DEH Section 3 pages PRA version 7 10 08

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS
3.1

Amount, Duration, and Scope of Services
Medicaid is provided in accordance with the requirements of sections 1902(a), 1902(e), 1903(i),
1905(a), 1905(p), 1905(r), 1905(s), 1906, 1915, 1916, 1920, 1925, 1929, and 1933 of the Act;
section 245A(h) of the Immigration and Nationality Act; and 42 CFR Parts 431, 440, 441, 442,
and 483.
A. Categorically Needy
The following items, numbered 1 though 30, identify the medical and remedial service provided
to the categorically needy, specifies all limitations on the amount, duration and scope of those
services.

1. Inpatient hospital services, other than those provided in an institution for mental diseases,
(provided in accordance with section 1905(a)(1) of the Social Security Act and 42 CFR
440.10 and, for infants and children, provided in accordance with 1902(e)(7) of the Social
Security Act).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

2. Outpatient hospital services, rural health clinic and federally qualified health center
services (provided in accordance with section 1905(a)(2) of the Social Security Act).
a. Outpatient hospital services (provided in accordance with 42 CFR 440.20).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

1

b. Rural health clinic services and other ambulatory services furnished by a rural
health clinic, which are otherwise included in the state plan.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

c. Federally-qualified health center (FQHC) services and other ambulatory services
that are offered by a Federally-qualified health center and which are otherwise
included in the plan.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

3. Other laboratory and x ray services (provided in accordance with section 1905(a)(3) of
the Social Security Act and 42 CFR 440.30).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

4. Nursing facility services for individuals age 21 or older (other than services in an
institution for mental disease), EPSDT, and family planning services and supplies
(provided in accordance with section 1095(a)(4) of the Social Security Act).
a. Nursing facility services (other than services in an institution for mental diseases)
for individuals 21 years of age or older. (See preprint item 28(d) for “Nursing
facility services under 21 years of age for cross-reference.)
Provided:

No limitations



With limitations



2

(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations for NF 21 years and older, not in IMDs.

b. Early and periodic screening, diagnostic and treatment services for individuals
who are eligible under the plan and are under the age of 21 (provided in
accordance with 1902(a)(43), 1905(a)(4) and 1905(r)).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations. (Note: The limits applied elsewhere in the State Plan
do not apply to EPSDT eligibles. Services provided to EPSDT eligibles are limited only
by medical necessity.)

c. Family planning services and supplies for individuals of child bearing age
(provided in accordance with 1905(a)(4)(C), 42 CFR 441.20 and 42 CFR 441
Subpart F ) .
Provided:

No limitations



With limitations



(When the State attests “No limitations” or “With limitations” then a text box, with header,
appears for the State to supply information.)
Instructions:
• Identify the codes for contraception and sterilization to be covered at 90% FFP. (Develop a
code matrix that distinguishes between those codes which are always considered family planning
services and those which require a family planning diagnosis in theV25 series (ICD-9-CM code)
or family planning (FP) modifier. There should be a distinct family planning code matrix for
women and one for men)
• Also, if the State is covering infertility services, describe these services and their codes.
(A coding matrix like the one above should be used for infertility services, one for women and
one for men.)

5. Physicians’ services and medical and surgical services of a dentist (provided in
accordance with section 1905(a)(5) of the Social Security Act and 42 CFR 440.50).
a. Physicians’ services furnished by a physician, whether furnished in the office,
the patient’s home, a hospital, or a nursing facility, or elsewhere.

3

Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

b. Medical and surgical services furnished by a dentist.
Provided:

No limitations



With limitations 

(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

6. Medical care and any other type of remedial care provided by licensed practitioners
within their scope of practice (provided in accordance with section 1905(a)(6) of the
Social Security Act and 42 CFR 440.60).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
List each type of Other Licensed Practitioner (other than those specified elsewhere in
1905(a) such as, physician, dentist, nurse practitioner, etc.) covered along with any
coverage limitations.

7. Home health services (provided in accordance with section 1905(a)(7) of the Social
Security Act, 42 CFR 440.70 and 42 CFR 441.15).
a. Home health services are provided to categorically needy recipients age 21 or
over.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)

4

Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.
b. Home health services are provided to all categorically needy recipients under
age 21.
Provided:

No limitations



With limitations



Not Provided:  (The State plan does not provide for skilled nursing facility services
for such recipients.)
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

c. Nursing service that is provided on a part-time or intermittent basis by a home
health agency or if there is no agency in the area, a registered nurse.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

d. Home health aide services provided by a home health agency.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)

5

Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

e. Medical supplies, equipment, and appliances suitable for use in home.
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

f. Physical therapy, occupational therapy, or speech pathology and audiology
services, provided by a home health agency or by a facility licensed by the State
to provide medical rehabilitation services (also provided in accordance with
42 CFR 440.110).
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

8. Private duty nursing services (provided in accordance with section 1905(a)(8) of the
Social Security Act and 42 CFR 440.80).
Provided:

No limitations



With limitations



Not Provided: 

6

(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

9. Clinic services (provided in accordance with section 1905(a)(9) of the Social Security Act
and 42 CFR 440.90).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

10. Dental services (provided in accordance with section 1905(a)(10) of the Social Security
Act and 42 CFR 440.100).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

11. Physical therapy and related services (provided in accordance with section 1905(a)(11)
of the Social Security Act and 42 CFR 440.110).
.
a. Physical therapy.
Provided:

No limitations



With limitations



Not Provided: 

7

(If State attests “With Limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

b. Occupational therapy.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

c. Services for individuals with speech, hearing, and language disorders.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a
physician skilled in diseases of the eye or by an optometrist (provided in accordance with
section 1905(a)(12) of the Social Security Act and 42 CFR 440.120).

8

a. Prescribed drugs.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a detailed description for each specific service
provided. For prescribed drugs, the description may include the
following information:
Details regarding coverage limitations such as prior authorization,
supplemental rebate agreements, preferred drug lists, coverage of
excluded drugs, quantity limits, monthly/annual prescription limits,
refill limits, generic drug substitution, and step therapy. States should
refer to the additional guidance below regarding requirements for
prior authorization and supplemental rebate agreements.
Prior Authorization
A State that uses prior authorization must provide response by
telephone or other telecommunication device within 24 hours of a
request for prior authorization. The State must also provide for the
dispensing of at least a 72-hour supply of a covered outpatient drug in
an emergency situation.
Supplemental Rebate Agreements
A State that enters into a supplemental rebate agreement that differs
from the model supplemental rebate agreement must submit the
agreement to CMS for authorization in addition to submitting a State
plan amendment. The State must also include in the State plan
amendment the name of the agreement and the date when the
agreement was submitted to CMS.
Multi-State supplemental rebate agreements should include the
following:
•

Standard multi-state pooling language incorporated into the
supplemental rebate agreement portion of the state plan.
Specifically, this language should read as follows: “CMS has
authorized the State of [insert State name] to enter into the
[insert the name of the multi-state pooling agreement]. This
Supplemental Drug Rebate Agreement was submitted to
CMS on [insert submittal date] and has been authorized by
CMS.”

•

A supplemental rebate agreement template. Consistent with
section 1902(a)(19) of the Social Security Act, we expect
that the SPA would include a standard template, to ensure
uniformity of the pool’s supplemental rebate agreements and
for ease of administration. The template should be the same

9

for each participating State and should not include an
effective date that is earlier than the first day of the quarter in
which the SPA was submitted. In addition, as a template, the
model agreement should not contain any manufacturerspecific information.
•

A document referenced in the supplemental rebate agreement
template that indicates the State’s participation in the
purchasing pool. This document will serve as the
mechanism by which other states will be added to the multistate pooling agreement and should be filled in with any
necessary state-specific information. This document will
also serve as a template; therefore, it should be the same for
each participating state and should not contain any
manufacturer-specific information.

•

A document that indicates if a state joining the pool intends
to include its non-Medicaid program in the supplemental
rebate program that has been approved by CMS, if
applicable. States that intend to include non-Medicaid
programs must receive approval from CMS prior to joining
the pool under the procedures outlined in the letter from
Dennis Smith, Director, Center for Medicaid and State
Operations, to all State Medicaid Directors (Sept. 18, 2002).
In addition, each State should provide specific evidence to
demonstrate that its prior authorization requirement furthers
Medicaid goals and objectives and is designed to increase the
efficiency and economy of the Medicaid program.

Excluded Drugs
A State that chooses to cover excluded drugs must include a list of the
therapeutic drug classes that it covers. In the summer of 2005, we
provided an optional template that several States used to amend their
State plans upon the implementation of the Medicare Part D
prescription drug benefit.

b. Dentures.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

10

c. Prosthetic devices.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

d. Eyeglasses.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

13. Other diagnostic, screening, preventive, and rehabilitative services (provided in
accordance with section 1905(a)(13) of the Social Security Act and 42 CFR 440.130).
a. Diagnostic servicesProvided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

11

b. Screening services.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

c. Preventive services.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations

d. Rehabilitative services.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, should appears for the State to
supply information.)
Instructions:
The State must provide a description of each service it plans to provide. Please list and
describe the components of each service. Also include a service description for each
specific service provided within a model of care or program. The description will
include the following information:
For each of the specific 1905(a) services, the State must identify the providers of the
service(s) as well as the provider qualifications. Provider qualifications must include
the level of education/degree required, and any additional general information related
to licensing, credentialing, registration, and relevant supervisory arrangements.

12

14. Inpatient hospital services and nursing facility services for individuals 65 years of age
or over in an institution for mental diseases (IMD) that are Medicaid certified
facilities (provided in accordance with section 1905(a)(14) of the Social Security Act ,
42 CFR 431.620(c)&(d), 42 CFR 440.140, 42 CFR Part 441 Subpart C).
a. Inpatient hospital services.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

b. Nursing facility services.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

15. Services in an intermediate care facility for persons with mental retardation or a related
condition (ICFs/MR) who are in need of such care (provided in accordance with section
1905(a)(15) of the Social Security Act, 42 CFR 440.150, and 42 CFR 435.1010).
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)

13

Instructions:
Describe any coverage limitations.

16. Inpatient psychiatric facility services for individuals under 21 years of age (provided in
accordance with section 1905(a)(16) of the Social Security Act and 42 CFR 440.160).
.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

17. Nurse-midwife services (provided in accordance with section 1905(a)(17) of the Social
Security Act and 42 CFR 440.165).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

18. Hospice care (provided in accordance with section 1905(a)(18)(subsection (o)) of the
Social Security Act and 42 CFR section 418).
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)

14

Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

19. Case management services (provided in accordance with section 1905(a)(19) of the
Social Security Act).
a. Case management services (provided in accordance with section 1905(a)(19) or
1915(g) of the Social Security Act, 42 CFR 440.169 and 42 CFR 441.18).
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Target Group:
Please describe target group.

For case management services provided to individuals in medical institutions:


Target group is comprised of individuals transitioning to a community setting and casemanagement services will be made available for up to ______________ [insert a number;
not to exceed 180] consecutive days of the covered stay in the medical institution.

Areas of state in which services will be provided:


Entire State



Only in the following geographic areas (authority of section 1915(g)(1) of the Act is invoked to
provide services less than Statewide)

Comparability of services:


Services are provided in accordance with section 1902(a)(10)(B) of the Act.



Services are not comparable in amount duration and scope.

Definition of services:
Case management services are services furnished to assist individuals, eligible under the State Plan, in
gaining access to needed medical, social, educational and other services. Case Management includes the

15

following assistance:
•

Comprehensive assessment and periodic reassessment of individual needs to determine
the need for any medical, educational, social or other services. These assessment
activities include:
o Taking client history;
o Identifying the individual’s needs and completing related documentation; and
gathering information from other sources such as family members, medical
providers, social workers, and educators (if necessary), to form a complete
assessment of the individual.

•

Development (and periodic revision) of a specific care plan that:
o Is based on the information collected through the assessment;
o Specifies the goals and actions to address the medical, social, educational, and
other services needed by the individual;
o Includes activities such as ensuring the active participation of the eligible
individual, and working with the individual (or the individual’s authorized
health care decision maker) and others to develop those goals; and
o Identifies a course of action to respond to the assessed needs of the eligible
individual.

•

Referral and related activities:
o To help an eligible individual obtain needed services including activities that
help link an individual with:
• Medical, social, educational providers; or
• Other programs and services capable of providing needed services,
such as making referrals to providers for needed services and
scheduling appointments for the individual.

•

Monitoring and follow-up activities:
o Activities, and contact, necessary to ensure the care plan is implemented and
adequately addressing the individual’s needs. These activities, and contact,
may be with the individual, his or her family members, providers, other entities
or individuals and may be conducted as frequently as necessary; including at
least one annual monitoring to assure following conditions are met:
• Services are being furnished in accordance with the individual’s care
plan;
• Services in the care plan are adequate; and
• If there are changes in the needs or status of the individual, necessary
adjustments are made to the care plan and to service arrangements
with providers.

Case management may include:
• Contact with non-eligible individuals that are directly related to identifying the needs
and supports for helping the eligible individual to access services.

For plans that provide case management services to assist individuals who reside in medical institutions
to transition to the community: Case management services are coordinated with and do not duplicate
activities provided as a part of institutional services and discharge planning activities.
Qualifications of providers:

16

Please specify provider qualifications that are reasonably related to the population being served
and the case management services furnished.
Freedom of choice:
The State assures that the provision of case management services will not restrict an individual’s free
choice of providers in violation of section 1902(a)(23) of the Act.
•
•

Eligible recipients will have free choice of the providers of case management services
within the specified geographic area identified in this plan.
Eligible recipients will have free choice of the providers of other medical care under the
plan.

Freedom of Choice Exception:
 Target group consists of eligible individuals with developmental disabilities or with chronic
mental
illness. Providers are limited to providers of case management services capable of ensuring that
individuals with developmental disabilities or with chronic mental illness receive needed
services.
Access to Services:
The State assures that:
• Case management services will not be used to restrict an individual’s access to
other services under the plan;
• Individuals will not be compelled to receive case management services, condition
receipt of case management services on the receipt of other Medicaid services, or
condition receipt of other Medicaid services on receipt of case management
services;
• Individuals will receive comprehensive, case management services, on a one-to-one
basis, through one case manager; and
• Providers of case management services do not exercise the agency’s authority to
authorize or deny the provision of other services under the plan.
For plans that provide case management services to assist individuals who reside in medical institutions to
transition to the community, the State assures that:
•

•

The amount, duration, and scope of the case management activities would be
documented in an individual’s plan of care which includes case management
activities prior to and post-discharge, to facilitate a successful transition to the
community; and
Case management is only provided by and reimbursed to community case
management providers.

Case Records:
Providers maintain case records that document for all individuals receiving case management the
following: the name of the individual; dates of the case management services; the name of the provider
agency (if relevant) and the person providing the case management service; the nature, content, units of
the case management services received and whether goals specified in the care plan have been achieved;
whether the individual has declined services in the care plan; the need for, and occurrences of,
coordination with other case managers; the timeline for obtaining needed services; and a timeline for

17

reevaluation of the plan.
Payment:
Payment for case management services under the plan does not duplicate payments made to public
agencies or private entities under other program authorities for this same purpose.
Case management providers are paid on a unit-of-service basis as specified in case management
regulations. A detailed description of the reimbursement methodology, identifying the data used to
develop the rate, is included in Attachment 4.19B.
Limitations:
Case Management does not include the following:
• Case management activities that are an integral component of another covered
Medicaid service;
• The direct delivery of an underlying medical, educational, social, or other service to
which an eligible individual has been referred.
• Activities integral to the administration of foster care programs; or
• Activities, for which an individual may be eligible, that are integral to the
administration of another non-medical program, except for case management that is
included in an individualized education program or individualized family service
plan consistent with section 1903(c) of the Social Security Act.
Additional limitations:
Please specify any additional limitations.

b. Special tuberculosis (TB) related services (provided in accordance with section
1905(a)(19) and 1902 (z)(2) of the Social Security Act).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

20. Respiratory care services (in accordance with section 1905(a)(20) and as defined in
section 1902(e)(9) of the Social Security Act and 42 CFR 440.185).
Provided:

No limitations



With limitations



Not Provided: 

18

(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

21. Certified pediatric nurse practitioner or certified family nurse practitioner services (in
accordance with section 1905(a)(21) of the Social Security Act and 42 CFR 440.166).
Provided:

No limitations



With limitations



(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

22. Reserved
23. Reserved
24. Personal care services (in accordance with section 1905(a)(24) of the Social Security Act
and 42 CFR 440.167).
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
The State must provide a description for each specific service covered.
The description will include the following information:
For each of the specific 1905(a) services, the State must identify the
providers of the service(s) as well as the provider qualifications.

25. Primary care case management services (in accordance with section 1905(a)(25) of the
Social Security Act and 42 CFR 440.168).

19

Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations

26. PACE program services (in accordance with section 1905(a)(26) and 1934 of the Social
Security Act and 42 CFR Part 460).
Provided:



Not Provided: 
(If State attests “Provided” then the State is redirected to Enclosures 3, 4, 5, 6, and 7 (page 1
through 5) to supply additional information. Please note that the above referenced
“Enclosures” have gone through the PRA process and were approved in November 2007.)
Enclosure 3
Enclosure 4
Enclosure 5
Enclosure 6
Enclosure 7, Page 1
Enclosure 7, Page 2
Enclosure 7, Page 3
Enclosure 7, Page 4
Enclosure 7, Page 5
Enclosure 7, Page 6

27. Sickle Cell Disease services (in accordance with section 1905(a)(27) of the Social
Security Act).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations

20

28. Any other medical care, and any other type of remedial care recognized under State law,
specified by the Secretary (in accordance with section 1905(a)(28) of the Social Security
Act and 42 CFR 440.170).
a. Transportation (provided in accordance with 42 CFR 440.170 as an optional
medical service) excluding “school-based” transportation.
 Not Provided:
 Provided without a broker as an optional medical service:
(If state attests “Provided without a broker as an optional medical service” then a text box, with
header, appears for the State to supply supplement information.)
Instructions:
Describe how the transportation program operates including types of transportation and
transportation related services provided and any limitations. Describe emergency and nonemergency transportation services separately. Include any interagency or cooperative
agreements with other Agencies or programs.
 Non-emergency transportation is provided through a brokerage program as an
optional medical service in accordance with 1902(a)(70) of the Social Security Act
and 42 CFR 440.170(a)(4).
(If the State attests that non-emergency transportation is being provided through a brokerage
program then a text box, with a header, appears for the State to supply information about the
brokerage program.)
Instructions:

 The State assures it has established a non-emergency medical transportation program in
accordance with 1902(a)(70) of the Social Security Act in order to more cost-effectively
provide transportation, and can document, upon request from CMS, that the transportation
broker was procured in compliance with the requirements of 45 CFR 92.36 (b)-(i).
(1) The State will operate the broker program without the requirements of the
following paragraphs of section 1902(a);
 (1) state-wideness (indicate areas of State that are covered)
 (10)(B) comparability (indicate participating beneficiary groups)
 (23) freedom of choice (indicate mandatory population groups)
(2) Transportation services provided will include:
 wheelchair van
 taxi
 stretcher car
 bus passes

21

 tickets
 secured transportation
 other transportation
(If State attests “other transportation” then a text box, with header, appears for the State to
supply information.)
Instructions:
Describe other transportation.

(3) The State assures that transportation services will be provided under a contract with
a broker who:
(i) is selected through a competitive bidding process based on the State’s
evaluation of the broker’s experience, performance, references, resources, qualifications,
and costs:
(ii) has oversight procedures to monitor beneficiary access and complaints and
ensures that transportation is timely and transport personnel are licensed qualified,
competent and courteous:
(iii) is subject to regular auditing and oversight by the State in order to ensure the
quality and timeliness of the transportation services provided and the adequacy of
beneficiary access to medical care and services:
(iv) complies with such requirements related to prohibitions on referrals and conflict
of interest as the Secretary shall establish (based on prohibitions on physician referrals
under Section 1877 and such other prohibitions and requirements as the Secretary
determines to be appropriate.)
(4) The broker contract will provide transportation to the following categorically needy
mandatory populations:
 Low-income families with children (section 1931)
 Deemed AFCD-related eligibles
 Poverty-level related pregnant women
 Poverty-level infants
 Poverty-level children 1 through 5
 Poverty-level children 6 – 18
 Qualified pregnant women AFDC – related
 Qualified children AFDC – related
 IV-E foster care and adoption assistance children
 TMA recipients (due to employment) (section 1925)
 TMA recipients (due to child support)
 SSI recipients
(5) The broker contract will provide transportation to the following categorically needy

22

optional populations:
 Optional poverty-level - related pregnant women
 Optional poverty-level - related infants
 Optional targeted low income children
 Non IV-E children who are under State adoption assistance agreements
 Non IV-E independent foster care adolescents who were in foster care on
their 18th birthday
 Individuals who meet income and resource requirements of AFDC or SSI
 Individuals who would meet the income & resource requirements of AFDC
if child care costs were paid from earnings rather than by a State agency
 Individuals who would be eligible for AFDC if State plan had been as broad
as allowed under Federal law
 Children aged 15-20 who meet AFDC income and resource requirements
 Individuals who would be eligible for AFDC or SSI if they were not in a
medical institution
 Individuals infected with TB
 Individuals screened for breast or cervical cancer by CDC program
 Individuals receiving COBRA continuation benefits
 Individuals in special income level group, in a medical institution for at least
30 consecutive days, with gross income not exceeding 300% of SSI income
standard
 Individuals receiving home and community based waiver services who
would only be eligible under State plan if in a medical institution
 Individuals terminally ill if in a medical institution and will receive hospice
Care
 Individuals aged or disabled with income not above 100% FPL
 Individuals receiving only an optional State supplement in a 209(b) State
 Individuals working disabled who buy into Medicaid (BBA working
disabled group)
 Employed medically improved individuals who buy into Medicaid under
TWWIIA Medical Improvement Group
 Individuals disabled age 18 or younger who would require an institutional
level of care (TEFRA 134 kids).
(6)

Payment Methodology
(A) The State will pay the contracted broker by the following method:
 (i) risk capitation
 (ii) non-risk capitation
 (iii) other (e.g., brokerage fee and direct payment to providers)
(If the State attests to “other” then a text box will appear with the instructions to describe

23

the other payment methodology.)

(B) Who will pay the transportation provider?
 (i) Broker
 (ii) State
 (iii)

other

(If the State attests to “other” then a text box will appear with the instructions to describe
who other than the state will pay the transportation provider.)

(C) What is the source of the non-Federal share of the transportation payments?

Instructions:
What is the source of the non-Federal share of the transportation payments proposed
under this State plan amendment? If more than one source exists to fund the non-Federal
share of the transportation payments, please separately identify each source of nonFederal share funding.

(D) The State assures that no agreement (contractual or otherwise) exists between the
State or any form of local government and the transportation broker to return or
redirect any of the Medicaid payment to the State or form of local government
(directly or indirectly). This assurance is not intended to interfere with the ability of
a transportation broker to contract for transportation services at a lesser rate and
credit any savings to the program.
(E) The State assures that payments proposed under this State plan amendment will be
made directly to transportation providers and that the transportation provider payments
are fully retained by the transportation providers and no agreement (contractual or
otherwise) exists between the State or local government and the transportation provider
to return or redirect any of the Medicaid payment to the State or form of local
government (directly or indirectly).


(7) The broker is a non-governmental entity:


The broker is not itself a provider of transportation nor does it refer to or
subcontract with any entity with which it has a prohibited financial
relationship as described at 45 CFR 440.170(4)(ii).

24



The broker is itself a provider of transportation or subcontracts with or
refers to an entity with which it has a prohibited financial relationship and:
(i)

transportation is provided in a rural area as defined at 412.62(f) and
there is no other available Medicaid participating provider or other
provider determined by the State to be qualified except the nongovernmental broker

(ii)

transportation is so specialized that there is no other available
Medicaid participating provider or other provider determined by the
State to be qualified except the non-governmental broker.

(iii)

the availability of other non-governmental Medicaid participating
providers or other providers determined by the State to be qualified is
insufficient to meet the need for transportation.

 (8) The broker is a governmental entity and provides transportation itself or refers to or
subcontracts with another governmental entity for transportation. The governmental broker
will:


Maintain an accounting system such that all funds allocated to the Medicaid
brokerage program and all costs charged to the Medicaid brokerage will be
completely separate from any other program.



Document that with respect to each individual beneficiary’s specific
transportation needs, the government provider is the most appropriate and
lowest cost alternative.



Document that the Medicaid program is paying no more for fixed route
public transportation than the rate charged to the general public and no
more for public paratransit services than the rate charged to other
State human services agencies for the same service.

(9) 

Please describe how the NEMT brokerage program operates.

(If State attests it “will describe how the NEMT brokerage program will operate” then a
text box, with header, appears for the state to supply supplement information.)
Instructions:
Describe how the Brokerage program will operate. Include the services that will be provided by the
broker. If applicable, describe any services that will not be provided by the broker and name the entity
that will provide these services.

25

b. Services furnished in a religious non-medical health care institution.
Provided



Not Provided 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

c. Reserved
d. Nursing facility services for individuals under age 21.
Provided:

No limitations



With limitations



Not Provided: 
(If State attests “With limitations” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe any coverage limitations.

e. Emergency hospital services.
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

f. Reserved
g. Critical access hospital (CAH)

26

Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe services covered including any limitations.

29. Enhanced services for pregnant women (provided in accordance with
1902(a)(10)(end)(V) and 42 CFR 440.250(p)).
Provided:



Not Provided: 
(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
Describe additional pregnancy related services.

30. State Plan Home and Community Based Services Benefit (in accordance
with section 1915(i) of the Social Security Act and 42 CFR Part 441 Subpart K).
Provided:



Not Provided: 
(If State attests “Provided” then the State is redirected to 1915(i) preprint pages to supply
additional information. Please note that the following referenced “1915(i) preprint pages” are
currently going through the PRA process.)
1915(i) preprint
OMB Approval pending

31. Self-Directed Personal Assistance Services (in accordance with section 1915(j) of the
Social Security Act and 42 CFR Part 441).
Provided:



Not Provided: 

27

(If State attests “Provided” then the State is redirected to 1915(j) preprint pages to supply
additional information. Please note that the following referenced “1915(j) preprint pages” have
gone through the PRA process and were approved in June 2007.)
1915(j) preprint
OMB Approved 0938-1024
Version: June 2007

32. Limited Coverage for Certain Aliens (provided in accordance with section 1903(v) of the
Social Security Act, sections 401-403 of PRWORA, 42 CFR 435.139, 435.406(a)(2)(ii),
435.406(b), and 440.255(b)(1)&(c)).
Illegal or otherwise ineligible aliens, who meet the eligibility conditions under this plan except the
alien eligibility requirements, are provided Medicaid only for care and services
necessary for the treatment of an emergency medical condition
(including labor and delivery) as defined in section 1903(v)(3)of the Act.

33. Limited Coverage for Poverty Level Pregnant Women (provided in accordance with
1902(a)(10)(G)(VII) of the Social Security Act).
Coverage for pregnant or postpartum women who are eligible as categorically needy under
1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(ii)(IX), 1902(e)(5) or 1902(e)(6) of the Social Security Act is
limited to services related to pregnancy (including prenatal, labor and delivery, postpartum and
family planning services) and to other conditions which may complicate pregnancy.

28

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

B. Medically Needy
The following identifies the medical and remedial service covered for medically needy groups,
specifies all limitations on the amount, durations and scope of those services.


Medically Needy not covered.



The same amount, duration and scope of services covered for the Medically Needy
as the Categorically Needy.



The amount, duration and scope of services covered for the Medically Needy are
different than the services covered for the Categorically Needy.*

(If the State attests “The amount, duration and scope of services covered for the Medically Needy
are different than the services covered for the Categorically Needy” then a text box, with header,
appears for the State to supply information.)
Instructions:
The State must provide a description of the service(s) it plans to cover for the Medically
Needy. The description will include the specific differences in service(s) between the
Categorically Needy group(s), as identified in 3.1(A)(1-32), and the
Medically Needy group(s).

29

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

C. Benchmark Benefit Package and Benchmark Equivalent Benefit Package (provided in
accordance with 1937 of the Act and 42 CFR Part 440).
The State elects to provide alternative benefits:
Provided:



Not Provided: 
(If the State attests “Provided”, then the State is redirected to a Pre-print to supply additional
information. Please note that the above referenced “Pre-print” has gone through the PRA process
and was approved in October 2006.)
Pre-print
OMB-0938-0993

30

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

D.

Methods of Providing Transportation as an Administrative Activity in accordance with
1902(a)(4)(A) of the Act and 42 CFR 431.53 (excluding “school based” transportation).
Provided:



Not Provided: 
(If the State attests that transportation is provided as an administrative activity, then a
text box with header appears for the State to supply supplemental information.)

Instructions:
Describe how the transportation program operates including the types of transportation
and transportation related services provided and any limitations. Describe emergency
and non-emergency transportation services separately. Note: transportation provided
as an administrative expense should be reported on the CMS-64.10 and/or CMS64.10P. Additionally, the information should be separately broken out and identified
on the CMS-64Narr (narrative page).

31

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

E. Standards for the coverage of organ transplant services.
Section 1903(i)(1) requires written standards in the State plan for coverage of organ
transplants. Such standards must provide that individuals with the same/similar
medical conditions and risk factors are treated alike and that any restriction/s on the
facilities or practitioners providing organ transplantation procedures are consistent
with the accessibility of high quality care to those individuals eligible for the
procedures under the State plan. (Organ transplants for children under the age of 21
must be covered if determined to be medically necessary.)
Provided:



Not Provided: 
(If the State attests that organ transplant services are provided, then a text box with header appears
for the State to supply supplement information.)
Instructions:
Describe the standards for the coverage of transplant services.

32

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

F. Provisions Relating to Managed Care (provided in accordance with 1932 of the Social Security
Act and 42 CFR 438.50).
Provided:



Not Provided: 
(If the State attests “Provided”, then the State is redirected to a Pre-print to supply additional
information. Please note that the above referenced “Pre-print” has gone through the PRA process
and was approved in August 2008.)
Pre-print
OMB-0938-0933

33

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

G. Families Receiving Transitional Medical Assistance (TMA) Benefits (provided in accordance with
1902(a)(52) and 1925 of the Act and 42 CFR 435.112)
1. Services provided to families during the first 6-month period of extended Medicaid
benefits under section 1925 of the Act are equal in amount, duration, and scope to
services provided to categorically needy recipients eligible under section 1931, as
described in Section 3.1(A); or may be greater if provided through a health insurance
plan of the caretaker relative’s employer.
2. Services provided to families during the second 6-month period of extended Medicaid
benefits under section 1925 of the Act are equal in amount, duration, and scope to
services provided to categorically needy recipients eligible under section 1931, as
described in Section 3.1(A); or may be greater if provided through a health insurance
plan of the caretaker relative’s employer.


Provided



Provided; minus one or more of the following non-acute care services:








Other diagnostic, screening, preventive, and rehabilitative
services.
Inpatient hospital services and nursing facility services for
individuals 65 years old or older in an institution for mental
diseases.
Intermediate care facility services for individuals with mental
retardation or a related condition.
Inpatient psychiatric hospital services for individuals under age
21.
Hospice care.
Respiratory care services.
Any other medical care and any other type of remedial care
recognized under State law and specified by the Secretary.

3. Payments for premiums, deductibles and coinsurance.


The agency provides wrap-around coverage by paying the family’s premiums,
enrollment fees, deductibles, coinsurance, and similar costs for health insurance or
other health coverage offered by the caretaker relative’s or absent parent’s
employer as payments for medical assistance.
 Provided the first 6-month period.
 Provided the second 6-month period.

34



The agency requires caretaker relatives to enroll in employers’ health plans as a
condition of the extended eligibility, but only if the caretaker relative is not
required to make financial contributions for such coverage and the State provides
for the payments of any costs that the employee is otherwise required to pay.
 Provided the first 6-month period.
 Provided the second 6-month period.

4. Alternative assistance during the second 6-month period of extended Medicaid
benefits.


Provided; through enrollment of the caretaker relative and dependent children
under one or more of the following:







Enrollment in family option of an employer’s health plan.
Enrollment in family option of a State employee health plan.
Enrollment in State health plan for the uninsured.
Enrollment in Medicaid managed care organization (as defined in section
1903(m)(1)(A) of the Act and the applicable requirements of section
1932).

Not Provided

(If State attests “Provided” then a text box, with header, appears for the State to supply
information.)
Instructions:
1. By providing alternative assistance during the second 6-month period of extended
Medicaid benefits the State shall pays all premiums and enrollment fees imposed
on the family for such plan(s). The State also:



Pays all deductibles and coinsurance imposed on the family for
such plan(s).
Imposes a premium for a family for the 2nd six months in the
extension period in accordance with §1925(b)(5) of the Act, if
the family’s gross monthly earnings (less the average monthly
costs for child care necessary for the caretaker relative’s
employment) for the premium base period exceed 100 percent
of the official Federal poverty level for the family size involved,
as revised annually in the Federal Register.

2. Describe the alternative health care plans(s) offered, including requirements for assuring
that recipients have access of adequate quality.

35

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

H. Health Opportunity Accounts Demonstration Program (provided in accordance with 1938 of the
Act).
The State Participates:



The State Does Not Participate: 
(If the State attests that “Participates”, then the State is redirected to a Pre-print to supply
additional information. Please note that the above referenced “Pre-print” has gone through the
PRA process and was approved in August 2007.)
Pre-print
OMB-0938-1007

36

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

I. Standards and Methods to Assure High Quality Care (provided in accordance with 1902(a)(30)(A)
of the Social Security Act and 42 CFR 440.260)
Standards and quality of care are assured by the medical community. All hospitals and
skilled nursing facilities have utilization review processes. All medical and dental
procedures must be provided by duly licensed and qualified practitioners.

37

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

3.2

Coordination of Medicaid with Medicare and Other Insurance
Medicaid is provided in accordance with requirements of sections 1843, 1902(a), 1902(n),
1902(u), 1905(a), 1905(p), 1905(s), 1906, 1916, 1933 of the Act; and 42 CFR 431.625.
A. States
The following items, numbered 1 though 3, identify the coordination of Medicaid with Medicare
and other insurance provided by States and specifies all limitations on the amount, duration
and scope of those services.
1.

Medicare Part A and/or Part B Premiums
a. The Medicaid Agency has a Buy-in agreement under section 1843 of the Act for:
 Part A Premiums
 Part B Premiums
b. The Medicaid agency pays Medicare premiums for the following individuals:
i. Qualified Medicare Beneficiary (QMB) (provided in accordance with
sections 1902(a)(10)(E)(i) and 1905(p)(1) of the Act).
The Medicaid agency pays Part A and Part B premiums under the State Buy-in
process for individuals in the QMB group, as defined in ATTACHMENT 2.2-A,
item 24 of this plan.
ii. Qualified Disabled Working Individual (QDWI) (provided in accordance
with sections 1902(a)(10)(E)(ii) and 1905(s) of the Act).
The Medicaid agency pays Part A premiums under a group premium payment
arrangement, subject to any contribution required as described in ATTACHMENT
4.18-E, for individuals in the QDWI group, as defined in ATTACHMENT 2.2-A,
item 25 of this plan.
iii. Specified Low-Income Medicare Beneficiary (SLMB) (provided in
accordance with sections 1902(a)(10)(E)(iii) and 1905(p)(3)(A)(ii) of the
Act).
The Medicaid agency pays Medicare Part B premiums under the State Buy-in
process for individuals in the SLMB group, as defined in ATTACHMENT 2.2-A,
item 26 of this plan.

38

iv. Qualified Individuals (QI) (provided in accordance with sections
1902(a)(10)(E)(iv) and 1933 of the Act).
The Medicaid agency pays Medicare Part B premiums under the State Buy-in
process for individuals in the QI group as defined in ATTACHMENT 2.2-A,
item 27 of this plan, subject to the limitations set forth in section 1933 of
the Social Security Act.
v.

Other Medicaid Recipients (provided in accordance with sections 1843(b) and
1905(a) of the Act and 42 CFR 431.625).
 Medicaid agency pays Medicare Part B premiums, for which FFP is available, for
certain individuals.

(If State attests “Medicaid agency pays Medicare Part B premiums for which FFP is available”
then a text box, with header, appears for the State to supply information.)
Instructions:
In accordance with 42 CFR 407.42(b) the Medicaid agency pays Medicare Part B
premiums, for which FFP is available to all individuals in Buy-in group _________.

 Medicaid agency pays Medicare Part B premiums, for which FFP is not available,
for certain individuals
(If State attests “Medicaid agency pays Medicare Part B premiums for which FFP is not available”
then a text box, with header, appears for the State to supply information.)
Instructions:
Medicaid agency pays Medicare Part B premiums, for which FFP is not available,
for the following individuals (specify):

2.

Medicare Deductibles and Coinsurance
a. Medicare Part A & B (provided in accordance with 1902(a)(30), 1902(n) and
1916 of the Act).
Supplement 1 to ATTACHMENT 4.19-B describes the methods and standards for
establishing payment rates for services covered under Medicare, and/or the methodology
for payment of Medicare deductible and coinsurance amounts, to the extent available for
each of the following groups.
b. Qualified Medicare Beneficiary (QMB) (provided in accordance with
1902(a)(10)(E)(i) and 1905(p)(3) of the Act).
The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance
amounts for QMBs (subject to any nominal Medicaid co-payment) for all services

39

available under Medicare, including Part A and B services received through a plan
operating under Medicare Part C.
c. Other Medicaid Recipients- Non-QMB Dual Eligibles (provided in accordance
with 1902(a), 1902(a)(30) and 1905(a) of the Act and 42 CFR 431.625).
The Medicaid agency pays for Medicaid services also covered under Medicare and
furnished to recipients entitled to Medicare (subject to any nominal Medicaid copayment). For services furnished to individuals who are not QMB, but who are eligible
for both Medicaid and Medicare, payment is made as follows:
 For the entire range of services available under Medicare Part B.
 Only for the amount, duration and scope of services otherwise available
under this plan.
d. Qualified Medicare Beneficiary Plus Medicaid (QMB Plus) Eligibles (provided in
accordance with 1902(a)(10), 1902(a)(30), 1905(a) and 1905(p) of the Act).
The Medicaid agency pays Medicare Part A and Part B 1905(a) deductible and
coinsurance amounts for all services available under Medicare and pays for all Medicaid
services furnished to individuals eligible as both QMB and categorically or medically
needy (subject to any nominal Medicaid co-payment).

3. Other Health Insurance
 The Medicaid agency pays insurance premiums for medical or
any other type of remedial care to maintain a third party resource for
Medicaid covered services provided to an eligible individual (except
individuals 65 years of age or older and disabled individuals who are entitled
to Medicare Part A but who are not enrolled in Medicare Part B) (provided
in accordance with 1902(a)(30) and 1905(a) of the Act).
 COBRA Continuation (provided in accordance with 1902(a)(10)(f) and
1902(u) of the Act).
The Medicaid agency pays premiums for individuals, as described in
ATTACHMENT 2.2-A, item 20.
 Health Insurance Premium Payment Program (HIPP) (in accordance with
1906 of the Act).
When cost effective, the Medicaid agency elects to pay premiums for enrollment
of eligible individuals in employer based group health plans. The Medicaid
agency pays all deductibles, coinsurance and other cost sharing obligations for
items and services covered under both the group health plan and the state plan
(subject to any nominal Medicaid co-payment). Eligible individuals are entitled
to all services under the state plan that are not covered by the group health plan.

40

a. The Medicaid agency uses the following guidelines to determine the cost
effectiveness of an employer-based group health plan:
 The Secretary’s method as provided in the State Medicaid Manual, Section
3910.
 The State’s method for determining cost effectiveness.
(If State attests “The State’s method” then a text box, with header, appears for the State to supply
information.)
Instructions:
Please describe the State’s method for determining cost effectiveness.

b. When eligible family members may not enroll in a cost-effective group
health insurance plan unless ineligible family members are also
enrolled, the Medicaid agency pays premiums for the ineligible family
members, if cost effective. Ineligible family members so enrolled are not
entitled to payment of any deductibles, coinsurance or other cost
sharing obligations, nor are they entitled to any other services under the
state plan.

41

Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

3.2

Coordination of Medicaid with Medicare and Other Insurance
Medicaid is provided in accordance with requirements of sections 1843, 1902(a), 1902(n),
1902(u), 1905(a), 1905(p), 1905(s), 1906, 1916, 1933 of the Act; and 42 CFR 431.625.
B.

Territories
The following items, numbered 1 though 3, identify the coordination of Medicaid with Medicare
and other insurance provided by Territories and specifies all limitations on the amount, duration
and scope of those services.

1. Medicare Part A and/or Part B Premiums
a. The Medicaid Agency has a Buy-in agreement under section 1843 of the Act for:
 Part A Premiums
 Part B Premiums
b. The Medicaid agency pays Medicare premiums for the following individuals:
 Qualified Medicare Beneficiary (QMB) (provided in accordance with
sections 1902(a)(10)(E)(i) and 1905(p)(1) & (4) of the Act).
The Medicaid agency pays Part A and Part B premiums under the State Buy-in
process for individuals in the QMB group, as defined in ATTACHMENT 2.2-A,
item (D)(1) of this plan.
 Qualified Disabled Working Individual (QDWI) (provided in accordance
with sections 1902(a)(10)(E)(ii) and 1905(s) of the Act).
The Medicaid agency pays Part A premiums under a group premium payment
arrangement, subject to any contribution required as described in ATTACHMENT
4.18-E, for individuals in the QDWI group, as defined in ATTACHMENT 2.2-A,
item (D)(2) of this plan.
 Specified Low-Income Medicare Beneficiary (SLMB) (provided in
accordance with sections 1902(a)(10)(E)(iii) and 1905(p)(3)(A)(ii) of the Act).
The Medicaid agency pays Medicare Part B premiums under the State Buy-in
process for individuals in the SLMB group, as defined in ATTACHMENT 2.2-A,
item (D)(3) of this plan.

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 Qualified Individuals (QI) (provided in accordance with sections
1902(a)(10)(E)(iv) and 1933 of the Act).
The Medicaid agency pays Medicare Part B premiums under the State Buy-in
process for individuals in the QI group, as defined in ATTACHMENT 2.2-A,
item 27 of this plan and subject to the limitations set forth in section 1933 of
the Social Security Act.
 Other Medicaid Recipients (provided in accordance with sections 1843(b)
and 1905(a) of the Act and 42 CFR 431.625).
 Medicaid agency pays Medicare Part B premiums, for which FFP is
available, for certain individuals.
(If State attests “Medicaid agency pays Medicare Part B premiums for which FFP is available”
then a text box, with header, appears for the State to supply information.)
Instructions:
In accordance with 42 CFR 407.43(b) the Medicaid agency pays Medicare Part B
premiums, for which FFP is available to all individuals in Buy-in group _________.

 Medicaid agency pays Medicare Part B premiums, for which FFP is not
available, for certain individuals
(If State attests “Medicaid agency pays Medicare Part B premiums for which FFP is not available”
then a text box, with header, appears for the State to supply information.)
Instructions:
Medicaid agency pays Medicare Part B premiums, for which FFP is not available,
for the following individuals (specify):

2.

Medicare Deductibles and Coinsurance
a. Medicare Part A & B (provided in accordance with 1902(a)(30), 1902(n) and
1916 of the Act).
Supplement 1 to ATTACHMENT 4.19-B describes the methods and standards for
establishing payment rates for services covered under Medicare, and/or the methodology
for payment of Medicare deductible and coinsurance amounts, to the extent available for
each of the following groups.
b. Qualified Medicare Beneficiary (QMB) (provided in accordance with
1902(a)(10)(E)(i) and 1905(p)(3) of the Act).
 The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance
amounts for QMBs (subject to any nominal Medicaid co-payment) for all services

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available under Medicare, including Part A and B services received through a plan
operating under Medicare Part C.
c. Other Medicaid Recipients- Non-QMB Dual Eligibles (provided in accordance
with 1902(a), 1902(a)(30) and 1905(a) of the Act and 42 CFR 431.625).
The Medicaid agency pays for Medicaid services also covered under Medicare and
furnished to recipients entitled to Medicare (subject to any nominal Medicaid copayment). For services furnished to individuals who are not QMB, but who are eligible
for both Medicaid and Medicare, payment is made as follows:
 For the entire range of services available under Medicare Part B.
 Only for the amount, duration and scope of services otherwise available
under this plan.
d. Qualified Medicare Beneficiary Plus Medicaid (QMB Plus) Eligibles (provided in
accordance with 1902(a)(10), 1902(a)(30), 1905(a) and 1905(p) of the Act).
 The Medicaid agency pays Medicare Part A and Part B 1905(a) deductible and
coinsurance amounts for all services available under Medicare and pays for all
Medicaid services furnished to individuals eligible as both QMB and categorically
or medically needy (subject to any nominal Medicaid co-payment).

3. Other Health Insurance
 The Medicaid agency pays insurance premiums for medical or
any other type of remedial care to maintain a third party resource for
Medicaid covered services provided to an eligible individual (except
individuals 65 years of age or older and disabled individuals who are entitled
to Medicare Part A but who are not enrolled in Medicare Part B) (provided
in accordance with 1902(a)(30) and 1905(a) of the Act).
 COBRA Continuation (provided in accordance with 1902(a)(10)(f) and
1902(u) of the Act).
The Medicaid agency pays premiums for individuals, as described in
ATTACHMENT 2.2-A, item (B)(16).
 Health Insurance Premium Payment Program (HIPP) (in accordance with
1906 of the Act).
When cost effective, the Medicaid agency elects to pay premiums for enrollment
of eligible individuals in employer based group health plans. The Medicaid
agency pays all deductibles, coinsurance and other cost sharing obligations for
items and services covered under both the group health plan and the state plan
(subject to any nominal Medicaid co-payment). Eligible individuals are entitled
to all services under the state plan that are not covered by the group health plan.

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a. The Medicaid agency uses the following guidelines to determine the cost
effectiveness of an employer-based group health plan:
 The Secretary’s method as provided in the State Medicaid Manual, Section
3910.
 The State’s method for determining cost effectiveness.
(If State attests “The State’s method” then a text box, with header, appears for the State to supply
information.)
Instructions:
Please describe the State’s method for determining cost effectiveness.

b. When eligible family members may not enroll in a cost-effective group
health insurance plan unless ineligible family members are also
enrolled, the Medicaid agency pays premiums for the ineligible family
members, if cost effective. Ineligible family members so enrolled are not
entitled to payment of any deductibles, coinsurance or other cost
sharing obligations, nor are they entitled to any other services under the
state plan.

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Revision by FCHPG/DEHPG:

JULY 10, 2008

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS; continued

3.3

Integrated Medicare and Medicaid Services
A.

State Plan for Integrated Care Programs
1.

The Integrated Care Preprint is an optional tool for use by States to highlight the arrangements
provided between a State and Medicare Advantage (MA) organizations offering MA Special
Needs Plans (SNP) that also contract with the State to provide Medicaid services to dual
eligible individuals enrolled in the SNP. The Preprint also provides the opportunity for States
to confirm that their integrated care model complies with both federal statutory and regulatory
requirements.
The State opts to use the tool:



(If State attests “opts to use the tool” then the State is redirected to “Integrated Medicare and
Medicaid State Plan Preprint Instructions” and “State Plan Preprint for Integrated Care Programs”
preprint pages to supply additional information. Please note that the following referenced
instructions and preprint pages are currently going through the PRA process.)
Integrated Medicare and Medicaid State Plan Preprint Instructions
State Plan Preprint for Integrated Care Programs
OMB Approval pending

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