Medicaid State Plan (Title XIX)

 
2
Medicaid Related Assistance
Medicaid & Long-Term Care
 
No
No

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What you need to know

​​The State Plan is the official document describing the nature and scope of the Nebraska Medicaid Program. There are seven sections that comprise the State Plan (Part 1) as well as many accompanying attachments and amendments (Parts 2 and 3). Each part was developed by Nebraska and approved by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS).

Questions regarding the Nebraska State Plan may be sent to DHHS.MedicaidSPA@nebraska.gov.

The State Plan is available in 3 large sections (Parts 1-3), located at the bottom of the page.

Section 1 - Single State Agency Organization

  
  
collapse Subsection : 1 ‎(3)
collapse State Plan : Part 1 ‎(1)
Designation and Authority.pdfDesignation and Authority
collapse State Plan : Part 2-3 ‎(2)
Attachment 1.1a - Attorney General's Certification.pdfAttachment 1.1a - Attorney General's Certification
Attachment 1.1b - Waiver(s) of the Single State Agency Requirement Granted Under the Intergovernmental Cooperation Act.pdfAttachment 1.1b - Waiver(s) of the Single State Agency Requirement Granted Under the Intergovernmental Cooperation Act
collapse Subsection : 2 ‎(4)
collapse State Plan : Part 1 ‎(1)
Organization and Administration.pdfOrganization and Administration
collapse State Plan : Part 2-3 ‎(3)
Attachment 1.2a - Organization and Functions of the Medicaid Agency.pdfAttachment 1.2a - Organization and Functions of the Medicaid Agency
Attachment 1.2b - Organization and Function of the Medical Assistance Unit.pdfAttachment 1.2b - Organization and Function of the Medical Assistance Unit
Attachment 1.2c - Medical Professionals Involved in the Administration of the Medical Assistance Program.pdfAttachment 1.2c - Medical Professionals Involved in the Administration of the Medical Assistance Program
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
Statewide Operation.pdfStatewide Operation
collapse Subsection : 4 ‎(1)
collapse State Plan : Part 1 ‎(1)
State Medical Care Advisory Committee.pdfState Medical Care Advisory Committee
collapse Subsection : 5 ‎(1)
collapse State Plan : Part 1 ‎(1)
Pediatric Immunization Program.pdfPediatric Immunization Program

 

Section 2 - Coverage and Eligibility

  
  
collapse Subsection : 1 ‎(1)
collapse State Plan : Part 1 ‎(1)
Application, Determination of Eligibility and Furnishing Medicaid.pdfApplication, Determination of Eligibility and Furnishing Medicaid
collapse Subsection : 2 ‎(4)
collapse State Plan : Part 1 ‎(1)
Coverage and Conditions of Eligibility.pdfCoverage and Conditions of Eligibility
collapse State Plan : Part 2-3 ‎(3)
Attachment 2.2a - Groups Covered and Agencies Responsible for Eligibility Determinations.pdfAttachment 2.2a - Groups Covered and Agencies Responsible for Eligibility Determinations
Supplement 1 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18.pdfSupplement 1 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18
Supplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home.pdfSupplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
Residence.pdfResidence
collapse Subsection : 4 ‎(1)
collapse State Plan : Part 1 ‎(1)
Blindness.pdfBlindness
collapse Subsection : 5 ‎(1)
collapse State Plan : Part 1 ‎(1)
Disability.pdfDisability
collapse Subsection : 6 ‎(25)
collapse State Plan : Part 1 ‎(1)
Financial Eligibility.pdfFinancial Eligibility
collapse State Plan : Part 2-3 ‎(24)
Attachment 2.6a -  Eligibility Conditions and Requirements.pdfAttachment 2.6a - Eligibility Conditions and Requirements
Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries.pdfSupplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries
Supplement 2 -  Resource Levels - Categorically Needy, Including Groups with Income Up to a Percentage of the Federal Poverty Level, Medically Needy, and Other Optional Groups.pdfSupplement 2 - Resource Levels - Categorically Needy, Including Groups with Income 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 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.pdfSupplement 8b - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act
Supplement 8c - State Long-Term Care Insurance Partnership.pdfSupplement 8c - State Long-Term Care Insurance Partnership
Supplement 9 - Transfer of Resources.pdfSupplement 9 - Transfer of Resources
Supplement 9a - Transfer of Assets.pdfSupplement 9a - Transfer of Assets
Supplement 9b - Transfer of Assets.pdfSupplement 9b - Transfer of Assets
Supplement 10 - Consideration of Medicaid Qualifying Trusts- Undue Hardship.pdfSupplement 10 - Consideration of Medicaid Qualifying Trusts- Undue Hardship
Supplement 11 - Cost-Effective Methods for COBRA Groups.pdfSupplement 11 - Cost-Effective Methods for COBRA Groups
Supplement 12 - Eligibility Under Section 1931 of the Act.pdfSupplement 12 - Eligibility Under Section 1931 of the Act
Supplement 13 - Section 1924 Provisions.pdfSupplement 13 - Section 1924 Provisions
Supplement 14 - Qualified Disabled and Working Individuals.pdfSupplement 14 - Qualified Disabled and Working Individuals
Supplement 15 - Variations From the Basic Personal Needs Allowance.pdfSupplement 15 - Variations From the Basic Personal Needs Allowance
Supplement 16 - Asset Verification System.pdfSupplement 16 - Asset Verification System
Supplement 17 - Disqualifications for Long-Term Care Assistance for Individuals with Substantial Home Equity.pdfSupplement 17 - Disqualifications for Long-Term Care Assistance for Individuals with Substantial Home Equity
collapse Subsection : 7 ‎(1)
collapse State Plan : Part 1 ‎(1)
Medicaid Furnished out of State.pdfMedicaid Furnished out of State

 

Section 2 - MMDL System Approvals

  
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
S33 - Mandatory Coverage - Former Foster Care Children
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

  
  
collapse Subsection : 1 ‎(54)
collapse State Plan : Part 1 ‎(1)
Amount, Duration, and Scope of Services.pdfAmount, Duration, and Scope of Services
collapse State Plan : Part 2-3 ‎(53)
Attachment 3.1a - Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy.pdfAttachment 3.1a - Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
Item 1 - Limitations - Inpatient Hospitals.pdfItem 1 - Limitations - Inpatient Hospitals
Item 2a - Limitations - Outpatient Hospitals.pdfItem 2a - Limitations - Outpatient Hospitals
Item 2b - Limitations - Rural Health Clinic Services.pdfItem 2b - Limitations - Rural Health Clinic Services
Item 2c - Limitations - Federally Qualified Health Centers.pdfItem 2c - Limitations - Federally Qualified Health Centers
Item 3 - Limitations - Other Laboratory and X-Ray Services.pdfItem 3 - Limitations - Other Laboratory and X-Ray Services
Item 4a - Limitations - Assessments of Developmentally Disabled Person in SNF.pdfItem 4a - Limitations - Assessments of Developmentally Disabled Person in SNF
Item 4b - Limitations - Early and Periodic Screening and Diagnosis and Treatment of Conditions Found.pdfItem 4b - Limitations - Early and Periodic Screening and Diagnosis and Treatment of Conditions Found
Item 5 - Limitations - Physician’s Services.pdfItem 5 - Limitations - Physician’s Services
Item 6a - Limitations - Podiatrists’ Services.pdfItem 6a - Limitations - Podiatrists’ Services
Item 6b - Limitations - Optometrists’ Services.pdfItem 6b - Limitations - Optometrists’ Services
Item 6c - Limitations - Chiropractic Services.pdfItem 6c - Limitations - Chiropractic Services
Item 6d - Limitations - Other Practitioners Services.pdfItem 6d - Limitations - Other Practitioners Services
Item 7a - Limitations - Home Health Nursing Services.pdfItem 7a - Limitations - Home Health Nursing Services
Item 7b - Limitations - Home Health Agencies - Home Health Aide Services.pdfItem 7b - Limitations - Home Health Agencies - Home Health Aide Services
Item 7c - Limitations - Medical Supplies, Equipment, and Appliances Suitable for Use in the Home.pdfItem 7c - Limitations - Medical Supplies, Equipment, and Appliances Suitable for Use in the Home
Item 7d - Limitations - Home Health Services - Physical Therapy, Occupational Therapy, and Speech Pathology and Audiology.pdfItem 7d - Limitations - Home Health Services - Physical Therapy, Occupational Therapy, and Speech Pathology and Audiology
Item 8 - Limitations - Private Duty Nursing Services.pdfItem 8 - Limitations - Private Duty Nursing Services
Item 9 - Limitations - Clinic Services.pdfItem 9 - Limitations - Clinic Services
Item 10 - Limitations - Dental Services.pdfItem 10 - Limitations - Dental Services
Item 11a - Limitations - Physical Therapy.pdfItem 11a - Limitations - Physical Therapy
Item 11b - Limitations - Occupational Therapy.pdfItem 11b - Limitations - Occupational Therapy
Item 11c - Limitations - Services for Individuals with Speech, Hearing, and Language Disorders.pdfItem 11c - Limitations - Services for Individuals with Speech, Hearing, and Language Disorders
Item 12a - Limitations - Prescribed Drugs.pdfItem 12a - Limitations - Prescribed Drugs
Item 12b - Limitations - Dentures.pdfItem 12b - Limitations - Dentures
Item 12c - Limitations - Prosthetic Devices.pdfItem 12c - Limitations - Prosthetic Devices
Item 12d - Limitations - Eye Glasses.pdfItem 12d - Limitations - Eye Glasses
Item 13b - Limitations - Screening Services.pdfItem 13b - Limitations - Screening Services
Item 13c - Limitations - Preventative Services.pdfItem 13c - Limitations - Preventative Services
Item 13d - Limitations - Rehabilitative Services.pdfItem 13d - Limitations - Rehabilitative Services
Item 14a - Limitations - Services for Individuals Age 65 or Older in Institutions    for Mental Diseases - Inpatient Hospital Services.pdfItem 14a - Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Inpatient Hospital Services
Item 14b - Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Skilled Nursing Facility Services.pdfItem 14b - Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Skilled Nursing Facility Services
Item 14c - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Intermediate Care Facility Services.pdfItem 14c - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Intermediate Care Facility Services
Item 15 - ICF-DD Services.pdfItem 15 - ICF-DD Services
Item 16 - Inpatient Psychiatric Facility Services for Individuals Under Age 21.pdfItem 16 - Inpatient Psychiatric Facility Services for Individuals Under Age 21
Item 17 - Nurse-Midwife Services.pdfItem 17 - Nurse-Midwife Services
Item 18 - Medical and Remedial Care and Services.pdfItem 18 - Medical and Remedial Care and Services
Item 20a - Limitations - Pregnancy -related and Postpartum Services for 60 Days After the Pregnancy Ends.pdfItem 20a - Limitations - Pregnancy -related and Postpartum Services for 60 Days After the Pregnancy Ends
Item 20b - Limitations - Services for Any Other Medical Conditions that May Complicate Pregnancy.pdfItem 20b - Limitations - Services for Any Other Medical Conditions that May Complicate Pregnancy
Item 23 - Limitations - Certified Pediatric or Family Nurse Practitioners’ Services.pdfItem 23 - Limitations - Certified Pediatric or Family Nurse Practitioners’ Services
Item 24a - Limitations - Transportation.pdfItem 24a - Limitations - Transportation
Item 24d - Limitations - Nursing Facility Services for Patients Under 21 Years of Age.pdfItem 24d - Limitations - Nursing Facility Services for Patients Under 21 Years of Age
Item 24e - Limitations - Emergency Hospital Services.pdfItem 24e - Limitations - Emergency Hospital Services
Item 24f - Limitations - Critical Access Hospitals.pdfItem 24f - Limitations - Critical Access Hospitals
Item 26 - Limitations - Personal Assistance Services.pdfItem 26 - Limitations - Personal Assistance Services
Item 27 - Limitations - Freestanding Birth Center Services.pdfItem 27 - Limitations - Freestanding Birth Center Services
Supplements 1-3 - Case Management Services.pdfSupplements 1-3 - Case Management Services
Supplement 4 - PACE.pdfSupplement 4 - PACE
Attachment 3.1b - Amount, Duration, and Scope of Services Provided Medically Needy Groups.pdfAttachment 3.1b - Amount, Duration, and Scope of Services Provided Medically Needy Groups
Attachment 3.1c - Standards and Methods of Assuring High Quality Care.pdfAttachment 3.1c - Standards and Methods of Assuring High Quality Care
Attachment 3.1d - Transportation.pdfAttachment 3.1d - Transportation
Attachment 3.1e - Standards for the Coverage of Organ Transplant Services.pdfAttachment 3.1e - Standards for the Coverage of Organ Transplant Services
Attachment 3.1f - MCO and enhanced PCCM programs (replaced with the 1915(b) Waiver).pdfAttachment 3.1f - MCO and enhanced PCCM programs (replaced with the 1915(b) Waiver)
collapse Subsection : 2 ‎(2)
collapse State Plan : Part 1 ‎(1)
Coordination of Medicaid with Medicare and Other Insurance.pdfCoordination of Medicaid with Medicare and Other Insurance
collapse State Plan : Part 2-3 ‎(1)
Attachment 3.2a - Coordination of Title XIX with Part B of Title XVIII.pdfAttachment 3.2a - Coordination of Title XIX with Part B of Title XVIII
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases.pdfMedicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
collapse Subsection : 4 ‎(1)
collapse State Plan : Part 1 ‎(1)
Special Requirements Applicable to Sterilization Procedures.pdfSpecial Requirements Applicable to Sterilization Procedures
collapse Subsection : 5 ‎(1)
collapse State Plan : Part 1 ‎(1)
Families Receiving Extended Medicaid Benefits.pdfFamilies Receiving Extended Medicaid Benefits

 

Section 4 - General Program Administration

 

  
  
collapse Subsection : 1 ‎(1)
collapse State Plan : Part 1 ‎(1)
Methods of Administration.pdfMethods of Administration
collapse Subsection : 2 ‎(1)
collapse State Plan : Part 1 ‎(1)
Hearings for Applicants and Recipients.pdfHearings for Applicants and Recipients
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
Safeguarding Information on Applicants and Recipients.pdfSafeguarding Information on Applicants and Recipients
collapse Subsection : 4 ‎(1)
collapse State Plan : Part 1 ‎(1)
Medicaid Quality Control.pdfMedicaid Quality Control
collapse Subsection : 5 ‎(1)
collapse State Plan : Part 1 ‎(1)
Medicaid Agency Fraud Detection and Investigation Program.pdfMedicaid Agency Fraud Detection and Investigation Program
collapse Subsection : 6 ‎(1)
collapse State Plan : Part 1 ‎(1)
Records.pdfRecords
collapse Subsection : 7 ‎(1)
collapse State Plan : Part 1 ‎(1)
Maintenance of Records.pdfMaintenance of Records
collapse Subsection : 8 ‎(1)
collapse State Plan : Part 1 ‎(1)
Availability of Agency Program Manuals.pdfAvailability of Agency Program Manuals
collapse Subsection : 9 ‎(1)
collapse State Plan : Part 1 ‎(1)
Reporting Provider Payments to the Internal Revenue Service.pdfReporting Provider Payments to the Internal Revenue Service
collapse Subsection : 10 ‎(1)
collapse State Plan : Part 1 ‎(1)
Free Choice of Providers.pdfFree Choice of Providers
collapse Subsection : 11 ‎(2)
collapse State Plan : Part 1 ‎(1)
Relations with Standard-Setting and Survey Agencies.pdfRelations with Standard-Setting and Survey Agencies
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.11a - Standards for Institution.pdfAttachment 4.11a - Standards for Institution
collapse Subsection : 12 ‎(1)
collapse State Plan : Part 1 ‎(1)
Consultation to Medical Facilities.pdfConsultation to Medical Facilities
collapse Subsection : 13 ‎(1)
collapse State Plan : Part 1 ‎(1)
Required Provider Agreement.pdfRequired Provider Agreement
collapse Subsection : 14 ‎(1)
collapse State Plan : Part 1 ‎(1)
Utilization and Quality Control.pdfUtilization and Quality Control
collapse Subsection : 15 ‎(1)
collapse State Plan : Part 1 ‎(1)
Inspection of Care in Intermediate Care Facilities for the Developmentally Disabled, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals.pdfInspection of Care in Intermediate Care Facilities for the Developmentally Disabled, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals
collapse Subsection : 16 ‎(2)
collapse State Plan : Part 1 ‎(1)
Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees.pdfRelations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.16a - Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees.pdfAttachment 4.16a - Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees
collapse Subsection : 17 ‎(2)
collapse State Plan : Part 1 ‎(1)
Liens and Adjustments or Recoveries.pdfLiens and Adjustments or Recoveries
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.17a - Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home – Liens and Adjustments or Recoveries.pdfAttachment 4.17a - Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home – Liens and Adjustments or Recoveries
collapse Subsection : 18 ‎(7)
collapse State Plan : Part 1 ‎(1)
Cost Sharing and Similar Charges.pdfCost Sharing and Similar Charges
collapse State Plan : Part 2-3 ‎(6)
Attachment 4.18a - Charges Imposed on Categorically Needy.pdfAttachment 4.18a - Charges Imposed on Categorically Needy
Attachment 4.18b - Medically Needy - Premium.pdfAttachment 4.18b - Medically Needy - Premium
Attachment 4.18c - Charges Imposed on Medically Needy and Other Optional Groups.pdfAttachment 4.18c - Charges Imposed on Medically Needy and Other Optional Groups
Attachment 4.18d - Premiums Imposed on Low Income Pregnant Women and Infants.pdfAttachment 4.18d - Premiums Imposed on Low Income Pregnant Women and Infants
Attachment 4.18e - Premiums Imposed on Qualified Disabled and Working Individuals.pdfAttachment 4.18e - Premiums Imposed on Qualified Disabled and Working Individuals
Attachment 4.18f - Premiums for Families Above 100 percent of FPL.pdfAttachment 4.18f - Premiums for Families Above 100 percent of FPL
collapse Subsection : 19 ‎(52)
collapse State Plan : Part 1 ‎(1)
Payment for Services.pdfPayment for Services
collapse State Plan : Part 2-3 ‎(51)
Attachment 4.19a - Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care.pdfAttachment 4.19a - Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care
Attachment 4.19b Item 1 -  General statement on fee schedules.pdfAttachment 4.19b Item 1 - General statement on fee schedules
Attachment 4.19b Item 1c - Payment Adjustment for Provider Preventable Conditions.pdfAttachment 4.19b Item 1c - Payment Adjustment for Provider Preventable Conditions
Attachment 4.19b Item 2a - Outpatient hospital and emergency room; hospital-affiliated ambulatory surgical centers, out-of-state hospital; telehealth.pdfAttachment 4.19b Item 2a - Outpatient hospital and emergency room; hospital-affiliated ambulatory surgical centers, out-of-state hospital; telehealth
Attachment 4.19b Item 2b - Rural Health Centers-Clinic; telehealth.pdfAttachment 4.19b Item 2b - Rural Health Centers-Clinic; telehealth
Attachment 4.19b Item 2c - Federally-qualified health centers; telehealth.pdfAttachment 4.19b Item 2c - Federally-qualified health centers; telehealth
Attachment 4.19b Item 2d - Indian Health Service and Tribal health facilities; telehealth.pdfAttachment 4.19b Item 2d - Indian Health Service and Tribal health facilities; telehealth
Attachment 4.19b Item 3 -  Other laboratory and x-ray services; telehealth.pdfAttachment 4.19b Item 3 - Other laboratory and x-ray services; telehealth
Attachment 4.19b Item 4a - Skilled nursing facilities.pdfAttachment 4.19b Item 4a - Skilled nursing facilities
Attachment 4.19b Item 4b - EPSDT; telehealth.pdfAttachment 4.19b Item 4b - EPSDT; telehealth
Attachment 4.19b Item 4c - Family Planning Services; telehealth.pdfAttachment 4.19b Item 4c - Family Planning Services; telehealth
Attachment 4.19b Item 5 - Physicians’ services; telehealth.pdfAttachment 4.19b Item 5 - Physicians’ services; telehealth
Attachment 4.19b Item 6a - Podiatrists’ services; telehealth.pdfAttachment 4.19b Item 6a - Podiatrists’ services; telehealth
Attachment 4.19b Item 6b - Optometrists’ services; telehealth.pdfAttachment 4.19b Item 6b - Optometrists’ services; telehealth
Attachment 4.19b Item 6c - Chiropractors' services; telehealth.pdfAttachment 4.19b Item 6c - Chiropractors' services; telehealth
Attachment 4.19b Item 6d - Other practitioner services - Certified registered nurse anesthetists; telehealth.pdfAttachment 4.19b Item 6d - Other practitioner services - Certified registered nurse anesthetists; telehealth
Attachment 4.19b Item 7 - Home Health Services; telehealth.pdfAttachment 4.19b Item 7 - Home Health Services; telehealth
Attachment 4.19b Item 7c - Medical supplies, equipment, and appliances for suitable use in the home.pdfAttachment 4.19b Item 7c - Medical supplies, equipment, and appliances for suitable use in the home
Attachment 4.19b Item 8 - Private duty nursing services.pdfAttachment 4.19b Item 8 - Private duty nursing services
Attachment 4.19b Item 9 - Clinic services and outpatient mental health services; telehealth; ambulatory surgical centers.pdfAttachment 4.19b Item 9 - Clinic services and outpatient mental health services; telehealth; ambulatory surgical centers
Attachment 4.19b Item 10 - Dental Services; telehealth.pdfAttachment 4.19b Item 10 - Dental Services; telehealth
Attachment 4.19b Item 11a - Physical Therapy; telehealth.pdfAttachment 4.19b Item 11a - Physical Therapy; telehealth
Attachment 4.19b Item 11b - Occupational Therapy; telehealth.pdfAttachment 4.19b Item 11b - Occupational Therapy; telehealth
Attachment 4.19b Item 11c - Speech, hearing, and Language services.pdfAttachment 4.19b Item 11c - Speech, hearing, and Language services
Attachment 4.19b Item 12a - Prescribed drugs.pdfAttachment 4.19b Item 12a - Prescribed drugs
Attachment 4.19b Item 12b - Dentures.pdfAttachment 4.19b Item 12b - Dentures
Attachment 4.19b Item 12c - Prosthetic devices.pdfAttachment 4.19b Item 12c - Prosthetic devices
Attachment 4.19b Item 12d - Eyeglasses.pdfAttachment 4.19b Item 12d - Eyeglasses
Attachment 4.19b Item 13b - Screening services; telehealth.pdfAttachment 4.19b Item 13b - Screening services; telehealth
Attachment 4.19b Item 13c - Preventative Services.pdfAttachment 4.19b Item 13c - Preventative Services
Attachment 4.19b Item 13d - Community-based comprehensive psychiatric rehabilitation and support services program; telehealth; Assertive Community Treatment.pdfAttachment 4.19b Item 13d - Community-based comprehensive psychiatric rehabilitation and support services program; telehealth; Assertive Community Treatment
Attachment 4.19b Item 14a - Services for Individuals Age 65 or Older in Institutions for Tuberculosis.pdfAttachment 4.19b Item 14a - Services for Individuals Age 65 or Older in Institutions for Tuberculosis
Attachment 4.19b Item 14b - Individuals age 65 or older in institutions for mental diseases.pdfAttachment 4.19b Item 14b - Individuals age 65 or older in institutions for mental diseases
Attachment 4.19b Item 15 - Intermediate Care Facility Services.pdfAttachment 4.19b Item 15 - Intermediate Care Facility Services
Attachment 4.19b Item 16 - Inpatient psychiatric facilities for individuals age 21 or younger; telehealth.pdfAttachment 4.19b Item 16 - Inpatient psychiatric facilities for individuals age 21 or younger; telehealth
Attachment 4.19b Item 17 - Nurse midwife services.pdfAttachment 4.19b Item 17 - Nurse midwife services
Attachment 4.19b Item 18 - Medical and remedial care and services.pdfAttachment 4.19b Item 18 - Medical and remedial care and services
Attachment 4.19b Item 19 - Case Management services.pdfAttachment 4.19b Item 19 - Case Management services
Attachment 4.19b Item 20 - Extended services to pregnant women; telehealth.pdfAttachment 4.19b Item 20 - Extended services to pregnant women; telehealth
Attachment 4.19b Item 21- Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period; telehealth.pdfAttachment 4.19b Item 21- Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period; telehealth
Attachment 4.19b Item 23 - Pediatric or family nurse practitioners.pdfAttachment 4.19b Item 23 - Pediatric or family nurse practitioners
Attachment 4.19b Item 23a - Ambulance and Other Medical Transportation.pdfAttachment 4.19b Item 23a - Ambulance and Other Medical Transportation
Attachment 4.19b Item 24a - Transportation.pdfAttachment 4.19b Item 24a - Transportation
Attachment 4.19b Item 24d - Skilled nursing facility services for patients under 21 years of age.pdfAttachment 4.19b Item 24d - Skilled nursing facility services for patients under 21 years of age
Attachment 4.19b Item 24e - Emergency hospital services.pdfAttachment 4.19b Item 24e - Emergency hospital services
Attachment 4.19b Item 26 - Personal Care Aid services.pdfAttachment 4.19b Item 26 - Personal Care Aid services
Attachment 4.19b Item 27 - Freestanding Birth Center Services.pdfAttachment 4.19b Item 27 - Freestanding Birth Center Services
Attachment 4.19b Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible and Coinsurance.pdfAttachment 4.19b Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible and Coinsurance
Attachment 4.19c - Payments for Reserved Beds.pdfAttachment 4.19c - Payments for Reserved Beds
Attachment 4.19d - Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services.pdfAttachment 4.19d - Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services
Attachment 4.19e - Timely-Claims Payment - Definition of Claim.pdfAttachment 4.19e - Timely-Claims Payment - Definition of Claim
collapse Subsection : 20 ‎(1)
collapse State Plan : Part 1 ‎(1)
Direct Payments to Certain Recipients for Physicians’ or Dentists’ Services.pdfDirect Payments to Certain Recipients for Physicians’ or Dentists’ Services
collapse Subsection : 21 ‎(1)
collapse State Plan : Part 1 ‎(1)
Prohibition Against Reassignment of Provider Claims.pdfProhibition Against Reassignment of Provider Claims
collapse Subsection : 22 ‎(5)
collapse State Plan : Part 1 ‎(1)
Third Party Liability.pdfThird Party Liability
collapse State Plan : Part 2-3 ‎(4)
Attachment 4.22a - Requirements for Third Party Liability - Identifying Liable Resources.pdfAttachment 4.22a - Requirements for Third Party Liability - Identifying Liable Resources
Attachment 4.22b - Requirements for Third Party Liability - Payment of Claims.pdfAttachment 4.22b - Requirements for Third Party Liability - Payment of Claims
Attachment 4.22c - State Methodology on Cost-Effectiveness of Employer-Based Group Health Plans.pdfAttachment 4.22c - State Methodology on Cost-Effectiveness of Employer-Based Group Health Plans
Supplement to 4.22 - State Laws Regarding Third Party Liability.pdfSupplement to 4.22 - State Laws Regarding Third Party Liability
collapse Subsection : 23 ‎(1)
collapse State Plan : Part 1 ‎(1)
Use of Contracts.pdfUse of Contracts
collapse Subsection : 24 ‎(1)
collapse State Plan : Part 1 ‎(1)
Standards for Payments for Nursing Facility and Intermediate Care Facility for the Developmentally Disabled Services.pdfStandards for Payments for Nursing Facility and Intermediate Care Facility for the Developmentally Disabled Services
collapse Subsection : 25 ‎(1)
collapse State Plan : Part 1 ‎(1)
Program for Licensing Administrators of Nursing Homes.pdfProgram for Licensing Administrators of Nursing Homes
collapse Subsection : 26 ‎(1)
collapse State Plan : Part 1 ‎(1)
Drug Utilization Review Programs.pdfDrug Utilization Review Programs
collapse Subsection : 27 ‎(1)
collapse State Plan : Part 1 ‎(1)
Disclosure of Survey Information and Provider or Contractor Evaluation.pdfDisclosure of Survey Information and Provider or Contractor Evaluation
collapse Subsection : 28 ‎(1)
collapse State Plan : Part 1 ‎(1)
Appeals Process (Long-Term Care Facilities).pdfAppeals Process (Long-Term Care Facilities)
collapse Subsection : 29 ‎(1)
collapse State Plan : Part 1 ‎(1)
Conflict of Interest Provisions.pdfConflict of Interest Provisions
collapse Subsection : 30 ‎(2)
collapse State Plan : Part 1 ‎(1)
Exclusion of Providers and Suspension of Practitioners and Other Individuals.pdfExclusion of Providers and Suspension of Practitioners and Other Individuals
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.30 - Sanctions for Psychiatric Hospitals.pdfAttachment 4.30 - Sanctions for Psychiatric Hospitals
collapse Subsection : 31 ‎(1)
collapse State Plan : Part 1 ‎(1)
Disclosure of Information by Providers and Fiscal Agents (4.31) and Income and Eligibility Verification System (4.32).pdfDisclosure of Information by Providers and Fiscal Agents (4.31) and Income and Eligibility Verification System (4.32)
collapse Subsection : 32 ‎(1)
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.32a - Income and Eligibility Verification System Procedures Requests to Other State Agencies.pdfAttachment 4.32a - Income and Eligibility Verification System Procedures Requests to Other State Agencies
collapse Subsection : 33 ‎(2)
collapse State Plan : Part 1 ‎(1)
Medicaid Eligibility Cards for Homeless Individuals.pdfMedicaid Eligibility Cards for Homeless Individuals
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.33a - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals.pdfAttachment 4.33a - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals
collapse Subsection : 34 ‎(2)
collapse State Plan : Part 1 ‎(1)
Systematic Alien Verification for Entitlements.pdfSystematic Alien Verification for Entitlements
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.34a - Requirements for Advance Directives for State Plans for Medical Assistance.pdfAttachment 4.34a - Requirements for Advance Directives for State Plans for Medical Assistance
collapse Subsection : 35 ‎(2)
collapse State Plan : Part 1 ‎(1)
Enforcement of Compliance for Nursing Facilities.pdfEnforcement of Compliance for Nursing Facilities
collapse State Plan : Part 2-3 ‎(1)
Attachments 4.35a-h - Eligibility Conditions and Requirements Enforcement of Compliance for Nursing Facilities.pdfAttachments 4.35a-h - Eligibility Conditions and Requirements Enforcement of Compliance for Nursing Facilities
collapse Subsection : 36 ‎(1)
collapse State Plan : Part 1 ‎(1)
Required Coordination Between the Medicaid and WIC Programs.pdfRequired Coordination Between the Medicaid and WIC Programs
collapse Subsection : 38 ‎(3)
collapse State Plan : Part 1 ‎(1)
Nurse Aide Training and Competency Evaluation for Nursing Facilities.pdfNurse Aide Training and Competency Evaluation for Nursing Facilities
collapse State Plan : Part 2-3 ‎(2)
Attachment 4.38 - Disclosure of Additional Registry Information.pdfAttachment 4.38 - Disclosure of Additional Registry Information
Attachment 4.38a - Collection of Additional Registry Information.pdfAttachment 4.38a - Collection of Additional Registry Information
collapse Subsection : 39 ‎(3)
collapse State Plan : Part 1 ‎(1)
Preadmission Screening and Annual Resident Review in Nursing Facilities.pdfPreadmission Screening and Annual Resident Review in Nursing Facilities
collapse State Plan : Part 2-3 ‎(2)
Attachment 4.39 - Definition of Specialized Services.pdfAttachment 4.39 - Definition of Specialized Services
Attachment 4.39a - Categorical Determinations.pdfAttachment 4.39a - Categorical Determinations
collapse Subsection : 40 ‎(6)
collapse State Plan : Part 1 ‎(1)
Survey and Certification Process.pdfSurvey and Certification Process
collapse State Plan : Part 2-3 ‎(5)
Attachment 4.40a - Survey and Certification Education Program.pdfAttachment 4.40a - Survey and Certification Education Program
Attachment 4.40b - Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property.pdfAttachment 4.40b - Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
Attachment 4.40c - Procedures for Scheduling and Conduct of Standard Surveys.pdfAttachment 4.40c - Procedures for Scheduling and Conduct of Standard Surveys
Attachment 4.40d - Programs to Measure and Reduce Inconsistency.pdfAttachment 4.40d - Programs to Measure and Reduce Inconsistency
Attachment 4.40e - Process of Investigations of Complaints and Monitoring - Nursing Facilities.pdfAttachment 4.40e - Process of Investigations of Complaints and Monitoring - Nursing Facilities
collapse Subsection : 41 ‎(1)
collapse State Plan : Part 1 ‎(1)
Resident Assessment for Nursing Facilities.pdfResident Assessment for Nursing Facilities
collapse Subsection : 42 ‎(2)
collapse State Plan : Part 1 ‎(1)
Employee Education About False Claims Recoveries.pdfEmployee Education About False Claims Recoveries
collapse State Plan : Part 2-3 ‎(1)
Attachment 4.42 - P.S. 109-171, Section 6032 - Monitoring Provider Compliance.pdfAttachment 4.42 - P.S. 109-171, Section 6032 - Monitoring Provider Compliance
collapse Subsection : 43 ‎(1)
collapse State Plan : Part 1 ‎(1)
Cooperation with Medicaid Integrity Program Efforts.pdfCooperation with Medicaid Integrity Program Efforts
collapse Subsection : 44 ‎(1)
collapse State Plan : Part 1 ‎(1)
Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States.pdfMedicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States
collapse Subsection : 45 ‎(1)
collapse State Plan : Part 1 ‎(1)
RESERVED (4.45).pdfRESERVED (4.45)
collapse Subsection : 46 ‎(1)
collapse State Plan : Part 1 ‎(1)
Provider Screening and Enrollment.pdfProvider Screening and Enrollment

 

Section 5 - Personnel Administration

 

  
  
collapse Subsection : 1 ‎(1)
collapse State Plan : Part 1 ‎(1)
Standards of Personnel Administration.pdfStandards of Personnel Administration
collapse Subsection : 2 ‎(1)
collapse State Plan : Part 1 ‎(1)
RESERVED (5.2).pdfRESERVED (5.2)
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
Training Programs; Subprofessional and Volunteer Programs.pdfTraining Programs; Subprofessional and Volunteer Programs

 

Section 6 - Financial Administration

 

  
  
collapse Subsection : 1 ‎(1)
collapse State Plan : Part 1 ‎(1)
Fiscal Policies and Accountability.pdfFiscal Policies and Accountability
collapse Subsection : 2 ‎(1)
collapse State Plan : Part 1 ‎(1)
Cost Allocation.pdfCost Allocation
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
State Financial Participation.pdfState Financial Participation

 

Section 7 - General Provisions  

  
  
collapse Subsection : 1 ‎(1)
collapse State Plan : Part 1 ‎(1)
Plan Amendments.pdfPlan Amendments
collapse Subsection : 2 ‎(2)
collapse State Plan : Part 1 ‎(1)
Nondiscrimination.pdfNondiscrimination
collapse State Plan : Part 2-3 ‎(1)
Attachment 7.2a - Non-discrimination - Civil Rights Act (Title VI).pdfAttachment 7.2a - Non-discrimination - Civil Rights Act (Title VI)
collapse Subsection : 3 ‎(1)
collapse State Plan : Part 1 ‎(1)
RESERVED (7.3).pdfRESERVED (7.3)
collapse Subsection : 4 ‎(1)
collapse State Plan : Part 1 ‎(1)
State Governor's Review.pdfState Governor's Review

 

State Plan Parts 1-3 

Part 1 (Sections 1-7)

Part 2 (Attachments 1.1a through 4.17a)

Part 3 (Attachments 4.18a through 7.2a) - Updated May 13, 2019