42 U.S.C. § 1396R
Section 1396r · Repealed. Pub. L. 10533, title IV, 4713(a), Aug. 5, 1997, 111 Stat. 509
This is § 1926 of the Social Security Act of 1935
Amended 2 times on record
Applied in 2 court decisions — leading case Arkansas Medical Society, Inc. v. Reynolds (1992)
Most recently applied in 819 F. Supp. 816 - Arkansas Medical Society, Inc. v. Reynolds (April 1993)
(1) A State plan under this subchapter shall not be considered to meet the requirement of section 1396a(a)(30)(A) of this title with respect to obstetrical services (as defined in paragraph (4)(A)), as of July 1 of each year (beginning with 1990), unless, by not later than April 1 of such year, the State submits to the Secretary an amendment to the plan that specifies the payment rates to be used for such services under the plan in the succeeding period and includes in such submission such additional data as will assist the Secretary in evaluating the State's compliance with such requirement, including data relating to how rates established for payments to health maintenance organizations under section 1396b(m) of this title take into account such payment rates.
(2) A State plan under this subchapter shall not be considered to meet the requirement of section 1396a(a)(30)(A) of this title with respect to pediatric services (as defined in paragraph (4)(B)), as of July 1 of each year (beginning with 1990), unless, by not later than April 1 of such year, the State submits to the Secretary an amendment to the plan that specifies, by pediatric procedure, the payment rates to be used for such services under the plan in the succeeding period and includes in such submission such additional data as will assist the Secretary in evaluating the State's compliance with such requirement, including data relating to how rates established for payments to health maintenance organizations under section 1396b(m) of this title take into account such payment rates.
(3) The Secretary, by not later than 90 days after the date of submission of a plan amendment under paragraph (1) or (2), shall—
(A) review each such amendment for compliance with the requirement of section 1396a(a)(30)(A) of this title, and
(B) approve or disapprove each such amendment.
If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement.
(4) In this section:
(A) The term “obstetrical services” means services relating to pregnancy covered under the State plan provided by an obstetrician, obstetrician-gynecologist, family practitioner, certified nurse midwife, or certified family nurse practitioner and does not include inpatient or outpatient hospital services or other institutional services.
(B) The term “pediatric services” means services covered under the State plan provided by a pediatrician, family practitioner, or certified pediatric nurse practitioner to children under 18 years of age and does not include inpatient or outpatient hospital services or other institutional services.
For amendments submitted under subsection (a)(1) of this section in 1992 and thereafter, the data submitted under such subsection must include, for the second previous year, at least the statewide average payment rates under the State plan for obstetrical services furnished by obstetricians, obstetrician-gynecologists, family practitioners, certified family nurse practitioners, and certified nurse midwives, by procedure. Such information shall be provided separately for providers located in each metropolitan statistical area (or similar area) in the State and in the remainder of the State.
For amendments submitted under subsection (a)(2) of this section in 1992 and thereafter, the data submitted under such subsection must include, for the second previous year, at least the statewide average payment rates under the State plan for pediatric services furnished by pediatricians, family practitioners, and certified pediatric nurse practitioners 1 by procedure. Such information shall be provided separately for providers located in each metropolitan statistical area (or similar area) in the State and in the remainder of the State.
Nothing in this subchapter (including section 1396a(a)(30)(A) of this title) shall be construed as preventing a State from establishing payment levels for obstetrical or pediatric services that are higher for those services furnished in rural areas than those furnished in metropolitan statistical areas.
Editorial notes U.S. Code · Office of the Law Revision Counsel
Prior Provisions
A prior section 1926 of act Aug. 14, 1935, was renumbered section 1928, and is classified to section 1396s of this title.
Demonstration Projects To Study Effect of Allowing States To Extend Medicaid to Pregnant Women and Children Not Otherwise Qualified To Receive Medicaid Benefits
Section 6407 of Pub. L. 101–239, as amended by Pub. L. 103–66, title XIII, §13643(b), Aug. 10, 1993, 107 Stat. 647, provided that:
“(a) In General.—In order to allow States to develop and carry out innovative programs to extend health insurance coverage to pregnant women and children under age 20 who lack insurance and to encourage workers to obtain health insurance for themselves and their children, the Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall enter into agreements with several States submitting applications in accordance with subsection (b) for the purpose of conducting demonstration projects to study the effect on access to health care, private insurance coverage, and costs of health care when such States are allowed to extend benefits under title XIX of the Social Security Act [this subchapter], either directly, in the same manner, or otherwise as alternative assistance authorized in section 1925(b)(4)(D) of such Act [section 1396r–6(b)(4)(D) of this title], to pregnant women and children under 20 years of age who are not otherwise qualified to receive benefits under such section.
“(b) Project Requirements.—(1) Each State applying to participate in the demonstration project under subsection (a) shall assure the Secretary that eligibility shall be limited to pregnant women and children who have not attained 20 years of age who are in families with income below 185 percent of the income official poverty line (referred to in subsection (c)(1)).
“(2) The Secretary shall further provide in conducting demonstration projects under this section that, if one or more of such demonstration projects utilizes employer coverage as allowed under section 1925(b)(4)(D) of the Social Security Act [section 1396r–6(b)(4)(D) of this title], such project shall require an employer contribution.
“(c) Premiums.—In the case of pregnant women and children eligible to participate in such demonstration projects whose family income level is—
“(1) below 100 percent of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981 [section 9902(2) of this title]) applicable to a family of the size involved, there shall be no premium charged; and
“(2) between 100 and 185 percent of such income official poverty line, there shall be a premium equal to—
“(A) an amount based on a sliding scale relating to income, or
“(B) 3 percent of the family's average gross monthly earnings,
whichever is less.
“(d) Duration.—Each demonstration project under this section shall be conducted for a period not to exceed 3 years.
“(e) Waiver.—The Secretary where he deems appropriate may waive the statewideness requirement described in section 1902(a)(1) of the Social Security Act [section 1396a(a)(1) of this title].
“(f) Limit on Expenditures.—The Secretary in conducting the demonstration projects described in this section shall limit the amount of the Federal share of benefits paid and expenses incurred under title XIX of the Social Security Act [this subchapter] to $30,000,000.
“(g) Evaluation and Report.—(1) For each demonstration project conducted under this section, the Secretary shall assure that an evaluation is conducted on the effect of the project with respect to—
“(A) access to health care;
“(B) private health care insurance coverage;
“(C) costs with respect to health care; and
“(D) developing feasible premium and cost-sharing policies.
“(2) The Secretary shall submit to Congress an interim report containing a summary of the evaluations conducted under paragraph (1) not later than January 1, 1992, and a final report containing such summary together with such further recommendations as the Secretary may determine appropriate not later than one year after the termination of the demonstration projects.”
[Section 13643(b) of Pub. L. 103–66 provided in part that the amendment made by that section to section 6407 of Pub. L. 101–239, set out above, is effective as if included in enactment of Pub. L. 101–239.]