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42 U.S.C. § 1397ll — Optional coverage of targeted low-income pregnant women through a State plan amendment

Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397ll — Optional coverage of targeted low-income pregnant women through a State plan amendment

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Source file: Laws/federal/codes/united-states-code/title-42/section-1397ll-optional-coverage-of-targeted-low-income-pregnant-women-through-a-state--9262b16b11.md
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Source location: Title 42, Chapter 7, § 1397ll; chapter-007-social-security.md

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**(a) In general** Subject to the succeeding provisions of this section, a State may elect through an amendment to its State child health plan under [section 1397bb of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397bb&num=0&edition=prelim) to provide pregnancy-related assistance under such plan for targeted low-income pregnant women. **(b) Conditions** A State may only elect the option under subsection (a) if the following conditions are satisfied: (1) **Minimum income eligibility levels for pregnant women and children** — The State has established an income eligibility level— (A) for pregnant women under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of [section 1396a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a&num=0&edition=prelim) that is at least 185 percent (or such higher percent as the State has in effect with regard to pregnant women under this subchapter) of the poverty line applicable to a family of the size involved, but in no case lower than the percent in effect under any such subsection as of July 1, 2008; and (B) for children under 19 years of age under this subchapter (or subchapter XIX) that is at least 200 percent of the poverty line applicable to a family of the size involved. (2) **No CHIP income eligibility level for pregnant women lower than the State’s Medicaid level** — The State does not apply an effective income level for pregnant women under the State plan amendment that is lower than the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) specified under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of [section 1396a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a&num=0&edition=prelim), on February 4, 2009, to be eligible for medical assistance as a pregnant woman. (3) **No coverage for higher income pregnant women without covering lower income pregnant women** — The State does not provide coverage for pregnant women with higher family income without covering pregnant women with a lower family income. (4) **Application of requirements for coverage of targeted low-income children** — The State provides pregnancy-related assistance for targeted low-income pregnant women in the same manner, and subject to the same requirements under [section 1397cc(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397cc/c&num=0&edition=prelim), as the State provides child health assistance for targeted low-income children under the State child health plan, and in addition to providing child health assistance for such women. (5) **No preexisting condition exclusion or waiting period** — The State does not apply any exclusion of benefits for pregnancy-related assistance based on any preexisting condition or any waiting period (including any waiting period imposed to carry out [section 1397bb(b)(3)(C) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397bb/b/3/C&num=0&edition=prelim)) for receipt of such assistance. (6) **Application of cost-sharing protection** — The State provides pregnancy-related assistance to a targeted low-income woman consistent with the cost-sharing protections under [section 1397cc(e) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397cc/e&num=0&edition=prelim) and applies the limitation on total annual aggregate cost sharing imposed under paragraph (3)(B) of such section to the family of such a woman. (7) **No waiting list for children** — The State does not impose, with respect to the enrollment under the State child health plan of targeted low-income children during the quarter, any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment. **(c) Option to provide presumptive eligibility** A State that elects the option under subsection (a) and satisfies the conditions described in subsection (b) may elect to apply [section 1396r–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396r-1&num=0&edition=prelim) (relating to presumptive eligibility for pregnant women) to the State child health plan in the same manner as such section applies to the State plan under subchapter XIX. **(d) Definitions** For purposes of this section: (1) **Pregnancy-related assistance** — The term “pregnancy-related assistance” has the meaning given the term “child health assistance” in [section 1397jj(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397jj/a&num=0&edition=prelim) with respect to an individual during the period described in paragraph (2)(A). (2) **Targeted low-income pregnant woman** — The term “targeted low-income pregnant woman” means an individual— (A) during pregnancy and through the end of the month in which the 60-day period, or, in the case that subparagraph (A) of [section 1396a(e)(16) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/e/16&num=0&edition=prelim) applies to the State child health plan (or waiver of such plan), pursuant to [section 1397gg(e)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397gg/e/1&num=0&edition=prelim), the 12-month period,11 So in original. The comma probably should not appear. (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this subchapter for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of [section 1397jj(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397jj/b&num=0&edition=prelim) in the same manner as a child applying for child health assistance would have to satisfy such requirements. **(e) Automatic enrollment for children born to women receiving pregnancy-related assistance** If a child is born to a targeted low-income pregnant woman who was receiving pregnancy-related assistance under this section on the date of the child’s birth, the child shall be deemed to have applied for child health assistance under the State child health plan and to have been found eligible for such assistance under such plan or to have applied for medical assistance under subchapter XIX and to have been found eligible for such assistance under such subchapter, as appropriate, on the date of such birth and to remain eligible for such assistance until the child attains 1 year of age. During the period in which a child is deemed under the preceding sentence to be eligible for child health or medical assistance, the child health or medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires). **(f) States providing assistance through other options** (1) **Continuation of other options for providing assistance** — The option to provide assistance in accordance with the preceding subsections of this section shall not limit any other option for a State to provide— (A) child health assistance through the application of sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) of title 42, Code of Federal Regulations (as in effect after the final rule adopted by the Secretary and set forth at 67 Fed. Reg. 61956–61974 (October 2, 2002)), or (B) pregnancy-related services through the application of any waiver authority (as in effect on June 1, 2008). (2) **Clarification of authority to provide postpartum services** — Any State that provides child health assistance under any authority described in paragraph (1) may continue to provide such assistance, as well as postpartum services, through the end of the month in which the 60-day period (beginning on the last day of the pregnancy) ends, in the same manner as such assistance and postpartum services would be provided if provided under the State plan under subchapter XIX, but only if the mother would otherwise satisfy the eligibility requirements that apply under the State child health plan (other than with respect to age) during such period. (3) **No inference** — Nothing in this subsection shall be construed— (A) to infer congressional intent regarding the legality or illegality of the content of the sections specified in paragraph (1)(A); or (B) to modify the authority to provide pregnancy-related services under a waiver specified in paragraph (1)(B).

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1396 — Medicaid and CHIP Payment and Access Commission

**(a) Establishment** There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as “MACPAC”). **(b) Duties** (1) **Review of access policies for all States and annual reports** — MACPAC shall— (A) review policies of the Medicaid program established under this subchapter (in this section referred to as “Medicaid”) and the State Children’s Health Insurance Program established under subchapter XXI (in this section referred to as “CHIP”) affecting access to covered items and services, including topics described in paragraph (2); (B) make recommendations to Congress, the Secretary, and States concerning such access policies; (C) by not later than March 15 of each year (beginning with 2010), submit a report to Congress containing the results of such reviews and MACPAC’s recommendations concerning such policies; and (D) by not later than June 15 of each year (beginning with 2010), submit a report to Congress containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs. (2) **Specific topics to be reviewed** — Specifically, MACPAC shall review and assess the following: (A) *Medicaid and CHIP payment policies* — Payment policies under Medicaid and CHIP, including— (i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of ot

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397bb — General contents of State child health plan; eligibility; outreach

**(a) General background and description** A State child health plan shall include a description, consistent with the requirements of this subchapter, of— (1) the extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children classified by income and other relevant factors, currently have creditable health coverage (as defined in [section 1397jj(c)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397jj/c/2&num=0&edition=prelim)); (2) current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships; (3) how the plan is designed to be coordinated with such efforts to increase coverage of children under creditable health coverage; (4) the child health assistance provided under the plan for targeted low-income children, including the proposed methods of delivery, and utilization control systems; (5) eligibility standards consistent with subsection (b); (6) outreach activities consistent with subsection (c); and (7) methods (including monitoring) used— (A) to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan; (B) to assure access to covered services, including emergency services and services described in paragraphs (5) and (6) of [section 1397cc(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397cc/c&num=0&edition=prelim); and (C) to ensure that the Sta

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1397bb

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1396a — State plans for medical assistance

**(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

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396a

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397ll — Optional coverage of targeted low-in-

Page 4508 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397ll 1 So in original. The comma probably should not appear. Editorial Notes REFERENCES IN TEXT Section 6102(c)(3) of the Deficit Reduction Act of 2005, referred to in subsec. (c)(1), is section 6102(c)(3) of Pub. L. 109–171, which is set out as a note under section 1397gg of this title. AMENDMENTS 2015—Subsec. (b)(2)(B)(i). Pub. L. 114–10 substituted ‘‘section 1397dd(m)(5)’’ for ‘‘section 1397dd(m)(4)’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE Section effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of Pub. L. 111–3, set out as a note under section 1396 of this title. § 1397ll. Optional coverage of targeted low-in- come pregnant women through a State plan amendment (a) In general Subject to the succeeding provisions of this section, a State may elect through an amend- ment to its State child health plan under sec- tion 1397bb of this title to provide pregnancy-re- lated assistance under such plan for targeted low-income pregnant women. (b) Conditions A State may only elect the option under sub- section (a) if the following conditions are satis- fied: (1) Minimum income eligibility levels for preg- nant women and children The State has established an income eligi- bility level— (A) for pregnant women under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1396a of this title that is at least 185 percent (or such higher percent as the State has in effect with regard to pregnant women under this subchapter) of the poverty line applicable to a family of the size in- volved, but in no case lower than the percent in effect under any such subs

Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 1397ll

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