Reference Guide to Federal Medicaid Statute and Regulations

In the 50 years since Medicaid was enacted as Title XIX of the Social Security Act, Congress has made significant changes to statutory provisions governing eligibility, covered services, and financing. Federal regulations have been added, rescinded, and modified to interpret and implement the statute. As a result, the statute and regulations are dense and not always easy to navigate.

This reference guide is intended to help users locate specific provisions in statute and regulation, as well as in state plans. Please note that the terms or topics do not always align across these sources. This may be because a particular statutory provision does not have corresponding regulations or because a regulation addresses a detail not specified in statute.

The Centers for Medicare & Medicaid Services also provides administrative guidance to states through the State Medicaid Manual, State Medicaid Director and State Health Official letters, and other materials posted at

Updated October 20, 2017

IssueStatutory ProvisionRegulation (Citations are to 42 CFR unless otherwise indicated)
209(b) StatesSection 209(b) of Public Law 92-603; 1902(f); 1917(c)(4)435.121; 435.230; 435.330; 435.631; 435.733
1115 Waiver1115431.400-431.428
Application Procedures1115(d)431.412
Authority to Waive 1902 Requirements1115(a)(1)431.54; 431.55
Cost-Sharing Limitations1916(f)447.56
Costs Not Otherwise Matchable1115(a)(2)Not Specified in regulation
EvaluationNot specified in statute431.424
Extension1115(e), (f)431.41224
Monitoring and Compliance1115(d)431.42
Public Notice and Comment1115(d)431.408; 431.416
1115A Waiver1115ANot specified in regulation
Center for Medicare and Medicaid Innovation (CMMI)1115A(a)Not specified in regulation
Expansion of Payment Models1115A(c); 1902(a)(83)Not specified in regulation
Testing of Models1115A(b)Not specified in regulation
Waiver Authority1115A(d)(1)Not specified in regulation
1915(b) Waiver1915(b)431.55
1915(c) Waiver1915(c)441.300-441.310; 441.350-441.365
2176 WaiversSee HCBS WaiversSee Home and Community-Based Services (HCBS) Waivers
Abortion Services1932(e)(1)(B)441.200-441.208
ACA (Affordable Care Act) Medicaid ExpansionSee New Adult GroupSee New Adult Group
Eligibility Group1902(a)(10)(A)(i)(VIII); see also New Adult Group435.119
Enhanced FMAP1905(y)(1); 1905(cc)433.1
Expansion State Enhanced FMAP1905(y)(2), (3); 1905(cc), 1905(z)(2)433.1
Active Treatment Requirement
Inpatient Psychiatric Hospital Services for Individuals Under 211905(h)(1)(B)441.151
Intermediate Care Facility for the Mentally Retarded (ICF/MR) [1]1905(d)(2)483.4
Preadmission Screening and Resident Review (PASARR)1919(f)(8)(B)483.100-483.138
Activities of Daily Living (ADL)1915(i)(1)(D)(i), (F)(i); 1915(k)(1)(A), (B); 1915(k)(6)(A), (F)441.500(b); 441.505; 441.520(a); 441.715; 441.720
Actuarial Soundness1903(m)(2)(A)(iii)438.4
AdministrationSee also Eligibility Determination, Managed Care, Program Integrity, Quality StandardsSee also Eligibility Determination, Managed Care, Presumptive Eligibility, Program Integrity, Quality Standards
Agency Program ManualNot specified in statute431.18(b)
Alignment with Exchange Initial Open EnrollmentNot specified in statute435.1205
Audits of State OperationsNot specified in statute430.33
Best Interest of Applicants and Beneficiaries1902(a)(19)435.902
Community Service AidesNot specified in statute432.31
Cooperative Arrangements1902(a)(11)433.151-433.154
Coordination with Other AgenciesNot specified in statute431.610-431.635; 435.1200- 435.1205
Cost AllocationOmnibus Budget Reconciliation Act of 1981 (P.L. 97-35)433.34; 45 CFR 95.501-95.519
FFP for Staffing Costs1903(a)(2)432.5
Fiscal AccountabilityNot specified in statute433.32
Fiscal Agent ContractsNot specified in statute434.1-434.78
Fraud Detection and Investigation Program1902(a)(61); 1903(q)455.12-455.23
General MethodsNot specified in statute435.901-435.904
Incentive Payments1903(p)433.153-433.154
Matching Rates1903(a)(7)433.15
Medical Care Advisory Committee1902(a)(4)431.12
Methods of Administration1902(a)(4)431.15
Merit Personnel Standards1902(a)(4)431.10(c)(2); 432.10(c)(2)
Operation of State Plans1902(a)(4)430.10-430.25
Organization and Function of Medicaid Agency1902(a)(4)431.11
Personnel Administration1902(a)(4)432.1-432.55
Personnel Standards1902(a)(4)Not specified in regulation
Requirements1902(a)(24); 1902(a)(27); 1902(a)(36); 1902(a)(58)431.105-431.120
Simplicity of Administration1902(a)(19)435.902
Single State Agency1902(a)(4); 1902(a)(5)431.10-431.18
State Medicaid Health Information Technology (HIT) PlanNot specified in statute495.332
Sub-Professional and Volunteer ProgramNot specified in statute432.31
TrainingNot specified in statute432.30-432.32
Withholding of FFP for Noncompliance1904430.35; 430.38
Administrative Simplification (HIPAA)1172(a)(1); 1171(5)(E); 1903(r)(1)(D)See HIPAA
Adult Health Quality Measures1139BNot specified in regulation
Adults, Non-Aged and Non-DisabledSee New Adult Group, Parents, Pregnant WomenSee New Adult Group, Parents, Pregnant Women
Advance Directive1902(a)(57), (58); 1902(w); 1919(c)(2)(E)431.2
AFDC (Aid to Families with Dependent Children)1902(a)(10)(A)(i)(I); 1925(a)(1)(A); 1931(a), (b)435.4; 435.110-435.115; 435.220
Age Requirements1905(a)(iii); 1902(b)(1);435.52
Exemption from MAGI-Based Eligibility1902(e)(14)(D)435.603(j)(2)
Functionally Disabled Elderly Individual1929(b)[2]Not specified in regulation
Medically Needy1902(a)(10)(c); 1925(b)(3)(c)(ii)435.320; 435.330
Medicare Buy-In1902(a)(10)( E);1902(n);1905(a);1905(p); 1933(a-g)431.625
Not Receiving Supplemental Security Income (SSI)1905(a)(iii)435.230 (C)(1)
Poverty-Related Aged and Disabled1902(a)(10)(A)(ii)(X); 1902(m)435.23
Special Income Level1915(i)435.236; 435.622; 435.1005
State Supplement or State Supplementary Payment1902(a)(10)(A)(ii)(IV); 1618(g)435.130; 435.232; 435.234; 435.1006; 435.1011-435.1012
Supplemental Security Income (SSI) Recipients1902(a)(10)(i)(II); 1902(a)(10)(A)(ii)(IV); 1618(g)435.120; 435.725; 435.603(j)(1)
Aid Paid PendingNot specified in statute431.230; 438.420
AIDS (Acquired Immune Deficiency Syndrome)
Boarder Babies1915(e)Not specified in regulation
COBRA (Consolidated Omnibus Budget Reconciliation Act) Continuation Coverage1902(a)(10)(F); 1902(u)Not specified in regulation
Hospice1905(o)(1)(B)Not specified in regulation
Targeted Case Management1905(a)(19); 1915(g)(2)Not specified in regulation
Alcoholism and Drug Dependency TreatmentLast sentence of 1905(a)Not specified in regulation
AliensSee Non-CitizensSee Non-Citizens
Alternate Payee1902(a)(79)Not specified in regulation
Alternative Benefit PlansSee Benchmark BenefitsSee Benchmark Benefits
Amount, Duration, and Scope1902(a)(10)(B); 1902(a)(10) after (G); 1903(i) in first sentence after (26); last sentence of 1902(a)440.23
Appeals (Selected Provisions)
In GeneralNot specified in statute430.3
By Beneficiaries
Fair Hearings1902(a)(3); 1919(f)(3); 1919(e)(7)(F)431.200-431.250; 435.919
MCO Grievance and Appeals Procedures1932(b)(4)438.400-438.424
By Providers or Plans
From Civil Money Penalties and ExclusionsNot specified in statute1005.1-1005.23
Nursing Facilities and ICFs/IDNot specified in statute431.151-431.154; 498.3(a)(2)(i), (ii)
By State
ComplianceNot specified in statute430.38; 430.60-430.104
ApplicantSee also Eligibility Determination, Fair HearingSee also Eligibility Determination, Fair Hearing
Authorized RepresentativeNot specified in statute435.923
DefinedNot specified in statute400.203
ApplicationSee also Single Streamlined Application FormSee also Single Streamlined Application Form
Application for Medicaid1902(a)(8)435.905-435.910
Applications for Other BenefitsNot specified in statute435.608
Certified Application CounselorsNot specified in statute435.908(c)
Simplicity of Administration1902(a)(19)435.902
Appropriation1901Not specified in regulation
Asset Verification Program1940(b); 1902(a)(71); 1903(i)(24); 1940Not specified in regulation
Mandatory Acceptance by Providers1128A(a)(2)(B); 1916(e); 1902(a)(25)(C)447.15; 447.20-447.21
Medical Support by Beneficiaries1902(a)(45); 1912433.145-433.148; 435.610(a)(1)
Prohibition on Factoring1902(a)(32)Not specified in regulation
Rights to Benefits by BeneficiariesNot specified in statute435.61
Assisted Suicide Prohibition1903(i)(16); last sentence of 1903(i)Not specified in regulation
Average Manufacturer Price (AMP)1927(k)(1)447.504
Average Sales Price (ASP)1927(b)(3)(A)(iii)(I); 1927(b)(3)(B); 1847A(c)Not specified in regulation
Bedholds (Reserve Beds) PaymentNot specified in statute447.4
Benchmark Benefits
In General1937440.300-440.395
Alternative Benefit PlansNot specified in statute440.345(d); 440.347; 440.360; 440.386
Benchmark Coverage1937(b)(1)440.33
Benchmark Equivalent Coverage1937(b)(2); 1937(b)(3)440.335; 440.340
Comparability1937(a)(1)(A); 1902(a)(10)(B)440.375
EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Services1937(a)(1)(A)(ii)440.345(a)
Essential Health Benefits1937(b)(5)440.345(d), (e); 440.347
Exempt Individuals1937(a)(2)(B)440.315; 440.320
Family Planning Services and Supplies1937(b)(7)440.345(b)
FQHC (Federally Qualified Health Center) Services1937(b)(4)440.365
Managed Care EntitiesNot specified in statute440.385
Mental Health Parity1937(b)(6)440.395
Mental Health Services1937(b)(2)(A)(v)440.347(a)(5)
New Adult Group1902(k)(1); 1903(i)(26); 1902(a)(10) in subdivision (XV) in the matter after (G)Not specified in regulation
Rural Health Clinic (RHC) Services1937(b)(4)440.365
State Option1937(a)Not specified in regulation
TransportationNot specified in statute440.39
Assignment1128A(a)(2)Not specified in regulation
Assignment of Medical Support1902(a)(45); 1912(a)(1); 1903(p)433.145-433.148; 435.610(a)(1)
Assignment of Rights to BenefitsNot specified in statute433.145-433.148; 435.610
Coverage Groups and Conditions of Eligibility1902(a); 1902(e); 1902(f) 1902(l); 1902(m);1902(u); 1902(v); 1905(a); 1905(n); 1905(p); 1905(q); 1905(s); 1905(u); 1905(w)435.2-435.1110
Direct Payment1905(a)447.25
Fair Hearings1902(a)(3)431.200-431.250
Fraud1128J(c)Not specified in regulation
Freedom of Choice1902 (a)(23); 1915(b)431.51; 431.54; 431.55
Mandatory Managed Care Enrollment and Disenrollment1903(m)(2)(A)(vi); 1932(a)(1)(A), (a)(4)438.52; 438.54; 438.56
Medical Care Advisory Committee RepresentationNot specified in statute431.12(d)(2)
Notice of Adverse ActionsNot specified in statute435.917
Nursing Facility Residents' Rights1919(c)483.10; 483.12; 483.15
Opportunity to Apply1902(a)(8)435.905-435.908
Protection Against Balance Billing1902(n); 1916(e)447.15; 447.20-447.21
Protection Against MCO Liability1903(m)(1)(A)(ii); 1932(b)(6)438.106
Reasonable Promptness of Benefits1902(a)(8)435.93
Simplicity of Administration1902(a)(19)435.902
Mandatory1902(a)(10)(A) before (i); 1905(a)(1)-(5), (17), (21)440.210; 440.220
Optional1905(a)(6)-(16), (18)-(20), (22)-(27)440.225
Best Interests of Applicants, Beneficiaries, and Recipients1902(a)(19)435.902; 431.808; 431.10(c)(5)
Best Price1927(c)(1)(C)447.505; 447.508
Blindness, Individuals with1614(a)(2); 1619(b); 1905(a)(iv); see also SSI435.530; 435.531; see also SSI
Definition of Blindness1614(a)(2); 1619(b)435.53
Eligibility1905(a)(iv); see also SSIsee also SSI
Breast or Cervical Cancer
Cost-Sharing Prohibition1916A(b)(3)(B)(viii)447.56(a)(1)(xi)
Coverage Group1902(a)(10)(A)(ii)(XVIII); 1902(a)(10) in subdivision (XIV) in the matter after (G); 1902(aa); 1905(b) in the matter at (4)435.213
Premium Prohibition1916A(b)(3)(A)(v)447.56(a)(1)(xi)
Presumptive Eligibility1920B435.1103(b)
Capitation Payments1903(m)(2)(A)(iii); 1934(d)438.6(c)
Caretaker Relative1931(b)435.4; 435.110
Case Management
Benefits Defined1915(g)(2)440.169; 441.18
HCBS Waiver1915(c); 1915(d); 1915(i)440.180(b)(1); 440.181(b)(1)
Optional Service1905(a)(19); 1915(g)(1), (2)(A)440.225
Primary Care System1915(b)(1)431.55(c)
Waivered Service1915(c)(4)(B); 1915(d)(4)440.180(b)(1); 440.181(b)(1)
Categorically Needy
Mandatory1902(a)(10)(A)(i)435.100-435.170; 435.1007
Optional1902(a)(10)(A)(ii)435.200-435.236; 435.1007
Center for Medicare and Medicaid Innovation (CMMI)1115A(a); see 1115A WaiverSee 1115A Waiver
Certified Application AssistersNot specified in statute435.908(c)
Certified Public Expenditure (CPE)1903(w)(6)433.51(b)
Child Health Quality Measures1139A(a); 1903(a)(3)(A)(iii)Not specified in regulation
Child Support Enforcement1902(a)(25)(F); see Medical Child Support433.151-433.152; 433.152(b); 435.115(f); 435.610(a)(2) see also Medical Support, Paternity Determination
Adoption Assistance1902(a)(10)(A)(ii)(VIII); second to last sentence of 1902(a); 473(b)(1)435.145; 435.227
Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF)1902(a)(10)(A)(i)(I); 1902(a)(63); 1931(b); 1902(c); 1902(e)(10)435.110; 435.112-435.115; 435.210
AFDC-UP (AFDC-Unemployed Parent)1902(a)(10)(A)(i)(V); 1905(m)435.119; 435.116
Child Health Quality Demonstrations1139A(d)Not specified in regulation
Child Health Quality Measures1139A(a), (b), (g); 1903(a)(3)(A)(iii)Not specified in regulation
Child Support Collections408(a)(11)(B); 1931(c)(1)435.115(f)
Childhood Obesity Demonstrations1139A(e)Not specified in regulation
Continuous Eligibility for Children's Inpatient Services1902(e)(7)435.926
Cost-Sharing Prohibition1916(a)(2)(A), (b)(2)(A); 1916A(b)(3)(B)(i)447.56(a)(1)(i)-(vi)
Dependency DeterminationNot specified in statute435.51
Dependent Child1931(b)435.4
Disabled Living at Home1902(e)(3); 1915(c)(10)435.225
Disabled Supplemental Security Income (SSI) Recipients1902(a)(10)(A)(i)(II)(cc)435.12
Eligibility1902(a)(10)(A)(i)(III), (IV), (V), (VI), (VII); 1902(a)(10)(A)(ii)(IV), (IX); 193(b), (d)435.118
EPSDT ServicesSee Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)See Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)
Exemption from Income Limit of 133 Percent of AFDC Payment Amount1903(f)(4)Not specified in regulation
Express Lane Option1902(e)(13); 2107(e)(1)435.603(j)(1)
Family Opportunity Act Option1902(a)(10)(A)(ii)(XIX); 1902(cc)447.55(a)(3); 447.56(a)(1)(vi)
Five-Year Bar1903(v)(4); 2107(e)(1)(J)435.406(b); 440.250(m)
Foster Care1902(a)(10)(A)(i)(I); second to last sentence of 1902(a); 473(b)(1)435.145
ImmunizationsSee Immunizations, VFCSee Immunizations, VFC
Independent Foster Care Adolescents1902(a)(10)(A)(ii)(XVII); 1905(w)(1)435.226
Katie Beckett Option1902(e)(3)435.225
Less Restrictive Income and Resource Methodology1902(r)(2); 1931(b)(2)(C)435.601; 435.1007(e), (f)
Medically Needy1902(a)(10)(C)(ii)(I), (iii)435.308
NewbornsSee InfantsSee Infants
Optional Targeted Low-Income Child (CHIP)1902(a)(10)(A)(ii)(XIV); 1902(u)(2)(B); 2110(b)435.4; 435.229
Outreach1943(b)(1)(F)457.340; 457.350
Outreach for EPSDT1902(a)(43)441.56(a)
Outstation Eligibility1902(a)(55)435.904(b)
Outstation Locations for Application1902(a)(55)(A)435.904(c)
Poverty-Related1902(a)(10)(A)(i)(VI), (VII); 1902(I)(1)(C), (D)435.118
Premium Assistance1902(a)(10)(G)(XI); 1905(a) in the second to last sentence in the matter after paragraph (29); 1906; 1906A; 2105(c)(3); 2105(c)(10)435.1015, 457.810
Premium Prohibition1916A(b)(3)(A)(i)447.56(a)(1)(i)-(vi)
Premiums for Certain Disabled Children1916(i)447.55(a)(3)
Presumptive Eligibility1902(a)(47)(A); 1920A; 2107(e)(1)435.1001(a)(2); 435.1002(c); 435.1100-1102; 447.88
Prohibition Against Requiring Application for TANF1902(c); 1902(e)(10)Not specified in regulation
Psychiatric Hospital Services1905(a)(16); 1905(h)441.150 - 441.184
Qualified1902(a)(10)(A)(i)(III); 1905(n)(2)436.12
ResidenceNot specified in statute435.403(i)
Restraints in Inpatient Psychiatric FacilitiesSection 591 of the Children's Health Act of 2000 (P.L. 106-310).483.350-483.376
Ribicoff1905(a) in (i) before (1); 1902(a)(10)(A)(ii)(I)435.222
Support Enforcement1912(a)(1); 408(a)(11)(B); 1903(p)435.115(f)(3), (h)
Transitional Medical Assistance (TMA) (4 Months)1902(a)(52); 1902(e)(1); 1925; 1931(c)(2); 408(a)(11)(A)435.112
Child Welfare
Children Receiving Title IV-E Payments1902(a)(10)(A)(i)(I); 473(b)435.145
Cost-Sharing Prohibition1916A(b)(3)(A)(i), (B)(i)447.56(a)(1)(iv)
Exemption from Citizenship Documentation1903(x)(2)(C)435.406(a)(1)(iii)(D)
Exemption from Mandatory Managed Care Enrollment1932(a)(2)(A)(iv), (v)438.50(d)(3)(iii), (iv)
Former Foster Care Youth1902(a)(10)(A)(i)(IX); 1902(a)(10) in subdivision (XVII) in the matter after G; 1905(a)(xiv)435.15
Independent Adolescents1902(a)(10)(A)(ii)(XVII); 1905(w)435.226
Optional Eligibility1902(a)(10)(A)(ii)(VIII)435.227
Optional Eligibility: Independent Foster Care Adolescents (Chafee Option)1902(a)(10)(A)(ii)(XVII); 1905(w)435.226
Premium Prohibition1916A(b)(3)(B)(i)447.56(a)(1)(iv)
ResidencyNot specified in statute435.403(g)
CHIP (State Children's Health Insurance Program) (Selected Provisions)
In General2101-2113457.1-457.1285
Application of Medicaid Provisions2107(e)(1)Not specified in regulation
Coordination with MedicaidSee Application of Medicaid ProvisionsSee Application of Medicaid Provisions
Enhanced Matching RateFourth sentence of 1905(b); 1905(u)(1); 2105(b); 2105(d)(1)433.11; 457.622
Enrollment Performance Bonus Payments2105(a)(3)Not specified in regulation
Express Lane Option1902(e)(13), (e)(14)(D)(ii); 2107(e)(1)(G)Not specified in regulation
MAGI (Modified Adjusted Gross Income)2107(e)(1)(F)457.315
Maintenance of Effort (MOE)2105(d)(3)Not specified in regulation
Medicaid Expansion CHIP Option2101(a)(2)457.70(c)
Optional Targeted Low-Income Child1905(u)(2)(B); 2110(b)435.4; 435.229
PERM (Payment Error Rate Measurement)2107(e)(1)(G)431.950-431.1002
Premium Assistance Option2105(c)(10)457.800-457.810
Screen and Enroll2102(b)(3)(B); 1902(e)(13)(A)(i)(III)457.350-457.353
Citizenship DocumentationSee also Eligibility DeterminationSee also Eligibility Determination
Eligibility Verification1137(d)(2); 1902(dd)435.406(a)(2)(i)
Express Lane Option1902(e)(13)(A)(i)(IV)Not specified in regulation
FFP Limitation1902(a)(46)(B)435.1008
Requirement1902(a)(46)(B); 1903(i)(22)435.406
Satisfactory Evidence1903(x)435.407
SSA Alternative1902(ee); 1903(a)(3)(H)435.406(b)
Citizenship Requirement1902(b)(3)435.406
Civil Money Penalties
In General1128A1003.100-1003.1600; 1005.1-1005.23
Clinical Laboratories1846493.1834
Community Supported Living Arrangement (CSLA) Services1930(h)(2)[2]Not specified in regulation
Drug Rebates1927(b)(3)(B), (C)1003.1200-1003.1220
Eligibility Data Exchange1943(c)(1)Not specified in regulation
Home and Community Care1929(j)(1)(B), (j)(2)(C)[2]Not specified in regulation
MCOs and Risk Contractors1903(m)(5); 1932(e)(2)(A)438.700-438.704
Nursing Facilities1919(b)(3)(B)(ii); 1919(g)(2)(A); 1919(h)(2)(A)(ii); 1919(h)(3)(C)(ii); 1903(i)(8)488.430-488.442
PACE (Program of All-Inclusive Care for the Elderly)Not specified in statute460.46
Claims, Reassignment Prohibition1842(b)(6)424.8
Clawback (Payments)1935(c)423.908, 423.910
Clinic Services1905(a)(9)440.9
Clinical Laboratory Services
Benefit1905(a)(3)440.30; 493.1809
Competitive Bidding1915(a)(1)(B)Not specified in regulation
Payment Limits1903(i)(7)Not specified in regulation
Quality Standards (Clinical Laboratory Improvement Amendments of 1998 or CLIA)1902(a)(9)(C); 1861(s)(17)493.1-493.1850
Clinical Preventive Services1905(a)(13)(A)440.13
Clinical Trial1902(e)(14)(3)Not specified in regulation
COBRA Continuation
Beneficiaries Defined1902(u)(1)Not specified in regulation
Optional Coverage1902(a)(10)(F); 1902(a)(10) in subdivision (XII) in the matter after (G)Not specified in regulation
Premiums1902(u)(2)Not specified in regulation
CoinsuranceSee Cost Sharing447.51; see Cost Sharing
Collection of Child or Spousal Support1931(c)(1)435.115(f)
Community First Choice Option1915(k)441.500-441.590
Community SpouseSee Spousal ImpoverishmentSee Spousal Impoverishment
Community Supported Living Arrangements (CSLA) Services1930[2]441.400-441.404
In General1902(a)(10)(B)440.24
Exceptions1902(a)(10) in the matter after (G); 1902(a)(70); last sentence of 1902(a); 1915(g)(1), (2)(B); 1932(a)(1)(A)440.250; 440.375
Optional Self-Directed Personal Assistant Services (PAS) Services1915(j)441.462
Waiver1115; 1115A(d); 1915(a), (b), (c)(3), (d)(3), (e)(3), (i)(3), (j)(3)Not specified in regulation
Comparative Clinical Effectiveness Research1180(d)(3), (j)(1)(B)Not specified in regulation
Compliance Programs
Managed Care and Other Entities1902(a)(68)438.600-438.610
Nursing Facilities1128I(b)Not specified in regulation
Providers and Suppliers1902(kk)(5); 1866(j)(7)455.400-455.470
Compliance by State Medicaid Plans1904430.3(a); 430.35; 430.60-430.104
Applicants and Beneficiaries1902(a)(7)431.300-431.307
Drug Manufacturer Price Data1927(b)(3)(D)Not specified in regulation
Electronic Health Record (EHR) Content Exchange StandardsNot specified in statute170.205
External Quality Review Organization (EQRO) ResultsNot specified in statute438.364(c)
HIPAA Standards1173(d)(2); 117744 CFR 164.102-164.534
Nursing Facility Residents1919(c)(1)(iv)483.10(e)
Providers Sanctioned by State Licensure Authorities1921(c)Not specified in regulation
Quality Improvement Organizations (QIOs)Not specified in statute480.101-480.144
Conflict of Interest Prohibition
Appeals DecisionsNot specified in statute431.10(c)(3)(i)(A)
Eligibility Determination1902(a)(5)431.10(c)(3)(i)(A)
Enrollment Broker1903(b)(4)(A)438.810(c)
Expenditures1902(a)(4)(C)Not specified in regulation
Integrity Audit Program Contractor1936455.238; 455.240
MCO Contracts1932(d)(3)438.58
Procurement1902(a)(4)(D)Not specified in regulation
Conformity HearingsNot specified in statute430.60-430.104
Consultation with Tribes1902(a)(73)Not specified in regulation
Consultative Services of Agencies1902(a)(24)431.105(b)
Continuous Eligibility
Children Under 191902(e)(12)435.926
Children Under 19 Who are Inpatients1902(e)(7)435.172
Group Health Plan Enrollees1902(e)(11)Not specified in regulation
MCO Enrollees1902(e)(2); 1903(m)(2)(H)435.212; 435.326
Pregnant Women1902(e)(5), (6)435.17
Transitional Medical Assistance (TMA) Due to Increased Work or Child or Spousal Support (4 Months)1902(e)(1); 1925435.112; 435.115(f)
Copayments1902(a)(14); 1916; 1916A447.51; see Cost Sharing
Correctional Facilities1905(a) in subdivision (A) after paragraph 29435.1009(a)(10); 435.1010
Cost AllocationNot specified in statute433.34; 45 CFR 95.501-95.519
Cost AvoidanceNot specified in statute433.139(a)(2); see also Third Party Liability
Cost SharingSee Assignment; Copayments; Deductibles; Spend-Down; WaiversSee also Assignment, Premiums, Spend-Down
In General1902(a)(14); 1916; 1916A447.50-447.57
Aggregate Limit1916A(2)(B); 1916A(b); 1916(c)(2)(C); 1916A(e)(2)(C)447.56(f)
Emergency Services1916(b)(2)(D)447.54 and 447.56(a)(2)(i)
Enforcement by Providers1916(e); 1916A(d)(2)447.15; 447.52(e)
Exempt Groups1916(a)447.56(a)(1); 447.53(d); 447.54(c)
Exempt Services1916(b)(2)447.56(a)(2)
Family Planning Services1916(b)(2)(D)447.56(a)(2)(ii)
FQHC Safe Harbor1128B(b)(3)(D)1001.952(k)(2)
Income-Related Protections
At or Below 100 Percent FPL1916A(a)(2)447.52(b); 447.53(b); 447.54(b)
101-150 Percent FPL1916A(b)(1)447.52(b); 447.53(b); 447.54(b)
Above 150 Percent FPL1916A(b)(2)447.52(b); 447.53(b); 447.54(b); 447.55(a)
Indian Health Programs Prohibition1916(j)447.51; 447.56(a)(1)(x)
Maximum Amounts
Aggregate Limit1916(a)(2)(B), (b)(1)(B)(ii), (c)(2)(C)447.56(f)
Cost Sharing1916(a)(3), b(3); 1916A(b)(1)(B), (2)(B), (c)(2)447.52(b); 447.53(b); 447.54(b)
Premiums1916(c), (d), (g), (i)447.55
Medicare1902(a)(10)(E); 1905(p)(3)431.625
MCOsNot specified in statute447.52(h); 447.56(d); 1001.952(l)
Non-Emergency Services in a Hospital Emergency Department1916A(e)447.54
Notice to BeneficiariesNot specified in statute447.57
Payments to ProvidersNot specified in statute447.56(c)
Pregnant Women1916(b)(2)(B); 1916A(b)(3)(B)(iii)447.56(a)(2)(iv)
Prescription Drugs1916A(c)447.53
Preventive Services for Children1916A(b)(3)(B)(ii)447.56(a)(2)(iii)
State Plan Amendment1916A(a)(1)447.57(c)
Targeted Cost SharingNot specified in statute447.52(d); 447.56(b)
Well-Baby and Well-Child Services1916A(b)(3)(B)(ii)447.56(a)(2)(iii)
County-Operated Health Insuring Organizations1932(a)(3)(C)438.2
Creditable Coverage1902(aa)(4); see Third Party LiabilityNot specified in regulation
Criminal Background ChecksNot specified in statute455.434
Criminal Penalties1128BNot specified in regulation
Cross References to Other Laws1939Not specified in regulation
Data Collection Requirements1902(a)(76)Not specified in regulation
Deductibles1902(a)(14); 1916447.51; see Cost Sharing
Deeming of Income or Resources
In General1902(a)(17)(B)435.602
Deferral of FFPNot specified in statute430.4
Demonstration Authorities1115; 1115A; 1938; 1139A(d), (e)Not specified in regulation
Dental Services1905(a)(10)440.1
Departmental Appeals Board (DAB)1116(e)(2)45 CFR Part 16
DESI (Drug Efficacy Study Implementation) Drugs1903(i)(5); 1927(k)(2)(A)(iii)Not specified in regulation
DisabledSee also Medically NeedySee also Medically Needy
Auxiliary Aids and ServicesNot specified in statute435.905(b)(2)
Blindness Determined1614(a)(2)435.530-435.531
Developmentally Disabled Individual1930(b)[2]Not specified in regulation
Disability Determined1614(a)(3)435.540; 435.541
Disabled Widows or Widowers1634(b)435.137; 435.138
Exemption from MAGI-Based Eligibility1902(e)(14)(D)435.603(j)(3)
Family Opportunity Act Option1902(a)(10)(A)(ii)(XIX); 1902(cc); 1916(i)447.55(a)(3); 447.56(a)(1)(vi)
Katie Beckett Option1902(e)(3)435.225
Medically Needy1902(a)(10)(C)435.324; 435.330
Model Home and Community-Based Services (HCBS) Waivers1915(c)(10)Not specified in regulation
Part B and Part H of Individuals with Disabilities Education Act1903(c)Not specified in regulation
Persons With Related ConditionsNot specified in statute435.101
Poverty-Related Aged and Disabled1902(a)(10)(A)(ii)(X); 1902(m); 1903(f)(4)435.23
Qualified Disabled and Working Individuals (QDWIs)1902(a)(10)(E)(ii); 1905(s); 1916(d)435.121(b)(2); 447.55(a)(4)
Qualified Medicare Beneficiaries (QMBs)1905(p); 1905(s)435.121(b)(2)
Qualified Severely Impaired Individuals1902(a)(10)(A)(i)(II); 1905(q); 1619435.12
Social Security Administration Eligibility Determinations1634(a)435.541(a), (b)
Special Income LevelNot specified in statute435.236; 435.622; 435.1005
State Eligibility Determinations1902(v)435.541(c)
State Supplement or State Supplementary Payment1902(a)(10)(A)(ii)(IV); 1616; 1618(g); 1905(j)435.4; 435.130; 435.232; 435.234; 435.403(f); 435.1006; 435.1011-1012
Supplemental Security Income (SSI) Recipients1902(a)(10)(A)(i)(II)435.120; 435.603(j)(1); 435.725
Working Disabled Individuals1902(a)(10)(A)(ii)(XIII); (XV); 1916(g)435.120(c); 435.121(b)(3)
Ticket to Work Act Medical Improvements Group (Working Individuals with Medically Improved Disability)1902(a)(1)(A)(ii)(XVI); 1905(v)(1); 1916(g)447.55(a)(2)
Disallowance of FFP1116(d); 1903(d)(2), (5)430.3(b); 430.42; 431.865; 433.38
Disaster-Recovery State1905(aa)Not specified in regulation
In General1124, 1126, 1902(a)(38), 1903(i)(2), 1903(n)455.100-455.106
Business Transactions1856(j)(5)455.105
Durable Medical Equipment (DME) Suppliers1902(a)(65)(A); 1902(kk)(3)Not specified in regulation
Hospital Financial Interest and Referral Patterns1146Not specified in regulation
MCO External Quality Reviews1932(c)(2)(A)(iv)Not specified in regulation
MCO Transactions with Parties in Interest1903(m)(4)Not specified in regulation
Nurse Aide Registry Information1919(e)(2)(B)483.156(d)
Nursing Facility Ownership Change1919(d)(1)(B)483.75(h)
Nursing Facility Survey Results1919(g)(5)(A)488.325
Nursing Home Compare Website1919(i)(1)Not specified in regulation
Ownership and Related Information1902(a)(35); 1902(a)(38); 1124; 1126455.104
Persons Convicted of Crimes1126455.106
Physician Transparency Reports1128G403.900-403.914
Providers and Suppliers1902(kk)(3); 1886(j)(4)455.104
QIO Information Relating to Fraud1106(b)(1)(A)480.137
Survey Results1902(a)(36)431.115
In General1109435.601(d); 435.1007(e), (f); 435.603(g)
Clinical Trial1902(e)(14)Not specified in regulation
Five Percentage Point Disregard1902(e)(14)(I)435.603(d)(4)
Less Restrictive Income and Resource Methodologies1902(r)(2)435.601(d)
Native American Property1902(ff)435.603(e)(3)
DME (Durable Medical Equipment)440.70(b)(3); 440.70(g)(1)
Disclosure1902(a)(65)(A); 1902(kk)(3)Not specified in regulation
Surety Bond1902(a)(65)(B)424.57(d)
Donations (Provider-Related)See Provider-Related DonationsSee Provider-Related Donations
Draw Down of FFPNot specified in statute430.30(d)(4)
Drug Rebates447.500-447.522
Additional Rebate1927(c)(2), (3)(C)447.509(a)(2)
Average Manufacturer Price (AMP)1927(k)(1)447.504
Average Sales Price (ASP)1927(b)(3)(A)(iii)(I), 1847A(c)Not specified in statute
Basic Rebate
Authorized Generic Drugs1927(c)(1)(C)(ii)(IV)447.506
Brand Name Drugs1927(c)(1); 1927(k)(7)(A)(ii), (iv)447.509
Generic Drugs1927(c)(3); 1927(k)(7)(A)(iii)447.506; 447.509
Best Price1927(c)(1)(C); 1927(b)(3)(A)(i)(II); 1860D-2(d)(C)447.505; 447.508
Covered Outpatient Drug1927(k)(2), (3)447.502
Managed Care1903(m)(2)(A)(xiii); 1927(j)(1)438.3(s); 438.8(e)(2)(ii)(B); 438.10(e)(2)(vi), (i); 447.500; 447.509
Manufacturer Agreements1903(i)(10), 1927(a)447.502
Manufacturer Reporting Requirements1927(b)(3)447.51
Nominal Price1927(c)(1)(D)447.502; 447.504(b), (c), (d), (e); 447.505(c)(15), (e), 447.508
State Requirements Related to Covered Outpatient Drugs1902(a)(54)447.511; 447.518-447.522
Drug Use Review (DUR)1927(g); 1903(a)(3)(D)456.700-456.725
DSH (Disproportionate Share) Hospitals
Additional Payment for Cook County Hospital, Illinois701(d) of Appendix F of P.L. 106-554Not specified in regulation
Annual Audit and Report1923(j)447.299; 455.300-455.304
California Hospital Specific Limit4721(e) of P.L. 105-33; 701(c)(2) of Appendix F of P.L. 106-554Not specified in regulation
Carve-Out from MCO Contracts1923(i)Not specified in regulation
Deemed DSH Eligibility Criteria1923(b)Not specified in regulation
Definition of UninsuredNot specified in statute447.295
DSH Allotment Reductions1923(f)(7)447.294
Hospital Specific DSH Limit1923(g)447.295
Identification of MCO Enrollees1932(g)Not specified in regulation
Limit on Payments to Mental Hospitals1923(h)Not specified in regulation
Low-DSH State1923(f)(5)Not specified in regulation
Minimum Eligibility Requirements1923(d)Not specified in regulation
State DSH Allotments1923(f)447.297-447.298
Dually Eligible Beneficiaries
Exemption from MCO Enrollment1932(a)(2)(B)438.50(d)(1)
Low-Income Subsidy (LIS) Beneficiaries1902(a)(66); 1935(a)(2); 1860D-14(a)(3)(v)423.34; 423.771-423.800; 423.900-423.910
MAGI Exemption1902(e)(14)(D), (F)435.603(j)(4)
Medicaid Assistance with Medicare Premiums and Cost Sharing1902(a)(10)(E); 1902(n); 1905(a) in the matter before (i); 1905(p)(3); 1935(a)(3)431.625; 447.55(a)(4)
Lesser of1902(n)(2)Not specified in regulation
Medicare Part D Coverage1935(c); 1860D-14(a)(3)(v)423.772; 423.902
Partial BenefitSee QMB, SLMB, and QISee QMB, SLMB, and QI
Poverty-Level Aged and Disabled1902(a)(10)(A)(ii)(X); 1902(m)435.23
Waiver Duration1915(h)(2)Not specified in regulation
Due Process for Beneficiaries
Aid Paid PendingNot specified in statute431.230; 438.420
Best Interests1902(a)(19)435.902; 431.808; 431.10(c)(5)
Fair Hearing1902(a)(3); 1924(e)(2)431.200-431.250
Right to Apply1902(a)(8)435.905-435.908
Due Process for Managed Care Plans1932(e)(4)(B), (5)438.710; 438.730
Due Process for Providers
Civil Money Penalties and Exclusions1128(a)1005.1-1005.23
ICFs/IDNot specified in statute431.151-431.154; 442.40
Nursing FacilitiesNot specified in statute431.151-431.153; 488.546(d); 489.53
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
In General1902(a)(43); 1905(r); 1905(a)(4)(B)441.50-441.62
Benchmark Benefits1937(a)(1)(A)(ii)440.345
Benefit1905(a)(4)(B); 1905(r)440.40(b)
Continuing Care ProviderNot specified in statute441.6
Mental Health Parity Compliance1937(b)(6)(B)Not specified in regulation
Reporting1902(a)(43)(D)Not specified in regulation
Screening Services1902(a)(43)(B); 1905(r)(1)441.56(b); 441.58; 441.59
Third Party Liability (TPL)1902(a)(25)(E)433.139(b)(3)(i)
TransportationNot specified in statute441.62
Treatment Services1902(a)(43)(C); 1905(r)(5)441.56(c)
E-FMAP (Enhanced Federal Medical Assistance Percentage)2105(b)433.10(c)(4); 433.11; 457.622(b)
Electronic Health Records (EHRs)
In General1903(a)(3)(F); 1903(t)495.2-495.5; 495.20; 495.22; 495.24; 495.40; 495.300-495.370
Matching Rates1903(a)(3)(F)495.320-495.322
Meaningful UseNot specified in statute495.4; 495.316(b)(2)
Medicaid Eligible ProfessionalNot specified in statute495.40; 495.60
Medicaid Information Technology Architecture (MITA)Not specified in statute495.302; 495.332(a)(2)
Payments for Adoption and Use1903(t)495.310-495.316
Reporting RequirementsNot specified in statute495.20; 495.316
Electronic Signature1902(dd); 1943(b)(1)(A)Not specified in regulation
Eligibility DeterminationSee also Income, ResourcesSee also Fair Hearing, Income, Resources
In General1902(a)(4), (a)(8), (a)(10)(A), (a)(19), (e)(14); 1943435.911
Agreement with Federal or State and Local EntitiesNot specified in statute431.10(d)
Alignment with Exchange Initial Open EnrollmentNot specified in statute435.1205
ApplicationsNot specified in statute435.905-435.910
Asset Verification Program1902(a)(71); 1940Not specified in regulation
Authorized RepresentativeNot specified in statute435.923
Beneficiary Choice of CategoryNot specified in statute435.404
Citizenship Documentation1137; 1902(a)(46); 1902(ee); 1903(x); 1903(a)(3)(H)435.406
Continuous EligibilitySee Continuous EligibilitySee Continuous Eligibility
Coordination with Other Insurance Affordability ProgramsNot specified in statute435.12
Data Exchange Authorization1942; 1943(b)(1)(D)Not specified in regulation
Disability DeterminationNot specified in statute435.541
Electronic NoticeNot specified in statute435.918
Electronic Signature1902(dd); 1943(b)(1)(A)Not specified in regulation
Eligibility Determination System Enhanced Matching Rate1903(a)(3)(A)(i)433.112(b)(14), (16); 433.112(c)
Enrollment Website1943(b)(1)(A), (B); 1943(b)(4)435.907(a)(1); 435.1200(f)
Express Lane Eligibility (Express Lane Option)1902(e)(13)435.603(j)(1)
1931 Applicants1902(a)(63)435.11
MAGI-Based1902(e)(14)431.10(c)(3); 435.603
Medicaid Agency Authority1905(a)(5)431.10(b)(3), (c)(1)(i), and (d)
Medicaid Eligibility Quality Control (MEQC)1903(u)(1)(A)431.800-431.865
Merit System PersonnelNot specified in statute431.10(c)(2)
NoticeNot specified in statute435.912; 435.918
Outstation Locations for Application1902(a)(55)435.904
Presumptive Eligibility1902(a)(47); See also Presumptive EligibilitySee Presumptive Eligibility
Prohibition Against Requiring Application for TANF1902(c)Not specified in regulation
Redetermination1915(i)(1)(I)435.908; 435.916; 435.1003; see also Renewal
Reinstatement of Withdrawn ApplicationNot specified in statute435.907(h)
Screen and Enroll (CHIP)2102(b)(3)457.350-457.353
Single Application1943(b)(3); 1413(b) of the Patient Protection and Affordable Care Act (P.L. 111-148)435.907(b); 435.909
Single State Agency1902(a)(4)431.10(b)(3), (c)(1)(i), and (d)
1634 States1634435.541
State or Local Agency1902(a)(5)431.10(c)
Streamlined Enrollment1943(b)(3); 1413 of the Patient Protection and Affordable Care Act (P.L. 111-148)435.909
Social Security NumberNot specified in statute435.910; 435.920; 435.907(e)(3)
Verification1137; 1902(a)(4), 1902(a)(19), 1902(a)(46)(B), 1902(ee); 1903(r)(3), 1903(x); 1943(b)(3); section 1413 of the Patient Protection and Affordable Care Act435.940-435.965
Eligibility Requirements
In General1902(a); 1905; 1931435.400-435.403
CategoricalNot specified in statute435.500-435.541
FinancialNot specified in statute435.600-435.640
Emergency Services
Beneficiary RightNot specified in statute435.930(c)
Emergency Hospital Services1932(b)(2)440.170(e)
Emergency Medical Condition Defined1932(b)(2)(C)438.114(a); 440.255(c)
Exclusion from Cost Sharing1916(a)(2)(D), (b)(2)(D); 1916A(b)(3)(B)(vi)447.56(a)(2)(i)
Exemption from Freedom of Choice Waivers1915(b)(1), (4)430.25(c)(1)(iv); 431.55(f)(2)(iii)
MCO Obligation to Make Payment (Prudent Layperson)1932(b)(2)438.114(b)
Non-Emergency Use of Hospital Emergency Department1916(a)(3), (b)(3); 1916A(e)447.54
Prohibition Against Patient Dumping (Emergency Medical Treatment and Labor Act or EMTALA)1867; 1916A(e)(1)(B), (e)(3)(A)489.24
Unauthorized Immigrant and Qualified Alien Eligibility1903(v); last sentence of 1902(a); 401(b)(1)(A) and 403(c)(2)(A) of P.L. 104-193435.139; 435.350; 435.406(a)(2)(ii); 440.210(c); 440.250(m)-(n); 440.255(c)
Encounter Data (Requirements)1903(m)(2)(A)(xi); 1903(i)(25)438.358(c)(1); 438.242; 438.604(a)
End Stage Renal Disease FacilityNot specified in statute441.4
Certified Application AssistersNot specified in statute435.908(c)
Enrollment Broker1932(a)(4)(A), (d)(3); 1902(b)(4)438.81
Enrollment Performance Bonus Payments2105(a)(3)Not specified in regulation
Enrollment Simplification1943(b)Not specified in regulation
To Individuals1902(a)(3); 1902(a)(8); 1902(a)(10); 1904; 1905(a); 1933(e)435.930; 435.1002(a); 435.902; 435.906; 435.909; 431.200-431.250
To States1903(a); 1904435.1002(a); 430.30(a); 430.38; 430.42; 430.60-430.104
Equal Access Payment Requirement1902(a)(30)(A)447.204
Erectile Dysfunction Drugs1903(i)(21); 1927(d)(2)(K)Not specified in regulation
Error Rates1903(u); 1902(e)(13)(E); 1902(ee)(3)See Medicaid Eligibility Quality Control (MEQC), Payment Error Rate Measurement (PERM)
Essential Health Benefits1937(b)(5); 1302 of the Patient Protection and Affordable Care Act (P.L. 111-148)440.347
Estate Recovery (see also Liens)1902(a)(18); 1917(b)433.36(h)(1), (2); 433.310(b)(2)
ExclusionSee also TerminationSee also Termination
In General1128; 1128A(a)(1)(D); 1902(a)(39); 1902(p)(1); 1903(i)(2); 1919(h)(5)1001.1-1001.3005; 1003.114-1003.135; 1005.1-1005.23
Enrollment Broker1903(b)(4)(B)438.81
Managed Care1902(p)(2)438.808
State Option1902(p)(1)1002.1-1002.215
Expansion State
DefinedNot specified in statute433.204(b)
Expansion State FMAP1905(z)(2)433.10(c)(8)
Express Lane Eligibility (Express Lane Option)1902(e)(13); 1902(e)(14)(D)(ii); 1902(dd); 1942(a)435.603(j)(1)
External Quality Review Organization (EQRO)1903(a)(3)(C)(ii); 1932(c)(2)438.310-438.370
Factoring Prohibition1902(a)(32)447.1
Fair Hearing1902(a)(3); 1924(e)431.200-431.250
False Claims Act (Certifications)1902(a)(68)455.18-455.19
Family Opportunity Act Option1902(a)(10)(A)(ii)(XIX); 1902(cc)Not specified in regulation
Cost-Sharing Prohibition1916A(b)(3)(B)(ix)447.56(a)(1)(vi)
Eligibility1902(a)(10)(A)(ii)(XIX); 1902(cc)Not specified in regulation
Premiums1916(i); 1916A(b)(3)(A)(vi)447.55(a)(3)
Family Planning Services and Supplies
Defined1905(a)(4)(C);440.40(c) [reserved]
Administration FFP1903(a)(5)432.50(b)(5); 433.15(b)(2)
Benchmark Benefit/Alternative Benefit Plans1937(b)(7)440.345(b)(6)
Comparability1902(a)(10) in subdivision (I) in the matter after (G)440.250(c)
Cost-Sharing Prohibition1916(a)(2)(D), (b)(2)(D); 1916A(b)(3)(B)(vii)447.56(a)2)(ii)
Enhanced FMAP1903(a)(5)433.10(c)(1)
Freedom of Choice1902(a)(23); last sentence of 1915(b)431.51(a)(3), (4)
Freedom from CoercionNot specified in statute441.2
Mandatory Coverage1902(a)(10)(A) in matter before (i)440.21
Presumptive Eligibility1902(a)(47)(A); 1920C435.1103(c)
State Plan Option1902(a)(10)(A)(ii)(XXI); 1902(a)(10) in subdivision (XVI) in the matter after (G); 1902(ii); 1905(a)(xvi)435.214
Federally Qualified Health CenterSee FQHCSee FQHC
FFP (Federal Financial Participation)
In General1903(a)400.203; 430.30-430.48; 435.1000-435.1011
Administrative Costs1903(a)(2-7); 1931(h)(2)432.50; 433.15
Continuation for Institutional Services1915(i)(5)441.11
Cost SharingNot specified in statute447.56(e)
Credible Allegations of Fraud1903(i)(2)(C)447.90; 455.2
Deferral ofNot specified in statute430.4
Disallowance of1116(d); 1903(d)(5)430.42
EHR Incentive Payments1903(t)(9)495.320-495.322; 495.326; 495.362
Eligibility DeterminationSee Administrative Costs435.1001
Eligibility Determination System1903(a)(3)(A)(i)433.112(c); 433.116(j)
Enrollment BrokerNot specified in statute438.81
EQRO1903(a)(3)(C)(ii); 1932(c)(2)433.15(b)(10); 438.370
EquipmentNot specified in statute433.35
ESRD FacilitiesNot specified in statute441.4
Estimation of1903(d)(1)430.30(b)
Failure to DiscloseNot specified in statute455.104(e); 455.105(c)
Fair HearingNot specified in statute431.25
Family Planning Services Administration1903(a)(5)432.50(b)(5); 433.15(b)(2)
HCBS Waiver Services1915(c)(6); 1915(k)(2)441.310; 441.360
ICF/IID Services1905(a)(15)441.13(b); 442.40; 442.42
IMD (Institutions for Mental Disease) Services1905(a)(14), (16), (29)(B)441.13(a)(2)
Income Limitation (133 Percent of AFDC Payment Amount)1903(f)435.1007
Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments1923(j)(2)455.304
Inmates in Public Institutions1905(a)(29)(A)435.1010; 441.13(a)(1)
Inpatient Hospital Tests1903(i)(6)441.12
Institutional ReimbursementNot specified in statute447.257
Intergovernmental Transfer (IGT)1903(w)(6)433.51(b)
Licensure of Nursing Facility Administrators1902(a)(29); 1908431.700-431.715; 431.715
Limitations on1137; 1902(a)(46)(B); 1903(f)(4); 1905(a)(29)(A);435.1005-435.1010
Local Share1902(a)(2)433.51
Medicaid Fraud Control Units (MFCUs)1903(a)(6); 1903(b)(3)1007.19
Medicare Part B Premiums1935(b)431.625(d)
MMIS (Medicaid Management Information System)1903(a)(3)432.50(b)(2), (3); 432.50(d); 433.15(b)(3), (4); 433.116; 433.117(c)
Nurse Aide Training and Competency Evaluation1903(a)(2)(B)433.15(b)(8); 483.158
Organ Procurement Organization1138(b)441.13(c); 486.360
Organ Transplants1903(i)(1)441.35
Overcoming Eligibility ConditionsNot specified in statute435.1004
PASARR (Pre-Admission Screening and Annual Resident Review)1903(a)(2)(C)433.15(b)(9); 483.122-483.124; 483.138
Physician-Administered Drugs1927(a)(7)447.52
Prescription Drugs1903(i)(5)441.25
Presumptive Eligibility1920A(D)435.1001(a)(2); 435.1002(c)(1)
Presumptive Eligibility for Children1920A(D)447.88
Prohibition on Matching Certain Expenditures1903(i)Not specified in regulation
Provider-Related Donation1903(w)(1)(A)(i), (2)433.54; 433.66-433.67
Provider Taxes1903(w); 1903(b)(5)433.68-433.72
RedeterminationsNot specified in statute435.1003
Skilled Medical Personnel1903(a)(2)(A)432.50(b)(1), (d); 433.15(b)(5)
Staffing and Training1903(a)(2)432.5
State Share1902(a)(2)433.51; 433.53(b), (c)
SterilizationNot specified in statute441.253-441.256
Upper Payment Limits1903(i)(3)447.257; 447.304(c); 447.271
Utilization Review Penalty1903(g)456.650-456.657
Utilization Review Plans1903(i)(4)456.501
Withholding for Noncompliance1904430.35; 430.38
Financial Participation, State1902(a)(2)433.1
Financial Responsibility of Relatives and Other Individuals1902(a)(17)(D)435.602
Fiscal Agent ContractsNot specified in statute434.1-434.14
Five-Year Bar1903(v)(4); 2107(e)(1)(J)435.406(b); 440.250(m)
FMAP (Federal Medical Assistance Percentage)
In General1905(b); 1101(a)(8)(B)400.203; 433.10(b)
E-FMAP (CHIP Program)2105(b); fourth sentence of 1905(b)433.10(c)(4); 433.11; 457.622(b)
Expansion State FMAP1905(z); 1905(cc)433.10(c)(8)
Local Share1902(a)(2); 1905(cc)Not specified in regulation
Newly Eligible FMAP1905(y)433.10(c)(6)
Other Enhanced FMAPs
Community First Choice Option1915(k)(2)441.59
Disaster-Recovery FMAP Adjustment State1905(aa)Not specified in regulation
District of Columbia1905(b) in the matter at (3)Not specified in regulation
Family Planning Services1903(a)(5)433.10(c)(1)
Health Home1945(c)(1)Not specified in regulation
Indian Health ServiceThird sentence of 1905(b)433.10(c)(2)
Matching RatesSee Matching RatesSee Matching Rates
Preventive Services1905(b) in the matter at (5)Not specified in regulation
Primary Care Services1905(dd)447.415
Qualified Individuals (QIs)1933(d)433.10(c)(5)
State Share1902(a)(2)433.51
Temporary IncreaseSection 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5); 1905(cc)Not specified in regulation
Territories1905(b) in the matter at (2)433.10(b)
Threshold MethodologyNot specified in statute433.206
Updating Regular Matching Rates1101(a)(8)(B)Not specified in regulation
Formularies1927(d)(4)Not specified in regulation
FPL (Federal Poverty Level)See Federal Poverty LevelSee Federal Poverty Level
FQHCs (Federally Qualified Health Centers)
Alternative Payment Methodology1902(bb)(6)Not specified in regulation
Benchmark Benefits1937(b)(4)440.365
Best Price Exclusion1927(c)(1)(C)(i)447.505(d)(1)
Coverage of Services1905(a)(2)(c)405.2462(c); 405.2467
Dental Providers1902(a)(72); 42 U.S.C. 1396a(a)(72)Not specified in regulation
Drug Price Discount1927(a)(5)Not specified in regulation
FQHCs Defined1905(l)(2)(B)405.2401(b)
Medicaid Eligible Professional (EP)495.304(b)(5), (c)(3)
Outstationing Eligibility1902(a)(55)(A)435.904(d)(3)
Outstation Location1902(a)(55)(A)435.904(c)(1)(i)
Payment by MCO1903(m)(2)(A)(ix); 1902(bb)(5)1001.952(t)(4)(iii); 447.46
Presumptive Eligibility Providers1920(b)(2)(D)(i); 1920A(b)(3)(A)435.1101; 435.1103(c)(2)
Prospective Payment1902(a)(15); 1902(bb); 42 U.S.C. 1396a(a)447.371(c); 405.2462(c); 405.2467
Safe Harbor from Anti-Kickback Prohibition1128B(b)(3)(D)1001.952(k)(2); 1001.952(w)
Services Defined1905(l)(2)(A); 42 U.S.C. 1396a(a)(10)(A); 42 U.S.C. 1396d(a)(2)(C); 42 U.S.C. 1396d(l)(2)447.371(c); 405.2446(b)
Waiver Protection1915(b)Not specified in regulation
Fraud and AbuseSee also Civil Money Penalties; Criminal Penalties; Disclosure; Exclusion; Program IntegritySee also Civil Money Penalties; Criminal Penalties; Disclosure; Exclusion; Program Integrity
Beneficiary Fraud1128J(c)455.15(b), (c)
Beneficiary Reports of Fraud1902(a)(64)Not specified in regulation
Compliance Programs for Providers and Suppliers1902(kk)(5); 1866(j)(7)455.400-455.470
Cost Avoidance1902(a)(25)(A)-(D)433.139(a)(2)
Credible Allegations of Fraud1903(i)(2)(C)455.2, 455.450(e)(1)
False Claims Act Employee Information1902(a)(68)Not specified in regulation
Health Care Fraud and Abuse Control Program (HCFAC)1128C; 1817(k)Not specified in regulation
Health Care Fraud and Abuse Data Collection Program1128ENot specified in regulation
Lock-Out of Providers1915(a)(2)431.54(f)
Managed Care Entities1932(d); 1128A(a)(9)438.600-438.610
Medicaid Fraud Control Unit (MFCU)1902(a)(61); 1903(a)(6); 1903(b)(3); 1903(q)455.15(a); 455.211; 455.23(d)
Medicaid Management Information System (MMIS)1903(r)(2)(B)433.116(h)
Moratorium on Enrollment of New Providers or Suppliers1902(kk)(4)455.47
Overpayments1903(d)433.304; 433.312; 433.316(d); 495.368
Pay and Chase1902(a)(25)(E), (F)433.139(a)(2)
QIO Information Disclosure1160480.133; 480.137
Safe Harbors from Anti-Kickback Prohibition1128B(b)(3)1001.952
State False Claims Act1909495.368(d)
Freedom of Choice
In General1902(a)(23)(A)431.51
Emergency Services1915(b)(1), (4)430.25(c)(1)(iv); 431.55(f)(2)(iii)
Family Planning Services1902(a)(23)(B)430.25(c)(1)(iv); 431.51(b)(2)
Felony Conviction1902(a)(23), second exceptionNot specified in regulation
Mandatory MCO Enrollment1932(a)(1), (2)438.52; 431.55(f); 440.250(j)
Non-Emergency Medical Transportation Brokerage Program1902(a)(70)440.170(a)(4)
Optometrist/Ophthalmologist1905(e)Not specified in regulation
PACE1934(g)(3)460.90; 460.154
Targeted Case Management Services1915(g)(1)431.51(c)(4); 440.169
Temporary Moratoria1902(a)(23); 1902(kk)(4)455.47
Territories1902(a)(23) in the matter after (B)431.51(b)
Waiver1115; 1915(b)430.25; 431.54-431.55
Freestanding Birth Center Services1902(a)(10)(A) before (i); 1905(a)(28); 1905(l)(3)Not specified in regulation
FUL (Federal Upper Limit) Drugs1927(e)(4)447.332
Governor's ReviewNot specified in statute430.12(b)
Grants to StatesSee FFP (Federal Financial Participation)See FFP (Federal Financial Participation)
Group Health Plans
Continuation of Eligibility1902(e)(11)Not specified in regulation
Enrollment Under1906433.136
Payment of Premiums1902(a)(10) in subdivision (XI) in the matter after (G)Not specified in regulation
Third Party Liability1902(a)(25)(G); 1906(c)(2)433.139; 447.20-447.21
HCFAC (Health Care Fraud and Abuse Control) Program1128C; 1817(k)Not specified in regulation
Health and Vocational Rehabilitation Agencies, Cooperative Arrangements1902(a)(11), (22)(C)431.615
Health Care-Acquired ConditionsSection 2702 of the Patient Protection and Affordable Care Act (P.L. 111-148)447.26(b)
Health Disparities Data1902(a)(76); 1946; section 3101 of the Public Health Service ActNot specified in regulation
Health Home Option1945Not specified in regulation
Health Information Technology PlanNot specified in statute495.332
HIFA (Health Insurance Flexibility and Accountability) WaiversSee 1115 WaiverSee 1115 Waiver
High-DSH State1923(g)(2)447.298(a)(3)
HIPAA (Health Insurance Portability and Accountability Act of 1996)
Administrative Simplification1171(5)(E); 1172(a); 1903(r)(1)(D)45 CFR 160.103
General Administrative RequirementsSections 261-262 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191)45 CFR 160.101-160.552
Health Care Fraud and Abuse Control Program (HCFAC)1128C; 1817(k)Not specified in regulation
Security and Privacy1173(d); 1177; 1180; 264 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191)45 CFR 164.102-164.534
Unique Identifiers and Transactions1171-1180; section 262 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191)45 CFR 162.100-162.1902
Health Information Standards1171(5)(E); 1172(a)(1); 1903(r)(1)(D)45 CFR 164.302-318
Health Opportunity Accounts1938; section 613 of the Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3)Not specified in regulation
HMOs (waiver)Not specified in statute434.2
Home and Community-Based Attendant Services and Supports State Plan Option1915(k)441.500-590
Home and Community-Based (HCBS) Services
Assessment by State1943(b)(5)441.715(d); 441.720
Benefit Defined1915(c)(4)(B)440.180; 440.181; 440.250(k)
Community Supported Living Arrangements (CSLA) Services for Developmentally Disabled1930[2]441.400-441.404
HCBS State Plan Option1915(i); 1902(a)(10)(ii)(XXII); 1903(f)(4); 1905(a)(xvii)441.700-441.745
HCBS or 2176 Waiver1915(c)430.25
HCBS Waiver Eligibility1902(a)(10)(A)(ii)(VI)435.217
HCBS Waiver for Individuals 65 and Over Requirements1915(d)441.350-441.365
HCBS Waiver Requirements1915(c)441.300-441.310
HIV/AIDS Boarder Babies Waiver1915(e)435.219(b)
Home and Community Care for Functionally Disabled Elderly Individuals1929[2]Not specified in regulation
ICF/MR[1] Reduction Plan1922(b)(2), (c)(2), (c)(3)Not specified in regulation
MAGI-Based Eligibility Exemption1902(e)(14)(A)(D)435.603(j)(4)
Money Follows the Person (MFP) Rebalancing Demonstration2403 of the Patient Protection and Affordable Care Act (P.L. 111-148); 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171)Not specified in regulation
PACE1934(a)(2)(B)460.92(b); 460.106
PAS (Self-Directed Personal Assistance Services) Option1915(j)441.450-441.484
Payment1902(h)Not specified in regulation
Post-Eligibility Treatment of Income1902(r)(1)(A)435.726; 435.735; 460.184
Home Health Services1902(a)(10)(D); 1903(i)(18); last sentence of 1903(i)440.70; 441.15
Eligibility Cards1902(a)(48)Not specified in regulation
Health Care for Homeless Clinics as FQHCs1905(l)(2)(B)(i)Not specified in regulation
Residency Requirement1902(b)(2)435.403(h)(1)(i), (i)(2)(i)
Hospice Care
Advance Directive1902(a)(57); 1902(w)(2)(D)Not specified in regulation
Cost-Sharing Prohibition1916(a)(2)(E), (b)(2)(E); 1916A(b)(3)(B)(iv)447.56(a)(ix)
Covered Service (Optional)1905(a)(18)Not specified in regulation
Optional Coverage1902(a)(10)(A)(ii)(VII); 1902(a)(10) in subdivision (VI) in the matter after (G)Not specified in regulation
Payment1902(a)(13)(B)Not specified in regulation
Premium Prohibition1916A(b)(3)(A)(iii)447.56(a)(ix)
Advance Directive1902(a)(57); 1902(w)(2)(A)489.100-489.104
Conditions of Participation1905(a)482.1-482.104
Cost Sharing for Non-Emergency Services in Emergency Department1916A(e)447.54
Disclosure1902(a)(35); 1902(a)(38)455.101(a)
Disproportionate ShareSee DSH (Disproportionate Share) HospitalsSee DSH (Disproportionate Share) Hospitals
Emergency Hospital Services1932(b)(2)440.170(e)
Hospital Closure or Conversion Transitional Payments1903(e)Not specified in regulation
Inpatient Services1905(a)(1)440.10; 447.272
Inpatient Tests1903(i)(6)441.12
Mental Hospital1902(y)456.600-456.614
Organ Procurement1138486.301-486.360
Outpatient Services1905(a)(2)(A)440.20(a); 447.321
Physician Certification of Need1902(a)(44)456.6
Presumptive Eligibility1902(a)(47)(B)435.111
Psychiatric Hospital1902(y); see also IMD456.600-456.614
Restraints or SeclusionNot specified in statute482.13(e)
Swing-Bed Hospitals1913447.28
Upper Payment Limits1902(a)(30)(A447.271-447.272
Utilization Review1903(g)(1)456.50-456.145
ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities) ServicesFormerly ICF/MR (Intermediate Care Facility for the Mentally Retarded)[1]Formerly ICF/MR (Intermediate Care Facility for the Mentally Retarded)[1]
AppealsNot specified in statute431.151-431.154; 498.1-498.95
Benefit Defined1905(d)440.15
Changes in Ownership1919(d)(1)(B)447.253(d)
Conditions of Participation1905 (c) and (d)483.400-483.480
Correction/Reduction Plans1922Not specified in regulation
Covered Service (Optional)1905(a)(15)440.15
Educational Services1903(c)Not specified in regulation
FFP During AppealsNot specified in statute442.40; 442.42
FFP LimitationNot specified in statute441.13(b)
Inspection of Care and Independent Professional Review1902(a)(31); 1903(g)(1)456.600-456.614
Level of Services for PASARR1919(e)(7)(B)(ii)483.132; 483.136
Medical Review1903(g)(1)456.37
Physician Certification of Need1902(a)(44); 1903(g)(6)(B)456.36
Provider Agreement1902(a)(27)442.10-442.42
Sanctions for Noncompliance1902(i); 1910(b)442.117-442.119
Upper Payment Limits1902(a)(30(A)447.271-447.272
Utilization Review1902(a)(33)456.350-456.438
IDEA (Individuals with Disabilities Education Act)1903(c)Not specified in regulation
IEVS (Income and Eligibility Verification System)1137; 1902(a)(46)(A); 1902(dd); 1903(a)(4); 1942(a)435.940-435.965
IGT (Intergovernmental Transfer)See Intergovernmental TransferSee Intergovernmental Transfer
IHS (Indian Health Service)See Indian Health ServiceSee Indian Health Service
IMD (Institution for Mental Diseases)
Alternatives to Care in Public IMDs1902(a)(21)441.106
Covered Service (Optional)
Services for Individuals Ages 65 and Older1905(a)(14)441.100-441.106
Services for Individuals Under Age 211905(a)(16); 1905(h)441.150-441.184
Exclusion for Individuals Under 651905(a) in subdivision (B) after paragraph 29435.1009(a)(2)
Inspections of Care1903(g)(4)(B)456.600-456.614
Level of Services for PASSAR1919(e)(7)(B)(i)483.132; 483.134
Medical Review1902(a)(26); 1903(g)(1)456.17
Plan of Care1902(a)(20)(B), (C); 1902(a)(26)456.180; 456.48; 456.482
Utilization Review1902(a)(26); 1902(a)(30); 1903(g)(1); 1903(i)(4)456.150-456.245
ImmigrantsSee Non-CitizensSee Non-Citizens
Benchmark Benefits1937(b)(2)(A)(vi), (b)(5)440.335(b)(4)
Coordination with Title V Programs1902(a)(11)(B)(iii)Not specified in regulation
Coordination with WIC Programs1902(a)(11)(C)431.635
Payment for Administration1902(a)(13)(C), 1902(jj)(2)441.615
Vaccines for Children (VFC)1928441.600-441.615
Improper PaymentsSee Fraud and Abuse; PERM; Program IntegritySee Fraud and Abuse; PERM; Program Integrity
Income CountingSee also Children, Disabled, Elderly, Infants, Pregnant Women, QMBs, MAGI, disregardsSee also Children, Disabled, Elderly, Infants, Pregnant Women, QMBs, MAGI, disregards
Community Spouse1924(d)435.725(c)(2)
Cost Sharing1916A(b)(4)Not specified in regulation
Disregards1902(r)(2); 1902(e)(14)(3)435.601; 435.603(g)
Eligibility StandardsSee Children, Disabled, Elderly, Infants, Medically Needy, Pregnant Women, QMBsSee Children, Disabled, Elderly, Infants, Medically Needy, Pregnant Women, QMBs
Incurred Medical Expenses1902(f)436.831
Methodologies1902(e)(14); 1902(a)(17)435.601; 435.603
Modified Adjusted Gross Income (MAGI)1902(e)(14)See MAGI, MAGI-equivalent Income Standard
Post-Eligibility Treatment of Income1902(r)(1)435.700-435.735; 435.800-435.832; 460.184
Reasonable Standards1902(a)(17)435.952(c)
Treatment of Trusts1917(d)(3)Not specified in regulation
Verification1902(a)(46); 1137435.940-435.965
Indian Health Service (IHS)
In General1911Not specified in regulation
Consultation Requirement1902(a)(73)Not specified in regulation
Cooperation with States1139(b)Not specified in regulation
Cost-Sharing Prohibition1916(j)447.56(a)(1)(x)
Enhanced FMAPThird sentence of 1905(b); 1911433.10(c)(2)
Express Lane Agencies1902(e)(13)(F)(ii)(IV)Not specified in regulation
FQHCs1905(l)(2)(B) in the matter after (iv)438.14(c)
IHS Facilities as ProvidersNot specified in statute431.110(b)
Indian Health Care Provider DefinedSection 4 of the Indian Health Care Improvement Act (P.L. 94-437)447.51
Indian Managed Care Entity1932(h)(4)(B)438.14
Licensure of IHS FacilitiesNot specified in statute431.11
Medicaid Payment Accepted in FullNot specified in statute489.29
Outstation LocationNot specified in statute435.904(c)(3)
Payment by Medicaid MCOs1932(h)(2)438.14(c)
IndiansSee also Indian Health ServiceSee also Indian Health Service
DefinedSection 4 of the Indian Health Care Improvement Act (P.L. 94-437)447.51
Contract Health ServicesNot specified in statute489.29
Cost-Sharing Prohibition1916A(b)(3)(B)(x)447.56(a)(1)(x)
Enrollment in Medicaid MCO1932(a)(2)(C)438.50(d)(2)
Estate Recovery Exemptions1917(b)(3)(B)Not specified in regulation
Income Exclusions from MAGI1902(e)(14)(D)435.603(e)(3)
Outreach and Enrollment1139(a)Not specified in regulation
Premium Prohibition1916A(b)(3)(A)(vii)447.56(a)(1)(x)
Primary Care Provider in MCO1932(h)(1)438.14(b)(3)
Continuous of Eligibility for Inpatient Services1902(e)(7)435.172
Deemed Eligibility for Newborns1902(e)(4)435.117
Exemption from Day Limits, Outlier Hospital Payments1902(a)(10) in subdivision (X) after (G); 1902(a)(56); 1902(s)Not specified in regulation
Medicaid-Only Application1902(a)(55)(B)Not specified in regulation
Medically Needy Eligibility1902(a)(10)(C)(ii)(I), (iii)435.301(b)(1)(ii)
No Requirement for Application or Receipt of Cash Assistance Application1902(c); 1902(e)(10)Not specified in regulation
Outstationed Eligibility Workers1902(a)(55)435.904(b)(1)
Poverty-Related Eligibility
Mandatory1902(a)(10)(A)(i)(IV); 1902(l)(1)(B)435.118
Optional1902(a)(10)(A)(ii)(IX); 1902(l)(2)435.118(c)(2)
Premiums and Cost Sharing1916(a)(2)(A); 1916(b)(2(A); 1916A(b)(3)(A)(i); 1916A(b)(3)(B)(i)447.56(a)(1)(ii)
Information, DisclosureNot specified in statute431.301
Information on Applicants and Beneficiaries1902(a)(7)431.300-431.307
Inmates of Public Institutions1905(a) in subdivision (A) after paragraph (29)435.1009(a)(1); 435.1010; 441.13(a)(1)
Innovation Waiver1115ANot specified in regulation
Inpatient Psychiatric Services for Individuals Under Age 21
Admission and Plan of CareNot specified in statute456.480-456.482
Benefit Defined1905(h)440.160; 440.250(e)
Inspections of CareNot specified in statute456.600-456.614
Maintenance of EffortNot specified in statute441.180-441.182
RequirementsNot specified in statute441.150-441.182
Restraints or SeclusionNot specified in statute483.350-483.376
Inspections of CareNot specified in statute456.600-456.614
Insurance Affordability ProgramNot specified in statute435.4; 435.1200; 435.1205
Intellectual DisabilityNot specified in statute400.203
Intergovernmental Transfer (IGT)1903(w)(6)433.51(b)
Judicial Review
Civil Money Penalties and Exclusions1128(a)1005.21(k)
State Plan Material or ComplianceNot specified in statute430.38
Katie Beckett Option1902(e)(3)435.225
Data Collection and Reporting1902(a)(76); 1946; 3101 of the Public Health Service ActNot specified in regulation
Legal ImmigrantsSee Non-CitizensSee Non-Citizens
Less Restrictive Methodologies1902(r)(2); 1931(2)(C)435.601(d); 435.1007(f)
Lesser of Policy for Medicaid Payment of Medicare Cost Sharing1902(n)(2)Not specified in regulation
Licensure1902(a)(9)(A), (B)Not specified in regulation
Liens1902(a)(18); 1917(a), (b)433.36
Living WillSee Advance DirectiveSee Advance Directive
Local Share1902(a)(2); 5001 of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5); 1905(cc)Not specified in regulation
Locality as Central BrokerNot specified in statute431.55(d)
One-Year MCO Enrollment1903(m)(2)(A)(vi); 1932(a)(4)(A)(I)(ii)438.56(c)(2)(ii)
Overutilizers in Fee for Service1915(a)(2)431.54(e)
Lock-Out of Providers1915(a)(2)431.54(f); see also Exclusion
Long-Term Care Insurance1917(b)(1)(C); 1917(b)(5)Not specified in regulation
Look-Behind (Validation) Surveys
In General1902(a)(33)(B)488.9
ICFs/MR[1]1903(g)(2); 1910(b)Not specified in regulation
IMDs (Institutions for Mental Diseases)1903(g)(2)Not specified in regulation
Long-Stay Inpatient ServicesNot specified in statute456.655
Nursing Facilities1919(g)(3)488.33
Low-DSH State1923(f)(5)447.298(a)(3)(ii)
Low-Income Subsidy (LIS) Program
In General1860D-14423.34; 423.771-423.800; 423.900-423.910
Application Assistance by the Social Security Administration (SSA)1144(c)Not specified in regulation
Default EnrollmentNot specified in statute423.34
Eligibility Determinations1902(a)(66); 1935(a)(2)423.774; 432.904
Outreach by SSA1144(a)Not specified in regulation
Screening for Eligibility and Enrollment of Beneficiaries for Assistance with Medicare Cost Sharing1935(a)(3)Not specified in regulation
MACPAC (Medicaid and CHIP Payment and Access Commission)1900Not specified in regulation
MAGI (Modified Adjusted Gross Income)
Defined1902(e)(14)(G), (H); 36B(d)(2) of the Internal Revenue Code of 1986435.4; 435.603; 26 CFR 1.36B-1(e)(2)
Excluded Eligibility Groups1902(e)(14)(D)435.603(j)
Five Percentage Point Disregard1902(e)(14)(I)435.603(d)(4)
No Asset Tests1902(e)(14)(C)435.603(g)(1)
No Disregards1902(e)(14)(B)435.603(g)(2)
MAGI-Equivalent Income Standard
In General1902(e)(14)(A), (E)435.603
Infants1902(e)(14)(A), (E)435.118(c)(2)(ii)
Parents and Other Caretaker Relatives1902(e)(14)(A), (E)435.110(c)
Pregnant Women1902(e)(14)(A), (E)435.116(c)(2)(i), (d)(4)
Maintenance of Effort (MOE)
CHIP2105(d)(1), (d)(3)Not specified in regulation
Community Supported Living Arrangements Services1930(e)[2]Not specified in regulation
Exceptions1902(gg)(3), (4)Not specified in regulation
Home and Community Care1929(e)(2)[2]Not specified in regulation
Inpatient Psychiatric Hospital Services for Individuals <211905(h)(2)441.180 - 441.182
Medicaid1902(a)(74); 1902(gg)(1)Not specified in regulation
Medicaid Children1902(a)(74); 1902(gg)(2)Not specified in regulation
Ticket to Work Act Groups1903(i)(20)Not specified in regulation
Transition to MAGI1902(e)(14)Not specified in regulation
Managed CareSee also PCCMSee also PCCM
In General1903(m); 1932438.1-438.930
Access StandardsNot specified in statute438.206
Actuarial Soundness1903(m)(2)(A)(iii)438.4
Advance Directives1902(a)(57); 1902(w)(2)(E)438.3(j)
Benchmark Benefits1937440.330, 440.385
Beneficiary ChoiceNot specified in statute438.52; 438.71
Beneficiary Support SystemNot specified in statute438.71; 438.810; 438.816
Civil Money Penalties1903(b)(4)(B);1903(m)(5); 1932(e )(2)438.700-438.704
Continuous Eligibility1903(m)(2)(H); see also Minimum Enrollment Period435.212; 435.326; see also Minimum Enrollment Period
Contract Requirements1903(m)(2)(A)438.3
Coordination and Continuity of CareNot specified in statute438.62; 438.208, 438.420; 431.230
Default Enrollment1932(a)(4)(D)438.54(d)(5)
Disclosure of Ownership1902(a)(38); 1124(a)(2)(B); 1128(b)(9)455.104(b)
Drug Rebates1903(m)(2)(A)(xiii); 1927(j)447.509(b)
EHR PaymentsNot specified in statute495.332(d)(3)
Encounter Data1903(m)(2)(A)(xi); 1903(i)(25)438.604(a); 438.818
Enrollee Rights and Protections1932(b)438.100-438.116
Enrollment Broker1932(a)438.71; 438.810; 438.816
Enrollment and Disenrollment1932(a)(4)438.10; 438.52; 438.54, 438.56
External Quality Review Organization (EQRO)1903(a)(3)(C )(ii); 1932(c ); 1902(d)438.310-438.370
Exclusion of Entities1902(p)(2); 1932(d)(1)438.808
Failure to Provide Services1903(m)(5)(A)(i)438.700(b)(1); 1001.801
FQHC and RHC Payment Requirements1903(m)(2)(A)(ix)1001.952(t)(1)(i)(A)(4)(iii); 438.6
Fraud and Abuse1932(d)438.600-438.610
Gag Rule Prohibition1932(b)(3)438.102(a)
Grievances and Appeals1932(a)(5)(B(iii); 1932(b)(4)438.400-438.424
Incentive ArrangementsNot specified in statute438.6
Indians1932(a)(2)(C); 1932(h)438.14
Limitation on Enrollee Liability1932(b)(6)438.106; 438.114(d)(2)
Managed Care Entity (MCE)1932(a)(1)(B); second sentence after 1903(i)(26)438.2
Mandatory Enrollment1932(a)(1)(A)(i), 1932(a)(2)438.54(d)
Managed Long Term Services and Supports (MLTSS)Not specified in statute438.7
Marketing and Outreach1932(d)(2)438.10; 438.102; 438.104
Medical Loss RatioNot specified in statute438.8; 438.74
Mental Health Parity and Substance Use Disorder Benefits1932(b)(8)438.6(e); 438.900-438.930
Minimum Enrollment Period1902(e)(2)435.212; 435.326
Network Adequacy1932(b)(5)438.68; 438.206(b); 438.207
Network Provider or Supplier Integrity1128A(a)(9)438.214(d)
Payments for Primary Care1932(f)447.400(d)
Physician Incentive Plans1903(m)(2)(A)(x)438.700(b)(6); 422.208
Program IntegritySee also Disclosure of Ownership, Exclusion of Entities, Fraud and Abuse438.600-438.610
Prudent Layperson Standard1932(b)(2)(C)438.114(a); 447.54(e)(2)
Quality Measurement and Improvement1932(c )438.310-438.370
Rate Setting ProcessNot specified in statute438.5; 438.6; 438.7
Requirements for Federal Financial Participation1903(m); 1932(b)438.370; 438.802; 438.806
Risk Contracts1903(m)(2)(A)438.6
Safe Harbor from Anti-Kickback ProhibitionNot specified in statute1001.952(h), (l), (m), (t)
Sanctions for Noncompliance1932(e)438.700-438.730
State Plan Option1932438.50; 438.52
Technical Assistance1903(k)Not specified in regulation
Timeliness of Payment to Subcontractors1932(f)Not specified in regulation
Transactions with Party in Interest1903(m)(4)Not specified in regulation
Twelve-Month Lock-In1932(a)(4)(A)(ii)(II); 1903(m)(2)(A)(vi)438.56(c)(2)(ii)
Waivers (Freedom of Choice)1915(b)(1), (4)430.25; 431.54(b); 431.55(c), (h)
Eligibility Groups1902(a)(10)(A)(i)435.100-435.172
Services (see also Benchmark Benefits)1902(a)(10)(A) in the matter before (i); 1902(a)(10)(D)440.210; 440.220
Matching Rates
Administrative1903(a)(2-7); 1931(h)See FFP
Asset Verification Program1940(j)Not specified in regulation
Child Health Measures Reporting1903(a)(3)(A)(iii)Not specified in regulation
Covered Services1903(a)(1)Not specified in regulation
DUR (Drug Utilization Review)1903(a)(3)(D)Not specified in regulation
Enhanced (CHIP Program)2105(b)See FMAP
External Quality Review Organization (EQRO)1903(a)(3)(C)(ii); 1932(c)(2)See FFP
Family Planning Services1903(a)(5)See FMAP
Fraud Control Units1903(a)(6); 1903(b)(3)See FFP
Home and Community-Based Attendant Services and Supports1915(k)(2)Not specified in regulation
Income and Eligibility Verification System (IEVS)1903(a)(4)Not specified in regulation
Medicare Savings Program (MSP)1935(b)Not specified in regulation
MMIS (Medicaid Management Information System)1903(a)(3)(A), (B)See FFP
Nurse Aide Training1903(a)(2)(B)See FFP
Nursing Facility Survey and Certification1903(a)(2)(D)Not specified in regulation
PASARR (Preadmission Screening and Resident Review)1903(a)(2)(C)See FFP
PRO (Peer Review Organization)1903(a)(3)(C)(i)Not specified in regulation
Skilled Personnel1903(a)(2)(A)See FFP
Transitional Increase1931(h)Not specified in regulation
MCH (Maternal and Child Health) Title V Block Grant1902(a)(11)(B); 1915(c)(8); 1920(b)(2)(D)(i)(II); 505(a)(5)(F)431.615
Medicaid AgencyNot specified in statute400.203
Medicaid Eligibility Quality Control (MEQC)1902(e)(13)(E); 1903(u)431.800-431.865
Medicaid Fraud Control Unit (MFCU)1902(a)(61); 1903(a)(6); 1903(q); 1919(g)(5)(D)455.15(a); 455.21; 455.23(d); 1007.1-1007.21
Medicaid Improvement Fund1941(4)Not specified in regulation
Medicaid Integrity Program1902(a)(69); 1936455.200-455.240
Medicaid Pharmacy Subrogation TransactionNot specified in statute45 CFR 162.1901-162.1902
Medicaid Qualifying Trusts1917(d)(4)Not specified in regulation
Medicaid Transformation Payments1903(z)Not specified in regulation
Medical Assistance, Defined1905(a)Not specified in regulation
Medical Care Advisory Committee1902(a)(4)431.12
Medical Child Support1902(a)(60); 1908A; 1912; 1903(p)433.145-433.148; 433.153-433.154
Medically Necessary1901; 1902(a)(30)(A); 1903(m)(2)(A)(vii)Not specified in regulation
Medically Needy
In General1902(a)(10)(C)435.4; 435.300-435.301
Aged1902(a)(10)(C)435.320; 435.330
Ambulatory Services1902(a)(10)(C)(iii)(l)440.250(h)
Blind/Disabled1902(a)(10)(C)435.322; 435.324; 435.330; 435.340
Children1902(a)(10)(C)(ii)(I), (iii)(I)435.301(b)(1)(ii), (iii); 435.308
Federal Financial Participation (FFP)1903(f)435.1002; 435.1007
Income Eligibility Determination/Spend-DownMatter in 1902(a)(17) after (D)435.831
Income Standard1902(a)(10)(C)(i); Matter in 1902(a)(17) after (D)435.811
MAGI Exception1902(e)(14)(D)(IV)435.603(j)(6)
Mandatory Services1902(a)(10)(C)(iii) and (iv)440.22
Medicare Part D Drug Benefit1935(c)(6)(B)423.772; 423.902
Optional Premium1903(f)(2)(B)447.55(a)(5); 447.56(a)(viii)
Post-Eligibility Application of Income to Cost of CareNot specified in statute435.832
Pregnant Women1902(a)(10)(C)(ii)(II), (iii)(II)435.301(b)(1)(i), (iii)
Resource Standard1902(a)(10)(c)(i); Matter in 1902(a)(17) after (D)435.840; 435.845
Medicare BeneficiariesSee also Dually Eligible BeneficiariesSee also Dually Eligible Beneficiaries, Medicare Buy-In, Medicare Savings Program (MSP)
Drug Coverage1935(d)(1)Part 423
Exemption from Citizenship DocumentationNot specified in statute435.406(a)(iii)(B)
Exemption from Mandatory Enrollment in MCOs1932(a)(2)(B)438.50(d)(1)
Low-Income Subsidy (LIS) Program1935(a)(2)(A); 1860D-14423.771-423.800; 423.900-423.910
Medicare Savings Program (MSP)1935(a)(4); 1144(c)(7)Not specified in regulation
Medicare Buy-InSee also Dually Eligible BeneficiariesSee also Dually Eligible Beneficiaries
ComparabilityNot specified in statute440.250(f)
Dually Eligible Beneficiaries1903(b)(1)Not specified in regulation
FFP for Part B PremiumsNot specified in statute431.625(d)
Medicaid Assistance with Medicare Premiums and Cost Sharing1902(a)(10)(E); 1902(n); 1905(a) in the matter before (i); 1905(p)(3)431.625; 447.55(a)(4)
Outreach1144(a)45 CFR 1331.1-1331.7
Poverty-Related Elderly or Disabled1902(a)(10)(A)(ii)(X); 1902(m)Not specified in regulation
Qualified Medicare BeneficiarySee QMBSee QMB
Qualifying IndividualsSee QISee QI
Specified Low-Income Medicare BeneficiariesSee SLMBSee SLMB
Medicare Savings Program (MSP)See also Medicare Buy-In and Low-Income Subsidy (LIS) ProgramSee also Medicare Buy-In and Low-Income Subsidy (LIS) Program
Defined1144(c)(7); 1935(a)(4)Not specified in regulation
Application Assistance1144(c)Not specified in regulation
Data Transmitted by SSA1935(a)(4)Not specified in regulation
Medicaid Assistance with Medicare Premiums and Cost Sharing1902(a)(10)(E); 1902(n); 1905(a) in the matter before (i); 1905(p)(3); 1935(a)(3)431.625; 447.55(a)(4)
Outreach by SSA1144(a)Not specified in regulation
Screening for Eligibility and Enrollment of Beneficiaries for Assistance with Medicare Cost Sharing as Part of LIS Eligibility Determination1935(a)(3)Not specified in regulation
Mental Health Parity
CHIP2103(c)(6); 2103(f)(2)457.1201(l); 457.480; 457.496
Managed Care1932(b)(8)438.3(n); 438.900-438.930
Non-Managed Care Alternative Benefit Plans1937(b)(6)440.345(c); 440.395
Mental Illness and Substance Use DisordersSee also Institution for Mental DiseasesSee also Institution for Mental Diseases (IMD)
Inpatient Psychiatric Hospital Services for Individuals Under Age 211905(a)(16); 1905(h)440.160; 440.250(e); 441.150-441.184; 456.480-456.482
Medicaid for Individuals Age 65 and Older in an IMD1902(a)(20) and (21); 1905(a)(14)440.250(d); 431.620; 440.140; 441.100-441.106
Medical Review and Utilization Control for Inpatient Mental Hospital Services1902(a)(26); 1902(a)(30); 1903(g)(1); 1903(i)(4)456.1; 456.150-456.245; 456.600-456.614
Mental Health and Substance Use Disorder Benefits in Benchmark and Benchmark Equivalent Plans1937(b)(5)440.347
State Mental Health AgencyNot specified in statute431.62
Substance Use Disorder Treatment1905(a) last sentence after (29)Not specified in regulation
Merit Systems of Personnel AdministrationNot specified in statute432.10(c)(2)
MethodologiesSee Disregards; Income; Less Restrictive Methodologies; MAGI; ResourcesSee Disregards; Income; Less Restrictive Methodologies; MAGI; Resources
MFCUSee Medicaid Fraud Control UnitSee Medicaid Fraud Control Unit
Miller Trust1917(d)(4)(B)Not specified in regulation
Minimum Enrollment PeriodSee Continuous Eligibility; MCOs; PCCMSee Continuous Eligibility; MCOs; PCCM
MITA (Medicaid Information Technology Architecture)Not specified in statute433.111(c); 433.112(11); 495.302; 495.332(a)(2)
MMIS (Medicaid Management Information System)1903(r); 1903(a)(3)(A)(i), (B); 1902(a)(25)(A)(ii)433.110-433.131; 433.138(k); 495.332(a)
MOE (Maintenance of Effort)See Maintenance of EffortSee Maintenance of Effort
Money Follows the Person (MFP) Rebalancing Demonstration2403 of the Patient Protection and Affordable Care Act (P.L. 111-148); 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171)Not specified in regulation
Moratorium on Providers and Suppliers1902(kk)(4); 1902(a)(23)455.47
MSIS (Medicaid Statistical Information System)1903(r)(1)(F); 1903(i)(25)Not specified in regulation
MSP (Medicare Savings Program)See Medicare Savings ProgramNot specified in regulation
National Emergency Waiver1135Not specified in regulation
National Practitioner Data Bank1921; 1902(a)(49)45 CFR 60.1-60.16
National Provider Identifier (NPI)1902(kk)(7)(B); 1128J(e); 1902(a)(77)455.440; 45 CFR 162.402-162.414
Native AmericansSee IndiansSee Indians
New Adult Eligibility Group
At or Below 133 Percent FPL (Effective January 1, 2014)1902(a)(10)(A)(i)(VIII)435.119
Benchmark Benefits1902(a)(10) in subdivision (XV) in the matter after (G); 1902(k)(1); 1903(i)(26) [See also Benchmark Benefits]440.305(b)
Early Expansion Option At or Below 133 Percent FPL (Effective April 1, 2010 Before January 1, 2014)1902(k)(2), (3)Not specified in regulation
Optional Expansion Above 133 Percent FPL (Effective January 1, 2014)1902(a)(10)(A)(ii)(XX); 1902(e)(14); 1902(hh); 1903(f)(4); 1905(a)(xv)435.218
Presumptive Eligibility1920(e)435.1103(b)
Use of MAGI1902(e)(14); 1903(f)(4)435.603
NewbornsSee InfantsSee Infants
Newly Eligible1905(y)(2)(A)433.204(a); 433.10(c)(6)
Nominal Cost Sharing1916(a)(3), (b)(3), (h); 1916A(c)(2)(B)Not specified in regulation
Nominal Price1927(c)(1)(D)447.502; 447.505(c)(15); 447.508
In General401, 402(b), 403, and 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193)435.4; 435.406(a)(2)(b)
Coverage for Emergency Services1903(v); last sentence of 1902(a); 401(b)(1)(A) and 403(c)(2)(A) of P.L. 104-193435.139; 435.350; 440.250(m), (n); 440.255
Eligibility for Newborns1902(e)(4)435.117(b)(i), (c)(2)(i); 435.406(a)(1)(E)(1)
Five-Year Bar1903(v)(4); 2107(e)(1)(J); 403(a) of P.L. 104-193440.250(m); 435.406(a)(2), (b)
Optional Coverage for Children and Pregnant Women Within the Five-Year Bar1903(v)(4)Not specified in regulation
Qualified Alien401, 402(b), 403, 421, and 431(b) of P.L. 104-193435.4
Verification of Immigration Status1902(a)(46)(A); 1137(d), (f); 1903(x); 1902(ee)435.406-407, 435.956(a)
Non-Emergency Medical Transportation (NEMT) Broker1902(a)(70)440.170(a)(4)
Non-Emergency Services Alternate Providers1916A(e)(1)(A); 1916A(e)(4)(B)447.54(d)(2)(ii)
Non-US Financial Institutions1902(a)(80)Not specified in regulation
Nurse Aide
Investigation of Allegations1919(g)(1)(C)Not specified in regulation
Registry1919(e)(2), (g)(1)(D); 1902(a)(28)(D)(i)483.156
Training and Competency Evaluation1919(b)(5); 1919(e)(1); 1903(a)(2)(B)433.15(b)(8); 483.150-483.160
Nurse Midwife Services1905(a)(17)440.165; 441.21
Nurse Practitioner Services1905(a)(21)440.166; 441.22
Nursing Facilities (NF)
In General1919431.120; 431.621; 483.1-483.95
Advance Directive1902(a)(57); 1902(w)489.100-489.104
Antipsychotic or Psychopharmacologic Drugs1919(c)(1)(D)483.45(e)(5)
Appeals1919(e)(7)(F)431.151-431.154; 498
Benefit Defined1905(a)(4)(A); 1905(a)(14)440.40(a); 440.155; 440.170(d)
Care GuidelinesNot specified in statute488.115
Certification1919(g)442.10-442.14; 442.30; 442.42
Change in Ownership1919(d)(1)(B)447.253(d)
Civil Money Penalties1919(b)(3)(B)(ii); 1919(g)(2)(A)(i); 1919(h)(2)(A)(ii); 1919(h)(3)(C)(ii); 1903(i)(8)488.430-488.444
Compliance and Ethics Program1128I(b)483.85
Consumer-Oriented Website1902(a)(9)(D)Not specified in regulation
Covered Items and Services1905(a)(4)(A); 1902(a)(28)(B)440.155
Disclosure of Inspection and Survey Results1919(g)(5)488.325
Eligibility for Services Prohibition1917(f)Not specified in regulation
Enforcement of Requirements for Participation1902(a)(28)(D); 1919(h)488.400-488.456; 498.1-498.103
Home Health Service Requirement1902(a)(10)(D)440.220(a)(ii)(3)
Investigation of Complaints1919(g)(4)488.332
Investigation of Resident Neglect and Abuse and Misappropriation of Resident Property1919(g)(1)(C)488.335
Involuntary Transfers1919(c)(1)(x); 1919(c)(2)483.10-483.15; 483.204(a)(1); 483.206(b)
Nursing Facility Level of Care (NFLOC)1915(c)(1); 1915(d)(1); 1915(e)(1)(A); 1915(i)(1)(B); 1915(k)(1)441.302(c)(1); 441.351(e)(3); 441.510(c)
Licensing of Administrators1902(a)(29); 1908431.700-431.715
Notification of Closure1128I(h)483.15(c)(8), (l), (m)
Nurse Aide Training and Competency Evaluation1919(b)(5); 1919(e)(1); 1903(a)(2)(B)433.15(b)(8); 483.150-483.160
Paid Feeding AssistantsNot specified in statute483.16
Payment1902(a)(13)(A); 1902(a)(28)(C); 1903(i)(13)447.251-447.272
Posting of Survey Results1919(c)(8); 1919(d)(1)(V)483.10(g)(11)(i)
Preadmission Screening and Resident Review (PASARR)1919(e)(7); 1919(f)(8); 1919(b)(3)(F)433.15(b)(9); 483.100-483.138; 483.200-483.206
Pressure UlcersNot specified in statute483.25(b); 488.115 (F128-129)
Provider AgreementNot specified in statute442.12-442.13; 442.30; 442.42
Quality Assurance and Performance Improvement (QAPI) Program1128I(c)438.33
Reporting of Crimes Against Residents1150B493.12(b)(5)(i)(A)
Requirements for Participation1902(a)(28)(A); 1919(b), (c), (d)431.120; 483.1-483.95
Resident Access to Information1919(c)(8)483.10(g)
Resident Assessment1919(b)(3)483.20; 483.315
Resident Neglect and Abuse1919(g)(1)(C)483.12; 488.335
Residents' Rights1919(c)483.10; 483.12; 483.15
Restraints1919(c)(1)(A)(ii)483.12; 488.115 (F130)
Special Focus Facility Program1919(f)(10)Not specified in regulation
Staffing Information1128I(g); 1919(i)(1)(A)(i)483.35
Standardized Complaint Form1128I(f); 1919(i)(1)(A)(iii)Not specified in regulation
Sufficient Nursing Staff1919(b)(4)483.35(a)
Surety Bond1919(c)(6)(C)483.10(f)(10)(vi)
Survey and Certification1902(a)(28)(D); 1919(g)488.300-488.335; 488.100-488.115
Swing Beds in Hospitals1913447.28
Termination1919(h)(5)489.52-489.57; 498.3(a)(2)(i); 498.4-498.103
Transparency1124(c)420.206 and 455.104 ; 483.70(k)
Upper Payment LimitNot specified in statute447.272
Waiver of Staffing Standards (Nursing)1919(b)(4)(C)483.35(e) and (f)
Nursing Facility Level of Care (NFLOC)1915(c)(1); 1915(d)(1); 1915(e)(1)(A); 1915(i)(1)(B); 1915(k)(1)441.302(c)(1); 441.351(e)(3); 441.510(c)
Nursing Home Administrator Licensing1902(a)(29); 1908431.700-431.715
Nursing Home Compare Website1919(i); 1919(g)(5)(E)Not specified in regulation
Nursing Home Reform1902(a)(28); 1919483.1-483.315; 488.1-488.115; 488.400-488.456
Office of Inspector General (OIG)
In GeneralNot specified in statute1000-1008
Audits of State OperationsNot specified in statute430.33
Authority to Obtain Information1128J(b)Not specified in regulation
Civil Money Penalty AuthoritiesNot specified in statute1003.100-1003.160
Exclusion AuthoritiesNot specified in statute1001.101-1001.3005
Medicaid Fraud Control UnitsNot specified in statute1007.1-1007.21
Eligibility Groups1902(a)(10)(A)(ii)435.200-435.236; 435.300-435.350
Services (see also Benchmark Benefits)1905(a)(1)-(29) other than those specified in 1902(a)(10)(A) in matter before (i)440.225
Optometric ServicesNot specified in statute441.3
Organ Procurement OrganizationNot specified in statute441.13(c); 486.301-486.360
Organ Transplants1903(i)(1); last sentence of 1903(i); 1138441.35
Orphan Drugs1902(e)(14)[3]Not specified in regulation
Out-of-State Coverage1902(a)(16)431.52
Certified Application AssistersNot specified in statute435.908(c)
CHIP State Plan Requirement2102(c)(1)457.350-457.353
Indians1139(a)Not specified in regulation
Low-Income Medicare Beneficiaries1144(a)Not specified in regulation
MCH Block Grant Requirement506(a)(3)(E)Not specified in regulation
Reporting Requirement1902(a)(75)(B)Not specified in regulation
Title IV-E (Foster Care and Adoption Assistance)402(a)(3)Not specified in regulation
Vulnerable and Underserved Populations1943(b)(1)(F)Not specified in regulation
WIC1902(a)(53)Not specified in regulation
Outstation Locations
Provider Donations for1903(w)(2)(C); 1903(w)(1)(A)(i)(II)433.66(b)(2); 433.67(a)(2)
Duty to Report and Return1128J(d); 1128A(a)(10)Not specified in regulation
Medicaid Integrity Program1936(b)(3)455.200-455.240
Recovery Audit Contractors (RACs)1902(a)(42)(B)455.506; 455.510
Recovery of Improper PaymentsNot specified in statute431.1002
Recovery of Medicaid Overpayments from Medicaid Providers1903(d)(2); 1903(q)(5)433.300-433.322
Recovery of Medicaid Overpayments from Medicare Providers1885447.31
Recovery of Medicare Overpayments from Medicaid Providers1903(j); 1914447.3
Recovery from Third Parties1902(a)(25)(A)(ii); 1903(d)(2)(B)433.310(b)(1); 433.135-433.140
State False Claims Act Recoveries1909495.368(d)
PACE (Program of All-Inclusive Care for the Elderly)
In General1934460.2-460.210
Medicaid Payment1903(f)(4)(C); 1905(a)(26)460.182
Participant RightsNot specified in statute460.110-460.124
Payment to Non-PACE Providers1902(a)(67)Not specified in regulation
Use of RestraintsNot specified in statute460.114
Voluntary EnrollmentNot specified in statute460.150-460.172
Waiver of RequirementsNot specified in statute460.26-460.28
ACA Medicaid Expansion (New Adult Group)1902(a)(10)(A)(i)(VIII)435.119
Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF)1902(a)(10)(A)(i)(I); 1931(b), (d)435.110; 435.115; 435.210
Caretaker Relative1931(b), (d); 1902(a)(10)(A)(i)(I)435.4; 435.110
Mandatory Coverage1902(a)(10)(A)(i)(I); 1931(b)(1)(A)435.11
Medically Needy Eligibility1902(a)(10)(C); 1902(a)(17) after D435.301(b)(2)(ii); 435.310(a)
1931 Eligibility1931(b) and (d)435.11
Optional Coverage1931(b)(2); 1902(a)(10)(A)(ii)(I); 1902(a)(10)(A)(ii)(XX); 1902(hh)435.218; 435.220
Premium Assistance Option1906A; 1906435.1015
Transitional Medical Assistance (TMA)1925; 1931(c)(2)435.112
PARIS (Public Assistance Reporting Information System)1903(r)(3)Not specified in regulation
PAS (Self-Directed Personal Assistance Services) Option441.450-441.484
PASARR (Preadmission Screening and Resident Review)
In General1919(e)(7); 1919(f)(8); 1919(b)(3)(F)483.100-483.138; 483.200-483.206
Payments to States1903(a)(2)(C)433.15(b)(9)
Preadmission Screening1919(b)(3)(F); 1919(e)(7)(A); 1919(f)(8)483.112
Resident Review1919(e)(7)(B); 1919(f)(8)483.114
Paternity Determination1912(a)(1)(B)433.145-433.148; 435.610(a)(2)
Patient Safety
ICF/IID[1]1902(i)Not specified in regulation
Nursing Facilities1919(h)Not specified in regulation
Provider-Preventable ConditionsNot specified in statute434.6(a)(12); 447.26
Psychiatric Hospitals1902(y)Not specified in regulation
Pay and Chase Exception (see also Third-Party Liability)1902(a)(25)(E)433.139(b)(3)
Payments to Providers
In General1902(a)(30)447.200-447.371
Disproportionate Share Hospitals1902(a)(13); 1923447.294; 447.299; 455.300-455.304
Equal Access1902(a)(30)(A)447.203-447.204
FQHCs (Federally Qualified Health Centers)1902(a)(15), 1902(bb)447.371(c); 405.2462(c); 405.2467
Health Home1945(c)(2)Not specified in regulation
Home and Community Care1902(h)Not specified in regulation
Hospice Care1902(a)(13)(B);418.302
Hospitals1902(a)(13)(A); 1903(e); 1903(i)(3); 1913447.250, 447.253(b)(1)(ii)
ICFs/IID1902(a)(13)(A)447.250; 447.253(b)(1)(i); 447.253(c)
Nursing Facilities1902(a)(13)(A); 1902(a)(28)(C)447.250; 447.253(b)(1)(iii)
PACE Programs1934(a)(1)(B); 1934(b)(4) and (d)460.182
Pharmacies1903(i)(10); 1927(e)447.512; 447.514; 447.518
Primary Care Physicians1902(a)(13)(C), 1902(jj)447.400-447.415
Prohibition on Balance BillingNot specified in statute447.15
Prohibition on Payment for Health Care-Acquired Conditions/Provider-Preventable Conditions2702 of the Patient Protection and Affordable Care Act (P.L. 111-148)447.26; 434.6(a)(12)
Recovery of Medicare and Medicaid Overpayments1885; 1903(d)(2); 1903(j); 1903(q)(5); 1914447.30; 447.31
Rural Health Clinics (RHCs)1902(a)(15), 1902(bb)447.371(c); 405.2462(c); 405.2467
Suspension of Payments in Cases of Fraud1903(i)(2)455.23
Third Party Liability1902(a)(25); 1902(g); 1903(d)(2)(B)433.135-433.154
Timely Claims Payment1902(a)(37); third to last sentence of 1902(a)447.45
Upper Payment Limits (UPLs)1902(a)(30)(A)447.271-272; 447.300-362
VFC ProvidersNot specified in statute441.615
PCCM (Primary Care Case Management) Services
Defined1905(a)(25); 1905(t)400.203; 438.2; 440.168
Benchmark BenefitsNot specified in statute440.385
Continuous Eligibility1903(m)(2)(H)435.212; 435.326
Contracts1905(t)438.3; 438.14
Disclosure of OwnershipNot specified in statute455.104(c)
Indians1932(h)(1), (2)Not specified in regulation
State Plan Option1932(a)438.50; 438.52
PCP (Primary Care Physician)1902(a)(13)(C)400.203; 447.400(a)
Pediatric VaccinesSee Immunizations, Vaccines for Children (VFC) ProgramSee Immunizations, Vaccines for Children (VFC) Program
PERM (Payment Error Rate Measurement)1902(e)(13)(E); 1903(u)431.950-431.1002
Personal Care Services1905(a)(24); 1915(c)(1), (c)(4)(B)440.167
Personal Needs Allowance (PNA)1902(a)(50); 1902(q); 1924(d)(1)(A)435.725(c)(1); 435.733(c)(1)
Pharmacy Reimbursement Limits1927(e)447.512(b); 447.518
Pharmacy Subrogation TransactionsNot specified in statute45 CFR 162.1901-162.1902
Physician-Administered Drugs1927(a)(7)447.52
Physician Certification of Need for Inpatient Services1902(a)(44)456.60; 456.160; 456.360; 456.481
Physician Incentive Plans1903(m)(2)(A)(x); 1876(i)(8)422.208-422.210; 438.3(i); 438.9(b)(1)(i); 438.10(f)(3); 438.700(b)(6)
Physician Transparency Reports1128GNot specified in regulation
Unique Physician Identification Number (UPIN)1902(a)(59); 1902(x); 1902(kk)(7)(B); 1903(i)(11)See National Provider Identifier (NPI)
Physician ServicesNot specified in statute440.5
Pickle Amendment1939(a)(5)(E)435.135
Post-Eligibility Application Of Income to Cost of Care1902(r)(1); 1902(a)(17); 1902(o); 1902(q); 1924(d); 1934(i)435.700-435.735; 435.800-435.832; 460.184
Poverty-Related EligibilitySee Infants, Children, Pregnant Women, Medicare Buy-In, Working Disabled, Less Restrictive MethodologiesSee Infants, Children, Pregnant Women, Medicare Buy-In, Working Disabled, Less Restrictive Methodologies
PNA (Personal Needs Allowance)Not specified in statute435.725(c)(1); 435.733(c)(1)
PPS (Prospective Payment System)See Prospective Payment System for FQHCs and RHCsNot specified in regulation
Pregnant Women
Abortion Services1932(e)(1)(B)441.200-441.208
Comparability1902(a)(10) in subdivisions (V), (VII) after (G)440.250(p)
Continuous Eligibility1902(e)(6)435.17
Cost-Sharing Prohibition1916(a)(2)(B), (b)(2)(B); 1916A(b)(3)(B)(iii)447.56(a)(1)(vii)
Exemption from Income Limit of 133 Percent of AFDC Payment Amount1903(f)(4)435.1007(a)
Option to Cover Immigrant Pregnant Women During the Five-Year Bar1903(v)(4)Not specified in regulation
Medicaid-Only Application1902(a)(55)(B)Not specified in regulation
Medically Needy Eligibility1902(a)(10)(C)(ii)(II), (iii)(II)435.301(b)(1)(i), (iii)
No Requirement for Cash Assistance Application1902(c); 1902(e)(10)Not specified in regulation
Outreach1943(b)(1)(F)Not specified in regulation
Outstationed Eligibility Workers1902(a)(55)435.904(b)(1)
60-Day Post-Partum Eligibility1902(e)(5)435.17
Poverty-Related EligibilitySee belowSee below
Minimum Standard1902(l)(2)(A)435.116
Mandatory1902(a)(10)(A)(i)(III), (IV); 1902(l)(1)(A); 1905(n)435.116
Optional1902(a)(10)(A)(ii)(I), (IV), and (IX); 1902(l)(2)(A)(ii)(I)435.116
Pregnancy-Related Services1902(a)(10) in subdivisions (V), (VII) after (G)435.116(d); 440.210(a)(2), (3); 440.250(p); 447.56(a)(2)(iv)
Premiums1916(c); 1916A(b)(3)(A)(ii)447.55(a)(1); 447.56(a)(1)(vii)
Third Party Liability (TPL)
Paternity Determination1902(a)(25)(A)433.145-433.148; 435.610(a)(2)
Prenatal Care Exception to TPL1902(a)(25)(E)433.139(b)(3)(i)
Presumptive Eligibility1902(a)(47)(A); 1920; last sentence of 1902(e)(6)435.1103(a)
Tobacco Use Cessation Counseling and Pharmacotherapy1905(bb); 1916A(b)(3)(B)(iii); 1927(d)(2)(F)447.56(a)(2)(iv)
WIC Outreach and Referral1902(a)(53)Not specified in regulation
Premium Assistance1906; 1906A; 1902(a)(10) in the matter after (G) in subdivision (XI); 1905(a) in the second to last sentence in the matter after paragraph (29); 2105(c)(3); 2105(c)(10)435.1015
Applicability to Beneficiaries
In General1902(a)(14); 1916(a), (b); 1916A447.51; 447.55; 447.56
Benchmark BenefitsNot specified in statute440.355
Disabled Child1916(i)(1)447.55(a)(3)
Income-Related Protections1916A(a)(2); 1916A(b)447.55
Individuals with Breast or Cervical CancerNot specified in statute447.56(a)(1)(xi)
Maximum AmountsNot specified in statute447.55
Medically NeedyNot specified in statute447.55(a)(5)
PACE ProgramNot specified in statute460.186(d)
Pregnant Women and Infants1916(a)(2)(A); 1916(a)(2)(B)447.55(a)(1); 447.56(a)(1)(ii); 447.56(a)(1)(vii)
Qualified Disabled and Working Individual (QDWI)1916(d)447.55(a)(4)
Terminally Ill Individual1916(b)(2)(E)447.56(a)(1)(ix)
Transitional Medical Assistance (TMA)1925(b)(5)Not specified in regulation
Working Disabled Individuals1916(g)447.55(a)(2)
Paid on Behalf of Beneficiaries
COBRA Continuation1902(u)(2); 1902(a)(10)(F); 1902(a)(10) in subdivision (XII) after (G)See Medicare Buy-In, Premium Assistance
Group Health Plans1906(a)(3); 1902(a)(10) in subdivision (XI) after (G); 1906ASee Medicare Buy-In, Premium Assistance
Medicare Buy-In1905(p)(3); 1905(a) in the matter before (i); 1902(a)(10)(E)See Medicare Buy-In, Premium Assistance
State or Local Funds1916(c)(4)See Medicare Buy-In, Premium Assistance
Wrap-Around Coverage1925(a)(4)(B); 1925(b)(4)(C), (D)440.350(c)
Prepaid Ambulatory Health Plan (PAHP)Not specified in statute438.2; 438.9
Prepaid Inpatient Health Plan (PIHP)Not specified in statute438.2; 438.8
Prescription Drugs
Benefit1905(a)(12); 1902(a)(54)440.120(a)
Cost Sharing for Preferred and Non-Preferred Drugs1916A(c)447.51; 447.53
DESI (Drug Efficacy Study Implementation) Drugs ExclusionNot specified in statute441.25; 21 CFR 310.6
Dispensing Fee1927(e)447.502; 447.512(b)
Drug Sample Information1128HNot specified in regulation
Drug Use Review (DUR)1927(g); 1903(a)(3)(D)456.700-456.725
Federal Upper Limit (FUL)1927(e)(4), (5)447.512; 447.514
FFP Prohibition1903(i)(10), (21) and (23); 1927(d)(2)(K)441.25
Formularies1927(d)(4)Not specified in regulation
Physician Transparency Reports1128GNot specified in regulation
Prior Authorization
General Utilization Management Authority1902(a)(30)(A)Not specified in regulation
Emergency Care Exception1927(d)(5)(B); 1932(b)(2)(A)(i)Not specified in regulation
Prescription Drugs1927(d)Not specified in regulation
RebatesSee Drug RebatesSee Drug Rebates
Retail Price Surveys1927(f)Not specified in regulation
Tamper-Resistant Pads1903(i)(23)Not specified in regulation
Presumptive Eligibility
In General1902(a)(47)435.1100-1101
Childless Adults1920(e)435.1103(b)
Children1920A; 1902(a)(47)(A)435.1102; 447.88
Determined by Hospitals1902(a)(47)(B)435.111
Excluded from Error Rates1903(u)(1)(D)(v)Not specified in regulation
Family Planning Services1920C; 1902(a)(47)(A)435.1103(c)
FFPNot specified in statute435.1001(a)(2) and 435.1002(c)
Former Foster Care ChildrenNot specified in statute435.1103(b)
HCBS Services Assessment1915(i)(1)(J)Not specified in regulation
ParentsNot specified in statute435.1103(b)
Pregnant Women1920; 1902(a)(47)(A); 1902(e)(6)435.1103(a)
Breast or Cervical Cancer Patients1920B; 1902(a)(47)(A)435.1103(c)
Preventive ServicesSee also VaccinesSee also Vaccines
In General1905(a)(13)(A)440.130(c)
Enhanced Matching Rate1905(b) in the matter at (5)Not specified in regulation
EPSDT Screening Services1905(r)(1)-(5)Not specified in regulation
Pay and Chase1902(a)(25)(E)Not specified in regulation
Primary Care Case Management (PCCM) ServicesSee PCCMSee PCCM
Primary Care Physicians (PCPs)
Defined1902(jj)400.203; 447.400
Payment1902(a)(13)(C); 1932(f)447.400-447.415
Payment by MCOs1932(f)Not specified in regulation
Prior Authorization
General Utilization Management Authority1902(a)(30)(A)Not specified in regulation
MCO Prior Authorization Emergency Care Exception1932(b)(2)(A)(i)438.10(g)(2)(v)(B)
Prescription Drugs1927(d)(1), (5)Not specified in regulation
PRO (Peer Review Organization)See QIO (Quality Improvement Organization)See QIO (Quality Improvement Organization)
Program IntegritySee also Conflict of Interest; Disclosure; Exclusion; Fraud and Abuse; Medicaid Fraud Control Unit; OverpaymentsSee also Conflict of Interest; Disclosure; Exclusion; Fraud and Abuse; Medicaid Fraud Control Unit; Overpayments
In General1936455
Alternate Payee or Clearinghouse1902(a)(79)Not specified in regulation
Asset Verification1903(i)(24); 1940Not specified in regulation
Audits1902(a)(42)(A); 1936(a)(2)447.202; 455.300-455.304
Conflict of Interest in Managed Care ContractingNot specified in statute438.58
ContractsNot specified in statute434.1-434.78; 438.6; 455.234-236
Cost AvoidanceNot specified in statute433.139(a)(2)
Credible Allegations of FraudNot specified in statute447.9
Criminal Background ChecksNot specified in statute455.434
Disclosure of Information by Providers and Fiscal AgentsNot specified in statute455.100-455.106
DME Suppliers1902(a)(65)Not specified in regulation
Error Rates and PERM1902(e)(13)(E); 1903(u)431 (Subpart Q)
False Claims Act1902(a)(68)495.368
Five-Year Plan1936(d)Not specified in regulation
Home Health Services1903(i)(18); last sentence of 1903(i)441.16
Integrated Data Repository1128J(a)(1)Not specified in regulation
Managed Care Contracting1932(d)(3)438.600-438.610
Medicaid Integrity Program (MIP)1902(a)(69); 1936455.200-455.240
Medical Support1912; 1903(p)435.610(a)(1)
MEQC (Medicaid Eligibility Quality Control)Not specified in statute431.800-431.836
Moratoria on Enrollment of Providers and Suppliers1902(kk)(4)455.47
National Provider Identifier1128J(e); 1902(a)(77); 1902(kk)(7)431.107(b)(5); 455.440
Non-US Financial Institutions1902(a)(80)Not specified in regulation
OIG Authorities1128J(b)1000-1008
OverpaymentsSee Overpayments433.300-433.322
Physician Transparency Reports1128GNot specified in regulation
Provider Screening and Enrollment and Supplier Screening1866(j); 1902(a)(77); 1902(kk)455.400-455.470
Provider Records1902(a)(27)Not specified in regulation
Recovery Audit Contractor (RAC) Program1902(a)(42)(B)455.500-455.518
Reporting Provider Payments to IRSNot specified in statute433.37
State-Initiated ExclusionsNot specified in statute1002.1-1002.230
State Licensure Sanctions1902(a)(49); 1921Not specified in regulation
SubcontractsNot specified in statute434.6(b)
Surety BondsNot specified in statute441.16
Suspension of PaymentsNot specified in statute455.23
Suspension or Termination1902(a)(41)Not specified in regulation
Third Party Liability (TPL)1902(a)(25)433.135-433.154; 435.610(a)(1)
Uncashed or Cancelled ChecksNot specified in statute433.4
Waste, Fraud and Abuse1902(a)(64)See Fraud and Abuse
Prompt Payment to Providers1902(a)(37)(A); third to last sentence in 1902(a); 1915(b)(4); 1932(f)447.45; 447.46; 431.55(f)(4)
Prospective Payment System (PPS) for FQHCs and RHCs1902(bb); 1902(a)(15); 1915(b)447.371(c); 405.2462(c); 405.2467
ProviderNot specified in statute400.203
Provider Agreements1902(a)(27)431.107; 431.108; 441.11; 442.10-442.42; 488.456
Provider Screening and Enrollment1902(a)(77); 1902(kk)455.400-455.470; see also Fraud and Abuse
Provider ExclusionSee Exclusion1002
Provider-Preventable ConditionsNot specified in statute434.6(a)(12); 447.26
Provider ReimbursementSee Payments to ProvidersSee Payments to Providers
Provider-Related Donations1903(w)(2); 1903(d)(6)(A)433.50; 433.52; 433.54; 433.57; 433.66-433.67; 433.74
Provider TaxesSee Payments to Providers433.50; 433.52; 433.55-433.57; 433.68-433.74; See also Payments to Providers
Prudent Layperson1932(b)(2); 1916A(e)(3)(B)438.114
Psychiatric Hospital1902(y); 1905(a)(16); 1905(h)456.600-456.614
QAPI (Quality Assurance and Performance Improvement for NFs)1128I(c)Not specified in regulation
QC (Quality Control)See Error Rates; Medicaid Eligibility Quality Control (MEQC)See Error Rates; Medicaid Eligibility Quality Control (MEQC)
QDWIs (Qualified Disabled Working Individuals)1902(a)(10)(E)(ii); 1905(s); 1916(d)400.200; 447.55(a)(4)
QI (Qualifying Individuals)See also Medicare Savings ProgramsSee also Medicare Savings Programs
Allocation1933(c)Not specified in regulation
Application Assistance1144(c)Not specified in regulation
Enhanced FMAP1933(d)433.10(c)(5)
Mandatory Coverage1902(a)(10)(E)(iv); 1933(a); 1905(p)(4)Not specified in regulation
Outreach1144(a)Not specified in regulation
Selection1933(b), (g)Not specified in regulation
QIO (Quality Improvement Organization)
In General1154; 1903(a)(3)(C)476; 478; 480
Contracts1902(d)434.6; 475.100-475.107
Coordination with Medicaid1158(a)431.63
Disclosure of Information Relating to FraudNot specified in statute480.137
Imposition of SanctionsNot specified in statute1004
QISMC (Quality Improvement System for Managed Care)1932(c)(1)Not specified in regulation
QMBs (Qualified Medicare Beneficiaries)See also Medicare Savings ProgramSee also Medicare Savings Program
Defined1905(p)(1); 1902(m)(4)400.2
Application Assistance1144(c)Not specified in regulation
Application Form1905(p)(5)Not specified in regulation
Delay in Social Security Cost of Living Adjustment (COLA)1905(p)(2)(D); 1902(m)(2)(C)Not specified in regulation
Exception to 3-Month Retroactive Coverage1902(e)(8); 1905(a) in the matter before (i)Not specified in regulation
Exemption from Income Limit of 133 Percent of Aid to Families with Dependent Children (AFDC) Payment Amount1903(f)(4)435.1007(a)
Exemption from Modified Adjusted Gross Income (MAGI)1902(e)(14)(A)(D)435.603(j)(5)
Income Standard1905(p)(2)(D); 1902(m)(3), (4)Not specified in regulation
Less Restrictive Income and Resource MethodologiesNot specified in statute435.601(d)(i)
Mandatory Coverage1902(a)(10)(E)(i); 1905(a)Not specified in regulation
Medicaid Payment Level for Medicare Cost Sharing1902(n)Not specified in regulation
Medicare Cost Sharing Defined1905(p)(3); 1902(a)(10) in subdivision (VIII) in the matter after (G)Not specified in regulation
Outreach by the Social Security Administration (SSA)1144(a)Not specified in regulation
Redetermination Period1902(e)(8)Not specified in regulation
209(b) StatesSection 209(b) of P.L. 92-603; 1902(f)435.121(b)(2)
Quality Control (QC)See Error Rates; Medicaid Eligibility Quality Control (MEQC)See Error Rates; Medicaid Eligibility Quality Control (MEQC)
Quality Standards
In General1902(a)(9)(A); 1902(a)(22)(D); 1902(a)(30)(A); 1902(a)(33)(A); See also Survey and Certification, "Look-Behind" (validation) surveys.431.800-431.836;440.260; 456.3(b); 456.5; see also Survey and Certification, "Look-Behind" (validation) surveys
Adult Health Quality Measures1139BNot specified in regulation
Child Health Quality Demonstrations1139A(d)Not specified in regulation
Child Health Quality Measures1139A(a); 1903(a)(3)(A)(iii)Not specified in regulation
Clinical LaboratoriesNot specified in statute493.1200-493.1299
Guides to States1112Not specified in regulation
Managed Care Organizations (MCOs)1932(c); 1903(a)(3)(C)(ii)438.236-438.242; see also EQRO
National Practitioner Data BankNot specified in statute45 CFR 60.1-60.16
Nurse Aides1919(e)(2); 1919(g)(1)(C), (D)Not specified in regulation
Nursing Facilities (NFs)1919(b), (c), (d); 1128I(c)483.1-483.95
Program of All-Inclusive Care for the Elderly (PACE)1934(b)(2)460.130-460.140
Pediatric Quality Measures1139A(b)Not specified in regulation
Physicians and Other Practitioners1902(a)(49); 19211004.10(b)
Quality Improvement Organizations (QIOs)1902(d); 1903(a)(3)(C)(i); 1152; 1158(a)475.100-475.107; 1004.30-1004.90
Quality Assessment and Performance Improvement1112; 1139A(c); 1139B(d); 1902(a)(33)(A)438.310-438.370 (Subpart E)
Reasonable Promptness1902(a)(3), (8)435.912; 435.911(c)(1); 435.930
RebatesSee Drug RebatesSee Drug Rebates
Records, Maintenance RequirementNot specified in statute431.17
Recovery Audit Contractors (RACs)1902(a)(42)(B)455.500-455.518
Redetermination and Renewal1915(i)(1)(I)435.916-926; 435.1003
Refugees1939(a)(4)45 CFR 400.90-400.107
In General1102Not specified in regulation
Regulatory Flexibility Analysis5 U.S.C. 601-612Not specified in regulation
Regulatory Impact AnalysisExecutive Order 12291Not specified in regulation
Rural Hospital Impact Analysis1102(b)(1)Not specified in regulation
State or Local Impact AnalysisExecutive Order 12612Not specified in regulation
Religious Beliefs1907; 1932(b)(3)(B)(i)440.27
Religious Nonmedical Health Care InstitutionLast sentence of first paragraph after 1902(a)(83); 1861(ss)(1)440.170(b), (c); 442.12(b)
Reparation Payments1902(r)(1)Not specified in regulation
Adverse Provider Actions1902(kk)(6)Not specified in regulation
Data Collection Requirements1902(a)(76)Not specified in regulation
Enrollment and Retention1902(a)(75)Not specified in regulation
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services1902(a)(43)(D)Not specified in regulation
MACPAC Annual Reports1900(b)(3)Not specified in regulation
Provider Payment Information1902(a)(27)Not specified in regulation
Requirement, Medicaid AgencyNot specified in statute431.16
State Program Information1902(a)(6)Not specified in regulation
Residency1902(a)(16); second to last sentence of 1902(a); 1902(b)(2)435.403
Annuity Disclosure1917(e)Not specified in regulation
Indian Property1902(ff)Not specified in regulation
Less Restrictive Methodologies1902(r)(2)435.601(d); 435.1007(f)
Nursing Facility Services Eligibility1917(f)Not specified in regulation
Pregnant Women and Children1902(l)(3)(C)Not specified in regulation
Prohibition on Resource Test1902(e)(14)(C)435.603(g)
Reasonable Standards1902(a)(17)(C)Not specified in regulation
Transfer ProhibitionsSee Transfer of AssetsNot specified in regulation
Trusts1917(d)Not specified in regulation
Respiratory Care Services1902(e)(9)(C); 1902(a)(10) in subdivision (IX) in the matter after (G); 1905(a)(20)440.185
Responsibility of Relatives and Others1902(a)(17)(D)435.602
HospitalsNot specified in statute482.13(e)
Inpatient Psychiatric Residential Treatment Facilities for Individuals Under 21Not specified in statute483.350-483.376
Nursing FacilitiesNot specified in statute483.12
Program of All-Inclusive Care for the Elderly (PACE)Not specified in statute460.114
Retroactive Coverage (Three Months)
General (Three Month) Rule1902(a)(34); 1903(b)(1); 1905(a) in the first parenthetical435.915
Exception for QMBs1902(e)(8)Not specified in regulation
Ribicoff Children1905(a) in (i) before (1); 1902(a)(10)(A)(ii)(I)435.222
Risk Contract1903(m)(2)(A)438.6; 438.802; 438.806
Roads, Bridges and Stadiums1903(i)(17); last sentence of 1903(i)Not specified in regulation
Rural Health Clinic (RHC)
Defined1905(l)(1)440.20(b), (c)
Alternative Payment Methodology1902(bb)(6)Not specified in regulation
Benchmark Benefits1937(b)(4)440.365
Covered Service1905(a)(2)(B)Not specified in regulation
Payment by Medicaid MCOs1903(m)(2)(A)(ix); 1902(bb)(5)447.371
Prospective Payment System1902(bb)447.371(c); 405.2462(c); 405.2467
Required Coverage Under Medicaid MCOs1915(a)(1)(A)438.2
SCHIP (State Children's Health Insurance Program)See CHIPSee CHIP
School Breakfast Program1902(a)(7)(B)Not specified in regulation
School Lunch Program1902(a)(7)(B)Not specified in regulation
Screen and EnrollNot specified in statute457.350-457.353
CHIP2102(b)(3)Not specified in regulation
Express Lane Option1902(e)(13)(C)Not specified in regulation
Section 1115 WaiverSee 1115 WaiverSee 1115 Waiver
Section 209(b)See 209(b) StatesSee 209(b) States
Secure Electronic Interface1943(b)(1)(D); 1942Not specified in regulation
Selective Contracting Waiver1915(b)(4); 1923(a)(4)431.55(f)
Self-Directed Services1915(i)(1)(G)(iii)441.450; 441.452
Self-Directed Personal Assistance Services1915(j)(4)441.450-441.484
ServicesSee BenefitsSee Benefits
Sickle Cell Disease Services1903(a)(3)(E); 1905(a)(27); 1905(x)Not specified in regulation
Simplicity of Administration1902(a)(19)435.902
Single State Agency1902(a)(5)431.10-431.18
Single Streamlined Application Form1413(b) of the Patient Protection and Affordable Care Act (P.L. 111-148)435.4; 435.907
SLMB (Specified Low-Income Medicare Beneficiaries)See Medicare Savings ProgramSee Medicare Savings Program
In General1902(a)(10)(E)(iii)435.603(j)(5)
Application Assistance by SSA1144(c)Not specified in regulation
Exemption from Income Limit of 133 Percent of AFDC Payment Amount1903(f)(4)Not specified in regulation
Mandatory Coverage1902(a)(10)(E)(iii)Not specified in regulation
Social Security Number (SSN)1902(ee); 1903(x)(2)(E)435.910; 435.920; 435.907(e)(3)
SPA (State Plan Amendment)See State Medicaid PlanSee State Medicaid Plan
Special Income Level Eligibility Category1902(a)(10)(A)(ii)(V)435.236; 435.622; 435.1005; 435.230(c)(2)(v)
Medically Needy1902(a)(17) after (D); 1903(f)(2)(A)435.831
209(b) StatesSee 209(b) States435.121(e)(5)
Spousal Impoverishment1902(a)(17)(D); 1902(a)(51); 1924435.725(c)(2); 435.733(c)(2); 435.832(c)(2)
SSI (Supplemental Security Income)See Supplemental Security IncomeSee Supplemental Security Income
Standards for Income and Resources1902(a)(17)Not specified in regulation
State False Claims Acts1909Not specified in regulation
State Health Insurance Exchange1943(b)(2)Not specified in regulation
State Licensure1902(a)(49); 1921431.610(b), (e)(1)
State Medicaid Agency1902(a)(5)See Administration, Single State Agency
State Medicaid ManualNot specified in statute433.110; 433.112; 433.119; 433.123; 433.138
Defined1902400.203; 430.10
State Medicaid Plan
Cost SharingNot specified in statute447.57(c)
Federal Requirements1902; 1904430.10, 430.15
State Plan Amendments (SPAs)Not specified in statute430.12; 430.14-430.20; 447.256
Waivers of Federal RequirementsNot specified in statute430.25
State Share
In General1903(a); 1905(b); 1101(a)(8)(B)433.50(a)(1); 433.51; 433.10(b)
Intergovernmental Transfer (IGT)1903(w)(6)433.51(b)
Local Share1902(a)(2)433.53
State Supplement or State Supplementary Payment1902(a)(10)(A)(ii)(IV); 1616; 1618(g); 1905(j)435.4; 435.130; 435.232; 435.234; 435.403(f); 435.1006; 435.1011-435.1012
State Survey Agency1902(a)(33)(B); 1919(g)(1)431.610(e)
Exceptions1902(a)(70); 1915(g)(1); 1929(I)[2]; 1930(g)(2)[2]; 1932(a)(1)(A); 1934(g)(1); 1938(a)(4); 1945(a)431.50(c); 431.54
Optional Self-Directed Personal Assistance Services Program1915(j)(3)441.462
Waiver1115; 1115A(d)(1); 1915(a), (b), (c)(3), (d)(3), (e)(3), (j)(3)431.55
Streamlined Enrollment System1943(b)(3); 1413 of the Patient Protection and Affordable Care Act (P.L. 111-148)Not specified in regulation
SubcontractsNot specified in statute434.6(b)
Subpoenas1918Not specified in regulation
Substance Use Disorder Treatment1905(a) last sentence after (29); See also Mental Health ParitySee also Mental Health Parity
Supplemental PaymentsSee Upper Payment Limit (UPL)See Upper Payment Limit (UPL)
Supplemental Security Income (SSI)See also Aged; Working DisabledSee also Aged; Working Disabled
In GeneralTitle XVI435.120-435.121
Disregard of Income Post-Eligibility1902(o)435.725(c)(5); 435.733(c)(5)
Exemption from Citizenship DocumentationNot specified in statute435.406(a)(1)(iii)(A)
Mandatory Eligibility1902(a)(10)(A)(i)(II)435.12
State Supplement PaymentNot specified in statute435.4; 435.130; 435.232; 435.1006; 435.1011-435.1012
209(b) States1902(f)435.121
Surety Bond
Coordination with Medicare1128FNot specified in regulation
Durable Medical Equipment (DME) Suppliers1902(a)(65)(B)Not specified in regulation
Home Health Agencies1903(i)(18)441.16
Nursing Facilities1919(c)(6)(C)Not specified in regulation
Survey and Certification
In General1919(g); 1929(i)[2]488
Disclosure of Survey Findings1902(a)(36); 1919(d)(1)(V); 1919(g)(5)431.115; 488.325
Facilities other than Nursing Facilities1902(a)(33)(B)488.52-68; 488.604-865
Home and Community Care1929(i)[2]Not specified in regulation
Information Reporting System1902(a)(49); 1921Not specified in regulation
Investigation of Resident Neglect and Abuse and Misappropriation of Resident Property at Nursing Facilities1919(g)(1)(C)488.335
Nursing Facilities1919(g)488.100-115; 488.300-488.456
Care Guidelines1919(g)488.115
Survey FormsNot specified in statute488.100; 488.105
Survey Guidelines1919(g)488.11
Survey Requirements1919(g)488.300-488.335
State Survey Agency1864(a); 1902(a)(9)431.610(e)
Suter v. Artist M1123; 1130ANot specified in regulation
Swing Beds1913447.28
TANF (Temporary Assistance for Needy Families)Title IV-A; 1931(a)Not specified in regulation
Targeted Case Management Services1915(g)(2)431.54(g); 441.18
Taxes1902(t); see also Provider TaxesNot specified in regulation
Technical Assistance to Providers1902(a)(24)Not specified in regulation
Temporary MoratoriaNot specified in statute455.470; 424.570
Terminally Ill Individual Receiving Hospice Care1905(o)447.56(a)(1)(ix)
Termination1902(a)(41); see also Exclusion; Fair HearingSee also Exclusion; Fair Hearing
Beneficiary EligibilityNot specified in statute433.148
Managed Care Entity Contract1932(e)(4)438.708-438.722
Nursing Facility1919(h)(1)(B)(i); 1919(h)(5); 1919(h)(7)489.53-489.57; 498.3(a)(2)(i); 498.4; 498.5-498.103
Provider1902(a)(41)455.416; 455.450(d)
Defined1108(c)(1)Not specified in regulation
EligibilityNot specified in statute436
Exemption from Requirements1902(a)(23); 1902(j); 1903(u)(4); 1905(p)(4); 1924(a)(4)(B); 1925(c)(2)431.56
Limit on Federal Matching Payments1108(f), (g)433.10(b)
Matching Rates (FMAP)1905(b) in the matter at (2)433.10(b)
Medicare Part D Drug Coverage1935(e)423.907
WaiversNot specified in statute431.56
Third-Party Liability (TPL)
In General1902(a)(25); 1902(g); 1903(d)(2)(B)433.135-433.154
Assignment of Rights to Payment1912(a)(1)(A), (C); 1903(p)433.145-433.148; 435.610(a)(1)
Insurer Exclusionary Clauses1903(o)433.140(a)(3)
OverpaymentsNot specified in statute433.310(b)(1)
Pay and Chase Exception1902(a)(25)(E)433.139(b)(3)
Provider RestrictionsNot specified in statute447.20-447.21
Wrap-Around Coverage1925(a)(4)(B), (b)(4)(C)Not specified in regulation
Three-Month Retroactive Coverage1902(a)(34); 1903(b)(1); 1905(a) in the first parenthetical435.915
Threshold MethodologyNot specified in statute433.206
Ticket to Work1148; 1902(a)(10)(A)(ii)(XV), (XVI); 1916(g); 1903(f)(4); 1903(i)(20)Not specified in regulation
Timely Claims PaymentNot specified in statute447.45; 447.46
Title IV-AFormerly Aid to Families with Dependent Children (see AFDC), currently Temporary Assistance for Needy Families (TANF)Formerly Aid to Families with Dependent Children (see AFDC), currently Temporary Assistance for Needy Families (TANF)
Title IV-CSee Child Support EnforcementSee Child Support Enforcement
Title IV-ESee Child Welfare; ChildrenSee Child Welfare; Children
Title XVISee Aged; Supplemental Security Income (SSI)See Aged; Supplemental Security Income (SSI)
TMA (Transitional Medical Assistance)See Transitional Medical AssistanceSee Transitional Medical Assistance
Tobacco Use Cessation Counseling and Pharmacotherapy for Pregnant Women1905(bb); 1916A(b)(3)(B)(iii); 1927(d)(2)(E)Not specified in regulation
Tobacco Settlement1903(d)(3)(B); 1903(i)(19)Not specified in regulation
TPLSee Third Party Liability (TPL)See Third Party Liability (TPL)
Transfer of Assets
Annuity Disclosure1917(e)Not specified in regulation
Asset Verification Program1902(a)(71); 1903(i)(24); 1940Not specified in regulation
Irrevocable Trust1917(d)(3)(B)Not specified in regulation
Prohibition1902(a)(18); 1917(c)Not specified in regulation
Revocable Trust1917(d)(3)(A)Not specified in regulation
Transfer to Community Spouse1902(a)(51); 1924(f)Not specified in regulation
Transitional Medical Assistance (TMA)See also Collection of Child or Spousal SupportSee also Collection of Child or Spousal Support
Child or Spousal Support1931(c)(1); 408(a)(11)(B)435.115
Working Families1902(a)(52); 1902(e)(1); 1925; 1931(c)(2); 408(a)(11)(A)435.112
TransportationSee also Non-Emergency Medical Transportation (NEMT) BrokerSee also Non-Emergency Medical Transportation (NEMT) Broker
DefinedNot specified in statute440.170(a)
Benchmark BenefitsNot specified in statute440.39
EPSDTNot specified in statute441.62
RequirementNot specified in statute431.53
Tribal Health OrganizationSee Indian Health ServiceSee Indian Health Service
In General1902(a)(18); 1917(d)Not specified in regulation
Spousal Impoverishment1924(b)(2)(B)Not specified in regulation
Tuberculosis (TB)1902(a)(10)(A)(ii)(XII); 1902(a)(10) in subdivision (XIII) after (G); 1902(z)435.215; 435.1009; 435.1010
Unauthorized ImmigrantsSee Non-CitizensSee Non-Citizens
Uniform Reporting1902(a)(40); 1121Not specified in regulation
Unique Physician Identification Number (UPIN)1902(a)(58); 1932(d)(4); 1173(b)See National Provider Identifier (NPI)
Upper Payment Limit (UPL)
In GeneralNot specified in statute447.253(b)(2); 447.257-447.271; 447.300-447.362; 447.512-447.518
Authority1902(a)(30) (as cited in 42 CFR 447.300)447.3
Deadline for Regulations705 of Appendix F of P.L. 106-554Not specified in regulation
Durable Medical Equipment1903(i)(27)Not specified in regulation
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)Not specified in statute447.272
Inpatient HospitalNot specified in statute447.272
Non-Risk Prepaid Capitation PlanNot specified in statute447.362
Nursing FacilityNot specified in statute447.272
Outpatient Hospital and ClinicNot specified in statute447.321
Prescription DrugsNot specified in statute447.512-447.516
Reporting1923(j)(2)(D)Not specified in regulation
Urban Indian Health ProgramSee Indian Health ServiceSee Indian Health Service
Utilization Review
In General1902(a)(30)(B); 1902(a)(33)(A); see also Drug Utilization Review (DUR), PRO456.1-456.23; see also Drug Utilization Review (DUR), Quality Improvement Organization (QIO)
Hospitals1903(g)(1); 1903(i)(4)456.50-456.145
ICFs/IID1902(a)(31); 1903(g)(1)456.350-456.438
Intermediate Care FacilitiesNot specified in statute456.350-456.438
Mental Hospitals1902(a)(26); 1903(g)(1)456.150-456.245
Penalties1903(g)433.10(c)(3); 456.650-456.657
WaiversNot specified in statute456.500-456.508
VaccinesSee ImmunizationsSee Immunizations
Adult1905(a)(13)(B)Not specified in regulation
Drug Rebates Exclusion1927(k)(2)(B)Not specified in regulation
Single Antigen1903(i)(15)Not specified in regulation
Vaccines for Children (VFC) Program1902(a)(62); 1928; 1902(a)(11)(B)(iii); 1903(i)(14); see also 1902(a)(32)(D)441.600-441.615
Validation SurveysSee "Look-Behind" (Validation) SurveysSee "Look-Behind" (Validation) Surveys
Ventilator-Dependent Individuals1902(e)(9)(A), (B); see also Respiratory Care Services440.185
Veterans Affairs Drug Discount1927(a)(6)Not specified in regulation
Veterans Pension1902(r)(1)(B); 1939(a)(5)(F)Not specified in regulation
Vocational Rehabilitation Agencies1902(a)(22)(C)Not specified in regulation
Voluntary ContributionsSee Provider-Related DonationsSee Provider-Related Donations
In General1115, 1915, and 1916430.25; 431.55
Cost-Sharing Nominality1916(a)(3), (b)(3)Not specified in regulation
Demonstration (Section 1115)1115431.400-431.428
Dually Eligible Beneficiaries1915(h)(2)Not specified in regulation
Freedom of Choice1915(b); 1915(h)(1)431.55
Home and Community-Based Services1915(c), (d), (e)441.300-441.310; 441.350-441.365; 435.603(j)(4)
Innovation1115A(d)(1)Not specified in regulation
Limit on Cost Sharing1916(f)Not specified in regulation
MAGILast sentence of 1902(e)(14)(A); (F)Not specified in regulation
MMIS NoncomplianceNot specified in statute433.131
National Emergency1135Not specified in regulation
Nursing Facility Staffing Standards1919(b)(4)(C)483.30(e)
Provider Taxes1903(w)(3)(E)433.72
Renewals1915(h)(1)Not specified in regulation
Selective Contracting1915(b)(4)431.55(f)
TPL RequirementsNot specified in statute433.139(e)
Utilization Review RequirementsNot specified in statute456.500-456.508
Waste, Fraud, and AbuseSee Fraud and AbuseSee Fraud and Abuse
Enrollment1943(b)(1)(A), (B)435.905(a); 435.907(a); 435.908(a); 435.1200(f)
Quality of Nursing Facilities1902(a)(9)(D)Not specified in regulation
Well-Baby and Well-Child ServicesNot specified in statute447.56(a)(2)(iii); 457.520
Whistleblower Employee Information1902(a)(68)(c)Not specified in regulation
Special Supplemental Food Program for Woman, Infants and Children (WIC)
Outreach and Referral1902(a)(53)431.635(d)
Presumptive Eligibility1920(b)(2)(D)(ii)(l); 1920A(b)(3)(A)(i)(lI)435.1101
Withhold of FFPNot specified in statute430.35; 430.38; 431.865
Working Disabled
Balanced Budget Act (BBA) Group (Work Incentives Eligibility Group)1902(a)(10)(A)(ii)(XIII); 1903(f)(4)Not specified in regulation
Qualified Disabled and Working Individual (QDWI)1902(a)(10)(E)(ii); 1905(s); 1916(d)435.121(b)(2); 447.55(a)(4)
Qualified Severely Impaired Individual1902(a)(10)(A)(i)(ll); 1905(q); 1619435.120(c)
Supplemental Security Income (SSI) Eligibles1902(a)(10)(A)(i)(l)435.120(c); 435.121(b)(1); 435.603(j)(1)
Ticket to Work Act Basic Group1902(a)(10)(A)(ii)(XV); 1916(g); 1903(f)(4); 1903(i)(20)447.55(a)(2)
Ticket to Work Act Medical Improvements Group (Working Individuals with Medically Improved Disability)1902(a)(1)(A)(ii)(XVI); 1905(v)(1); 1916(g)447.55(a)(2)
Work Requirement1931(b)(3); 407(e)(1)(B)Not specified in regulation
Wrap-Around Coverage
Medicaid as Secondary Payer1902(a)(25)(A)Not specified in regulation
Premium Assistance Option1906; 1902(a)(10) in subdivision (XI) in the matter after (G); 1906ANot specified in regulation
Transitional Medical Assistance1925(a)(4)(B), (b)(4)(C)Not specified in regulation
Written Plan of Care
Inpatient Mental Hospital Services1902(a)(26)Not specified in regulation
Intermediate Care Facility for the Mentally Retarded (ICF/MR) [1]1902(a)(31)Not specified in regulation
Institution for Mental Diseases (IMD)1902(a)(20)(B)Not specified in regulation


[1] Rather than this statutory term, federal regulations use the term “individuals with intellectual disabilities” (e.g., 42 CFR Part 442).

[2] While these provisions remain in the statute, appropriations were provided only in the early 1990s.

[3] This version of paragraph 1902(e)(14) is “Exclusion of Compensation for Participation in a Clinical Trial for Testing of Treatments for a Rare Disease or Condition.” Paragraph 1902(e)(14) is also designated as “Income Determined Using Modified Adjusted Gross Income.”

[4] While this provision remains in the statute, amounts available were rescinded by section 2007 of the Patient Protection and Affordable Care Act, P.L. 111-148.