42 USC 1396r-6 - Extension of eligibility for medical assistance

U.S Code last checked for updates: Oct 16, 2024

§ 1396r–6.

Extension of eligibility for medical assistance

(a)

Initial 6-month extension

(1)

Requirement

(A)

In general

(B)

State option to waive requirement for 3 months before receipt of medical assistance

(2)

Notice of benefits

Each State, in the notice of termination of aid under part A of subchapter IV sent to a family meeting the requirements of paragraph (1)—

(A)

shall notify the family of its right to extended medical assistance under this subsection and include in the notice a description of the reporting requirement of subsection (b)(2)(B)(i) and of the circumstances (described in paragraph (3)) under which such extension may be terminated; and

(B)

shall include a card or other evidence of the family’s entitlement to assistance under this subchapter for the period provided in this subsection.

(3)

Termination of extension

(A)

No dependent child

(B)

Notice before termination

(C)

Continuation in certain cases until redetermination

(4)

Scope of coverage

(A)

In general

(B)

State medicaid “wrap-around” option

A State, at its option, may pay a family’s expenses for premiums, deductibles, coinsurance, and similar costs for health insurance or other health coverage offered by an employer of the caretaker relative or by an employer of the absent parent of a dependent child. In the case of such coverage offered by an employer of the caretaker relative—

(i)

the State may require the caretaker relative, as a condition of extension of coverage under this subsection for the caretaker and the caretaker’s family, to make application for such employer coverage, but only if—

(I)

the caretaker relative is not required to make financial contributions for such coverage (whether through payroll deduction, payment of deductibles, coinsurance, or similar costs, or otherwise), and

(II)

the State provides, directly or otherwise, for payment of any of the premium amount, deductible, coinsurance, or similar expense that the employee is otherwise required to pay; and

(ii)

the State shall treat the coverage under such an employer plan as a third party liability (under section 1396a(a)(25) of this title).

Payments for premiums, deductibles, coinsurance, and similar expenses under this subparagraph shall be considered, for purposes of section 1396b(a) of this title, to be payments for medical assistance.

(5)

Option of 12-month initial eligibility period

(b)

Additional 6-month extension

(1)

Requirement

(2)

Notice and reporting requirements

(A)

Notices

(i)

Notice during initial extension period of option and requirements

(ii)

Notice during additional extension period of reporting requirements and premiums

(B)

Reporting requirements

(i)

During initial extension period

(ii)

During additional extension period

(iii)

Clarification on frequency of reporting

(3)

Termination of extension

(A)

In general

Subject to subparagraphs (B) and (C), extension of assistance during the 6-month period described in paragraph (1) to a family shall terminate (during the period) as follows:

(i)

No dependent child

(ii)

Failure to pay any premium

(iii)

Quarterly income reporting and test

The extension under this subsection shall terminate at the close of the 1st or 4th month of the 6-month period if—

(I)

the family fails to report to the State, by the 21st day of such month, the information required under paragraph (2)(B)(ii), unless the family has established, to the satisfaction of the State, good cause for the failure to report on a timely basis;

(II)

the caretaker relative had no earnings in one or more of the previous 3 months, unless such lack of any earnings was due to an involuntary loss of employment, illness, or other good cause, established to the satisfaction of the State; or

(III)

the State determines that the family’s average gross monthly earnings (less such costs for such child care as is necessary for the employment of the caretaker relative) during the immediately preceding 3-month period exceed 185 percent of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 9902(2) of this title) applicable to a family of the size involved.

Information described in clause (iii)(I) shall be subject to the restrictions on use and disclosure of information provided under section 602(a)(9) ¹ of this title. Instead of terminating a family’s extension under clause (iii)(I), a State, at its option, may provide for suspension of the extension until the month after the month in which the family reports information required under paragraph (2)(B)(ii), but only if the family’s extension has not otherwise been terminated under subclause (II) or (III) of clause (iii). The State shall make determinations under clause (iii)(III) for a family each time a report under paragraph (2)(B)(ii) for the family is received.

(B)

Notice before termination

(C)

Continuation in certain cases until redetermination

(i)

Dependent children

(ii)

Medically needy

(4)

Coverage

(A)

In general

During the extension period under this subsection—

(i)

the State plan shall offer to each family medical assistance which (subject to subparagraphs (B) and (C)) is the same amount, duration, and scope as would be made available to the family if it were still receiving aid under the plan approved under part A of subchapter IV; and

(ii)

the State plan may offer alternative coverage described in subparagraph (D).

(B)

Elimination of most non-acute care benefits

(C)

State medicaid “wrap-around” option

(D)

Alternative assistance

At a State’s option, the State may offer families a choice of health care coverage under one or more of the following, instead of the medical assistance otherwise made available under this subsection:

(i)

Enrollment in family option of employer plan

(ii)

Enrollment in family option of State employee plan

(iii)

Enrollment in State uninsured plan

(iv)

Enrollment in medicaid managed care organization

If a State elects to offer an option to enroll a family under this subparagraph, the State shall pay any premiums and other costs for such enrollment imposed on the family and may pay deductibles and coinsurance imposed on the family. A State’s payment of premiums for the enrollment of families under this subparagraph (not including any premiums otherwise payable by an employer and less the amount of premiums collected from such families under paragraph (5)) and payment of any deductibles and coinsurance shall be considered, for purposes of section 1396b(a)(1) of this title, to be payments for medical assistance.

(E)

Prohibition on cost-sharing for maternity and preventive pediatric care

(i)

In general

If a State offers any alternative option under subparagraph (D) for families, under each such option the State must assure that care described in clause (ii) is available without charge to the families through—

(I)

payment of any deductibles, coinsurance, and other cost-sharing respecting such care, or

(II)

providing coverage under the State plan for such care without any cost-sharing,

or any combination of such mechanisms.

(ii)

Care described

The care described in this clause consists of—

(I)

services related to pregnancy (including prenatal, delivery, and post partum services), and

(II)

ambulatory preventive pediatric care (including ambulatory early and periodic screening, diagnosis, and treatment services under section 1396d(a)(4)(B) of this title) for each child who meets the age and date of birth requirements to be a qualified child under section 1396d(n)(2) of this title.

(5)

Premium

(A)

Permitted

(B)

Level may vary by option offered

(C)

Limit on premium

(D)

Definitions

In this paragraph:

(i)

A “premium payment period” described in this clause is a 3-month period beginning with the 1st or 4th month of the 6-month additional extension period provided under this subsection.

(ii)

The term “premium base period” means, with respect to a particular premium payment period, the period of 3 consecutive months the last of which is 4 months before the beginning of that premium payment period.

(c)

Applicability in States and territories

(1)

States operating under demonstration projects

(2)

Inapplicability in commonwealths and territories

(d)

General disqualification for fraud

(1)

Ineligibility for aid

(2)

General disqualifications

(e)

“Caretaker relative” defined

(f)

Collection and reporting of participation information

(1)

Collection of information from States

(2)

Annual reports to Congress

(Aug. 14, 1935, ch. 531, title XIX, § 1925, as added Pub. L. 100–485, title III, § 303(a)(1), Oct. 13, 1988, 102 Stat. 2385; amended Pub. L. 100–647, title VIII, § 8436(a), Nov. 10, 1988, 102 Stat. 3805; Pub. L. 101–239, title VI, § 6411(i)(1), (3), Dec. 19, 1989, 103 Stat. 2273; Pub. L. 101–508, title IV, §§ 4601(a)(3)(B), 4716(a), Nov. 5, 1990, 104 Stat. 1388–167, 1388–192; Pub. L. 104–193, title I, § 114(c), Aug. 22, 1996, 110 Stat. 2180; Pub. L. 105–33, title IV, §§ 4701(b)(2)(A)(ix), (D), 4703(b)(2), Aug. 5, 1997, 111 Stat. 493, 495; Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 608(t)], Nov. 29, 1999, 113 Stat. 1536, 1501A–398; Pub. L. 106–554, § 1(a)(6) [title VII, § 707(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–577; Pub. L. 108–40, § 7(a), June 30, 2003, 117 Stat. 837; Pub. L. 111–5, div. B, title V, § 5004(a)(1), (b)–(d), Feb. 17, 2009, 123 Stat. 503, 504; Pub. L. 111–309, title I, § 111, Dec. 15, 2010, 124 Stat. 3289; Pub. L. 112–78, title III, § 311, Dec. 23, 2011, 125 Stat. 1286; Pub. L. 112–96, title III, § 3102, Feb. 22, 2012, 126 Stat. 191; Pub. L. 112–240, title VI, § 622, Jan. 2, 2013, 126 Stat. 2352; Pub. L. 113–67, div. B, title II, § 1202, Dec. 26, 2013, 127 Stat. 1199; Pub. L. 113–93, title II, § 202, Apr. 1, 2014, 128 Stat. 1046; Pub. L. 114–10, title II, § 212(a), Apr. 16, 2015, 129 Stat. 152.)

cite as: 42 USC 1396r-6

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