
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1396p]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
    SUBCHAPTER XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
 
Sec. 1396p. Liens, adjustments and recoveries, and transfers of 
        assets
        

(a) Imposition of lien against property of an individual on account of 
        medical assistance rendered to him under a State plan

    (1) No lien may be imposed against the property of any individual 
prior to his death on account of medical assistance paid or to be paid 
on his behalf under the State plan, except--
        (A) pursuant to the judgment of a court on account of benefits 
    incorrectly paid on behalf of such individual, or
        (B) in the case of the real property of an individual--
            (i) who is an inpatient in a nursing facility, intermediate 
        care facility for the mentally retarded, or other medical 
        institution, if such individual is required, as a condition of 
        receiving services in such institution under the State plan, to 
        spend for costs of medical care all but a minimal amount of his 
        income required for personal needs, and
            (ii) with respect to whom the State determines, after notice 
        and opportunity for a hearing (in accordance with procedures 
        established by the State), that he cannot reasonably be expected 
        to be discharged from the medical institution and to return 
        home,

    except as provided in paragraph (2).

    (2) No lien may be imposed under paragraph (1)(B) on such 
individual's home if--
        (A) the spouse of such individual,
        (B) such individual's child who is under age 21, or (with 
    respect to States eligible to participate in the State program 
    established under subchapter XVI of this chapter) is blind or 
    permanently and totally disabled, or (with respect to States which 
    are not eligible to participate in such program) is blind or 
    disabled as defined in section 1382c of this title, or
        (C) a sibling of such individual (who has an equity interest in 
    such home and who was residing in such individual's home for a 
    period of at least one year immediately before the date of the 
    individual's admission to the medical institution),

is lawfully residing in such home.
    (3) Any lien imposed with respect to an individual pursuant to 
paragraph (1)(B) shall dissolve upon that individual's discharge from 
the medical institution and return home.

(b) Adjustment or recovery of medical assistance correctly paid under a 
        State plan

    (1) No adjustment or recovery of any medical assistance correctly 
paid on behalf of an individual under the State plan may be made, except 
that the State shall seek adjustment or recovery of any medical 
assistance correctly paid on behalf of an individual under the State 
plan in the case of the following individuals:
        (A) In the case of an individual described in subsection 
    (a)(1)(B) of this section, the State shall seek adjustment or 
    recovery from the individual's estate or upon sale of the property 
    subject to a lien imposed on account of medical assistance paid on 
    behalf of the individual.
        (B) In the case of an individual who was 55 years of age or 
    older when the individual received such medical assistance, the 
    State shall seek adjustment or recovery from the individual's 
    estate, but only for medical assistance consisting of--
            (i) nursing facility services, home and community-based 
        services, and related hospital and prescription drug services, 
        or
            (ii) at the option of the State, any items or services under 
        the State plan.

        (C)(i) In the case of an individual who has received (or is 
    entitled to receive) benefits under a long-term care insurance 
    policy in connection with which assets or resources are disregarded 
    in the manner described in clause (ii), except as provided in such 
    clause, the State shall seek adjustment or recovery from the 
    individual's estate on account of medical assistance paid on behalf 
    of the individual for nursing facility and other long-term care 
    services.
        (ii) Clause (i) shall not apply in the case of an individual who 
    received medical assistance under a State plan of a State which had 
    a State plan amendment approved as of May 14, 1993, which provided 
    for the disregard of any assets or resources--
            (I) to the extent that payments are made under a long-term 
        care insurance policy; or
            (II) because an individual has received (or is entitled to 
        receive) benefits under a long-term care insurance policy.

    (2) Any adjustment or recovery under paragraph (1) may be made only 
after the death of the individual's surviving spouse, if any, and only 
at a time--
        (A) when he has no surviving child who is under age 21, or (with 
    respect to States eligible to participate in the State program 
    established under subchapter XVI of this chapter) is blind or 
    permanently and totally disabled, or (with respect to States which 
    are not eligible to participate in such program) is blind or 
    disabled as defined in section 1382c of this title; and
        (B) in the case of a lien on an individual's home under 
    subsection (a)(1)(B) of this section, when--
            (i) no sibling of the individual (who was residing in the 
        individual's home for a period of at least one year immediately 
        before the date of the individual's admission to the medical 
        institution), and
            (ii) no son or daughter of the individual (who was residing 
        in the individual's home for a period of at least two years 
        immediately before the date of the individual's admission to the 
        medical institution, and who establishes to the satisfaction of 
        the State that he or she provided care to such individual which 
        permitted such individual to reside at home rather than in an 
        institution),

    is lawfully residing in such home who has lawfully resided in such 
    home on a continuous basis since the date of the individual's 
    admission to the medical institution.

    (3) The State agency shall establish procedures (in accordance with 
standards specified by the Secretary) under which the agency shall waive 
the application of this subsection (other than paragraph (1)(C)) if such 
application would work an undue hardship as determined on the basis of 
criteria established by the Secretary.
    (4) For purposes of this subsection, the term ``estate'', with 
respect to a deceased individual--
        (A) shall include all real and personal property and other 
    assets included within the individual's estate, as defined for 
    purposes of State probate law; and
        (B) may include, at the option of the State (and shall include, 
    in the case of an individual to whom paragraph (1)(C)(i) applies), 
    any other real and personal property and other assets in which the 
    individual had any legal title or interest at the time of death (to 
    the extent of such interest), including such assets conveyed to a 
    survivor, heir, or assign of the deceased individual through joint 
    tenancy, tenancy in common, survivorship, life estate, living trust, 
    or other arrangement.

(c) Taking into account certain transfers of assets

    (1)(A) In order to meet the requirements of this subsection for 
purposes of section 1396a(a)(18) of this title, the State plan must 
provide that if an institutionalized individual or the spouse of such an 
individual (or, at the option of a State, a noninstitutionalized 
individual or the spouse of such an individual) disposes of assets for 
less than fair market value on or after the look-back date specified in 
subparagraph (B)(i), the individual is ineligible for medical assistance 
for services described in subparagraph (C)(i) (or, in the case of a 
noninstitutionalized individual, for the services described in 
subparagraph (C)(ii)) during the period beginning on the date specified 
in subparagraph (D) and equal to the number of months specified in 
subparagraph (E).
    (B)(i) The look-back date specified in this subparagraph is a date 
that is 36 months (or, in the case of payments from a trust or portions 
of a trust that are treated as assets disposed of by the individual 
pursuant to paragraph (3)(A)(iii) or (3)(B)(ii) of subsection (d) of 
this section, 60 months) before the date specified in clause (ii).
    (ii) The date specified in this clause, with respect to--
        (I) an institutionalized individual is the first date as of 
    which the individual both is an institutionalized individual and has 
    applied for medical assistance under the State plan, or
        (II) a noninstitutionalized individual is the date on which the 
    individual applies for medical assistance under the State plan or, 
    if later, the date on which the individual disposes of assets for 
    less than fair market value.

    (C)(i) The services described in this subparagraph with respect to 
an institutionalized individual are the following:
        (I) Nursing facility services.
        (II) A level of care in any institution equivalent to that of 
    nursing facility services.
        (III) Home or community-based services furnished under a waiver 
    granted under subsection (c) or (d) of section 1396n of this title.

    (ii) The services described in this subparagraph with respect to a 
noninstitutionalized individual are services (not including any services 
described in clause (i)) that are described in paragraph (7), (22), or 
(24) of section 1396d(a) of this title, and, at the option of a State, 
other long-term care services for which medical assistance is otherwise 
available under the State plan to individuals requiring long-term care.
    (D) The date specified in this subparagraph is the first day of the 
first month during or after which assets have been transferred for less 
than fair market value and which does not occur in any other periods of 
ineligibility under this subsection.
    (E)(i) With respect to an institutionalized individual, the number 
of months of ineligibility under this subparagraph for an individual 
shall be equal to--
        (I) the total, cumulative uncompensated value of all assets 
    transferred by the individual (or individual's spouse) on or after 
    the look-back date specified in subparagraph (B)(i), divided by
        (II) the average monthly cost to a private patient of nursing 
    facility services in the State (or, at the option of the State, in 
    the community in which the individual is institutionalized) at the 
    time of application.

    (ii) With respect to a noninstitutionalized individual, the number 
of months of ineligibility under this subparagraph for an individual 
shall not be greater than a number equal to--
        (I) the total, cumulative uncompensated value of all assets 
    transferred by the individual (or individual's spouse) on or after 
    the look-back date specified in subparagraph (B)(i), divided by
        (II) the average monthly cost to a private patient of nursing 
    facility services in the State (or, at the option of the State, in 
    the community in which the individual is institutionalized) at the 
    time of application.

    (iii) The number of months of ineligibility otherwise determined 
under clause (i) or (ii) with respect to the disposal of an asset shall 
be reduced--
        (I) in the case of periods of ineligibility determined under 
    clause (i), by the number of months of ineligibility applicable to 
    the individual under clause (ii) as a result of such disposal, and
        (II) in the case of periods of ineligibility determined under 
    clause (ii), by the number of months of ineligibility applicable to 
    the individual under clause (i) as a result of such disposal.

    (2) An individual shall not be ineligible for medical assistance by 
reason of paragraph (1) to the extent that--
        (A) the assets transferred were a home and title to the home was 
    transferred to--
            (i) the spouse of such individual;
            (ii) a child of such individual who (I) is under age 21, or 
        (II) (with respect to States eligible to participate in the 
        State program established under subchapter XVI of this chapter) 
        is blind or permanently and totally disabled, or (with respect 
        to States which are not eligible to participate in such program) 
        is blind or disabled as defined in section 1382c of this title;
            (iii) a sibling of such individual who has an equity 
        interest in such home and who was residing in such individual's 
        home for a period of at least one year immediately before the 
        date the individual becomes an institutionalized individual; or
            (iv) a son or daughter of such individual (other than a 
        child described in clause (ii)) who was residing in such 
        individual's home for a period of at least two years immediately 
        before the date the individual becomes an institutionalized 
        individual, and who (as determined by the State) provided care 
        to such individual which permitted such individual to reside at 
        home rather than in such an institution or facility;

        (B) the assets--
            (i) were transferred to the individual's spouse or to 
        another for the sole benefit of the individual's spouse,
            (ii) were transferred from the individual's spouse to 
        another for the sole benefit of the individual's spouse,
            (iii) were transferred to, or to a trust (including a trust 
        described in subsection (d)(4) of this section) established 
        solely for the benefit of, the individual's child described in 
        subparagraph (A)(ii)(II), or
            (iv) were transferred to a trust (including a trust 
        described in subsection (d)(4) of this section) established 
        solely for the benefit of an individual under 65 years of age 
        who is disabled (as defined in section 1382c(a)(3) of this 
        title);

        (C) a satisfactory showing is made to the State (in accordance 
    with regulations promulgated by the Secretary) that (i) the 
    individual intended to dispose of the assets either at fair market 
    value, or for other valuable consideration, (ii) the assets were 
    transferred exclusively for a purpose other than to qualify for 
    medical assistance, or (iii) all assets transferred for less than 
    fair market value have been returned to the individual; or
        (D) the State determines, under procedures established by the 
    State (in accordance with standards specified by the Secretary), 
    that the denial of eligibility would work an undue hardship as 
    determined on the basis of criteria established by the Secretary; 
    \1\
---------------------------------------------------------------------------
    \1\ So in original. The semicolon probably should be a period.

    (3) For purposes of this subsection, in the case of an asset held by 
an individual in common with another person or persons in a joint 
tenancy, tenancy in common, or similar arrangement, the asset (or the 
affected portion of such asset) shall be considered to be transferred by 
such individual when any action is taken, either by such individual or 
by any other person, that reduces or eliminates such individual's 
ownership or control of such asset.
    (4) A State (including a State which has elected treatment under 
section 1396a(f) of this title) may not provide for any period of 
ineligibility for an individual due to transfer of resources for less 
than fair market value except in accordance with this subsection. In the 
case of a transfer by the spouse of an individual which results in a 
period of ineligibility for medical assistance under a State plan for 
such individual, a State shall, using a reasonable methodology (as 
specified by the Secretary), apportion such period of ineligibility (or 
any portion of such period) among the individual and the individual's 
spouse if the spouse otherwise becomes eligible for medical assistance 
under the State plan.
    (5) In this subsection, the term ``resources'' has the meaning given 
such term in section 1382b of this title, without regard to the 
exclusion described in subsection (a)(1) thereof.

(d) Treatment of trust amounts

    (1) For purposes of determining an individual's eligibility for, or 
amount of, benefits under a State plan under this subchapter, subject to 
paragraph (4), the rules specified in paragraph (3) shall apply to a 
trust established by such individual.
    (2)(A) For purposes of this subsection, an individual shall be 
considered to have established a trust if assets of the individual were 
used to form all or part of the corpus of the trust and if any of the 
following individuals established such trust other than by will:
        (i) The individual.
        (ii) The individual's spouse.
        (iii) A person, including a court or administrative body, with 
    legal authority to act in place of or on behalf of the individual or 
    the individual's spouse.
        (iv) A person, including any court or administrative body, 
    acting at the direction or upon the request of the individual or the 
    individual's spouse.

    (B) In the case of a trust the corpus of which includes assets of an 
individual (as determined under subparagraph (A)) and assets of any 
other person or persons, the provisions of this subsection shall apply 
to the portion of the trust attributable to the assets of the 
individual.
    (C) Subject to paragraph (4), this subsection shall apply without 
regard to--
        (i) the purposes for which a trust is established,
        (ii) whether the trustees have or exercise any discretion under 
    the trust,
        (iii) any restrictions on when or whether distributions may be 
    made from the trust, or
        (iv) any restrictions on the use of distributions from the 
    trust.

    (3)(A) In the case of a revocable trust--
        (i) the corpus of the trust shall be considered resources 
    available to the individual,
        (ii) payments from the trust to or for the benefit of the 
    individual shall be considered income of the individual, and
        (iii) any other payments from the trust shall be considered 
    assets disposed of by the individual for purposes of subsection (c) 
    of this section.

    (B) In the case of an irrevocable trust--
        (i) if there are any circumstances under which payment from the 
    trust could be made to or for the benefit of the individual, the 
    portion of the corpus from which, or the income on the corpus from 
    which, payment to the individual could be made shall be considered 
    resources available to the individual, and payments from that 
    portion of the corpus or income--
            (I) to or for the benefit of the individual, shall be 
        considered income of the individual, and
            (II) for any other purpose, shall be considered a transfer 
        of assets by the individual subject to subsection (c) of this 
        section; and

        (ii) any portion of the trust from which, or any income on the 
    corpus from which, no payment could under any circumstances be made 
    to the individual shall be considered, as of the date of 
    establishment of the trust (or, if later, the date on which payment 
    to the individual was foreclosed) to be assets disposed by the 
    individual for purposes of subsection (c) of this section, and the 
    value of the trust shall be determined for purposes of such 
    subsection by including the amount of any payments made from such 
    portion of the trust after such date.

    (4) This subsection shall not apply to any of the following trusts:
        (A) A trust containing the assets of an individual under age 65 
    who is disabled (as defined in section 1382c(a)(3) of this title) 
    and which is established for the benefit of such individual by a 
    parent, grandparent, legal guardian of the individual, or a court if 
    the State will receive all amounts remaining in the trust upon the 
    death of such individual up to an amount equal to the total medical 
    assistance paid on behalf of the individual under a State plan under 
    this subchapter.
        (B) A trust established in a State for the benefit of an 
    individual if--
            (i) the trust is composed only of pension, Social Security, 
        and other income to the individual (and accumulated income in 
        the trust),
            (ii) the State will receive all amounts remaining in the 
        trust upon the death of such individual up to an amount equal to 
        the total medical assistance paid on behalf of the individual 
        under a State plan under this subchapter; and
            (iii) the State makes medical assistance available to 
        individuals described in section 1396a(a)(10)(A)(ii)(V) of this 
        title, but does not make such assistance available to 
        individuals for nursing facility services under section 
        1396a(a)(10)(C) of this title.

        (C) A trust containing the assets of an individual who is 
    disabled (as defined in section 1382c(a)(3) of this title) that 
    meets the following conditions:
            (i) The trust is established and managed by a non-profit 
        association.
            (ii) A separate account is maintained for each beneficiary 
        of the trust, but, for purposes of investment and management of 
        funds, the trust pools these accounts.
            (iii) Accounts in the trust are established solely for the 
        benefit of individuals who are disabled (as defined in section 
        1382c(a)(3) of this title) by the parent, grandparent, or legal 
        guardian of such individuals, by such individuals, or by a 
        court.
            (iv) To the extent that amounts remaining in the 
        beneficiary's account upon the death of the beneficiary are not 
        retained by the trust, the trust pays to the State from such 
        remaining amounts in the account an amount equal to the total 
        amount of medical assistance paid on behalf of the beneficiary 
        under the State plan under this subchapter.

    (5) The State agency shall establish procedures (in accordance with 
standards specified by the Secretary) under which the agency waives the 
application of this subsection with respect to an individual if the 
individual establishes that such application would work an undue 
hardship on the individual as determined on the basis of criteria 
established by the Secretary.
    (6) The term ``trust'' includes any legal instrument or device that 
is similar to a trust but includes an annuity only to such extent and in 
such manner as the Secretary specifies.

(e) Definitions

    In this section, the following definitions shall apply:
        (1) The term ``assets'', with respect to an individual, includes 
    all income and resources of the individual and of the individual's 
    spouse, including any income or resources which the individual or 
    such individual's spouse is entitled to but does not receive because 
    of action--
            (A) by the individual or such individual's spouse,
            (B) by a person, including a court or administrative body, 
        with legal authority to act in place of or on behalf of the 
        individual or such individual's spouse, or
            (C) by any person, including any court or administrative 
        body, acting at the direction or upon the request of the 
        individual or such individual's spouse.

        (2) The term ``income'' has the meaning given such term in 
    section 1382a of this title.
        (3) The term ``institutionalized individual'' means an 
    individual who is an inpatient in a nursing facility, who is an 
    inpatient in a medical institution and with respect to whom payment 
    is made based on a level of care provided in a nursing facility, or 
    who is described in section 1396a(a)(10)(A)(ii)(VI) of this title.
        (4) The term ``noninstitutionalized individual'' means an 
    individual receiving any of the services specified in subsection 
    (c)(1)(C)(ii) of this section.
        (5) The term ``resources'' has the meaning given such term in 
    section 1382b of this title, without regard (in the case of an 
    institutionalized individual) to the exclusion described in 
    subsection (a)(1) of such section.

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1917, as added Pub. L. 97-248, 
title I, Sec. 132(b), Sept. 3, 1982, 96 Stat. 370; amended Pub. L. 97-
448, title III, Sec. 309(b)(21), (22), Jan. 12, 1983, 96 Stat. 2410; 
Pub. L. 100-203, title IV, Sec. 4211(h)(12), Dec. 22, 1987, 101 Stat. 
1330-207; Pub. L. 100-360, title III, Sec. 303(b), title IV, 
Sec. 411(l)(3)(I), July 1, 1988, 102 Stat. 760, 803; Pub. L. 100-485, 
title VI, Sec. 608(d)(16)(B), Oct. 13, 1988, 102 Stat. 2417; Pub. L. 
101-239, title VI, Sec. 6411(e)(1), Dec. 19, 1989, 103 Stat. 2271; Pub. 
L. 103-66, title XIII, Secs. 13611(a)-(c), 13612(a)-(c), Aug. 10, 1993, 
107 Stat. 622-628.)


                               Amendments

    1993--Subsec. (b)(1). Pub. L. 103-66, Sec. 13612(a), substituted 
``except that the State shall seek adjustment or recovery of any medical 
assistance correctly paid on behalf of an individual under the State 
plan in the case of the following individuals:'' and subpars. (A) to (C) 
for ``except--'' and former subpars. (A) and (B) which read as follows:
    ``(A) in the case of an individual described in subsection (a)(1)(B) 
of this section, from his estate or upon sale of the property subject to 
a lien imposed on account of medical assistance paid on behalf of such 
individual, and
    ``(B) in the case of any other individual who was 65 years of age or 
older when he received such assistance, from his estate.''
    Subsec. (b)(3). Pub. L. 103-66, Sec. 13612(b), added par. (3).
    Subsec. (b)(4). Pub. L. 103-66, Sec. 13612(c), added par. (4).
    Subsec. (c)(1). Pub. L. 103-66, Sec. 13611(a)(1), amended par. (1) 
generally. Prior to amendment, par. (1) read as follows: ``In order to 
meet the requirements of this subsection (for purposes of section 
1396a(a)(51)(B) of this title), the State plan must provide for a period 
of ineligibility for nursing facility services and for a level of care 
in a medical institution equivalent to that of nursing facility services 
and for services under section 1396n(c) of this title in the case of an 
institutionalized individual (as defined in paragraph (3)) who, or whose 
spouse, at any time during or after the 30-month period immediately 
before the date the individual becomes an institutionalized individual 
(if the individual is entitled to medical assistance under the State 
plan on such date) or, if the individual is not so entitled, the date 
the individual applies for such assistance while an institutionalized 
individual, disposed of resources for less than fair market value. The 
period of ineligibility shall begin with the month in which such 
resources were transferred and the number of months in such period shall 
be equal to the lesser of--
        ``(A) 30 months, or
        ``(B)(i) the total uncompensated value of the resources so 
    transferred, divided by (ii) the average cost, to a private patient 
    at the time of the application, of nursing facility services in the 
    State or, at State option, in the community in which the individual 
    is institutionalized.''
    Subsec. (c)(2)(A). Pub. L. 103-66, Sec. 13611(a)(2)(A), substituted 
``assets'' for ``resources'' in introductory provisions.
    Subsec. (c)(2)(B). Pub. L. 103-66, Sec. 13611(a)(2)(B), amended 
subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: 
``the resources were transferred (i) to or from (or to another for the 
sole benefit of) the individual's spouse, or (ii) to the individual's 
child described in subparagraph (A)(ii)(II);''.
    Subsec. (c)(2)(C). Pub. L. 103-66, Sec. 13611(a)(2)(C), in 
introductory provisions, substituted ``with regulations'' for ``with any 
regulations'', in cl. (i), substituted ``assets'' for ``resources'' and 
struck out ``or'' at end, in cl. (ii), substituted ``assets'' for 
``resources'' and ``, or'' for ``; or'', and added cl. (iii).
    Subsec. (c)(2)(D). Pub. L. 103-66, Sec. 13611(a)(2)(D), amended 
subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: 
``the State determines that denial of eligibility would work an undue 
hardship.''
    Subsec. (c)(3). Pub. L. 103-66, Sec. 13611(a)(2)(E), added par. (3) 
and struck out former par. (3) which read as follows: ``In this 
subsection, the term `institutionalized individual' means an individual 
who is an inpatient in a nursing facility, who is an inpatient in a 
medical institution and with respect to whom payment is made based on a 
level of care provided in a nursing facility, or who is described in 
section 1396a(a)(10)(A)(ii)(VI) of this title.''
    Subsec. (c)(4). Pub. L. 103-66, Sec. 13611(a)(2)(F), inserted at end 
``In the case of a transfer by the spouse of an individual which results 
in a period of ineligibility for medical assistance under a State plan 
for such individual, a State shall, using a reasonable methodology (as 
specified by the Secretary), apportion such period of ineligibility (or 
any portion of such period) among the individual and the individual's 
spouse if the spouse otherwise becomes eligible for medical assistance 
under the State plan.''
    Subsec. (d). Pub. L. 103-66, Sec. 13611(b), added subsec. (d).
    Subsec. (e). Pub. L. 103-66, Sec. 13611(c), added subsec. (e).
    1989--Subsec. (c)(1). Pub. L. 101-239, Sec. 6411(e)(1)(A), inserted 
``or whose spouse,'' after ``an institutionalized individual (as defined 
in paragraph (3)) who,''.
    Subsec. (c)(2)(B)(i). Pub. L. 101-239, Sec. 6411(e)(1)(B)(i), 
amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: 
``to (or to another for the sole benefit of) the community spouse, as 
defined in section 1396r-5(h)(2) of this title,,''.
    Subsec. (c)(2)(B)(ii), (iii). Pub. L. 101-239, 
Sec. 6411(e)(1)(B)(ii), struck out ``, or'' after ``subparagraph 
(A)(ii)(II)'' in cl. (ii) and struck out cl. (iii) which read as 
follows: ``to (or to another for the sole benefit of) the individual's 
spouse if such spouse does not transfer such resources to another person 
other than the spouse for less than fair market value''.
    1988--Subsec. (c). Pub. L. 100-360, Sec. 303(b), amended subsec. (c) 
generally, substituting pars. (1) to (4) relating to taking into account 
certain transfers of assets, for former pars. (1) to (3) relating to 
denial of medical assistance, period of eligibility, and exceptions.
    Subsec. (c)(1). Pub. L. 100-485, Sec. 608(d)(16)(B)(i), substituted 
``period of ineligibility for nursing facility services and for a level 
of care in a medical institution equivalent to that of nursing facility 
services and for services under section 1396n(c) of this title in the 
case of an institutionalized individual (as defined in paragraph (3)) 
who, at any time during or after the 30-month period immediately before 
the date the individual becomes an institutionalized individual (if the 
individual is entitled to medical assistance under the State plan on 
such date) or, if the individual is not so entitled, the date the 
individual applies for such assistance while an institutionalized 
individual'' for ``period of ineligibility in the case of an 
institutionalized individual (as defined in paragraph (3)) who, at any 
time during the 30-month period immediately before the individual's 
application for medical assistance under the State plan''.
    Subsec. (c)(2)(A)(ii). Pub. L. 100-485, Sec. 608(d)(16)(B)(ii), 
inserted subcl. (I) and (II) designations.
    Subsec. (c)(2)(A)(iii). Pub. L. 100-485, Sec. 608(d)(16)(B)(iii), 
substituted ``the individual becomes an institutionalized individual'' 
for ``of the individual's admission to the medical institution or 
nursing facility''.
    Subsec. (c)(2)(A)(iv). Pub. L. 100-485, Sec. 608(d)(16)(B)(iv), 
substituted ``the individual becomes an institutionalized individual'' 
for ``of such individual's admission to the medical institution or 
nursing facility''.
    Subsec. (c)(2)(B). Pub. L. 100-485, Sec. 608(d)(16)(B)(v), inserted 
cl. (i) designation, substituted ``section 1396r-5(h)(2) of this 
title,,'' for ``section 1396r-5(h)(2) of this title, or the individual's 
child who is blind or permanently and totally disabled'', and added cl. 
(ii).
    Subsec. (c)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(3)(I), amended 
Pub. L. 100-203, Sec. 4211(h)(12)(B), see 1987 Amendment note below.
    Subsec. (c)(3). Pub. L. 100-485, Sec. 608(d)(16)(B)(vi), substituted 
``in a nursing facility, who is an inpatient in a medical institution 
and with respect to whom payment is made based on a level of care 
provided in a nursing facility, or who is described in section 
1396a(a)(10)(A)(ii)(VI) of this title'' for ``in a medical institution 
or nursing facility''.
    Subsec. (c)(5). Pub. L. 100-485, Sec. 608(d)(16)(B)(vii), added par. 
(5).
    1987--Subsecs. (a)(1)(B)(i), (c)(2)(B)(i). Pub. L. 100-203, 
Sec. 4211(h)(12)(A), substituted ``nursing facility, intermediate care 
facility for the mentally retarded'' for ``skilled nursing facility, 
intermediate care facility''.
    Subsec. (c)(2)(B)(ii). Pub. L. 100-203, Sec. 4211(h)(12)(B), as 
amended by Pub. L. 100-360, Sec. 411(l)(3)(I), substituted ``a nursing 
facility'' for ``a skilled nursing facility'' in two places each in 
subcls. (I) and (II).
    1983--Subsec. (b)(2)(B). Pub. L. 97-448, Sec. 309(b)(21), 
substituted ``who'' for ``and'' before ``has lawfully resided''.
    Subsec. (c)(2)(B)(iii). Pub. L. 97-448, Sec. 309(b)(22), substituted 
in subcl. (I) ``can'' for ``cannot'' and struck out from subcl. (IV) the 
introductory word ``if''.


                    Effective Date of 1993 Amendment

    Section 13611(e) of Pub. L. 103-66 provided that:
    ``(1) The amendments made by this section [amending this section and 
sections 1396a and 1396r-5 of this title] shall apply, except as 
provided in this subsection, to payments under title XIX of the Social 
Security Act [this subchapter] for calendar quarters beginning on or 
after October 1, 1993, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.
    ``(2) The amendments made by this section shall not apply--
        ``(A) to medical assistance provided for services furnished 
    before October 1, 1993,
        ``(B) with respect to assets disposed of on or before the date 
    of the enactment of this Act [Aug. 10, 1993], or
        ``(C) with respect to trusts established on or before the date 
    of the enactment of this Act.
    ``(3) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act [this subchapter] which the Secretary of 
Health and Human Services determines requires State legislation (other 
than legislation appropriating funds) in order for the plan to meet the 
additional requirements imposed by the amendment made by subsection (b) 
[amending this section], the State plan shall not be regarded as failing 
to comply with the requirements imposed by such amendment solely on the 
basis of its failure to meet these additional requirements before the 
first day of the first calendar quarter beginning after the close of the 
first regular session of the State legislature that begins after the 
date of the enactment of this Act [Aug. 10, 1993]. For purposes of the 
preceding sentence, in the case of a State that has a 2-year legislative 
session, each year of such session shall be deemed to be a separate 
regular session of the State legislature.''
    Section 13612(d) of Pub. L. 103-66 provided that:
    ``(1)(A) Except as provided in subparagraph (B), the amendments made 
by this section [amending this section] shall apply to payments under 
title XIX of the Social Security Act [this subchapter] for calendar 
quarters beginning on or after October 1, 1993, without regard to 
whether or not final regulations to carry out such amendments have been 
promulgated by such date.
    ``(B) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act which the Secretary of Health and Human 
Services determines requires State legislation (other than legislation 
appropriating funds) in order for the plan to meet the additional 
requirements imposed by the amendments made by this section, the State 
plan shall not be regarded as failing to comply with the requirements 
imposed by such amendments solely on the basis of its failure to meet 
these additional requirements before the first day of the first calendar 
quarter beginning after the close of the first regular session of the 
State legislature that begins after the date of the enactment of this 
Act [Aug. 10, 1993]. For purposes of the preceding sentence, in the case 
of a State that has a 2-year legislative session, each year of such 
session shall be deemed to be a separate regular session of the State 
legislature.
    ``(2) The amendments made by this section shall not apply to 
individuals who died before October 1, 1993.''


                    Effective Date of 1989 Amendment

    Amendment by Pub. L. 101-239 applicable to transfers occurring after 
Dec. 19, 1989, see section 6411(e)(4) of Pub. L. 101-239, set out as a 
note under section 1396a of this title.


                    Effective Date of 1988 Amendments

    Amendment by 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 303(b) of Pub. L. 100-360 applicable to 
payments under this subchapter for calendar quarters beginning on or 
after July 1, 1988 (except in certain situations requiring State 
legislative action), without regard to whether or not final regulations 
to carry out such amendment have been promulgated by such date, and 
subsection (c) of this section, as amended by section 303(b) of Pub. L. 
100-360, applicable to resources disposed of on or after July 1, 1988, 
but not applicable with respect to inter-spousal transfers occurring 
before Oct. 1, 1989, see section 303(g)(2), (5) of Pub. L. 100-360, set 
out as an Effective Date note under section 1396r-5 of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(l)(3)(I) 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 Amendment

    Amendment by 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.


                    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 added 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

    Section 132(d) of Pub. L. 97-248 provided that: ``The amendments 
made by this section [enacting this section and amending section 1396a 
of this title] shall become effective on the date of the enactment of 
this Act [Sept. 3, 1982], but the provisions of section 1917(c)(2)(B) of 
the Social Security Act [subsec. (c)(2)(B) of this section] shall not 
apply with respect to a transfer of assets which took place prior to 
such date of enactment.''

                  Section Referred to in Other Sections

    This section is referred to in sections 1320a-7b, 1382, 1382b, 
1396a, 1396r-5 of this title.
