LibGuides: Medicaid Law: Federal and Ohio: Federal Laws

Chart

The second aspect of Federal Medicaid Law is which services are covered. Federal law breaks this down into mandatory and optional services.

The list below outlines mandatory Medicaid benefits, which states are required to provide under federal law, and optional benefits that states may cover if they choose. Source : Medicaid.gov

Mandatory Benefits	Optional Benefits
Inpatient hospital services	Prescription Drugs
Outpatient hospital services	Clinic services
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services	Physical therapy
Nursing Facility Services	Occupational therapy
Home health services	Speech, hearing and language disorder services
Physician services	Respiratory care services
Rural health clinic services	Other diagnostic, screening, preventive and rehabilitative services
Federally qualified health center services	Podiatry services
Laboratory and X-ray services	Optometry services
Family planning services	Dental Services
Nurse Midwife services	Dentures
Certified Pediatric and Family Nurse Practitioner services	Prosthetics
Freestanding Birth Center services (when licensed or otherwise recognized by the state)	Eyeglasses
Transportation to medical care	Chiropractic services
Tobacco cessation counseling for pregnant women	Other practitioner services
	Private duty nursing services
	Personal Care
	Hospice
	Case management
	Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
	Services in an intermediate care facility for Individuals with Intellectual Disability
	State Plan Home and Community Based Services- 1915(i)
	Self-Directed Personal Assistance Services- 1915(j)
	Community First Choice Option- 1915(k)
	TB Related Services
	Inpatient psychiatric services for individuals under age 21
	Other services approved by the Secretary^*
	Health Homes for Enrollees with Chronic Conditions – Section 1945

*This includes services furnished in a religious nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).

Waivers

Waivers are the third prong of the federal Medicaid program. They allow states to waive the income qualification requirements for certain children and adults, so that they can live at home instead of being institutionalized.

Biden administration nixes Ohio’s Medicaid work requirements
Letter from HHS, 8/10/21
Ohio Section 1115 Demonstration Waiver for Substance Use Disorder Treatment

Katie Beckett Waivers
For disabled children

Home and Community-Based Waiver Services (HCBS)
Also known as 1915(c) waivers. Allows children and adults to stay in their homes, instead of going to nursing homes. In Ohio, the HCBS waiver program for the elderly is called the Passport waiver.
Section 1115 Demonstrations
These waivers gives states flexibility to experiment with their Medicaid programs.
Center for Medicaid & Chip Services Guidance on Opportunities to Promote Work among Medicaid Beneficiaries
Jan 11, 2018 CMS guidance letter describing considerations for states that may be interested in pursuing demonstration projects under section 1115(a) of the Act that have the goal of creating incentives for Medicaid beneficiaries to participate in work and community engagement activities. Pregnant, elderly, disabled and children would be exempt.
MEDICAID DEMONSTRATIONS: Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements GAO-20-149: Published: Oct 1, 2019. Publicly Released: Oct 10, 2019.

Cert Granted

Kerr v. Planned Parenthood South Atlantic
In 2025, the US Supreme Court will decide 1) whether the Medicaid Act’s any-qualified-provider provision unambiguously confers a private right upon a Medicaid beneficiary to choose a specific provider; and (2) what the scope of a Medicaid beneficiary’s alleged right is to choose a provider that a state has deemed disqualified.

US Code

42 U.S. Code Subchapter XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
42 USC 1396 et seq.
42 US Code Sec.1315 - Demonstration Projects
Codifies Sec. 1115 of the Social Security Act, which authorizes some flexibility in a state's Medicaid program, if waiver is granted.
42 USC 1382c
These definitions are used to determine eligibility for Medicaid.
42 US Code 1395w-114
Premium and cost-sharing subsidies for low-income individuals. State Medicaid agencies determine eligibility of Medicare beneficiaries for the low-income subsidy.
41 US Code 1396d
Defines federal medicaid program, including the calculation of the Federal Medical Assistance Percentage (FMAP) to each state each year.
42 USC 1396n
Authorizes home and community-based services waivers (HCBS). Also called 1915(c) waivers, after the section of the Social Security Act codified at 42 USC 1396n.
42 U.S. Code § 1396p
Medicaid Estate Recovery Program - liens, adjustments and recoveries, and transfers of asset
The Affordable Care Act, Public Law 111–148—MAR. 23, 2010
Expanded Medicaid coverage, for states that chose to accept it.

Case Law

Talevski v. Health and Hospital Corporation of Marion County
2023. US Supreme Court reiterated that spending clause legislation gives rise to privately enforceable rights under 42 U.S.C. § 1983.
Supreme Court Declines to Review Planned Parenthood v. Gee
The result is that people can continue to use Medicaid money for pregnancy-related Planned Parenthood services. Now, this is not for abortion-related services. Federal law prohibits people from using Medicaid money for abortion.
Planned Parenthood v. Gee
5th Cir. (2017)
Stewart v. Azar
UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA says HHS Secretary's approval of work requirements for recipients do not further the Medicaid program’s statutory purpose, which is to provide access to health care for people with low incomes. This case is about Kentucky.
Gresham v. Azar
Companion case to Stewart v. Azar above. This one is about Arkansas.
Court nixes upcoming argument on Medicaid work requirements
Scotus Blog 3/11/21. The Trump administration had appealed the above cases, but the Biden administration asked the US Supreme Court to drop the appeals, which the Court did.

Federal Regulations

42 CFR Chapter IV, Subchapter C - MEDICAL ASSISTANCE PROGRAMS
42 CFR sec. 430 et seq.
42 CFR Part 435
List all the groups of people eligible for Medicaid.
42 CFR 435.145
The state must provide Medicaid to individuals for whom an adoption assistance agreement is in effect with the state, regardless of whether adoption assistance is being provided or an interlocutory or other judicial decree of adoption has been issued.
42 CFR 435.225
"Katie Beckett" waivers. Allows states to waive income requirements for disabled children so that they can live at home.
42 CFR Part 440, Subpart B
Lists covered services, both mandatory and optional.
42 CFR Part 1003, Subpart A - Civil Penalties for Violations
42 CFR Part 1005 - APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS
45 CFR Part 160 - GENERAL ADMINISTRATIVE REQUIREMENTS
Administrative simplification of handling of heath care plans, including Medicaid.
DACA recipients to gain health coverage under new plan from Biden administration
White House says HHS will publish a rule that amends the definition of “lawful presence” to include DACA recipients in Medicaid and Affordable Care Act coverage.

Federal Register

Reducing Poverty in America by Promoting Opportunity and Economic Mobility A Presidential Document by the Executive Office of the President on 04/13/2018
85 FR 72754 Final Rule meant to streamline Medicaid and S-Chip
Modifies 42 CFR 438 and 42 CFR 457. These regulations went into effect on December 14, 2020, except for the additions of Sec. Sec. 438.4(c) (instruction 4) and 438.6(d)(6) (instruction 7), which became effective July 1, 2021.

Medicaid Law: Federal and Ohio: Federal Laws

Introduction