
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1396e]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
    SUBCHAPTER XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
 
Sec. 1396e. Enrollment of individuals under group health plans


(a) Requirements of each State plan; guidelines

    Each State plan--
        (1) may implement guidelines established by the Secretary, 
    consistent with subsection (b) of this section, to identify those 
    cases in which enrollment of an individual otherwise entitled to 
    medical assistance under this subchapter in a group health plan (in 
    which the individual is otherwise eligible to be enrolled) is cost-
    effective (as defined in subsection (e)(2) of this section);
        (2) may require, in case of an individual so identified and as a 
    condition of the individual being or remaining eligible for medical 
    assistance under this subchapter and subject to subsection (b)(2) of 
    this section, notwithstanding any other provision of this 
    subchapter, that the individual (or in the case of a child, the 
    child's parent) apply for enrollment in the group health plan; and
        (3) in the case of such enrollment (except as provided in 
    subsection (c)(1)(B) of this section), shall provide for payment of 
    all enrollee premiums for such enrollment and all deductibles, 
    coinsurance, and other cost-sharing obligations for items and 
    services otherwise covered under the State plan under this 
    subchapter (exceeding the amount otherwise permitted under section 
    1396o of this title), and shall treat coverage under the group 
    health plan as a third party liability (under section 1396a(a)(25) 
    of this title).

(b) Timing of enrollment; failure to enroll

    (1) In establishing guidelines under subsection (a)(1) of this 
section, the Secretary shall take into account that an individual may 
only be eligible to enroll in group health plans at limited times and 
only if other individuals (not entitled to medical assistance under the 
plan) are also enrolled in the plan simultaneously.
    (2) If a parent of a child fails to enroll the child in a group 
health plan in accordance with subsection (a)(2) of this section, such 
failure shall not affect the child's eligibility for benefits under this 
subchapter.

(c) Premiums considered payments for medical assistance; eligibility

    (1)(A) In the case of payments of premiums, deductibles, 
coinsurance, and other cost-sharing obligations under this section shall 
be considered, for purposes of section 1396b(a) of this title, to be 
payments for medical assistance.
    (B) If all members of a family are not eligible for medical 
assistance under this subchapter and enrollment of the members so 
eligible in a group health plan is not possible without also enrolling 
members not so eligible--
        (i) payment of premiums for enrollment of such other members 
    shall be treated as payments for medical assistance for eligible 
    individuals, if it would be cost-effective (taking into account 
    payment of all such premiums), but
        (ii) payment of deductibles, coinsurance, and other cost-sharing 
    obligations for such other members shall not be treated as payments 
    for medical assistance for eligible individuals.

    (2) The fact that an individual is enrolled in a group health plan 
under this section shall not change the individual's eligibility for 
benefits under the State plan, except insofar as section 1396a(a)(25) of 
this title provides that payment for such benefits shall first be made 
by such plan.

(d) Repealed. Pub. L. 105-33, title IV, Sec. 4741(b)(2), Aug. 5, 1997, 
        111 Stat. 523

(e) Definitions

    In this section:
        (1) The term ``group health plan'' has the meaning given such 
    term in section 5000(b)(1) of the Internal Revenue Code of 1986, and 
    includes the provision of continuation coverage by such a plan 
    pursuant to title XXII of the Public Health Service Act [42 U.S.C. 
    300bb-1 et seq.], section 4980B of the Internal Revenue Code of 
    1986, or title VI \1\ of the Employee Retirement Income Security Act 
    of 1974.
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    \1\ See References in Text note below.
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        (2) The term ``cost-effective'' means, as established by the 
    Secretary, that the reduction in expenditures under this subchapter 
    with respect to an individual who is enrolled in a group health plan 
    is likely to be greater than the additional expenditures for 
    premiums and cost-sharing required under this section with respect 
    to such enrollment.

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1906, as added Pub. L. 101-508, 
title IV, Sec. 4402(a)(2), Nov. 5, 1990, 104 Stat. 1388-161; amended 
Pub. L. 105-33, title IV, Sec. 4741(b), Aug. 5, 1997, 111 Stat. 523.)

                       References in Text

    The Internal Revenue Code of 1986, referred to in subsec. (e)(1), is 
classified generally to Title 26, Internal Revenue Code.
    The Public Health Service Act, referred to in subsec. (e)(1), is act 
July 1, 1944, ch. 373, 58 Stat. 682, as amended. Title XXII of the Act 
is classified generally to subchapter XX (Sec. 300bb-1 et seq.) of 
chapter 6A of this title. For complete classification of this Act to the 
Code, see Short Title note set out under section 201 of this title and 
Tables.
    The Employee Retirement Income Security Act of 1974, referred to in 
subsec. (e)(1), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 829, as 
amended. Title VI of the Act probably means part 6 of subtitle B of 
title I of the Act which is classified generally to part 6 (Sec. 1161 et 
seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor, 
because the Act has no title VI. For complete classification of this Act 
to the Code, see Short Title note set out under section 1001 of Title 29 
and Tables.


                            Prior Provisions

    A prior section 1396e, act Aug. 14, 1935, ch. 531, title XIX, 
Sec. 1906, as added Jan. 2, 1968, Pub. L. 90-248, title II, Sec. 226, 81 
Stat. 903, created Advisory Council on Medical Assistance, set forth 
composition of Council, term of membership of members, and purposes of 
Council, and provided for compensation of members, prior to repeal by 
Pub. L. 92-603, title II, Sec. 287, Oct. 30, 1972, 86 Stat. 1457, 
effective on the first day of the third calendar month following Oct. 
30, 1972.


                               Amendments

    1997--Subsec. (a). Pub. L. 105-33, Sec. 4741(b)(1), in introductory 
provisions, substituted ``Each'' for ``For purposes of section 
1396a(a)(25)(G) of this title and subject to subsection (d) of this 
section, each'' and, in pars. (1) and (2), substituted ``may'' for 
``shall''.
    Subsec. (d). Pub. L. 105-33, Sec. 4741(b)(2), struck out subsec. (d) 
which read as follows:
    ``(1) In the case of any State which is providing medical assistance 
to its residents under a waiver granted under section 1315 of this 
title, the Secretary shall require the State to meet the requirements of 
this section in the same manner as the State would be required to meet 
such requirement if the State had in effect a plan approved under this 
subchapter.
    ``(2) This section, and section 1396a(a)(25)(G) of this title, shall 
only apply to a State that is one of the 50 States or the District of 
Columbia.''


                             Effective Date

    Section 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 an 
Effective Date of 1990 Amendment note under section 1396a of this title.

                  Section Referred to in Other Sections

    This section is referred to in sections 1396a, 1396b of this title.
