Medicaid State Plan Documents

A State Plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. It gives an assurance that a state abides by Federal rules and may claim Federal matching funds for its Medicaid program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative requirements that States must meet to participate. States frequently send a state plan amendment, otherwise referred to as a SPA, to the Centers for Medicare and Medicaid Services (CMS) for review and approval. There are many reasons why a state might want to amend their state plan. For example, the state may wish to implement changes required by Federal or state law, Federal or state regulations, or court orders. States also have the flexibility to request permissible program changes, make corrections, or update their plan with new information.

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Table of Contents
List of Attachments

Medicaid Administration
A1 -State Plan Administration Designation and Authority
A2 -State Plan Administration Organization and Administration
A3 -State Plan Administration Assurances
1.4Tribal Consultation Requirements
1.5Pediatric Immunization Program
Medicaid Eligibility
S10 -MAGI Based Income Methodologies
S32 -Mandatory Coverage Adult Group
S88 -Non-Financial Eligibility State Residency
S89 -Non Financial Eligibility Citizenship and Non Citizen Eligibility
S94 -General Eligibility Requirements Eligibility Process

2.0Coverage and Eligibility
2.1 Application, Determination of Eligibility and Furnishing Medicaid
  • Attachment A: Definition of an HMO that is Not Federally Qualified
2.2 Coverage and Conditions of Eligibility
2.3 Residence
2.4 Blindness
2.5 Disability
2.6 Financial Eligibility
2.7 Medicaid Furnished Out of State

3.0 Services: General Provisions
3.1 Amount, Duration, and Scope of Services
3.2 Coordination of Medicaid with Medicare Part B
3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
3.4 Special Requirements Applicable to Sterilization Procedures
3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries
3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period

4.0 General Program Administration
4.1 Methods of Administration
4.2 Hearings for Applicants and Recipients
4.3 Safeguarding Information on Applicants and Recipients
4.4 Medicaid Quality Control
4.5 Medicaid Agency Fraud Detection and Investigation Program
4.6 Reports
4.7 Maintenance of Records
4.8 Availability of Agency Program Manuals
4.9 Reporting Provider Payments to the Internal Revenue Service
4.10 Free Choice of Providers
4.11 Relations with Standard-Setting and Survey Agencies
4.12 Consultation to Medical Facilities
4.13 Required Provider Agreement
4.14 Utilization Control
4.15 Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases
4.17 Liens and Recoveries
4.18 Cost Sharing and Similar Charges
  • Attachment A - Charges Imposed on Categorically Needy
  • AttachmentC - Charges Imposed on Categorically Needy and Other Optional Groups
  • AttachmentD - Premiums Imposed on Low-Income Pregnant Women and Infants
  • Attachment E - Premiums Imposed on Qualified Disabled and Working Individuals
4.19 Payment for Services
4.20 Direct Payments to certain Recipients for Physicians' or Dentists' Services
4.21 Prohibition Against Reassignment of Provider Claims
4.22 Third Party Liability
  • Attachment A - Requirements for Third Party Liability- Identifying Liable Resources
  • Attachment B - Requirements for Third Party Liability- Payment of Claims
  • Attachment C - Cost-Effective Methods for Employer-Based Group Health Plans
4.23 Use of Contracts
4.24 Standards for Payments for Skilled Nursing and Intermediate Care Facility Services
4.25 Program for Licensing Administrators of Nursing Homes
4.27 Disclosure of Survey information and Provider or Contractor Evaluation
4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities
4.29 Conflict of Interest Provisions
4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals
4.31 Disclosure of Information by Providers and Fiscal Agents
4.32 Income and Eligibility Verification System
  • Attachment A - Income and Eligibility Verification System Procedures: Requests to Other State Agencies
4.33 Medicaid Eligibility Cards for Homeless Individuals
  • Attachment A - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals
4.34 Systematic Alien Verification for Entitlements
4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation
4.36 Required Coordination Between the Medicaid and WIC Programs
4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities
4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities
4.40 Survey and Certification Process
4.41 Resident Assessment for Nursing Facilities
4.43 Frequency and Description of Method of Compliance Oversight

5.0Personnel Administration
5.1Standards of Personnel Administration
5.3Training Programs; Subprofessional and Volunteer Programs

6.0Financial Administration
6.1 Fiscal Policies and Accountability
6.2 Cost Allocation
6.3 State Financial Participation

7.0General Provisions
7.1Plan Amendments
  • Attachment A - Methods of Administration- Civil Rights Act (Title VI)
7.3Maintenance of AFDS Effort
7.4State Governor's Review

Assurance Pages

CHIP Eligibility
CS7 -Separate Child Health Insurance Program Eligibility Targeted Low-Income Children
CS12 -Separate Child Health Insurance Program Eligibility Dental Only Supplemental Coverage
CS14 -Child Health Insurance Program Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
CS15 -Separate Child Health Insurance Program MAGI-Based Income Methodologies
CS24 -Separate Child Health Insurance Program General Eligibility Eligibility Processing

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