chapter XVI of this chapter, insofar as it relates to the aged), the State agency which administered or supervised the administration of such plan approved under subchapter X of this chapter (or subchapter XVI of this chapter, insofar as it relates to the blind) may be designated to administer or supervise the administration of the portion of the State plan for medical assistance which relates to blind individuals and a different State agency may be established or designated to administer or supervise the administration of the rest of the State plan for medical assistance; and in such case the part of the plan which each such agency administers, or the administration of which each such agency supervises, shall be regarded as a separate plan for purposes of this subchapter (except for purposes of paragraph (10)). (b) Approval by Secretary.

The Secretary shall approve any plan which fulfills the conditions specified in subsection (a) of this section, except that he shall not approve any plan which imposes, as a condition of eligibility for medical assistance under the plan

or

(1) an age requirement of more than 65 years;

(2) effective July 1, 1967, any age requirement which excludes any individual who has not attained the age of 21 and is or would, except for the provisions of section 606(a)(2) of this title, be a dependent child under part A of subchapter IV of this chapter; or

(3) any residence requirement which excludes any individual who resides in the State; or

(4) any citizenship requirement which excludes any citizen of the United States.

(c) Same; reduction of aid or assistance under State plans under other subchapters.

Notwithstanding subsection (b) of this section, the Secretary shall not approve any State plan for medical assistance if he determines that the approval and operation of the plan will result in a reduction in aid or assistance in the form of money payments (other than so much, if any, of the aid or assistance in such form as was, immediately prior to the effective date of the State plan under this subchapter, attributable to medical needs) provided for eligible individuals under a plan of such State approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter. (d) Modification; certification requirements.

Whenever any State desires a modification of the State plan for medical assistance so as to reduce the scope or extent of the care and services provided as medical assistance under such plan, or to terminate any of such care and services, the Secretary shall, upon application of the State, approve any such modification if the Governor of such State certifies to the Secretary that—

(1) the average quarterly amount of non-Federal funds expended in providing medical assistance under the plan for any consecutive fourquarter period after the quarter in which such modification takes effect will not be less than the average quarterly amount of such funds expended in providing such assistance for the four-quarter

period which immediately precedes the quarter in which such modification is to become effective, (2) the State is fully complying with the provisions of its State plan (relating to control of utilization and costs of services) which are included therein pursuant to the requirements of subsection (a) (30) of this section, and

(3) the modification is not made for the purpose of increasing the standard or other formula for determining payments for those types of care or services which, after such modification, are provided under the State plan,

and if the Secretary finds that the State is complying with the provisions of its State plan referred to in clause (2); except that nothing in this subsection shall be construed to authorize any modification in the State plan of any State which would terminate the care or services required to be included pursuant to subsection (a) (13) of this section. Any increase in the formula or other standard for determining payments for those types of care or services which, after such modification, are provided under the State plan shall be made only after approval thereof by the Secretary. (Aug. 14, 1935, ch. 531, title XIX, § 1902, as added July 30, 1965, Pub. L. 89-91, title I, § 121(a), 79 Stat. 334, and amended Jan. 2, 1968, Pub. L. 90-248, title II, §§ 210(a)(6), 223(a), 224(a), (c)(1), 227(a), 228(a), 229(a), 231, 234(a), 235(a), 236(a), 237, 238, 241(f) (1)—(4), title III, § 302(b), 81 Stat. 896, 901-906, 908, 911, 917, 929; Aug. 9, 1969, Pub. L. 91-56 § 2(c), (d), 83 Stat. 99.)

AMENDMENTS

1969 Subsec. (c). Pub. L. 91-56, § 2(c), substituted "ald or assistance in the form of money payments (other than so much, if any, of the aid or assistance in such form as was, immediately prior to the effective date of the State plan under this subchapter, attributable to medical needs) for "aid or assistance (other than so much of the ald or assistance as is provided for under the plan of the State approved under this subchapter)".

Subsec. (d). Pub. L. 91-56, § 2(d), added subsec. (d). 1968-Subsec. (a)(2). Pub. L. 90-248, § 231, changed the date on which State plans must meet certain financial participation requirements by substituting "July 1, 1969" for "July 1, 1970".

Subsec. (a) (4). Pub. L. 90-248, § 210(a) (6), designated existing provisions as subpar. (A) and added subpar. (B). Subsec. (a) (10). Pub. L. 90-248, §§ 223(a), 241(f)(1), deleted "IV," after "I," and inserted ", and part A of subchapter IV of this chapter" after "XVI of this chapter", and designated existing provisions as item I and added item II.

Subsec. (a) (11). Pub. L. 90-248, § 302(b), designated existing provisions as cl. (A) and added cl. (B).

Subsec. (a) (13). Pub. L. 90-248, § 224(a), designated existing provisions as subpar. (A), incorporated existing cl. (A) in provisions designated as subpars. (B) and (C) (1), making subpar. (B) and (C) applicable to individuals receiving aid or assistance under an approved State plan and to individuals not covered under subpar. (B), respectively, added cl. (11) of subpar. (C), redesignated former cl. (B) as subpar. (D), and deleted effective date of July 1, 1967, for former cls. (A) and (B).

Subsec. (a) (13) (A). Pub. L. 90-248, § 224 (c) (1), designated existing provisions as cl. (1) and added cl. (11).

Subsec. (a) (14) (A). Pub. L. 90-248, § 235(a)(1), inserted "in the case of individuals receiving aid or assistance under State plans approved under subchapters I, X, XIV, XVI, and part A of subchapter IV of this chapter,".

Subsec. (a) (14) (B). Pub. L. 90-248, § 235 (a) (2), inserted "inpatient hospital services or" after "respect to" and substituted "to an individual" for "him".

Subsec. (a) (15). Pub. L. 90-248, § 235(a)(3), deleted subpar. (B) provision for meeting the full cost of any deductible imposed with respect to any such individual under the insurance program established by part A of such subchapter, deleted subpar. (B) designation preceding "where, under the plan", and substituted therein "established by such subchapter" for "established by part B of such subchapter".

Subsec. (a) (17). Pub. L. 90-248, § 238, inserted in the parenthetical expression "and may, in accordance with standards prescribed by the Secretary, differ with respect to income levels, but only in the case of applicants or recipients of assistance under the plan who are not receiving aid or assistance under the State's plan approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter, based on the variations between shelter costs in urban areas and in rural areas" following "all groups".

Pub. L. 90-248, § 241(f) (2), in clause (B) deleted "IV," after "I," and inserted “, or part A of subchapter IV of this chapter" after "XVI of this chapter".

Subsecs. (a) (23)—(30). Pub. L. 90-248, §§ 227(a), 228 (a), 229 (a), 234(a), 236(a), 237, added pars. (23), (24), (25), (26)-(28), (29), (30), respectively.

Subsec. (b)(2). Pub. L. 90-248, § 241(f) (3), inserted "part A of" before "subchapter IV".

Subsec. (c). Pub. L. 90-248, § 241(f) (4), deleted "“IV," after "I," and inserted ", or part A of subchapter IV of this chapter" after "XVI of this chapter".

EFFECTIVE DATE OF 1968 AmendmenT

Amendment of subsec. (a) (4) by section 210(a) (6) of Pub. L. 90-248 effective July 1, 1969, or, if earlier (with respect to a State's plan approved under this subchapter) on the date as of which the modification of the State plan to comply with such amendment is approved, see section 210(b) of Pub. L. 90-248, set out as a note under section 302 of this title.

Section 223(b) of Pub. L. 90-248 provided that: "The amendments made by subsection (a) [to subsec. (a) (10) of this section] shall apply with respect to calendar quarters beginning after June 30, 1967."

Section 224(b) of Pub. L. 90-248 provided that: "The amendment made by subsection (a) [to subsec. (a) (13) (other than (A) (11)) of this section] shall apply with respect to calendar quarters beginning after December 31, 1967."

Section 224 (c) (2) of Pub. L. 90-248 provided that: “The amendment made by paragraph (1) of this subsection [amending subsec. (a) (13) (A) of this section] shall apply with respect to calendar quarters beginning after June 30, 1970."

Section 227(b) of Pub. L. 90-248 provided that: "The amendments made by this section [enacting subsec. (a) (23) of this section] shall apply with respect to calendar quarters beginning after June 30, 1969; except that such amendments shall apply in the case of Puerto Rico, the Virgin Islands, and Guam only with respect to calendar quarters beginning after June 30, 1972."

Section 229 (b) of Pub. L. 90-248 provided that: "The amendment made by subsection (a) [enacting subsec. (a) (25) of this section] shall apply with respect to legal liabilities of third parties arising after March 31, 1968." Section 234 (b) of Pub. L. 90-248 provided that: "The amendments made by subsection (a) of this section [enacting subsecs. (a) (26)-(28) of this section] (unless otherwise specified in the body of such amendments) shall take effect on January 1, 1969."

Section 235 (b) of Pub. L. 90-248 provided that: "The amendments made by subsection (a) [to subsecs. (a) (14), (15) of this section] shall be effective in the case of calendar quarters beginning after December 31, 1967."

Enactment of subsec. (a) (29) by section 236 (a) of Pub. L. 90-248 effective July 1, 1970, except as otherwise specifiled in the text thereof, see section 236(c) of Pub. L. 90-248, set out as a note under section 1396g of this title.

Section 237 of Pub. L. 90-248 provided in part that enactment of subsec. (a) (30) of this section by section 237 shall be effective Apr. 1, 1968.

Section 238 of Pub. L. 90-248 provided in part that amendment of subsec. (a) (17) of this section by section 238 shall be effective July 1, 1969.

TRANSFER OF FUNCTIONS

Functions, powers, and duties of Secretary of Health, Education, and Welfare under subsec. (a) (4) (A) of this section transferred to United States Civil Service Commission, see section 4728(a) (3) (D) of this title. NURSING HOMES ELIGIBLE FOR MATCHING FUNDS FOR HOME SERVICES WHEN MEETING STATE LICENSURE REQUIREMENTS AFTER JUNE 30, 1968

Section 234 (c) of Pub. L. 90-248 provided that: "Notwithstanding any other provision of law, after June 30, 1968, no Federal funds shall be paid to any State as Federal matching under title [subchapter] I, X, XIV, XVI, or XIX of the Social Security Act [this chapter] for payments made to any nursing home for or on account of any nursing home services provided by such nursing home for any period during which such nursing home is determined not to meet fully all requirements of the State for licensure as a nursing home, except that the Secretary may prescribe a reasonable period or periods of time during which a nursing home which has formerly met such requirements will be eligible for payments which include Federal participation if during such period or periods such home promptly takes all necessary steps to again meet such requirements."

DISTRICT OF COLUMBIA; PLAN FOR MEDICAL ASSISTANCE Pub. L. 90-227, § 1, Dec. 27, 1967, 81 Stat. 744, provided: "That (a) the Commissioner of the District of Columbia (hereafter in this Act [enacting this note and material set out as a note under section 1395v of this title] referred to as the 'Commissioner') may submit under title XIX of the Social Security Act [this subchapter] to the Secretary of Health, Education, and Welfare (hereafter in this Act referred to as the 'Secretary') a plan for medical assistance (and any modifications of such plan) to enable the District of Columbia to receive Federal financial assistance under such title for a medical assistance program established by the Commissioner under such plan.

"(b) (1) Notwithstanding any other provision of law, the Commissioner may take such action as may be necessary to submit such plan to the Secretary and to establish and carry out such medical assistance program, except that in prescribing the standards for determining eligibility for and the extent of medical assistance under the District of Columbia's plan for medical assistance, the Commissioner may not (except to the extent required by title XIX of the Social Security Act) [this subchapter]— "(A) prescribe maximum income levels for recipients of medical assistance under such plan which exceed (1) the title XIX maximum income levels if such levels are in effect, or (ii) the Commissioner's maximum income levels for the local medical assistance program if there are no title XIX maximum income levels in effect; or

"(B) prescribe criteria which would permit an individual or family to be eligible for such assistance if such individual or family would be ineligible, solely by reason of his or its resources, for medical assistance both under the plan of the State of Maryland approved under title XIX of the Social Security Act [this subchapter] and under the plan of the State of Virginia approved under such title.

"(2) For purposes of subparagraph (A) of paragraph (1) of this subsection

"(A) the term 'title XIX maximum income levels' means any maximum income levels which may be specified by title XIX of the Social Security Act [this subchapter] for recipients of medical assistance under State plans approved under that title;

"(B) the term 'the Commissioner's maximum income levels for the local medical assistance program' means the maximum income levels prescribed for recipients of medical assistance under the District of Columbia's medical assistance program in effect in the fiscal year ending June 30, 1967; and

"(C) during any of the first four calendar quarters in which medical assistance is provided under such plan there shall be deemed to be no title XIX maximum income levels in effect if the title XIX maximum income levels in effect during such quarter are higher than than the Commissioner's maximum income levels for the local medical assistance program."

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1315, 1396b, 1396g of this title.

§ 1396b. Payment to States.
(a) Computation of amount.

From the sums appropriated therefor, the Secretary (except as otherwise provided in this section and section 1317 of this title) shall pay to each State which has a plan approved under this subchapter, for each quarter, beginning with the quarter commencing January 1, 1966

(1) an amount equal to the Federal medical assistance percentage (as defined in section 1396d (b) of this title) of the total amount expended during such quarter as medical assistance under the State plan (including expenditures for premiums under part B of subchapter XVIII of this chapter, for individuals who are recipients of money payments under a State plan approved under subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV of this chapter, and, except in the case of individuals sixty-five years of age or older who are not enrolled under part B of subchapter XVIII of this chapter, other insurance premiums for medical or any other type of remedial care or the cost thereof); plus

(2) an amount equal to 75 per centum of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the State agency or any other public agency; plus

(3) an amount equal to 50 per centum of the remainder of the amounts expended during such quarter as found necessary by the Secretary for the proper and efficient administration of the State plan.

(b) Quarterly expenditures to exceed average of total expenditures for each quarter of fiscal year ending June 30, 1965.

(1) Notwithstanding the preceding provisions of this section, the amount determined under such provisions for any State for any quarter which is attributable to expenditures with respect to individuals 65 years of age or older who are patients in institutions for mental diseases shall be paid only to the extent that the State makes a showing satisfactory to the Secretary that total expenditures from Federal, State, and local sources for mental health services (including payments to or in behalf of individuals with mental health problems) under State and local public health and public welfare programs for such quarter exceed the average of the total expenditures from such sources for such services under such programs for each quarter of the fiscal year ending June 30, 1965. For purposes of this subsection, expenditures for such services for each quarter in the fiscal year ending June 30, 1965, in the case of any State shall be determined on the basis of the latest data, satisfactory to the Secretary, available to him at the time of the first determination by him under this subsection for such State; and expenditures for such services for any quarter beginning after December 31, 1965, in the case of any State

shall be determined on the basis of the latest data, satisfactory to the Secretary, available to him at the time of the determination under this subsection for such State for such quarter; and determinations so made shall be conclusive for purposes of this subsection.

provisions

(2) Notwithstanding the preceding of this section, the amount determined under subsection (a)(1) of this section for any State for any quarter beginning after December 31, 1969, shall not take into account any amounts expended as medical assistance with respect to individuals aged 65 or over which would not have been so expended if the individuals involved had been enrolled in the insurance program established by part B of subchapter XVIII of this chapter.

(c) Federal medical assistance percentage; Federal share of State medical expenses during fiscal year ending June 30, 1965.

(1) If the Secretary finds, on the basis of satisfactory information furnished by a State, that the Federal medical assistance percentage for such State applicable to any quarter in the period beginning January 1, 1966, and ending with the close of June 30, 1969, is less than 105 per centum of the Federal share of medical expenditure by the State during the fiscal year ending June 30, 1965 (as determined under paragraph (2)), then 105 per centum of such Federal share shall be the Federal medical assistance percentage (instead of the percentage determined under section 1396d (b) of this title) for such State for such quarter and each quarter thereafter occurring in such period and prior to the first quarter with respect to which such a finding is not applicable.

(2) For purposes of paragraph (1), the Federal share of medical expenditures by a State during the fiscal year ending June 30, 1965, means the percentage which the excess of

(A) the total of the amounts determined under sections 303, 603, 1203, 1353, and 1383 of this title with respect to expenditures by such State during such year as aid or assistance under its State plans approved under subchapters I, IV, X, XIV, and XVI of this chapter, over

(B) the total of the amounts which would have been determined under such sections with respect to such expenditures during such year if expenditures as aid or assistance in the form of medical or any other type of remedial care had not been counted,

is of the total expenditures as aid or assistance in the form of medical or any other type of remedial care under such plans during such year.

(d) Estimates of amount of State entitlement; installments; adjustments; overpayment; obligated appropriations.

(1) Prior to the beginning of each quarter, the Secretary shall estimate the amount to which a State will be entitled under subsections (a), (b), and (c) of this section for such quarter, such estimates to be based on (A) a report filed by the State containing its estimate of the total sum to be expended in such quarter in accordance with the provisions of such subsections, and stating the amount appropriated or made available by the State and its political subdivisions for such expenditures in such

quarter, and if such amount is less than the State's proportionate share of the total sum of such estimated expenditures, the source or sources from which the difference is expected to be derived, and (B) such other investigation as the Secretary may find necessary.

(2) The Secretary shall then pay to the State, in such installments as he may determine, the amount so estimated, reduced or increased to the extent of any overpayment or underpayment which the Secretary determines was made under this section to such State for any prior quarter and with respect to which adjustment has not already been made under this subsection. Expenditures for which payments were made to the State under subsection (a) of this section shall be treated as an overpayment to the extent that the State or local agency administering such plan has been reimbursed for such expenditures by a third party pursuant to the provisions of its plan in compliance with section 1396a (a) (25) of this title. (3) The pro rata share to which the United States is equitably entitled, as determined by the Secretary, of the net amount recovered during any quarter by the State or any political subdivision thereof with respect to medical assistance furnished under the State plan shall be considered an overpayment to be adjusted under this subsection.

(4) Upon the making of any estimate by the Secretary under this subsection, any appropriations available for payments under this section shall be deemed obligated.

(e) Comprehensive care and services for eligible individuals by July 1, 1977.

The Secretary shall not make payments under the preceding provisions of this section to any State unless the State makes a satisfactory showing that it is making efforts in the direction of broadening the scope of the care and services made available under the plan and in the direction of liberalizing the eligibility requirements for medical assistance, with a view toward furnishing by July 1, 1977, comprehensive care and services to substantially all individuals who meet the plan's eligibility standards with respect to income and resources, including services to enable such individuals to attain or retain independence or self-care.

(f) Limitation on Federal participation in medical assistance.

(1) (A) Except as provided in paragraph (4), payment under the preceding provisions of this section shall not be made with respect to any amount expended as medical assistance in a calendar quarter, in any State, for any member of a family the annual income of which exceeds the applicable income limitation determined under this paragraph.

(B) (1) Except as provided in clause (ii) of this subparagraph, the applicable income limitation with respect to any family is the amount determined, in accordance with standards prescribed by the Secretary, to be equivalent to 1333 percent of the highest amount which would ordinarily be paid to a family of the same size without any income or resources, in the form of money payments, under the plan of the State approved under Part A of subchapter IV of this chapter.

(ii) If the Secretary finds that the operation of a uniform maximum limits payments to families of more than one size, he may adjust the amount otherwise determined under clause (i) to take account of families of different sizes.

(C) The total amount of any applicable income limitation determined under subparagraph (B) shall, if it is not a multiple of $100 or such other amount as the Secretary may prescribe, be rounded to the next higher multiple of $100 or such other amount, as the case may be.

(2) In computing a family's income for purposes of paragraph (1), there shall be excluded any costs (whether in the form of insurance premiums or otherwise) incurred by such family for medical care or for any other type of remedial care recognized under State law.

(3) For purposes of paragraph (1) (B), in the case of a family consisting of only one individual, the "highest amount which would ordinarily be paid” to such family under the State's plan approved under part A of subchapter IV of this chapter shall be the amount determined by the State agency (on the basis of reasonable relationship to the amounts payable under such plan to families consisting of two or more persons) to be the amount of the aid which would ordinarily be payable under such plan to a family without any income or resources) consisting of one person if such plan (without regard to section 608 of this title) provided for aid to such a family. (4) The limitations on payment imposed by the preceding provisions of this subsection shall not apply with respect to any amount expended by a State as medical assistance for any individual who, at the time of the provision of the medical assistance giving rise to such expenditure

(A) is a recipient of aid or assistance under a plan of such State which is approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV of this chapter, or

(B) is not a recipient of aid or assistance under such a plan but (i) is eligible to receive such aid or assistance, or (ii) would be eligible to receive such aid or assistance if he were not in a medical institution.

(Aug. 14, 1935, ch. 531, title XIX, § 1903, as added July 30, 1965, Pub. L. 89-97, title I, § 121 (a), 79 Stat. 349, and amended Jan. 2, 1968, Pub. L. 90-248, title II, §§ 220 (a), 222(c), (d), 225 (a), 229 (c), 241(f) (5), 81 Stat. 898, 901, 902, 904, 917; June 28, 1968, Pub. L. 90-364, title III, § 303 (a) (1), 82 Stat. 274; Aug. 9, 1969, Pub. L. 91-56, § 2(a), 83 Stat. 99.)

REFERENCES IN TEXT

Section 1317 of this title, referred to in subsec. (a), was repealed by Pub. L. 90-248, title II, § 221(d), Jan. 2, 1968, 81 Stat. 900.

AMENDMENTS

1969 Subsec. (e). Pub. L. 91-56 extended from July 1, 1975, to July 1, 1977, the date by which comprehensive care and services for eligible individuals must be made available for a State to be eligible for payments.

1968 Subsec. (a)(1). Pub. L. 90–248, § 222(d), substituted "and, except in the case of individuals sixty-five years of age or older who are not enrolled under part B of subchapter XVIII of this chapter, other insurance premiums" for "and other insurance premiums".

Pub. L. 90-248, § 241 (f) (5), deleted "IV," after "I." and inserted "or part A of subchapter IV of this chapter." after "XVI of this chapter.".

Subsec. (a) (2). Pub. L. 90–248, § 225(a), substituted "of the State agency or any other public agency" for "of the State agency (or of the local agency administering the State plan in the political subdivision)".

Subsec. (b). Pub. L. 90-248, § 222(c), designated existing provisions as par. (1) and added par. (2).

Subsec. (b) (2). Pub. L. 90-364 substituted "1969" for "1967".

Subsec. (d) (2). Pub. L. 90-248, § 229 (c), provided for treatment of expenditures for which payments were made to the State under subsec. (a) as an overpayment to the extent that the State or local agency administering the plan has been reimbursed for such expenditures by a third party pursuant to the provisions of its plan in compliance with section 1396a (a) (25) of this title. Subsec. (f). Pub. L. 90-248, § 220 (a), added subsec. (f).

EFFECTIVE DATE OF 1968 AMENDMENTS

Section 220 (b) of Pub. L. 90-248 provided that:

"(b) (1) In the case of any State whose plan under title XIX of the Social Security Act [this subchapter] is approved by the Secretary of Health, Education, and Welfare under section 1902 [section 1396a of this title] after July 25, 1967, the amendment made by subsection (a) [enacting subsec. (f) of this section] shall apply with respect to calendar quarters beginning after the date of enactment of this Act. [Jan. 2, 1968].

"(2) In the case of any State whose plan under title XIX of the Social Security Act [this subchapter] was approved by the Secretary of Health, Education, and Welfare under section 1902 of the Social Security Act [section 1396a of this title] prior to July 26, 1967, amendments made by subsection (a) [enacting subsec. (f) of this section] shall apply with respect to calendar quarters beginning after June 30, 1968, except that

"(A) with respect to the third and fourth calendar quarters of 1968, such subsection shall be applied by substituting in subsection (f) of section 1903 of the Social Security Act [subsec. (f) of this section] 150 percent for 1331⁄2 percent each time such latter figure appears in such subsection (f), and

"(B) with respect to all calendar quarters during 1969, such subsection shall be applied by substituting in subsection (f) of section 1903 of such Act [subsec. (f) of this section] 140 percent for 1331⁄2 percent each time such latter figure appears in such subsection (f).” Section 222 (d) of Pub. L. 90-248, as amended by section 303 (a) (2) of Pub. L. 90-364, provided in part that amendment of subsec. (a)(1) of this section by such section 222(d) shall be effective with respect to calendar quarters beginning after December 31, 1969.

Section 225(b) of Pub. L. 90-248 provided that: "The amendment made by subsection (a) [to subsec. (a)(2) of this section] shall apply with respect to expenditures made after December 31, 1967."

Section 303 (b) of Pub. L. 90-364 provided that: "The amendments made by subsection (a) [amending subsec. (b) (2) of this section] shall be effective with respect to calendar quarters beginning after December 31, 1967." COMPREHENSIVE CARE AND SERVICES FOR ELIGIBLE INDIVIDUALS BY JULY 1, 1977; REQUIREMENT INAPPLICABLE FOR ANY PERIOD PRIOR TO JULY 1, 1971; REGULATIONS; ADVICE TO STATES

Section 2(b) of Pub. L. 91-56 provided that: "The provisions of section 1903 (e) of the Social Security Act [subsec. (e) of this section] shall not apply for any period prior to July 1, 1971. In performing his functions under title XIX of the Social Security Act [this subchapter], the Secretary of Health, Education, and Welfare shall issue regulations and give advice to the States consistent with the preceding sentence."

EXEMPTION OF PUERTO RICO, THE VIRGIN ISLANDS, AND GUAM FROM LIMITATIONS ON FEDERAL PAYMENTS MEDICAL ASSISTANCE

FOR

Section 248 (d) of Pub. L. 90-248 provided that: "The amendment made by section 220 (a) of this Act [enacting subsec. (f) of this section] shall not apply in the case of Puerto Rico, the Virgin Islands, or Guam."

NONDUPLICATION OF PAYMENTS TO STATES: PROHIBITION OF PAYMENTS AFTER DEC. 31, 1969

Section 121(b) of Pub. L. 89-97 provided that: "No payment may be made to an State under title I, IV, X, XIV, or XVI of the Social Security Act [subchapter I, IV, X, XIV, or XVI of this chapter] with respect to aid or assistance in the form of medical or any other type of remedial care for any period for which such State receives payments under title XIX of such Act [this subchapter], or for any period after December 31, 1969."

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 643, 1315, 1396a of this title.

§ 1396c. Operation of State plans.

If the Secretary, after reasonable notice and opportunity for hearing to the State agency administering or supervising the administration of the State plan approved under this subchapter, finds—

(1) that the plan has been so changed that it no longer complies with the provisions of section 1396a of this title; or

(2) that in the administration of the plan there is a failure to comply substantially with any such provision;

the Secretary shall notify such State agency that further payments will not be made to the State (or, in his discretion, that payments will be limited to categories under or parts of the State plan not affected by such failure), until the Secretary is satisfied that there will no longer be any such failure to comply. Until he is so satisfied he shall make no further payments to such State (or shall limit payments to categories under or parts of the State plan not affected by such failure). (Aug. 14, 1935, ch. 531, title XIX, § 1904, as added July 30, 1965, Pub. L. 89-97, title I, § 121(a), 79 Stat. 351.)

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in section 1316 of this title. § 1396d. Definitions.

For purposes of this subchapter

(a) Medical assistance.

The term "medical assistance" means payment of part or all of the cost of the following care and services (if provided in or after the third month before the month in which the recipient makes application for assistance) for individuals, and, with respect to physicians' or dentists' services, at the option of the State, to individuals not receiving aid or assistance under the State's plan approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV of this chapter, who are—

(i) under the age of 21,

(ii) relatives specified in section 606(b)(1) of this title with whom a child is living if such child, except for section 606 (a) (2) of this title, is (or would, if needy, be) a dependent child under part A of subchapter IV of this chapter, (iii) 65 years of age or older,

(iv) blind,

(v) 18 years of age or older and permanently and totally disabled, or

(vi) persons essential (as described in the second sentence of this subsection) to individuals receiving aid or assistance under State plans approved under subchapter I, X, XIV, or XVI of this chapter,