42 U.S.C. § 1396e — Enrollment of individuals under group

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 [42 U.S.C. 1396r(c), see Effective Date note set out under 42 U.S.C. 1396r], section 1905(c) of the Social Security Act [42 U.S.C. 1396d(c)] is deemed to include the requirement described in section 1919(c)(3)(A) of such Act (as in- serted by section 4211(a)(3) of OBRA).’’ REGULATIONS FOR INTERMEDIATE CARE FACILITIES FOR MENTALLY RETARDED Pub. L. 99–272, title IX, § 9514, Apr. 7, 1986, 100 Stat. 213, provided that: ‘‘The Secretary of Health and Human Services shall promulgate proposed regulations revising standards for intermediate care facilities for the mentally retarded under title XIX of the Social Se- curity Act [42 U.S.C. 1396 et seq.] within 60 days after the date of the enactment of this Act [Apr. 7, 1986].’’ LIFE SAFETY CODE RECOGNITION Pub. L. 99–272, title IX, § 9515, Apr. 7, 1986, 100 Stat. 213, provided that: ‘‘For purposes of section 1905(c) of the Social Security Act [42 U.S.C. 1396d(c)], an inter- mediate care facility for the mentally retarded (as de- fined in section 1905(d) of such Act) which meets the re- quirements of the relevant sections of the 1985 edition of the Life Safety Code of the National Fire Protection Association shall be deemed to meet the fire safety re- quirements for intermediate care facilities for the men- tally retarded until such time as the Secretary speci- fies a later edition of the Life Safety Code for purposes of such section, or the Secretary determines that more stringent standards are necessary to protect the safety of residents of such facilities.’’ STUDY OF FEDERAL MEDICAL ASSISTANCE PERCENTAGE FORMULA AND OF ADJUSTMENTS OF TARGET AMOUNTS FOR FEDERAL MEDICAID EXPENDITURES; REPORT TO CONGRESS Pub. L. 97–35, title XXI, § 2165, Aug. 13, 1981, 95 Stat. 806, directed the Comptroller General, in consultation with the Advisory Committee for Intergovernmental Relations, to study the Federal medical assistance per- centage formula as applicable to distribution of Fed- eral funds to States, with a view to revising the med- icaid matching formula so as to take into account fac- tors which might result in a more equitable distribu- tion of Federal funds to States under this chapter, and to report to Congress on such study not later than Oct. 1, 1982. COSTS CHARGED TO PERSONAL FUNDS OF PATIENTS IN INTERMEDIATE CARE FACILITIES; COSTS INCLUDED IN CHARGES FOR SERVICES; REGULATIONS Pub. L. 95–292, § 8(c), (d)(2), June 13, 1978, 92 Stat. 316, required the Secretary of Health, Education, and Wel- fare to issue regulations, within 90 days after enact- ment of Pub. L. 95–292 but not later than July 1, 1978, defining those costs that may be charged to the per- sonal funds of patients in intermediate care facilities who are individuals receiving medical assistance under a State plan approved under title XIX of the Social Se- curity Act, and those costs that are to be included in the reasonable cost or reasonable charge for inter- mediate care facility services. See section 1302 of this title. § 1396e. Enrollment of individuals under group health plans (a) Requirements of each State plan; guidelines Each State plan— (1) may implement guidelines established by the Secretary, consistent with subsection (b), to identify those cases in which enrollment of an individual otherwise entitled to medical as- sistance under this subchapter in a group health plan (in which the individual is other- wise 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 assist- ance under this subchapter and subject to sub- section (b)(2), notwithstanding any other pro- vision 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). (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 as- sistance 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 sub- chapter. (c) Premiums considered payments for medical assistance; eligibility (1)(A) In the case of payments of premiums, deductibles, coinsurance, and other cost-sharing Page 4212 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1396e–1 1 See References in Text note below. obligations under this section shall be consid- ered, for purposes of section 1396b(a) of this title, to be payments for medical assistance. (B) If all members of a family are not eligible for medical assistance under this subchapter and enrollment of the members so eligible in a group health plan is not possible without also enroll- ing members not so eligible— (i) payment of premiums for enrollment of such other members shall be treated as pay- ments for medical assistance for eligible indi- viduals, if it would be cost-effective (taking into account payment of all such premiums), but (ii) payment of deductibles, coinsurance, and other cost-sharing obligations for such other members shall not be treated as payments for medical assistance for eligible individuals. (2) The fact that an individual is enrolled in a group health plan under this section shall not change the individual’s eligibility for benefits under the State plan, except insofar as section 1396a(a)(25) of this title provides that payment for such benefits shall first be made by such plan. (d) Repealed. Pub. L. 105–33, title IV, § 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 in- cludes the provision of continuation coverage by such a plan pursuant to title XXII of the Public Health Service Act [42 U.S.C. 300bb–1 et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI 1 of the Employee Re- tirement Income Security Act of 1974. (2) The term ‘‘cost-effective’’ has the mean- ing given that term in section 1397ee(c)(3)(A) of this title. (Aug. 14, 1935, ch. 531, title XIX, § 1906, as added Pub. L. 101–508, title IV, § 4402(a)(2), Nov. 5, 1990, 104 Stat. 1388–161; amended Pub. L. 105–33, title IV, § 4741(b), Aug. 5, 1997, 111 Stat. 523; Pub. L. 111–148, title X, § 10203(b)(1), Mar. 23, 2010, 124 Stat. 927.) Editorial Notes REFERENCES IN TEXT The Internal Revenue Code of 1986, referred to in sub- sec. (e)(1), is classified generally to Title 26, Internal Revenue Code. The Public Health Service Act, referred to in subsec. (e)(1), is act July 1, 1944, ch. 373, 58 Stat. 682. Title XXII of the Act is classified generally to subchapter XX (§ 300bb–1 et seq.) of chapter 6A of this title. For com- plete classification of this Act to the Code, see Short Title note set out under section 201 of this title and Ta- bles. The Employee Retirement Income Security Act of 1974, referred to in subsec. (e)(1), is Pub. L. 93–406, Sept. 2, 1974, 88 Stat. 829. Title VI of the Act probably means part 6 of subtitle B of title I of the Act which is classi- fied generally to part 6 (§ 1161 et seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor, because the Act has no title VI. For complete classification of this Act to the Code, see Short Title note set out under section 1001 of Title 29 and Tables. PRIOR PROVISIONS A prior section 1396e, act Aug. 14, 1935, ch. 531, title XIX, § 1906, as added Jan. 2, 1968, Pub. L. 90–248, title II, § 226, 81 Stat. 903, created Advisory Council on Medical Assistance, set forth composition of Council, term of membership of members, and purposes of Council, and provided for compensation of members, prior to repeal by Pub. L. 92–603, title II, § 287, Oct. 30, 1972, 86 Stat. 1457, effective on the first day of the third calendar month following Oct. 30, 1972. AMENDMENTS 2010—Subsec. (e)(2). Pub. L. 111–148 substituted ‘‘has the meaning given that term in section 1397ee(c)(3)(A) of this title.’’ for ‘‘means, as established by the Sec- retary, that the reduction in expenditures under this subchapter with respect to an individual who is en- rolled in a group health plan is likely to be greater than the additional expenditures for premiums and cost-sharing required under this section with respect to such enrollment.’’ 1997—Subsec. (a). Pub. L. 105–33, § 4741(b)(1), in intro- ductory provisions, substituted ‘‘Each’’ for ‘‘For pur- poses of section 1396a(a)(25)(G) of this title and subject to subsection (d) of this section, each’’ and, in pars. (1) and (2), substituted ‘‘may’’ for ‘‘shall’’. Subsec. (d). Pub. L. 105–33, § 4741(b)(2), struck out sub- sec. (d) which read as follows: ‘‘(1) In the case of any State which is providing med- ical assistance to its residents under a waiver granted under section 1315 of this title, the Secretary shall re- quire the State to meet the requirements of this sec- tion in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this subchapter. ‘‘(2) This section, and section 1396a(a)(25)(G) of this title, shall only apply to a State that is one of the 50 States or the District of Columbia.’’ Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2010 AMENDMENT Pub. L. 111–148, title X, § 10203(b), Mar. 23, 2010, 124 Stat. 927, provided that the amendment made by sec- tion 10203(b)(1) of Pub. L. 111–148 is effective as if in- cluded in the enactment of the Children’s Health Insur- ance Program Reauthorization Act of 2009 (Pub. L. 111–3). EFFECTIVE DATE Section applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after Jan. 1, 1991, without regard to whether or not final regulations to carry out the amendments by section 4402 of Pub. L. 101–508 have been promulgated by such date, see section 4402(e) of Pub. L. 101–508, set out as an Effective Date of 1990 Amendment note under section 1396a of this title. § 1396e–1. Premium assistance (a) In general A State may elect to offer a premium assist- ance subsidy (as defined in subsection (c)) for qualified employer-sponsored coverage (as de- fined in subsection (b)) to all individuals who are entitled to medical assistance under this subchapter (and, in the case of an individual under age 19, to the parent of such an individual) who have access to such coverage if the State meets the requirements of this section and the offering of such a subsidy is cost-effective, as de- fined for purposes of section 1397ee(c)(3)(A) of this title.