§1395v Agreements with States

Summary

The Secretary must, if a State asks before January 1, 1970, or during 1981 or after 1988, make an agreement to enroll certain eligible people in the federal insurance program. The agreement can cover either people who get cash payments from a State plan approved under subchapter I or XVI, or people who get cash payments under a set of State plans approved under subchapters I, X, XIV, XVI, and part A of subchapter IV. A person is eligible only if they meet the eligibility rules in section 1395o on the date the agreement starts or become eligible later, and they must be getting the listed cash payments in the month the agreement starts or any month after. The State pays the monthly premium set by section 1395r (with no extra increase under that law). Coverage for a person begins on the latest of: July 1, 1966; the first day of the third month after the State agreement starts; the first day of the first month the person is both eligible and in the covered group; or a date the agreement names. Coverage ends on the last day of the first month when the State finds the person no longer gets the listed cash payments (and, if the agreement was changed under a later modification, no longer gets medical assistance), or on the month before the person first gets benefits under subchapter II or an annuity or pension under the Railroad Retirement Act of 1974. When coverage ends this way, the person is treated as having enrolled under section 1395p in the initial general enrollment period in section 1395p(c). If a person files notice in the last month of their coverage or within the next six months that they do not want to participate, their coverage ends at the end of the month the notice is filed. If the State agreement says so, the State agency that runs certain State plans can act as the “carrier” for those people, and the agreement must make financial dealings (like deductions and coinsurance) and operations efficient. At the same request dates, the Secretary must also make two kinds of changes if the State asks: one change can remove the broader multi-plan coverage rule, and another can broaden the covered group to add people who get Medicaid under subchapter XIX or qualified Medicare beneficiaries (as defined in section 1396d(p)(1), including those in section 1396a(a)(10)(E)(iii)). For the broadening change, a person counts as eligible if they are found eligible for Medicaid in the month the change is made or any month after, and some enrollment date rules shift from the “first month” to the “second month following the first month” except for qualified Medicare beneficiaries. For Part A enrollment rules for qualified Medicare beneficiaries, see section 1395i–2(g).