PRIA Logo™
Take the PRIA Score
Title 42 — The Public Health and WelfareRelease 119-73

§1396b–1 Payment adjustment for health care-acquired conditions

Title 42 › Chapter CHAPTER 7— - SOCIAL SECURITY › Subchapter SUBCHAPTER XIX— - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS › § 1396b–1

Last updated Apr 6, 2026|Official source

Summary

The HHS Secretary must find state rules that stop payment for health care-acquired conditions and use them to make Medicaid rules. Those rules must start July 1, 2011, and block federal Medicaid payments for care costs tied to the listed conditions. The rules must not make Medicaid patients lose access to care. A "health care-acquired condition" is a condition identified by a specific secondary diagnosis code. The Secretary must apply similar Medicare non-payment rules to Medicaid plans and waivers when appropriate and may leave out Medicare-listed conditions that don't fit Medicaid patients.

Full Legal Text

Title 42, §1396b–1

The Public Health and Welfare — Source: USLM XML via OLRC

(a)The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall identify current State practices that prohibit payment for health care-acquired conditions and shall incorporate the practices identified, or elements of such practices, which the Secretary determines appropriate for application to the Medicaid program in regulations. Such regulations shall be effective as of July 1, 2011, and shall prohibit payments to States under section 1903 of the Social Security Act [42 U.S.C. 1396b] for any amounts expended for providing medical assistance for health care-acquired conditions specified in the regulations. The regulations shall ensure that the prohibition on payment for health care-acquired conditions shall not result in a loss of access to care or services for Medicaid beneficiaries.
(b)In this section.11 So in original. The period probably should be a comma. the term “health care-acquired condition” means a medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)).
(c)In carrying out this section, the Secretary shall apply to State plans (or waivers) under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] the regulations promulgated pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the prohibition of payments based on the presence of a secondary diagnosis code specified by the Secretary in such regulations, as appropriate for the Medicaid program. The Secretary may exclude certain conditions identified under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for non-payment under title XIX of such Act when the Secretary finds the inclusion of such conditions to be inapplicable to beneficiaries under title XIX.

Legislative History

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsec. (c), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XIX of the Act is classified generally to this subchapter. Title XVIII of the Act is classified generally to subchapter XVIII (§ 1395 et seq.) of this chapter. For complete classification of this Act to the Code, see section 1305 of this title and Tables. Codification Section was enacted as part of the Patient Protection and Affordable Care Act, and not as part of the Social Security Act which comprises this chapter.

Reference

Citations & Metadata

Citation

42 U.S.C. § 1396b–1

Title 42 — The Public Health and Welfare

Last Updated

Apr 6, 2026

Release point: 119-73