Medicaid State Plan
A Medicaid State Plan is a set of rules that the state uses to provide Medicaid health insurance to people who need it. Each state has its own plan that follows federal guidelines, but can also make some choices about how the program works. The plan details who is eligible for Medicaid, what services are covered, and how the state will pay for those services.
Section 1 - Single State Agency Organization
- Section 1.1 - Designation and Authority
- Attachment 1.1a - Certification of Single State Agency
- Section 1.2 - Organization for Administration
- Attachment 1.2a - State Agency Organization and Functions
- Attachment 1.2b - Organization and Function of Bureau of Health Services Financing
- Attachment 1.2c - Professional Medical and Supporting Staff
- Attachment 1.2d - Description of Staff Making Eligibility Decisions
- Section 1.3 - Statewide Operation
- Section 1.4 - State Medical Care Advisory Committee
- Section 1.5 - Pediatric Immunization Program
- Section 1.6 - Tribal Consultation of SPA Process
Section 2 - Coverage and Eligibility
- Section 2.1 - Application Determination of Eligibility and Furnishing Medicaid
- Section 2.2 - Coverage and Conditions of Eligibility
- Attachment 2.2a - Groups Covered and Agencies Responsible for Eligibility
- Supplement 1 - Reasonable Classifications of Individuals
- Attachment 2.2a - Groups Covered and Agencies Responsible for Eligibility
- Section 2.3 - Residence
- Section 2.4 - Blindness
- Section 2.5 - Disability
- Section 2.6 - Financial Eligibility
- Attachment 2.6A Eligibility Conditions and Requirements
- Supplement 1 - Eligibility Income Levels
- Supplement 2 - Eligibility Resource Levels
- Supplement 3 - Reasonable Limits
- Supplement 5 - Methodologies for Treatment of Income and Resources that Differ from SSI
- Supplement 5a - Methodologies for Treatment of Resources for Individuals with Income up to a Percentage of FPL
- Supplement 6 - Standards for Optional State Supplementary Payments
- Supplement 7 - Categorically Needy who are Covered under Requirements more Restrictive than SSI
- Supplement 8a - More Liberal Methods of Treating Income under 1902(r)(2) of the Act
- Supplement 8b - More Liberal Methods of Treating Resources under 1902(r)(2) of the Act
- Supplement 8c - State Long-Term Care Insurance Partnership
- Supplement 9 - Transfer of Resources
- Supplement 9a - Transfer of Assets
- Supplement 10 - Consideration of Medicaid Qualifying Trusts - Undue Hardship
- Supplement 12 - Variations from the Basic Personal Needs Allowance
- Supplement 13 - Section 1924 Provisions
- Supplement 14 - Income and Resource Requirements for Tuberculosis Infected Individuals
- Supplement 15 - Treatment of Optional Groups of Qualified Aliens
- Supplement 16 - Eligibility under Section 1931 of the Act
- Supplement 17 - Disqualification for Long-Term Care Assistance for Individuals with Substantial Home Equity
- Supplement 18 – Federal Medical Assistance Percentage (FMAP)
- Attachment 2.6A Eligibility Conditions and Requirements
- Section 2.7 - Medicaid Furnished Out of State
- Section 2.8 - Modified Adjusted Gross Income (MAGI)
Section 2 - MMDL and MACPro System Approvals
- MACPro - General Eligibility Requirements - Application
- MACPro - Eligibility and Enrollment Processes
- MACPro – Eligibility Groups – Mandatory Coverage
- MACPro – Eligibility Groups – Optional Coverage
- Children under Age 19 with a Disability
- Age and Disability-Related Poverty Level
- Individuals Eligible for Cash Except for Institutionalization
- Individuals in Institutions Eligible under a Special Income Level
- Medically Needy Population Based on Age, Blindness or Disability
- Medically Needy
- Optional Eligibility Groups
- PACE Participants
- Ticket to Work Basic
- MACPro - General Administration
- MMDL SPAs
- A1 - A3 Medicaid Administration
- S10 - MAGI-Based Income Methodologies
- S14 - AFDC Income Standards
- S21 - Presumptive Eligibility by Hospitals
- S25 - Mandatory Coverage - Parents and Other Caretaker Relatives
- S28 - Mandatory Coverage - Pregnant Women
- S30 - Mandatory Coverage - Infants and Children Under Age 19
- S32 - Mandatory Coverage - Adult Group
- S50 - Options for Coverage - Individuals above 133 FPL
- S51 - Options for Coverage - Optional Coverage of Parents and Other Caretaker Relatives
- S52 - Options for Coverage - Reasonable Classification of individuals Under Age 21
- S53 - Options for Coverage - Children with Non IV-E Adoption Assistance
- S54 - Options for Coverage - Optional Targeted Low Income Children
- S55 - Options for Coverage - Individuals with Tuberculosis
- S57 - Options for Coverage - Independent Foster Care Adolescents
- S59 - Options for Coverage - Individuals Eligible for Family Planning Services
- S88 - Non-Financial Eligibility State Residency
- S89 - Non-Financial Eligibility Citizenship and Non-citizen Eligibility
- S94 - General Eligibility Requirements - Eligibility Process
Section 3 - Services: General Provisions
- Section 3.1 - Amount, Duration and Scope of Services
- Attachment 3.1a - Amount Duration and Scope of Services for Categorically Needy
- Item 1 - Inpatient Hospital Services
- Item 2a - Outpatient Hospital Services
- Item 2b - Rural Health Clinic Services
- Item 2c - FQHC Services
- Item 3 - Other Laboratory and X-Ray Services
- Item 4a - Skilled Nursing and Surgical Services for Individuals 21 or Older
- Item 4b - EPSDT Services
- Item 4c - Family Planning
- Item 5 - Physician Services
- Item 5b - Medical and Surgical Services Furnished by a Dentist
- Item 6 - Medical and Remedial Care Furnished by Other Licensed Practitioners
- Item 7 - Home Health Care Services
- Item 9 - Clinic Services
- Item 12a - Prescribed Drugs
- Item 12b - Dentures
- Item 12c - Prosthetic Devices
- Item 13c - Preventive Services
- Item 13d - Rehabilitative Services
- Item 14a - Services for Individuals 65 or older in Institutions for Mental Diseases
- Item 15 - Intermediate Care Facility Services
- Item 16 - Inpatient Psychiatric Facility Services for Under 21
- Item 17 - Nurse Midwife Services
- Item 18 - Hospice Care Services
- Item 19 - Targeted Case Management Services
- Item 19b - Special Tuberculosis-Related Services for Tuberculosis Infected Individuals
- Item 20a - Pregnancy Related and Postpartum Services
- Item 20b - Extended Services for Pregnant Women
- Item 23 - Nurse Practitioner Services
- Item 24a - Medical Transportation Services
- Item 24d - Skilled Nursing Facility Services for Individuals Under 21
- Item 26 - Personal Care Services
- Supplement 1 - Targeted Case Management
- Supplement 2 - Self-Directed Personal Assistance Services
- Supplement 3 - PACE
- Supplement 4 - Medication-Assisted Treatment
- Attachment 3.1b - Amount, Duration and Scope of services Provided to Medically Needy Groups
- Attachment 3.1c - Standards and Methods for Assuring High Quality Care
- Attachment 3.1d - Methods of Providing Transportation
- Attachment 3.1e - Standards for Coverage of Organ Transplants
- Attachment 3.1f - Managed Care
- Attachment 3.1a - Amount Duration and Scope of Services for Categorically Needy
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Section 3.2 - Coordination of Medicaid with Medicare and Other Insurance
- Attachment 3.2a - Coordination of Medicare
- Section 3.3 - Medicaid for Individuals 65 or Over in Institutions for Mental Disease
- Section 3.4 - Special Requirements Applicable to Sterilization Procedures
- Section 3.5 - Families Receiving Extended Medicaid Benefits
- Section 3.6 - Additional Amounts for Nursing Facility Residents
Section 3 - MMDL System Approvals
Alternative Benefit Plan (ABP)
- ABP1 - Alternative Benefit Plan Populations
- ABP2a - Voluntary Benefit Package Selection Assurances - Eligibility Group Under 1902
- ABP3 - Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package
- ABP4 - Alternative Benefit Plan Cost-Sharing
- ABP5 - Benefits Description
- ABP7 - Benefits Assurances
- ABP8 - Service Delivery Systems
- ABP9 - Employer Sponsored Insurance and Payment of Premiums
- ABP11 - Payment Methodology
Section 4 - General Program Administration
- Section 4.1 - Methods of Administration
- Section 4.2 - Hearings for Applicants and Recipients
- Attachment 4.2a - Fair Hearings
- Section 4.3 - Safeguarding Information on Applicants and Recipients
- Section 4.4 - Medicaid Quality Control
- Section 4.5 - Medicaid Agency Fraud Detection and Investigation Program
- Section 4.6 - Reports
- Section 4.7 - Maintenance of Records
- Section 4.8 - Availability of Agency Program Manuals
- Section 4.9 - Reporting Provider Payments to the IRS
- Section 4.10 - Free Choice of Providers
- Section 4.11 - Relations with Standard-Setting and Survey Agencies
- Attachment 4.11a - Standards for Institutions
- Section 4.12 - Consultation to Medical Facilities
- Section 4.13 - Required Provider Agreement
- Section 4.14 - Utilization Control
- Attachment 4.14b - Utilization Review Methods for Intermediate Care Facilities
- Section 4.15 - Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Disease
- Section 4.16 - Relations with State Health and Vocational Rehab Agencies and Title V Grantees
- Section 4.17 - Liens and Adjustments or Recoveries
- Attachment 4.17a - Liens and Adjustments or Recoveries
- Section 4.18 - Medicaid Premiums and Cost Sharing
- Attachment 4.18
- Section 4.19 - Payment for Services
- Attachment 4.19a
- Attachment 4.19b
- Item 2a - Outpatient Hospital Services
- Item 2b - Rural Health Clinic Services
- Item 2c - FQHC Services
- Item 2d - Reimbursement for Indian Health Services Tribal 638 Facilities
- Item 3 - Other Laboratory and X-Ray Services
- Item 4b - EPSDT Services
- Item 4c - Family Planning Services and Supplies for Individuals of Child Bearing Age
- Item 5 - Physician Services
- Item 5b - Medical and Surgical Services Provided by a Dentist
- Item 6 - Medical and Remedial Care Furnished by Other Licensed Providers
- Item 7 - Home Health Care Services
- Item 9 - Clinic Services
- Item 12a - Prescribed Drugs
- Item 12b - Dentures
- Item 12c - Prosthetic Devices
- Item 13c - Preventive Services
- Item 13d - Rehabilitative Services
- Item 17 - Nurse Midwife Services
- Item 18 - Hospice Care Services
- Item 19 - Targeted Case Management Services
- Item 19b - Special Tuberculosis-related Services for Tuberculosis Infected Individuals
- Item 20a - Pregnancy-related and Postpartum Services
- Item 20b - Extended Services for Pregnant Women
- Item 23 - Nurse Practitioner Services
- Item 24a - Medical Transportation Services
- Item 24d - Skilled Nursing Facility Services for Individuals under 21
- Item 26 - Personal Care Services
- Item 28 - Self-directed Personal Assistance Services
- Item 28(i) - Free-Standing Birthing Centers
- Item 29 - Medication-Assisted Treatment
- Item 30 – Qualifying Clinical Trials
- Supplement 1 - Payment Rates for Title XIII Part A and Part B Deductible/Coinsurance
- Attachment 4.19c - Methods of Payment for Reserving Beds During a Recipients Absence from an Inpatient Facility
- Attachment 4.19d(1) - Payments for Skilled Nursing Facilities
- Attachment 4.19d(2) - Payments for Intermediate Care Facilities
- Attachment 4.19e - Timely Claims Payment - Definition of Claim
- Attachment 4.19a
- Section 4.20 - Direct Payment to Certain Recipients for Physician or Dentist Services
- Section 4.21 - Prohibition Against Reassignment of Provider Claims
- Section 4.22 - Third Party Liability
- Attachment 4.22a - Requirements for Third Party Liability - Identifying Liable Resources
- Attachment 4.22b - Requirements for Third Party Liability - Payment of Claims
- Attachment 4.22c - Requirements for Third Party Liability - Cost Effectiveness for Employer Based Group Health Benefit Plans
- Supplement 1 - State Laws Requiring Third Parties to Provide Coverage Eligibility and Claims Data
- Section 4.23 - Use of Contracts
- Section 4.24 - Standards for Payments for Skilled Nursing and Intermediate Care Facility Services
- Section 4.25 - Program for Licensing Administrators of Nursing Homes
- Section 4.26 - Drug Utilization Program
- Section 4.27 - Disclosure of Survey Information and Provider or Contractor Evaluation
- Section 4.28 - Appeals Process for Skilled Nursing and Intermediate Care Facility Services
- Section 4.29 - Conflict of Interest Provisions
- Section 4.30 - Exclusion of Providers and Suspension of Practitioners and Other Individuals
- Attachment 4.30 - Sanctions for Psychiatric Hospitals
- Section 4.31 - Disclosure of Information by Providers and Fiscal Agents
- Section 4.32 - Income and Eligibility Verification System
- Section 4.33 - Medicaid Eligibility Cards for Homeless Individuals
- Attachment 4.33a - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals
- Section 4.34 - Systematic Alien Verification for Entitlements
- Attachment 4.34a - Requirements for Advance Directives
- Section 4.35 - Enforcement of Compliance for Nursing Homes
- Attachment 4.35a - Enforcement of Compliance for Nursing Facilities
- Section 4.36 - Required Coordination Between Medicaid and WIC Programs
- Section 4.38 - Nurse Aide Training and Competency Evaluation for Nursing Facilities
- Attachment 4.38 - Collection and Disclosure of Additional Registry Information
- Section 4.39 - Pre-admission Screening and Annual Resident Review in Nursing Facilities
- Attachment 4.39 - Definition of Specialized Services
- Attachment 4.39a - Categorical Determinations
- Section 4.41 - Resident Assessment for Nursing Facilities
- Section 4.42 - Employee Education About False Claims Recoveries
- Section 4.43 - Cooperation with Medicaid Integrity Program Efforts
- Section 4.44 - Prohibition on Payments to Institutions or Entities Located Outside the U.S.
- Section 4.46 - Provider Screening and Enrollment
Section 5 - Personnel Administration
- Section 5.1 - Standards of Personnel Administration
- Section 5.2 - Reserved
- Section 5.3 - Training Programs - Sub-professional and Volunteer Programs
Section 6 - Financial Administration
- Section 6.1 - Fiscal Policies and Accountability
- Section 6.2 - Cost Allocation
- Section 6.3 - State Financial Participation
Section 7 - General Provisions
- Section 7.1 - Plan Amendments
- Section 7.2 - Non-discrimination
- Attachment 7.2a - Methods of Administration - Compliance with Civil Rights Act (Title VI)
- Section 7.4 - State Governor's Review
- Section 7.4.A - Rescissions to Medicaid Disaster Relief COVID-19 National Emergency
- Section 7.4.B - Temporary Extensions to the Disaster Relief Policies for the COVID-19 National Emergency
- Section 7.4.C - Temporary Policies in Effect Following the COVID-19 National Emergency
- Section 7.4.1 - Medicaid Disaster Relief COVID-19 National Emergency
- Medicaid Disaster Relief Increase Reimbursement Vaccine Administration
- Medicaid Disaster Relief Laboratory Services
- Medicaid Disaster Relief Administrative Claiming
- Medicaid Disaster Relief FQHC and RHC - Alternative Payment Methodology
- Medicaid Disaster Relief FQHC and RHC - Alternative Payment Methodology COVID-19 Monoclonal Treatment
- Medicaid Disaster Relief SPA - ICF-IID Direct Care Add-On
- Medicaid Disaster Relief SPA – Home and Community-Based Services Spending Plan – Targeted Case Management and Personal Care Services
- Medicaid Disaster Relief SPA – Home and Community-Based Services - Personal Care Services
- Section 7.7 - COVID-19 Vaccine and Vaccine Administration, Testing, and Treatment
- Section 7.7-A - COVID-19 Vaccine and Vaccine Administration
- Section 7.7-B - COVID 19 Testing
- Section 7.7-C - COVID-19 Treatment