Nebraska Medicaid Program

PDF State Plan Attachments

List of Attachments

1.1-A Attorney General’s Certification

1.1-B Waiver(s) of the Single State Agency Requirement Granted Under the Intergovernmental Cooperation Act

1.2-A Organization and Functions of the Medicaid Agency

1.2-B Organization and Function of the Medical Assistance Unit

1.2-C Medical Professionals Involved in the Administration of the Medical Assistance Program

2.2-A Groups Covered and Agencies Responsible for Eligibility Determinations

Supplement 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

2.6-A Eligibility 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 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

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 Resources

Supplement 9a Transfer of Assets

Supplement 10 Consideration of Medicaid Qualifying Trusts- Undue Hardship

Supplement 11 Cost - Effective Methods for COBRA Groups

Supplement 12 Eligibility Under Section 1931 of the Act

Supplement 13 Section 1924 Provisions

Supplement 14 Qualified Disabled and Working Individuals

Supplement 15 Variations From the Basic Personal Needs Allowance

Supplement 17 Disqualifications for Long-Term Care Assistance for Individuals with Substantial Home Equity

3.1-A Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy

Item 1 Limitations - Inpatient Hospitals

Item 2a Limitations -Outpatient Hospitals

Item 2b Limitations -Rural Health Clinic Services

Item 2c Limitations -Federally Qualified Health Centers

Item 3 Limitations - Other Laboratory and X-Ray Services

Item 4a Limitations - Assessments of Developmentally Disabled Person in SNF

Item 4b Limitations - Early and Periodic Screening and Diagnosis and Treatment of Conditions Found

Item 5 Limitations - Physician’s Services

Item 6a Limitations - Podiatrists’ Services

Item 6b Limitations - Optometrists’ Services

Item 6c Limitations -Chiropractic Services

Item 6d Limitations - Other Practitioners Services

Item 7a  Limitations - Home Health Nursing Services

Item 7b Limitations - Home Health Agencies – Home Health Aide Services

Item 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

Item 8 Limitations - Private Duty Nursing Services

Item 9 Limitations - Clinic Services

Item 10 Limitations - Dental Services

Item 11a Limitations - Physical Therapy

Item 11b Limitations - Occupational Therapy

Item 11c Limitations - Services for Individuals with Speech, Hearing, and Language Disorders

Item 12a Limitations - Prescribed Drugs

Item 12b Limitations - Dentures

Item 12c Limitations - Prosthetic Devices

Item 12d Limitations - Eye Glasses

Item 13b Limitations - Screening Services

Item 13d Limitations - Rehabilitative Services

Item 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

Item 14c Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases – Intermediate Care Facility Services

Item 15 Limitations - ICF-MR Services

Item 16 Limitations - Inpatient Psychiatric Facility Services for Individuals Under Age 21

Item 17 Limitations - Nurse-Midwife Services

Item 18 Limitations - Medical and Remedial Care and Services

Item 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

Item 23 Limitations - Certified Pediatric or Family Nurse Practitioners’ Services

Item 24a Limitations - Transportation

Item 24d Limitations - Nursing Facility Services for Patients Under 21 Years of Age

Item 24e Limitations - Emergency Hospital Services

Item 24f Limitations – Critical Access Hospitals

Item 26 Limitations - Personal Assistance Services

Item 27 Limitations - Freestanding Birth Center Services

Supplements 1-3 Case Management Services

Supplement 4 PACE

3.1-B Amount, Duration, and Scope of Services Provided Medically Needy Groups

3.1-C Standards and Methods of Assuring High Quality Care

3.1-D Transportation

3.1-E Standards for the Coverage of Organ Transplant Services

3.1-F MCO and enhanced PCCM programs

3.2-A Coordination of Title XIX with Part B of Title XVIII

4.11-A Standards for Institutions

4.16-A Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

4.17-A Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home – Liens and Adjustments or Recoveries

4.18-A Charges Imposed on Categorically Needy

4.18-B Medically Needy - Premium

4.18-C Charges Imposed on Medically Needy and Other Optional Groups

4.18-D Premiums Imposed on Low Income Pregnant Women and Infants

4.18-E Premiums Imposed on Qualified Disabled and Working Individuals

4.18-F Premiums for Families Above 100% of FPL

4.19-A Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care

4.19-B Methods and Standards for Establishing Payment Rates - Other Types of Care

Item 1 General statement on fee schedules

Item 1a General statement on telehealth fees

Item 1c Payment Adjustment for Provider Preventable Conditions

Item 2a Outpatient hospital and emergency room; hospital-affiliated ambulatory surgical centers, out-of-state hospital; telehealth

Item 2b Rural Health Centers/Clinic; telehealth;

Item 2c Federally-qualified health centers; telehealth

Item 2d Indian Health Service and Tribal health facilities; telehealth

Item 3 Other laboratory and x-ray services; telehealth;

Item 4a Skilled nursing facilities

Item 4b EPSDT; telehealth

Item 4c Family Planning Services; telehealth

Item 5 Physicians’ services; telehealth

Item 6a Podiatrists’ services; telehealth

Item 6b Optometrists’ services; telehealth

Item 6c Chiropractors’ services; telehealth

Item 6d Other practitioner services - Certified registered nurse anesthetists; telehealth

Item 7 Home Health Services; telehealth

Item 7c Medical supplies, equipment, and appliances for suitable use in the home

Item 8 Private duty nursing services

Item 9 Clinic services and outpatient mental health services; telehealth; ambulatory surgical centers

Item 10 Dental Services; telehealth

Item 11a Physical Therapy; telehealth

Item 11b Occupational Therapy; telehealth

Item 11c Speech, hearing, and Language services

Item 12a Prescribed drugs

Item 12b Dentures

Item 12c Prosthetic devices

Item 12d Eyeglasses

Item 13b Screening services; telehealth

Item 13d Community-based comprehensive psychiatric rehabilitation and support services program; telehealth; Assertive Community Treatment

Item 14a Services for Individuals Age 65 or Older in Institutions for Tuberculosis

Item 14b Individuals age 65 or older in institutions for mental diseases

Item 15 Intermediate Care Facility Services

Item 16 Inpatient psychiatric facilities for individuals age 21 or younger; telehealth

Item 17 Nurse midwife services

Item 18 Medical and remedial care and services

Item 19 Case Management services

Item 20 Extended services to pregnant women; telehealth

Item 21 Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period; telehealth

Item 23 Pediatric or family nurse practitioners

Item 23a Ambulance and Other Medical Transportation

Item 24a Transportation

Item 24d Skilled nursing facility services for patients under 21 years of age

Item 24e Emergency hospital services

Item 26 Personal Care Aid services

Item 27 Freestanding Birth Center Services

Supplement 1 Methods and Standards for Establishing Payment Rates for Title XVIII Deductible/Coinsurance

4.19-C Payments for Reserved Beds

4.19-D Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services

4.19-E Timely-Claims Payment - Definition of Claim

4.22-A Requirements for Third Party Liability - Identifying Liable Resources

4.22-B Requirements for Third Party Liability - Payment of Claims

4.22-C State Methodology on Cost-Effectiveness of Employer-Based Group Health Plans

Supplement to 4.22 – State Laws Regarding Third Party Liability

4.30 Sanctions for Psychiatric Hospitals

4.32-A Income and Eligibility Verification System Procedures: Requests to Other State Agencies

4.33-A Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals

4.34-A Requirements for Advance Directives for State Plans for Medical Assistance

4.35-A-H Eligibility Conditions and Requirements Enforcement of Compliance for Nursing Facilities

4.38 Disclosure of Additional Registry Information

4.38-A Collection of Additional Registry Information

4.39 Definition of Specialized Services

4.39-A Categorical Determinations

4.40-A Survey and Certification Education Program

4.40-B Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property

4.40-C Procedures for Scheduling and Conduct of Standard Surveys

4.40-D Programs to Measure and Reduce Inconsistency

4.40-E Process of Investigations of Complaints and Monitoring - Nursing Facilities

4.42-A P.S. 109-171, Section 6032 - Monitoring Provider Compliance

7.2-A Non-discrimination - Civil Rights Act (Title VI)


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