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U.S. Code as of:
01/19/04
Section 1396r-6. Extension of eligibility for medical assistance
(a) Initial 6-month extension
(1) Requirement
Notwithstanding any other provision of this subchapter, each
State plan approved under this subchapter must provide that each
family which was receiving aid pursuant to a plan of the State
approved under part A of subchapter IV of this chapter in at
least 3 of the 6 months immediately preceding the month in which
such family becomes ineligible for such aid, because of hours of,
or income from, employment of the caretaker relative (as defined
in subsection (e) of this section) or because of section
602(a)(8)(B)(ii)(II) )1(! of this title (providing for a
time-limited earned income disregard), shall, subject to
paragraph (3) and without any reapplication for benefits under
the plan, remain eligible for assistance under the plan approved
under this subchapter during the immediately succeeding 6-month
period in accordance with this subsection.
(2) Notice of benefits
Each State, in the notice of termination of aid under part A of
subchapter IV of this chapter 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) of this section 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
Subject to subparagraphs (B) and (C), extension of assistance
during the 6-month period described in paragraph (1) to a
family shall terminate (during such period) at the close of the
first month in which the family ceases to include a child,
whether or not the child is (or would if needy be) a dependent
child under part A of subchapter IV of this chapter.
(B) Notice before termination
No termination of assistance shall become effective under
subparagraph (A) until the State has provided the family with
notice of the grounds for the termination.
(C) Continuation in certain cases until redetermination
With respect to a child who would cease to receive medical
assistance because of subparagraph (A) but who may be eligible
for assistance under the State plan because the child is
described in clause (i) of section 1396d(a) of this title or
clause (i)(IV), (i)(VI), (i)(VII), or (ii)(IX) of section
1396a(a)(10)(A) of this title, the State may not discontinue
such assistance under such subparagraph until the State has
determined that the child is not eligible for assistance under
the plan.
(4) Scope of coverage
(A) In general
Subject to subparagraph (B), during the 6-month extension
period under this subsection, the amount, duration, and scope
of medical assistance made available with respect to a family
shall be the same as if the family were still receiving aid
under the plan approved under part A of subchapter IV of this
chapter.
(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.
(b) Additional 6-month extension
(1) Requirement
Notwithstanding any other provision of this subchapter, each
State plan approved under this subchapter shall provide that the
State shall offer to each family, which has received assistance
during the entire 6-month period under subsection (a) of this
section and which meets the requirement of paragraph (2)(B)(i),
in the last month of the period the option of extending coverage
under this subsection for the succeeding 6-month period, subject
to paragraph (3).
(2) Notice and reporting requirements
(A) Notices
(i) Notice during initial extension period of option and
requirements
Each State, during the 3rd and 6th month of any extended
assistance furnished to a family under subsection (a) of this
section, shall notify the family of the family's option for
additional extended assistance under this subsection. Each
such notice shall include (I) in the 3rd month notice, a
statement of the reporting requirement under subparagraph
(B)(i), and, in the 6th month notice, a statement of the
reporting requirement under subparagraph (B)(ii), (II) a
statement as to whether any premiums are required for such
additional extended assistance, and (III) a description of
other out-of-pocket expenses, benefits, reporting and payment
procedures, and any pre-existing condition limitations,
waiting periods, or other coverage limitations imposed under
any alternative coverage options offered under paragraph
(4)(D). The 6th month notice under this subparagraph shall
describe the amount of any premium required of a particular
family for each of the first 3 months of additional extended
assistance under this subsection.
(ii) Notice during additional extension period of reporting
requirements and premiums
Each State, during the 3rd month of any additional extended
assistance furnished to a family under this subsection, shall
notify the family of the reporting requirement under
subparagraph (B)(ii) and a statement of the amount of any
premium required for such extended assistance for the
succeeding 3 months.
(B) Reporting requirements
(i) During initial extension period
Each State shall require (as a condition for additional
extended assistance under this subsection) that a family
receiving extended assistance under subsection (a) of this
section report to the State, not later than the 21st day of
the 4th month in the period of extended assistance under
subsection (a) of this section, on the family's gross monthly
earnings and on the family's costs for such child care as is
necessary for the employment of the caretaker relative in
each of the first 3 months of that period. A State may permit
such additional extended assistance under this subsection
notwithstanding a failure to report under this clause if the
family has established, to the satisfaction of the State,
good cause for the failure to report on a timely basis.
(ii) During additional extension period
Each State shall require that a family receiving extended
assistance under this subsection report to the State, not
later than the 21st day of the 1st month and of the 4th month
in the period of additional extended assistance under this
subsection, on the family's gross monthly earnings and on the
family's costs for such child care as is necessary for the
employment of the caretaker relative in each of the 3
preceding months.
(iii) Clarification on frequency of reporting
A State may not require that a family receiving extended
assistance under this subsection or subsection (a) of this
section report more frequently than as required under clause
(i) or (ii).
(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
The extension shall terminate at the close of the first
month in which the family ceases to include a child, whether
or not the child is (or would if needy be) a dependent child
under part A of subchapter IV of this chapter.
(ii) Failure to pay any premium
If the family fails to pay any premium for a month under
paragraph (5) by the 21st day of the following month, the
extension shall terminate at the close of that following
month, unless the family has established, to the satisfaction
of the State, good cause for the failure to pay such premium
on a timely basis.
(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) )2(! 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
No termination of assistance shall become effective under
subparagraph (A) until the State has provided the family with
notice of the grounds for the termination, which notice shall
include (in the case of termination under subparagraph
(A)(iii)(II), relating to no continued earnings) a description
of how the family may reestablish eligibility for medical
assistance under the State plan. No such termination shall be
effective earlier than 10 days after the date of mailing of
such notice.
(C) Continuation in certain cases until redetermination
(i) Dependent children
With respect to a child who would cease to receive medical
assistance because of subparagraph (A)(i) but who may be
eligible for assistance under the State plan because the
child is described in clause (i) of section 1396d(a) of this
title or clause (i)(IV), (i)(VI), (i)(VII), or (ii)(IX) of
section 1396a(a)(10)(A) of this title, the State may not
discontinue such assistance under such subparagraph until the
State has determined that the child is not eligible for
assistance under the plan.
(ii) Medically needy
With respect to an individual who would cease to receive
medical assistance because of clause (ii) or (iii) of
subparagraph (A) but who may be eligible for assistance under
the State plan because the individual is within a category of
person for which medical assistance under the State plan is
available under section 1396a(a)(10)(C) of this title
(relating to medically needy individuals), the State may not
discontinue such assistance under such subparagraph until the
State has determined that the individual is not eligible for
assistance under the plan.
(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 of this
chapter; and
(ii) the State plan may offer alternative coverage
described in subparagraph (D).
(B) Elimination of most non-acute care benefits
At a State's option and notwithstanding any other provision
of this subchapter, a State may choose not to provide medical
assistance under this subsection with respect to any (or all)
of the items and services described in paragraphs (4)(A), (6),
(7), (8), (11), (13), (14), (15), (16), (18), (20), and (21)
)3(! of section 1396d(a) of this title.
(C) State medicaid "wrap-around" option
At a State's option, the State may elect to apply the option
described in subsection (a)(4)(B) of this section (relating to
"wrap-around" coverage) for families electing medical
assistance under this subsection in the same manner as such
option applies to families provided extended eligibility for
medical assistance under subsection (a) of this section.
(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
Enrollment of the caretaker relative and dependent children
in a family option of the group health plan offered to the
caretaker relative.
(ii) Enrollment in family option of State employee plan
Enrollment of the caretaker relative and dependent children
in a family option within the options of the group health
plan or plans offered by the State to State employees.
(iii) Enrollment in State uninsured plan
Enrollment of the caretaker relative and dependent children
in a basic State health plan offered by the State to
individuals in the State (or areas of the State) otherwise
unable to obtain health insurance coverage.
(iv) Enrollment in medicaid managed care organization
Enrollment of the caretaker relative and dependent children
in a medicaid managed care organization (as defined in
section 1396b(m)(1)(A) of this title).
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
Notwithstanding any other provision of this subchapter
(including section 1396o of this title), a State may impose a
premium for a family for additional extended coverage under
this subsection for a premium payment period (as defined in
subparagraph (D)(i)), but only if the family's average gross
monthly earnings (less the average monthly costs for such child
care as is necessary for the employment of the caretaker
relative) for the premium base period exceed 100 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.
(B) Level may vary by option offered
The level of such premium may vary, for the same family, for
each option offered by a State under paragraph (4)(D).
(C) Limit on premium
In no case may the amount of any premium under this paragraph
for a family for a month in either of the premium payment
periods described in subparagraph (D)(i) exceed 3 percent of
the family's average gross monthly earnings (less the average
monthly costs for such child care as is necessary for the
employment of the caretaker relative) during the premium base
period (as defined in subparagraph (D)(ii)).
(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
In the case of any State which is providing medical assistance
to its residents under a waiver granted under section 1315(a) of
this title, the Secretary shall require the State to meet the
requirements of this section in the same manner as the State
would be required to meet such requirement if the State had in
effect a plan approved under this subchapter.
(2) Inapplicability in commonwealths and territories
The provisions of this section shall only apply to the 50
States and the District of Columbia.
(d) General disqualification for fraud
(1) Ineligibility for aid
This section shall not apply to an individual who is a member
of a family which has received aid under part A of subchapter IV
of this chapter if the State makes a finding that, at any time
during the last 6 months in which the family was receiving such
aid before otherwise being provided extended eligibility under
this section, the individual was ineligible for such aid because
of fraud.
(2) General disqualifications
For additional provisions relating to fraud and program abuse,
see sections 1320a-7, 1320a-7a, and 1320a-7b of this title.
(e) "Caretaker relative" defined
In this section, the term "caretaker relative" has the meaning of
such term as used in part A of subchapter IV of this chapter.
(f) Sunset
This section shall not apply with respect to families that cease
to be eligible for aid under part A of subchapter IV of this
chapter after September 30, 2003.
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