Medicaid State Plan Outline
Section
State Plan Submittal Statement
Section 1 – Single State Agency Organization
1.1Designation and Authority
1.2Organization for Administration
1.3Statewide Operation
1.4State Medical Care Advisory Committee/Tribal Consultation Requirements
Section 2 – Coverage and Eligibility
2.1Application, Determination of Eligibility and Furnishing Medicaid
2.2Coverage and Conditions of Eligibility
2.3Residence
2.4Blindness
2.5Disability
2.6Financial Eligibility
2.7Medicaid Furnished Out of State
Section 3 – Services: General Provisions
3.1Amount, Duration, and Scope of Services
3.2Coordination of Medicaid with Medicare Part B
3.3Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
3.4Special Requirements Applicable to Sterilization Procedures
3.5Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries
3.6Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period
Section 4 – General Program Administration
4.1Methods of Administration
4.2Hearings for Applicants and Recipients
4.3Safeguarding Information on Applicants and Recipients
4.4Medicaid Quality Control
4.5Medicaid Audit Recovery Program
4.6Reports
4.7Maintenance of Records
4.8Availability of Agency Program Manuals
4.9Reporting Provider Payments to the Internal Revenue Service
4.10Free Choice of Providers
4.11Relations With Standard-Setting and Survey Agencies
4.12Consultation to Medical Facilities
4.13Required Provider Agreement
4.14Utilization Control
4.15Inspections of Care in Intermediate Care Facilities for the Mentally Retarded, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals
4.16Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
4.17Liens and Recoveries
4.18Cost Sharing and Similar Charges
4.19Payment for Services
4.20Direct Payments to Certain Recipients for Physicians’or Dentists’ Services
4.21Prohibition against Reassignment of Provider Claims
4.22Third Party Liability
4.23Use of Contracts
4.24Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services
4.25Program for Licensing Administrators of Nursing Homes
4.26Drug Utilization Review Program
4.27Disclosure of Survey Information and Provider or Contractor Evaluation
4.28Appeals Process
4.29Conflict of Interest Provisions
4.30Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals
4.31Disclosure of Information by Providers and Fiscal Agents
4.32Income and Eligibility Verification System
4.33Medicaid Eligibility Cards for Homeless Individuals
4.34 Systematic Alien Verification for Entitlements
4.35Enforcement of Compliance for Nursing Facilities
4.36Required Coordination between Medicaid and WIC
4.37BLANK
4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities
4.39 Preadmission Screening and Resident Review (PASRR)
4.40 Survey and Certification Process
4.41 Resident Assessment for Nursing Facilities
4.42 Employee Education about False Claims Recoveries
4.43Cooperation with Medicaid Integrity Program Efforts
4.44Medicaid Prohibition on Payments to Institutions or Entities Located Outside the United States
Section 5 — Personnel Administration
5.1Standards of Personnel Administration
5.2RESERVED
5.3Training Programs; Subprofessional and Volunteer Programs
Section 6 — Financial Administration
6.1Fiscal Policies and Accountability
6.2Cost Allocation
6.3State Financial Participation
Section 7 — General Provisions
7.1Plan Amendments
7.2Nondiscrimination
7.3Maintenance of AFDC Effort
7.4State Governor’s Review
Attachment
1.1-AAttorney General’s Certification
1.2-AOrganization and Function of State Agency
1.2-BOrganization and Function of Medical Assistance Unit
1.2-CProfessional Medical and Supporting Staff
1.2-DDescription of Staff Making Eligibility Determination
2.1-AHealth Maintenance Organizations/Managed Care Entities - Definitions
2.2-AGroups Covered and Agencies Responsible for Eligibility Determinations
Supplement 1:Reasonable Classification of Individuals under the Age of 21, 20, 19, and 18
Supplement 2:Definitions of Blindness and Disability (Territories only)
Supplement 3:Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home (Katie Beckett)
2.6-AEligibility Conditions and Requirements (States only)
Supplement 1:Income Eligibility Levels — Categorically Needy, Medically Needy, and Qualified Medicare Beneficiaries
Supplement 2:Resource Levels — Categorically Needy, including Groups with Incomes up to a Percentage of the Federal Poverty Level, Medically Needy, and Other Optional Groups
Supplement 3:Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid
Supplement 4:Section 1902(f) Methodologies for Treatment of Income that Differ from those of the SSI Program
Supplement 5:Section 1902(f) Methodologies for Treatment of Resources that Differ from those of the SSI Program
Supplement 5a:Methodologies for Treatment of Resources for Individuals with Incomes Up to a Percentage of the Federal Poverty Level
Supplement 6:Standards for Optional State Supplementary Payments
Supplement 7:Income Levels for 1902(f) States — Categorically Needy Who Are Covered under Requirements More Restrictive than SSI
Supplement 8:Resource Standards for 1902(f) States — Categorically Needy
Supplement 8a:More Liberal Methods of Treating Income under Section 1902(r)(2) of the Act
Supplement 8b:More Liberal Methods of Treating Resources under Section 1902(r)(2) of the Act
Supplement 9:Transfer of Assets (pre-OBRA’93)
Supplement 9a:Transfer of Assets (OBRA ’93)
Supplement 9b:Transfer of Assets (DRA ’05)
Supplement 10:Consideration of Medicaid Qualifying Trusts — Undue Hardship
Supplement 11:Cost-Effective Methods for COBRA Groups (States and Territories)
Supplement 12:Variations from the Basic Personal Needs Allowance/Eligibility Under Section 1931 of the Act
Supplement 13: Treatment of Income Under Section 1924 of the Act
Supplement 14: Income and Resource Requirements for Tuberculosis (TB) Infected individuals
Supplement 15:BLANK
Supplement 16:Asset Verification System
Supplement 17: Disqualifications for Long-Term Care Assistance for Individuals with Substantial Home Equity
2.6-AEligibility Conditions and Requirements (Territories only)
Supplement 1:Income Eligibility Levels — Categorically Needy, Medically Needy, and Qualified Medicare Beneficiaries
Supplement 2:Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid
Supplement 3:Resource Levels for Optional Groups with Incomes up to a Percentage of the Federal Poverty Level and Medically Needy
Supplement 4:Consideration of Medicaid Qualifying Trusts —Undue Hardship
Supplement 5:More Liberal Methods of Treating Income under Section 1902(r)(2) of the Act
Supplement 6:More Liberal Methods of Treating Resources under Section 1902(r)(2) of the Act
3.1-AAmount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
3.1-BAmount, Duration, and Scope of Services Provided Medically Needy Groups
3.1-CStandards and Methods of Assuring High Quality Care
3.1-DMethods of Providing Transportation
3.1-EStandards for the Coverage of Organ Transplant Procedures
3.1-FCommunity Supported Living Arrangements Services Provided to the Developmentally Disabled
3.2-ACoordination of Title XIX with Part B of Title XVIII
4.11-AStandards for Institutions
4.14-A/BUtilization Review Methods for Intermediate Care Facilities
4.16-ACooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees
4.17-ALiens and Adjustment or Recoveries
4.18-ACharges Imposed on Categorically Needy
4.18-BMedically Needy - Premium
4.18-CCharges Imposed on Medically Needy and Other Optional Groups
4.18-DPremiums Imposed on Low Income Pregnant Women and Infants
4.18-EPremiums Imposed on Qualified Disabled and Working Individuals
4.19-AMethods and Standards for Establishing Payment Rates – Inpatient Hospital Care
4.19-BMethods and Standards for Establishing Payment Rates — Other Types of Care
Supplement 1:Payment of Medicare Part A and Part B Deductible/Coinsurance
4.19-CPayments for Reserved Beds
4.19-DMethods and Standards for Establishing Payment Rates — Skilled Nursing and Intermediate Care Facility Services
4.19-ETimely Claims Payment — Definition of Claim
4.22-ARequirements for Third Party Liability — Identifying Liable Resources
4.22-BRequirements for Third Party Liability — Payment of Claims
4.22-CCost-Effective Methods for Employer-Based Group Health Plans
4.32-AIncome and Eligibility Verification System Procedures: Requests to Other State Agencies
4.33-AMethod for Issuance of Medicaid Eligibility Cards to Homeless Individuals
4.34-A Requirements for Advance Directives Under State Plans for Medical Assistance
4.35-AEnforcement of Compliance for Nursing Facilities
4.35-BTermination of Provider Agreement
4.35-CTemporary Management
4.35-DDenial of Payment for New Admission
4.35-ECivil Monetary Penalty
4.35-FState Monitoring
4.35-GTransfer of Residents
4.35-HAdditional Remedies
4.38Disclosure of Additional Registry Information
4.38-ACollection of Additional Registry Information
4.39Definition of Specialized Services
4.39-ACategorical Determinations
4.40-ASurvey and Certification Education Program
4.40-BInvestigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
4.40-CProcedures for Scheduling and Conduct of Standard Surveys
4.40-DPrograms to Measure and Reduce Inconsistency
4.40-EProcess for Investigation of Complaints and Monitoring
4.42-AEmployee Education about False Claims ActRecoveries
7.2-AMethods of Administration – Civil Rights
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