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42 U.S.C. § 1396e — Enrollment of individuals under group health plans
Federal law — U.S. Code and appendices · legal_authorities
**(a) Requirements of each State plan; guidelines** Each State plan—
(1) may implement guidelines established by the Secretary, consistent with subsection (b), to identify those cases in which enrollment of an individual otherwise entitled to medical assistance under this subchapter in a group health plan (in which the individual is otherwise eligible to be enrolled) is cost-effective (as defined in subsection (e)(2));
(2) may require, in case of an individual so identified and as a condition of the individual being or remaining eligible for medical assistance under this subchapter and subject to subsection (b)(2), notwithstanding any other provision of this subchapter, that the individual (or in the case of a child, the child’s parent) apply for enrollment in the group health plan; and
(3) in the case of such enrollment (except as provided in subsection (c)(1)(B)), shall provide for payment of all enrollee premiums for such enrollment and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under section 1396o of this title), and shall treat coverage under the group health plan as a third party liability (under [section 1396a(a)(25) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/a/25&num=0&edition=prelim)).
**(b) Timing of enrollment; failure to enroll**
(1) In establishing guidelines under subsection (a)(1), the Secretary shall take into account that an individual may only be eligible to enroll in group health plans at limited times and only if other individuals (not entitled to medical assistance under the plan) are also enrolled in the plan simultaneously.
(2) If a parent of
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Source file: Laws/federal/codes/united-states-code/title-42/section-1396e-enrollment-of-individuals-under-group-health-plans--5682b64f9e.md
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Source location: Title 42, Chapter 7, § 1396e; chapter-007-social-security.md
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**(a) Requirements of each State plan; guidelines** Each State plan—
(1) may implement guidelines established by the Secretary, consistent with subsection (b), to identify those cases in which enrollment of an individual otherwise entitled to medical assistance under this subchapter in a group health plan (in which the individual is otherwise eligible to be enrolled) is cost-effective (as defined in subsection (e)(2));
(2) may require, in case of an individual so identified and as a condition of the individual being or remaining eligible for medical assistance under this subchapter and subject to subsection (b)(2), notwithstanding any other provision of this subchapter, that the individual (or in the case of a child, the child’s parent) apply for enrollment in the group health plan; and
(3) in the case of such enrollment (except as provided in subsection (c)(1)(B)), shall provide for payment of all enrollee premiums for such enrollment and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under section 1396o of this title), and shall treat coverage under the group health plan as a third party liability (under [section 1396a(a)(25) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/a/25&num=0&edition=prelim)).
**(b) Timing of enrollment; failure to enroll**
(1) In establishing guidelines under subsection (a)(1), the Secretary shall take into account that an individual may only be eligible to enroll in group health plans at limited times and only if other individuals (not entitled to medical assistance under the plan) are also enrolled in the plan simultaneously.
(2) If a parent of a child fails to enroll the child in a group health plan in accordance with subsection (a)(2), such failure shall not affect the child’s eligibility for benefits under this subchapter.
**(c) Premiums considered payments for medical assistance; eligibility**
(1)
(A) In the case of payments of premiums, deductibles, coinsurance, and other cost-sharing obligations under this section shall be considered, for purposes of [section 1396b(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396b/a&num=0&edition=prelim), to be payments for medical assistance.
(B) If all members of a family are not eligible for medical assistance under this subchapter and enrollment of the members so eligible in a group health plan is not possible without also enrolling members not so eligible—
(i) payment of premiums for enrollment of such other members shall be treated as payments for medical assistance for eligible individuals, if it would be cost-effective (taking into account payment of all such premiums), but
(ii) payment of deductibles, coinsurance, and other cost-sharing obligations for such other members shall not be treated as payments for medical assistance for eligible individuals.
(2) The fact that an individual is enrolled in a group health plan under this section shall not change the individual’s eligibility for benefits under the State plan, except insofar as [section 1396a(a)(25) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/a/25&num=0&edition=prelim) provides that payment for such benefits shall first be made by such plan.
**(d) Repealed. Pub. L. 105–33, title IV, § 4741(b)(2), Aug. 5, 1997, 111 Stat. 523**
**(e) Definitions** In this section:
(1) The term “group health plan” has the meaning given such term in section 5000(b)(1) of the Internal Revenue Code of 1986, and includes the provision of continuation coverage by such a plan pursuant to title XXII of the Public Health Service Act [[42 U.S.C. 300bb–1](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300bb-1&num=0&edition=prelim) et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI 11 See References in Text note below. of the Employee Retirement Income Security Act of 1974.
(2) The term “cost-effective” has the meaning given that term in [section 1397ee(c)(3)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ee/c/3/A&num=0&edition=prelim).
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Benefit plans as affecting interstate commerce and the Federal taxing power** The Congress finds that the growth in size, scope, and numbers of employee benefit plans in recent years has been rapid and substantial; that the operational scope and economic impact of such plans is increasingly interstate; that the continued well-being and security of millions of employees and their dependents are directly affected by these plans; that they are affected with a national public interest; that they have become an important factor affecting the stability of employment and the successful development of industrial relations; that they have become an important factor in commerce because of the interstate character of their activities, and of the activities of their participants, and the employers, employee organizations, and other entities by which they are established or maintained; that a large volume of the activities of such plans are carried on by means of the mails and instrumentalities of interstate commerce; that owing to the lack of employee information and adequate safeguards concerning their operation, it is desirable in the interests of employees and their beneficiaries, and to provide for the general welfare and the free flow of commerce, that disclosure be made and safeguards be provided with respect to the establishment, operation, and administration of such plans; that they substantially affect the revenues of the United States because they are afforded preferential Federal tax treatment; that despite the enormous growth in such plans many employees with long years of employment are losing anticipated retirement benefits owing to the lack of vesting provisions in such plans; that owing to the inadequacy of current minimum standards, the soundness and stabilit
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Waiver of State plan requirements; costs regarded as State plan expenditures; availability of appropriations** In the case of any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of subchapter I, X, XIV, XVI, or XIX, or part A or D of subchapter IV, in a State or States—
(1) the Secretary may waive compliance with any of the requirements of section 302, 602, 654, 1202, 1352, 1382, or 1396a of this title, as the case may be, to the extent and for the period he finds necessary to enable such State or States to carry out such project, and
(2)
(A) costs of such project which would not otherwise be included as expenditures under section 303, 655, 1203, 1353, 1383, or 1396b of this title, as the case may be, and which are not included as part of the costs of projects under [section 1310 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1310&num=0&edition=prelim), shall, to the extent and for the period prescribed by the Secretary, be regarded as expenditures under the State plan or plans approved under such subchapter, or for administration of such State plan or plans, as may be appropriate, and
(B) costs of such project which would not otherwise be a permissible use of funds under part A of subchapter IV and which are not included as part of the costs of projects under [section 1310 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1310&num=0&edition=prelim), shall to the extent and for the period prescribed by the Secretary, be regarded as a permissible use of funds under such part.
In addition, not to exceed $4,000,000 of the aggregate amount appropriated for payments to States under such subch
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1315
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Federal law — U.S. Code and appendices · legal_authorities
Beginning with fiscal year 2010, the Secretary shall transfer from the Public Health and Social Services Emergency Fund such sums as may be necessary to carry out this part.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 201
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Contents** A State plan for medical assistance must—
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
(2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under [section 1396b of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396b&num=0&edition=prelim) are authorized by this subchapter; and, effective July 1, 1969, provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan;
(3) provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness;
(4) provide (A) such methods of administration (including methods relating to the establishment and maintenance of personnel standards on a merit basis, except that the Secretary shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods, including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan, and, subject to [section 1396b(i) of this title](https://uscode.house.gov/view.xhtml?req=granulei
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Computation of amount** From the sums appropriated therefor, the Secretary (except as otherwise provided in this section) shall pay to each State which has a plan approved under this subchapter, for each quarter, beginning with the quarter commencing January 1, 1966—
(1) an amount equal to the Federal medical assistance percentage (as defined in [section 1396d(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d/b&num=0&edition=prelim), subject to subsections (g) and (j) of this section and [section 1396r–4(f) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396r–4/f&num=0&edition=prelim)) of the total amount expended during such quarter as medical assistance under the State plan; plus
(2)
(A) an amount equal to 75 per centum of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the State agency or any other public agency; plus
(B) notwithstanding paragraph (1) or subparagraph (A), with respect to amounts expended for nursing aide training and competency evaluation programs, and competency evaluation programs, described in [section 1396r(e)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396r/e/1&num=0&edition=prelim) (including the costs for nurse aides to complete such competency evaluation programs), regardless of whether the programs are provided in or outside nursing facilities or of the skill of the personnel involved in such programs, an amount equal to 50 percent (or, for calendar
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Federal law — U.S. Code and appendices · legal_authorities
Page 4211
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1396e
tion 1905(h) of the Social Security Act [42 U.S.C.
1396d(h)], and such determination has not been subject
to a final judicial decision, any disallowance or deferral
of Federal financial participation under such Act [42
U.S.C. 301 et seq.] based on such determination shall
only apply to the period of time beginning with the
first day of noncompliance and ending with the date by
which the psychiatric facility develops documentation
(using plan of care or utilization review procedures) of
the need for inpatient care with respect to such individ-
uals.
‘‘(2) Any disallowance of Federal financial participa-
tion under title XIX of the Social Security Act [42
U.S.C. 1396 et seq.] relating to the failure of a psy-
chiatric facility to comply with certification of need
requirements—
‘‘(A) shall not exceed 25 percent of the amount of
Federal financial participation for the period de-
scribed in paragraph (1); and
‘‘(B) shall not apply to any fiscal year before the
fiscal year that is 3 years before the fiscal year in
which the determination of noncompliance described
in paragraph (1) is made.
‘‘(b) EFFECTIVE DATE.—Subsection (a) shall apply to
disallowance actions and deferrals of Federal financial
participation with respect to services provided before
the date of enactment of this Act [Nov. 5, 1990].’’
INTERMEDIATE CARE FACILITY; ACCESS AND VISITATION
RIGHTS
Pub. L. 100–360, title IV, § 411(l)(3)(C)(i), formerly
§ 411(l)(3)(C), July 1, 1988, 102 Stat. 803, as redesignated
by Pub. L. 100–485, title VI, § 608(d)(27)(E), Oct. 13, 1988,
102 Stat. 2423, provided that: ‘‘Effective as of the date
of the enactment of this Act [July 1, 1988] and until the
effective date of section 1919(c) of such Act [
Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 1396e
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