facility 
services does not exist for any calendar quarter beginning after June 
30, 1973.
    Subsec. (i). Pub. L. 100-203, Sec. 4118(d)(1)(B), inserted sentence 
at end that nothing in par. (1) be construed as permitting a State to 
provide services under its plan under this subchapter that are not 
reasonable in amount, duration, and scope to achieve their purpose.
    Subsec. (i)(1). Pub. L. 100-203, Sec. 4118(d)(1)(A), substituted ``; 
or'' for period at end.
    Subsec. (i)(2). Pub. L. 100-93, Sec. 8(g), amended par. (2) 
generally. Prior to amendment, par. (2) read as follows: ``with respect 
to any amount paid for services furnished under the plan after December 
31, 1972, by a provider or other person during any period of time, if 
payment may not be made under subchapter XVIII of this chapter with 
respect to services furnished by such provider or person during such 
period of time solely by reason of a determination by the Secretary 
under section 1395y(d)(1) of this title or under clause (D), (E), or (F) 
of section 1395cc(b)(2) of this title, or by reason of noncompliance 
with a request made by the Secretary under clause (C)(ii) of such 
section 1395cc(b)(2) or under section 1396a(a)(38) of this title; or''.
    Subsec. (i)(2)(A). Pub. L. 100-203, Sec. 4118(e)(11)(A), as added by 
Pub. L. 100-360, Sec. 411(k)(10)(D), as amended by Pub. L. 100-485, 
Sec. 608(d)(26)(K)(ii), substituted ``under subchapter V, XVIII, or XX 
of this chapter or under this subchapter pursuant to section 1320a-7, 
1320a-7a, 1320c-5, or 1395u(j)(2) of this title'' for ``in the State 
plan under this subchapter pursuant to section 1320a-7 of this title or 
section 1320a-7a of this title''.
    Subsec. (i)(2)(B). Pub. L. 100-203, Sec. 4118(e)(11)(B), as added by 
Pub. L. 100-360, Sec. 411(k)(10)(D), as amended by Pub. L. 100-485, 
Sec. 608(d)(26)(K)(ii), substituted ``from participation under 
subchapter V, XVIII, or XX of this chapter or under this subchapter 
pursuant to section 1320a-7, 1320a-7a, 1320c-5, or 1395u(j)(2) of this 
title'' for ``pursuant to section 1320a-7 of this title or section 
1320a-7a of this title from participation in the program under this 
subchapter''.
    Subsec. (i)(3). Pub. L. 100-203, Sec. 4112(b), as added by Pub. L. 
100-360, Sec. 411(k)(6)(B)(x), inserted ``(other than amounts 
attributable to the special situation of a hospital which serves a 
disproportionate number of low income patients with special needs)'' 
before ``to the extent''.
    Subsec. (i)(4). Pub. L. 100-203, Sec. 4211(i), struck out ``or 
skilled nursing facility'' after ``hospital'' in three places.
    Subsec. (i)(8). Pub. L. 100-203, Sec. 4213(b)(2), added par. (8).
    Subsec. (m)(2)(F). Pub. L. 100-203, Sec. 4113(d)(1), which directed 
the substitution of ``subparagraphs (E) or (G)'' for ``subparagraph 
(G)'', was repealed by Pub. L. 100-360, Sec. 411(k)(7)(D).
    Pub. L. 100-203, Sec. 4113(a)(1)(B), as amended by Pub. L. 100-360, 
Sec. 411(a)(3)(A), (B)(iii), (k)(7)(A), substituted ``(F) In the case 
of--'' and cls. (i) and (ii) for ``(F) In the case of a contract with an 
entity described in subparagraph (G) or with a qualified health 
maintenance organization (as defined in section 300e-9(d) of this title) 
which meets the requirement of subparagraph (A)(ii),''.
    Subsec. (m)(6). Pub. L. 100-203, Sec. 4113(a)(1)(A), added par. (6).
    Subsec. (n). Pub. L. 100-93, Sec. 8(h)(1), struck out subsec. (n) 
which related to State agency action upon disclosure or failure to 
disclose required information by institution, organization, etc.
    Subsec. (r). Pub. L. 100-203, Sec. 4212(c)(2), substituted 
``paragraphs (2)(A)'' for ``paragraphs (2)'' in pars. (1)(A), (C) and 
(2)(A), (C).
    1986--Subsec. (a)(1). Pub. L. 99-509, Sec. 9403(g)(2), as amended by 
Pub. L. 100-360, Sec. 301(f), inserted ``including expenditures for 
medicare cost-sharing and'' before ``including expenditures''.
    Subsec. (a)(3)(C). Pub. L. 99-509, Sec. 9431(b)(2), inserted ``or 
quality review'' after ``medical and utilization review''.
    Subsec. (a)(4). Pub. L. 99-603 added par. (4).
    Subsec. (d)(2). Pub. L. 99-272, Sec. 9512(a), designated first 
sentence as subpar. (A), designated second sentence as subpar. (B), 
properly indented and aligned below subpar. (A), and added subpars. (C) 
and (D).
    Subsec. (f)(4). Pub. L. 99-509, Sec. 9401(e)(2), inserted ``for any 
individual described in section 1396a(a)(10)(A)(ii)(IX) of this title 
or'' after ``as medical assistance''.
    Subsec. (i)(1). Pub. L. 99-272, Sec. 9507(a), added par. (1).
    Subsec. (m)(2)(A). Pub. L. 99-272, Sec. 9517(a)(1), substituted 
``subparagraphs (B), (C), and (G)'' for ``subparagraphs (B) and (C)'' in 
introductory text.
    Pub. L. 99-272, Sec. 9517(c)(1), inserted ``(including a health 
insuring organization)'' after ``any entity'' and ``(directly or through 
arrangements with providers of services)'' after ``responsible for the 
provision'' in introductory text.
    Subsec. (m)(2)(A)(iii). Pub. L. 99-509, Sec. 9434(a)(2), inserted 
before the semicolon ``and under which the Secretary must provide prior 
approval for contracts providing for expenditures in excess of 
$100,000''.
    Subsec. (m)(2)(A)(viii). Pub. L. 99-509, Sec. 9434(a)(1)(A), added 
cl. (viii).
    Subsec. (m)(2)(F). Pub. L. 99-514, Sec. 1895(c)(2), substituted ``In 
the case'' for ``in the case''.
    Pub. L. 99-272, Sec. 9517(a)(2), struck out designation ``(i)'' at 
beginning of subpar. (F), substituted ``in the case of a contract with 
an entity described in subparagraph (G) or with a qualified health 
maintenance organization (as defined in section 300e-9(d) of this title) 
which meets the requirement of subparagraph (A)(ii)'' for ``In the case 
of a contract with a health maintenance organization described in clause 
(ii)'', substituted ``such entity or organization'' for ``such 
organization'', and struck out cl. (ii) which defined a health 
maintenance organization.
    Subsec. (m)(2)(G). Pub. L. 99-272, Sec. 9517(a)(3), added subpar. 
(G).
    Subsec. (m)(4). Pub. L. 99-509, Sec. 9434(a)(1)(B), added par. (4).
    Subsec. (m)(5). Pub. L. 99-509, Sec. 9434(b), added par. (5).
    Subsec. (r)(1)(B). Pub. L. 99-272, Sec. 9518(a), substituted 
``September 30, 1985'' for ``the earlier of (i) September 30, 1982, or 
(ii) the last day of the sixth month following the date specified for 
operation of such systems in the State's most recently approved advance 
planning document submitted before October 7, 1980''.
    Subsec. (r)(4)(A). Pub. L. 99-272, Sec. 9503(b)(2), substituted 
``once every three years'' for ``once each fiscal year'' and inserted at 
end ``Reviews may, at the Secretary's discretion, constitute reviews of 
the entire system or of only those standards, systems requirements, and 
other conditions which have demonstrated weakness in previous reviews.''
    Subsec. (r)(6)(J). Pub. L. 99-272, Sec. 9503(b)(1), amended subpar. 
(J) generally. Prior to amendment, subsec. (J) read as follows: ``report 
on or before October 1, 1981, to the Congress on the extent to which 
States have developed and operated effective mechanized claims 
processing and information retrieval systems.''
    Subsec. (u)(1)(D)(iv). Pub. L. 99-272, Sec. 9503(f), added cl. (iv).
    Subsec. (u)(1)(D)(v). Pub. L. 99-509, Sec. 9407(c), added cl. (v).
    Subsec. (v). Pub. L. 99-509, Sec. 9406(a), added subsec. (v).
    1984--Subsec. (g)(1). Pub. L. 98-369, Sec. 2363(a)(2)(A), (B), in 
provision preceding subpar. (A), substituted ``inpatient hospital 
services or intermediate care facility services for 60 days, skilled 
nursing facility services for 30 days, or inpatient mental hospital 
services for'' for ``care as an inpatient in a hospital (including an 
institution for tuberculosis), skilled nursing facility or intermediate 
care facility on 60 days, or in a hospital for mental diseases on'', and 
struck out ``which for purposes of this section means the four calendar 
quarters ending with June 30,'' before ``the Federal medical assistance 
percentage'', and struck out ``in the same fiscal year'' before ``shall 
be decreased by a per centum thereof''.
    Pub. L. 98-369, Sec. 2363(a)(2)(C), substituted ``, skilled nursing 
facility services, or intermediate care facility services furnished 
beyond 60 days (or inpatient mental hospital services furnished beyond 
90 days), such State has an effective program of medical review of the 
care of patients in mental hospitals, skilled nursing facilities, and 
intermediate care facilities pursuant to paragraphs (26) and (31) of 
section 1396a(a) of this title whereby the professional management of 
each case is reviewed and evaluated at least annually by independent 
professional review teams'' for ``(including tuberculosis hospitals), 
skilled nursing facility services, or intermediate care facility 
services furnished beyond 60 days (or inpatient mental hospital services 
furnished beyond 90 days), there is in operation in the State an 
effective program of control over utilization of such services; such a 
showing must include evidence that--'' and former subpars. (A) through 
(D) requirement for evidence concerning an effective program of 
utilization of certain medical services.
    Subsec. (g)(4)(B). Pub. L. 98-369, Sec. 2373(b)(11), substituted 
``paragraphs (26)'' for ``paragraph (26)'' and ``diligence'' for 
``deligence''.
    Subsec. (g)(6). Pub. L. 98-369, Sec. 2363(a)(4), in amending par. 
(6) generally, substituted provisions relating to recertifications for 
provisions relating to reports to Congress concerning Secretary's 
determination and review of showing respecting any decrease of Federal 
medical assistance percentage of amounts paid for services.
    Subsec. (g)(7). Pub. L. 98-369, Sec. 2363(b), as amended by Pub. L. 
98-617, Sec. 3(a)(6), added par. (7).
    Subsec. (i)(7). Pub. L. 98-369, Sec. 2303(g)(2), added par. (7).
    Subsec. (m)(2)(A)(vi). Pub. L. 98-369, Sec. 2364(1), inserted 
``except as provided under subparagraph (F),'' after ``(I)''.
    Subsec. (m)(2)(B)(i)(I). Pub. L. 98-369, Sec. 2373(b)(12)(A), (C), 
struck out ``(II)'' before ``for the period'' and substituted ``period'' 
for ``peroid''.
    Subsec. (m)(2)(B)(i)(II). Pub. L. 98-369, Sec. 2373(b)(12)(B), 
substituted ``of section 1396d(a) of this title'' for ``of such 
section''.
    Subsec. (m)(2)(C). Pub. L. 98-369, Sec. 2373(b)(13), realigned 
margin of subpar. (C).
    Subsec. (m)(2)(E), (F). Pub. L. 98-369, Sec. 2364(2), added subpars. 
(E) and (F).
    Subsec. (s)(3)(B). Pub. L. 98-369, Sec. 2373(b)(14), substituted 
``non-Federal'' for ``nonfederal''.
    1983--Subsec. (t)(3). Pub. L. 97-448 substituted ``purposes'' for 
``purpose'' and ``the lower of the Federal medical assistance percentage 
for the State in effect for fiscal year 1981, or the Federal medical 
assistance percentage for the State in effect for fiscal year 1982'' for 
``the Federal medical assistance percentage for States in effect for 
fiscal year 1981, disregarding any change in such percentage after 
fiscal year 1981''.
    1982--Subsec. (a)(3)(C). Pub. L. 97-248, Sec. 146(b), substituted 
``utilization and quality control peer review organization'' for 
``Professional Standards Review Organization''.
    Subsec. (f)(3). Pub. L. 97-248, Sec. 137(g), struck out ``(without 
regard to section 608 of this title)'' after ``consisting of one person 
if such plan''.
    Subsec. (g)(1). Pub. L. 97-248, Sec. 137(b)(11), inserted ``or which 
is a qualified health maintenance organization (as defined in section 
300e-9(d) of this title)''.
    Subsec. (g)(1)(A). Pub. L. 97-248, Sec. 137(b)(12), substituted 
``provided in an institution for the mentally retarded'' for ``described 
in section 1396d(d) of this title''.
    Subsec. (k). Pub. L. 97-248, Sec. 137(b)(13), substituted 
``subsection (m) of this section'' for ``section 1395mm of this title''.
    Subsec. (m)(2)(A). Pub. L. 97-248, Sec. 137(b)(14), substituted 
``or'' for ``and'' before ``(II)'' in cl. (iv), and substituted 
``unforeseen'' for ``unforseen'' in cl. (vii)(II).
    Subsec. (s). Pub. L. 97-248, Sec. 137(a)(2), amended directory 
language of Pub. L. 97-35, Sec. 2161(c)(1), to correct an error, and did 
not involve any change in text. See 1981 Amendment note below.
    Subsec. (s)(1)(A). Pub. L. 97-248, Sec. 137(b)(15)(A), (B), in 
provisions following cl. (iii), substituted ``fiscal year 1982'' for 
``fiscal year 1981'', and ``subsections (a)(6) and (t) of this section, 
without regard to payments for claims relating to expenditures made for 
medical assistance for services received through a facility of the 
Indian Health Service,'' for ``subsection (t) of this section''.
    Subsec. (s)(1)(C). Pub. L. 97-248, Sec. 137(b)(15)(C), inserted ``a 
program in operation under'', before ``a plan approved''.
    Subsec. (s)(3)(D). Pub. L. 97-248, Sec. 137(b)(15)(D), substituted 
``must determine that'' for ``determines that'', ``most recent year 
(which shall consist of a 12-month period determined by the Secretary 
for this purpose)'' for ``most recent calendar year'', and ``2- or 3-
year period'' for ``2 or 3 calendar year period'', and struck out 
``calendar'' wherever appearing.
    Subsec. (s)(4)(B). Pub. L. 97-248, Sec. 137(b)(15)(E), inserted 
``and paragraph (3)(D)''.
    Subsec. (s)(5)(A)(i). Pub. L. 97-248, Sec. 137(b)(15)(F), inserted 
``(including amounts saved, to the extent such amounts can be documented 
to the satisfaction of the Secretary, by reason of the suspension or 
termination of a provider or other person for fraud or abuse, but only 
during the period of such suspension or termination or, if shorter, the 
1-year period beginning on the date of such termination or suspension)'' 
after ``recovered or diverted''.
    Subsec. (s)(5)(B). Pub. L. 97-248, Sec. 137(b)(27), inserted ``or 
quarters'' after ``carried forward to the following quarter''.
    Subsec. (t). Pub. L. 97-248, Sec. 137(a)(1), (2), amended directory 
language of Pub. L. 97-35, Sec. 2161(b), (c)(2), to correct an error, 
and did not involve any change in text. See 1981 Amendment note below.
    Subsec. (t)(1)(A). Pub. L. 97-248, Sec. 137(b)(16)(A), substituted 
``payments under subsection (a)(6) of this section, interest paid under 
subsection (d)(5) of this section, and payments for claims relating to 
expenditures made for medical assistance for services received through a 
facility of the Indian Health Service'' for ``interest paid under 
subsection (d)(5) of this section''.
    Subsec. (t)(1)(B). Pub. L. 97-248, Sec. 137(b)(16)(B), (D), 
substituted ``Consumer Price Index for all urban consumers (U.S. city 
average) published by the Bureau of Labor Statistics'' for ``consumer 
price index for all urban consumers (published by the Bureau of Labor 
Statistics)'' and ``for the 12-month period ending on September 30, 
1983'' for ``between September 1982 and September 1983''.
    Subsec. (t)(1)(C). Pub. L. 97-248, Sec. 137(b)(16)(C), (D), 
substituted ``Consumer Price Index for all urban consumers (U.S. city 
average) published by the Bureau of Labor Statistics'' for ``consumer 
price index for all urban consumers (published by the Bureau of Labor 
Statistics)'' and ``for the 24-month period ending on September 30, 
1984'' for ``between September 1982 and September 1984''.
    Subsec. (t)(2)(A). Pub. L. 97-248, Sec. 137(b)(16)(A), substituted 
``payments under subsection (a)(6) of this section, interest paid under 
subsection (d)(5) of this section, and payments for claims relating to 
expenditures made for medical assistance for services received through a 
facility of the Indian Health Service'' for ``interest paid under 
subsection (d)(5) of this section''.
    Subsec. (t)(3). Pub. L. 97-248, Sec. 137(b)(16)(E), substituted 
``for fiscal years 1982, 1983, and 1984'' for ``for fiscal year 1984'' 
wherever appearing, ``years 1983, 1984, and 1985, respectively'' for 
``year 1985'', ``in effect for fiscal year 1981'' for ``in effect for 
fiscal year 1983'', and ``after fiscal year 1981'' for ``between fiscal 
year 1983 and fiscal year 1984''.
    Subsec. (u). Pub. L. 97-248, Sec. 133(a), added subsec. (u).
    1981--Subsec. (a)(3)(B). Pub. L. 97-35, Sec. 2113(n), substituted 
``and'' for ``plus'' at the end of subpar. (B) and added subpar. (C).
    Subsec. (d)(5). Pub. L. 97-35, Sec. 2163, substituted 
``determination at a rate'' for ``determination (but not to exceed a 
period of twelve months with respect to disallowances made prior to 
October 1, 1981, or six months with respect to disallowances made 
thereafter) at a rate''.
    Subsec. (e). Pub. L. 97-35, Sec. 2101(a)(2), added subsec. (e).
    Subsec. (g)(1)(A). Pub. L. 97-35, Sec. 2183(a), inserted ``and the 
physician, or a physician assistant or nurse practitioner under the 
supervision of a physician'' and ``or, in the case of services that are 
intermediate care facility services described in section 1396d(d) of 
this title, every year'' in parenthetical text.
    Subsec. (i)(1). Pub. L. 97-35, Sec. 2174(b), struck out par. (1) 
which provided that payments shall not be made with respect to any 
amount paid for items or services furnished under the plan after Dec. 
31, 1972, to the extent that such amount exceeds the charge which would 
be determined to be reasonable for such items or services under fourth 
and fifth sentences of section 1395u(b)(3) of this title.
    Subsec. (i)(5). Pub. L. 97-35, Sec. 2103(b)(1), added par. (5).
    Subsec. (i)(6). Pub. L. 97-35, Sec. 2164(a), added par. (6).
    Subsec. (m)(1)(A). Pub. L. 97-35, Sec. 2178(a)(1), redefined 
``Health Maintenance Organization'' substantially, and substituted 
reference to public and private organizations making services to 
individuals eligible for benefits under this subchapter and which makes 
adequate provision against the risk of insolvency for reference to a 
legal entity which provides health services to individuals enrolled in 
such organization and providing services and benefits to individuals 
eligible for benefits under specified provisions of this subchapter.
    Subsec. (m)(2)(A). Pub. L. 97-35, Sec. 2178(a)(2), in cl. (ii), 
substituted ``75 percent of the membership of the entity which is 
enrolled on a prepaid basis'' for ``one-half of the membership of the 
entity'', and added cls. (iii) to (vii).
    Subsec. (m)(2)(D). Pub. L. 97-35, Sec. 2178(a)(3), added subpar. 
(D).
    Subsec. (n). Pub. L. 97-35, Sec. 2106(b)(3), struck out ``of this 
section'' after ``section 1395cc of this title'' thereby perfecting the 
amendment made by Pub. L. 96-499, Sec. 905(c)(2).
    Subsec. (s). Pub. L. 97-35, Sec. 2161(c)(1), as amended by Pub. L. 
97-248, Sec. 137(a)(2), repealed subsec. (s) which provided for 
reduction in medicaid payments to States, limitations on reductions, 
States included, and percentage reductions reduced under certain 
circumstances. See Effective Date of 1981 Amendment note below.
    Pub. L. 97-35, Sec. 2161(a), added subsec. (s).
    Subsec. (t). Pub. L. 97-35, Sec. 2161(c)(2), as amended by Pub. L. 
97-248, Sec. 137(a)(2), repealed subsec. (t) which provided for offset 
for meeting Federal medicaid expenditure targets, and computation for 
meeting expenditure targets. See Effective Date of 1981 Amendment note 
below.
    Pub. L. 97-35, Sec. 2161(b), as amended by Pub. L. 97-248, 
Sec. 137(a)(1), added subsec. (t).
    1980--Subsec. (a)(1). Pub. L. 96-499, Sec. 905(b), inserted 
reference to subsection (j) of this section.
    Subsec. (a)(6). Pub. L. 96-499, Sec. 963, substituted ``such a 
quarter within the twelve-quarter period beginning with the first 
quarter in which a payment is made to the State pursuant to this 
paragraph, and (B) 75 per centum of the sums expended during each 
succeeding calendar quarter'' for ``each quarter beginning on or after 
October 1, 1977, and ending before October 1, 1980''.
    Subsec. (d)(5). Pub. L. 96-499, Sec. 961(a), added par. (5).
    Subsec. (g)(3)(B). Pub. L. 96-499, Sec. 964, substituted ``January 
1, 1978'' for ``October 1, 1977'' and ``any calendar quarter ending on 
or before December 31, 1978'' for ``the calendar quarter ending on 
December 31, 1977''.
    Subsec. (j). Pub. L. 96-499, Sec. 905(c)(1), substituted provisions 
relating to the adjustment of amounts determined under subsec. (a)(1) of 
this section in accordance with section 1396m of this title for 
provisions relating to orders for suspension of payment.
    Subsec. (n). Pub. L. 96-499, Sec. 905(c)(2), struck out ``or is 
subject to a suspension of payment order issued under subsection (j)'' 
after ``section 1395cc of this title''.
    Subsec. (r). Pub. L. 96-398 added subsec. (r).
    1979--Subsec. (m)(2)(C). Pub. L. 96-79 substituted ``the date the 
entity qualifies as a health maintenance organization (as determined by 
the Secretary)'' for ``the date the entity enters into a contract with 
the State under this subchapter for the provision of health services on 
a prepaid risk basis''.
    1978--Subsec. (m)(1)(B). Pub. L. 95-559 struck out ``shall be 
administered through the Assistant Secretary for Health and in the 
Office of the Assistant Secretary for Health, and the administration of 
such duties and functions'' after ``subparagraph (A),''.
    Subsec. (m)(2)(B)(i)(I). Pub. L. 95-626 substituted ``section 
254b(d)(1)(A)'' for ``section 247d(d)(1)(A)''.
    1977--Subsec. (a)(3)(B). Pub. L. 95-142, Sec. 10(a), inserted 
provisions relating to notice to individuals in a sample group and 
provisions exempting notice respecting confidential services from notice 
requirements.
    Subsec. (a)(6), (7). Pub. L. 95-142, Sec. 17(a), added par. (6) and 
redesignated former par. (6) as (7).
    Subsec. (b)(3). Pub. L. 95-142, Sec. 17(b), added par. (3).
    Subsec. (g). Pub. L. 95-142, Sec. 20(a), in par. (1) substituted 
``Subject to paragraph (3), with respect to'' for ``With respect to'' 
and ``by a per centum thereof (determined under paragraph (5))'' for 
``by 33\1/3\ per centum thereof'', in par. (2) inserted ``timely'' 
before ``sample onsite surveys'', and added pars. (3) to (6).
    Subsec. (i)(2). Pub. L. 95-142, Sec. 3(c)(2), inserted provisions 
relating to noncompliance under sections 1395cc(b)(2) and 1396a(a)(38) 
of this title.
    Subsec. (m)(2)(A). Pub. L. 95-83, Sec. 105(a)(1), in revising text, 
incorporated former cl. (i) (I) and (II) provisions in introductory text 
relating to responsibility for providing inpatient hospital services and 
other described services, substituting ``capitation basis'' for 
``capitation risk basis'' and inserting ``unless''; redesignated as cl. 
(i) former cl. (ii), substituting ``has determined that the entity is a 
health maintenance organization'' for ``has not determined to be a 
health maintenance organization''; and redesignated as cl. (ii) former 
cl. (iii), substituting ``less than one-half of the membership of the 
entity consists of individuals who (I) are insured for benefits under 
part B of subchapter XVIII of this chapter or for benefits under both 
parts A and B of such subchapter, or (II) are eligible to receive 
benefits under this subchapter'' for ``more than one-half of the 
membership of which consists of individuals who are insured under parts 
A and B of subchapter XVIII of this chapter or recipients of benefits 
under this subchapter.''
    Subsec. (m)(2)(C). Pub. L. 95-83, Sec. 105(a)(2), substituted 
reference to subpar. ``(A)(ii)'' for ``(A)(iii)'' wherever appearing.
    Subsec. (n). Pub. L. 95-142, Sec. 8(c), added subsec. (n).
    Subsecs. (o), (p). Pub. L. 95-142, Sec. 11(a), added subsecs. (o) 
and (p).
    Subsec. (q). Pub. L. 95-142, Sec. 17(c), added subsec. (q).
    1976--Subsec. (l). Pub. L. 94-552 repealed subsec. (l) which 
provided for reduction of amount of payments to States found not to be 
in compliance with section 1396a(g) of this title.
    Subsec. (m). Pub. L. 94-460 added subsec. (m).
    1975--Subsec. (g)(1)(C). Pub. L. 94-182, Sec. 110(a), inserted 
provisions specifying the method by which the size and composition of 
the sample of admissions subject to review is to be established.
    Subsec. (l). Pub. L. 94-182, Sec. 111(b), added subsec. (l).
    1973--Subsec. (a). Pub. L. 93-233, Sec. 18(x)(5), struck out 
reference to section 1317 of this title in introductory parenthetical 
phrase.
    Subsec. (a)(1). Pub. L. 93-233, Secs. 13(a)(11), 18(r)(1), 
substituted ``individuals who are eligible for medical assistance under 
the plan and (A) are receiving aid or assistance under any plan of the 
State approved under subchapter I, X, XIV, or part A of subchapter IV of 
this chapter, or with respect to whom supplemental security income 
benefits are being paid under subchapter XVI of this chapter, or (B) 
with respect to whom there is being paid a State supplementary payment 
and are eligible for medical assistance equal in amount, duration, and 
scope to the medical assistance made available to individuals described 
in section 1396a(a)(10)(A) of this title'' for ``individuals who are 
recipients of money payments under a State plan approved under 
subchapter I, X, XIV, or XVI, or part A of subchapter IV of this 
chapter'' and inserted ``and disabled individuals entitled to hospital 
insurance benefits under subchapter XVIII of this chapter,'' after 
``individuals sixty-five years of age or older''.
    Subsec. (a)(4). Pub. L. 93-233, Sec. 18(s), substituted ``sums 
expended with respect to costs incurred'' for ``sums expended''.
    Subsec. (a)(5). Pub. L. 93-233, Sec. 18(t), struck out ``(as found 
necessary by the Secretary for the proper and efficient administration 
of the plan)'' after ``such quarter''.
    Subsec. (b). Pub. L. 93-233, Secs. 18(r)(2), (u), (x)(6), inserted 
in par. (2) after ``individuals sixty-five years of age or older'' text 
reading ``and disabled individuals entitled to hospital insurance 
benefits under subchapter XVIII of this chapter'' and end text reading 
``, other than amounts expended under provisions of the plan of such 
State required by section 1396a(a)(34) of this title,'' and redesignated 
pars. (2) and (3) as (1) and (2), respectively.
    Subsec. (c). Pub. L. 93-233, Sec. 18(y)(1)(A), struck out subsec. 
(c) which provided for Federal medical assistance percentage and Federal 
share of State medical expenses during fiscal year ending June 30, 1965.
    Subsec. (d)(1). Pub. L. 93-233, Sec. 18(y)(1)(B), struck out 
reference to subsec. (c) of this section.
    Subsec. (f)(4). Pub. L. 93-233, Sec. 13(a)(12), in subpar. (A), made 
payment limitations inapplicable to individual with respect to whom 
supplemental security income benefits are being paid under subchapter 
XVI of this chapter; in subpar. (B), made payment limitations 
inapplicable to individual with respect to whom such benefits are not 
being paid, and in cls. (i) and (ii) inserted ``to have such benefits 
paid with respect to him'', and added subpar. (C).
    Subsec. (g)(1)(C). Pub. L. 93-233, Sec. 18(v), substituted 
``directly responsible for the care of the patient or financially 
interested in any such institution or, except in the case of hospitals, 
employed by the institution'' for ``directly responsible for the care of 
the patient and who are not employed by or financially interested in any 
such institution''.
    Subsec. (j). Pub. L. 93-66 struck out provisions respecting skilled 
nursing facility services and intermediate care facility services.
    1972--Subsec. (a)(1). Pub. L. 92-603, Sec. 207(a)(2), inserted 
reference to subsecs. (g) and (h) and of this section.
    Subsec. (a)(3). Pub. L. 92-603, Sec. 235(a), added par. (3). Former 
par. (3) redesignated (4).
    Subsec. (a)(4). Pub. L. 92-603, Sec. 249B, temporarily added par. 
(4) which provided for payments to States of 100 per centum of sums 
expended for costs incurred during a quarter attributable to 
compensation or training of personnel responsible for inspecting public 
or private institutions providing long-term care to recipients of 
medical assistance to determine compliance with health or safety 
standards. Former par. 4 redesignated (5). See Effective Date of 1972 
Amendment note below.
    Pub. L. 92-603, Sec. 235(a), redesignated former par. (3) as (4).
    Subsec. (a)(5). Pub. L. 92-603, Sec. 299E(a), added par. (5). Former 
par. (5) redesignated (6).
    Pub. L. 92-603, Sec. 249B, redesignated former par. (4) as (5).
    Subsec. (a)(6). Pub. L. 92-603, Sec. 299E, redesignated former par. 
(5) as (6).
    Subsec. (b)(1). Pub. L. 92-603, Sec. 295, struck out par. (1) which 
related to amount of quarterly expenditures exceeding average of total 
expenditures for each quarter of fiscal year ending June 30, 1965.
    Subsec. (b)(3). Pub. L. 92-603, Sec. 221(c)(6), added par. (3).
    Subsec. (e). Pub. L. 92-603, Sec. 230, repealed subsec. (e) which 
related to furnishing for comprehensive care and services by July 1, 
1977.
    Subsec. (g). Pub. L. 92-603, Secs. 207(a)(1), 278(b)(1), added 
subsec. (g) and substituted ``skilled nursing facility'' for ``skilled 
nursing home'' and ``skilled nursing facilities'' for ``skilled nursing 
homes'' wherever appearing.
    Subsec. (h). Pub. L. 92-603, Secs. 207(a)(1), 278(b)(1)(5), added 
subsec. (h) and substituted ``skilled nursing facility'' for ``skilled 
nursing home'' wherever appearing.
    Subsec. (i). Pub. L. 92-603, Secs. 224(c), 229(c), 233(c), 
237(a)(1), 278(b)(7), added subsec. (i) and substituted ``skilled 
nursing facility'' for ``skilled nursing home'' wherever appearing.
    Subsec. (j). Pub. L. 92-603, Sec. 290, added subsec. (j) relating to 
orders for suspension of payment.
    Pub. L. 92-603, Secs. 225, 278(b)(16), added subsec. (j) relating to 
skilled nursing facilities services, and substituted ``skilled nursing 
facility for ``skilled nursing home'' wherever appearing.
    Subsec. (k). Pub. L. 92-603, Sec. 226(e), added subsec. (k).
    1969--Subsec. (e). Pub. L. 91-56 extended from July 1, 1975, to July 
1, 1977, the date by which comprehensive care and services for eligible 
individuals must be made available for a State to be eligible for 
payments.
    1968--Subsec. (a)(1). Pub. L. 90-248, Sec. 222(d), substituted 
``and, except in the case of individuals sixty-five years of age or 
older who are not enrolled under part B of subchapter XVIII of this 
chapter, other insurance premiums'' for ``and other insurance 
premiums''.
    Pub. L. 90-248, Sec. 241(f)(5), struck out ``IV,'' after ``I,'' and 
inserted ``or part A of subchapter IV of this chapter,'' after ``XVI of 
this chapter,''.
    Subsec. (a)(2). Pub. L. 90-248, Sec. 225(a), substituted ``of the 
State agency or any other public agency'' for ``of the State agency (or 
of the local agency administering the State plan in the political 
subdivision)''.
    Subsec. (b). Pub. L. 90-248, Sec. 222(c), designated existing 
provisions as par. (1) and added par. (2).
    Subsec. (b)(2). Pub. L. 90-364 substituted ``1969'' for ``1967''.
    Subsec. (d)(2). Pub. L. 90-248, Sec. 229(c), provided for treatment 
of expenditures for which payments were made to the State under subsec. 
(a) as an overpayment to the extent that the State or local agency 
administering the plan has been reimbursed for such expenditures by a 
third party pursuant to the provisions of its plan in compliance with 
section 1396a(a)(25) of this title.
    Subsec. (f). Pub. L. 90-248, Sec. 220(a), added subsec. (f).


                    Effective Date of 1999 Amendments

    Amendment by section 201(a)(4), (b) of Pub. L. 106-170 applicable to 
medical assistance for items and services furnished on or after Oct. 1, 
2000, see section 201(d) of Pub. L. 106-170, set out as a note under 
section 1396a of this title.
    Pub. L. 106-170, title IV, Sec. 407(d), Dec. 17, 1999, 113 Stat. 
1914, provided that: ``The amendments made by this section [amending 
this section] take effect on the date of the enactment of this Act [Dec. 
17, 1999].''
    Amendment by section 1000(a)(6) [title VI, Sec. 604(a)(2)(B), 
(b)(2)] of Pub. L. 106-113 applicable as of such date as the Secretary 
of Health and Human Services certifies to Congress that the Secretary is 
fully implementing section 1396u-2(c)(2) of this title, see section 
1000(a)(6) [title VI, Sec. 604(c)(2)] of Pub. L. 106-113, set out as a 
note under section 1396a of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(aa)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided that the amendment 
made by section 1000(a)(6) [title VI, Sec. 608(aa)(2)] is effective as 
if included in the enactment of BBA [the Balanced Budget Act of 1997, 
Pub. L. 105-33].
    Amendment by section 1000(a)(6) [title VI, Sec. 608(e)-(k)] of Pub. 
L. 106-113 effective Nov. 29, 1999, see section 1000(a)(6) [title VI, 
Sec. 608(bb)] of Pub. L. 106-113, set out as a note under section 1396a 
of this title.
    Pub. L. 106-31, title III, Sec. 3031(c), May 21, 1999, 113 Stat. 
104, provided that: ``This section [amending this section] and the 
amendments made by this section shall apply to amounts paid to a State 
prior to, on, or after the date of the enactment of this Act [May 21, 
1999].''


                    Effective Date of 1997 Amendments

    Section 162 of Pub. L. 105-100 provided that the amendment made by 
that section is effective as if included in the enactment of subtitle J 
(Secs. 4901-4923) of title IV of the Balanced Budget Act of 1997, Pub. 
L. 105-33.
    Section 4710 of title IV of Pub. L. 105-33 provided that:
    ``(a) General Effective Date.--Except as otherwise provided in this 
chapter [chapter 1 (Secs. 4701-4710) of subtitle H of title IV of Pub. 
L. 105-33, enacting section 1396u-2 of this title, amending this section 
and sections 1320a-3, 1320a-7b, 1396a, 1396d, 1396o, 1396r-6, 1396r-8, 
1396u-2, and 1396v of this title, and enacting provisions set out as a 
note under section 1396u-2 of this title] and section 4759 [enacting 
provisions set out as a note under section 1396a of this title], the 
amendments made by this chapter shall take effect on the date of the 
enactment of this Act [Aug. 5, 1997] and shall apply to contracts 
entered into or renewed on or after October 1, 1997.
    ``(b) Specific Effective Dates.--Subject to subsection (c) and 
section 4759--
        ``(1) PCCM option.--The amendments made by section 4702 
    [amending this section and sections 1396a and 1396d of this title] 
    shall apply to primary care case management services furnished on or 
    after October 1, 1997.
        ``(2) 75:25 rule.--The amendments made by section 4703 [amending 
    this section and section 1396r-6 of this title] apply to contracts 
    under section 1903(m) of the Social Security Act (42 U.S.C. 
    1396b(m)) on and after June 20, 1997.
        ``(3) Quality standards.--Section 1932(c)(1) of the Social 
    Security Act [section 1396u-2(c)(1) of this title], as added by 
    section 4705(a), shall take effect on January 1, 1999.
        ``(4) Solvency standards.--
            ``(A) In general.--The amendments made by section 4706 
        [amending this section] shall apply to contracts entered into or 
        renewed on or after October 1, 1998.
            ``(B) Transition rule.--In the case of an organization that 
        as of the date of the enactment of this Act [Aug. 5, 1997] has 
        entered into a contract under section 1903(m) of the Social 
        Security Act [subsec. (m) of this section] with a State for the 
        provision of medical assistance under title XIX of such Act 
        [this subchapter] under which the organization assumes full 
        financial risk and is receiving capitation payments, the 
        amendment made by section 4706 shall not apply to such 
        organization until 3 years after the date of the enactment of 
        this Act.
        ``(5) Sanctions for noncompliance.--Section 1932(e) of the 
    Social Security Act [section 1396u-2(e) of this title], as added by 
    section 4707(a), shall apply to contracts entered into or renewed on 
    or after April 1, 1998.
        ``(6) Limitation on ffp for enrollment brokers.--The amendment 
    made by section 4707(b) [amending this section] shall apply to 
    amounts expended on or after October 1, 1997.
        ``(7) 6-month guaranteed eligibility.--The amendments made by 
    section 4709 [amending section 1396a of this title] shall take 
    effect on October 1, 1997.
    ``(c) Nonapplication to Waivers.--Nothing in this chapter (or the 
amendments made by this chapter) shall be construed as affecting the 
terms and conditions of any waiver, or the authority of the Secretary of 
Health and Human Services with respect to any such waiver, under section 
1115 or 1915 of the Social Security Act (42 U.S.C. 1315, 1396n).''
    Amendment by section 4712(b)(2) of Pub. L. 105-33 applicable to 
services furnished on or after Oct. 1, 1997, see section 4712(b)(3) of 
Pub. L. 105-33, set out as a note under section 1396a of this title.
    Pub. L. 105-33, title IV, Sec. 4712(c), Aug. 5, 1997, 111 Stat. 509, 
as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, 
Sec. 603(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-394, provided that 
the amendment made by section 4712(c) is effective for services 
furnished on or after Oct. 1, 2004.
    Section 4722(d) of Pub. L. 105-33 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to taxes 
imposed before, on, or after the date of the enactment of this Act [Aug. 
5, 1997] and the amendment made by subsection (b) [amending this 
section] shall apply to taxes imposed on or after such date.''
    Section 4724(b)(2) of Pub. L. 105-33 provided that: ``The amendments 
made by paragraph (1) [amending this section] shall apply to home health 
care services furnished on or after January 1, 1998.''
    Section 4742(b) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after the date of the enactment of this Act [Aug. 5, 
1997].''
    Amendment by section 4753(a) of Pub. L. 105-33 effective Jan. 1, 
1998, except as otherwise specifically provided, see section 4753(c) of 
Pub. L. 105-33, set out as a note under section 1396a of this title.
    Amendment by section 4912(b)(2) of Pub. L. 105-33 effective Aug. 5, 
1997, see section 4912(c) of Pub. L. 105-33, set out as a note under 
section 1396a of this title.
    Amendment by Pub. L. 105-12 effective Apr. 30, 1997, and applicable 
to Federal payments made pursuant to obligations incurred after Apr. 30, 
1997, for items and services provided on or after such date, subject to 
also being applicable with respect to contracts entered into, renewed, 
or extended after Apr. 30, 1997, as well as contracts entered into 
before Apr. 30, 1997, to the extent permitted under such contracts, see 
section 11 of Pub. L. 105-12, set out as an Effective Date note under 
section 14401 of this title.


                    Effective Date of 1996 Amendments

    Section 1(b)(2) of Pub. L. 104-248 provided that: ``The amendments 
made by paragraph (1) [amending this section] shall apply to physicians' 
services furnished on or after January 1, 1992.''
    Amendment by Pub. L. 104-193 effective July 1, 1997, with transition 
rules relating to State options to accelerate such date, rules relating 
to claims, actions, and proceedings commenced before such date, rules 
relating to closing out of accounts for terminated or substantially 
modified programs and continuance in office of Assistant Secretary for 
Family Support, and provisions relating to termination of entitlement 
under AFDC program, see section 116 of Pub. L. 104-193, as amended, set 
out as an Effective Date note under section 601 of this title.


                    Effective Date of 1993 Amendment

    Amendment by section 13602(b) of Pub. L. 103-66 effective as if 
included in enactment of the Omnibus Budget Reconciliation Act of 1990, 
Pub. L. 101-508, see section 13602(d)(1) of Pub. L. 103-66, set out as a 
note under section 1396r-8 of this title.
    Section 13604(b) of Pub. L. 103-66 provided that:
    ``(1) Subject to paragraph (2), the amendments made by subsection 
(a) [amending this section] shall apply as if included in the enactment 
of OBRA-1986 [Pub. L. 99-509].
    ``(2) The Secretary of Health and Human Services shall not disallow 
expenditures made for the care and services described in section 
1903(v)(2)(C) of the Social Security Act [subsec. (v)(2)(C) of this 
section], as added by subsection (a), furnished before the date of the 
enactment of this Act [Aug. 10, 1993].''
    Amendment by section 13622(a)(2) of Pub. L. 103-66 applicable to 
items and services furnished on or after Oct. 1, 1993, see section 
13622(d)(3) of Pub. L. 103-66, set out as a note under section 1396a of 
this title.
    Section 13624(b) of Pub. L. 103-66 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to referrals 
made on or after December 31, 1994.''
    Section 13631(h)(2) of Pub. L. 103-66 provided that: ``The 
amendments made by paragraph (1) [amending this section] shall apply to 
amounts expended for vaccines administered on or after October 1, 
1993.''
    Amendment by section 13631(c) of Pub. L. 103-66 applicable to 
payments under State plans approved under this subchapter for calendar 
quarters beginning on or after Oct. 1, 1994, see section 13631(i) of 
Pub. L. 103-66, set out as a note under section 1396a of this title.


                    Effective Date of 1991 Amendment

    Amendments by section 2(a), (b)(2) of Pub. L. 102-234 effective Jan. 
1, 1992, without regard to whether or not regulations have been 
promulgated to carry out such amendments by such date, see section 
2(c)(1) of Pub. L. 102-234, set out as a note under section 1396a of 
this title.
    Amendment by section 3(b)(2)(B) of Pub. L. 102-234 effective Jan. 1, 
1992, see section 3(e)(1) of Pub. L. 102-234, set out as a note under 
section 1396a of this title.
    Section 4(b) of Pub. L. 102-234 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply to fiscal years 
ending after the date of the enactment of this Act [Dec. 12, 1991].''


                    Effective Date of 1990 Amendments

    Amendment by section 4402(b), (d)(3) of Pub. L. 101-508 applicable, 
except as otherwise provided, to payments under this subchapter for 
calendar quarters beginning on or after Jan. 1, 1991, without regard to 
whether or not final regulations to carry out the amendments by section 
4402 of Pub. L. 101-508 have been promulgated by such date, see section 
4402(e) of Pub. L. 101-508, set out as a note under section 1396a of 
this title.
    Amendment by section 4601(a)(3)(A) of Pub. L. 101-508 applicable, 
except as otherwise provided, to payments under this subchapter for 
calendar quarters beginning on or after July 1, 1991, without regard to 
whether or not final regulations to carry out the amendments by section 
4601 of Pub. L. 101-508 have been promulgated by such date, see section 
4601(b) of Pub. L. 101-508, set out as a note under section 1396a of 
this title.
    Section 4701(c) of Pub. L. 101-508 provided that: ``The amendment 
made by subsection (b) [amending this section and section 1396a of this 
title] shall take effect on January 1, 1991.''
    Amendment by section 4704(b)(1), (2) of Pub. L. 101-508 effective as 
if included in the enactment of the Omnibus Budget Reconciliation Act of 
1989, Pub. L. 101-239, see section 4704(f) of Pub. L. 101-508, set out 
as a note under section 1396a of this title.
    Amendment by section 4711(c)(2) of Pub. L. 101-508 applicable to 
civil money penalties imposed after Nov. 5, 1990, see section 
4711(e)(2)(B) of Pub. L. 101-508, set out as a note under section 1396a 
of this title.
    Section 4731(c) of Pub. L. 101-508 provided that: ``The amendments 
made by subsections (a) and (b)(2) [amending this section] shall apply 
with respect to contract years beginning on or after January 1, 1992, 
and the amendments made by subsection (b)(1) [amending section 1320a-7a 
of this title] shall take effect on the date of the enactment of this 
Act [Nov. 5, 1990].''
    Amendment by section 4751(b)(1) of Pub. L. 101-508 applicable with 
respect to services furnished on or after first day of first month 
beginning more than 1 year after Nov. 5, 1990, see section 4751(c) of 
Pub. L. 101-508, set out as a note under section 1396a of this title.
    Section 4752(b)(2) of Pub. L. 101-508 provided that: ``The 
amendments made by paragraph (1) [amending this section] shall apply to 
contract years beginning after the date of the establishment of the 
system described in section 1902(x) of the Social Security Act [section 
1396a(x) of this title].''
    Section 4801(a)(9) of Pub. L. 101-508 provided that: ``Except as 
provided in paragraph (6), the amendments made by this subsection 
[amending this section and section 1396r of this title] shall take 
effect as if they were included in the enactment of the Omnibus Budget 
Reconciliation Act of 1987 [Pub. L. 100-203].''
    Section 4801(e)(16)(B) of Pub. L. 101-508 provided that: ``The 
amendments made by subparagraph (A) [amending this section] shall apply 
with respect to actions initiated on or after the date of the enactment 
of this Act [Nov. 5, 1990].''


                    Effective Date of 1989 Amendments

    Amendment by section 6401(b) of Pub. L. 101-239 applicable, except 
as otherwise provided, to payments under this subchapter for calendar 
quarters beginning on or after Apr. 1, 1990, with respect to eligibility 
for medical assistance on or after such date, without regard to whether 
or not final regulations to carry out the amendments by section 6401 of 
Pub. L. 101-239 have been promulgated by such date, see section 6401(c) 
of Pub. L. 101-239, set out as a note under section 1396a of this title.
    Amendment by section 6901(b)(5)(A) of Pub. L. 101-239 effective as 
if included in the enactment of the Omnibus Budget Reconciliation Act of 
1987, Pub. L. 100-203, see section 6901(b)(6) of Pub. L. 101-239, set 
out as a note under section 1395i-3 of this title.
    Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section 
201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a of 
this title.


                    Effective Date of 1988 Amendments

    Amendment by section 608(d)(26)(K)(ii) of Pub. L. 100-485 effective 
as if included in the enactment of the Medicare Catastrophic Coverage 
Act of 1988, Pub. L. 100-360, see section 608(g)(1) of Pub. L. 100-485, 
set out as a note under section 704 of this title.
    Amendment by section 608(f)(4) of Pub. L. 100-485 effective Oct. 13, 
1988, see section 608(g)(2) of Pub. L. 100-485, set out as a note under 
section 704 of this title.
    Amendment by section 202(h)(2) of Pub. L. 100-360 applicable to 
items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. 
L. 100-360, set out as a note under section 1395u of this title.
    Section 301(f) of Pub. L. 100-360 provided that the amendment made 
by that section is effective as though included in the enactment of the 
Omnibus Budget Reconciliation Act of 1986, Pub. L. 99-509.
    Amendment by section 302(c)(3) of Pub. L. 100-360 applicable, except 
as otherwise provided, to payments under this subchapter for calendar 
quarters beginning on or after July 1, 1989, with respect to eligibility 
for medical assistance on or after that date, without regard to whether 
or not final regulations to carry out such amendment have been 
promulgated by such date, see section 302(f) of Pub. L. 100-360, set out 
as a note under section 1396a of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(a)(3)(A), (B)(iii), (k)(6)(B)(x), (7)(A), (D), 
(10)(D), (G)(ii) of Pub. L. 100-360, as it relates to a provision in the 
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as 
if included in the enactment of that provision in Pub. L. 100-203, see 
section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA; 
Effective Date note under section 106 of Title 1, General Provisions.
    Section 411(k)(12)(B) of Pub. L. 100-360 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall apply 
to actions occurring on or after the date of the enactment of this Act 
[July 1, 1988].''
    Section 411(k)(13)(B) of Pub. L. 100-360 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall take 
effect on the date of the enactment of this Act [July 1, 1988].''


                    Effective Date of 1987 Amendments

    Section 4118(d)(2) of Pub. L. 100-203 provided that: ``The 
amendments made by paragraph (1) [amending this section] shall be 
effective as if included in the enactment of section 9507 of the 
Consolidated Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99-
272].''
    Amendment by section 4118(h)(1) of Pub. L. 100-203 applicable to 
costs incurred after Dec. 22, 1987, see section 4118(h)(3) of Pub. L. 
100-203, as amended, set out as a note under section 1396a of this 
title.
    Amendments by sections 4211(d)(1), (g), (i), 4212(c)(1), (2), 
(d)(1), (e)(2) of Pub. L. 100-203 applicable to nursing facility 
services furnished on or after Oct. 1, 1990, without regard to whether 
regulations implementing such amendments are promulgated by such date, 
except as otherwise specifically provided in section 1396r of this 
title, with transitional rule, see section 4214(a), (b)(2) of Pub. L. 
100-203, as amended, set out as an Effective Date note under section 
1396r of this title.
    Amendment by section 4212(d)(1) of Pub. L. 100-203 not applicable 
until such date as of which the State has specified the resident 
assessment instrument under section 1396r(e)(5) of this title, and the 
State has begun conducting surveys under section 1396r(g)(2) of this 
title, see section 4212(d)(4) of Pub. L. 100-203, set out as a note 
under section 1396a of this title.
    Amendment by section 4213(b)(2) of Pub. L. 100-203 applicable to 
payments under this subchapter for calendar quarters beginning on or 
after Dec. 22, 1987, without regard to whether regulations implementing 
such amendment are promulgated by such date, except as otherwise 
specifically provided in section 1396r of this title, see section 
4214(b)(1) of Pub. L. 100-203, as amended, set out as an Effective Date 
note under section 1396r of this title.
    Amendment by Pub. L. 100-93 effective at end of fourteen-day period 
beginning Aug. 18, 1987, and inapplicable to administrative proceedings 
commenced before end of such period, see section 15(a) of Pub. L. 100-
93, set out as a note under section 1320a-7 of this title.


                    Effective Date of 1986 Amendments

    Amendment by Pub. L. 99-603 effective Oct. 1, 1987, see section 
121(c)(2) of Pub. L. 99-603, set out as a note under section 502 of this 
title.
    Amendment by Pub. L. 99-514 effective, except as otherwise provided, 
as if included in enactment of the Consolidated Omnibus Budget 
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub. 
L. 99-514, set out as a note under section 162 of Title 26, Internal 
Revenue Code.
    Amendment by section 9401(e)(2) of Pub. L. 99-509 applicable to 
medical assistance furnished in calendar quarters beginning on or after 
Apr. 1, 1987, without regard to whether of not final regulations to 
carry out such amendment have been promulgated by such date, see section 
9401(f) of Pub. L. 99-509, set out as a note under section 1396a of this 
title.
    Amendment by section 9403(g)(2) of Pub. l. 99-509 applicable to 
payments under this subchapter for calendar quarters beginning on or 
after July 1, 1987, without regard to whether or not final regulations 
to carry out such amendments have been promulgated by such date, see 
section 9403(h) of Pub. L. 99-509, set out as a note under section 1396a 
of this title.
    Amendment by section 9406(a) of Pub. L. 99-509 applicable, except as 
otherwise provided, to medical assistance furnished to aliens on or 
after Jan. 1, 1987, without regard to whether or not final regulations 
to carry out such amendments have been promulgated by such date, see 
section 9406(c) of Pub. L. 99-509, set out as a note under section 1396a 
of this title.
    Amendment by section 9407(c) of Pub. L. 99-509 applicable to 
ambulatory prenatal care furnished in calendar quarters beginning on or 
after Apr. 1, 1987, without regard to whether or not final regulations 
to carry out such amendments have been promulgated by such date, see 
section 9407(d) of Pub. L. 99-509, set out as a note under section 1396a 
of this title.
    Amendment by section 9431(b)(2) of Pub. L. 99-509 applicable to 
payments under this subchapter for calendar quarters beginning on or 
after July 1, 1987, without regard to whether or not final regulations 
to carry out such amendments have been promulgated by such date, see 
section 9431(c) of Pub. L. 99-509, set out as a note under section 1396a 
of this title.
    Section 9434(a)(3) of Pub. L. 99-509 provided that:
    ``(A) The amendments made by paragraph (1) [amending this section] 
shall take effect 6 months after the date of the enactment of this Act 
[Oct. 21, 1986].
    ``(B) The amendment made by paragraph (2) [amending this section] 
shall take effect on the date of the enactment of this Act and shall 
apply to contracts entered into, renewed, or extended after the end of 
the 30-day period beginning on the date of the enactment of this Act.''
    Amendment by section 9503(b), (f) of Pub. L. 99-272 applicable to 
calendar quarters beginning on or after Apr. 7, 1986, except as 
otherwise provided, see section 9503(g)(1), (2) of Pub. L. 99-272, set 
out as a note under section 1396a of this title.
    Section 9507(b) of Pub. L. 99-272 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to medical 
assistance furnished on or after January 1, 1987.''
    Section 9512(b) of Pub. L. 99-272 provided that: ``The amendments 
made by this section [amending this section] shall apply to overpayments 
identified for quarters beginning on or after October 1, 1985.''
    Section 9517(c)(2), (3) of Pub. L. 99-272, as amended by Pub. L. 99-
509, title IX, Sec. 9435(e), Oct. 21, 1986, 100 Stat. 2070; Pub. L. 99-
514, title XVIII, Sec. 1895(c)(4), Oct. 22, 1986, 100 Stat. 2935; Pub. 
L. 101-508, title IV, Sec. 4734, Nov. 5, 1990, 104 Stat. 1388-196; Pub. 
L. 104-240, Sec. 1(a), Oct. 8, 1996, 110 Stat. 3140, provided that:
    ``(2)(A) Except as provided in subparagraph (B) and in paragraph 
(3), the amendments made by paragraph (1) [amending this section] shall 
apply to expenditures incurred for health insuring organizations which 
first become operational on or after January 1, 1986. For purposes of 
this paragraph, a health insuring organization is not considered to be 
operational until the date on which it first enrolls patients.
    ``(B) In the case of a health insuring organization--
        ``(i) which first becomes operational on or after January 1, 
    1986, but
        ``(ii) for which the Secretary of Health and Human Services has 
    waived, under section 1915(b) of the Social Security Act [section 
    1396n(b) of this title] and before such date, certain requirements 
    of section 1902 of such Act [section 1396a of this title],
clauses (ii) and (vi) of section 1903(m)(2)(A) of such Act [subsec. 
(m)(2)(A)(ii) and (vi) of this section] shall not apply during the 
period for which such waiver is effective.
    ``(C) In the case of the Hartford Health Network, Inc., clauses (ii) 
and (vi) of section 1903(m)(2)(A) of the Social Security Act shall not 
apply during the period for which a waiver by the Secretary of Health 
and Human Services, under section 1915(b) of such Act, of certain 
requirements of section 1902 of such Act is in effect (pursuant to a 
request for a waiver under section 1915(b) of such Act submitted before 
January 1, 1986).
    ``(D) Nothing in section 1903(m)(1)(A) of the Social Security Act 
shall be construed as requiring a health-insuring organization to be 
organized under the health maintenance organization laws of a State.
    ``(3)(A) Subject to subparagraph (C), in the case of up to 3 health 
insuring organizations which are described in subparagraph (B), which 
first become operational on or after January 1, 1986, and which are 
designated by the Governor, and approved by the Legislature, of 
California, the amendments made by paragraph (1) shall not apply.
    ``(B) A health insuring organization described in this subparagraph 
is one that--
        ``(i) is operated directly by a public entity established by a 
    county government in the State of California under a State enabling 
    statute;
        ``(ii) enrolls all medicaid beneficiaries residing in the county 
    or counties in which it operates;
        ``(iii) meets the requirements for health maintenance 
    organizations under the Knox-Keene Act (Cal. Health and Safety Code, 
    section 1340 et seq.) and the Waxman-Duffy Act (Cal. Welfare and 
    Institutions Code, section 14450 et seq.);
        ``(iv) assures a reasonable choice of providers, which includes 
    providers that have historically served medicaid beneficiaries and 
    which does not impose any restriction which substantially impairs 
    access to covered services of adequate quality where medically 
    necessary;
        ``(v) provides for a payment adjustment for a disproportionate 
    share hospital (as defined under State law consistent with section 
    1923 of the Social Security Act [section 1396r-4 of this title]) in 
    a manner consistent with the requirements of such section; and
        ``(vi) provides for payment, in the case of childrens' hospital 
    services provided to medicaid beneficiaries who are under 21 years 
    of age, who are children with special health care needs under title 
    V of the Social Security Act [subchapter V of this chapter], and who 
    are receiving care coordination services under such title, at rates 
    determined by the California Medical Assistance Commission.
    ``(C) Subparagraph (A) shall not apply with respect to any period 
for which the Secretary of Health and Human Services determines that the 
number of medicaid beneficiaries enrolled with health insuring 
organizations described in subparagraph (B) exceeds 10 percent of the 
number of such beneficiaries in the State of California.
    ``(D) In this paragraph, the term `medicaid beneficiary' means an 
individual who is entitled to medical assistance under the State plan 
under title XIX of the Social Security Act [this subchapter], other than 
a qualified medicare beneficiary who is only entitled to such assistance 
because of section 1902(a)(10)(E) of such title [section 1396a(a)(10)(E) 
of this title].''
    [Pub. L. 104-240, Sec. 1(b), Oct. 8, 1996, 110 Stat. 3140, provided 
that: ``The amendment made by subsection (a) [amending section 
9517(c)(3)(B)(ii) of Pub. L. 99-272, set out above] shall apply to 
quarters beginning on or after October 1, 1996.'']
    Section 9518(b) of Pub. L. 99-272 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to payment 
under section 1903(a) of the Social Security Act [subsec. (a) of this 
section] for calendar quarters beginning on or after October 1, 1982.''


                    Effective Date of 1984 Amendments

    Amendment by Pub. L. 98-617 effective as if originally included in 
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of 
Pub. L. 98-617, set out as a note under section 1395f of this title.
    Amendment by section 2303(g)(2) of Pub. L. 98-369 applicable to 
payments for calendar quarters beginning on or after Oct. 1, 1984, but 
not applicable to clinical diagnostic laboratory tests furnished to 
inpatients of a provider operating under a waiver granted pursuant to 
section 602(k) of Pub. L. 98-21, set out as a note under section 1395y 
of this title, see section 2303(j)(2) and (3) of Pub. L. 98-369, set out 
as a note under section 1395l of this title.
    Section 2363(c) of Pub. L. 98-369 provided that: ``The amendments 
made by subsection (a) [amending this section and section 1396a of this 
title] apply to calendar quarters beginning on or after the date of the 
enactment of this Act [July 18, 1984], except that, in the case of 
individuals admitted to skilled nursing facilities before such date, the 
amendments made by such subsection shall not require recertifications 
sooner or more frequently than were required under the law in effect 
before such date.''


                    Effective Date of 1983 Amendment

    Amendment by Pub. L. 97-448 effective as if originally included as a 
part of this section as this section was amended by the Tax Equity and 
Fiscal Responsibility Act of 1982, Pub. L. 97-248, see section 309(c)(2) 
of Pub. L. 97-448, set out as a note under section 426-1 of this title.


                    Effective Date of 1982 Amendment

    Section 133(b) of Pub. L. 97-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall become effective on the 
date of the enactment of this Act [Sept. 3, 1982].''
    Amendment by section 137(a)(1), (2) of Pub. L. 97-248 effective as 
if originally included in the provision of the Omnibus Budget 
Reconciliation Act of 1981, Pub. L. 97-35, to which such amendment 
relates, see section 137(d)(1) of Pub. L. 97-248, set out as a note 
under section 1396a of this title.
    Amendment by section 137(b)(11)-(16), (27) of Pub. L. 97-248 
effective as if originally included as part of this section as this 
section was amended by the Omnibus Budget Reconciliation Act of 1981, 
Pub. L. 97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a 
note under section 1396a of this title.
    Section 137(g) of Pub. L. 97-248 provided that the amendment made by 
that section is effective Oct. 1, 1982.
    Amendment by section 146(b) of Pub. L. 97-248 effective with respect 
to contracts entered into or renewed on or after Sept. 3, 1982, see 
section 149 of Pub. L. 97-248, set out as an Effective Date note under 
section 1320c of this title.


                    Effective Date of 1981 Amendment

    Amendment by section 2101(a)(2) of Pub. L. 97-35 applicable only to 
services furnished by a hospital during any accounting year beginning on 
or after Oct. 1, 1981, see section 2101(c) of Pub. L. 97-35, set out as 
an Effective Date note under section 1395uu of this title.
    Section 2103(b)(2) of Pub. L. 97-35 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to amounts 
expended on or after October 1, 1981.''
    Amendment by section 2113(n) of Pub. L. 97-35 applicable to 
agreements with Professional Standards Review Organizations entered into 
on or after Oct. 1, 1981, see section 2113(o) of Pub. L. 97-35, set out 
as a note under section 1396a of this title.
    Section 2161(c)(1) of Pub. L. 97-35, as amended by Pub. L. 97-248, 
title I, Sec. 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the 
amendment made by such section 2161(c)(1) is effective for calendar 
quarters beginning on or after Oct. 1, 1984.
    Section 2161(c)(2) of Pub. L. 97-35, as amended by Pub. L. 97-248, 
title I, Sec. 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the 
amendment made by such section 2161(c)(2) is effective after payments 
for the first quarter of fiscal year 1985.
    Section 2164(b) of Pub. L. 97-35 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to tests 
occurring on or after October 1, 1981.''
    Amendment by section 2174(b) of Pub. L. 97-35 applicable to services 
furnished on or after Oct. 1, 1981, see section 2174(c) of Pub. L. 97-
35, set out as a note under section 1396a of this title.
    Amendment by section 2178(a) of Pub. L. 97-35 applicable with 
respect to services furnished, under a State plan approved under this 
subchapter, on or before Oct. 1, 1981, except that such amendments not 
applicable with respect to services furnished by a health maintenance 
organization under a contract with a State entered into under this 
subchapter before Oct. 1, 1981, unless the organization requests that 
such amendments apply and the Secretary and the State agency agree to 
such request, see section 2178(c) of Pub. L. 97-35, set out as a note 
under section 1396a of this title.
    Section 2183(b) of Pub. L. 97-35 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to payments 
made to States for calendar quarters beginning on or after October 1, 
1981.''


                    Effective Date of 1980 Amendment

    Section 961(b) of Pub. L. 96-499 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be effective with 
respect to expenditures for services furnished on or after October 1, 
1980.''


                    Effective Date of 1977 Amendments

    Amendment by section 3(c)(2) of Pub. L. 95-142 effective Jan. 1, 
1978, see section 3(e) of Pub. L. 95-142, set out as an Effective Date 
note under section 1320a-3 of this title.
    Amendment by section 8(c) of Pub. L. 95-142 effective with respect 
to contracts, agreements, etc., made on and after the first day of the 
fourth month beginning after Oct. 25, 1977, see section 8(e) of Pub. L. 
95-142, set out as an Effective Date note under section 1320a-5 of this 
title.
    Section 10(b) of Pub. L. 95-142 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
calendar quarters beginning after the date of the enactment of this Act 
[Oct. 25, 1977].''
    Section 11(c) of Pub. L. 95-142 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
medical assistance provided, under a State plan approved under title XIX 
of the Social Security Act [this subchapter], on and after January 1, 
1978.''
    Section 17(e)(1) of Pub. L. 95-142 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply with respect 
to calendar quarters beginning after September 30, 1977.''
    Section 20(c) of Pub. L. 95-142, as amended by Pub. L. 95-292, 
Sec. 8(e), June 13, 1978, 92 Stat. 316, provided that:
    ``(1) Except as provided in paragraph (2), the amendments made by 
this section [amending this section and section 1396a of this title] 
shall be effective on October 1, 1977, and the Secretary of Health, 
Education, and Welfare shall promptly adjust payments made to States 
under section 1903 of the Social Security Act [this section] to reflect 
the changes made by such amendments.
    ``(2) The amount of any reduction in the Federal medical assistance 
percentage of a State, otherwise required to be imposed under section 
1903(g)(1) of the Social Security Act [subsec. (g)(1) of this section] 
because of an unsatisfactory or invalid showing made by the State with 
respect to a calendar quarter beginning on or after January 1, 1977, 
shall be determined under such section as amended by this section. 
Subparagraph (B) of paragraph (4) of section 1903(g) of such Act 
[subsec. (g)(4)(B) of this section], as added by this section, shall 
apply to any showing made by a State under such section with respect to 
a calendar quarter beginning on or after January 1, 1977.''
    Section 105(a)(3) of Pub. L. 95-83 provided that: ``The amendments 
made by paragraphs (1) and (2) [amending this section] shall apply with 
respect to payments under title XIX of the Social Security Act [this 
subchapter] to States for services provided--
        ``(A) after October 8, 1976, under contracts under such title 
    [this subchapter] entered into or renegotiated after such date, or
        ``(B) after the expiration of the one-year period beginning on 
    such date,
whichever occurs first.''


                    Effective Date of 1976 Amendments

    Amendment by Pub. L. 94-552 effective Jan. 1, 1976, see section 2 of 
Pub. L. 94-552, set out as a note under section 1396a of this title.
    Section 202(b) of Pub. L. 94-460 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
payments under title XIX of the Social Security Act [this subchapter] to 
States for services provided--
        ``(1) after the date of enactment of subsection (a) [Oct. 8, 
    1976] under contracts under such title entered into or renegotiated 
    after such date, or
        ``(2) after the expiration of the 1-year period beginning on 
    such date of enactment,
whichever occurs first.''


                    Effective Date of 1975 Amendment

    Section 110(b) of Pub. L. 94-182 provided that: ``The amendment made 
by subsection (a) [amending this section] shall take effect on the first 
day of the first calendar month which begins not less than 90 days after 
the date of enactment of this Act [Dec. 31, 1975].''
    Amendment by section 111(b) of Pub. L. 94-182 effective January 1, 
1976, except as otherwise provided therein, see section 111(c) of Pub. 
L. 94-182, set out as a note under section 1396a of this title.


                    Effective Date of 1973 Amendments

    Amendment by section 13(a)(11), (12) of Pub. L. 93-233 effective 
with respect to payments under this section for calendar quarters 
commencing after Dec. 31, 1973, see section 13(d) of Pub. L. 93-233, set 
out as a note under section 1396a of this title.
    Amendment by section 18(u) of Pub. L. 93-233 effective July 1, 1973, 
see section 18(z-3)(4) of Pub. L. 93-233, set out as a note under 
section 1396a of this title.
    Section 234(b) of Pub. L. 93-66 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be applicable in the 
case of expenditures for skilled nursing services and for intermediate 
care facility services furnished in calendar quarters which begin after 
December 31, 1972.''


                    Effective Date of 1972 Amendment

    Section 207(b) of Pub. L. 92-603 provided that: ``The amendments 
made by subsection (a) [amending this section] shall, except as 
otherwise provided therein, be effective July 1, 1973.''
    Amendment by section 226(e) of Pub. L. 92-603 effective with respect 
to services provided on or after July 1, 1973, see section 226(f) of 
Pub. L. 92-603, set out as an Effective Date note under section 1395mm 
of this title.
    Amendment by section 233(c) of Pub. L. 92-603 applicable with 
respect to services furnished by hospitals in accounting periods 
beginning after Dec. 31, 1972, see section 233(f) of Pub. L. 92-603, set 
out as a note under section 1395f of this title. See, also, section 16 
of Pub. L. 93-233, set out as an Effective Date note under section 1395f 
of this title.
    Section 235(b) of Pub. L. 92-603 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply with respect 
to expenditures under State plans approved under title XIX of the Social 
Security Act [this subchapter], made after June 30, 1971.''
    Section 237(d)(1) of Pub. L. 92-603 provided that: ``The amendments 
made by subsections (a)(1) and (b) [amending this section and section 
706 of this title] shall apply with respect to services furnished in 
calendar quarters beginning after June 30, 1973.''
    Section 249B of Pub. L. 92-603, as amended by Pub. L. 93-368, 
Sec. 8, Aug. 7, 1974, 88 Stat. 422; Pub. L. 95-83, title III, 
Sec. 309(b), Aug. 1, 1977, 91 Stat. 396, provided that the amendment 
made by that section is effective for period beginning Oct. 1, 1972, and 
ending Sept. 30, 1980.


                    Effective Date of 1968 Amendments

    Section 220(b) of Pub. L. 90-248 provided that:
    ``(b)(1) In the case of any State whose plan under title XIX of the 
Social Security Act [this subchapter] is approved by the Secretary of 
Health, Education, and Welfare under section 1902 [section 1396a of this 
title] after July 25, 1967, the amendment made by subsection (a) 
[amending this section] shall apply with respect to calendar quarters 
beginning after the date of enactment of this Act [Jan. 2, 1968].
    ``(2) In the case of any State whose plan under title XIX of the 
Social Security Act [this subchapter] was approved by the Secretary of 
Health, Education, and Welfare under section 1902 of the Social Security 
Act [section 1396a of this title] prior to July 26, 1967, amendments 
made by subsection (a) [amending this section] shall apply with respect 
to calendar quarters beginning after June 30, 1968, except that--
        ``(A) with respect to the third and fourth calendar quarters of 
    1968, such subsection shall be applied by substituting in subsection 
    (f) of section 1903 of the Social Security Act [subsec. (f) of this 
    section] 150 percent for 133\1/2\ percent each time such latter 
    figure appears in such subsection (f), and
        ``(B) with respect to all calendar quarters during 1969, such 
    subsection shall be applied by substituting in subsection (f) of 
    section 1903 of such Act [subsec. (f) of this section] 140 percent 
    for 133\1/2\ percent each time such latter figure appears in such 
    subsection (f).''
    Section 222(d) of Pub. L. 90-248, as amended by section 303(a)(2) of 
Pub. L. 90-364, provided that the amendment made by such section 222(d) 
is effective with respect to calendar quarters beginning after December 
31, 1969.
    Section 225(b) of Pub. L. 90-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
expenditures made after December 31, 1967.''
    Section 303(b) of Pub. L. 90-364 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be effective with 
respect to calendar quarters beginning after December 31, 1967.''


                               Regulations

    Section 5 of Pub. L. 102-234 provided that:
    ``(a) In General.--Subject to subsection (b), the Secretary of 
Health and Human Services shall issue such regulations (on an interim 
final or other basis) as may be necessary to implement this Act [see 
Short Title of 1991 Amendment note set out under section 1305 of this 
title] and the amendments made by this Act.
    ``(b) Regulations Changing Treatment of Intergovernmental 
Transfers.--The Secretary may not issue any interim final regulation 
that changes the treatment (specified in section 433.45(a) of title 42, 
Code of Federal Regulations) of public funds as a source of State share 
of financial participation under title XIX of the Social Security Act 
[this subchapter], except as may be necessary to permit the Secretary to 
deny Federal financial participation for public funds described in 
section 1903(w)(6)(A) of such Act [subsection (w)(6)(A) of this section] 
(as added by section 2(a) of this Act) that are derived from donations 
or taxes that would not otherwise be recognized as the non-Federal share 
under section 1903(w) of such Act.
    ``(c) Consultation With States.--The Secretary shall consult with 
the States before issuing any regulations under this Act.''
    Secretary of Health and Human Services to promulgate final 
regulations necessary to carry out subsec. (r)(6)(j) of this section 
within 6 months after Apr. 7, 1986, see section 9503(c) of Pub. L. 99-
272, set out as a note under section 1396a of this title.


     References to Provisions of Part A of Subchapter IV Considered 
        References to Such Provisions as in Effect July 16, 1996

    For provisions that certain references to provisions of part A 
(Sec. 601 et seq.) of subchapter IV of this chapter be considered 
references to such provisions of part A as in effect July 16, 1996, see 
section 1396u-1(a) of this title.


    Treatment of Donation or Tax Proceeds Prior to Effective Date of 
                             Subsection (w)

    Section 2(c)(2) of Pub. L. 102-234 provided that: ``Except as 
specifically provided in section 1903(w) of the Social Security Act 
[subsec. (w) of this section] and notwithstanding any other provision of 
such Act [this chapter], the Secretary of Health and Human Services 
shall not, with respect to expenditures prior to the effective date 
specified in section 1903(w)(1)(F) of such Act, disallow any claim 
submitted by a State for, or otherwise withhold Federal financial 
participation with respect to, amounts expended for medical assistance 
under title XIX of the Social Security Act [this subchapter] by reason 
of the fact that the source of the funds used to constitute the non-
Federal share of such expenditures is a tax imposed on, or a donation 
received from, a health care provider, or on the ground that the amount 
of any donation or tax proceeds must be credited against the amount of 
the expenditure.''


      Temporary Increase in Federal Match for Administrative Costs

    Section 4401(b)(2) of Pub. L. 101-508 provided that: ``The per 
centum to be applied under section 1903(a)(7) of the Social Security Act 
[subsec. (a)(7) of this section] for amounts expended during calendar 
quarters in fiscal year 1991 which are attributable to administrative 
activities necessary to carry out section 1927 (other than subsection 
(g)) of such Act [section 1396r-8 of this title] shall be 75 percent, 
rather than 50 percent; after fiscal year 1991, the match shall revert 
back to 50 percent.''


 Report on Errors in Eligibility Determinations; Error Rate Transition 
                                  Rules

    Section 4607 of Pub. L. 101-508 directed Secretary of Health and 
Human Services to report to Congress, by not later than July 1, 1991, on 
error rates by States in determining eligibility of individuals 
described in subparagraph (A) or (B) of section 1396a(l)(1) of this 
title for medical assistance under plans approved under this subchapter, 
and directed that there should not be taken into account, for purposes 
of subsec. (u) of this section, payments and expenditures for medical 
assistance attributable to medical assistance for individuals described 
in such subparagraph (A) or (B), and made on or after July 1, 1989, and 
before the first calendar quarter that begins more than 12 months after 
the date of submission of the Secretary's report.


   Medically Needy Income Levels for Certain        1-Member Families    


    Section 4718 of Pub. L. 101-508 provided that:
    ``(a) In General.--For purposes of section 1903(f)(1)(B) [probably 
means subsec. (f)(1)(B) of this section], for payments made before, on, 
or after the date of the enactment of this Act [Nov. 5, 1990], a State 
described in subparagraph (B) may use, in determining the `highest 
amount which would ordinarily be paid to a family of the same size' 
(under the State's plan approved under part A of title IV of such Act 
[probably means part A of subchapter IV of this chapter]) in the case of 
a family consisting only of one individual and without regard to whether 
or not such plan provides for aid to families consisting only of one 
individual, an amount reasonably related to the highest money payment 
which would ordinarily be made under such a plan to a family of two 
without income or resources.
    ``(b) States Covered.--Subsection (a) shall only apply to a State 
the State plan of which (under title XIX of the Social Security Act 
[this subchapter]) as of June 1, 1989, provided for the policy described 
in such paragraph. For purposes of the previous sentence, a State plan 
includes all the matter included in a State plan under section 
2373(c)(5) of the Deficit Reduction Act of 1984 [Pub. L. 98-369, set out 
as a note under section 1396a of this title] (as amended by section 9 of 
the Medicare and Medicaid Patient and Program Protection Act of 1987 
[Pub. L. 100-93]).''


                  Day Habilitation and Related Services

    Section 6411(g) of Pub. L. 101-239 provided that:
    ``(1) Prohibition of disallowance pending issuance of regulations.--
Except as specifically permitted under paragraph (3), the Secretary of 
Health and Human Services may not--
        ``(A) withhold, suspend, disallow, or deny Federal financial 
    participation under section 1903(a) of the Social Security Act 
    [subsec. (a) of this section] for day habilitation and related 
    services under paragraph (9) or (13) of section 1905(a) of such Act 
    [section 1396d(a)(9), (13) of this title] on behalf of persons with 
    mental retardation or with related conditions pursuant to a 
    provision of its State plan as approved on or before June 30, 1989, 
    or
        ``(B) withdraw Federal approval of any such State plan 
    provision.
    ``(2) Requirements for regulation.--A final regulation described in 
this paragraph is a regulation, promulgated after a notice of proposed 
rule-making and a period of at least 60 days for public comment, that--
        ``(A) specifies the types of day habilitation and related 
    services that a State may cover under paragraph (9) or (13) of 
    section 1905(a) of the Social Security Act on behalf of persons with 
    mental retardation or with related conditions, and
        ``(B) any requirements respecting such coverage.
    ``(3) Prospective application of regulation.--If the Secretary 
promulgates a final regulation described in paragraph (2) and the 
Secretary determines that a State plan under title XIX of the Social 
Security Act [this subchapter] does not comply with such regulation, the 
Secretary shall notify the State of the determination and its basis, and 
such determination shall not apply to day habilitation and related 
services furnished before the first day of the first calendar quarter 
beginning after the date of the notice to the State.''


Nurse Aide Training and Evaluation Programs; Allocation of Costs Before 
                             October 1, 1990

    Section 6901(b)(5)(B) of Pub. L. 101-239 provided that: ``In making 
payments under section 1903(a)(2)(B) of the Social Security Act [subsec. 
(a)(2)(B) of this section] for amounts expended for nurse aide training 
and competency evaluation programs, and competency evaluation programs, 
described in section 1919(e)(1) of such Act [section 1396r(e)(1) of this 
title], in the case of activities conducted before October 1, 1990, the 
Secretary of Health and Human Services shall not take into account, or 
allocate amounts on the basis of, the proportion of residents of nursing 
facilities that is entitled to benefits under title XVIII or XIX of such 
Act [this subchapter and subchapter XVIII of this chapter].''


  Clarification of Federal Matching Rate for Survey and Certification 
                               Activities

    Section 6901(d)(2) of Pub. L. 101-239 provided that: ``During the 
period before October 1, 1990, the Federal percentage matching payment 
rate under section 1903(a) of the Social Security Act [subsec. (a) of 
this section] for so much of the sums expended under a State plan under 
title XIX of such Act [this subchapter] as are attributable to 
compensation or training of personnel responsible for inspecting public 
or private skilled nursing or intermediate care facilities to 
individuals receiving medical assistance to determine compliance with 
health or safety standards shall be 75 percent.''


                  Quality Control Transition Provisions

    Section 608(h) of Pub. L. 100-485 provided that: ``There shall not 
be taken into account, for purposes of section 1903(u) of the Social 
Security Act [subsec. (u) of this section], payments and expenditures 
for medical assistance which are made on or after January 1, 1989, and 
before July 1, 1989, and which are attributable to medicare-cost [sic] 
sharing for qualified medicare beneficiaries (as defined in section 
1905(p) of such Act [section 1396d(p) of this title]).''


              Delay Quality Control Sanctions for Medicaid

    Section 4117 of Pub. L. 100-203 provided that: ``The Secretary of 
Health and Human Services shall not, prior to July 1, 1988, implement 
any reductions in payments to States pursuant to section 1903(u) of the 
Social Security Act [subsec. (u) of this section] (or any provision of 
law described in subsection (c) of section 133 of the Tax Equity and 
Fiscal Responsibility Act of 1982 [section 133(c) of Pub. L. 97-248, set 
out below]).''


                  Temporary Technical Error Definition

    Section 4118(n) of Pub. L. 100-203 provided that: ``For purposes of 
section 1903(u)(1)(E)(ii) of the Social Security Act [subsec. 
(u)(1)(E)(ii) of this section], effective for the period beginning on 
the date of enactment of this Act [Dec. 22, 1987] and ending December 
31, 1988, a `technical error' is an error in eligibility condition (such 
as assignment of social security numbers and assignment of rights to 
third-party benefits as a condition of eligibility) that, if corrected, 
would not result in a difference in the amount of medical assistance 
paid.''


                Enhanced Funding for Nurse Aide Training

    Section 4211(d)(2) of Pub. L. 100-203, as amended by Pub. L. 100-
360, title IV, Sec. 411(l)(3)(F), July 1, 1988, 102 Stat. 803, provided 
that: ``For the 8 calendar quarters (beginning with the calendar quarter 
that begins on July 1, 1988), with respect to payment under section 
1903(a)(2)(B) of the Social Security Act [subsec. (a)(2)(B) of this 
section] to a State for additional amounts expended by the State under 
its plan approved under title XIX of such Act [this subchapter] for 
nursing aide training and competency evaluation programs, and competency 
evaluation programs, described in section 1919(e)(1) of such title 
[section 1396r(e)(1) of this title], any reference to `50 percent' is 
deemed a reference to the sum of the Federal medical assistance 
percentage (determined under section 1905(b) of such Act [section 
1396d(b) of this title]) plus 25 percentage points, but not to exceed 90 
percent.''


 Expenses Incurred for Review of Care Provided to Residents of Nursing 
                               Facilities

    Section 4212(c)(3) of Pub. L. 100-203 provided that: ``For purposes 
of section 1903(a) of the Social Security Act [subsec. (a) of this 
section], proper expenses incurred by a State for medical review by 
independent professionals of the care provided to residents of nursing 
facilities who are entitled to medical assistance under title XIX of 
such Act [this subchapter] shall be reimbursable as expenses necessary 
for the proper and efficient administration of the State plan under that 
title.''


             Quality Control Studies and Penalty Moratorium

    Section 12301 of Pub. L. 99-272, as amended by Pub. L. 99-514, title 
XVII, Sec. 1710, Oct. 22, 1986, 100 Stat. 2783; Pub. L. 100-485, title 
VI, Sec. 609(b), Oct. 13, 1988, 102 Stat. 2425, provided that:
    ``(a) Studies.--(1) The Secretary of Health and Human Services 
(hereafter referred to in this section as the `Secretary') shall conduct 
a study of quality control systems for the Aid to Families with 
Dependent Children Program under title IV-A of the Social Security Act 
[part A of subchapter IV of this chapter] and for the Medicaid Program 
under title XIX of such Act [this subchapter]. The study shall examine 
how best to operate such systems in order to obtain information which 
will allow program managers to improve the quality of administration, 
and provide reasonable data on the basis of which Federal funding may be 
withheld for States with excessive levels of erroneous payments.
    ``(2) The Secretary shall also contract with the National Academy of 
Sciences to conduct a concurrent independent study for the purpose 
described in paragraph (1). For purposes of such study, the Secretary 
shall provide to the National Academy of Sciences any relevant data 
available to the Secretary at the onset of the study and on an ongoing 
basis.
    ``(3) The Secretary and the National Academy of Sciences shall 
report the results of their respective studies to the Congress within 
one year after the date the Secretary and the National Academy of 
Sciences enter into the contract required under paragraph (2).
    ``(b) Moratorium on Penalties.--(1) During the 24-month period 
beginning with the first calendar quarter which begins after the date of 
the enactment of this Act [Apr. 7, 1986] (hereafter in this section 
referred to as the `moratorium period'), the Secretary shall not impose 
any reductions in payments to States pursuant to section 403(i) of the 
Social Security Act [section 603(i) of this title] (or prior 
regulations), or pursuant to any comparable provision of law relating to 
the programs under title IV-A of such Act [part A of subchapter IV of 
this chapter] in Puerto Rico, Guam, the Virgin Islands, American Samoa, 
or the Northern Mariana Islands.
    ``(2) During the moratorium period, the Secretary and the States 
shall continue to operate the quality control systems in effect under 
title IV-A of the Social Security Act, and to calculate the error rates 
under the provisions referred to in paragraph (1).
    ``(c) Restructured Quality Control Systems.--(1) Not later than 6 
months after the date on which the results of both studies required 
under subsection (a)(3) have been reported, the Secretary shall publish 
regulations which shall--
        ``(A) restructure the quality control systems under title XIX of 
    the Social Security Act [this subchapter] to the extent the 
    Secretary determines to be appropriate, taking into account the 
    studies conducted under subsection (a); and
        ``(B) establish, taking into account the studies conducted under 
    subsection (a), criteria for adjusting the reductions which shall be 
    made for quarters prior to the implementation of the restructured 
    quality control systems so as to eliminate reductions for those 
    quarters which would not be required if the restructured quality 
    control systems had been in effect during those quarters.
    ``(2) Beginning with the first calendar quarter after the moratorium 
period, the Secretary shall implement the revised quality control 
systems under title XIX, and shall reduce payments to States--
        ``(A) for quarters after the moratorium period in accordance 
    with the restructured quality control systems; and
        ``(B) for quarters in and before the moratorium period, as 
    provided under the regulations described in paragraph (1)(B).
    ``(d) Effective Date.--This section shall become effective on the 
date of the enactment of this Act [Apr. 7, 1986].''


  Effectiveness of Laws Limiting Federal Financial Participation With 
Respect to Erroneous Payments Made by States Under a State Plan Approved 
                          Under This Subchapter

    Section 133(c) of Pub. L. 97-248 provided that: ``No provision of 
law limiting Federal financial participation with respect to erroneous 
payments made by States under a State plan approved under title XIX of 
the Social Security Act [this subchapter] (including any provision 
contained in, or incorporated by reference into, any appropriation Act 
or resolution making continuing appropriations), other than the 
limitations contained in section 1903 of such Act [this section], shall 
be effective with respect to payments to States under such section 1903 
for quarters beginning on or after October 1, 1982, unless such 
provision of law is enacted after the date of the date of the enactment 
of this Act [Sept. 3, 1982] and expressly provides that such limitation 
is in addition to or in lieu of the limitations contained in section 
1903 of the Social Security Act.''


   Medicaid Payments for Indian Health Service Facilities To Be Paid 
     Entirely by Federal Funds; Exclusion of Payments to States in 
      Computation of Target Amount of Federal Medicaid Expenditures

    Pub. L. 97-92, Secs. 102, 118, Dec. 15, 1981, 95 Stat. 1193, 1197, 
as amended by Pub. L. 97-161, Mar. 31, 1982, 96 Stat. 22, provided, for 
the period Dec. 15, 1981, to not later than Sept. 30, 1982, that: 
``Notwithstanding section 1903(s) of the Social Security Act [subsec. 
(s) of this section], all medicaid payments to the States for Indian 
health service facilities as defined by section 1911 of the Social 
Security Act [section 1396j of this title] shall be paid entirely by 
Federal funds, and notwithstanding section 1903(t) of the Social 
Security Act [subsec. (t) of this section], all medicaid payments to the 
States for Indian health service facilities shall not be included in the 
computation of the target amount of Federal medicaid expenditures.''


Promulgation of Regulations for Implementation of Amendments by Section 
                          17 of Pub. L. 95-142

    Section 17(e)(2) of Pub. L. 95-142 required Secretary of Health, 
Education, and Welfare to establish regulations, not later than 90 days 
after Oct. 25, 1977, to carry out amendments made by section 17 
(amending sections 1395b-1 and 1396b of this title). See section 1302 of 
this title.


        Deferral of Implementation of Decreases in Matching Funds

    Section 6 of Pub. L. 95-59, June 30, 1977, 91 Stat. 255, provided 
that: ``Notwithstanding the provisions of subsection (g) of section 1903 
of the Social Security Act [subsec. (g) of this section], the amount 
payable to any State for the calendar quarters during the period 
commencing April 1, 1977, and ending September 30, 1977, on account of 
expenditures made under a State plan approved under title XIX of such 
Act [this subchapter], shall not be decreased by reason of the 
application of the provisions of such subsection with respect to any 
period for which such State plan was in operation prior to April 1, 
1977.''


  Comprehensive Care and Services for Eligible Individuals by July 1, 
  1977; Requirement Inapplicable for Any Period Prior to July 1, 1971; 
                      Regulations; Advice to States

    Section 2(b) of Pub. L. 91-56, which provided that subsection (e) of 
this section was inapplicable to the period prior to July 1, 1971, and 
which authorized the Secretary to issue regulations, was repealed by 
Pub. L. 92-603, title II, Sec. 230, Oct. 30, 1972, 86 Stat. 1410.


Exemption of Puerto Rico, the Virgin Islands, and Guam From Limitations 
               on Federal Payments for Medical Assistance

    Section 248(d) of Pub. L. 90-248 provided that: ``The amendment made 
by section 220(a) of this Act [amending this section] shall not apply in 
the case of Puerto Rico, the Virgin Islands, or Guam.''


 Nonduplication of Payments to States; Limitation on Institutional Care

    Section 121(b) of Pub. L. 89-97, as amended by section 249D of Pub. 
L. 92-603, provided that: ``No payment may be made to any State under 
title I, IV, X, XIV, or XVI of the Social Security Act [subchapter I, 
IV, X, XIV, or XVI of this chapter] with respect to aid or assistance in 
the form of medical or any other type of remedial care for any period 
for which such State receives payments under title XIX of such Act [this 
subchapter], or for any period after December 31, 1969. After the date 
of enactment of the Social Security Amendments of 1972 [Oct. 30, 1972], 
Federal matching shall not be available for any portion of any payment 
by any State under title I, X, XIV, or XVI, or part A of title IV, of 
the Social Security Act [subchapter I, X, XIV, or XVI, or part A of 
subchapter IV of this chapter] for or on account of any medical or any 
other type of remedial care provided by an institution to any individual 
as an inpatient thereof, in the case of any State which has a plan 
approved under title XIX of such Act [this subchapter], if such care is 
(or could be) provided under a State plan approved under title XIX of 
such Act [this subchapter] by an institution certified under such title 
XIX [this subchapter].''

                  Section Referred to in Other Sections

    This section is referred to in sections 1315, 1320a-7, 1320a-7b, 
1320b-7, 1320c-7, 1395i-3, 1395eee, 1396a, 1396d, 1396e, 1396n, 1396r, 
1396r-1, 1396r-1a, 1396r-2, 1396r-4, 1396r-6, 1396r-8, 1396t, 1396u-1, 
1396u-2, 1396u-3, 1396u-4, 1397dd, 1397ee, 1397gg, 1786, 3058i of this 
title; title 7 section 2025; title 8 sections 1611, 1621; title 18 
section 506.
