42 U.S.C. § 1397ee - Payments to States

42 USC 1397ee - Payments to States

(a) Payments 

(1) In general 
Subject to the succeeding provisions of this section, the Secretary shall pay to each State with a plan approved under this subchapter, from its allotment under section 1397dd of this title, an amount for each quarter equal to the enhanced FMAP (or, in the case of expenditures described in subparagraph (B), the Federal medical assistance percentage (as defined in the first sentence of section 1396d (b) of this title)) of expenditures in the quarter
(A) for child health assistance under the plan for targeted low-income children in the form of providing medical assistance for which payment is made on the basis of an enhanced FMAP under the fourth sentence of section 1396d (b) of this title;
(B) for the provision of medical assistance on behalf of a child during a presumptive eligibility period under section 1396r–1a of this title;
(C) for child health assistance under the plan for targeted low-income children in the form of providing health benefits coverage that meets the requirements of section 1397cc of this title; and
(D) only to the extent permitted consistent with subsection (c) of this section
(i) for payment for other child health assistance for targeted low-income children;
(ii) for expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children);
(iii) for expenditures for outreach activities as provided in section 1397bb (c)(1) of this title under the plan; and
(iv) for other reasonable costs incurred by the State to administer the plan.
(2) Order of payments 
Payments under paragraph (1) from a States allotment shall be made in the following order:
(A) First, for expenditures for items described in paragraph (1)(A).
(B) Second, for expenditures for items described in paragraph (1)(B).
(C) Third, for expenditures for items described in paragraph (1)(C).
(D) Fourth, for expenditures for items described in paragraph (1)(D).
(b) Enhanced FMAP 
For purposes of subsection (a) of this section, the enhanced FMAP, for a State for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the first sentence of section 1396d (b) of this title) for the State increased by a number of percentage points equal to 30 percent of the number of percentage points by which
(1)  such Federal medical assistance percentage for the State, is less than
(2)  100 percent; but in no case shall the enhanced FMAP for a State exceed 85 percent.
(c) Limitation on certain payments for certain expenditures 

(1) General limitations 
Funds provided to a State under this subchapter shall only be used to carry out the purposes of this subchapter (as described in section 1397aa of this title) and may not include coverage of a nonpregnant childless adult, and any health insurance coverage provided with such funds may include coverage of abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. For purposes of the preceding sentence, a caretaker relative (as such term is defined for purposes of carrying out section 1396u–1 of this title) shall not be considered a childless adult.
(2) Limitation on expenditures not used for medicaid or health insurance assistance 

(A) In general 
Except as provided in this paragraph, the amount of payment that may be made under subsection (a) of this section for a fiscal year for expenditures for items described in paragraph (1)(D) of such subsection shall not exceed 10 percent of the total amount of expenditures for which payment is made under subparagraphs (A), (C), and (D) of paragraph (1) of such subsection.
(B) Waiver authorized for cost-effective alternative 
The limitation under subparagraph (A) on expenditures for items described in subsection (a)(1)(D) of this section shall not apply to the extent that a State establishes to the satisfaction of the Secretary that
(i) coverage provided to targeted low-income children through such expenditures meets the requirements of section 1397cc of this title;
(ii) the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under section 1397cc of this title; and
(iii) such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 254b of this title or with hospitals such as those that receive disproportionate share payment adjustments under section 1395ww (d)(5)(F) or 1396r–4 of this title.
(3) Waiver for purchase of family coverage 
Payment may be made to a State under subsection (a)(1) of this section for the purchase of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children only if the State establishes to the satisfaction of the Secretary that
(A) purchase of such coverage is cost-effective relative to the amounts that the State would have paid to obtain comparable coverage only of the targeted low-income children involved, and
(B) such coverage shall not be provided if it would otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage.
(4) Use of non-Federal funds for State matching requirement 
Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of non-Federal contributions required under subsection (a) of this section.
(5) Offset of receipts attributable to premiums and other cost-sharing 
For purposes of subsection (a) of this section, the amount of the expenditures under the plan shall be reduced by the amount of any premiums and other cost-sharing received by the State.
(6) Prevention of duplicative payments 

(A) Other health plans 
No payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that a private insurer (as defined by the Secretary by regulation and including a group health plan (as defined in section 1167 (1) of title 29), a service benefit plan, and a health maintenance organization) would have been obligated to provide such assistance but for a provision of its insurance contract which has the effect of limiting or excluding such obligation because the individual is eligible for or is provided child health assistance under the plan.
(B) Other Federal governmental programs 
Except as provided in subparagraph (A) or (B) of subsection (a)(1) of this section or any other provision of law, no payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that payment has been made or can reasonably be expected to be made promptly (as determined in accordance with regulations) under any other federally operated or financed health care insurance program, other than an insurance program operated or financed by the Indian Health Service, as identified by the Secretary. For purposes of this paragraph, rules similar to the rules for overpayments under section 1396b (d)(2) of this title shall apply.
(7) Limitation on payment for abortions 

(A) In general 
Payment shall not be made to a State under this section for any amount expended under the State plan to pay for any abortion or to assist in the purchase, in whole or in part, of health benefit coverage that includes coverage of abortion.
(B) Exception 
Subparagraph (A) shall not apply to an abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(C) Rule of construction 
Nothing in this section shall be construed as affecting the expenditure by a State, locality, or private person or entity of State, local, or private funds (other than funds expended under the State plan) for any abortion or for health benefits coverage that includes coverage of abortion.
(d) Maintenance of effort 

(1) In medicaid eligibility standards 
No payment may be made under subsection (a) of this section with respect to child health assistance provided under a State child health plan if the State adopts income and resource standards and methodologies for purposes of determining a childs eligibility for medical assistance under the State plan under subchapter XIX of this chapter that are more restrictive than those applied as of June 1, 1997.
(2) In amounts of payment expended for certain State-funded health insurance programs for children 

(A) In general 
The amount of the allotment for a State in a fiscal year (beginning with fiscal year 1999) shall be reduced by the amount by which
(i) the total of the State childrens health insurance expenditures in the preceding fiscal year, is less than
(ii) the total of such expenditures in fiscal year 1996.
(B) State children’s health insurance expenditures 
The term State childrens health insurance expenditures means the following:
(i) The State share of expenditures under this subchapter.
(ii) The State share of expenditures under subchapter XIX of this chapter that are attributable to an enhanced FMAP under the fourth sentence of section 1396d (b) of this title.
(iii) State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 1397cc (d) of this title.
(e) Advance payment; retrospective adjustment 
The Secretary may make payments under this section for each quarter on the basis of advance estimates of expenditures submitted by the State and such other investigation as the Secretary may find necessary, and may reduce or increase the payments as necessary to adjust for any overpayment or underpayment for prior quarters.
(f) Flexibility in submittal of claims 
Nothing in this section or subsections (e) and (f) of section 1397dd of this title shall be construed as preventing a State from claiming as expenditures in the quarter expenditures that were incurred in a previous quarter.
(g) Authority for qualifying States to use certain funds for medicaid expenditures 

(1) State option 

(A) In general 
Notwithstanding any other provision of law, a qualifying State (as defined in paragraph (2)) may elect to use not more than 20 percent of any allotment under section 1397dd of this title for fiscal year 1998, 1999, 2000, 2001, 2004, 2005, 2006, 2007, 2008, or 2009 (insofar as it is available under subsections (e) and (g) of such section) for payments under subchapter XIX of this chapter in accordance with subparagraph (B), instead of for expenditures under this subchapter.
(B) Payments to States 

(i) In general In the case of a qualifying State that has elected the option described in subparagraph (A), subject to the availability of funds under such subparagraph with respect to the State, the Secretary shall pay the State an amount each quarter equal to the additional amount that would have been paid to the State under subchapter XIX of this chapter with respect to expenditures described in clause (ii) if the enhanced FMAP (as determined under subsection (b) of this section) had been substituted for the Federal medical assistance percentage (as defined in section 1396d (b) of this title).
(ii) Expenditures described For purposes of this subparagraph, the expenditures described in this clause are expenditures, made after August 15, 2003, and during the period in which funds are available to the qualifying State for use under subparagraph (A), for medical assistance under subchapter XIX of this chapter to individuals who have not attained age 19 and whose family income exceeds 150 percent of the poverty line.
(iii) No impact on determination of budget neutrality for waivers In the case of a qualifying State that uses amounts paid under this subsection for expenditures described in clause (ii) that are incurred under a waiver approved for the State, any budget neutrality determinations with respect to such waiver shall be determined without regard to such amounts paid.
(2) Qualifying State 
In this subsection, the term qualifying State means a State that, on and after April 15, 1997, has an income eligibility standard that is at least 184 percent of the poverty line with respect to any 1 or more categories of children (other than infants) who are eligible for medical assistance under section 1396a (a)(10)(A) of this title or, in the case of a State that has a statewide waiver in effect under section 1315 of this title with respect to subchapter XIX of this chapter that was first implemented on August 1, 1994, or July 1, 1995, has an income eligibility standard under such waiver for children that is at least 185 percent of the poverty line, or, in the case of a State that has a statewide waiver in effect under section 1315 of this title with respect to subchapter XIX of this chapter that was first implemented on January 1, 1994, has an income eligibility standard under such waiver for children who lack health insurance that is at least 185 percent of the poverty line, or, in the case of a State that had a statewide waiver in effect under section 1315 of this title with respect to subchapter XIX of this chapter that was first implemented on October 1, 1993, had an income eligibility standard under such waiver for children that was at least 185 percent of the poverty line and on and after July 1, 1998, has an income eligibility standard for children under section 1396a (a)(10)(A) of this title or a statewide waiver in effect under section 1315 of this title with respect to subchapter XIX of this chapter that is at least 185 percent of the poverty line.
(3) Construction 
Nothing in paragraphs (1) and (2) shall be construed as modifying the requirements applicable to States implementing State child health plans under this subchapter.

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