Compilation of the Social Security Laws
Title XIX – Grants to states for medical assistance programs
Table of Contents (Links redirect to government website)
Sec. 1900. Medicaid and CHIP Payment and Access Commission
Sec. 1901. Appropriation
Sec. 1902. State plans for medical assistance
Sec. 1903. Payment to States
Sec. 1904. Operation of State plans
Sec. 1905. Definitions
Sec. 1906. Enrollment of individuals under group health plans
Sec. 1906A. Premium assistance
Sec. 1907. Observance of religious beliefs
Sec. 1908. State programs for licensing of administrators of nursing homes
Sec. 1908A. Required laws relating to medical child support
Sec. 1909. State false claims act requirements for increased state share of recoveries
Sec. 1910. Certification and approval of rural health clinics and intermediate care facilities for the mentally retarded
Sec. 1911. Indian Health Service facilities
Sec. 1912. Assignment of rights of payment
Sec. 1913. Hospital providers of nursing facility services
Sec. 1914. Withholding of Federal share of payments for certain medicare providers
Sec. 1915. Provisions respecting inapplicability and waiver of certain requirements of this title
Sec. 1916. Use of enrollment fees, premiums, deductions, cost sharing, and similar charges
Sec. 1916A. State option for alternative premiums and cost sharing
Sec. 1917. Liens, adjustments and recoveries, and transfers of assets
Sec. 1918. Application of provisions of Title II to subpoenas
Sec. 1919. Requirements for nursing facilities
Sec. 1920. Presumptive eligibility for pregnant women
Sec. 1920A. Presumptive eligibility for children
Sec. 1920B. Presumptive eligibility for certain breast or cervical cancer patients
Sec. 1920C. Presumptive eligibility for family planning services
Sec. 1921. Information concerning sanctions taken by State licensing authorities against health care practitioners and providers
Sec. 1922. Correction and reduction plans for intermediate care facilities for the mentally retarded
Sec. 1923. Adjustment in payment for inpatient hospital services furnished by disproportionate share hospitals
Sec. 1924. Treatment of income and resources for certain institutionalized spouses
Sec. 1925. Extension of eligibility for medical assistance
[Sec. 1926. Repealed.]
Sec. 1927. Payment for covered outpatient drugs
Sec. 1928. Program for distribution of pediatric vaccines
Sec. 1929. Home and community care for functionally disabled elderly individuals
Sec. 1930. Community supported living arrangements services
Sec. 1931. Assuring coverage for certain low-income families
Sec. 1932. Provisions relating to managed care
Sec. 1933. State coverage of medicare cost-sharing for additional low-income medicare beneficiaries
Sec. 1934. Program of all-inclusive care for the elderly (PACE)
Sec. 1935. Special provisions relating to medicare prescription drug benefit
Sec. 1936. Medicaid integrity program
Sec. 1937. State flexibility in benefit packages
Sec. 1938. Health opportunity accounts
Sec. 1939. References to laws directly affecting medicaid program
Sec. 1940. Asset verification through access to information held by financial institutions
Sec. 1941. Medicaid improvement fund
Sec. 1942. Authorization to receive relevant information
Sec. 1943. Enrollment simplification and coordination with State health insurance exchanges
Sec. 1944. REQUIREMENTS RELATING TO QUALIFIED PRESCRIPTION DRUG MONITORING PROGRAMS AND PRESCRIBING CERTAIN CONTROLLED SUBSTANCES
Sec. 1945. State option to provide coordinated care through a health home for individuals with chronic conditions
Sec. 1945A. State option to provide coordinated care through a health home for children with medically complex conditions
Sec. 1946. Addressing health care disparities
Medicaid and CHIP Payment and Access Commission
Sec. 1900. [42 U.S.C. 1396–1] (a) Establishment.—There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as “MACPAC”).
(1) Review of access policies for all states and annual reports.—MACPAC shall—
(A) review policies of the Medicaid program established under this title (in this section referred to as “Medicaid”) and the State Children’s Health Insurance Program established under title 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 the Statesconcerning 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 ofitems 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 other covered items and services;
(ii) payment methodologies; and
(iii) the relationship of such factors and methodologies to access and quality of care for Medicaid and CHIP beneficiaries (including how such factors and methodologies enable such beneficiaries to obtain the services for which they are eligible, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations).
(B) Eligibility policies.—Medicaid and CHIP eligibility policies, including a determination of the degree to which Federal and State policies provide health care coverage to needy populations.
(C) Enrollment and retention processes.— Medicaid and CHIP enrollment and retention processes, including a determination of the degree to which Federal and State policies encourage the enrollment of individuals who are eligible for such programs and screen out individuals who are ineligible, while minimizing the share of program expenses devoted to such processes.
(D) coverage policiesMedicaid and CHIP benefit and coverage policies, including a determination of the degree to which Federal and State policies provide access to the services enrollees require to improve and maintain their health and functional status.
(E) Quality of care.—Medicaid and CHIP policies as they relate to the quality of care provided under those programs, including a determination of the degree to which Federal and State policies achieve their stated goals and
(F) Interaction of medicaid and chip payment policies with health care delivery generally.—The effect of Medicaid and CHIP payment policies on access to items and services for children and other Medicaid and CHIP populations other than under this title or title XXI and the implications of changes in health care delivery in the United States and in the general market for health care items and services on Medicaid and CHIP.
(G) Interactions with medicare and medicaid.—)consistent with paragraph (11), the interaction of policies under Medicaid and the Medicare program under title XVIII, including with respect to how such interactions affect access to services, payments, and dual eligible individuals.
(H) Other access policies.—The effect of other Medicaid and CHIP policies on access to covered items and services, including policies relating to transportation and language barriers and preventive, acute, and long-term services and supports.
(3) Recommendations and reports.—
(A) review national and State-specific Medicaid and CHIP data; and
(B) submit reports and recommendations to Congress, the Secretary, and States based on such reviews.
(4) Creation of early-warning system.—MACPAC shall create an early-warning system to identify provider shortage areas , as well as other factors that adversely affect, or have the potential to adversely affect, access to care by, or the health care status of, Medicaid and CHIP beneficiaries. MACPAC shall include in the annual report required under paragraph (1)(D) a description of all such areas or problems identified with respect to the period addressed in the report.
(A) Comments on certain secretarial reports and regulations.—.If the Secretary submits to Congress (or a committee of Congress) a report that is required by law and that relates to access policies, including with respect to payment policies, under Medicaid or CHIP, the Secretary shall transmit a copy of the report to MACPAC. MACPAC shall review the report and, not later than 6 months after the date of submittal of the Secretary’s report to Congress, shall submit to the appropriate committees of Congress and the Secretarywritten comments on such report. Such comments may include such recommendations as MACPAC deems appropriate.
(B) Regulations.—MACPAC shall review Medicaid and CHIP regulations and may comment through submission of a report to the appropriate committees of Congress and the Secretary, on any such regulations that affect access, quality, or efficiency of health care.
(6) Agenda and additional reviews.—
(A) In general.— MACPAC shall consult periodically with the chairmen and ranking minority members of the appropriate committees of Congress regarding MACPAC’s agenda and progress towards achieving the agenda. MACPAC may conduct additional reviews, and submit additional reports to the appropriate committees of Congress, from time to time on such topics relating to the program under this title or title XXI as may be requested by such chairmen and members and as MACPAC deems appropriate.
(B) Review and reports regarding medicaid dsh.—
(i) In general.— MACPAC shall review and submit an annual report to Congress on disproportionate share hospital payments under section 1923. Each report shall include the information specified in clause (ii).
(ii) Required report information.—Each report required under this subparagraph shall include the following:
(I) Data relating to changes in the number of uninsured individuals.
(II) Data relating to the amount and sources of hospitals’ uncompensated care costs, including the amount of such costs that are the result of providing unreimbursed or under-reimbursed services, charity care, or bad debt.
(III) Data identifying hospitals with high levels of uncompensated care that also provide access to essential community services for low-income, uninsured, and vulnerable populations, such as graduate medical education, and the continuum of primary through quarternary care, including the provision of trauma care and public health services.
(IV) State-specific analyses regarding the relationship between the most recent State DSH allotment and the projected State DSH allotment for the succeeding year and the data reported under subclauses (I), (II), and (III) for the State.
(iii) Data.—Notwithstanding any other provision of law, the Secretary regularly shall provide MACPAC with the most recent State reports and most recent independent certified audits submitted under section 1923(j), cost reports submitted under title XVIII, and such other data as MACPAC may request for purposes of conducting the reviews and preparing and submitting the annual reports required under this subparagraph.
(iv) Submission deadlines.— The first report required under this subparagraph shall be submitted to Congress not later than February 1, 2016. Subsequent reports shall be submitted as part of, or with, each annual report required under paragraph (1)(C) during the period of fiscal years 2017 through 2024.
(7) Availability of reports.—MACPAC shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public.
(8) Appropriate committee of congress.—For purposes of this section, the term “appropriate committees of Congress” means the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate.
(9) Voting and reporting requirements.—With respect to each recommendation contained in a report submitted under paragraph (1), each member of MACPAC shall vote on the recommendation, and MACPAC shall include, by member, the results of that vote in the report containing the recommendation.
(10) Examination of budget consequences.—Before making any recommendations, MACPAC shall examine the budget consequences of such recommendations, directly or through consultation with appropriate expert entities, and shall submit with any recommendations, a report on the Federal and State-specific budget consequences of the recommendations.
(11) Consultation and coordination with medpac.—
(A) In general.—MACPAC shall consult with the Medicare Payment Advisory Commission (in this paragraph referred to as “MedPAC”) established under section 1805 in carrying out its duties under this section, as appropriate and particularly with respect to the issues specified in paragraph (2) as they relate to those Medicaid beneficiaries who are dually eligible for Medicaid and the Medicare program under title XVIII, adult Medicaid beneficiaries (who are not dually eligible for Medicare), and beneficiaries under Medicare. Responsibility for analysis of and recommendations to change Medicare policy regarding Medicare beneficiaries, including Medicare beneficiaries who are dually eligible for Medicare and Medicaid, shall rest with MedPAC.
(B) Information sharing.—MACPAC and MedPAC shall have access to deliberations and records of the other such entity, respectively, upon the request of the other such entity.
(12) Consultation.—MACPAC shall regularly consult with States in carrying out its duties under this section, including with respect to developing processes for carrying out such duties, and shall ensure that input from States is taken into account and represented in MACPAC’s recommendations and reports.
(13) Coordinate and consult with the federal coordinated health care office.—MACPAC shall coordinate and consult with the Federal Coordinated Health Care Office established under section 2081 of the Patient Protection and Affordable Care Act before making any recommendations regarding dual eligible individuals.
(14) Programmatic oversight vested in the secretary.—MACPAC’s authority to make recommendations in accordance with this section shall not affect, or be considered to duplicate, the Secretary’s authority to carry out Federal responsibilities with respect to Medicaid and CHIP.
(1) Number and appointment.—MACPAC shall be composed of 17 members appointed by the Comptroller General of the United States.
(A) In general.— The membership of MACPAC shall include individuals who have had direct experience as enrollees or parents or caregivers of enrollees in Medicaid or CHIP and individuals with national recognition for their expertise in Federal safety net health programs, health finance and economics, actuarial science, health plans and integrated delivery systems, reimbursement for health care, health information technology, and other providers of health services, public health, and other related fields, who provide a mix of different professions, broad geographic representation, and a balance between urban and rural representation.
(B) Inclusion.—The membership of MACPAC shall include (but not be limited to) physicians, dentists, and other health professionals, employers, third-party payers, and individuals with expertise in the delivery of health services. Such membership shall also include representatives of children, pregnant women, the elderly, individuals with disabilities, caregivers, and dual eligible individuals, current or former representatives of State agencies responsible for administering Medicaid, and current or former representatives of State agencies responsible for administering CHIP.
(C) Majority nonproviders.—Individuals who are directly involved in the provision, or management of the delivery, of items and services covered under Medicaid or CHIP shall not constitute a majority of the membership of MACPAC.
(D) Ethical disclosure.—The Comptroller General of the United States shall establish a system for public disclosure by members of MACPAC of financial and other potential conflicts of interest relating to such members. Members of MACPAC shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act of 1978 (Public Law 95-521).
(A) In general.—The terms of members of MACPAC shall be for 3 years except that the Comptroller General of the United States shall designate staggered terms for the members first appointed.
(B) Vacancies.—Any member appointed to fill a vacancy occurring before the expiration of the term for which the member’s predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member’s term until a successor has taken office. A vacancy in MACPAC shall be filled in the manner in which the original appointment was made.
(4) Compensation.—While serving on the business of MACPAC (including travel time), a member of MACPAC shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of title 5, United States Code; and while so serving away from home and the member’s regular place of business, a member may be allowed travel expenses, as authorized by the Chairman of MACPAC. Physicians serving as personnel of MACPAC may be provided a physician comparability allowance by MACPAC in the same manner as Government physicians may be provided such an allowance by an agency under section 5948 of title 5, United States Code, and for such purpose subsection (i) of such section shall apply to MACPAC in the same manner as it applies to the Tennessee Valley Authority. For purposes of pay (other than pay of members of MACPAC) and employment benefits, rights, and privileges, all personnel of MACPAC shall be treated as if they were employees of the United States Senate.
(5) Chairman; vice chairman.—The Comptroller General of the United States shall designate a member of MACPAC, at the time of appointment of the member as Chairman and a member as Vice Chairman for that term of appointment, except that in the case of vacancy of the Chairmanship or Vice Chairmanship, the Comptroller General of the United States may designate another member for the remainder of that member’s term.
(6) Meetings.—MACPAC shall meet at the call of the Chairman.
(d) Director and Staff; Experts and Consultants.—Subject to such review as the Comptroller General of the United States deems necessary to assure the efficient administration of MACPAC, MACPAC may—
(1) employ and fix the compensation of an Executive Director (subject to the approval of the Comptroller General of the United States) and such other personnel as may be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service);
(2) seek such assistance and support as may be required in the performance of its duties from appropriate Federal and State departments and agencies;
(3) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of MACPAC (without regard to section 3709 of the Revised Statutes (41 U.S.C. 5));
(4) make advance, progress, and other payments which relate to the work of MACPAC;
(5) provide transportation and subsistence for persons serving without compensation; and
(6) prescribe such rules and regulations as it deems necessary with respect to the internal organization and operation of MACPAC.
(1) Obtaining official data.—MACPAC may secure directly from any department or agency of the United States and, as a condition for receiving payments under sections 1903(a) and 2105(a), from any State agency responsible for administering Medicaid or CHIP,information necessary to enable it to carry out this section. Upon request of the Chairman, the head of that department or agency shall furnish that information to MACPAC on an agreed upon schedule.
(2) Data collection.—In order to carry out its functions, MACPAC shall—
(A) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section;
(B) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate; and
(C) adopt procedures allowing any interested party to submit information for MACPAC’s use in making reports and recommendations.
(3) Access of gao to information.— The Comptroller General of the United States shall have unrestricted access to all deliberations, records, and nonproprietary data of MACPAC, immediately upon request.
(4) Periodic audit.—MACPAC shall be subject to periodic audit by the Comptroller General of the United States.
(1) Request for appropriations.—MACPAC shall submit requests for appropriations (other than for fiscal year 2010) in the same manner as the Comptroller General of the United States submits requests for appropriations, but amounts appropriated for MACPAC shall be separate from amounts appropriated for the Comptroller General of the United States.
(2) Authorization.—There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section.
(3) Funding for fiscal year 2010.—
(A) In general.—Out of any funds in the Treasury not otherwise appropriated, there is appropriated to MACPAC to carry out the provisions of this section for fiscal year 2010, $9,000,000.
(B) Transfer of funds.—Notwithstanding section 2104(a)(13), from the amounts appropriated in such section for fiscal year 2010, $2,000,000 is hereby transferred and made available in such fiscal year to MACPAC to carry out the provisions of this section.
(4) Availability.—Amounts made available under paragraphs (2) and (3) to MACPAC to carry out the provisions of this section shall remain available until expended.
 Title XIX of the Social Security Act is administered by the Centers for Medicare and Medicaid Services. Title XIX appears in the United States Code as §§1396–1396v, subchapter XIX, chapter 7, Title 42. Regulations relating to Title XIX are contained in chapter IV, Title 42, and subtitle A, Title 45, Code of Federal Regulations.
 See Vol. II, 31 U.S.C. 6504–6505 with respect to intergovernmental cooperation. See Vol. II, 31 U.S.C. 7501-7507 with respect to uniform audit requirements for State and local governments receiving Federal financial assistance.
See Vol. II, P.L. 78-410, §317A(a) and (d), with respect to coordination required in lead poisoning prevention; §353(i)(3) and (n), with respect to clinical laboratories; §399HH, with respect to a national strategy for quality improvement in health care; §1301(c)(3), with respect to the requirement that health maintenance organizations enroll individuals entitled to medical assistance under Title XIX. See Vol. II, P.L. 79-396, §17(p), with respect to proprietary title XIX center. See Vol. II, P.L. 88-352, §601, for prohibition against discrimination in federally assisted programs. See Vol. II, P.L. 89-73, §§203 and §306(c) with respect to agreements with other agencies. See Vol. II, P.L. 94-566, §503, with respect to preservation eligibility for individuals who cease to be eligible for supplemental security income benefits on account of cost-of-living increases in social security benefits. See Vol. II, P.L. 99-319, §105, with respect to the rights of individuals with mental illness. See Vol. II, P.L. 100-203, §4211(j) with respect to the development of reimbursement methods for nursing facilities. See Vol. II, P.L. 100-204, §724(d), with respect to the United States Commission on Improving the Effectiveness of the United Nations; and §725(b), with respect to the detailing of Government personnel. See Vol. II, P.L. 100-235, §§5-8, with respect to Federal computer systems security and privacy. See Vol. II, P.L. 100-690, §2306(c)(4), with respect to the plan of Hawaii; and §5301(a)(1)(C) and (d)(1)(B), with respect to benefits of drug traffickers and possessors. See Vol. II, P.L. 101-121, with respect to the amounts collected under title IV of the Indian Health Care Improvement Act. See Vol. II, P.L. 101-239, §6507, with respect to research on infant mortality and medicaid services; §6509, with respect to a maternal and child health handbook. See Vol. II, P.L. 101-508, §4401(d), with respect to an annual report on drug pricing; §13302, with respect to protection of OASDI Trust Funds in the House of Representatives. See Vol. II, P.L. 104-191, §261, with respect to administrative simplification. See Vol. II, P.L. 104-193, §115, with respect to denial of benefits for certain drug-related convictions; §§401, 402, and 403, with respect to eligibility of aliens; and §911, with respect to fraud under means-tested programs. See Vol. II, P.L. 110-90, §4, with respect to the extension of the SSI Web-based Asset Demonstration Project. See Vol. II, P.L. 110-173, §206, with respect to a moratorium on certain payment restrictions. See Vol. II, P.L. 110-252, §7001(a)(3), with respect to additional moratoria regarding the Medicaid program and §7001(b), with respect to funds to reduce Medicaid fraud and abuse. See Vol. II, P.L. 111-148, §1103, with respect to immediate information that allows consumers to identify affordable coverage options; §1418, with respect to streamlining enrollment through exchange and State Medicaid, CHIP, and health subsidy programs; and §2602, with respect to providing coverage and payment coordination for dual eligible beneficiaries; and P.L. 112-240, §643, with respect to a commission on long-term care. See Vol. II, P.L. 114–10, §106(b), with respect to electronic health records systems and interoperability; §106(d) for a rule of construction regarding health providers and malpractice and liability claims; §305, with respect to HHS inspector General report on use of Express Lane Option under Medicaid and CHIP; §§506, 507, for limitations on funds appropriated for the administration of Title XIX programs. See Vol. II, P.L. 114–255, §12001, with respect to rule of construction preventing prohibition of certain separate payments under a state plan for primary care and mental health service on the same day; §12003, with respect to guidance to states on innovative service delivery systems for adults or children with serious emotional disturbances under title XIX; and §12004, with respect to report on emergency psychiatric demonstration program established by §2707 of subtitle I, P.L. 114–148. See Vol. II, P.L. 115–271, §1005, with respect to guidance to States to improve care for infants with neonatal abstinence syndrome and their families; §5012, with respect to MACPAC report on institutions for mental diseases requirements and practices under Medicaid; §5032 with respect to development of stakeholder best practices and state innovation in Medicaid reentry programs for formerly institutionalized individuals; §6032, with respect report to Congress regarding policies that are obstacles to effective response to the opioid crisis; and §8081, with respect to funding under Title IV and Medicaid for family-focused, residential treatment programs for substance use disorder. See P.L. 116–94, Div. N, §202, for program integrity requirements for the U.S. territories.
 This table of contents does not appear in the law.
 See Vol. II, P.L. 111-3, §506(b), with respect to the deadline for initial appointments and §506(c), with respect to an annual report on Medicaid.
 P.L. 113-93, §221(b)(1–2), revised paragraph (b)(6) into 2 subparagraphs, adding subparagraph (B). Effective April 1, 2014.