
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)]
[Document affected by Public Law 107-121 Section 2(b)(3)]
[CITE: 42USC1396n]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
    SUBCHAPTER XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
 
Sec. 1396n. Compliance with State plan and payment provisions


(a) Activities deemed as compliance

    A State shall not be deemed to be out of compliance with the 
requirements of paragraphs (1), (10), or (23) of section 1396a(a) of 
this title solely by reason of the fact that the State (or any political 
subdivision thereof)--
        (1) has entered into--
            (A) a contract with an organization which has agreed to 
        provide care and services in addition to those offered under the 
        State plan to individuals eligible for medical assistance who 
        reside in the geographic area served by such organization and 
        who elect to obtain such care and services from such 
        organization, or by reason of the fact that the plan provides 
        for payment for rural health clinic services only if those 
        services are provided by a rural health clinic; or
            (B) arrangements through a competitive bidding process or 
        otherwise for the purchase of laboratory services referred to in 
        section 1396d(a)(3) of this title or medical devices if the 
        Secretary has found that--
                (i) adequate services or devices will be available under 
            such arrangements, and
                (ii) any such laboratory services will be provided only 
            through laboratories--
                    (I) which meet the applicable requirements of 
                section 1395x(e)(9) of this title or paragraphs (16) and 
                (17) of section 1395x(s) of this title, and such 
                additional requirements as the Secretary may require, 
                and
                    (II) no more than 75 percent of whose charges for 
                such services are for services provided to individuals 
                who are entitled to benefits under this subchapter or 
                under part A or part B of subchapter XVIII of this 
                chapter; or

        (2) restricts for a reasonable period of time the provider or 
    providers from which an individual (eligible for medical assistance 
    for items or services under the State plan) can receive such items 
    or services, if--
            (A) the State has found, after notice and opportunity for a 
        hearing (in accordance with procedures established by the 
        State), that the individual has utilized such items or services 
        at a frequency or amount not medically necessary (as determined 
        in accordance with utilization guidelines established by the 
        State), and
            (B) under such restriction, individuals eligible for medical 
        assistance for such services have reasonable access (taking into 
        account geographic location and reasonable travel time) to such 
        services of adequate quality.

(b) Waivers to promote cost-effectiveness and efficiency

    The Secretary, to the extent he finds it to be cost-effective and 
efficient and not inconsistent with the purposes of this subchapter, may 
waive such requirements of section 1396a of this title (other than 
subsection (s)) (other than sections 1396a(a)(13)(C) and 1396a(a)(10)(A) 
of this title insofar as it requires provision of the care and services 
described in section 1396d(a)(2)(C) of this title) as may be necessary 
for a State--
        (1) to implement a primary care case-management system or a 
    specialty physician services arrangement which restricts the 
    provider from (or through) whom an individual (eligible for medical 
    assistance under this subchapter) can obtain medical care services 
    (other than in emergency circumstances), if such restriction does 
    not substantially impair access to such services of adequate quality 
    where medically necessary,
        (2) to allow a locality to act as a central broker in assisting 
    individuals (eligible for medical assistance under this subchapter) 
    in selecting among competing health care plans, if such restriction 
    does not substantially impair access to services of adequate quality 
    where medically necessary,
        (3) to share (through provision of additional services) with 
    recipients of medical assistance under the State plan cost savings 
    resulting from use by the recipient of more cost-effective medical 
    care, and
        (4) to restrict the provider from (or through) whom an 
    individual (eligible for medical assistance under this subchapter) 
    can obtain services (other than in emergency circumstances) to 
    providers or practitioners who undertake to provide such services 
    and who meet, accept, and comply with the reimbursement, quality, 
    and utilization standards under the State plan, which standards 
    shall be consistent with the requirements of section 1396r-4 of this 
    title and are consistent with access, quality, and efficient and 
    economic provision of covered care and services, if such restriction 
    does not discriminate among classes of providers on grounds 
    unrelated to their demonstrated effectiveness and efficiency in 
    providing those services and if providers under such restriction are 
    paid on a timely basis in the same manner as health care 
    practitioners must be paid under section 1396a(a)(37)(A) of this 
    title.

No waiver under this subsection may restrict the choice of the 
individual in receiving services under section 1396d(a)(4)(C) of this 
title.

(c) Waiver respecting medical assistance requirement in State plan; 
        scope, etc.; ``habilitation services'' defined; imposition of 
        certain regulatory limits prohibited; computation of 
        expenditures for certain disabled patients; coordinated 
        services; substitution of participants

    (1) The Secretary may by waiver provide that a State plan approved 
under this subchapter may include as ``medical assistance'' under such 
plan payment for part or all of the cost of home or community-based 
services (other than room and board) approved by the Secretary which are 
provided pursuant to a written plan of care to individuals with respect 
to whom there has been a determination that but for the provision of 
such services the individuals would require the level of care provided 
in a hospital or a nursing facility or intermediate care facility for 
the mentally retarded the cost of which could be reimbursed under the 
State plan. For purposes of this subsection, the term ``room and board'' 
shall not include an amount established under a method determined by the 
State to reflect the portion of costs of rent and food attributable to 
an unrelated personal caregiver who is residing in the same household 
with an individual who, but for the assistance of such caregiver, would 
require admission to a hospital, nursing facility, or intermediate care 
facility for the mentally retarded.
    (2) A waiver shall not be granted under this subsection unless the 
State provides assurances satisfactory to the Secretary that--
        (A) necessary safeguards (including adequate standards for 
    provider participation) have been taken to protect the health and 
    welfare of individuals provided services under the waiver and to 
    assure financial accountability for funds expended with respect to 
    such services;
        (B) the State will provide, with respect to individuals who--
            (i) are entitled to medical assistance for inpatient 
        hospital services, nursing facility services, or services in an 
        intermediate care facility for the mentally retarded under the 
        State plan,
            (ii) may require such services, and
            (iii) may be eligible for such home or community-based care 
        under such waiver,

    for an evaluation of the need for inpatient hospital services, 
    nursing facility services, or services in an intermediate care 
    facility for the mentally retarded;
        (C) such individuals who are determined to be likely to require 
    the level of care provided in a hospital, nursing facility, or 
    intermediate care facility for the mentally retarded are informed of 
    the feasible alternatives, if available under the waiver, at the 
    choice of such individuals, to the provision of inpatient hospital 
    services, nursing facility services, or services in an intermediate 
    care facility for the mentally retarded;
        (D) under such waiver the average per capita expenditure 
    estimated by the State in any fiscal year for medical assistance 
    provided with respect to such individuals does not exceed 100 
    percent of the average per capita expenditure that the State 
    reasonably estimates would have been made in that fiscal year for 
    expenditures under the State plan for such individuals if the waiver 
    had not been granted; and
        (E) the State will provide to the Secretary annually, consistent 
    with a data collection plan designed by the Secretary, information 
    on the impact of the waiver granted under this subsection on the 
    type and amount of medical assistance provided under the State plan 
    and on the health and welfare of recipients.

    (3) A waiver granted under this subsection may include a waiver of 
the requirements of section 1396a(a)(1) of this title (relating to 
statewideness), section 1396a(a)(10)(B) of this title (relating to 
comparability), and section 1396a(a)(10)(C)(i)(III) of this title 
(relating to income and resource rules applicable in the community). A 
waiver under this subsection shall be for an initial term of three years 
and, upon the request of a State, shall be extended for additional five-
year periods unless the Secretary determines that for the previous 
waiver period the assurances provided under paragraph (2) have not been 
met. A waiver may provide, with respect to post-eligibility treatment of 
income of all individuals receiving services under that waiver, that the 
maximum amount of the individual's income which may be disregarded for 
any month for the maintenance needs of the individual may be an amount 
greater than the maximum allowed for that purpose under regulations in 
effect on July 1, 1985.
    (4) A waiver granted under this subsection may, consistent with 
paragraph (2)--
        (A) limit the individuals provided benefits under such waiver to 
    individuals with respect to whom the State has determined that there 
    is a reasonable expectation that the amount of medical assistance 
    provided with respect to the individual under such waiver will not 
    exceed the amount of such medical assistance provided for such 
    individual if the waiver did not apply, and
        (B) provide medical assistance to individuals (to the extent 
    consistent with written plans of care, which are subject to the 
    approval of the State) for case management services, homemaker/home 
    health aide services and personal care services, adult day health 
    services, habilitation services, respite care, and such other 
    services requested by the State as the Secretary may approve and for 
    day treatment or other partial hospitalization services, 
    psychosocial rehabilitation services, and clinic services (whether 
    or not furnished in a facility) for individuals with chronic mental 
    illness.

Except as provided under paragraph (2)(D), the Secretary may not 
restrict the number of hours or days of respite care in any period which 
a State may provide under a waiver under this subsection.
    (5) For purposes of paragraph (4)(B), the term ``habilitation 
services''--
        (A) means services designed to assist individuals in acquiring, 
    retaining, and improving the self-help, socialization, and adaptive 
    skills necessary to reside successfully in home and community based 
    settings; and
        (B) includes (except as provided in subparagraph (C)) 
    prevocational, educational, and supported employment services; but
        (C) does not include--
            (i) special education and related services (as defined in 
        paragraphs (16) and (17) of section 1401(a) \1\ of title 20) 
        which otherwise are available to the individual through a local 
        educational agency; and
            (ii) vocational rehabilitation services which otherwise are 
        available to the individual through a program funded under 
        section 730 of title 29.

    (6) The Secretary may not require, as a condition of approval of a 
waiver under this section under paragraph (2)(D), that the actual total 
expenditures for home and community-based services under the waiver (and 
a claim for Federal financial participation in expenditures for the 
services) cannot exceed the approved estimates for these services. The 
Secretary may not deny Federal financial payment with respect to 
services under such a waiver on the ground that, in order to comply with 
paragraph (2)(D), a State has failed to comply with such a requirement.
    (7)(A) In making estimates under paragraph (2)(D) in the case of a 
waiver that applies only to individuals with a particular illness or 
condition who are inpatients in, or who would require the level of care 
provided in, hospitals, nursing facilities, or intermediate care 
facilities for the mentally retarded, the State may determine the 
average per capita expenditure that would have been made in a fiscal 
year for those individuals under the State plan separately from the 
expenditures for other individuals who are inpatients in, or who would 
require the level of care provided in, those respective facilities.
    (B) In making estimates under paragraph (2)(D) in the case of a 
waiver that applies only to individuals with developmental disabilities 
who are inpatients in a nursing facility and whom the State has 
determined, on the basis of an evaluation under paragraph (2)(B), to 
need the level of services provided by an intermediate care facility for 
the mentally retarded, the State may determine the average per capita 
expenditures that would have been made in a fiscal year for those 
individuals under the State plan on the basis of the average per capita 
expenditures under the State plan for services to individuals who are 
inpatients in an intermediate care facility for the mentally retarded, 
without regard to the availability of beds for such inpatients.
    (C) In making estimates under paragraph (2)(D) in the case of a 
waiver to the extent that it applies to individuals with mental 
retardation or a related condition who are resident in an intermediate 
care facility for the mentally retarded the participation of which under 
the State plan is terminated, the State may determine the average per 
capita expenditures that would have been made in a fiscal year for those 
individuals without regard to any such termination.
    (8) The State agency administering the plan under this subchapter 
may, whenever appropriate, enter into cooperative arrangements with the 
State agency responsible for administering the program for children with 
special health care needs under subchapter V of this chapter in order to 
assure improved access to coordinated services to meet the needs of such 
children.
    (9) In the case of any waiver under this subsection which contains a 
limit on the number of individuals who shall receive home or community-
based services, the State may substitute additional individuals to 
receive such services to replace any individuals who die or become 
ineligible for services under the State plan.
    (10) The Secretary shall not limit to fewer than 200 the number of 
individuals in the State who may receive home and community-based 
services under a waiver under this subsection.

(d) Home and community-based services for elderly

    (1) Subject to paragraph (2), the Secretary shall grant a waiver to 
provide that a State plan approved under this subchapter shall include 
as ``medical assistance'' under such plan payment for part or all of the 
cost of home or community-based services (other than room and board) 
which are provided pursuant to a written plan of care to individuals 65 
years of age or older with respect to whom there has been a 
determination that but for the provision of such services the 
individuals would be likely to require the level of care provided in a 
skilled nursing facility or intermediate care facility the cost of which 
could be reimbursed under the State plan. For purposes of this 
subsection, the term ``room and board'' shall not include an amount 
established under a method determined by the State to reflect the 
portion of costs of rent and food attributable to an unrelated personal 
caregiver who is residing in the same household with an individual who, 
but for the assistance of such caregiver, would require admission to a 
hospital, nursing facility, or intermediate care facility for the 
mentally retarded.
    (2) A waiver shall not be granted under this subsection unless the 
State provides assurances satisfactory to the Secretary that--
        (A) necessary safeguards (including adequate standards for 
    provider participation) have been taken to protect the health and 
    welfare of individuals provided services under the waiver and to 
    assure financial accountability for funds expended with respect to 
    such services;
        (B) with respect to individuals 65 years of age or older who--
            (i) are entitled to medical assistance for skilled nursing 
        or intermediate care facility services under the State plan,
            (ii) may require such services, and
            (iii) may be eligible for such home or community-based 
        services under such waiver,

    the State will provide for an evaluation of the need for such 
    skilled nursing facility or intermediate care facility services; and
        (C) such individuals who are determined to be likely to require 
    the level of care provided in a skilled nursing facility or 
    intermediate care facility are informed of the feasible alternatives 
    to the provision of skilled nursing facility or intermediate care 
    facility services, which such individuals may choose if available 
    under the waiver.

Each State with a waiver under this subsection shall provide to the 
Secretary annually, consistent with a reasonable data collection plan 
designed by the Secretary, information on the impact of the waiver 
granted under this subsection on the type and amount of medical 
assistance provided under the State plan and on the health and welfare 
of recipients.
    (3) A waiver granted under this subsection may include a waiver of 
the requirements of section 1396a(a)(1) of this title (relating to 
statewideness), section 1396a(a)(10)(B) of this title (relating to 
comparability), and section 1396a(a)(10)(C)(i)(III) of this title 
(relating to income and resource rules applicable in the community). 
Subject to a termination by the State (with notice to the Secretary) at 
any time, a waiver under this subsection shall be for an initial term of 
3 years and, upon the request of a State, shall be extended for 
additional 5-year periods unless the Secretary determines that for the 
previous waiver period the assurances provided under paragraph (2) have 
not been met. A waiver may provide, with respect to post-eligibility 
treatment of income of all individuals receiving services under the 
waiver, that the maximum amount of the individual's income which may be 
disregarded for any month is equal to the amount that may be allowed for 
that purpose under a waiver under subsection (c) of this section.
    (4) A waiver under this subsection may, consistent with paragraph 
(2), provide medical assistance to individuals for case management 
services, homemaker/home health aide services and personal care 
services, adult day health services, respite care, and other medical and 
social services that can contribute to the health and well-being of 
individuals and their ability to reside in a community-based care 
setting.
    (5)(A) In the case of a State having a waiver approved under this 
subsection, notwithstanding any other provision of section 1396b of this 
title to the contrary, the total amount expended by the State for 
medical assistance with respect to skilled nursing facility services, 
intermediate care facility services, and home and community-based 
services under the State plan for individuals 65 years of age or older 
during a waiver year under this subsection may not exceed the projected 
amount determined under subparagraph (B).
    (B) For purposes of subparagraph (A), the projected amount under 
this subparagraph is the sum of the following:
        (i) The aggregate amount of the State's medical assistance under 
    this subchapter for skilled nursing facility services and 
    intermediate care facility services furnished to individuals who 
    have attained the age of 65 for the base year increased by a 
    percentage which is equal to the lesser of 7 percent times the 
    number of years (rounded to the nearest quarter of a year) beginning 
    after the base year and ending at the end of the waiver year 
    involved or the sum of--
            (I) the percentage increase (based on an appropriate market-
        basket index representing the costs of elements of such 
        services) between the beginning of the base year and the 
        beginning of the waiver year involved, plus
            (II) the percentage increase between the beginning of the 
        base year and the beginning of the waiver year involved in the 
        number of residents in the State who have attained the age of 
        65, plus
            (III) 2 percent for each year (rounded to the nearest 
        quarter of a year) beginning after the base year and ending at 
        the end of the waiver year.

        (ii) The aggregate amount of the State's medical assistance 
    under this subchapter for home and community-based services for 
    individuals who have attained the age of 65 for the base year 
    increased by a percentage which is equal to the lesser of 7 percent 
    times the number of years (rounded to the nearest quarter of a year) 
    beginning after the base year and ending at the end of the waiver 
    year involved or the sum of--
            (I) the percentage increase (based on an appropriate market-
        basket index representing the costs of elements of such 
        services) between the beginning of the base year and the 
        beginning of the waiver year involved, plus
            (II) the percentage increase between the beginning of the 
        base year and the beginning of the waiver year involved in the 
        number of residents in the State who have attained the age of 
        65, plus
            (III) 2 percent for each year (rounded to the nearest 
        quarter of a year) beginning after the base year and ending at 
        the end of the waiver year.

        (iii) The Secretary shall develop and promulgate by regulation 
    (by not later than October 1, 1989)--
            (I) a method, based on an index of appropriately weighted 
        indicators of changes in the wages and prices of the mix of 
        goods and services which comprise both skilled nursing facility 
        services and intermediate care facility services (regardless of 
        the source of payment for such services), for projecting the 
        percentage increase for purposes of clause (i)(I);
            (II) a method, based on an index of appropriately weighted 
        indicators of changes in the wages and prices of the mix of 
        goods and services which comprise home and community-based 
        services (regardless of the source of payment for such 
        services), for projecting the percentage increase for purposes 
        of clause (ii)(I); and
            (III) a method for projecting, on a State specific basis, 
        the percentage increase in the number of residents in each State 
        who are over 65 years of age for any period.

    The Secretary shall develop (by not later than October 1, 1989) a 
    method for projecting, on a State-specific basis, the percentage 
    increase in the number of residents in each State who are over 65 
    years of age for any period. Effective on and after the date the 
    Secretary promulgates the regulation under clause (iii), any 
    reference in this subparagraph to the ``lesser of 7 percent'' shall 
    be deemed to be a reference to the ``greater of 7 percent''.
        (iv) If there is enacted after December 22, 1987, an Act which 
    amends this subchapter whose provisions become effective on or after 
    such date and which results in an increase in the aggregate amount 
    of medical assistance under this subchapter for nursing facility 
    services and home and community-based services for individuals who 
    have attained the age of 65 years, the Secretary, at the request of 
    a State with a waiver under this subsection for a waiver year or 
    years and in close consultation with the State, shall adjust the 
    projected amount computed under this subparagraph for the waiver 
    year or years to take into account such increase.

    (C) In this paragraph:
        (i) The term ``home and community-based services'' includes 
    services described in sections 1396d(a)(7) and 1396d(a)(8) of this 
    title, services described in subsection (c)(4)(B) of this section, 
    services described in paragraph (4), and personal care services.
        (ii)(I) Subject to subclause (II), the term ``base year'' means 
    the most recent year (ending before December 22, 1987) for which 
    actual final expenditures under this subchapter have been reported 
    to, and accepted by, the Secretary.
        (II) For purposes of subparagraph (C), in the case of a State 
    that does not report expenditures on the basis of the age categories 
    described in such subparagraph for a year ending before December 22, 
    1987, the term ``base year'' means fiscal year 1989.
        (iii) The term ``intermediate care facility services'' does not 
    include services furnished in an institution certified in accordance 
    with section 1396d(d) of this title.

    (6)(A) A determination by the Secretary to deny a request for a 
waiver (or extension of waiver) under this subsection shall be subject 
to review to the extent provided under section 1316(b) of this title.
    (B) Notwithstanding any other provision of this chapter, if the 
Secretary denies a request of the State for an extension of a waiver 
under this subsection, any waiver under this subsection in effect on the 
date such request is made shall remain in effect for a period of not 
less than 90 days after the date on which the Secretary denies such 
request (or, if the State seeks review of such determination in 
accordance with subparagraph (A), the date on which a final 
determination is made with respect to such review).

(e) Waiver for children infected with AIDS or drug dependent at birth

    (1)(A) Subject to paragraph (2), the Secretary shall grant a waiver 
to provide that a State plan approved under this subchapter shall 
include as ``medical assistance'' under such plan payment for part or 
all of the cost of nursing care, respite care, physicians' services, 
prescribed drugs, medical devices and supplies, transportation services, 
and such other services requested by the State as the Secretary may 
approve which are provided pursuant to a written plan of care to a child 
described in subparagraph (B) with respect to whom there has been a 
determination that but for the provision of such services the infants 
would be likely to require the level of care provided in a hospital or 
nursing facility the cost of which could be reimbursed under the State 
plan.
    (B) Children described in this subparagraph are individuals under 5 
years of age who--
        (i) at the time of birth were infected with (or tested 
    positively for) the etiologic agent for acquired immune deficiency 
    syndrome (AIDS),
        (ii) have such syndrome, or
        (iii) at the time of birth were dependent on heroin, cocaine, or 
    phencyclidine,

and with respect to whom adoption or foster care assistance is (or will 
be) made available under part E of subchapter IV of this chapter.
    (2) A waiver shall not be granted under this subsection unless the 
State provides assurances satisfactory to the Secretary that--
        (A) necessary safeguards (including adequate standards for 
    provider participation) have been taken to protect the health and 
    welfare of individuals provided services under the waiver and to 
    assure financial accountability for funds expended with respect to 
    such services;
        (B) under such waiver the average per capita expenditure 
    estimated by the State in any fiscal year for medical assistance 
    provided with respect to such individuals does not exceed 100 
    percent of the average per capita expenditure that the State 
    reasonably estimates would have been made in that fiscal year for 
    expenditures under the State plan for such individuals if the waiver 
    had not been granted; and
        (C) the State will provide to the Secretary annually, consistent 
    with a data collection plan designed by the Secretary, information 
    on the impact of the waiver granted under this subsection on the 
    type and amount of medical assistance provided under the State plan 
    and on the health and welfare of recipients.

    (3) A waiver granted under this subsection may include a waiver of 
the requirements of section 1396a(a)(1) of this title (relating to 
statewideness) and section 1396a(a)(10)(B) of this title (relating to 
comparability). A waiver under this subsection shall be for an initial 
term of 3 years and, upon the request of a State, shall be extended for 
additional five-year periods unless the Secretary determines that for 
the previous waiver period the assurances provided under paragraph (2) 
have not been met.
    (4) The provisions of paragraph (6) of subsection (d) of this 
section shall apply to this subsection in the same manner as it applies 
to subsection (d) of this section.

(f) Monitor of implementation of waivers; termination of waiver for 
        noncompliance; time limitation for action on requests for plan 
        approval, amendments, or waivers

    (1) The Secretary shall monitor the implementation of waivers 
granted under this section to assure that the requirements for such 
waiver are being met and shall, after notice and opportunity for a 
hearing, terminate any such waiver where he finds noncompliance has 
occurred.
    (2) A request to the Secretary from a State for approval of a 
proposed State plan or plan amendment or a waiver of a requirement of 
this subchapter submitted by the State pursuant to a provision of this 
subchapter shall be deemed granted unless the Secretary, within 90 days 
after the date of its submission to the Secretary, either denies such 
request in writing or informs the State agency in writing with respect 
to any additional information which is needed in order to make a final 
determination with respect to the request. After the date the Secretary 
receives such additional information, the request shall be deemed 
granted unless the Secretary, within 90 days of such date, denies such 
request.

(g) Optional targeted case management services

    (1) A State may provide, as medical assistance, case management 
services under the plan without regard to the requirements of section 
1396a(a)(1) of this title and section 1396a(a)(10)(B) of this title. The 
provision of case management services under this subsection shall not 
restrict the choice of the individual to receive medical assistance in 
violation of section 1396a(a)(23) of this title. A State may limit the 
provision of case management services under this subsection to 
individuals with acquired immune deficiency syndrome (AIDS), or with 
AIDS-related conditions, or with either, or to individuals described in 
section 1396a(z)(1)(A) of this title and a State may limit the provision 
of case management services under this subsection to individuals with 
chronic mental illness. The State may limit the case managers available 
with respect to case management services for eligible individuals with 
developmental disabilities or with chronic mental illness in order to 
ensure that the case managers for such individuals are capable of 
ensuring that such individuals receive needed services.
    (2) For purposes of this subsection, the term ``case management 
services'' means services which will assist individuals eligible under 
the plan in gaining access to needed medical, social, educational, and 
other services.

(h) Period of waivers; continuations

    No waiver under this section (other than a waiver under subsection 
(c), (d), or (e) of this section) may extend over a period of longer 
than two years unless the State requests continuation of such waiver, 
and such request shall be deemed granted unless the Secretary, within 90 
days after the date of its submission to the Secretary, either denies 
such request in writing or informs the State agency in writing with 
respect to any additional information which is needed in order to make a 
final determination with respect to the request. After the date the 
Secretary receives such additional information, the request shall be 
deemed granted unless the Secretary, within 90 days of such date, denies 
such request.

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1915, as added Pub. L. 97-35, 
title XXI, Sec. 2175(b), Aug. 13, 1981, 95 Stat. 809; amended Pub. L. 
97-35, title XXI, Secs. 2176, 2177(a), Aug. 13, 1981, 95 Stat. 812, 813; 
Pub. L. 97-248, title I, Sec. 137(b)(19)(A), (20)-(25), Sept. 3, 1982, 
96 Stat. 380; Pub. L. 97-448, title III, Sec. 309(b)(17), Jan. 12, 1983, 
96 Stat. 2409; Pub. L. 98-369, div. B, title III, Sec. 2373(b)(21), July 
18, 1984, 98 Stat. 1112; Pub. L. 99-272, title IX, Secs. 9502(a)-(e), 
(g)-(i), 9508(a), Apr. 7, 1986, 100 Stat. 202-204, 210; Pub. L. 99-509, 
title IX, Secs. 9320(h)(3), 9411(a)-(d), Oct. 21, 1986, 100 Stat. 2016, 
2061, 2062; Pub. L. 100-93, Sec. 8(h)(2), Aug. 18, 1987, 101 Stat. 694; 
Pub. L. 100-203, title IV, Secs. 4072(d), 4102(a)(1), (b)(2), 
4118(a)(1), (b), (i)(1), (k), (l)(1), (p)(10), 4211(h)(10), Dec. 22, 
1987, 101 Stat. 1330-117, 1330-143, 1330-146, 1330-154 to 1330-157, 
1330-160, 1330-206; Pub. L. 100-360, title II, Sec. 204(d)(3), title IV, 
Sec. 411(k)(3), (10)(A), (H), (I), (17)(A), (l)(3)(G), July 1, 1988, 102 
Stat. 729, 791, 794, 796, 799, 803; Pub. L. 100-485, title VI, 
Sec. 608(d)(26)(M), (f)(2), Oct. 13, 1988, 102 Stat. 2422, 2424; Pub. L. 
100-647, title VIII, Secs. 8432(a), (b), 8437(a), Nov. 10, 1988, 102 
Stat. 3804, 3806; Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 
103 Stat. 1981; Pub. L. 101-239, title VI, Secs. 6115(c), 6411(c)(2), 
Dec. 19, 1989, 103 Stat. 2219, 2270; Pub. L. 101-508, title IV, 
Secs. 4604(c), 4704(b)(3), 4741, 4742(a), (c)(1), (d)(1), Nov. 5, 1990, 
104 Stat. 1388-169, 1388-172, 1388-197, 1388-198; Pub. L. 102-119, 
Sec. 26(i)(2), Oct. 7, 1991, 105 Stat. 607; Pub. L. 103-66, title XIII, 
Sec. 13603(d), Aug. 10, 1993, 107 Stat. 620; Pub. L. 105-33, title IV, 
Secs. 4106(c), 4743(a), Aug. 5, 1997, 111 Stat. 368, 524; Pub. L. 106-
113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(o), (z)], Nov. 29, 
1999, 113 Stat. 1536, 1501A-397, 1501A-398.)

                       Amendment of Subsection (b)

        Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, 
    Sec. 608(z)], Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided 
    that, effective Oct. 1, 2004, subsection (b) of this section is 
    amended, in the matter preceding paragraph (1), by striking 
    ``sections 1396a(a)(13)(C) and'' and inserting ``section''.

                       References in Text

    Parts A and B of subchapter XVIII of this chapter, referred to in 
subsec. (a)(1)(B)(ii)(II), are classified to sections 1395c et seq. and 
1395j et seq., respectively, of this title.
    Section 1401 of title 20, referred to in subsec. (c)(5)(C)(i), was 
in the original a reference to section 602 of the Individuals with 
Disabilities Education Act, Pub. L. 91-230, title VI. Section 602 of 
Pub. L. 91-230 was omitted in the general amendment of subchapter I of 
chapter 33 of Title 20, Education, by Pub. L. 105-17, title I, Sec. 101, 
June 4, 1997, 111 Stat. 37. Pub. L. 105-17 enacted a new section 602 of 
Pub. L. 91-230, which is classified to section 1401 of Title 20, and 
which contains provisions defining ``special education'' and ``related 
services''.
    Part E of subchapter IV of this chapter, referred to in subsec. 
(e)(1)(B), is classified to section 670 et seq. of this title.


                               Amendments

    1999--Subsec. (b). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(o)(1)], substituted ``1396a(a)(13)(C)'' for ``1396a(a)(13)(E)'' 
in introductory provisions.
    Subsec. (d)(5)(B)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(o)(2)], which directed substitution of ``65'' for ``75'' in 
last sentence of cl. (iii), was executed by making the substitution in 
the penultimate sentence to reflect the probable intent of Congress.
    Subsec. (h). Pub. L. 106-113, Sec. 1000(a)(6) [title VI, 
Sec. 608(o)(3)], substituted ``90 days of such date'' for ``90 day of 
such date''.
    1997--Subsec. (a)(1)(B)(ii)(I). Pub. L. 105-33, Sec. 4106(c), 
substituted ``paragraphs (16) and (17)'' for ``paragraphs (15) and 
(16)''.
    Subsec. (c)(5). Pub. L. 105-33, Sec. 4743(a), in introductory 
provisions, struck out ``, with respect to individuals who receive such 
services after discharge from a nursing facility or intermediate care 
facility for the mentally retarded'' after `` `habilitation services' 
''.
    1993--Subsec. (g)(1). Pub. L. 103-66 inserted ``or to individuals 
described in section 1396a(z)(1)(A) of this title'' after ``or with 
either,''.
    1991--Subsec. (c)(5)(C)(i). Pub. L. 102-119 substituted ``(as 
defined in paragraphs (16) and (17) of section 1401(a) of title 20)'' 
for ``(as defined in section 1401(16) and (17) of title 20)''. The 
reference to section 1401 of title 20 includes the substitution of 
``Individuals with Disabilities Education Act'' for ``Education of the 
Handicapped Act'' in the original.
    1990--Subsec. (b). Pub. L. 101-508, Sec. 4704(b)(3), inserted 
``(other than sections 1396a(a)(13)(E) and 1396a(a)(10)(A) of this title 
insofar as it requires provision of the care and services described in 
section 1396d(a)(2)(C) of this title)'' after ``section 1396a of this 
title'' in introductory provisions.
    Pub. L. 101-508, Sec. 4604(c), which directed amendment of subsec. 
(b) by inserting ``(other than subsection (s))'' after ``Section 1396a 
of this title'', was executed by inserting the new language after 
``section 1396a of this title'' to reflect the probable intent of 
Congress.
    Subsec. (b)(4). Pub. L. 101-508, Sec. 4742(a), inserted before 
period at end ``and if providers under such restriction are paid on a 
timely basis in the same manner as health care practitioners must be 
paid under section 1396a(a)(37)(A) of this title''.
    Subsec. (c)(1). Pub. L. 101-508, Sec. 4741(a), inserted at end ``For 
purposes of this subsection, the term `room and board' shall not include 
an amount established under a method determined by the State to reflect 
the portion of costs of rent and food attributable to an unrelated 
personal caregiver who is residing in the same household with an 
individual who, but for the assistance of such caregiver, would require 
admission to a hospital, nursing facility, or intermediate care facility 
for the mentally retarded.''
    Subsec. (c)(4). Pub. L. 101-508, Sec. 4742(d)(1), inserted at end 
``Except as provided under paragraph (2)(D), the Secretary may not 
restrict the number of hours or days of respite care in any period which 
a State may provide under a waiver under this subsection.''
    Subsec. (c)(7)(C). Pub. L. 101-508, Sec. 4742(c)(1), added subpar. 
(C).
    Subsec. (d)(1). Pub. L. 101-508, Sec. 4741(a), inserted at end ``For 
purposes of this subsection, the term `room and board' shall not include 
an amount established under a method determined by the State to reflect 
the portion of costs of rent and food attributable to an unrelated 
personal caregiver who is residing in the same household with an 
individual who, but for the assistance of such caregiver, would require 
admission to a hospital, nursing facility, or intermediate care facility 
for the mentally retarded.''
    Subsec. (d)(5)(B)(iv). Pub. L. 101-508, Sec. 4741(b), substituted 
``this subchapter whose provisions become effective on or after such 
date'' for first reference to ``this subchapter''.
    1989--Subsec. (a)(1)(B)(ii)(I). Pub. L. 101-239, Sec. 6115(c), 
substituted ``paragraphs (15) and (16)'' for ``paragraphs (14) and 
(15)''.
    Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 204(d)(3), 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.
    Subsec. (b)(4). Pub. L. 101-239, Sec. 6411(c)(2), inserted ``shall 
be consistent with the requirements of section 1396r-4 of this title 
and'' after ``which standards''.
    1988--Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-360, Sec. 204(d)(3), 
substituted ``paragraphs (14) and (15)'' for ``paragraphs (13) and 
(14)''.
    Subsec. (a)(2). Pub. L. 100-485, Sec. 608(f)(2), substituted 
``restricts'' for ``Restricts'' in introductory provisions.
    Subsec. (c)(7). Pub. L. 100-360, Sec. 411(l)(3)(G), amended Pub. L. 
100-203, Sec. 4211(h)(10)(G), see 1987 Amendment note below.
    Subsec. (c)(7)(A). Pub. L. 100-647, Sec. 8437(a), substituted ``who 
are inpatients in, or who would require the level of care provided in, 
hospitals,'' for ``who are inpatients in hospitals,'' and ``who are 
inpatients in, or who would require the level of care provided in, those 
respective facilities'' for ``who are inpatients of those respective 
facilities''.
    Subsec. (c)(7)(B). Pub. L. 100-360, Sec. 411(k)(10)(H), inserted ``, 
without regard to the availability of beds for such inpatients'' before 
period at end.
    Subsec. (c)(10). Pub. L. 100-360, Sec. 411(k)(10)(A), substituted 
``The Secretary shall not limit to fewer than 200'' for ``No waiver 
under this subsection shall limit by an amount less than 200'' and 
``under a waiver under this subsection'' for ``under such waiver''.
    Subsec. (d)(5)(B)(i), (ii). Pub. L. 100-647, Sec. 8432(b), in 
introductory provisions, substituted ``the number of years (rounded to 
the nearest quarter of a year) beginning after the base year and ending 
at the end of the waiver year'' for ``the number of years beginning 
after the base year and ending before the waiver year'', in subcls. (I) 
and (II), substituted ``between the beginning of the base year and the 
beginning of the waiver year'' for ``between the base year and the 
waiver year'', and in subcl. (III), inserted ``(rounded to the nearest 
quarter of a year)'' after ``for each year'' and substituted ``at the 
end of the waiver year'' for ``before the waiver year''.
    Subsec. (d)(5)(B)(iii). Pub. L. 100-360, Sec. 411(k)(3)(A)(ii), 
inserted before last sentence ``The Secretary shall develop (by not 
later than October 1, 1989) a method for projecting, on a State-specific 
basis, the percentage increase in the number of residents in each State 
who are over 75 years of age for any period.''
    Subsec. (d)(5)(B)(iii)(III). Pub. L. 100-360, Sec. 411(k)(3)(A)(i), 
substituted ``65'' for ``75''.
    Subsec. (d)(5)(B)(iv). Pub. L. 100-647, Sec. 8432(a), added cl. 
(iv).
    Subsec. (d)(5)(C)(i). Pub. L. 100-360, Sec. 411(k)(3)(B), 
substituted ``paragraph (4), and personal care services'' for 
``paragraph (4)(B), personal care services, and services furnished 
pursuant to a waiver under subsection (c) of this section''.
    Subsec. (e). Pub. L. 100-360, Sec. 411(k)(17)(A)(ii), (iii), added 
subsec. (e), redesignated former subsec. (e)(1) as (f)(1), and struck 
out former subsec. (e)(2) which read as follows: ``The Secretary shall 
report, not later than September 30, 1984, to Congress on waivers 
granted under this section.''
    Subsec. (f)(1). Pub. L. 100-360, Sec. 411(k)(17)(A)(ii), 
redesignated former subsec. (e)(1) as (f)(1).
    Subsec. (f)(2). Pub. L. 100-360, Sec. 411(k)(17)(A)(i), redesignated 
former subsec. (f) as subsec. (f)(2).
    Subsec. (h). Pub. L. 100-360, Sec. 411(k)(10)(I), made technical 
amendment to directory language of Pub. L. 100-203, Sec. 4118(l)(1), see 
1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(k)(17)(A)(iv), as amended by Pub. L. 100-
485, Sec. 608(d)(26)(M), substituted ``, (d), or (e)'' for ``or (d)''.
    1987--Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-203, Sec. 4072(d), 
substituted ``paragraphs (13) and (14)'' for ``paragraphs (12) and 
(13)''.
    Subsec. (a)(2). Pub. L. 100-93 amended par. (2) generally. Prior to 
amendment, par. (2) read as follows: ``restricts--
        ``(A) for a reasonable period of time the provider or providers 
    from which an individual (eligible for medical assistance for items 
    or services under the State plan) can receive such items or 
    services, if the State has found, after notice and opportunity for a 
    hearing (in accordance with procedures established by the State), 
    that the individual has utilized such items or services at a 
    frequency or amount not medically necessary (as determined in 
    accordance with utilization guidelines established by the State), or
        ``(B) (through suspension or otherwise) for a reasonable period 
    of time the participation of a provider of items or services under 
    the State plan, if the State has found, after notice and opportunity 
    for a hearing (in accordance with procedures established by the 
    State), that the provider has (in a significant number or proportion 
    of cases) provided such items or services either (i) at a frequency 
    or amount not medically necessary (as determined in accordance with 
    utilization guidelines established by the State), or (ii) of a 
    quality which does not meet professionally recognized standards of 
    health care,
if, under such restriction, individuals eligible for medical assistance 
for such services have reasonable access (taking into account geographic 
location and reasonable travel time) to such services of adequate 
quality.''
    Subsec. (c)(1). Pub. L. 100-203, Sec. 4211(h)(10)(A), substituted 
``nursing facility or intermediate care facility for the mentally 
retarded'' for ``skilled nursing facility or intermediate care 
facility''.
    Subsec. (c)(2)(B). Pub. L. 100-203, Sec. 4211(h)(10)(C), in closing 
provisions, substituted ``need for inpatient hospital services, nursing 
facility services, or services in an intermediate care facility for the 
mentally retarded'' for ``need for such inpatient hospital, skilled 
nursing facility or intermediate care facility services''.
    Pub. L. 100-203, Sec. 4118(p)(10), in closing provisions inserted 
``such'' after ``need for''.
    Subsec. (c)(2)(B)(i). Pub. L. 100-203, Sec. 4211(h)(10)(B), 
substituted ``services, nursing facility services, or services in an 
intermediate care facility for the mentally retarded'' for ``, skilled 
nursing facility, or intermediate care facility services''.
    Subsec. (c)(2)(C). Pub. L. 100-203, Sec. 4211(h)(10)(D), (E), 
substituted ``, nursing facility, or intermediate care facility for the 
mentally retarded'' for ``or skilled nursing facility or intermediate 
care facility'' and ``, nursing facility services, or services in an 
intermediate care facility for the mentally retarded'' for ``or skilled 
nursing facility or intermediate care facility services''.
    Subsec. (c)(3). Pub. L. 100-203, Sec. 4118(a)(1), substituted ``, 
section 1396a(a)(10)(B) of this title (relating to comparability), and 
section 1396a(a)(10)(C)(i)(III) of this title (relating to income and 
resource rules applicable in the community)'' for ``and section 
1396a(a)(10)(B) of this title (relating to comparability)''.
    Subsec. (c)(5). Pub. L. 100-203, Sec. 4211(h)(10)(F), substituted 
``nursing facility or intermediate care facility for the mentally 
retarded'' for ``skilled nursing facility or intermediate care 
facility''.
    Subsec. (c)(7). Pub. L. 100-203, Sec. 4211(h)(10)(G), as amended by 
Pub. L. 100-360, Sec. 411(l)(3)(G), substituted ``, nursing facilities, 
or intermediate care facilities for the mentally retarded'' for ``or in 
skilled nursing or intermediate care facilities'' in subpar. (A) and 
``nursing facility'' for ``skilled nursing facility or intermediate care 
facility'' in subpar. (B).
    Pub. L. 100-203, Sec. 4118(k), designated existing provisions as 
subpar. (A) and added subpar. (B).
    Subsec. (c)(10). Pub. L. 100-203, Sec. 4118(b), added par. (10).
    Subsec. (d). Pub. L. 100-203, Sec. 4102(a)(1), added subsec. (d). 
Former subsec. (d) redesignated (h).
    Subsec. (g)(1). Pub. L. 100-203, Sec. 4118(i)(1), inserted at end 
``The State may limit the case managers available with respect to case 
management services for eligible individuals with developmental 
disabilities or with chronic mental illness in order to ensure that the 
case managers for such individuals are capable of ensuring that such 
individuals receive needed services.''
    Subsec. (h). Pub. L. 100-203, Sec. 4118(l)(1), as amended by Pub. L. 
100-360, Sec. 411(k)(10)(I), substituted ``, within 90 days after the 
date of its submission to the Secretary, either denies such request in 
writing or informs the State agency in writing with respect to any 
additional information which is needed in order to make a final 
determination with respect to the request. After the date the Secretary 
receives such additional information, the request shall be deemed 
granted unless the Secretary, within 90 day of such date, denies such 
request.'' for ``denies such request in writing within 90 days after the 
date of its submission to the Secretary.''
    Pub. L. 100-203, Sec. 4102(b)(2), substituted ``subsection (c) or 
(d) of this section'' for ``subsection (c) of this section''.
    Pub. L. 100-203, Sec. 4102(a)(1)(A), redesignated former subsec. (d) 
as (h).
    1986--Subsec. (a)(1)(B)(ii)(I). Pub. L. 99-509, Sec. 9320(h)(3), 
substituted ``paragraphs (12) and (13)'' for ``paragraphs (11) and 
(12)''.
    Subsec. (b). Pub. L. 99-272, Sec. 9508(a)(2), inserted provision, 
following par. (4), that no waiver under this subsection may restrict 
the choice of the individual in receiving services under section 
1396d(a)(4)(C) of this title.
    Subsec. (c)(1). Pub. L. 99-509, Sec. 9411(a)(1), inserted ``a 
hospital or'' after ``level of care provided in'', and struck out 
provision added by Pub. L. 99-272, Sec. 9502(b)(1).
    Pub. L. 99-272, Sec. 9502(b)(1), inserted provision relating to 
individuals with respect to whom there has been a determination that but 
for the provision of such services the individuals would continue to 
receive inpatient hospital services, skilled nursing facility services, 
or intermediate care facility services because they are dependent on 
ventilator support the cost of which is reimbursed under the State plan.
    Subsec. (c)(2)(B). Pub. L. 99-509, Sec. 9411(a)(2), substituted 
``inpatient hospital, skilled nursing facility, or'' for ``skilled 
nursing facility or'' in cl. (i) and inserted ``inpatient hospital,'' 
after ``need for'' in concluding provision following cl. (iii).
    Subsec. (c)(2)(C). Pub. L. 99-272, Sec. 9502(b)(2), inserted 
``hospital or'' after ``provided in a'', and ``inpatient hospital 
services or'' after ``the provision of''.
    Subsec. (c)(2)(D). Pub. L. 99-272, Sec. 9502(c)(1), inserted ``100 
percent of'' after ``does not exceed''.
    Subsec. (c)(3). Pub. L. 99-509, Sec. 9411(c), substituted ``and 
section 1396a(a)(10)(B) of this title (relating to comparability)'' for 
``and section 1396a(a)(10) of this title''.
    Pub. L. 99-272, Sec. 9502(g), substituted ``additional five-year 
periods'' for ``additional three-year periods'', and ``previous waiver 
period'' for ``previous three-year period''.
    Pub. L. 99-272, Sec. 9502(e), inserted at end ``A waiver may 
provide, with respect to post-eligibility treatment of income of all 
individuals receiving services under that waiver, that the maximum 
amount of the individual's income which may be disregarded for any month 
for the maintenance needs of the individual may be an amount greater 
than the maximum allowed for that purpose under regulations in effect on 
July 1, 1985.''
    Subsec. (c)(4)(B). Pub. L. 99-509, Sec. 9411(d), inserted before the 
period ``and for day treatment or other partial hospitalization 
services, psychosocial rehabilitation services, and clinic services 
(whether or not furnished in a facility) for individuals with chronic 
mental illness''.
    Subsec. (c)(5). Pub. L. 99-272, Sec. 9502(a), added par. (5).
    Subsec. (c)(6). Pub. L. 99-272, Sec. 9502(c)(2), added par. (6).
    Subsec. (c)(7). Pub. L. 99-509, Sec. 9411(a)(3), amended par. (7) 
generally. Prior to amendment, par. (7) read as follows: ``In making 
estimates under paragraph (2)(D) in the case of a waiver which applies 
only to physically disabled individuals who are inpatients in skilled 
nursing or intermediate care facilities, the State may determine the 
average per capita expenditure which would have been made in a fiscal 
year for those individuals under the State plan separately from the 
expenditure for other individuals who are inpatients of those 
facilities.''
    Pub. L. 99-272, Sec. 9502(d), added par. (7).
    Subsec. (c)(8). Pub. L. 99-272, Sec. 9502(h), added par. (8).
    Subsec. (c)(9). Pub. L. 99-272, Sec. 9502(i), added par. (9).
    Subsec. (g). Pub. L. 99-272, Sec. 9508(a)(1), added subsec. (g).
    Subsec. (g)(1). Pub. L. 99-509, Sec. 9411(b), inserted provision at 
end allowing a State to limit case management services to AIDS victims 
or to individuals with chronic mental illness.
    1984--Subsec. (c)(1). Pub. L. 98-369 substituted ``under this 
subchapter'' for ``under this part''.
    1983--Subsec. (c)(2)(B). Pub. L. 97-448 substituted ``need for such 
skilled nursing facility or intermediate care facility services'' for 
``need for such services'' in provisions following cl. (iii).
    1982--Subsec. (b). Pub. L. 97-248, Sec. 137(b)(19)(A), struck out 
``and section 1396b(m) of this title'' after ``section 1396a of this 
title''.
    Subsec. (b)(1). Pub. L. 97-248, Sec. 137(b)(20), inserted ``primary 
care'' before ``case-management system'', and substituted ``medical care 
services'' for ``primary care services''.
    Subsec. (c)(1). Pub. L. 97-248, Sec. 137(b)(21), inserted ``payment 
for part or all of the cost of'' after ``may include as `medical 
assistance' under such plan''.
    Subsec. (c)(2)(B). Pub. L. 97-248, Sec. 137(b)(22), redesignated 
existing provisions as cls. (i) and (ii) and added cl. (iii).
    Subsec. (c)(3). Pub. L. 97-248, Sec. 137(b)(23), substituted 
``section 1396a(a)(1) of this title'' for ``subsection (a)(1) of this 
section'' and ``section 1396a(a)(10) of this title'' for ``subsection 
(a)(10) of section 1396a of this title''.
    Subsec. (c)(4). Pub. L. 97-248, Sec. 137(b)(24), substituted ``this 
subsection'' for ``this section''.
    Subsec. (f). Pub. L. 97-248, Sec. 137(b)(25), inserted ``approval 
of'' before ``a proposed State plan''.
    1981--Subsecs. (c) to (e). Pub. L. 97-35, Sec. 2176, added subsec. 
(c), redesignated former subsec. (c) as (d) and inserted ``(other than a 
waiver under subsection (c) of this section)'', and redesignated former 
subsec. (d) as (e).
    Subsec. (f). Pub. L. 97-35, Sec. 2177(a), added subsec. (f).


                    Effective Date of 1999 Amendment

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title VI, Sec. 608(z)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-398, provided that the amendment 
made by section 1000(a)(6) [title VI, Sec. 608(z)] is effective Oct. 1, 
2004.
    Amendment by section 1000(a)(6) [title VI, Sec. 608o] 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.


                    Effective Date of 1997 Amendment

    Amendment by section 4106(c) of Pub. L. 105-33 applicable to bone 
mass measurements performed on or after July 1, 1998, see section 
4106(d) of Pub. L. 105-33, set out as a note under section 1395x of this 
title.
    Section 4743(b) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] apply to services 
furnished on or after October 1, 1997.''


                    Effective Date of 1993 Amendment

    Amendment by Pub. L. 103-66 applicable to medical assistance 
furnished on or after Jan. 1, 1994, without regard to whether or not 
final regulations to carry out the amendments by section 13603 of Pub. 
L. 103-66 have been promulgated by such date, see section 13603(f) of 
Pub. L. 103-66, set out as a note under section 1396a of this title.


                    Effective Date of 1990 Amendments

    Amendment by section 4604(c) of Pub. L. 101-508 effective with 
respect 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 4604 of Pub. L. 
101-508 have been promulgated by such date, see section 4604(d) of Pub. 
L. 101-508, set out as a note under section 1396a of this title.
    Amendment by section 4704(b)(3) 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.
    Section 4742(b) of Pub. L. 101-508 provided that: ``The amendment 
made by subsection (a) [amending this section] shall take effect as of 
the first calendar quarter beginning more than 30 days after the date of 
the enactment of this Act [Nov. 5, 1990].''
    Section 4742(c)(2) of Pub. L. 101-508 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply as if included 
in the enactment of the Omnibus Budget Reconciliation Act of 1981 [Pub. 
L. 97-35], but shall only apply to facilities the participation of which 
under a State plan under title XIX of the Social Security Act [this 
subchapter] is terminated on or after the date of the enactment of this 
Act [Nov. 5, 1990].''
    Section 4742(d)(2) of Pub. L. 101-508 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply as if included 
in the enactment of the Omnibus Budget Reconciliation Act of 1981 [Pub. 
L. 97-35].''


                    Effective Date of 1989 Amendments

    Amendment by section 6115(c) of Pub. L. 101-239 applicable to 
screening pap smears performed on or after July 1, 1990, see section 
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of 
this title.
    Section 6411(c)(4) of Pub. L. 101-239 provided that: ``The amendment 
made by paragraph (2) [amending this section] shall be effective as if 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1987 [Pub. L. 100-203].''
    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

    Section 8432(c) of Pub. L. 100-647 provided that: ``The amendments 
made by this section [amending this section] shall apply to waiver years 
beginning during or after fiscal year 1989.''
    Section 8437(b) of Pub. L. 100-647 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply with respect 
to waiver applications submitted before, on, or after the date of the 
enactment of this Act [Nov. 10, 1988].''
    Amendment by section 608(d)(26)(M) 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)(2) 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 204(d)(3) of Pub. L. 100-360 applicable to 
screening mammography performed on or after Jan. 1, 1990, see section 
204(e) of Pub. L. 100-360, set out as a note under section 1395m of this 
title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(k)(3), (10)(A), (H), (I), (17)(A), (l)(3)(G) 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.


                    Effective Date of 1987 Amendments

    For effective date of amendment by section 4072(d) of Pub. L. 100-
203, see section 4072(e) of Pub. L. 100-203, set out as a note under 
section 1395x of this title.
    Section 4102(a)(2) of Pub. L. 100-203 provided that: ``The 
amendments made by paragraph (1) [amending this section] shall become 
effective on January 1, 1988.''
    Section 4118(a)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective as if 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1986 [Pub. L. 99-509].''
    Section 4118(i)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall take effect as 
though it were included in the enactment of the Consolidated Omnibus 
Budget Reconciliation Act of 1985 [Pub. L. 99-272].''
    Section 4118(l)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to requests 
for continuation of waivers received after the date of the enactment of 
this Act [Dec. 22, 1987].''
    Section 4118(p)(10) of Pub. L. 100-203 provided that the amendment 
made by that section is effective as if included in the enactment of 
Pub. L. 99-509.
    Amendment by section 4211(h)(10) of Pub. L. 100-203 applicable to 
nursing facility services furnished on or after Oct. 1, 1990, without 
regard to whether regulations implementing such amendment 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 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 section 9320(h)(3) of Pub. L. 99-509 applicable to 
services furnished on or after Jan. 1, 1989, with exceptions for 
hospitals located in rural areas which meet certain requirements related 
to certified registered nurse anesthetists, see section 9320(i), (k) of 
Pub. L. 99-509, as amended, set out as notes under section 1395k of this 
title.
    Section 9411(e) of Pub. L. 99-509 provided that: ``The amendments 
made by this section [amending this section] shall apply to applications 
for waivers (or renewals thereof) approved on or after the date of the 
enactment of this Act [Oct. 21, 1986].''
    Section 9502(j) of Pub. L. 99-272, as amended by Pub. L. 99-509, 
title IX, Sec. 9435(a), Oct. 21, 1986, 100 Stat. 2069; Pub. L. 100-203, 
title IV, Sec. 4118(j), Dec. 22, 1987, 101 Stat. 1330-156, provided 
that:
    ``(1) Habilitation services.--The amendment made by subsection (a) 
[amending this section] shall be effective for services furnished on or 
after the date of the enactment of this Act [Apr. 7, 1986] to 
individuals eligible for services under a waiver granted under section 
1915(c) of the Social Security Act [subsec. (c) of this section], 
without regard to whether such individuals were receiving institutional 
services before their participation in the waiver.
    ``(2) Hospitalized patients.--The amendments made by subsection (b) 
[amending this section] shall be effective for services furnished on or 
after October 1, 1985.
    ``(3) Prohibition of regulatory limits and treatment of certain 
physically disabled individuals.--The amendments made by subsections (c) 
and (d) [amending this section] shall apply to applications for waivers 
(or renewals thereof) filed before, on, or after, the date of the 
enactment of this Act [Apr. 7, 1986] and for services furnished on or 
after August 13, 1981.
    ``(4) Income standards.--The amendment made by subsection (e) 
[amending this section] shall apply to waivers (or renewals thereof) 
approved before, on, or after the date of the enactment of this Act 
[Apr. 7, 1986].
    ``(5) Waiver extensions.--Subsection (f) [enacting provisions set 
out below] shall apply to waivers expiring on or after September 30, 
1985, and before September 30, 1986.
    ``(6) Waiver renewals.--The amendments made by subsection (g) 
[amending this section] shall become effective on September 30, 1986.
    ``(7) Coordinated services and substitution of participants.--The 
amendments made by subsections (h) and (i) [amending this section] shall 
become effective on the date of the enactment of this Act [Apr. 7, 
1986].''
    Section 9508(b) of Pub. L. 99-272, as amended by Pub. L. 99-509, 
title IX, Sec. 9435(d)(1), Oct. 21, 1986, 100 Stat. 2070, provided that: 
``The amendments made by this section [amending this section] shall 
apply to services furnished on or after the date of the enactment of 
this Act [Apr. 7, 1986], without regard to whether or not regulations to 
carry out the amendments have been promulgated by that date.''
    [Section 4118(j) of Pub. L. 100-203 provided that the amendment made 
by that section to section 9502(j)(1) of Pub. L. 99-272, set out above, 
is effective as if included in the enactment of section 9502 of Pub. L. 
99-272.]


                    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 137(b)(19)(B) of Pub. L. 97-248 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall not 
apply with respect to any waiver if such waiver was granted, and the 
arrangement covered by the waiver was in place, prior to August 10, 
1982.''
    Amendment by section 137(b)(20)-(25) 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.


                    Effective Date of 1981 Amendment

    Section 2177(b) of Pub. L. 97-35 provided that: ``The amendment made 
by this section [amending this section] shall become effective 90 days 
after the date of the enactment of this Act [Aug. 13, 1981]''.


  Permitting Adjustment in Estimates To Take Into Account Preadmission 
                          Screening Requirement

    Section 4742(e) of Pub. L. 101-508 provided that: ``In the case of a 
waiver under section 1915(c) of the Social Security Act [subsec. (c) of 
this section] for individuals with mental retardation or a related 
condition in a State, the Secretary of Health and Human Services shall 
permit the State to adjust the estimate of average per capita 
expenditures submitted under paragraph (2)(D) of such section, with 
respect to such expenditures made on or after January 1, 1989, to take 
into account increases in expenditures for, or utilization of, 
intermediate care facilities for the mentally retarded resulting from 
implementation of section 1919(e)(7)(A) of such Act [section 
1396r(e)(7)(A) of this title].''


               Extensions of Waivers Under Subsection (c)

    Section 4102(c) of Pub. L. 100-203 provided that: ``In the case of a 
State which, as of December 1, 1987, has a waiver approved with respect 
to elderly individuals under section 1915(c) of the Social Security Act 
[subsec. (c) of this section], which waiver is scheduled to expire 
before July 1, 1988, if the State notifies the Secretary of Health and 
Human Services of the State's intention to file an application for a 
waiver under section 1915(d) of such Act (as amended by subsection (a) 
of this section), the Secretary shall extend approval of the State's 
waiver, under section 1915(c) of such Act, on the same terms and 
conditions through September 30, 1988.''
    Section 9502(f) of Pub. L. 99-272 provided that: ``The Secretary of 
Health and Human Services shall extend, upon request of the State, any 
waiver under section 1915(c) of the Social Security Act [subsec. (c) of 
this section] which expires on or after September 30, 1985, and before 
September 30, 1986. Such extension shall be for a period of not less 
than one year nor more than five years, subject to section 1915(e)(1) of 
such Act.''

                  Section Referred to in Other Sections

    This section is referred to in sections 1320a-7, 1382c, 1396a, 
1396b, 1396d, 1396p, 1396r-4, 1396s, 1396t, 1396u-2, 1396u-4, 1786 of 
this title.
