42 U.S.C. § 1396u–3: State coverage of…

Summary

States must offer Medicaid help to pay the Medicare cost-sharing (like premiums and coinsurance) for certain low-income Medicare beneficiaries (called "qualifying individuals"). Qualifying individuals may apply any time during a calendar year. States pick applicants in the order they apply until the State’s yearly money runs out. People who got help in the last month of the previous year get priority the next year. If someone is picked for any month, they get the help for the rest of that calendar year as long as they still qualify. The federal government pays 100% of those costs up to each State’s allocation for the year and pays nothing for costs above that allocation. Getting help under these rules does not create any automatic legal right to get help in future years. The Health Secretary must move matching Part B trust money into the Treasury to cover the federal share of payments made under these rules. The total national amounts set for the program are: FY1998 $200,000,000; FY1999 $250,000,000; FY2000 $300,000,000; FY2001 $350,000,000; FY2002 $400,000,000; FY2003 $400,000,000. Special-period totals are: Jan 1–Sep 30, 2008 $315,000,000; Oct 1–Dec 31, 2008 $130,000,000; Jan 1–Sep 30, 2009 $350,000,000; Oct 1–Dec 31, 2009 $150,000,000; Jan 1–Sep 30, 2010 $462,500,000; Oct 1–Dec 31, 2010 $165,000,000; Jan 1–Sep 30, 2011 $720,000,000; Oct 1–Dec 31, 2011 $280,000,000; Jan 1–Sep 30, 2012 $450,000,000; Oct 1–Dec 31, 2012 $280,000,000; Jan 1–Sep 30, 2013 $485,000,000; Oct 1–Dec 31, 2013 $300,000,000; Jan 1–Sep 30, 2014 $485,000,000; Oct 1–Dec 31, 2014 $300,000,000; Jan 1–Mar 31, 2015 $250,000,000; Apr 1–Dec 31, 2015 $535,000,000; and for 2016 and each later year (subject to limits) $980,000,000. The Secretary divides the national total among States based on each State’s share of the qualifying population. For certain short calendar periods, the Secretary treats them as continuations of the prior period for selection and limits. For years after 2016, the Secretary may raise a State’s allocation up to a limit based on the previous year’s maximum, the change in the Medicare Part B premium, and the change in Part B enrollment as estimated by the Chief Actuary.

Title 42, §1396u–3

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

(a)In general

A State plan under this subchapter shall provide, under section 1396a(a)(10)(E)(iv) of this title and subject to the succeeding provisions of this section and through a plan amendment, for medical assistance for payment of the cost of medicare cost-sharing described in such section on behalf of all individuals described in such section (in this section referred to as “qualifying individuals”) who are selected to receive such assistance under subsection (b).

(b)Selection of qualifying individuals

A State shall select qualifying individuals, and provide such individuals with assistance, under this section consistent with the following:

(1)All qualifying individuals may apply

The State shall permit all qualifying individuals to apply for assistance during a calendar year.

(2)Selection on first-come, first-served basis

(A)In general

For each calendar year (beginning with 1998), from (and to the extent of) the amount of the allocation under subsection (c) for the State for the fiscal year ending in such calendar year, the State shall select qualifying individuals who apply for the assistance in the order in which they apply.

(B)Carryover

For calendar years after 1998, the State shall give preference to individuals who were provided such assistance (or other assistance described in section 1396a(a)(10)(E) of this title) in the last month of the previous year and who continue to be (or become) qualifying individuals.

(3)Limit on number of individuals based on allocation

The State shall limit the number of qualifying individuals selected with respect to assistance in a calendar year so that the aggregate amount of such assistance provided to such individuals in such year is estimated to be equal to (but not exceed) the State’s allocation under subsection (c) for the fiscal year ending in such calendar year.

(4)Receipt of assistance during duration of year

If a qualifying individual is selected to receive assistance under this section for a month in a year, the individual is entitled to receive such assistance for the remainder of the year if the individual continues to be a qualifying individual. The fact that an individual is selected to receive assistance under this section at any time during a year does not entitle the individual to continued assistance for any succeeding year.

(c)Allocation

(1)Total allocation

The total amount available for allocation under this section for— (A)

(B)fiscal year 1999 is $250,000,000;

(C)fiscal year 2000 is $300,000,000;

(D)fiscal year 2001 is $350,000,000; and

(E)each of fiscal years 2002 and 2003 is $400,000,000.

(2)Allocation to States

The Secretary shall provide for the allocation of the total amount described in paragraph (1) for a fiscal year, among the States that executed a plan amendment in accordance with subsection (a), based upon the Secretary’s estimate of the ratio of— (A)

(B)the sum of the amounts computed under subparagraph (A) for all eligible States.

(d)Applicable FMAP

With respect to assistance described in section 1396a(a)(10)(E)(iv) of this title furnished in a State for calendar quarters in a calendar year—

(1)to the extent that such assistance does not exceed the State’s allocation under subsection (c) for the fiscal year ending in the calendar year, the Federal medical assistance percentage shall be equal to 100 percent; and

(2)to the extent that such assistance exceeds such allocation, the Federal medical assistance percentage is 0 percent.

(e)Limitation on entitlement

Except as specifically provided under this section, nothing in this subchapter shall be construed as establishing any entitlement of individuals described in section 1396a(a)(10)(E)(iv) of this title to assistance described in such section.

(f)Coverage of costs through part B of medicare program

For each fiscal year, the Secretary shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title to the appropriate account in the Treasury that provides for payments under section 1396b(a) of this title with respect to medical assistance provided under this section, of an amount equivalent to the total of the amount of payments made under such section that is attributable to this section and such transfer shall be treated as an expenditure from such Trust Fund for purposes of section 1395r of this title.

(g)Special rules

(1)In general

With respect to each period described in paragraph (2), a State shall select qualifying individuals, subject to paragraph (3), and provide such individuals with assistance, in accordance with the provisions of this section as in effect with respect to calendar year 2003, except that for such purpose—

(A)references in the preceding subsections of this section to a year, whether fiscal or calendar, shall be deemed to be references to such period; and

(B)the total allocation amount under subsection (c) for such period shall be the amount described in paragraph (2) for that period.

(2)Periods and total allocation amounts described

For purposes of this subsection

(A)

(B)for the period that begins on October 1, 2008, and ends on December 31, 2008, the total allocation amount is $130,000,000;

(C)for the period that begins on January 1, 2009, and ends on September 30, 2009, the total allocation amount is $350,000,000;

(D)for the period that begins on October 1, 2009, and ends on December 31, 2009, the total allocation amount is $150,000,000;

(E)for the period that begins on January 1, 2010, and ends on September 30, 2010, the total allocation amount is $462,500,000;

(F)for the period that begins on October 1, 2010, and ends on December 31, 2010, the total allocation amount is $165,000,000;

(G)for the period that begins on January 1, 2011, and ends on September 30, 2011, the total allocation amount is $720,000,000;

(H)for the period that begins on October 1, 2011, and ends on December 31, 2011, the total allocation amount is $280,000,000;

(I)for the period that begins on January 1, 2012, and ends on September 30, 2012, the total allocation amount is $450,000,000;

(J)for the period that begins on October 1, 2012, and ends on December 31, 2012, the total allocation amount is $280,000,000;

(K)for the period that begins on January 1, 2013, and ends on September 30, 2013, the total allocation amount is $485,000,000;

(L)for the period that begins on October 1, 2013, and ends on December 31, 2013, the total allocation amount is $300,000,000;

(M)for the period that begins on January 1, 2014, and ends on September 30, 2014, the total allocation amount is $485,000,000;

(N)for the period that begins on October 1, 2014, and ends on December 31, 2014, the total allocation amount is $300,000,000;

(O)for the period that begins on January 1, 2015, and ends on March 31, 2015, the total allocation amount is $250,000,000;

(P)for the period that begins on April 1, 2015, and ends on December 31, 2015, the total allocation amount is $535,000,000; and

(Q)for 2016 and, subject to paragraph (4), for each subsequent year, the total allocation amount is $980,000,000.

(3)Rules for periods that begin after January 1

For any specific period described in subparagraph (B), (D), (F), (H), (J), (L), (N), or (P) of paragraph (2), the following applies:

(A)The specific period shall be treated as a continuation of the immediately preceding period in that calendar year for purposes of applying subsection (b)(2) and qualifying individuals who received assistance in the last month of such immediately preceding period shall be deemed to be selected for the specific period (without the need to complete an application for assistance for such period).

(B)The limit to be applied under subsection (b)(3) for the specific period shall be the same as the limit applied under such subsection for the immediately preceding period.

(C)The ratio to be applied under subsection (c)(2) for the specific period shall be the same as the ratio applied under such subsection for the immediately preceding period.

(4)Adjustment to allocations

The Secretary may increase the allocation amount under paragraph (2)(Q) for a year (beginning with 2017) up to an amount that does not exceed the product of the following:

(A)Maximum allocation amount for previous year

In the case of 2017, the allocation amount for 2016, or in the case of a subsequent year, the maximum allocation amount allowed under this paragraph for the previous year.

(B)Increase in part B premium

The monthly premium rate determined under section 1395r of this title for the year divided by the monthly premium rate determined under such section for the previous year.

(C)Increase in part B enrollment

The average number of individuals (as estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services in September of the previous year) to be enrolled under part B of subchapter XVIII for months in the year divided by the average number of such individuals (as so estimated) under this subparagraph with respect to enrollments in months in the previous year.

Notes & Related Subsidiaries

Editorial Notes

Prior Provisions

A prior section 1933 of act Aug. 14, 1935, was renumbered section 1939 and is classified to section 1396v of this title.

Amendments

2015—Subsec. (g)(2). Pub. L. 114–10, § 211(b)(1), redesignated subpars. (I) to (W) as (A) to (O), respectively, added subpars. (P) and (Q), and struck out former subpars. (A) to (H) which related to total allocation amounts for various periods beginning on

January 1, 2004, and ending on

December 31, 2007. Subsec. (g)(3). Pub. L. 114–10, § 211(b)(2), substituted “or (P)” for “(P), (R), (T), or (V)” in introductory provisions. Subsec. (g)(4). Pub. L. 114–10, § 211(b)(3), added par. (4). 2014—Subsec. (g)(2)(T). Pub. L. 113–93, § 201(b)(1)(A), struck out “and” at end. Subsec. (g)(2)(U). Pub. L. 113–93, § 201(b)(1)(B), substituted “

September 30, 2014” for “

March 31, 2014” and “$485,000,000;” for “$200,000,000.” Subsec. (g)(2)(V), (W). Pub. L. 113–93, § 201(b)(1)(C), added subpars. (V) and (W). Subsec. (g)(3). Pub. L. 113–93, § 201(b)(2), substituted “(T), or (V)” for “or (T)” in introductory provisions. 2013—Subsec. (g)(2)(S), (T). Pub. L. 112–240, § 621(b)(1), added subpars. (S) and (T). Subsec. (g)(2)(U). Pub. L. 113–67 added subpar. (U). Subsec. (g)(3). Pub. L. 112–240, § 621(b)(2), substituted “(R), or (T)” for “or (R)” in introductory provisions. 2012—Subsec. (g)(2)(Q), (R). Pub. L. 112–96, § 3101(b)(1), substituted “

September 30, 2012, the total allocation amount is $450,000,000; and” for “

February 29, 2012, the total allocation amount is $150,000,000.” in subpar. (Q) and added subpar. (R). Subsec. (g)(3). Pub. L. 112–96, § 3101(b)(2), substituted “(P), or (R)” for “or (P)” in introductory provisions. 2011—Subsec. (g)(2)(Q). Pub. L. 112–78 added subpar. (Q). 2010—Subsec. (g)(2)(M). Pub. L. 111–127, § 3(1), substituted “$462,500,000” for “$412,500,000”. Subsec. (g)(2)(N). Pub. L. 111–127, § 3(2), substituted “$165,000,000” for “$150,000,000”. Subsec. (g)(2)(O), (P). Pub. L. 111–309, § 110(b)(1), added subpars. (O) and (P). Subsec. (g)(3). Pub. L. 111–309, § 110(b)(2), substituted “(N), or (P)” for “or (N)” in introductory provisions. 2009—Subsec. (g)(2)(M), (N). Pub. L. 111–5, § 5005(b)(1), added subpars. (M) and (N). Subsec. (g)(3). Pub. L. 111–5, § 5005(b)(2), substituted “(L), or (N)” for “or (L)” in introductory provisions. 2008—Subsec. (g)(2)(I). Pub. L. 110–379, § 2(1), substituted “$315,000,000” for “$300,000,000”. Pub. L. 110–275, § 111(b)(1)(B)(i), (ii), substituted “September 30” for “June 30” and “$300,000,000” for “$200,000,000”. Subsec. (g)(2)(J). Pub. L. 110–379, § 2(2), substituted “$130,000,000” for “$100,000,000”. Pub. L. 110–275, § 111(b)(1)(A), (B)(iii), (C), added subpar. (J). Subsec. (g)(2)(K), (L). Pub. L. 110–275, § 111(b)(1)(C), added subpars. (K) and (L). Subsec. (g)(3). Pub. L. 110–275, § 111(b)(2), substituted “(H), (J), or (L)” for “or (H)” in introductory provisions. 2007—Subsec. (g)(2)(H). Pub. L. 110–90, § 3(b)(1), added subpar. (H). Subsec. (g)(2)(I). Pub. L. 110–173 added subpar. (I). Subsec. (g)(3). Pub. L. 110–90, § 3(b)(2), substituted “(F), or (H)” for “or (F)” in introductory provisions. 2005—Subsec. (g)(2)(D) to (G). Pub. L. 109–91, § 101(b)(1), added subpars. (D) to (G). Subsec. (g)(3). Pub. L. 109–91, § 101(b)(2), inserted “, (D), or (F)” after “subparagraph (B)” in introductory provisions. 2004—Subsec. (g). Pub. L. 108–448 amended heading and text of subsec. (g) generally. Prior to amendment, text read as follows: “With respect to the period that begins on

January 1, 2004, and ends on

September 30, 2004, a State shall select qualifying individuals, and provide such individuals with assistance, in accordance with the provisions of this section as in effect with respect to calendar year 2003, except that for such purpose— “(1) references in the preceding subsections of this section to ‘fiscal year’ and ‘calendar year’ shall be deemed to be references to such period; and “(2) the total allocation amount under subsection (c) of this section for such period shall be $300,000,000.” 2003—Subsec. (c)(1)(E). Pub. L. 108–89, § 401(b)(1), substituted “each of fiscal years 2002 and 2003” for “fiscal year 2002”. Subsec. (c)(2)(A). Pub. L. 108–89, § 401(b)(2), substituted “the total number of individuals described in section 1396a(a)(10)(E)(iv) of this title in the State; to” for “the sum of— “(i) twice the total number of individuals described in section 1396a(a)(10)(E)(iv)(I) of this title in the State, and “(ii) the total number of individuals described in section 1396a(a)(10)(E)(iv)(II) of this title in the State; to”. Subsec. (g). Pub. L. 108–173, § 103(f)(2)(A), substituted “

September 30, 2004” for “

March 31, 2004” in introductory provisions. Pub. L. 108–89, § 401(c), added subsec. (g). Subsec. (g)(2). Pub. L. 108–173, § 103(f)(2)(B), substituted “$300,000,000” for “$100,000,000”. 1999—Subsec. (b)(4). Pub. L. 106–113 inserted “a” after “for a month in”.

Statutory Notes and Related Subsidiaries

Effective Date

of 2007 AmendmentAmendment by Pub. L. 110–90 effective as of Sept. 30, 2007, see section 3(c) of Pub. L. 110–90, set out as a note under section 1396a of this title.

Effective Date

of 2005 AmendmentAmendment by Pub. L. 109–91 effective Sept. 30, 2005, see section 101(c) of Pub. L. 109–91, set out as a note under section 1396a of this title.

Effective Date

of 2003 AmendmentAmendment by Pub. L. 108–173 applicable to calendar quarters beginning on or after Apr. 1, 2004, see section 103(f)(3) of Pub. L. 108–173, set out as a note under section 1396a of this title.

§1396u–3 State Coverage of Medicare Cost-sharing for Additional Low-income Medicare Beneficiaries

Summary

Title 42, §1396u–3

Notes & Related Subsidiaries

Editorial Notes

Prior Provisions

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Effective Date

Effective Date

Citations & Metadata